Paper 1
Aircast Award for Basic Science - Return to Play Following In-season Anterior Shoulder Instability: A
Prospective Multicenter Study
Jonathan F. Dickens, MD1, Brett D. Owens, MD2, Kenneth L. Cameron, PhD, MPH, ATC2, Kelly G.
Kilcoyne, MD3, C. Dain Allred, MD4, Steven J. Svoboda, MD2, Robert T. Sullivan, MD5, John M. Tokish,
MD6, Karen Y. Peck, MEd, ATC7, John Paul H. Rue, MD8.
1
John A. Feagin Jr. Sports Medicine Fellowship/ Keller Army Program, West Point, NY, USA, 2Keller Army
Hospital, West Point, NY, USA, 3Bethesda, MD, USA, 4US Air Force Academy / 10 MDG, U S A F Academy,
CO, USA, 596th Medical Group, Eglin Afb, FL, USA, 6Tripler Army Medical CenterTripler Army Medical
Center, Hickam Afb, HI, USA, 7John A. Feagin Jr. Sports Medicine Fellowship, West Point, NY, USA, 8NHC
Annapolis, Annapolis, MD, USA.
Objectives: There is no consensus on the optimal treatment of young in-season athletes with anterior
shoulder instability and limited data are available to guide return to play and treatment. The purpose of
this study was to examine the likelihood of return to sport following an in-season shoulder instability
event based on the type of instability (subluxation vs. dislocation). Additionally, injury factors and
patient reported outcome scores administered at the time of injury were evaluated to assess the
predictability of eventual successful return to sport and time to return sport during the competitive
season following injury. Methods: Over two academic years, 45 contact intercollegiate athletes were
prospectively enrolled in a multicenter observational study to assess return to play following in-season
anterior glenohumeral instability. The primary outcomes of interest were the ability to return to sport
and time lost from sport following an acute anterior shoulder instability event. Baseline data collection
included sport played, previous instability events, direction of instability, and type of instability
(subluxation or dislocation). Patient reported outcome scores specific to the shoulder were obtained at
the time of injury and included the Western Ontario Shoulder Instability Index (WOSI), Single
Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), and American Shoulder and Elbow
Score (ASES). All observed patients underwent a standardized accelerated rehabilitation program
without shoulder immobilization, following the initial shoulder instability event. Subjects were followed
during the course of their competitive season to determine return to play success and recurrent
instability. Results: Thirty-three of 45 (73%) athletes returned to sport for either all or part of the
season after a median 5 days lost from competition (IQR=13)(Fig 1). Of the 33 athletes returning to inseason sport following an instability event, 63% (22/33) completed the season. Athletes with a
subluxation were 5.3 times more likely (OR=5.32, 95%CI: 1.00, 28.07, p=0.049) to return to sport
following an initial in-season shoulder instability event when compared to those with dislocations.
Logistic regression analysis suggests that the WOSI (OR=1.05; 95% CI 1.00, 1.09; p=0.037) and SST
(OR=1.03, 95% CI 1.00, 1.05; p=0.044) administered after the initial instability event are predictive of
ability to return to play . For every 1 point higher the WOSI scaled score at the time of injury, the athlete
was 5% more likely to return to play during the same season. Time loss from sport following a shoulder
instability event was inversely correlated with the WOSI (p=0.039), SST (p=0.007), and ASES (p=0.02)
scores at the time of initial injury. The SST demonstrated the strongest correlation with time lost from
sport, and for every 10 points higher the SST scale score was at the time of injury an athlete returned to
sport 1.2 (95%CI: 0.4, 1.9) days sooner (p=0.004). Based on the logistic regression analysis, time lost
from sport is predicted using the SST score after the initial instability event (Table 1).
Conclusion: In the largest prospective study evaluating shoulder instability in mid-season contact
athletes, we demonstrate that 73% of athletes return to play after one week. While the majority of
athletes who return to sport complete the season, recurrent instability events are common regardless of
whether the initial injury was a subluxation or dislocation.
Paper 2
Return to Play After Shoulder Stabilization in National Football League Athletes
Matthew J. White, MD1, Glenn S. Fleisig, PhD1, Kyle Aune, MPH1, James R. Andrews, MD2, Jeffrey R.
Dugas, MD3, E. Lyle Cain, MD3.
1
American Sports Medicine Institute, Birmingham, AL, USA, 2The Andrews Institute, Gulf Breeze, FL, USA,
3
Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL, USA.
Objectives: Shoulder instability is a common and limiting injury to football players. The return to play
(RTP) percentage and factors affecting RTP after shoulder stabilization in National Football League (NFL)
players are not defined. The purpose of this study was to determine the rate of return to professional
football play in the NFL after shoulder stabilization and to determine what factors may affect RTP in
these athletes. Methods: Sixty NFL players who had undergone shoulder stabilization at our institution
were followed to determine the rate of RTP and factors predicting RTP. Chart review was performed to
glean perioperative data and follow-up was performed by accessing the statistics database maintained
by the NFL. Successful RTP was defined as return to play in at least one regular season NFL game
following surgery. Chi square and Student’s t-tests were performed to examine differences between
perioperative and athletic history variables and a player’s ability to RTP. Results: Ninety percent (54 of
60) of NFL players were able to return to game play following shoulder stabilization. The average time to
RTP was 8.6 months. Age, number of games before surgery, and career length were not statistically
different between those that returned and those that did not. Eleven of the sixty patients underwent
open stabilization. Ninety-two percent (45/49) of the arthroscopically treated and eighty-two percent
(9/11) of the openly treated athletes were able to RTP; these rates were not found to be significantly
different. Playing history and demographics were similar between the open and arthroscopic groups.
Players selected before the fourth round of the NFL draft were 7.6 times more likely to RTP.
Circumferential labral tears were found in seven athletes, all of whom were able to RTP following
surgery. Conclusion: The RTP rates for NFL players following shoulder stabilization are quite high (90%).
There is no difference in RTP rates between open and arthroscopic repairs. Being selected in the first
four rounds of the NFL draft is highly predictive of a player’s ability to RTP.
Paper 3
“Subcritical” Glenoid Bone Loss Increases Redislocation Rates in Primary Arthroscopic Bankart Repair
James S. Shaha, MD1, Jay B. Cook, MD1, Daniel J. Song, MD2, Douglas J. Rowles, MD3, Craig R. Bottoni,
MD2, Steven H. Shaha, PhD, DBA4, John M. Tokish, MD5.
1
Tripler Army Medical Center, TAMC, HI, USA, 2Tripler Army Medical Center, Honolulu, HI, USA,
3
Orthopedic Surgeons Services, Tripler Amc, HI, USA, 4University of Utah, Salt Lake City, UT, USA, 5Tripler
Army Medical CenterTripler Army Medical Center, Hickam Afb, HI, USA.
Objectives: While bone loss is increasingly recognized as a risk factor for failure after arthroscopic
stabilization, the precise definition of critical bone loss has not been defined. Additionally, there is no
clarity on the amount of bone loss routinely present in patients presenting for primary arthroscopic
stabilization of anterior glenohumeral instability. The purpose of this study is to report on the average
bone loss measured in primary isolated Bankart reconstructions of the shoulder and to determine what
amount of bone loss correlated to a recurrence of instability. Methods: This is a retrospective review of
a consecutive series of 94 anterior instability patients (97 shoulders) who underwent arthroscopic labral
repair at a single military institution by one of three fellowship trained orthopaedic surgeons. Data was
collected on demographics and rate of redislocation as reported by the patient at the most recent
follow-up. Glenoid bone loss was calculated from preoperative imagining using a “perfect-circle”
technique. Patients were excluded if they had previously undergone any stabilization procedure.
Results: The average age at surgery was 25.6 years (range, 16-42) with average follow-up of 36.8
months (range, 20-57). There were 5 females (5 shoulders) and 89 males (92 shoulders). The average
bone loss in all patients was 14.4% (range, 0-34.7%). When analyzed based on the presence or absence
of recurrence, there were 77 stable shoulders with no redislocations. In this group, the average bone
loss was 14.5% (range, 0-33.3%) with a follow-up of 36.3 months (range, 20-57). There were 20 patients
with recurrent dislocations who had an average of 20.8% (range, 0-33.3%) with a 39.1 month (range, 2156) follow-up. There was a significantly greater amount of bone loss in those with redislocations
(p=0.004). When further analyzed, there was a 95% likelihood of redislocation with 17.1% bone loss
there was a 25% likelihood of redislocation with 7.0% bone loss. Conclusion: This study suggests that
glenoid bone loss is a common finding in patients undergoing primary arthroscopic stabilization.
Additionally, patients with “subcritical” bone loss of 17.1% are at a higher risk to have a recurrence than
those with lesser amounts of bone loss. Patients with bone loss beyond this threshold should be
counseled accordingly with consideration for alternative surgical procedures.
Paper 4
Classifying GBL: Severity And Attrition. Is There Enough Bone To Reconstruct The Glenoid?
John William McNeil, BA1, Andrew Bernhardson, MD2, Lance E. LeClere, MD, LT, MC, USNR1, Christopher
Dewing, MD1, Joseph Lynch, MD1, Tistia Gaston3, Matthew Provencher, MD3.
1
Naval Medical Center San Diego, San Diego, CA, USA, 2Coronado, CA, USA, 3Massachusetts General
Hospital, Boston, MA, USA.
Objectives: Glenoid bone loss (GBL) continues to be a challenge in the management of recurrent
anterior shoulder instability. Although the location of and percentage of GBL has been described, there
is little information on how much bone is left to reconstruct the glenoid. Thus, the objective of this study
is to describe a new GBL classification system that accounts for type of bone defect, amount of
attritional loss, and correlate this to age, total time of instability and number of instability events.
Methods: A total of 140 patients with recurrent anterior instability underwent an analysis of computed
tomography (CT) three-dimensional imaging to assess GBL. The glenoid bone fragment was digitally
analyzed (Osirix, Adobe) to qualitatively and quantitatively stratifyeach patient based upon attrition
into- Type I “minimal atrittional” (no attrition -33%), Type II “partial attritional” (34 - 66%), and Type III
“severe attritional” (67% - complete attrition). Additionally, demographic variables of age, total time of
instability, and number of instability events were correlated to type of bone loss.
Results: Patients had a mean age of 30.6 (range: 20 - 54) with a demonstrated mean GBL of 16.5%
(range 5.1 - 62.3). Furthermore, the mean size of the remaining glenoid bone fragment was 27.8% of the
full fragment size. Of 140 participants, 12 had attritional bone loss classified as Type I (12/140 = 8.6% of
patients), 45 as Type II (45/140 = 32.1%), and 83 as Type III (83/140 = 59.3%). The mean percent loss for
these three categories was 22.2%, 54.4%, and 88.5% respectively. Longer time of instability and more
dislocations were associated with type III bone loss, and higher attrition of bone loss.
Conclusion: This study highlights that GBL presents in a highly attritional nature and one should be
cognizant that the remaining bone fragment does not come close to reconstituting glenoid bone stock.
Patients with recurrent instability are predominantly severe attritional (Type III).
Paper 5
The Effect of Combined Glenoid and Humeral Head Defects on Glenohumeral Translation
Robert A. Arciero, MD1, Anthony Parrino, MD2, Vilmaris Diaz-Doran, MS,BMe3, Elifho Obopilwe,
MS,BMe4, Mark P. Cote, DPT,MSCTR5, Augustus D. Mazzocca, MD, MS6, Matthew Provencher, MD7.
1
Univ of Connecticut Health Center Dept of Orthopaedic Surgery, Farmington, CT, USA, 2University of
Connecticut, Farmington, CT, USA, 3USA, 4University of Connecticut Health Center, Farmingham, CT,
USA, 5University of Connecticut Health Center, Farmington, CT, USA, 6University of Connecticut Health
Center, Dept. of Orthopaedic Surgery, Farmington, CT, USA, 7Massachusetts General Hospital, Boston,
MA, USA.
Objectives: Bone loss in anterior glenohumeral instability has significant clinical implications and is
responsible for surgical failure. Previous work has focused on glenoid and humeral head defects
separately. There is no prior biomechanical work evaluating the combined effect of these lesions.
The purpose of this study is to determine the effect of the combination of humeral head and glenoid
bone loss on glenohumeral joint translation in a bipolar bone loss model with a Bankart lesion and after
Bankart repair
Our hypothesis is that when both humeral head and glenoid defects occur together, the amount of bone
loss required to compromise soft tissue Bankart repair is less than compared to when glenoid and
humeral head lesions occur in isolation.
Methods: Eight cadaveric shoulders were dissected to expose the intact capsule and glenohumeral joint.
The set-up and testing was as described by Itoi ,Sekiya and Yamamoto1,2,3.
The humeral shaft and scapula were potted and the shoulder mounted on a custom shoulder testing
device permitting 6 degrees of freedom. The test positions were 60 degrees of glenohumeral abduction
and 60 degrees of external rotation. A 50N compressive load was applied to the glenohumeral joint. A
MTS 858 Servohydraulic test system (MTS Systems, Eden Prairie, MN) was used to translate the humeral
head anteriorly 10mm at a rate of 2.0mm/sec. The peak force required to translate the humeral head
10mm was recorded. Three trials were performed in each condition, and the mean value was used for
data analysis.
All Bankart lesions were made sharply from the 2 o’clock to 6 o’clock position for a right shoulder.
Bankart repair was made with transosseous tunnels using high strength suture. A digital micrometer was
used to measure and create glenoid defects with a saw parallel to the anterior glenoid. Hill-Sachs lesions
were made from 3D models created from a clinical database of computerized tomographic images of
142 patients with shoulder instability (Figure 1). A bell-shape curve was created and the 50th percentile
lesion for size and location was selected, 1.47 cm3 .
Testing was conducted in the following sequence for each specimen:(1) intact (2)posterior capsulotomy,
(3)bankart lesion, (4)bankart repair, (5) 2mm glenoid defect with Bankart lesion, (6)bankart repair, (3)
Hill Sachs (1.47cm3) lesion, bankart lesion and 2mm defect, (7)bankart repair, (8) 4mm defect with Hill
Sachs defect and Bankart lesion,(9)bankart repair, (10)6mm glenoid defect with Hill Sachs, defect and
Bankart lesion (11)bankart repair.
Results: A linear mixed-effects approach was used to examine force needed to translate for each
condition. A statistically significant reduction in force needed to translate was observed with Bankart
repair performed with a 1.47 cm3 Hill-Sachs defect and a 2mm (p=0.01) and 4mm (p=0.04) glenoid bone
loss compared to Bankart repair with glenoid bone loss alone (Figure 2).
A 2mm glenoid defect with the Hill-Sachs defect resulted in a 25% reduction in stability. A 6mm glenoid
defect with the Hill-Sachs lesion resulted in a 50% reduction in load to translation compared to a
Bankart repair with no bone loss.
Conclusion: As little as a 2mm glenoid defect together with a Hill-Sachs lesion of the dimensions
observed in 50% of an actual clinical practice will compromise a soft tissue Bankart repair alone.
Combined lesions , even when small, may require surgical strategies that address bone defects to
optimize outcomes.
Paper 6
Glenoid Bone Loss in Posterior Shoulder Instability: Prevalence and Implications in Arthroscopic
Treatment
Adam Christopher Hines, MD1, Jay B. Cook, MD2, James S. Shaha, MD2, Kevin P. Krul, MD3, John M.
Tokish, MD4.
1
Tripler Army Medical Center, Hawaii, Tripler AMC, HI, USA, 2Tripler Army Medical Center, TAMC, HI,
USA, 3Tripler Army Medical Center, USA, 4Tripler Army Medical CenterTripler Army Medical Center,
Hickam Afb, HI, USA.
Objectives: Glenoid bone loss is a well accepted risk factor for failure after arthroscopic stabilization of
anterior glenohumeral instability. While less common than its anterior counterpart, posterior
glenohumeral instability can be a significant source of disability in a young athletic population. It has
been reported in as high as 10% of all glenohumeral instability cases. Bone loss in posterior instability,
however, has been rarely discussed, and it is unknown whether this is commonly present, or clinically
significant, in the treatment of posterior glenohumeral instability.
Methods: A retrospective review was conducted at an active Military Treatment Facility (MTF) over a
five-year period, between 1 Apr 2006 and 31 May 2011. Isolated, primary posterior instability cases
which underwent arthroscopic posterior labral repair were identified. Preoperative imaging was
available in all patients, and posterior glenoid bone loss was calculated using a standardized “perfect
circle” technique often employed in the measurement of bone loss in anterior instability. All medical
records were then reviewed to identify complications and reoperation rates from the primary repair.
Patients were divided into two groups based on percentage bone loss. Outcomes were analyzed across
all patients and within these groups.
Results: There were 47 consecutive cases of primary, isolated posterior instability cases, with 44 males
and 3 females. The average age at the time of surgery was 28.6 (range 20-47), 19 were documented to
have returned to full duty. Posterior glenoid bone loss in excess of 10% was found in 15/47 (32%) of
patients, while an additional 26% had no bone loss noted. Greater than 20% bone loss was noted in 2/47
(4.3%). The average across the cohort was 7.6% (range 0-21.5%). Bone loss was associated with younger
age. Those with >10% loss had an average age of 25.6 years compared to 30.1 years in those with <10%
bone loss (p=0.03). Those with >10% were not associated with lower return to duty, higher
complications (i.e. persistent symptoms), or increased return to the operating room. Those who
returned to full active duty did not have a significantly decreased bone loss versus those who did not
(6.5 vs 8.3%, p=0.17).
Conclusion: Posterior instability accounts for up to 10% of all glenohumeral instability. It carries a more
an insidious onset, and acute dislocations are not as commonly reported. While anterior glenoid bone
loss is known to significantly affect patient outcomes for anterior glenohumeral instability, our data
suggests posterior glenoid bone loss may not have as direct of a clinical correlation to patient outcomes.
Paper 7
Recurrence Of Cam Lesions: A Two-year Follow-up
Asheesh Gupta, MD, MPH1, John M. Redmond, MD1, Kevin F. Dunne, BS1, Nathan Finch, MA1, Christine
E. Stake, MA1, Benjamin G. Domb, MD2.
1
American Hip Institute, Westmont, IL, USA, 2Hinsdale Orthopaedics/American Hip Institute, Westmont,
IL, USA.
Objectives: Early skepticism of surgery for femoroacetabular impingement arose in part from suspicion
that the cam lesion on the femoral head-neck junction would recur after initial resection. There are
currently no studies that have looked at the recurrence of the cam lesion after femoral neck osteoplasty
for femoroacetabular impingement (FAI). While Patient Related Outcome (PRO) scores at mid-term
follow-up have shown continued success, the maintenance of a normalized alpha-angle has not been
shown radiographically. The purpose of the study was to assess the radiographic recurrence of cam
deformity at 2-year follow-up after adequate decompression during the index hip arthroscopy and
correlate with PRO scores. Our hypothesis is there will be no recurrence or regrowth of the cam
deformity at the two-year postoperative time-point following adequate cam decompression during hip
arthroscopy.
Methods: Between March 2009 and January 2011 data was prospectively collected on all patients
undergoing hip arthroscopy with femoral neck osteoplasty. Inclusion criteria consisted of all patients
during the study period with preoperative alpha angles greater than 60 degrees and postoperative alpha
angle less than 50 degrees after femoral osteoplasty. Minimum follow-up was two years with
radiographic images for review.
Results: A total of 47 patients met inclusion criteria. The mean age of our study group was 37.18 (31.7 47.43) years at the start of the study. There were 28 males (59.57%) and 19 females (40.43%). The mean
follow-up was 28.32 months. Mean preoperative alpha angle (Dunn view) was 70 degrees (60-97
degrees). At 2-week postoperative follow-up, the mean alpha angle was 42.79 degrees (32-50 degrees)
(p<.0001). The 2-year alpha angle was 42.72 degrees (32-54 degrees) which was not significantly
different compared to the 2-week alpha angle (p = 0.93). Additionally, mean preoperative femoral offset
was 3.7 mm (0-9.9 mm). Mean two-week postoperative femoral offset measurement was 7.8 mm (0.3 13.9 mm) which was significantly different (p<.0001). Two-year postoperative femoral offset
measurement was 8.0 mm (2.4-12.8 mm) which was not significantly different compared to the 2-week
femoral offset measurement (p = 0.63). All Patient Related Outcome (PRO) scores were significantly
improved at 3 months compared to preoperative scores and continued to show improvement except for
Visual Analog Scale (VAS) at 2-year follow-up.
Conclusion: There is no recurrence of cam deformity at 2-years following femoral neck osteoplasty for
FAI with improved PRO scores at the 3-month and 2-year postoperative time-points.
Paper 8
Early Clinical and Radiographic Outcomes of Combined Hip Arthroscopy and Periacetabular Osteotomy
James R. Ross, MD1, Angela Keith2, Gail Elizabeth Pashos, BS MT3, Stephen Duncan, MD4, Perry
Schoenecker, MD5, John C. Clohisy, MD6.
1
Ann Arbor, MI, USA, 2St Louis, MO, USA, 3Washingtong University School of Medicine, St. Louis, MO,
USA, 4Lexington, KY, USA, 5Washington University School of Medicine, St. Louis, MO, USA, 6Washington
University School of Medicine, St Louis, MO, USA.
Objectives: Modern treatment of hip dysplasia has focused on the correction of the structural deformity
with the periacetabular osteotomy (PAO), which addresses the deformity by redirecting the acetabulum
into an improved mechanical position. Hip arthroscopy has allowed an increased awareness of the intraarticular pathology associated with acetabular dysplasia. The combination of hip arthroscopy with
periacetabular osteotomy allows for treatment of both intra-articular and structural abnormalities
associated with hip dysplasia. However, there is limited information regarding this combined approach
for treating symptomatic acetabular dysplasia. The purpose of this study was to report the early clinical
and radiographic outcomes of combining hip arthroscopy with PAO compared to PAO alone.
Methods: We retrospectively reviewed 48 hips (46 patients) who underwent hip arthroscopy combined
with periacetabular osteotomy (HS-PAO) and compared them to a control group of 62 hips (54 patients)
who underwent PAO alone. The minimum clinical follow-up of the HS-PAO group was 12 months (mean,
31.4 months; range, 12-79 months), which was not significantly different from the control group (mean,
28.7 months; range, 12-71 months; p = 0.39). Pre-operative and post-operative standardized
radiographs were analyzed for findings of acetabular dysplasia, including lateral center-edge angle
(LCEA), acetabular inclination, anterior-center edge angle (ACEA), and Tönnis osteoarthritis grade.
Clinical outcomes were evaluated with the UCLA activity score, modified Harris hip score (mHHS), short
form-12 (SF-12), and the Western Ontario and McMaster Universities Arthritis Index (WOMAC).
Perioperative complications were graded and compared between the two groups.
Results: The mean age of the patients in the HS-PAO group was 28.0 years (range, 12 to 47 years), which
was not significantly different from the control group (p = 0.35). Forty-four hips (91.7%) were in female
patients, and 58% were right-sided. There was significant change in the mean LCEA (15.1° vs. 29.7°; p <
0.0001), acetabular inclination (15.0° vs. 2.8°; p < 0.0001), and ACEA (16.5° vs. 33.7°; p <0.0001). The
preoperative UCLA, mHHS, and SF-12 scores were not significantly different between groups. The HSPAO group had a significantly higher pre-operative total WOMAC score (40.6 vs. 30.8; p = 0.03). The HSPAO and control groups both saw significant improvement in the mHHS (23.5 vs. 21.3), SF-12 physical
(7.5 vs. 9.1) scores, which were not significantly different from each other (all p-values > 0.3). The PAOHS group, however, experienced a 0.9 improvement in the UCLA score, which was significantly different
from the control group (-0.2; p = 0.03). The PAO-HS group also experienced a significantly greater
improvement in the total WOMAC score (27.0 vs. 17.8; p = 0.03). There were no significant differences
in the complication between the groups. Within the PAO-HS group, there were 16 lateral femoral
cutaneous nerve palsies (33.3%) that resolved with outpatient management. There was 1 posterior
column fracture that was treated nonoperatively.
Conclusion: At short-term follow-up, hip arthroscopy with PAO shows equal to improved clinical
outcomes with similar radiographic changes when compared to PAO alone without an increase in major
complications. Patients that underwent hip arthroscopy combined with PAO also experienced a larger
increase in activity level when compared to PAO alone.
Paper 9
Microfracture Of The Hip: A Two-year Follow-up With A Matched-pair Control Group
Benjamin G. Domb, MD1, Asheesh Gupta, MD, MPH2, Kevin F. Dunne, BS2, Christine E. Stake, MA3, John
M. Redmond, MD2.
1
Hinsdale Orthopaedics/American Hip Institute, Westmont, IL, USA, 2American Hip Institute, Westmont,
IL, USA, 3Hinsdale Orthopaedics Associates, Westmont, IL, USA.
Objectives: Full thickness chondral defects have been suggested to portend poor prognosis in hip
arthroscopy. Although there is a small amount of data suggesting favorable outcomes with
microfracture for such cases, no comparative studies have been performed to assess outcomes of full
thickness chondral defects treated with microfracture. The purpose of this study is to compare two-year
clinical outcomes of patients treated with microfracture to a matched control group that did not have
full thickness chondral damage.
Methods: During the study period, between June 2008 and July 2011, data were collected on all patients
treated with hip arthroscopy who underwent microfracture. A matched-pair control group of patients
who did not undergo a microfracture procedure was selected in a 1:2 ratio. Matching criteria were age
within 5 years, sex, surgical procedures, and radiographic findings. All patients were assessed pre- and
post-operatively with 4 patient-reported outcome (PRO) measures: the modified Harris Hip Score
(mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip
Outcome Score-Sport Specific Subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS),
and satisfaction was measured on a scale from 0 to 10.
Results: Forty-nine hips were included in the microfracture group and 98 in the control group. There
was no significant difference in pre-operative PRO scores between the groups. For the microfracture
group, the score improvement from preoperative to 2-year follow-up was 57.5 to 75.4 for mHHS, 53.6 to
71.8 for NAHS, 59.5 to 79.1 for HOS-ADL, and 35.5 to 55.5 for HOS-SSS. For the control group, the score
improvement from preoperative to 2-year follow-up was 59.2 to 79.5 for mHHS, 54.4 to 76.2 for NAHS,
60.6 to 80.4 for HOS-ADL, and 38.6 to 64.2 for HOS-SSS. Both groups demonstrated statistically
significant postoperative improvement in all scores (p <.05). All post-operative PRO scores, and all
improvements in PRO scores, were found to be similar between the study and control groups.
Conclusion: Our study demonstrated that patients receiving microfracture during hip arthroscopy did
not show a statistically significant difference in PRO scores when compared to a matched-pair control
group at two year follow-up. Both groups demonstrated significant improvement in all PRO scores.
These results show that microfracture appears to be a viable treatment option for grade IV cartilage
damage identified at the time of hip arthroscopy. Furthermore, full thickness chondral defects may not
necessarily portend an inferior functional prognosis when treated with microfracture.
Paper 10
Trends in the Presentation, Management and Outcomes of Little League Shoulder
Benton E. Heyworth, MD1, Daniel Martin2, Dennis Kramer, MD3, Mininder S. Kocher, MD, MPH4, Donald
S. Bae, MD5.
1
Children's Hospital Boston, Division of Sports Medicine, Boston, MA, USA, 2USA, 3Boston, MA, USA,
4
Boston Children's Hospital, Boston, MA, USA, 5Brookline, MA, USA.
Objectives: With rising participation in youth sports such as baseball, proximal humeral epiphysiolysis
(“Little league Shoulder,” LLS), is being seen with increasing frequency. However, there remains a
paucity of literature regarding the causes or outcomes of LLS. This study’s purpose was to analyze the
demographics, symptoms, diagnosis, and treatment of LLS, with an emphasis on identifying underlying
risk factors for development and recurrence of LLS. Methods: A departmental database at a single
pediatric referral center was queried to identify cases of LLS between 1999 and 2013, which were
reviewed to analyze age, sex, physical examination and radiologic findings, treatment details, and rates
of recurrence. Results: 95 patients (93 males; mean age 13.1 years, range 8-17 years) were diagnosed
with LLS, with volumes increasing over the study period (Figure 1). In addition to the primary complaint
of shoulder pain with overhead athletics seen in all patients, 13% reported elbow pain, 10% reported
shoulder fatigue or weakness, and 8% reported mechanical symptoms. While the vast majority of
patients (97%) were baseball players (86% pitchers, 8% catchers, 7% other positions), 3% were tennis
players. On physical exam, 30% were reported to have glenohumeral internal rotation deficit (GIRD).
Treatment recommendations included rest in 98% of cases, physical therapy in 79% (100% of patients
with GIRD), and position change upon return to play in 25%. Average time to resolution of symptoms
was 2.6 months, while average time to return to competition was 4.2 months. Recurrent symptoms
were reported in 7.4% in the overall population at a mean of 8 months following symptom resolution.
The odds ratio of recurrence between the group with diagnosed GIRD (14.3%) and those without GIRD
(4.5%) was approximately 3:1. Conclusion: Little league shoulder is being diagnosed with increasing
frequency. While most common in male baseball pitchers, the condition can occur in females, youth
catchers, other baseball positions players, and tennis players. Concomitant elbow pain may be seen in
up to 13%. After rest and physical therapy, recurrent symptoms can occur, generally 6-12 months after
return to sports. Almost one-third of LLS patients with had GIRD, and this group had three times higher
probability of recurrence compared to those without GIRD.
Paper 11
No Side-to-Side Difference in Humeral Retroversion in Baseball Players with Shoulder Disorders Using a
True Three-Dimensional Measurement Technique: Validation and Comparison
Masayuki Saka, MS, PT1, Hiroki Yamauchi, PhD, PT2, Toru Yoshioka, MD3, Hidetoshi Hamada4, Kazuyoshi
Gamada, PhD, PT1.
1
Hiroshima International University, Higashihiroshima-shi, Japan, 2Kameda Medical Center, Kamogawashi, Japan, 3Saka Midori-i Hospital, Hiroshima, Japan, 4Osaka University, Suita-shi, Japan.
Objectives: Increased humeral retroversion in the throwing shoulder is considered to exist in many
baseball players and is often considered as a cause of internal rotation deficit. However, retroversion
angles using two-dimensional (2D) methods utilized in previous studies did not correlated with a true
three-dimensional measurement technique (3D retroversion) in our study. The purposes of this study
were to determine 1) if significant side-to-side differences in retroversion exist, and 2) the relationships
between retroversion and glenohumeral range of motion (ROM) in baseball players with a shoulder
disorder. Methods: Fourteen male baseball players (age: 21.4 ± 1.5 years; mean ± standard deviation)
with a throwing shoulder disorder were enrolled, including 11 in the collegiate and 3 in the adult levels,
comprising 5 pitchers and 9 position players. The mean age when the athletes had started playing
baseball was 9.1 years (range, 6 to 10 years) and the mean playing experience was 12.1 years (range, 9
to 17 years). Patients with history of fracture or surgery in the shoulder or elbow were excluded.
Outcome measurements included a 3D retroversion angle and glenohumeral ROM in bilateral shoulders.
Patients underwent CT scan at 1.0 mm slice pitch for the bilateral humerus and geometric bone models
were created. The 3D retroversion angle was defined as an angle between the projected humeral neck
line (connecting the spherical center of the humeral head and the cylindrical axis of the humeral shaft)
onto the horizontal plane and the flexion-extension axis of the distal humerus obtained by a cylinderfitting method for the capitulum and trochlea (intratester reliability: ICC 0.98, standard error of
measurement: 1.7º). The CT slices for the proximal and distal humerus were used to measure a 2D-CT
retroversion angle using a reported convention. An indirect measurement of retroversion was
performed using a bicipital grove-ulna angle by an ultrasound images dusing a reported convention.
Glenohumeral ROM measurements included internal rotation (IR) and horizontal adduction (HAd) in the
supine position with the scapula manually stabilized on the treatment table. Independent t tests were
used to determine if significant side-to-side differences exist in retroversion and glenohumeral ROM.
Pearson correlation coefficients were used to determine the association between retroversion and
glenohumeral ROM in the throwing shoulders. Statistical analysis was performed with PASW Statistics
18 (SPSS, Inc, Chicago, IL). An alpha level of 0.05 was set a priori for statistical significance. Results: No
significant difference was found in 3D retroversion between the throwing and non-throwing shoulders
(P = .182). The throwing shoulders demonstrated decreased IR and HAd compared with the nonthrowing shoulders (P < .001 and P = .002, respectively). There were no significant correlations between
retroversion and glenohumeral ROM for the throwing shoulders (Table). The 2D-CT retroversion and
bicipital grove-ulna angles were greater in the throwing shoulder (P = .007 and .009, respectively).
Conclusion: Contradicted to the previous studies, no side-to-side difference in retroversion and no
association between retroversion and glenohumeral ROM were observed in the baseball players with a
shoulder disorder. We believe that deficit in shoulder IR and HAd may be attributed to soft tissue
tightness. The results of the previous studies involving humeral retroversion should be reassessed.
Pearson correlation coefficients between humeral retroversion and ROM
Internal rotation
Horizontal adduction
3D retroversion
R = -.067, P = .820
R = .046, P = .876
2D-DT retroversion
R = -.388, P = .171
R = -.247, P = .394
Bicipital grove-ulna angle
R = -.205, P = .481
R = -.157, P = .591
Paper 12
Restoration of Neuromuscular Control During The Pitch After Operative Treatment Of Slap Tears
Peter Nissen Chalmers, MD1, Johannes Cip, MD1, Robert Trombley1, Brett Monson, BA2, Markus
Wimmer, PhD1, Brian J. Cole, MD, MBA3, Nikhil N. Verma, MD4, Anthony A. Romeo, MD5.
1
Rush University Medical Center, Chicago, IL, USA, 2Rush University Medical Center, USA, 3Midwest
Orthopaedics at Rush, Chicago, IL, USA, 4Rush Presbyterian St. Luke's Medical Center, Chicago, IL, USA,
5
Midwest Orthopaedics, Chicago, IL, USA.
Objectives: Superior labral anterior-posterior (SLAP) tears are a common cause of shoulder pain and
dysfunction in overhead throwers. Treatment outcomes remain unpredictable with a large percentage
of atheletes unable to return to sport. Persistent pain from the LHB (long head biceps) has been
postulated as etiology of failure following repair. Previous authors have hypothesized that maximal
stress is placed upon the biceps anchor during the cocking phase and that SLAP tears likely occur during
this phase. We hypothesized that operative treatment of SLAP tears with repair or tenodesis would
result in persistent alterations in neuromuscular control of the biceps during the overhand pitch postoperatively. Methods: We evaluated the activity of the biceps muscle in the overhand pitching motion
and correlate this activity with throwing phase in healthy collegiate and semi-professional pitchers,
collegiate pitchers status-post SLAP repair, and collegiate pitchers status-post biceps tenodesis. Patients
were at least one year post-operative and had returned to pitching with a painless shoulder. Subjects
pitched from a regulation-sized mound while surface electrodes collected electromyographic (sEMG)
signals at 1500 Hz from the long- and short-heads of the biceps (LHBM and SHBM respectively), the
deltoid, the infraspinatus, and the latissimus dorsi. Motion analysis data was captured at 120 Hz with a
14-camera three-dimensional markerless motion analysis system. At least five pitches were performed
by each subject. sEMG data was then normalized to maximal manual muscle testing and then divided
into previously described pitching phases (wind-up, stride, cocking, acceleration, deceleration, followthrough). Results: Eighteen pitchers participated: 7 normals, 6 status-post SLAP repair, and 5 statuspost tenodesis. While no significant differences were observed in mean LHBM, SHBM, deltoid,
infraspinatus, or latissimus activity between normals, pitchers status-post SLAP repair, and pitchers
status-post tenodesis during each phase, loss of the normal activation contours was seen for both
pitchers status-post SLAP repair and those status-post tenodesis, suggesting continued reflex inhibition.
As confirmation, significantly less overactivity (>100% activity) was seen in post-operative deltoids than
normal deltoids (p=0.025). Conclusion: Simultaneous EMG and motion analysis of pitchers status-post
operative treatment of SLAP tears suggests that while tenodesis and repair may restore physiologic
muscular activation amplitude, persistent changes in activation contours persist for both tenodesis and
repair. Both treatments may have biomechanical and neuromuscular consequences, even in pitchers
with a full painless return to play. Further study is needed to determine potential differences between
patients with persistent pain following surgery, as well as differing treatment modalities (tenotomy,
tenodesis, repair).
Figure Legend
Figure 1. Mean (±standard deviation) surface electromyographic activity in (A) the long-head of biceps
muscle (LHBM), (B) the short-head of biceps muscle (SHBM), (C) the deltoid muscle, and (D) the
infraspinatus muscle as compared to percent of the pitch, with 0% being front foot contact and 100%
being ball release (see images below.) As can be seen, operative intervention permanently alters the
activation contours of the LHBM.
Paper 13
The Effects of Ulnar Collateral Reconstruction on Major League Pitching Performance
Robert A. Keller, MD1, Matt Steffes, BA1, David Zhuo, BA1, Michael J. Bey, PhD1, Vasilios Moutzouros,
MD2.
1
Henry Ford Hospital, Detroit, MI, USA, 2Henry Ford Medical Group, Novi, MI, USA.
Objectives: A tremendous stress is placed on the elbow while pitching a baseball. Due to these stresses,
Major League Baseball (MLB) pitchers are at increased risk for Ulnar Collateral Ligament (UCL) injuries.
Previous studies have been limited in sample size, but have shown most players return to previous
uninjured statistical levels after undergoing UCL reconstruction. We sought the largest cohort of MLB
pitchers who have undergone UCL reconstruction and hypothesized that MLB pitchers do not return to
their pre-injury statistical level after undergoing UCL reconstruction. Methods: The statistics for 168
major league pitchers, who threw at least one season at the Major League level and subsequently
underwent UCL reconstruction, were reviewed. Statistical data including earned run average (ERA),
walks and hits per innings pitched (WHIP), win percentage, innings pitched, and salary were compared
for the 3 years before and 3 years after undergoing UCL reconstruction. This data was compared to 178
age matched controlled MLB pitchers. All data was analyzed to determine the effects of UCL
injury/reconstruction on pitching performance. Risk factors for reconstruction were analyzed using a
multivariable generalized estimating equation (GEE) model Results: Of the pitchers undergoing UCL
reconstruction surgery 87% returned to the Major League Level. Of the pitchers that returned, they had
a statistically significant decline in their ERA (P=0.001), WHIP (P=0.011), Innings Pitched (0.026),
compared to pre-reconstruction performance. Reconstructed pitchers had a statistically significant
decline in their pitching statistical performance in the season before their surgery (ERA p=0.014, WHIP
p=0.036, Innings pitched p<0.001, Win Percentage p=0.004). Approximately 60% of pitchers requiring
UCL reconstruction had surgery with in the first 5 years of being in the Major Leagues. Compared to age
matched controls, the reconstructed pitchers had statistically more major league experience at the
same age suggesting that arm stress from earlier Major League experience contributed to injury. This
was validated by a multivariable GEE model that examined risk factors showing an increase in MLB
experience being a risk factor for requiring surgery (p<0.001). Conclusion: This is the largest cohort of
MLB pitchers, to date, that have undergone UCL reconstruction. Its results suggest that UCL
reconstructive surgery does a tremendous job in allowing players to return to their same level of sport.
This study is the first to describe a decline in pitching performance after undergoing reconstruction. It
also found that there is a statistically significant decline in pitching performance the year before
reconstructive surgery and this decline was found to be a risk factor for requiring surgery. We also found
that there is an increased risk of players requiring surgery if they enter the Major Leagues at a younger
age. Figure 1
Figure 2
Figure 3
Paper 14
Osteochondral Autograft Plug Transfer for Treatment of Osteochondritis Dissecans of the Capitellum in
Adolescent Athletes
Matthew Lawrence Lyons, MD1, Joseph M. Hart, PhD, ATC2, Aaron M. Freilich, MD3, Angelo R. Dacus,
MD3, David R. Diduch, MD4, Abhinav Bobby Chhabra, MD5.
1
University of Virginia Program, Charlottesville, VA, USA, 2University of Virginia, Charlottesville, VA, USA,
3
University of Virginia Program, USA, 4UVA-Orthopaedics, Charlottesville, VA, USA, 5University of
VirginiaDept. of Orthopaedics, Charlottesville, VA, USA.
Objectives: Osteochondritis dissecans (OCD) of the capitellum is a condition most commonly seen in
adolescents involved in repetitive over-head sports and can profoundly affect both ability to return to
play and long-term elbow function. Large, unstable defects, defined as those greater than 1 cm in size,
have unproven or poor long term outcomes with surgical interventions such as fragment excision,
microfracture or attempted fixation. Treatment of similarly sized OCD lesions in the knee with
osteochondral autograft plug transfer has proven both effective and safe. While interest has developed
for expansion of its use to the elbow, it has yet to be adequately studied. The goal of this study is to
evaluate clinical outcomes and return to play in adolescent athletes treated with osteochondral
autograft plug transfer from the knee for large, unstable OCD defects of the capitellum. Methods:
Inclusion Criteria: 1) Inability to participate in competitive sports 2) OCD defect of the capitellum that
was either unstable on MRI or in patients who had failed 6 months of conservative treatment 3) Defect
measuring at least 1 cm in area on diagnostic arthroscopy 4)Reconstruction of capitellar OCD with
osteochondral autograft plug transfer 5) Minimum of 6 months post-operative follow-up. Data
collection included chart review, determination of return to play, elbow range of motion, and DASH
outcomes. The surgical technique was the same for all patients. It included initial diagnostic elbow
arthroscopy, including loose body removal, followed by posterolateral approach to the elbow with
lateral collateral ligament takedown from lateral epicondyle and eventual suture anchor repair,
preparation of the capitellar osteochondral defect and appropriate plug transfer from the lateral
trochlear ridge of the ipsilateral knee through a lateral approach. All patients followed the same post
operative protocol, consisting of splint immobilization for 2 weeks, conversion to a hinged elbow brace
for 4 weeks with progressive range of motion, and resumption of throwing and strengthening exercises
at 3 months. Results: A cohort of 11 patients with a minimum of 6 months post procedure was
identified. All patients were available for evaluation at an average 22.7 months follow up (range 6-49
months). Average age at the time of surgery was 14.5 years (range 13-17 years). The group consisted of
10 males and 1 female, all of which were involved in competitive athletics. Average return to play was
4.4 months (range 3-7 months). All athletes returned to at least their same level of play as preoperatively. 3 have received Division 1 college scholarships (gymnastics, lacrosse and baseball pitcher).
Of the 5 pitchers, 4 returned to pitching. The average DASH score was 1.36 (95% CI 0.59-2.12) and the
average Sport Specific DASH score was 1.7 (95% CI -1.78-5.17). There were statistically significant
improvements in elbow flexion from 125.45 degrees to 141.36 degrees (p=0.009) and extension from
20.45 degrees to 4.55 degrees (p=0.006). There was one adverse event. This consisted of a superficial
wound infection, which resolved with surgical debridement and antibiotics and did not adversely affect
eventual return to play. There were no complications or donor site morbidity related to graft harvest.
Conclusion: Treatment of large, unstable osteochondritis dissecans lesions of the capitellum in
adolescent athletes allows reliable return to high level of sports, is safe and has excellent long-term
clinical outcomes.
Paper 15
Correlation of Meniscal and Chondral Injuries to Chronicity of ACL Tears in Children and Adolescents
Allen F. Anderson, MD.
Tennessee Orthopaedic Alliance, Nashville, TN, USA.
Objectives: The increase in ACL injuries among children and adolescents has intensified debate about
the timing of ACL reconstruction in this age group. Historically, the prevailing opinion was that nonoperative management until skeletal maturity was the treatment of choice. There is now some evidence
to suggest that early reconstruction is preferable because increased time from injury to surgery may be
associated with a higher rate of meniscal and articular cartilage injury. The purpose of this observational
cohort study was to assess the risk of meniscal and chondral injury with delay of ACL reconstruction. Our
hypotheses were that increased time from injury to surgery, recurrent giving-way, and return to sports
participation prior to reconstruction was associated with a higher rate of meniscal and articular cartilage
injuries. Methods: After obtaining IRB approval, 135 consecutive patients, ages 8-16, (mean 13.8) with
ACL tears were evaluated. The time from injury to surgery was divided into three periods: acute, less
than six weeks; subacute, six weeks to three months; and chronic, greater than three months.
The type and grade of lateral and medial meniscus tears was documented according to the ISAKOS
Meniscal Documentation Criteria and chondral injury location and grade was documented according to
the ICRS Criteria. Results: There were 62 patients who were treated acutely, 37 subacute, and 36
chronic. One hundred twelve meniscal tears, 70 lateral and 42 medial, were found in this cohort. Eighty
percent of the patients, ages 8 - 12 had a meniscal tear and 84% of patients ages 13 - 16 had a meniscal
tear. Multi-variant logistic regression revealed the risk factors for lateral meniscus tears were younger
age (P = .007) and increased time to surgery (P = .008). The odds ratio of lateral meniscus tears for
patients who had a single episode of instability was 3.1. For time to surgery, the odds ratio was 1 for
acute reconstruction, 2.6 for subacute, and 2.59 for reconstruction of chronic injuries. The odds ratio for
increased grade of tear was 3.3 for a giving-way episode and 6.5 for increased time to surgery.
For medial meniscus tears, the risk factors were: older age (P = .001), increasing time to surgery (P =
.007), return to sports (P = .044), and instability episodes (P = .001). Risk factors for increasing grade of
medial meniscus tears were: time to surgery, return to sports, and any instability episode (P = < .001 for
all). The odds ratio for increasing frequency of medial meniscus tears was 4.7 for an instability episode,
8.08 for having played sports prior to reconstruction, and 4.49 for increased time to surgery. The odds
ratio for having increased severity of meniscal tears was: any instability episode 6.61; having played
sports prior to reconstruction 15.25, and time to surgery 4.28. There were 17 chondral injuries in this
cohort. The risk factors for chondral injury were: increased time to surgery (P = .005) and any instability
episode (P = .001). For increased grade of chondral injury, the risk factors were: time to surgery (P = less
than .001) and any instability episode (P = .003). Conclusion: These data provide evidence that initial
nonoperative treatment of ACL tears in this age group carries a high risk of additional meniscal and
chondral injury, which may result in long-term knee impairment.
Paper 16
Return to Play and Clinical Outcomes after All-Inside, Anterior Cruciate Ligament Reconstruction in
Skeletally Immature Athletes
Danyal H. Nawabi, MD1, Moira McCarthy, MD2, Jessica Graziano3, Polly deMille4, Theresa Chiaia, PT1,
Daniel W. Green, MD1, Frank A. Cordasco, MD, MS1.
1
Hospital for Special Surgery, New York, NY, USA, 2Hospital for Special Surgery/Cornell Medical Center
Program, New York, NY, USA, 3Hospital for Special Surgery, USA, 4Hospital for Special SurgeryWomen's
Sports Medicine Center, New York, NY, USA.
Objectives: Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are on the rise
because of increased participation and level of competition within sports, sports specialization and
societal factors. Conservative treatment of these injuries has a poor natural history due to recurrent
instability with meniscal and articular cartilage damage. The purpose of this study was to evaluate the
results of an all-inside, physeal-sparing ACL reconstruction in skeletally immature athletes, with a focus
on return to play. Methods: Forty-two skeletally immature athletes (mean chronologic age 12.7 yrs,
[range 10-15]) were prospectively evaluated following an all-inside ACL reconstruction utilizing
hamstring autograft. The mean bone age (Greulich and Pyle method) was 13.5 years. There were 10
females and 32 males. Twenty-six patients had an all-epiphyseal (AE) ACL reconstruction and 16 patients
had a partial transphyseal (PTP) ACL reconstruction, which spared the femoral physis but crossed the
tibial physis. The PTP option was reserved for patients with minimal proximal tibial growth remaining.
Fourteen athletes were involved in recreational sport and 28 participated competitively. Lacrosse (36%)
and Soccer (32%) were the two most common sports associated with ACL injury in our cohort. All
athletes were evaluated with a physical examination, KT-1000 arthrometry, isokinetic testing, validated
outcome scores including the International Knee Documentation Committee score (IKDC), the Lysholm
score and Marx activity rating scale. Standing radiographs and SPGR MRI analysis was performed at 6, 12
and 24 months post-op depending upon skeletal age. A ‘Return to Play’ performance analysis was also
performed where symmetry, alignment control and the ability to decelerate were assessed during
progressively challenging movement patterns encountered in sport. Results: At a mean follow-up of
16.7 months (range 12-24), the mean IKDC score was 92.9 ± 7.2, the mean Lysholm score was 97.7 ± 4.6
and the mean Marx activity rating scale score was 12.4 ± 3.5. Lachman and pivot shift testing was
negative in all patients. The mean side-to-side difference in the KT-1000 arthrometry was 0.9 ± 0.7 mm,
with the maximum difference in the cohort being 2 mm. Isokinetic testing showed a mean deficit of
4.1% in extension torque and 9.2% in flexion torque at a repetition speed of 180 degrees per second. No
angular deformities, significant leg length discrepancy or physeal disturbances were observed on
postoperative radiographs or MRI. One athlete had a traumatic graft disruption at 12 months and
underwent revision ACL reconstruction and one athlete sustained a contralateral ACL rupture at 11
months. The mean time for return to unrestricted competitive activity after successful completion of the
‘Return to Play’ analysis was 12.5 +/- 1.3 months from the time of surgery. Conclusion: An all-inside,
physeal-sparing ACL reconstruction technique using hamstring autograft demonstrates excellent
subjective and objective clinical outcomes in skeletally immature athletes without growth disturbance.
‘Return to Play’ assessment is an important tool to guide the young athlete and her or his family
regarding resumption of competitive sports. In our experience, athletes were on average released for
full return to sport after 1 year from ACL reconstruction.
Paper 17
Deficits in Hip-Ankle Coordination in Female Athletes who Suffer a Second Anterior Cruciate Ligament
(ACL) Injury after ACL Reconstruction and Return to Sport
Mark V. Paterno, PhD, PT, ATC1, Adam W. Kiefer, PhD2, Scott H. Bonnette, BS3, Michael A. Riley, PhD3,
Laura Schmitt, PhD, PT4, Kevin R. Ford, PhD5, Gregory D. Myer, PhD, CSCS6, Kevin Shockley, PhD7,
Timothy E. Hewett, PhD, FACSM8.
1
Sports Medicine Biodynamics Ctr, Cincinnati, OH, USA, 2Cincinnati Children's Hospital Medical Center,
Cincinnati, OH, USA, 3University of Cincinnati, USA, 4Cincinnati, OH, USA, 5High Point University, High
Point, NC, USA, 6Cincinnati Children's Hospital Medical Ctr, Cincinnati, OH, USA, 7University of Cincinnati,
Cincinnati, OH, USA, 8The Ohio State U. Sports Health & Performance Inst., Columbus, OH, USA.
Objectives: Athletes who return to sport after ACL reconstruction (ACLR) are at increased risk of future
ACL injury. Proprioceptive deficits at the knee, known to be present at thetime of ACL injury, may persist
for up to 2 years after ACLR. Coordinated movements of the hip and ankle are critical in the absence of
normal knee proprioception during dynamic athletic movements. Failure to optimally position the knee
may make the passive structures susceptible to pathologic stresses that increase the risk of subsequent
ligament or graft failure. The purpose of this work was to prospectively determine if altered lower
extremity coordination patterns exist in female athletes, who go on to suffer a second ACL injury to
either limb, after ACLR and return to sport (RTS). The study tested the hypothesis that female athletes
who sustained a second ACL injury would demonstrate altered lower extremity coordination patterns
indicative of persistent neuromuscular deficits at the time of return to sport compared to female
athletes who would not subsequently sustain a second ACL injury. Methods: Sixty-one female athletes,
who sustained an ACL injury, underwent ACLR, completed rehabilitation and were medically cleared for
RTS were enrolled in this study. Hip-ankle coordination was assessed on all athletes prior to RTS as they
performed a dynamic postural coordination task. The task required participants to stand on a single leg
and track the anterior-posterior (AP) movement of an oscillating 3-D square target displayed on a
computer monitor. Participants tracked the target with the head so as to maintain a constant perceived
distance between their head and the target by matching the amplitude and frequency of the target
oscillations. Fourteen patients sustained a second ACL injury within 12 months of RTS (ACLR2). Fourteen
matched subjects after ACLR, who did not suffer a second ACL injury (ACLR1), were selected for
comparative analysis. Cross-recurrence quantification analysis (Figure 1) was used to characterize hipankle coordination patterns through the variable cross-maxline (CML). A group (ACLR1 vs. ACLR2) X
target speed (slow vs. fast) X leg (affected vs. unaffected) mixed-model analysis of variance was used to
identify coordination differences. Results: A significant main effect of group was observed (p = 0.02),
and indicated that the ACLR1 group exhibited more stable hip-ankle coordination overall (M = 166.2 ±
18.9) compared to the ACLR2 group (M = 108.4 ± 10.1), irrespective of target speed or tested leg. A leg x
group interaction was also observed (p = .04). A Mann-Whitney test was employed due to unequal
variances between groups, and indicated that the affected leg of the ACLR1 group exhibited more stable
coordination (M = 187.1 ± 23.3)compared to the affected leg of the ACLR2 group (M = 110.13 ± 9.8), p =
0.03. Conclusion: Hip-ankle coordination was altered in female athletes who subsequently sustain a
second ACL injury after initial ACLR and RTS. Failure to appropriately coordinate lower extremity
movement between the adjoining proximal and distal hip and ankle in the absence of normal knee
proprioception, may place the knee in a high-risk position and increase the likelihood of a second ACL
injury in this population.
Paper 18
Rates and Determinants of Return to Play after Anterior Cruciate Ligament Reconstruction in Division I
College Women Soccer Athletes: A Study of the Southeastern Conference
Mark Lembach, MD1, Adam V. Metzler, MD1, Jennifer Sebert Howard, MS, ATC1, Darren L. Johnson,
MD2.
1
University of Kentucky, Lexington, KY, USA, 2Univ of Kentucky Sports Medicine, Lexington, KY, USA.
Objectives: We sought to determine the overall return to play (RTP) rate of female collegiate soccer
athletes after anterior cruciate ligament (ACL) reconstruction in the Southeastern Conference (SEC).
Additionally, we examined particular athlete related and surgical technique related variables as they
correlated to RTP. We hypothesized that RTP after ACL reconstruction would be higher than previously
published results and that it would be independent of graft type utilization or surgical techniques
employed. Methods: Head team physicians and athletic training staff of the 14 institutions of the SEC
were contacted to request participation in the study. All institutions were sent information regarding
the nature of the study, a standardized spreadsheet with standardized response choices for the purpose
of data collection from the participating institutions, and instructions regarding athlete inclusion criteria.
The spreadsheet provided queried certain athlete and technical surgical related variables for ACL
reconstructions performed at the participating institutions over the previous 8 years (2005-2013).
Results: All 14 of the SEC institutions chose to participate and provided data. 79 reconstructions were
reported with RTP data available for 78 women soccer athletes. Overall RTP rate was 84.6%. There was
statistical significance in RTP rates favoring athletes in earlier years of eligibility versus later years
(p<0.05). Athletes in eligibility years 4 and 5 combined had a RTP rate of 40%. Scholarship status likewise
showed statistical significance (p<0.001) favoring RTP rate for scholarship athletes (91%) vs. nonscholarship athletes (45.5%). Athlete position (p=0.242) and depth chart status (p=0.110) showed no
significant effect on RTP. In examining surgery specific variables; RTP rate for autograft (87.9%), allograft
(75%), and combined graft (50%) demonstrated no difference (p=0.218). RTP rates were similar for the
two most commonly used grafts: patellar tendon autograft and hamstring autograft (p=0.186). Femoral
tunnel drilling technique showed no effect (p=0.725) on RTP rate for transtibial, accessory medial portal,
or two incision techniques. When comparing multiple graft fixation constructs on both the femoral and
tibial side, no difference was observed as it relates to RTP. RTP in isolated ACL reconstruction (77.3%)
versus ACL reconstruction with concomitant procedures (88.9%) showed no difference. For players
undergoing revision ACL reconstruction versus primary, RTP rate was 77.3% and 87.3% respectively,
without significant difference (p=0.499). Conclusion: Of Division I collegiate women soccer athletes
undergoing ACL reconstruction, overall RTP rate approaches 85%. Undergoing ACL reconstruction earlier
in the college career before the 4th year of eligibility as well as the presence of a scholarship had a
positive effect on RTP. Surgical factors including graft type, fixation methods, tunnel placement
technique, concomitant knee surgery, and revision status played showed no significant effect on RTP
rate.
Paper 19
Extraaarticular Reconstruction In ACL Deficient Knee: 25 Years Later.
Andrea Ferretti, MD1, raffaele iorio, MD1, luca basiglini1, Antonio Ponzo, MD1, Ludovico Caperna, MD1,
Edoardo Monaco2, Fabio Conteduca, MD1.
1
Sant’Andrea Hospital, Rome, Italy, 2Rome, Italy.
Objectives: Extraarticular Reconstructions (ERs), isolated or in association with Intraarticular ACL
Reconstructions (IRs) were popular in the eighties. However they were almost completely given up as a
result of a consensus conference organized by AOSSM in 1989 in Snowmass (Co) where the experts
concluded that ERs, even if biomechanically justified, were unable to provide any improvement in
clinical results with greater morbidity, higher risk of complications and increased rate of degenerative
osteoarthritis (DOA). However, as since then the surgical techniques and postoperative rehabilitation
have radically changed, it could be helpful to reconsider ERs and their long term effect on knee stability
and on DOA. Methods: One hundred consecutive patients who underwent an anatomic single bundle
ACL reconstruction with hamstrings were re-evaluated at a minimum follow up of eleven years.
In 23 cases (group B), due to the presence of a Pivot Shift test graded as +++ or in cases of athletes
involved in high risk sports, a lateral tenodesis (Coker/Arnold) was associated. The other 77 patients,
where an isolated IR was performed with the same technique (group A), served as control. All patients
followed the same, standard postoperative rehabilitation program. At follow up Lysholm, IKDC and
Tegner activity scores were used. A side to side maximum manual (S/S MM) KT1000 measurement was
done. Comparative weight bearing antero-posterior and lateral radiograms were performed and
analyzed according to Fairbank, Kellgren and IKDC classification. Tibio-femoral and patella-femoral joints
were analyzed separately. Statistical analysis was performed using Student t-test, Pearson chi-square
test with SPPS 9.0 software. Results: Group A and B were homogeneous for sex and age.
At final follow up seven patients were lost. Subjectively Lysholm score, IKDC and Tegner Activity score
improved significantly in both groups with no significant difference. Objectively the number of patient
categorized as A and B according to the IKDC was significantly higher in group B than in group A (
P=0.05). Considering as a failure a S/S M/M difference > 5mm or a Pivot Shift test graded as ++ or +++ or
a recurrence of any giving way episode, we found 7 cases in group A and no cases in group B (P=0.006).
Radiogical evaluation showed no statistically significant difference between the two groups in all scales
in both femoro-tibial and patello-femoral joints. Conclusion: The main limitation of the study is that the
two groups were not homogeneous in term of preoperative conditions. However as highest grades of
activity level and Pivot Shift correlate with an increased risk of DOA, this limitation appears to
strengthen the value of the study. Adding a lateral tenodesis to an ACL IR with hamstrings, followed by
a standard rehabilitative protocol, seems not to increase the risk of development of DOA, improving
rotatory knee stability and reducing risk of recurrence. The meeting in Snowmass has been a milestone
event in the evaluation of role of ERs in ACL deficent knee, giving an outstanding contribution to their
definition, their biomechanical effect and their role in rotatory instability. However, on the basis of the
results of this study, we could speculate that the conclusions of the meeting were somewhat misleading
or at least misinterpreted, as they were based on surgical techniques and rehabilitation procedures no
more in use in the modern ACL surgery.
Paper 20
MRI Evaluation of the Anterolateral Ligament of the Knee In The Setting of ACL Rupture
Ross Wodicka1, Jean Jose, DO2, Michael G. Baraga, MD3, Lee D. Kaplan, MD1, Bryson P. Lesniak, MD4.
1
University of Miami, Miami, FL, USA, 2University of Miami Miller School of Medicine, Miami, FL, USA,
3
UHealth Sports Medicine, Miami, FL, USA, 4UHealth Sports Med, Miami, FL, USA.
Objectives: The anterolateral ligament (ALL) of the knee was recently described in the literature. It was
hypothesized to help control internal tibial rotation and affect the pivot shift phenomenon. The purpose
of this study was to identify the normal appearance of the ALL on magnetic resonance imaging (MRI)
and to examine its role in stability of the knee. Methods: A retrospective chart review was performed
and 50 patients from a single surgeon’s practice with full thickness anterior cruciate ligament tears over
a 2 year period were selected at random. Operative reports detailing the pivot shift examination under
anesthesia were documented. Preoperative MRIs were reviewed by a fellowship trained
musculoskeletal radiologist. Axial, sagittal, and coronal cuts were used to identify the presence and
degree of injury to the ALL (Grade 0-3). The popliteus tendon, lateral collateral ligament, biceps femoris
tendon, and iliotibial band were analyzed and graded 0-3. The presence or absence of a Segond fracture
was noted. Results: The ALL was identified in 100% of the anterior cruciate ligament deficient knees
evaluated. In 27 knees, there was no MRI evidence of ALL injury (Grade 0). A grade 1 injury was noted in
18 knees. A grade 2 injury was noted in 2 knees. A grade 3 injury was observed in only 1 knee. This was
the same knee in which the single Segond fracture among the group was noted. Eighty four percent
(42/50) of knees showed a positive pivot shift on examination under anesthesia. A positive pivot shift
was noted in 37 patients who had no (Grade 0) or mild (Grade 1) ALL injury. Thirteen MRIs showed
evidence of injury to the posterolateral corner structures, with 92% (12/13) consisting of mild (Grade 1)
injuries. Conclusion: The anterolateral ligament of the knee is readily identifiable on MRI. Its structural
integrity was maintained in the overwhelming majority of knees with a complete tear of the ACL, both
with and without the presence of rotatory instability on examination. We found no correlation between
degree of injury to the ALL and degree of instability. The only complete rupture of the ligament was in
the setting of complete rupture of the IT band, which supports its identity as an extension of the IT
band. Therefore, we propose that the ALL in itself plays a minimal if any role in stability of the knee.
Further biomechanical studies are needed to confirm this.
Paper 21
Autograft vs Allograft ACL Reconstructions: A Prospective, Randomized Clinical Study with Minimum 10
Year Follow-up
Craig R. Bottoni, MD1, Eric L. Smith, MD2, Sarah G. Raybin2, James S. Shaha, MD3, Steven H. Shaha, PhD,
DBA4, John M. Tokish, MD5, Douglas J. Rowles, MD6.
1
Tripler Army Medical Center, Honolulu, HI, USA, 2USA, 3Tripler Army Medical Center, TAMC, HI, USA,
4
University of Utah, Salt Lake City, UT, USA, 5Tripler Army Medical CenterTripler Army Medical Center,
Hickam Afb, HI, USA, 6Orthopedic Surgeons Services, Tripler Amc, HI, USA.
Objectives: To evaluate the long-term results of primary Anterior Cruciate Ligament (ACL)
reconstructions using either allograft or autograft. Methods: From June 2002 to August 2003, patients
with a symptomatic ACL deficient knee were randomized to either hamstring autograft (AUTO) or tibialis
posterior allograft (ALLO). All allografts were from a single tissue bank, aseptically processed and fresh
frozen without terminal irradiation. Graft fixation was identical in all knees. All patients followed the
same post-operative rehabilitation protocol, blinded to the therapists. Preoperative and postoperative
assessments were performed via examination and/or telephonic and internet-based questionnaire to
ascertain functional and subjective status using established knee metrics. The primary outcome
measures were graft integrity, subjective knee stability and functional status. Results: There were 99
patients (100 knees); 87 were male and 95 active duty military. Both groups were similar in
demographics and preoperative activity level. The mean and median age of both groups was identical
at 29 and 26, respectively. Concomitant meniscal and chondral pathology, microfracture and meniscal
repairs performed at the time of reconstruction were similar in both groups. At a minimum 10 years
(range: 120-134 mos) from surgery, 96 pts (97 knees) were contacted (2 patients were deceased and 1
was unable to be located). There were 4 (8.3%) autograft and 13 (26.5%) allograft failures which
required revision reconstruction. In the remaining patients whose graft was intact, there was no
difference in the mean SANE, Tegner, or IKDC scores. Conclusion: At a minimum of 10 years following
ACL reconstruction in a young athletic population, over 80% of all grafts were intact and had maintained
stability. However, those patients who had an allograft, failed at a rate over three times higher than
those reconstructed with a autograft.
Paper 22
ACL Reconstruction: Is There A Difference In Graft Motion For Bone-patellar Tendon-bone Vs Hamstring
Autograft At 6 Weeks Post-operatively?
James N. Irvine, MD1, Eric Thorhauer, BS2, Ermias Shawel Abebe, MD3, Scott Tashman, PhD4, Christopher
D. Harner, MD5.
1
University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2University of Pittsburgh Biodynamics Lab,
University of Pittsburgh, PA, USA, 3UPITT, USA, 4University of Pittsburgh, Pittsburgh, PA, USA, 5UPMC
Center for Sports Medicine, Pittsburgh, PA, USA.
Objectives: Graft-tunnel healing following ACL reconstruction (ACLR) is a complex process influenced by
multiple surgical variables, one of which is graft type. Clinical outcomes of bone-patellar tendon-bone
(BTB) and hamstring (HS) autografts are similar, yet animal studies suggest that the healing processes
may differ between the two autografts. Moreover, little is known about the relationship between grafttunnel motion and the healing process in vivo in humans. This study was designed to compare BTB and
HS graft motion within the femoral and tibial tunnels and the intra-articular graft post-operatively. We
hypothesized that tunnel motion and mid-substance stretch would be greater for HS than BTB at 6
weeks following surgery. Methods: After IRB approval, 16 subjects (8 BTB, 8 HS) with an average age of
20 (range 16 to 37) underwent anatomic single-bundle ACLR by the same surgeon. Tunnel location,
drilling and fixation were identical for all patients. Six 0.8 mm tantalum beads were embedded into ACL
grafts prior to implantation using a custom injector. Pairs of beads were located within each bone tunnel
and in the graft mid-substance (See image of graft constructs). Six weeks after surgery, CT scans were
obtained and used to create 3D femur and tibia bone models. Cylindrical coordinate systems were fit to
the bone tunnels to assess motion along tunnel axes. Dynamic stereo x-ray (DSX) images were collected
at 100 frames/s while subjects performed treadmill walking and stair descent. Tibiofemoral kinematics
were analyzed by combining the 3D models with DSX data. Graft-tunnel motion was defined as the
maximum displacement of the implanted beads along the direction of the bone tunnel axis following
footstrike. BTB and HS graft tunnel motions were compared using t-tests, with a significance level of p <
0.05. Results: Data are currently available for 6 BTB and 6 HS patients (N=12). Graft motion was seen in
both groups within the femoral and tibial tunnels (range: 0.39 - 3.97 mm). Contrary to our hypothesis
there was a trend towards greater femoral tunnel graft motion in the BTB relative to HS grafts during
walking and stair descent (P=0.14 and 0.12, Table 1A-1B). There was more BTB graft motion in the
femoral tunnel than in the tibial tunnel (significantly different for gait), and conversely more HS graft
motion in the tibial tunnel than in the femoral tunnel (significantly different for stair descent). There was
no detectable mid-substance stretch across all subjects. Conclusion: Six weeks following ACLR, less
tunnel motion was expected for the BTB group compared to HS, due to the perceived advantages of
bone-on-bone healing. However, more motion was observed for the BTB group within the femoral
tunnel compared to HS, challenging the assumption that at 6 weeks after surgery there is greater grafttunnel healing with BTB grafts. Based on previous studies, the native ACL elongates around 1-4% (0.31.2 mm) during loaded knee extension. At 6 weeks post surgery, it appears that the ACL grafts are
moving in the tunnels rather than stretching in the mid-substance portion. This pattern may reverse
over time, as graft-tunnel healing progresses (1-year followup testing is planned). Additionally, graft
type appeared to affect the relative amount of motion between the tibial and femoral tunnels, though
the cause and clinical significance of this finding is unclear. Results of this study could have important
implications for graft selection, rehabilitation progression and return to sports.
Tunnel motion (mean ± SD, in mm) of grafts during walking and stair descent
Walking
BTB Grafts
HS Grafts
P-Value:BTB vs HS
Femoral Tunnel
2.70 ± 0.95
1.85 ± 0.76
0.14
Tibial Tunnel
1.63 ± 0.64
2.06 ± 0.83
0.36
P-Value:Tibia vs Femur
0.004
0.13
Stair Descent
BTB Grafts
HS Grafts
P-Value:BTB vs HS
Femoral Tunnel
1.86 ± 0.90
1.12 ± 0.52
0.12
Tibial Tunnel
1.39 ± 0.57
2.08 ± 1.02
0.21
P-Value:Tibia vs Femur
0.14
0.01
Paper 23
ACL Injury, Return To Play And Reinjury In The Elite, Collegiate Athlete: An Analysis Of A Single, Division I
NCAA Cohort
Ganesh V. Kamath, MD1, Timothy Murphy2, Robert A. Creighton, MD3, Timothy N. Taft, MD4, Jeffrey T.
Spang, MD1.
1
UNC Orthopaedics, Chapel Hill, NC, USA, 2University of North Carolina - Chapel Hill, USA, 3UNC Chapel
HillDept of Ortho Surgery, Chapel Hill, NC, USA, 4UNC Chapel Hill, Chapel Hill, NC, USA.
Objectives: Graft survivorship, reinjury rates, and career length are poorly understood after ACL
reconstruction in the elite, NCAA Division-I athlete. The purpose of this study was to examine the
outcomes of ACL reconstruction in a Division-I athlete cohort . Methods: Retrospective chart review
was performed of all Division-I athletes at a single, public university from 2000 to 2009 until completion
of eligibility. Athletes with a Pre-collegiate (PC) and Intra-collegiate (IC) ACL reconstruction were
separated into two cohorts. Graft survivorship, reoperation rates, and career length information was
collected. Results: 35 athletes were identified with a pre-collegiate (PC) ACL reconstruction; 60 with an
intra-collegiate (IC) reconstruction. The PC group had a 17.1% injury rate to the original graft, with a
20.0% rate of contralateral ACL injury. For the IC group, the reinjury rates were 1.9% to the ACL graft,
with a 9.2% rate of contralateral ACL injury after an IntraCollegiate ACL reconstruction. The PC group
used 78% of their total eligibility (avg 3.11 yrs). Athletes in the IC group used an average of 77% of their
remaining NCAA eligibility. 88.3% of the IC group played an additional non-redshirt year after their
injury. Reoperation rate for the PC group was 51.4% and 20.3% for the IC group. Conclusion:
Reoperation and reinjury rates are high after ACL reconstruction in the Division-I athlete. Pre-collegiate
ACL reconstruction is associated with a very high rate of repeat ACL reinjury to the graft or opposite
knee (37.1%). The majority of athletes are able to return to play after successful reconstruction.
Paper 24
Risk Factors and Predictors Of Subsequent ACL Injury After ACL Reconstruction: Prospective Analysis Of
2801 Primary ACL Reconstructions.
Christopher C. Kaeding, MD1, Angela Pedroza, MPH1, Emily Reinke, PhD2, Laura J. Huston, MS3, MOON
Group4, Kurt P. Spindler, MD3.
1
Department of Orthopaedics - Div of Sports Medicine, Columbus, OH, USA, 2Vanderbilt University,
Nashville, TN, USA, 3Vanderbilt Orthopaedic Institute, Nashville, TN, USA, 4USA.
Objectives: Retear of an ACL after an ACL reconstruction (ACLR) is devastating for all involved.
Understanding risk factors and predictors of subsequent ACL tear after an ACLR is vital for patient
education of subsequent risk of injury and if a predictor is modifiable, to make adjustments to minimize
the risk of repeat ACL tear. The objectives of this study were 1) to identify the risk factors and predictors
for ispilateral and contralateral ACL tears after primary ACLR and 2) to compare retear risk between the
2002/03 and 2007/08 cohorts. This is the largest and most comprehensive prospective analysis of this
kind in the literature. Methods: Data from the 2002-2008 MOON database was used to identify risk
factors for ACL retear. Subjects who had a primary ACLR with no history of contralateral knee surgery
and had 2 year follow-up data were included. Subjects who had multiligament surgery were excluded.
Graft type (auto-BTB, auto-hamstring, allograft), age, Marx score at time of index surgery, sport played
post ACLR, sex, smoking status, lateral meniscus tear at the time of ACLR, medial meniscus tear at the
time of ACLR, BMI, and MOON site were evaluated to determine their contribution to both ipsilateral
retear and contralateral ACL tear. The analysis was repeated using the 2002/3 and 2007/8 cohort and
included age, graft, sex, and Marx. An ANOVA with post-hoc analysis was performed to detect significant
differences in age and Marx score by graft type over time. Results: A total of 2801 subjects met all
inclusion/exclusion criteria. There were 165/2801 (5.89%) ipsilateral and 177/2801 (6.32%) contralateral
ACL tears identified in the cohort at the two year follow-up. The odds of ipsilateral retear are 1.68 times
greater for hamstring autograft (p=0.04) and 4.67 times greater for an allograft (p<0.001) compared to
auto-BTB. The odds of ipsilateral retear decrease by 8% for every yearly increase in age (p < 0.001) and
increases by 6% for every increased point on the Marx score (p = 0.017). The odds of contralateral ACL
tear increase by 7% for every increased point on the Marx score (p = 0.004) and decreases by 5% for
every one point increase in BMI (p = 0.03). In 2002/3, there were 61/815 (7.5%) retears compared to
37/1056 (3.5%) in 2007/8. The odds of retear by for the 2002/03 and 2007/08 cohorts are summarized
in table 1. The mean age (figure 1) of subjects receiving BTB and hamstring remained constant over time
whereas the mean age of subjects receiving allograft rose by seven years (p < 0.001). Hamstring use was
a predictor of retear compared to BTB in the 02/03 group (7.9% vs. 4.2%), but not in the 07/08 group
(4.1% vs. 3.4%). Conclusion: Age, activity, and graft type were predictors of increased risk of ipsilateral
graft failure after ACLR. Higher activity and lower BMI were found to be risk factors in contralateral ACL
tears. Allograft use in young active patients was shown to be a risk factor for graft retear in the 02/03
group, subsequent to this, graft choice changed to using allografts in older and less active patients with
an associated decrease in graft retear risk in the 07/08 group. The contralateral ACL injury risk did not
change from the early group to the later group. The risk of ACL graft retear was lower for all graft types
in the 07/08 group compared to the 02/03 group. The relative decrease risk in hamstring autografts
compared to BTB in 07/08 compared to 02/03 may be due to improved surgical techniques,
rehabilitation, and/or slower return to play guidelines, and bears further investigation.
Odds ratio over time
2002-2003(n=815) 2007-2008(n=1056)
Ipsilateral retear Odds ratio (p-value) Odds ratio (p-value)
Age
0.92 (<0.001)
0.88 (<0.001)
Marx (t0)
1.04 (0.243)
1.12 (0.082)
Auto-BTB
REF
REF
Auto-Hamstring 2.52 (0.009)
1.38 (0.379)
Allograft
7.96 (<0.001)
4.36 (0.021)
Male
REF
REF
Female
1.13 (0.670)
0.81 (0.551)
Paper 25
Lateral Tibial Slope is Increased with Patients with Early Graft Failure Following ACL Reconstruction
Joshua Christensen, MD1, William Engasser2, Matthias Vanhees, MD3, Mark S. Collins, MD1, Diane L.
Dahm, MD1.
1
Mayo Clinic, Rochester, MN, USA, 2Mayo Clinic Department of Orthopedic Surgery, Rochester, MN,
USA, 3University of Antwerp, Antwerp, Belgium.
Objectives: To determine the relationship between lateral tibial slope and probability of early graft
failure in patients who have undergone anterior cruciate ligament (ACL) reconstruction. Methods: Fiftyeight patients were initially identified who experienced graft failure following primary ACL
reconstruction and were revised between 1989 and 2009. Exclusion criteria were: clinical follow-up of
less than four years, graft failure occurring greater than two years from primary surgery, skeletal
immaturity, deep infection, lack of availability of preoperative MRI imaging, and history of previous
trauma to the proximal tibia. This left 35 cases of early (within 2 years) failure of primary ACL
reconstruction. These cases were matched to 35 controls that had undergone ACL reconstruction with a
minimum of 4 years of clinical follow-up and no evidence of graft failure. Patients were matched by age,
gender, date of primary surgery, and graft type. Lateral tibial slope was then determined on MRI imaging
in blinded fashion. Results: All 35 cases failed within 2 years of primary ACL reconstruction. Mean time
to failure in this group was 1 year (range 0.6-1.4 years). Mean follow-up of the matched control group
was 6.9 years (range 4.0-13.9 years). Mean lateral tibial slope in the early ACL failure group was found to
be 8.4 degrees, which was significantly larger than the control group at 6.5 degrees (p=0.02). The odds
ratio for failure considering a 2 degree increase in tibial slope was 1.5 (95% CI 1.02-2.2), and continued
to increase to 2.2 (95% CI 1.1-4.6) and 3.3 (95% CI 1.1-10) with 4 degree and 6 degree increases in tibial
slope, respectively (Fig 1). No significant association was identified between graft type and primary ACL
reconstruction failure. Conclusion: Increased lateral tibial slope is associated with an increased risk for
early ACL graft failure, regardless of graft type. Orthopaedic surgeons should consider measuring lateral
tibial slope as part of the preoperative assessment of ACL-injured patients.
Paper 26
Combined Meniscus and Osteochondral Allograft Transplantation: Minimum Two-Year Follow-up with
an Analysis of Failures
Geoffrey D. Abrams, MD1, Kristen Hussey, BA2, Joshua David Harris, MD3, Brian J. Cole, MD, MBA4.
1
VA Palo Alto, Palo Alto, CA, USA, 2Rush University Medical Center, Chicago, IL, USA, 3The Methodist
Hospital Center for Sports Medicine, Houston, TX, USA, 4Midwest Orthopaedics at Rush, Chicago, IL,
USA.
Objectives: The purpose of this investigation was to report mid- and long-term follow-up on the clinical
outcomes of patients undergoing combined MAT and osteochondral allograft procedures for
symptomatic knee pain in the setting of meniscal deficiency and focal cartilage damage. We
hypothesized that patients undergoing combined MAT and osteochondral allograft will demonstrate
improved pain and functional scores following surgery. Methods: This was a prospective case series.
Thirty two patients with a minimum two-year follow-up were identified who initially presented with
persistent symptoms following meniscectomy and an isolated International Cartilage Repair Society
(IRCS) Grade 3 or 4 defect of the femoral condyle underwent combined MAT and fresh osteochondral
allograft transplantation. Demographic and intra-operative data, including condylar defect size, was
recorded as well as pre- and post-operative International Knee Documentation Committee (IKDC), Short
Form-12 (SF-12), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm scores. Pre- and
post-operative data was compared with paired t-tests while the association between functional scores
and condylar defect size, age, gender, and involved compartment were analyzed with regression
analysis. An alpha value of 0.05 was set as significant with Bonferroni correction utilized in the case of
multiple comparisons. Results: Average follow up was 4.2 years (range 2-11). Mean condylar defect size
was 4.7 ± 2.0 cm2 at the time of index procedure. Lysholm, IKDC, and all KOOS subdomains showed
significant improvement from pre- to post-operatively (p < 0.001). Patients with a condylar defect of less
than 4 cm2 had a significantly greater increase in pre- versus post-operative IKDC (p = 0.010), Lysholm (p
= 0.018), and KOOS (p = 0.016) versus those with greater than 4 cm2. Femoral condyle defect size was
also significantly inversely correlated with post-operative IKDC (p = 0.015), KOOS (p = 0.003), and
Lysholm score (p = 0.010). Patient satisfaction with the procedure was 82%. Conclusion: Patients
undergoing combined MAT and osteochondral allograft showed improved functional scores following
surgery. There was an inverse association between post-operative functional scores and the size of the
condylar defect.
Paper 27
Factors Predictive of Improved Patient Reported Outcomes Following Distal Femoral Osteochondral
Allograft Transplantation
Zachary Beck Domont, MD, Samantha Quilici, PA, Matthew Dehart, BS, Dennis C. Crawford, MD.
Oregon Health & Sciences University, Portland, OR, USA.
Objectives: Osteochondral injury is associated with pain and/or dysfunction and has been implicated as
a factor leading to early degenerative joint disease. Fresh osteochondral allograft (OCA) transplantation
is a well-described surgical replacement therapy for patients with large osteochondral defects. Optimal
selection of patients and factors most associated with a successful outcome is of clinical importance.
Previous studies have found age and prior surgery to be predictive of graft failure; however, the
potential influence of BMI, coronal plane alignment, and degree of osteoarthritis as well as donor
factors such as donor age, graft age and donor match for gender and specific graft locations on patient
reported outcomes remains less well characterized. Methods: We utilized a prospective database of 97
consecutive patients receiving osteochondral allograft transplantation to the distal femur from a single
surgeon practice over 5 years (2006-2011). Patient and donor characteristics were routinely collected, as
were patient reported outcome measures (PRO) including KOOS and IKDC. Pre-operative full length
standing lower extremity radiographs were measured. Values were considered as both continuous
(degrees of varus/valgus) and dichotomous variables (WB axis through the recipient condyle). We used
AP X-rays to grade osteoarthritis using the Kellgren-Lawrence scale. Responder analysis was applied to
individual patient scores using solitary and dual threshold criteria. Logistic regression was then applied
to determine relationships between the candidate variables and response according to the responder
analysis threshold. We considered 19 candidate variables in the analysis (Figure 1) and used a forward
process for variable selection and multivariate model building based on Akaike Information Criterion
(AIC) as the measure of relative goodness-of-fit for the models. Results: 53 patients (36 male, 17
female, mean age 38.6 years) with a minimum of 24-month data (mean 35.7 months) and without
concurrent osteotomy are reported. A statistically significant improvement from baseline to final followup (p<.006) was seen for KOOS (Pain: +14.6, ADL: +15.6, Sports: +33.8, QOL: +27.8) and IKDC (+18.7).
Patient factors independently associated with greater improvement included a BMI of less than 30
(p<.047), prior cartilage surgery (p=.019), and Kellgren-Lawrence score of 2-4 (p=.024). Valgus alignment
trended to greater improvement (p=.08), but medial vs lateral condyle did not. We built predictive
multivariate models for our six dependent variables (KOOS, IKDC) and identified 4 significant
contributors within patient and donor characteristics. Amongst the factors, the most prominent
predictors were valgus alignment (p=.03), smaller defect size (p=.03), younger age (p=.01), and no
additional simultaneous procedure (p=.01). Conclusion: We confirm that at an average of 3 years after
surgery, patients undergoing OCA to the distal femur can expect significantly improved PRO scores.
Independent factors resulting in greater patient improvement in this cohort included the absence of
obesity, a history of prior cartilage surgery, and, to our surprise, advanced osteoarthritis (KellgrenLawrence 2-4). In the multivariate model, younger age, valgus alignment, smaller defect size, and no
simultaneous procedure were predictive of better PRO. Surgeons may use this data to select and advise
potential patients under consideration for OCA transplant.
Paper 28
Use of Preoperative Patient Reported Outcome Scores to Predict Outcome Following Autologous
Chondrocyte Implantation
Jennifer Sebert Howard, PhD, ATC1, Christian Lattermann, MD2.
1
University of Kentucky, Lexington, KY, USA, 2Univ of Kentucky Medical Ctr, Lexington, KY, USA.
Objectives: Autologous chondrocyte implantation(ACI) has become an accepted treatment for articular
cartilage defects; however, selection of appropriate patients in routine clinical practice remains
challenging. The purpose of this study was to evaluate the use of preoperative patient reported
outcome(PRO) scores in predicting postoperative self-reported global function following ACI with the
goal of defining a minimum entry score that is predictive of a successful patient outcome. Methods: A
case series of patients a minimum of 1-year following ACI (n = 73, 27 female, age = 35 ± 7 yrs, BMI = 30 ±
5, mean defect = 7.4 ± 5.1 cm2, average follow-up = 2.3 ± 1.2 yrs) were evaluated. All patients were
enrolled prospectively and completed PROs pre-surgery and 3, 6, and 12 months and annually postsurgery. As part of the ICRS Cartilage Injury Standard Evaluation Form, postoperatively patients were
asked to rate their current function as “severely restricted in everything I do”, “restricted, many things
are not possible”, “I can do nearly everything”, or “I can do everything”. Receiver operator curves (ROCs)
were used to explore the discriminative accuracy of preoperative PROs (Total WOMAC Knee Score, IKDC
Subjective Knee Form, and Lysholm Knee Scale) for identifying patients reporting to be able to do
“nearly everything” or “everything” at the last available follow-up. From the ROCs cut-point scores for
the values with the highest combined sensitivity and specificity were identified. Patients were then
classified for each PRO instrument as having preoperative scores above or below the identified cut-point
values. Cut-point status for preoperative WOMAC, IKDC, and Lysholm along with BMI, gender, age,
defect area, and defect location (patellofemoral/tibiofemoral) were analyzed in a backwards entry
logistic regression model to predict patients experiencing a positive outcome. Results: Area under the
curve was significantly greater than 0.5(range 0.80(IKDC)-0.82(Lysholm), p≤0.001) for each PRO ROC,
demonstrating high accuracy in using preoperative PROs to predict post-operative function. The
WOMAC score demonstrated a cut-point value of 34 with a sensitivity of 0.89 and specificity of 0.60 for
identifying patients who went on to a positive outcome. For IKDC the cut-point was 35 (sensitivity=0.86,
specificity=0.67). For Lysholm the cut-point was 41 (sensitivity =0.89, specificity=0.61). The only
variables contributing to the final logistic model were IKDC score > 35 (p=0.002), and Lysholm score > 41
(p=0.002). The model demonstrated that those individuals with a preoperative IKDC score > 35 had 7.4
(95%CI: 2.1 - 26.9) greater odds of a positive outcome compared to those with an IKDC score ≤ 35 and
those with a preoperative Lysholm score > 41 had 8.5 (2.2 - 33.2) greater odds of a positive outcome
compared to those with a Lysholm score ≤ 41. Overall 85.5% of patients were correctly classified by the
model as having a good or poor outcome. Conclusion: Pre-operative PROs can provide patients and
physicians with accurate expectations for post-operative global levels of function. These results suggest
that there may exist a minimum threshold of self-reported function for which ACI procedures can result
in meaningful functional outcomes. Patients with functional levels below these cut-points should
undergo preoperative interventions aimed at improving their function to above cut-point values and be
counseled for realistic treatment expectations or available treatment alternatives.
Paper 29
Survivorship and Complications of the Distal Femoral Osteotomy
Deepak Ramanathan, MBBS1, Arvind Von Keudell, MD2, Tom Minas, MD3, Andreas H. Gomoll, MD4.
1
Harvard Medical School, Boston, MA, USA, 2Boston, MA, USA, 3Brigham & Women's Hospital, Chestnut
Hill, MA, USA, 4Brigham and Women's Hospital, Chestnut Hill, MA, USA.
Objectives: Distal femoral osteotomy (DFO) is a useful procedure in the young patient with symptomatic
unicompartmental osteoarthritis and valgus malalignment to avoid or postpone knee arthroplasty. Distal
femoral osteotomy can be technically demanding and various complications are reported in the
literature. Our retrospective study aims to evaluate the outcomes and analyze survivorship of the distal
femoral osteotomy until eventual conversion to knee arthroplasty. Methods: We performed a
retrospective review of 78 open-wedge distal femoral osteotomies done on 74 patients at our institution
between 2001 and 2011. The average patient age at surgery is 33 ± 11 years with mean BMI of 28 ± 6.
All surgeries were performed by two of the senior authors and 60.3% were done in conjunction with
cartilage repair procedures such as autologous chondrocyte implantation and osteochondral graft
transfer. Other associated procedures included lateral release, tibial tubercle osteotomy,
quadricepsplasty and ACL reconstruction. The average follow-up duration was 43 ± 31 months and the
need for further procedures (such as arthroscopic adhesiolysis, hardware removal, revision osteotomy
and eventual progression to arthroplasty) was identified with relation to complications. Statistical
analyses for survivorship were performed using MedCalc for Windows, version 12.5 (MedCalc Software,
Ostend, Belgium). Results: Of the 71 patients who followed -up beyond six months post-operatively,
seven eventually converted to total knee arthroplasty (9.9%). The most common complication was
hardware pain (20.5%) followed by arthrofibrosis (12.8%). All cases of arthrofibrosis were noted to have
had intra-articular surgical manipulation for associated procedures such as cartilage repair. Other less
common complications included hardware failure (3.8%), septic arthritis (3.8%) and nonunion (2.6%).
Osteotomy hardware removal was performed in fourteen cases (17.9%). Kaplan - Meier survivorship
analysis estimates mean survival time of 123 ± 8 months (with 95% confidence interval of 107 - 138) and
survival probability at 10 years follow-up is estimated at 78%. Conclusion: Distal femoral osteotomy is
an acceptable surgical option for the young patient with severe unicompartmental knee osteoarthritis
and malalignment. Its combination with various cartilage repair procedures has been shown to further
improve outcomes. Careful selection of each surgical candidate is necessary to ensure maximum
benefit. The unloading osteotomy is especially useful in the young, active patient as an adjunct
procedure for cartilage repair. However, osteoarthritis continues to progress and multiple arthroscopic
or open procedures may be required despite a successful osteotomy. When performed at the optimal
time in a carefully selected patient, distal femoral osteotomy can provide adequate joint function for
many years until arthroplasty becomes inevitable.
Paper 30
Closing Wedge and Opening Wedge High Tibial Osteotomy in the ACL Deficient Knee:A Comparison of
Stability and Alignment
K. Durham Weeks, MD, Saker Khamaisy, MD, Benjamin Stone, Andrew Pearle, MD, Anil S. Ranawat, MD.
Hospital for Special Surgery, New York, NY, USA.
Objectives: Opening and closing wedge high tibial osteotomies for the treatment of medial
compartment arthritis can lead to secondary intended and unintended changes in posterior tibial slope.
The effect of slope neutralization using high tibial osteotomies in ACL deficient knees has not been fully
defined. The purpose of this study was to quantify the changes in anterior tibial translation and
rotational stability in the ACL deficient knee following mulitplanar high tibial osteotomies comparing
opening wedge to closing wedge techniques. Methods: Anterior drawer, Lachman, and Pivot-shift tests
were performed on hip-to-toe cadaveric specimens (n=16) and translation of the lateral and medial
compartments was measured using Praxim navigation system. The ACL was then sectioned and stability
testing repeated and compartment translation recorded. Half of the knees then underwent a closing
wedge (LCW) high tibial osteotomy using a lateral titanium Tomofix plate and screws (n=8). The
contralateral knees underwent an opening wedge (MOW) high tibial osteotomy using a medial titanium
Tomofix plate and screws (n=8). The goal of both procedures was for an 8-10mm correction with
maximal sagittal slope neutralization. Following this procedure, stability testing and translation
measurements were once again performed. Pre and post-operative CT scans were performed to assess
initial posterior tibial slope and slope correction, as well as coronal plane correction. Results: Sectioning
the ACL resulted in a significant increase in anterior tibial translation (ATT) during Anterior drawer,
Lachman, and Pivot shift testing (P < 0.05). In the ACL deficient knee the tibia translated on average an
additional 2.1mm (±1.2) during Anterior drawer and 4.1mm (±2.1) during Lachman testing. Performing a
LCW osteotomy demonstrated a significant decrease in ATT during Lachman testing that approached the
native knee kinematics (P< 0.05), however, this decrease was not found during Anterior Drawer testing.
ATT did not significantly improve following MOW osteotomy in the ACL deficient knee during any of the
three tests. In fact, absolute translation values were unchanged following this procedure. The pivot shift
was not significantly changed following either MOW or LCW. The mean Tibial Coronal alignment
correction in the MOW group was 7.2º(±0.95) compared to 5.9º(±1.8) in the LCW group. Although the
coronal correction was improved in the MOW, this difference did not reach significance (P = 0.08).
The mean tibial slope neutralization achieved with a LCW was 7.1º(±1.8), which was significantly higher
than 5.1 º(±0.9) found using MOW (P< 0.05). Conclusion: LCW HTO shows more reproducible slope
neutralization than MOW and this benefits anterior translation during Lachman stability testing. When
considering the use of an HTO in the setting of ACL deficiency, LCW should be considered given its
favorable post-operative knee kinematics.
Paper 31
Changes in the Hip of Youth Hockey Players over 3 Seasons as Seen on MRI and Physical Exam
Marc J. Philippon, MD, Charles Ho, MD, PhD, Karen K. Briggs, MPH, MBA, N. Dawn Ommen, MD.
Steadman Philippon Research Institute, Vail, CO, USA.
Objectives: It has been reported that relative to other sports participants, ice hockey players suffer from
cam femoroacetabular impingement (FAI) in higher numbers. Alpha angles have been reported to
increase with the likelihood of symptomatic FAI. It is unclear how alpha angle and other factors related
to FAI change over early childhood years. The objective of this study was to track youth hockey players
over 3 years and determine if factors associated with FAI increased as they aged and increased skating
time. Methods: 15 asymptomatic youth ice hockey players(ages 10 to 16 years) had pre-participation
screening prior to starting youth hockey season. All players started in the peewee(ages 10 to 12) division
and moved up in divisions over the 3 years. All players had a clinical hip examination consisting of the
FABER test, impingement testing, and measurement of hip internal rotation. An limited screening MRI
was taken and the hip alpha angle was measured and labral tears were documented. Results: These
youth hockey players played an average of 42 weeks/year over 3 years. Four goalies were included.
Players had significantly increased alpha angle by year 3 of screening. The average alpha angle at year 1
was 56(range 45 to 63), year 2 average was 59 (range 52 to 68) and year 3 average was 75 (range 64 to
88). By year 3, 12/15 had asymptomatic labral tears. The 3 players who did not have labral tears had
alpha angles of 60, 62, and 64 degrees. There were no significant changes in internal rotation over the 3
years. There was a trend toward decreased internal rotation in goalies. One goalie reported symptoms
after the completion of the 3rd season when he was 16 years old. Conclusion: Young ice hockey players
show increasing alpha angles and development of asymptomatic labral tears. Stresses inherent to ice
hockey likely enhance the development of a bony overgrowth on the femoral neck contributing to cam
FAI. Further study into the etiology of the increase in the alpha angle in ice hockey players is
recommended to determine if preventative measures may be adapted to decrease the incidence of hip
symptoms which decrease activity level.
Paper 32
Arthroscopic Management of Femoroacetabular Impingement (FAI) in Adolescents
J. W. Thomas Byrd, MD, Kay S. Jones, MSN, RN.
Nashville Sports Medicine Foundation, Nashville, TN, USA.
Objectives: Arthroscopic management of symptomatic femoroacetabular impingement (FAI) is a well
accepted treatment. FAI is known to lead to early-age onset osteoarthritis in middle-aged adults and can
result in significant secondary joint damage in young adults. Few studies report on the role of
arthroscopy for FAI in adolescents and none provide comparative data. The purpose of this study is to
report the outcomes of hip arthroscopy for adolescents with symptomatic FAI in relation to a control
group. Methods: All patients undergoing arthroscopy are prospectively assessed with a modified Harris
Hip Score. 122 consecutive hips among 108 adolescents less than 18 years of age were identified who
had undergone arthroscopic surgery for FAI and had achieved minimum 1-year follow-up. A
chronologically matched control group of 122 patients 18-50 years of age was identified who had also
undergone arthroscopic surgery for FAI contemporaneous with the study group. Results: Follow-up
averaged 29 months for both groups (range 12-60 months). For the study group, the average age was 16
years (range 12-17 years). There were 49 males and 59 females. For the control group, the average age
was 36 years (range 18-50 years) with 71 males and 51 females. The average improvement of the study
group was 23 points (preop 69; postop 92) and, for the control group, 21 points (preop 63; postop 84).
For the study group, FAI correction was performed for 36 cam, 17 pincer, and 69 combined lesions. 111
labral tears underwent 85 refixations and 26 debridements. There were 101 acetabular chondral lesions
(42 Grade I, 18 Grade II, 47 Grade III and 4 Grade IV) with 4 microfractures. There were 3 femoral
chondral lesions (1 Grade II, 2 Grade III). 7 loose bodies were removed and 19 lesions of the ligamentum
teres were debrided. Concomitant extraarticular procedures included 13 iliopsoas tendon releases and 2
iliotibial band tendoplasties. Among the control group, FAI correction was performed for 53 cam, 5
pincer and 64 combined lesions. 103 labral tears underwent 52 refixations and 50 debridements. There
were 112 acetabular chondral lesions (9 Grade I, 11 Grade II, 59 Grade III, 33 Grade IV) with 20
microfractures. There were 17 femoral chondral lesions (1 Grade II, 11 Grade III, 5 Grade IV). 17 loose
bodies were removed and 21 lesions of the ligamentum teres debrided. Concomitant extraarticular
procedures included 4 iliopsoas tendon releases and 1 abductor repair. There were 2 complications in
the study group: transient perineal neurapraxias that resolved within 2 weeks. In the control group, 1
patient had a transient perineal neurapraxia and lateral thigh numbness, both of which resolved. In the
study group, 4 patients underwent repeat arthroscopy and 1 a PAO. In the control group, 1 patient
underwent repeat arthroscopy. Conclusion: This study reports favorable outcomes of arthroscopic
management of FAI in adolescents with improvement more than comparable to those of an adult
population and higher absolute scores. Concomitant extraarticular procedures and revision were both
more common among adolescents. This data supports that arthroscopy does have a role in the
management of FAI in adolescents.
Paper 33
Gender Differences in Outcome After an Acute Achilles Tendon Rupture
Karin Gravare Silbernagel, PT, ATC, PhD1, Katarin Nilsson-Helander, MD,PhD2, Nicklas Olsson, MD3,
Annelie Brorsson, PT4, Bengt I. Eriksson, MD, PhD4, Jon Karlsson, MD, PhD5.
1
University of the Sciences in Philadelphia, Departmen of Physical Therapy, Philadelphia, PA, USA,
2
Kungsbacka Hospital, Kungsbacka, Sweden, 3USA, 4University of Gothenburg, USA, 5Sahlgrenska
University Hospital Molndal, Molndal, Sweden.
Objectives: There is an indication in the literature that there is a difference in tendon healing between
genders. However comparisons in outcome are often not possible due to the small sample size of
women with an acute Achilles tendon rupture. In most studies on patients with Achilles tendon rupture
the women only account for less then 20% of the patients. The objective of this study was to evaluate if
there are any differences in outcome between genders when combining the data from two large
randomized controlled trials, which used identical outcome measures.
Methods: Patients included in two consecutive randomized controlled trials, comparing surgical and
non-surgical treatment, were included in the evaluation. Patients who had a re-rupture were excluded
from the analysis. A total of 184 patients (154 males, 30 females) mean (SD) age of 40 (11) years were
included. 96 (78 males, 18 females) were treated with surgery and 88 (76 males, 12 females) nonsurgically. Patient reported outcome was evaluated with the Achilles tendon Total rupture Score (ATRS)
and the functional outcome were measured with a single-leg standing heel-rise test (measurement of
muscular endurance and heel-rise height) 6 and 12 months after injury in our research laboratory.
Results: For the whole group there were no significant difference between treatments on ATRS at 6 and
12 months. The surgical group was significantly better then the non-surgical group in heel-rise
endurance at 6 and 12 months and in heel-rise height recovery at 6 months (p<0.03). When comparing
the genders, disregarding the treatment, there were no significant differences except for at 12 months
the males had a greater improvement in heel-rise height (p=0.004). When comparing the genders for
each treatment group separately it was found that the females had significantly (p<0.04) more
symptoms after surgical treatment (mean (SD) ATRS 61 (24)) compared to the males (74 (19)) at 6
months and (74 (27) vs. 87 (17)) at 12 months. This difference was not found when comparing the
genders in the non-surgical treatment group.
Conclusion: Females has a greater degree of deficit in heel-rise height as compared to males irrespective
of treatment. Females have more symptoms compared to males after surgery both at 6 and 12 months
but this difference is not found when treated non-surgically. Further research is needed to determine if
women will benefit more from non-surgical compared to surgical treatment after an Achilles tendon
rupture.
Paper 34
An American Experience with a New Olympic Collision Sport: Rugby Sevens
Victor Lopez, Jr., DO1, Richard Ma, MD2, Meryle G. Weinstein, PhD3, James L. Chen, MD, MPH4,
Christopher M. Black, MS5, Arun T. Gupta, MD6, Erica D. Marcano, MS7, Answorth A. Allen, MD8.
1
Rugby Research and Injury Prevention Group, Inc., New York, NY, USA, 2MIssouri Orthopaedic Institute,
Columbia, MO, USA, 3Steinhardt School of Culture, Education, and Human Development, New York, NY,
USA, 4Sportsmed Orthopaedic Group, San Francisco, CA, USA, 5Rugby Research and Injury Prevention
Group, Inc, New York, NY, USA, 6Alberta Health Services, Medical Physiatry, Calgary, AB, Canada,
7
Professional Orthopaedic and Sports Physical Therapy, New York, NY, USA, 8The Hospital for Special
Surgery, New York, NY, USA.
Objectives: Rugby Sevens is a future Olympic collision sport that is played globally with a high incidence
of injury. The sport is growing exponentially in the U.S. There is limited injury data on Rugby Sevens.
Currently, there is no study evaluating incidence of injury in the National Rugby Sevens population in the
U.S. The objective of this study was to characterize the injury rates among amateur Rugby Sevens
players in the U.S.
Methods: This was a prospective descriptive injury epidemiology study involving American Rugby
Sevens tournaments from 2010-2013. The injury data were collected from both male and female Rugby
Sevens players (13, 524 players) and conformed to the international consensus statement on rugby
injury definitions. The study included a total of 1,127 teams competing in under-15 to national candidate
level tournaments (USA Rugby Local Area, Territorial Union, National and All-Star Sevens Series, USA
Sevens Invitational and Collegiate Rugby Championships). A total of 2746 matches were played, 2734
lasting 14-minutes (0.23 hours) in length and 12 lasting 20-minutes (0.33 hours) in length. The overall
injury exposure for all players was 8858.9 playing hours (7 players per side * 2 teams per match * 0.23
hours per match * 2734 matches + 7 players per side * 2 teams per match * 0.33 hours per match * 12
matches). Player injury data were reported as proportion (%), mean (SD), and rate of injury as injuries
per 1000 playing hours.
Results: Incidence of combined medical attention and time-loss injuries was 97.7/1000 playing hours
(n=875 injuries) (23.6±5 years old). Time-loss injuries alone were encountered at 43.1/1000 playing
hours (n=380 injuries) (forwards, 14.3/1000, n=127; backs 25.7/1000, n=228) (RR: 1.8; 1.53-2.11, P <
0.001). Elite/national male competitors (242.6/1000) were injured more often than lower playing levels
(147.6/1000) (P < 0.001). Most injuries were acute injuries (96%) that occurred during the tackling phase
of play (97%), and it resulted mainly from contact with an opposing player (67%). The main injuries seen
were ligament sprain in lower extremities (43%). Upper extremity injuries were seen more often among
male players (76%) than female players (24%) (RR: 0.31,CI: 0.25-0.40, P < 0.001). Knee injuries were seen
more often in women’s elite players than men’s elite players (P = 0.014). Head/neck injuries (backs,
58%; forwards, 42%) occurred more often in male players (74%) (RR: 0.34; CI: 0.26-0.44, P < 0.001).
Conclusion: Injury prevention in American Rugby Sevens should focus on proper tackling technique as
most injuries in our series occurred during tackling. We also saw a significant number of head/neck
injuries in our U.S. playing population, which may reinforce the importance of proper tackling technique
in this collision sport. The rate of head/neck injuries (23%) in our U.S. cohort (National candidates, 25%;
lower competitors, 23%) was higher than the rate reported among international male Rugby Sevens
players (5%) (Table 1). Overall, our National candidates had higher rates of time loss injuries than lower
American amateur playing levels. Our observed injury rate among U.S. elite players is also higher than
that reported for international male Rugby Sevens population. Understanding the injury profile of
American Rugby Sevens is important to healthcare providers and would direct the growth and safety of
this growing collision sport, allowing safe return-to-play decisions and formulation of prevention
protocols.
TABLE I: Comparison of Injury Rates in Rugby Sevens by Body Region in the Literature
PlayerHead & Upper
Lower
Injuries /
Trunk
hours of
Extremity
Extremity Other
Neck
match
Athletes
Injuries
Injuries Injuries
Injuries
exposure
American 7s (men &
women) 2010-2013
380/
Amateur to
13524
Elite/National
Candidates
Local Area Union 7s
(Lopez et al AJSM
2012)
Amateur Men &
Women
23.4%
48/ 1536 33.3%
Rugby Sevens World
Series
(Fuller et al CJSM
104/ 290 4.9%
2010)(International
Men)
25.9%
6.5%
42.8%
Incidence of
Injury/1000
player hours
1.4% 8858.9
43.1 (timeloss)
31.3%
18.8% 14.6%
2.0% 866.4
55.4
(combined
medical
attention &
time-loss)
17.5%
7.8%
1.9% 979.1
106.2(timeloss)
69.9%
Paper 35
Surgical versus Non-surgical Management of Rotator Cuff Tears: Predictors of Treatment Allocation
Christopher Y. Kweon, MD1, Joel Joseph Gagnier, ND, PhD2, Christopher Robbins2, Asheesh Bedi, MD1,
James E. Carpenter, MD1, Bruce S. Miller, MD, MS1.
1
MedSport, University of Michigan, Ann Arbor, MI, USA, 2University of Michigan, Ann Arbor, MI, USA.
Objectives: Rotator cuff tears are a common shoulder disorder resulting in significant disability to
patients and strain on the health care system. While both surgical and non-surgical management are
accepted treatment options, little data exist to guide the surgeon in treatment allocation. Defining
variables to guide treatment allocation may be important for patient education and counseling, as well
as to deliver the most efficient care plan at the time of presentation. The objective of this study was to
identify patient characteristics at the time of initial clinical presentation that are associated with
allocation to surgical versus non-surgical management for patients with known full-thickness rotator cuff
tears.
Methods: 185 consecutive adult patients with known full-thickness rotator cuff tears were enrolled into
a prospective cohort study. Robust data were collected for each subject at baseline, including age,
gender, body mass index (BMI), shoulder activity score, smoking status, size of cuff tear, duration of
symptoms, functional comorbidity index, treating surgeon, the American Shoulder and Elbow Society
(ASES) score, the Western Ontario Rotator Cuff Index (WORC), and the Veterans Rand 12 Item Health
Survey (VR-12). Logistic regression was performed in order to identity variables associated with
treatment allocation, and the corresponding odds ratios were calculated.
Results: Of the 185 subject enrolled, 100 underwent surgical intervention and 85 non-operative
management. While controlling for co-variates, significant baseline patient characteristics predictive of
eventual allocation to surgical treatment included the following: non-smoking status [OR .039 (0.005,
0.300) p=0.002], lower functional comorbidity index [OR 0.739 (0.518, 1.055) p=0.096], younger age [OR
0.872 (0.820, 0.927) p<0.001], lower BMI [OR 0.895 (0.826, 0.970) p=0.007], and symptoms present for
fewer than 4 months [OR 3.258 (1.070, 9.921) p=0.038]. Factors that were not associated with
treatment allocation included gender, tear size, diabetes, treating surgeon, or any of the patient derived
outcome scores at presentation (ASES, WORC, VR-12, shoulder activity score).
Conclusion: This prospective cohort study suggests that the factors predictive of treatment allocation
are related more to patient demographics at presentation than patient derived outcome scores or
intrinsic characteristics of the rotator cuff such as tear size. Further study is warranted to help define
appropriate indications for treatment allocation in patients with rotator cuff tears.
Paper 36
Two-Year Outcomes Following Arthroscopic Treatment for Partial-Thickness Tears of the Supraspinatus
Tendon
Peter J. Millett, MD, MSc1, Ryan J. Warth, MD2, Marilee P. Horan, BS3.
1
Steadman Clinic, Vail, CO, USA, 2Steadman Philippon Research Institute (COOR), Vail, CO, USA,
3
Steadman Philippon Research Institute, Vail, CO, USA.
Objectives: Treatment for partial-thickness (PT) supraspinatus tears are largely based on surgeon
intuition since little is known regarding the outcomes of specific treatment methods. Therefore, the
purpose of this study was to evaluate the outcomes following arthroscopic management of partialthickness supraspinatus tears.
Methods: Institutional Review Board approval was obtained prior to initiation of this study. All data
were prospectively collected and retrospectively analyzed. Between March 2006 and April 2011, 61
shoulders underwent arthroscopic treatment for PT supraspinatus tears. Inclusion criteria were: age >18
years, primary arthroscopic treatment for a PT supraspinatus tear, and were 2 years removed from the
index surgery. Treatments included debridement (< 50% thickness), side-to-side repair with sutures and
repair (> 50% thickness) using either single- (50-75%) or double-row (>75%) suture anchor constructs.
Concomitant treatments were recorded. Demographic data were collected pre- and postoperatively
along with ASES, SF-12 PCS, QuickDASH, SANE and satisfaction after minimum two-year follow-up. Data
regarding intraoperative findings, treatments, complications and revision surgeries were collected.
Treatment failure was defined as subsequent surgery on the supraspinatus tendon. Outcomes data were
compared with preoperative baselines along with various demographic and surgical variables. Statistical
significance was set at p<0.05.
Results: 69 shoulders (38 men, 29 women, 2 bilateral) with a mean age of 52 years (range, 20-74)
underwent arthroscopic treatment for PT supraspinatus tears. There were 2 complications (2.9%): 1
shoulder developed axillary nerve symptoms and 1 developed a superficial wound infection. 8 of the 69
shoulders (11.6%) underwent subsequent surgery on the index shoulder unrelated to the rotator cuff
before final follow-up and were omitted from the outcomes analysis. 24/61 shoulders had bursal-sided
tears (39.3%) and 37/61 had articular-sided tears (60.7%). 31 shoulders (50.8%) had a tear involving
<25% of the tendon thickness. 35 tears (57.4%) were repaired whereas 26 tears (42.6%) underwent
debridement alone. 28 shoulders also had proximal biceps tendon lesions (45.9%), 28 had SLAP tears
(45.9%) and 18 had other pathologies. Treatment failure occurred in 4 shoulders (6.6%) and they were
subsequently removed from outcomes analysis. 57 shoulders had a mean follow-up of 41.3 months
(range, 24.0-74.2 months). All postoperative outcomes scores and pain scores improved significantly
over preoperative baselines (p<0.05) (Table 1). ASES scores returned to levels of age-matched normals.
Tears that underwent debridement only demonstrated significantly worse QuickDASH scores compared
to the rest of the cohort (mean 12.0 [SE 4.3] versus mean 7.8 [SE 2.1]; p<0.05) whereas shoulders that
underwent acromioplasty demonstrated significantly improved QuickDASH scores compared to the rest
of the cohort (mean 6.8 [SE 2.1] versus mean 13.6 [SE 3.5]; p=0.026).
Conclusion: Arthroscopic treatment for PT supraspinatus tears provides excellent outcomes and
satisfaction in the majority of patients. There were no differences in outcomes between articular- versus
bursal-sided supraspinatus tears; however, QuickDASH scores were affected negatively by debridement
and positively by acromioplasty.
Paper 37
A Prospective Cohort Study of Patients Treated Surgically or Non-Surgically for Full-thickness Rotator
Cuff Tears
Joel Joseph Gagnier, ND, PhD1, Christopher Robbins1, James E. Carpenter, MD2, Asheesh Bedi3, Bruce
Miller4.
1
University of Michigan, Ann Arbor, MI, USA, 2University of Michigan Hosp, Ann Arbor, MI, USA,
3
MedSport, Univ of Michigan, Ann Arbor, MI, USA, 4Ann Arbor, MI, USA.
Objectives: The objectives of this project are: (1) to compare the efficacy of surgical versus non-surgical
management of full-thickness rotator cuff tears, and (2) to detect variables that predict success within
each treatment group.
Methods: Adult patients presenting at MedSport, University of Michigan, with full thickness rotator cuff
tears diagnosed by MRI or ultrasound and no history of shoulder surgery were recruited for inclusion in
the study. Consenting subjects were given baseline written questionnaires which included a Functional
Comorbidity Index, a Charlson Comorbidity Index, demographics form, WORC score, ASES score, VR-12,
modified shoulder activity level, and patient satisfaction forms, as well as an 100 point visual analogue
pain scale. Patients then proceeded with planned treatment, either surgical or non-surgical, as
recommended by their treating surgeon and decided upon themselves. Written questionnaires were
mailed to participants at the following intervals after baseline: 4 weeks, 8 weeks, 16 weeks, 32, weeks,
48 weeks, and 64 weeks. Electronic medical records of subjects were monitored for treatment received.
We described all patient demographic characteristics, and performed logistic regression for variables
associated with treatment allocation and longitudinal modeling with generalized estimating equations
for treatment effects across the follow-up period. We also used Student’ t-tests and Wilcoxon rank-sum
tests where appropriate, to explore differences in treatment effects between the groups for all outcome
measures at all time points.
Results: A total of 184 patients were included with 101 allocated to surgery and 73 to non-surgical
treatment. Those allocated to surgery were younger (OR=0.87, P<0.0001), had a lower BMI (OR=0.83,
P=0.007), less likely to be smokers (OR=0.04, P=0.002), more likely to have a known traumatic injury
(OR=2.40, P=0.002), and had a lower comorbidity score (OR=0.74, P=0.096). Table 1 contains the results
of all clinical outcomes measures used. At baseline the surgery group tended to be in more pain and
have a higher, worse, WORC score. Both the surgical group and non-surgical group tended to improve
on all outcome measures across the follow up period with the surgery group improving at a faster rate
and to a greater degree after 8 or 16 weeks post baseline (see figure 1). Several variables predicted
improvements across time in the surgical group including: older age, non-diabetic, shorter duration of
symptoms, being male, without a known traumatic injury and a lower BMI. For the non-surgical group
the following variables predicted improved outcomes across time: shorter duration of symptoms, higher
baseline activity score, non-smoker, non-worker’s compensation case, nonsmoker, younger in age and
lower BMI. These predictors varied by outcome measure.
Conclusion: Patients with rotator cuff tears who undergo surgical or nonsurgical treatment tend to
improve, with surgical patients improving to a greater degree. There appear to be several predictors of
improved of treatment allocation and outcomes that may help us to tailor our treatments to individuals
Table 1: Stratified outcome data Clinical Measures: those had surgery vs. those
who have not
Total
Mean
SD
Surgery
Mean
Non-Surgery
Mean
SD
SD
Functional
Comorbidity Score
Charlson Comorbidity
Score
Baseline Shoulder
Activity Score
1.3
1.5
1.0**
1.2
1.6**
1.7
0.2
0.8
.12
.60
.34
1.1
10.4
4.9
10.9
4.7
9.6
5.2
VAS Pain
SANE
50.1
28.8
26.7
24.2
55.1**
26.2
24.6
22.6
43.9**
32.1
27.9
25.8
Baseline ASES score
4 week ASES score
8 week ASES score
16 week ASES score
32 week ASES score
55.1
54.2
57.3
67.6
78.4
20.2
22.2
21.9
21.3
19.9
51.9
50.9
52.5**
69.1
83.2**
18.4
21.7
20.5
19.7
17.2
59.1
58.5
64.4**
65.3
70.5**
21.8
22.5
22.3
23.5
21.9
Baseline WORC
1166.7 433.7
1254.3**
366.0
1061.2**
score
4 week WORC score
1130.1 458.5
1257.1**
377.7
973.0**
8 week WORC score
1057.7 474.7
1198.8**
396.2
876.0**
16 week WORC
867.2
450.9
853.0
422.4
886.6
score
32 week WORC
710.6
496.9
509.9*
426.4
710.6*
score
Note: *Significant at p<.05 **Significant at p,<.01 ASES higher score=better, WORC
higher score=worse, Functional and Charlson Comorbidity index higher=worse
484.9
502.6
507.5
490.7
496.9
Paper 38
Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Location,
Restoration of Length-Tension and Mechanical Strength Between Techniques
Brian C. Werner, MD, Matthew Lawrence Lyons, MD, Cody Evans, B.S., Justin W. Griffin, MD, Joseph M.
Hart, PhD, ATC, Mark D. Miller, MD, Stephen F. Brockmeier, MD.
University of Virginia, Charlottesville, VA, USA.
Objectives: The approach to biceps tenodesis remains controversial, as the procedure can be performed
open or arthroscopically. Little data exists directly comparing the arthroscopic suprapectoral and open
subpectoral techniques, particularly in terms of location, restoration of the long head biceps lengthtension relationship, and the mechanical strength of the tenodesis. The purpose of this study was to (1)
determine the in-vivo tenodesis location using arthroscopic suprapectoral (ASPBT) and open subpectoral
techniques (OSPBT) for long head biceps tenodesis and compare this to the location achieved in a
separate clinical cohort, (2) evaluate the in-vivo restoration of the long head biceps length-tension
relationship for both ASPBT and OSPBT techniques and (3) assess how location in the proximal humerus
(suprapectoral or subpectoral) and method of fixation affects pull-out strength for biceps tenodesis
using an interference screw implant. Our null hypothesis was that no difference existed between ASPBT
and OSPBT with regards to location, restoration of the length-tension relationship, and pull-out
strength.
Methods: 18 matched cadaveric shoulder specimens were randomized to either open subpectoral or
arthroscopic suprapectoral tenodesis groups (9 open, 9 arthroscopic.) Tenodesis was performed by two
sports fellowship-trained surgeons using identical clinical techniques. Prior to surgery, a metallic bead
was sutured in place, 1 cm distal to the musculotendinous junction of the long head of the biceps, and a
pre-operative fluoroscopic image was obtained. Post-operatively, an additional fluoroscopic image was
obtained to evaluate the location of the tenodesis and the metallic bead, which was compared to the
pre-operative image to determine tensioning (Fig 1). Biomechanical testing was then performed using a
MTS machine with 2.5kN load cell. Constructs were cycled for 100 cycles, then load to failure testing was
performed.
Results: The average tenodesis location in the ASPBT group of cadaveric specimens was 4.68 cm ± 0.97
cm distal to the top of the humerus, compared with 7.46 cm ± 1.7 cm (p < 0.0001) in the OSPBT group.
This was very similar to the location observed in a separate clinical cohort. The ASPBT technique
resulted in an average of 2.15 ± 0.62 cm of biceps over-tensioning compared with 0.78 ± 0.35 cm (p <
0.001) in the OSPBT group. The average load to failure in the ASPBT group was 138.8 ± 29.1 N compared
to 197 ± 38.6 N (p = 0.002) in the OSPBT group. Implant pullout was significantly more frequent in the
ASPBT (7/9) compared to the OSPBT (1/9) group.
Conclusion: This study revealed several notable differences between the arthroscopic suprapectoral and
open subpectoral biceps tenodesis techniques. The described ASPBT technique using an interference
screw implant results in a more proximal tenodesis location, has the tendency to over-tension the biceps
and has a significantly decreased ultimate load to failure compared with an open subpectoral technique
in matched cadaver specimens. Modification of currently published arthroscopic suprapectoral
techniques is necessary to improve restoration of the physiologic length-tension relationship of the
biceps. Improved implants are likely necessary to achieve equivalent construct strength to the open
subpectoral technique, although the clinical ramifications of this strength discrepancy have not been
established.
Paper 39
Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Minimum Two
Year Clinical Outcomes
Brian C. Werner, MD, Cody Evans, B.S., Russell Holzgrefe, BS, BBA, Matthew Lawrence Lyons, MD,
Joseph M. Hart, PhD, ATC, Eric W. Carson, MD, David R. Diduch, MD, Mark D. Miller, MD, Stephen F.
Brockmeier, MD.
University of Virginia, Charlottesville, VA, USA.
Objectives:While a vast body of literature exists describing biceps tenodesis techniques and evaluating
the biomechanical aspects of tenodesis locations or various implants, little literature presents useful
clinical outcomes to guide surgeons in their decision to perform a particular method of tenodesis. The
goal of this study is to compare the clinical outcomes of open subpectoral biceps tenodesis and
arthroscopic suprapectoral tenodesis. Our null hypothesis is that both methods yield satisfactory results
with regards to shoulder and biceps function, postoperative shoulder scores, pain relief and
complications. Methods: Retrospective cohort study. Patients who underwent either arthroscopic
suprapectoral or open subpectoral biceps tenodesis for superior labral or long head biceps pathology
with a minimum follow-up of 2 years were included in the study. Patients were excluded if they
underwent significant additional shoulder procedures, including rotator cuff repair or procedures to
address glenohumeral instability, if there was significant pre-operative range of motion deficits due to
frozen shoulder or glenohumeral arthritis, or if they had significant contralateral shoulder pathology or
surgery. Subjects were evaluated with several clinical outcome measures and physical examination
including range of motion and strength. Range of motion and strength measurements were normalized
to the asymptomatic contralateral limb. Power analysis indicated that a minimum of 17 subjects were
required in each group (34 total) to determine a clinically meaningful difference in the outcome
measures. Results: Between 2007 and 2011, 79 patients met all inclusion and exclusion criteria, which
included 30 arthroscopic suprapectoral tenodesis (ASPBT) patients and 49 open subpectoral biceps
tenodesis (OSPBT) patients. 23 of 30 (76.7%) ASPBT and 28 of 49 (57.1%) OSPBT patients completed
clinical follow-up at an average of 3.1 year postoperative (range 2.2 - 4.3 years). The cohorts were
similar in terms of age, gender, BMI, smoking and workers compensation status.
Overall outcomes for both procedures were satisfactory. No significant differences were noted in postoperative Constant Murley (ASPBT: 89, OSPBT: 92, p = 0.567), ASES (ASPBT: 89, OSPBT: 88, p = 0.845),
SANE (ASPBT: 86, OSPBT: 86, p = 0.982), SST (ASPBT: 10, OSPBT: 10, p = 0.597), LHB Score (ASPBT: 91,
OSPBT: 94, p = 0.329), or VR-36 (ASPBT: 80, OSPBT: 79, p = 0.833). No significant range of motion or
strength differences (expressed as percent of asymptomatic contralateral limb) were noted between
procedures. (Table I)
$$MISSING OR BAD IMAGE SPECIFICATION {88FF9C4F-B87D-46CC-970B-E0C91582913C}$$
Conclusion: Arthroscopic suprapectoral and open subpectoral biceps tenodesis both yield excellent
clinical and functional results for the management of isolated superior labrum or long head biceps
pathology. No significant differences in clinical outcomes as determined by several validated outcomes
measures were found between the two tenodesis methods, nor were any range of motion or strength
deficits noted at minimum two-years post-operatively.
Paper 40
Subpectoral Biceps Tenodesis For The Treatment Of Type Two And Four Slap Lesions
Michael Brandon Gottschalk, MD1, Spero G. Karas, MD2, Timothy N. Ghattas, MD3, Rachel Burdette, ATC
OTC1.
1
Emory University, Atlanta, GA, USA, 2Emory Sports Medicine Center, Atlanta, GA, USA, 3Stockbridge,
GA, USA.
Objectives: Despite unsatisfactory outcomes in middle aged patients with SLAP lesions, surgical repair
remains the gold standard for most Type II and Type IV SLAP lesions. Given recent data demonstrating
higher SLAP repair failure rates in this subset of patients, biceps tenodesis may offer an excellent
alternative. To our knowledge, only one study has investigated biceps tenodesis as an alternative to
SLAP repair. This study investigates that subpectoral biceps tenodesis provides satisfactory outcomes for
the treatment of Type II and Type IV SLAP lesions in middle aged patients.
Methods: Patients who were older than 18 years old and underwent subpectoral biceps tenodesis for
isolated Type II or Type IV SLAP lesions by a single board certified shoulder surgeon from 2006-2012
were included. Exclusion criteria included those patients with Type II or Type IV SLAP lesions who
underwent biceps tenodesis with rotator cuff repair, Bankart repair, or labral repair. Outcome measures
included Visual Analog Pain Scale (VAS), American Shoulder and Elbow Surgeons Scores (ASES), and
demographic data.
Results: Between 2006-2012, 33 patients underwent 36 subpectoral biceps tenodesis for isolated Type II
or Type IV SLAP lesions by a single board certified shoulder surgeon. 26 patients with 29 shoulder
surgeries consented to participate in the study. Average age was 46.7 years with 16 males and 10
females participating in the study. Average follow up was 29.3 months. A statistically significant
improvement in ASES and VAS scores were found with an average of 48.1 and 6.4 preoperatively and an
average of 87.5 and 1.5 post-operatively (p < .001). There was no statistically significant difference
noted based on SLAP lesion type, age, activity level, or gender. 26 of 29 shoulders (89.65%) were able to
return to their previous activity.
Conclusion: Our study is able to confirm that biceps tenodesis results in statistically significant
improvement in pain and functional outcomes for Type II and IV SLAP lesions. The results of biceps
tenodesis for Type II and IV SLAP lesions is comparable to historical data. Based on these results, biceps
tenodesis is a safe, effective, and technically straightforward alternative to SLAP repair in middle aged
patients.
Demographic, Outcome, and Frequency Data
P
Value
Demographic Data
N=26
Average AgeAge RangeMaleFemaleAverage Follow
UpRange of Follow Up
46.701963161029.307-70
Outcomes
N=29
Average Pre Op ASESRange of Pre Op ASESAverage
Post Op ASESRange of Post Op ASES
48.10326887.5046.7-100
.001
Average Pre Op VASRange of Pre Op VASAverage Post
6.404-101.500-8
Op VASRange of Post Op VAS
.001
Type of Lesions
N=29
Type II SLAP Lesions
19
Type IV SLAP Lesions
10
Associated
Lesions/Surgery
Buford ComplexGlenohumeral ChangesAC Joint
ArthritisImpingement/SAD
151426
N=29
Partial RTC TearAdhesive CapsulitisPrior SLAP Repair
1033
Paper 41
Significant Association Between Snapping Scapula Syndrome and Anterior Angulation of the
Superomedial Scapular Angle
Peter J. Millett, MD, MSc1, Sean Smith2, Charles Ho, MD, PhD2, Ulrich Spiegl, MD2.
1
Steadman Clinic, Vail, CO, USA, 2Steadman Philippon Research Institute, Vail, CO, USA.
Objectives: Significant Association Between Snapping Scapula Syndrome and Anterior Angulation of the
Superomedial Scapular Angle Methods: In this Institutional Review Board approved study, bony
morphologies of the scapula were evaluated on the MRIs of 28 patients (28 scapulae) with SSS and 20
patients (22 scapulae) with non-SSS pathologies. Patients with SSS were identified from a prospective
surgical registry that had undergone a preoperative shoulder MRI along with scapular bursectomy
and/or superomedial angle resection. The non-SSS patients underwent shoulder MRIs for other reasons
that subsequently allowed for evaluation of the scapula. The medial scapula corpus angle (MSCA), was
measured on axial STIR or PD FSE sequences cranial to the spine of the scapula (Figure 1). Scapula length
angled towards rib cage was documented. Scapulae were categorized as straight, s-shaped or concave.
Two blinded observers, one radiologist and one orthopedic surgeon, reviewed all MRIs. MSCAs were
measured using Stryker OfficePACS Power 4.1 Express Edition (Kalamazoo, MI). Positive MSCAs were
defined as anterior scapular angulation towards the thorax in the axial plane whereas negative MSCAs
were defined as posterior scapular angulation away from the thorax in the axial plane.
Results: Axial scapula corpus configurations were identified: 31 scapulae were of the straight type, 14
were s-shaped and 5 were concave. All five concave scapulae had surgically confirmed SSS. The
measurement of MSCA had excellent inter-observer agreement of 0.81 [95% CI, 0.68 to 0.89] and a fair
to good intra-observer agreement of 0.68 [95% CI, 0.50 to 0.80]. There were significant differences in
the mean MSCAs between those with SSS (14.4° ± 19.3°) and those with other pathologies (-3.3° ± 15.3°;
p = 0.001). After excluding all concave scapulae (n = 5), the differences in the mean MSCAs between the
SSS and non-SSS groups were significant (MSCA for SSS: 15.3° ± 17.5° MSCA for non-SSS: -3.3° ± 15.3°; p
< 0.0001). Twenty of 28 (71.4%) scapulae with a positive MSCA had SSS, whereas only 3 of 17 (25%)
scapulae with a negative MSCA had SSS (see Figure 1). The mean length of the medial scapula border
angled to towards the rib cage was 14.4mm (± 4.6mm). Conclusion: Anterior angulation of the
superomedial angle in the axial plane had an association with SSS. Those patients with a concave-shaped
scapula and a positive MSCA may be at risk for SSS. This information may have clinical relevance in the
treatment of SSS patients since there are no guidelines on the amount of scapular resection may or may
not be needed. The MSCA may prove helpful in determining the location and amount of scapula
resection needed to reduce SSS symptoms in patients.
Paper 42
Outcomes of Operative and Non-operative Treatment of Adolescent Mid-diaphyseal Clavicle Fractures
Benton E. Heyworth, MD1, Collin May, MD2, Sasha Carsen, MD3, Kyna Donohue, BS2, Patricia Miller4,
Dennis E. Kramer, MD5, Mininder S. Kocher, MD, MPH2, Donald S. Bae, MD6.
1
Children's Hospital Boston, Division of Sports Medicine, Boston, MA, USA, 2Boston Children's Hospital,
Boston, MA, USA, 3Boston Children's Hospital, USA, 4USA, 5Children's Hospital (Boston) Program, Boston,
MA, USA, 6Brookline, MA, USA.
Objectives: The optimal treatment approach to clavicle fractures in adolescents remains an area of
significant controversy. The purpose of this study was to review the demographic characteristics,
treatment approaches, and complications in a large series of adolescent clavicle fractures receiving
operative and non-operative treatment.
Methods: Radiographic and medical record review was conducted for all cases of patients ages 10-18
years-old who presented to a single tertiary care children’s hospital between 2003-2012 with a middiaphyseal clavicle fracture. Demographic data, radiographic features, such as fracture pattern,
operative details when applicable, and post-treatment clinical course was analyzed, including the
reported time to healing and any known complications.
Results: Out of 641 cases reviewed (79% male; mean age 14.3 years), 408 (64%) fractures were
sustained during sports, most frequently football (25%), hockey (18%), soccer (12%), snowboarding
(12%) and skiing (9%). Other common mechanisms of injury were falls sustained outside of athletic
activity (19%) and motor vehicle accidents (5%), with similar distribution of mechanism and similar rates
of associated injuries seen within the operative (5%) and non-operative (6%) treatment groups. Greater
numbers of clavicle fractures were seen annually over the study period. Among the overall cohort, 82%
were treated non-operatively, while 18% were treated surgically, with increasing percentage of patients
undergoing surgery over the course of the study period. The mean age was higher in the operative
group (15.5 years) than the nonoperative group (14.1 years)(p<0.001). Fifty-eight documented
complications occurred in 46 patients (7.2%), were significantly more common in the operative (16%)
group than the non-operative (5%) group (p<0.001), and were more common in older patients
(p=0.007). Only 1 case of nonunion occurred in each treatment group (p=0.56). The rate of symptomatic
implants was 13% in the operative group (leading to plate removal in 9% cases), while the rate of
symptomatic malunion was 2% in the nonoperative group. Refracture was significantly more common in
the nonoperative group (3%) than the operative group (2%) (p=0.03). Refracture in the non-operative
group most commonly occurred in the period before complete healing had occurred. Of the 2 cases of
refracture in the operative group, 1 case was a peri-implant fracture and 1 case occurred over 1 year
following plate removal. No infections were reported in either group. One of the nonoperative
symptomatic malunion patients developed thoracic outlet syndrome requiring osteotomy, which led to
symptom resolution. One of the operative patients developed contralateral recurrent laryngeal and
hypoglossal neuropraxia (Tapia’s syndrome), causing vocal cord paralysis, tongue deviation, and
hoarseness, with near complete resolution at the time of most recent follow up, four months postoperatively.
Conclusion: Greater numbers of clavicle fractures are being seen in the adolescent population, with over
60% of cases occurring during sports and an increasing trend towards operative treatment in recent
years. Nonunion and symptomatic malunion are rare in adolescents. While refracture is more common
following nonoperative treatment, overall complication rates appear to be more common following
operative management, the most common of which is symptomatic implants.
Paper 43
Biomechanical Consequences of Coracoclavicular Reconstruction Techniques on Clavicle Strength
Ulrich Spiegl, MD1, Sean Smith1, Simon A. Euler, MD1, Grant Dornan1, Peter J. Millett, MD, MSc2, Coen A.
Wijdicks, PhD1.
1
Steadman Philippon Research Institute, Vail, CO, USA, 2Steadman Clinic, Vail, CO, USA.
Objectives: Lateral clavicle fractures have been reported following coracoclavicular (CC) ligament
reconstruction with bone tunnels through the clavicle. Several techniques for CC reconstruction with
different drill-hole measurements have been described. Our objective was to evaluate clavicle
weakening related to tunnel diameters for common CC-reconstruction techniques.
Methods: Testing was performed on 2 groups of 18 matched pair clavicles, which were randomly
distributed between groups. There were no significant differences between the groups regarding bone
mess density (BMD), clavicle width, age, and gender. One clavicle from each pair was prepared
according to one of two reconstruction techniques; the contralateral clavicle was left intact. Both
techniques placed 2 tunnels through the medial clavicle, 30 mm and 45 mm from the lateral border.
Group 1 (mean age: 53, range: 44-63; mean BMD: 0.48, range: 0.39-0.59) was prepared with 2.4 mm
tunnels and augmentation devices. Group 2 (mean age: 56, range: 45-63; mean BMD: 0.47, range 0.350.61) was prepared with 6.0 mm tunnels with hamstring grafts and tenodesis screws. A 3-point bending
load was applied to the distal clavicles at 15 mm/min until failure. Ultimate failure load and anteriorposterior width 45 mm medial from the lateral border were recorded for each specimen. Strength
reduction was determined as the percent reduction in ultimate failure load between paired intact and
surgically prepared clavicles. Relative tunnel size was determined as the quotient of tunnel diameter and
clavicle width. An independent observer performed all clavicle width measurements. Non-parametric
statistics were used (MWU, Kendall’s Tau).
Results: The 6.0 mm technique significantly reduced clavicle strength relative to intact (p = 0.02) and
caused significantly more strength reduction than the 2.4 mm technique (p = 0.02) (Figure). The 2.4 mm
technique was not significantly different from intact. All but one fractures occurred at the medial tunnel.
Clavicle width at the medial hole varied highly (mean: 18.1 mm, range: 12.3 - 27.1 mm). There was a
significant approximately linear correlation between clavicle width and strength reduction (p = 0.04, tau
= -0.36) and between relative tunnel size and strength reduction (p < 0.01, tau = 0.51). Therefore,
clavicle strength reductions of 30% and 50% relative to the intact state can be expected with relative
tunnel diameters of 34.5% and 49.8% of the clavicle width, respectively. The intra-observer correlation
coefficient of the width measurement was excellent (0.99; 95% CI: 0.98 - 0.99).
Conclusion: Coracoclavicular ligamentous reconstruction with 6.0 mm tunnels, graft, and tenodesis
screws caused significantly greater decreases in the strength of the clavicle when compared to 2.4 mm
tunnels with augementation devices and undrilled controls. Additionally, strength reductions correlated
highly with the ratio of tunnel width relative to overall clavicle width. This information can help optimize
techniques for reconstructing unstable distal clavicles and can influence the intraoperative decision-
making process based on the individual clavicle width.
Paper 44
Meniscal Repair with Concurrent Anterior Cruciate Ligament Reconstruction: Operative Success and
Patient Outcomes at 6-Year Follow-up
Robert W. Westermann, MD1, Rick W. Wright, MD2, Laura J. Huston, MS3, MOON Knee Group4, Brian R.
Wolf, MD, MS5.
1
University of Iowa, Iowa City, IA, USA, 2Washington University Dept of Orthopaedic Surgery, Saint Louis,
MO, USA, 3Vanderbilt Orthopaedic Institute, Nashville, TN, USA, 4Vanderbilt University School of
Medicine, Nashville, TN, USA, 5UI Sports Medicine, Iowa City, IA, USA.
Objectives: Meniscus repairs are commonly performed concurrently with anterior cruciate ligament
reconstruction (ACLR) in the acutely injured knee. Properly functioning menisci coupled with knee
stability are thought to be critical factors in achieving optimal outcomes. While meniscal repair in
conjunction with ACLR has demonstrated good success at 2 years, no large-scale, prospective,
multicenter studies have evaluated long-term patient-oriented outcomes after combined ACLR and
meniscus repair. We hypothesize that patient-centered outcome scores will deteriorate and ipsilateral
reoperations will increase at 6 years following combined ACLR and meniscus repair.
Methods: All unilateral primary ACL reconstructions from the Multicenter Orthopaedic Outcomes
Network (MOON) between 2002 and 2004 were evaluated, and patients who underwent concurrent
meniscus repair were selected. Validated patient-oriented outcome data [Knee Injury and Osteoarthritis
Outcome Score (KOOS), Western Ontario and McMaster Universities (WOMAC) scores, Marx activity
scores and International Knee Documentation Committee (IKDC) scores] was gathered at 2 and 6 years
following the index procedure. Subsequent ipsilateral knee re-operation was confirmed by operative
reports to evaluate for failure of meniscal repairs.
Results: In total, 1440 primary ACLR’s were performed between 2002 and 2004 as part of the study
cohort. Of these, 286 subjects underwent concurrent meniscus repair (298 meniscal repairs). 235/286
(82.2%) were available for follow up at 6 years (154 medial meniscus repairs, 72 lateral meniscal repairs,
and 9 patients who underwent both lateral and medial meniscal repairs). Overall, the success rate of
meniscal repair at the time of ACLR was 86% (202/235) at 6 years.
We found an 86.4% six year success rate with combined ACLR and medial meniscal repair, 86.1% for
lateral meniscal repairs and 77.8% when both medial and lateral menisci were repaired. 27.3% (9/33) of
the failures were associated revision ACL surgery. Medial meniscal repairs failed earlier (mean 2.1 years)
than lateral meniscal repairs (mean 3.7 years) (p=0.01).
All-inside techniques were performed in 88.5% of cases. There were 31 failures with this technique
representing a 14.9% failure rate. There was one failure in the inside-out technique group (1/19, 5.2%),
and one failure noted in the outside-in technique group (1/6, 16.6%).
Significant improvements were observed in patient reported outcomes [KOOS Symptoms, KOOS Pain,
KOOS KRQOL, WOMAC Pain, and IKDC scores] when baseline scores were compared to 6-year follow-up.
No significant clinical differences were observed between 2 and 6 year follow up indicating there was no
clinical deterioration over this time period. Marx Activity levels gradually declined from time of injury to
6-year follow-up.
Conclusion: Concurrent meniscal repair with ACLR is associated with success rates approximating 86% at
6-year follow-up. Patient-oriented outcome measures were generally similar between 2 and 6 years
follow up. Surgeons may expect good clinical outcomes 6 years after combined ACLR and meniscus
repairs.
Paper 45
10 Year Outcome Following Meniscus Repair Using Inside-Out Technique: A Comparative Cohort of
Patients 40 years and Older vs Patients Younger than 40
J. Richard Steadman, MD1, Bernardo Crespo2, Nicholas Johnson, MD3, Lauren Matheny, BA2, Karen K.
Briggs, MPH, MBA3.
1
The Steadman Clinic, Vail, CO, USA, 2Steadman Philippon Research Institute, Vail, CO, USA, 3Steadman
Philippon Research Institute, Vail, CO, USA.
Objectives: The number of meniscus repairs being performed is increasing, as research supports the
need to preserve native meniscus tissue. Although excellent short-term results have been published
after meniscus repair, there are limited data available on longer outcomes in patients treated with a
single type of repair. The purpose of this study was to compare failure rate and clinical outcomes 10
years following mensicus repair, using inside-out technique, by a single surgeon in patients 40 years and
older and patients younger than 40 years.
Methods: A prospective data registry was queried for knee arthroscopies between 1992 and 2003 for
meniscus repairs performed by a single surgeon. This study was IRB approved. Patients who underwent
arthroscopic meniscus repair using inside-out technique were included. Exclusion criteria included
patients younger than 18 years. Repairs were considered a failure if the knee had a subsequent surgery
on the same meniscus or the knee was converted to a total knee arthroplasty(TKA). If knees required
subsequent surgery on the meniscus, it was documented if it was a re-repair or meniscectomy. General
health measure included the SF12 physical component score (PCS) and the mental component
score(MCS). Condition specific outcomes included the Lysholm score, WOMAC and IKDC score. Activity
was measured by the Tegner activity scale and patient satisfaction with outcome was measure on a 1 to
10 scale with 10 being very satisfied. Outcomes and failures were compared between patients 40 years
and older(40P) and patients younger than 40(40Y).
Results: 206 patients were met the inclusion criteria. The average age was 33 years
(range, 18 to 70 years) and there were 75 females and 131 males. Sixty-four (31%) knees underwent a
subsequent knee surgery; 61 patients had a second meniscus surgery on the same meniscus and three
had a TKA, and were therefore considered failures. Of the 61 patients who underwent a second
meniscus surgery, 47 had a meniscectomy and 14 had a meniscus repair. The average age of the failure
group was 33 years (range, 18 to 65 years), with 15 over the age of 40 at time of repair. The was no
difference in the number of failures between 40P group and 40Y group(p=0.975) The average time to
failure was 4.9 years postoperatively (range, 0.8 months to 18.6 years). Of the remaining patients,
average followup was 14 years (range, 10 to 21 years). The average PCS was 54 and the average MCS
was 54. The average Lysholm at latest followup was 86, the average WOMAC was 6 and the average
IKDC was 73. The median Tegner activity scale was 6 (range, 1 to 9). The median patient satisfaction with
outcome was 9 (range, 1 to 10). There was no difference in any outcome measure between the 40P
group and the 40Y group.
Conclusion: Ten years following meniscus repair, 30% of patients required repeat surgery of the
meniscus or had a TKA. Older patients did not experience increased failures. Outcomes showed
excellent function, low disability and high activity level 10 years following meniscus repair.
Paper 46
Outcome of All-Inside Second Generation Meniscal Repair: Minimum 5-year Follow-up
Ljiljana Bogunovic, MD1, Amanda Haas, MA2, Lisa Kruse, MD3, Rick W. Wright, MD4.
1
Washington University Orthopaedic Surgery, Saint Louis, MO, USA, 2Washington University School of
Medicine, St. Louis, MO, USA, 3St Louis, MO, USA, 4Washington University Dept of Orthopaedic Surgery,
Saint Louis, MO, USA.
Objectives: In the setting of injury, meniscal repair and preservation is the goal when possible. Current
research on second generation all-inside repair systems is limited to a maximum of three year follow-up.
The purpose of this study is to evaluate the long-term (> 5 years) clinical success of isolated meniscal
repairs and those performed with concomitant ACL reconstruction using a second generation all-inside
repair device.
Methods: This a retrospective review of patients who underwent meniscal repair utilizing the all-inside
FasT-Fix meniscal repair system (Smith & Nephew Arthroscopy, Andover, MA) between December 1999
and January 2007. Eighty-three meniscal repairs in 81 patients were identified and follow-up was
obtained in 90%. Twenty-six patients (35%) had isolated meniscal repair. Clinical failure was defined as
repeat surgical intervention involving resection or revision repair. Clinical outcomes (KOOS, IKDC, Marx
Activity) were also assessed.
Results: Minimum follow-up was 5 years (avg. 7 years). Twelve patients failed meniscal repair (16%). The
average time to failure was 47 months (range, 15 - 94). There was no difference in average patient age,
sex or number of sutures utilized between successful repairs and failures. There was no difference in
failure rate between isolated repairs (11.5% CI: -0.76%-23.76%) and those performed with concurrent
ACL reconstruction (18.3% CI: 7.47%-29.13%) and the average time to failure was similar between these
two groups (48.1 months versus 46.6 months, p=0.243). Postoperative outcome scores were also similar
(KOOS and IKDC).
Conclusion: This first report of long term (> 5 yrs) follow-up of second generation all-inside meniscal
repair demonstrates it is an effective method of primary meniscal repair for both isolated repairs and
those performed with concurrent ACL reconstruction. After minimum five year follow-up, over 84% of
patients continue to demonstrate successful repair. Treatment success is further supported by favorable
results on patient based outcome measures.
Paper 47
A Load-Sharing Tissue Engineered Meniscus Scaffold: One Year Outcome
Charles J. Gatt, MD, Jay Milan Patel, BS, Aaron R. Merriam, PhD, Brian Culp, MD, Michael G. Dunn, PhD.
Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Objectives: Arthroscopic partial meniscectomy is one of the most commonly performed orthopaedic
procedures. Although the procedure provides good symptom relief, long term follow up suggests the
procedure results in an early onset of degenerative knee arthritis in a significant percentage of patients.
Currently, treatment options for lost meniscal tissue are extremely limited and those available do not
provide a long term solution. Therefore, there exists a need for a functional meniscus replacement in
order to prevent joint deterioration. The objective of this project was to test a cross-linked collagenhyaluronan sponge reinforced with synthetic, resorbable poly(DTD DD) fibers for meniscal implantation
in an ovine model.
Methods: Meniscus scaffolds were fabricated from poly(DTD DD) fibers woven into a semi-lunar wedge
shape with extended tails for rigid tibial fixation. A dispersion of hyaluronic acid and type I bovine
collagen was injected into the woven fiber scaffold. The scaffold was then lyophilized, crosslinked, and
irradiated. The time-zero mechanical properties of the scaffold were evaluated with ultimate tensile
testing and compression creep testing, and for load sharing function with a novel hoop stress evaluation
and joint pressure distribution using Tekscan monitoring. The scaffolds were evaluated in an in vivo
ovine model. A total medial meniscectomy was performed in the right hind leg of 30 sheep. Twenty-four
of these sheep received a tissue engineered scaffold. The scaffold was anchored to the tibial plateau at
the anterior and posterior root locations with titanium interference screws and sutured to the medial
capsule. The remaining 6 sheep did not receive an implant and served as controls. Eight experimental
and two control sheep were sacrificed at 16, 32 and 52 weeks. Scaffolds and adjacent articular cartilage
underwent comprehensive mechanical and histological evaluation.
Results: Pre-implantation characterization: Ultimate tensile strength of the implant was 660N. The
compressive modulus was 0.15MPa. Hoop stress evaluation demonstrated a linear correlation between
joint axial load and tensile stress in the implant. Tekscan evaluation demonstrated the implant increased
joint contact area and decreased peak contact stress. In vivo evaluation demonstrated, at all time
points, all 24 implants were fully intact and well healed to the surrounding capsule and maintained the
meniscus-like shape (Figure 1). Gross and histological evaluation of the articular cartilage adjacent to the
implant demonstrated minimal degenerative change in experimental knees. Control knees
demonstrated advanced cartilage degradation adjacent to the meniscal resection. Robust tissue
ingrowth into the implants was histologically demonstrated with tissue deposition occurring in a pattern
consistent with tensile stresses in the implant. The tensile strength of the scaffold explant was 255N at
16 weeks and 237N at 32 weeks and 210N at 52 weeks. The compressive modulus was 0.29 MPa at 16
weeks, 0.34 MPa at 32 weeks, and 0.49 MPa at 52 weeks.
Conclusion: The results of this study support the feasibility of a tissue engineered load sharing scaffold
for treatment of significant meniscal damage. The scaffold has the potential to prevent degenerative
changes that occur after meniscectomy. Longer term studies will be necessary to confirm the true
chondroprotective capabilities of this scaffold.
Paper 48
Arthroscopy Skills Development with a Surgical Simulator: A Comparative Study in Orthopaedic Surgery
Residents
Brian J. Rebolledo, MD1, Alejandro Leali, MD2, Jennifer Hammann2, Anil S. Ranawat, MD1.
1
Hospital for Special Surgery, New York, NY, USA, 2New York, NY, USA.
Objectives:Traditional resident assessment of orthopaedic surgical technical proficiency relies
exclusively on subjective parameters. More standardized objective measures are needed to ensure
training consistency and surgical competency. The purpose of this study was to determine if orthopaedic
surgery residents who train with a virtual reality simulator can lead to improved arthroscopy
performance and to determine if a standardized arthroscopic shoulder and knee test were appropriate
means for evaluating a resident's arthroscopic skill after completing a training course. Methods: Study
participants were first and second year orthopaedic surgery residents at a single institution who were
randomized to either train on the virtual reality surgical simulator (Insight Arthro VR) for a total of 2.5
hours (n=8) or receive 2 hours of didactic lectures with models (non-simulator) (n=6). Both groups were
then evaluated in both knee and shoulder arthroscopy using a cadaver. Performance was measured by
time to completion of a standardized protocol checklist and cartilage grading index (CGI) (scale 0-10).
Results: All subjects had no previous arthroscopy experience prior to the study. The simulator group had
a shorter time to completion in both knee (simulator: 5.1 ± 1.8 min, non-simulator: 8.0 ± 4.4 min;
p=0.09) and shoulder (simulator: 6.1 ± 1.5 min, non-simulator: 9.9 ± 3.2 min; p=0.02) arthroscopy.
Similarly, the simulator group had improved CGI scores in both the knee (simulator: 4.0 ± 1.1, nonsimulator: 5.3 ± 1.5; p=0.07) and shoulder (simulator: 3.4 ± 0.8, non-simulator: 5.5 ± 1.6; p=0.008)
arthroscopy. Conclusion: This study suggests that surgical simulators are beneficial in arthroscopy skills
development for orthopaedic surgery residents. An arthroscopic testing model was able to measure a
statistical improvement for a resident's arthroscopic skill. Instituting standardized cadaveric testing
based on common orthopaedic surgical procedures such as knee and shoulder arthroscopy will not only
ensure graduating residents possess the necessary skills to be technically proficient surgeons but it will
also allow objective identification of residents in need of remediation.
Paper 49
Comparison of Transtibial and Tibial Inlay Techniques for Posterior Cruciate Ligament Reconstruction
with an Average of 10 Year- Followup.
Jong Keun Seon, MD1, Eun Kyoo Song2, Hyoungwon Park3.
1
Chonnam National University Hwasun Hospital, Hwasun, Korea, Republic of, 2Chonnan National
University, Hwasun, Korea, Republic of, 3Hwasun.
Objectives: We performd this study to determine the long-term results based on clinical and
radiographic outcome comparison following either transtibial or tibial inlay technique, and to find out
factors related to osteoarthritis after PCL reconstruction.
Methods: Seventy-seven patients (77 knees) treated with the PCL reconstruction for chronic injuries
constituted the study cohort. The 77 patients were divided into 2 groups, namely, transtibial (44
patients) and tibial inlay (33 patients). The mean time from injury to reconstruction was 12.2 months
(range, 2 to 60 months), and their average follow-up was 142 months (range, 97 to 192 months).
Outcomes were measured using Lysholm knee scores, Tegner activity scores, laxity test using Telos
device, and development of osteoarthritis.
Results: There was significant improvement of Lysholm knee scores, Tegner activity scores, and laxity
test using Telos device between the preoperative values and final follow-up values (P < .05). However,
there was no significant difference in the final follow-up outcomes (P > .05). The final follow-up
radiographs according to International Knee Documentation Committee guidelines showed that 7
patients (22.7%) in transtibial group and 4 patients (18.2%) in tibial inlay group were rated as Grade C.
We found correlation between meniscectomy and osteoarthritis, but other factors including
reconstruction technique, sex, age, and posterior instability did not influence the arthritic changes in
both groups (Fig 1).
Conclusion: The clinical and radiographic outcomes between the two surgical techniques of PCL
reconstruction were comparable. Osteoarthritis was observed in some patients with a significant
proportion showing some loss of joint space, and factors except meniscectomy did not show correlation
with development of osteoarthritis.
Paper 50
Quantification Of Trochlea Dysplasia Via Computed Tomography: Assessment Of Morphology Difference
Between Control And Chronic Patellofemoral Instability Patients
Sangmin Ryan Shin1, Anthony A. Schepsis, MD2, Akira Murakami, MD3, Cory M. Edgar, MD, PhD4.
1
Brigham & Women's Hospital, Harvard Medical School Program, Chestnut Hill, MA, USA, 2Boston
University Medical Center, Boston, MA, USA, 3Boston Medical Center, USA, 4University of Connecticut,
Farmington, CT, USA.
Objectives: Trochlear dysplasia is an important risk factor for the development of recurrent patella
instability. Owing to its complex 3-Dimensional morphology, the need for a true lateral radiograph, and
poor inter-observer reliability, the Dejour classification system of dysplasia may not be the most optimal
measure for quantification. The purpose of this study is to report a novel technique to define and
quantify the trochlea volume and length using an axial computed tomography. This technique was
applied to a series of patients surgically treated for recurrent patellofemoral instability and the
measurements compared to a control group.
Methods: From 2007 to 2013, 99 control patients (136 knees) were identified from trauma CT scans
obtained during admission at our Level I trauma hospital. Patients’s older than 35y/o or with fractures in
the distal femur were excluded. Axial cuts at 1.25mm were used to measure trochlea volume; defined to
be from the physeal scar to the final axial image in which the sulcus could be visualized (Figure 1).
Trochlear groove distance was measured from a midline sagittal reformatted image perpendicular to the
posterior margin of the femoral condyles. The inter-observer reliability was assessed with independent
measurements from attending orthopedist, MSK radiologist and two senior residents.
Dysplasia patient cohort was a series of 35 patients (70knees) who were surgically treated for recurrent
instability, by AAS or CME, from 2007-2013 and a diagnosis of dysplasia based on lateral knee
radiograph. CT tracking studies are obtained from bilateral knees as a normal part of our pre-operative
assessment. Institutional IRB approval was obtained for data retrieval.
Results: Control cohort average age 25 +/- 4 years, 68M:31F, without documented history of patella
instability on chart review. Dysplastic cohort average age 24 +/- 5 years, 2M:33F, all 35 patients had
bilateral knees scanned. Statistically significant differences were noted in comparing the trochlea
volume (3.75 +/- 0.97 cm3 vs. 2.0+/- 0.56 cm3) and the trochlea length (34.8 +/- 4.9 mm vs. 31.7 +/- 4.2
mm) between control and dysplastic cohorts respectively. Comparing female only patients
demonstrated difference in trochlea volume (2.89 +/- 0.57 cm3 vs. 2.0+/- 0.36 cm3), but not trochlea
length (31.7 +/- 2.5 mm vs. 31.7 +/- 2.7 mm). No difference in trochlea volume or length b/w
symptomatic knee to asymptomatic contralateral knees in patients with recurrent instability (2.31 cm3
vs. 2.24 cm3) and (30.0 mm vs. 30.5 mm). Inter-observer reliability was assess measuring trochlea
volume: ICC for Right Trochlea: 0.98, ICC Left Trochlea: 0.97.
Conclusion: This novel technique clearly defines and quantifies the trochlea morphology into volume
and length values with high ICC values. Applying this technique demonstrates a significant difference in
both trochlea volume and length between a control group and patients treated for recurrent
patellofemoral instability.
Figure 1.
Example of CT quantification method comparing a control patient A-C and dysplastic patient D-F,
volumaized trochlea represented in C (control) and F (dysplastic).
Paper 51
Prospective Hip and Knee Strength Measures Associated with Increased Risk for Patellofemoral Pain
Incidence
Kristen Herbst, D.O.1, Kim D. Barber Foss, MS, ATC2, Timothy E. Hewett, PhD, FACSM3, Denver T.
Stanfield, MD4, Gregory D. Myer, PhD, CSCS5.
1
Mercy Hospital Anderson/University of Cincinnati College of Medicine Program, Cincinnati, OH, USA,
2
Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA, 3The Ohio State U. Sports Health &
Performance Inst., Columbus, OH, USA, 4Wellington Orthopedic and Spts Med., Cincinnati, OH, USA,
5
Cincinnati Children's Hospital Medical Ctr, Cincinnati, OH, USA.
Objectives: Hip and knee strength abnormalities have been implicated in patellofemoral pain (PFP) in
multiple studies in the recent literature. However, many authors have noted that hip muscle weakness
has not yet been defined as having a causal relationship to PFP due to the fact that many studies used
subjects already diagnosed with PFP. The purpose of this study was to compare prospective hip and
knee isokinetic strength measures in young females who subsequently went on to develop PFP relative
to their uninjured healthy peers.
Methods: Middle and high school female athletes (n=255) were evaluated by a physician for PFP
prevalence. Isokinetic strength measurements of the knee (flexion and extension at 300°/sec) and hip
(abduction at 120°/sec) were obtained prior to the start of their basketball and soccer seasons.
Isokinetic torque measures (newton*meters) were normalized to leg length by mass and are described
as a normalized torque (NT). Those diagnosed with PFP at pre-season were excluded and the remaining
athletes were monitored by certified athletic trainers for PFP incidence during their competitive
seasons. A one-way ANOVA was used to determine significant differences in knee and hip strength
measures between the incident PFP and the control groups.
Results: Young females who developed PFP were not different in age 12.6 ± 0.9 yrs., mass 51.4 ± 13.2
kg, height 158.8 ± 7.3 cm, or leg length 83.8 ± 4.2cm compared to the referent control group (P>0.05).
Females who developed PFP demonstrated increased normalized hip strength 0.013 ± 0.003 NT relative
to the referent control group 0.011 ± 0.003 NT (P<0.05). Normalized knee extension and knee flexion
strength were not different between the females with incident PFP compared to the referent control
group (P>0.05).
Conclusion: The findings in this study indicate that young females with greater hip abduction strength
may be at an increased risk for the development of PFP. Previous studies that have looked at landing
biomechanics indicated that those with PFP have increased knee abduction and increased hip adduction
during landing. Combining our current data and previous literature, we theorize that greater hip
abduction strength may be a resultant symptom of increased eccentric loading of the hip abductors
associated with increased dynamic valgus biomechanics demonstrated to underlie increased PFP
incidence. Future research is warranted to dissect the relative contributions of hip strength and
recruitment and dynamic valgus alignments during landing to the pathomechanics of PFP.
Paper 52
Return to Play Following Metacarpal Fractures in Football Players
Brian Etier, MD1, Anthony J. Scillia, MD1, Darin D. Tessier, MD1, Kyle Aune, MPH1, Benton A. Emblom,
MD2, Jeffrey R. Dugas, MD2, E. Lyle Cain, MD2.
1
American Sports Medicine Institute, Birmingham, AL, USA, 2Andrews Sports Medicine and Orthopaedic
Center, Birmingham, AL, USA.
Objectives: Injuries involving fractures of the metacarpals are common among football players of all
levels. These injuries are typically treated conservatively with casting or splinting among non-in-season
athletes, a method that involves a relatively lengthy recovery time (four weeks). To our knowledge,
there are no previous reports documenting return to play in elite football players after operative
management of metacarpal fractures. The purpose of this study was to retrospectively review and
describe the results of operative treatment of metacarpal shaft fractures in 19 high level football players
with respect to return to play. We hypothesized that in-season football players with metacarpal
fractures treated surgically would be able to return to play more quickly than the typical recovery time
following non-operative treatment.
Methods: Surgically treated metacarpal fractures in elite football players were queried over a three-year
period (2009-2012) from a database maintained by American Sports Medicine Institute (ASMI) in
Birmingham, AL. Over the study period, 19 football players were identified who underwent open
reduction internal fixation of metacarpal fractures by one of three attending surgeons. Retrospective
chart review and phone interviews with the patient and their athletic trainers were performed to
identify player position, level of competition, mechanism of injury, return to play, post-operative
bracing, and re-fracture event. Radiographs were used to classify the fractures, and operative reports
were reviewed for implant choice. Numerical means were calculated for in-season return to play as well
as for brace time.
Results: Ten high school players (53%) and nine college players (47%) were injured. The most common
injured positions were wide receivers and defensive backs (26% each). Most injuries occurred through
player to player contact (63%) at a game (37%) or practice (47%). The long finger (58%) was the most
commonly involved metacarpal. Two players (11%) had multiple metacarpal fractures. The most
common location was mid-diaphyseal (74%). Twelve patients were stabilized with plates and screws,
five of whom underwent lag screw augmentation. Six patients were stabilized with a metacarpal nail and
one was stabilized with only lag screws. All athletes were able to return to their pre-injury level of play
without recurrence of fracture. Return to play for in-season athletes (N=11) was 6.3 days. The average
time to return to play for in-season high school football players (N=6) was 9.2 days and 2.8 days for inseason collegiate football players (N=5). All in-season athletes returned to play with protective
equipment in the form of a padded glove, bivalve padded cast, padded club cast, or padded splint. The
protective equipment was used for an average of 21 days.
Conclusion: This study provides support for the surgical treatment of displaced metacarpal shaft
fractures with immediate return to play as tolerated for in-season football players. No re-fractures or
complications were identified with the use of a plate, nail, or with lag screws. Elite football players can
return to play with or without protective bracing depending on the position played and within a week of
operative fixation.
Paper 53
MRI Characterization and Diagnosis of Individual Syndesmotic Structures in Asymptomatic and Injured
Cohorts
Thomas O. Clanton, MD1, Charles P. Ho, MD, PhD2, Robert F. LaPrade, MD, PhD1, Brady T. Williams, BS3,
Rachel Kathleen Surowiec, MSc2, Coley Gatlin, MD2, C. Thomas Haytmanek, MD4.
1
The Steadman Clinic, Vail, CO, USA, 2Steadman Philippon Research Institute, Vail, CO, USA, 3Steadman
Philippon Research Institute, USA, 4The Steadman Clinic, USA.
Objectives: The purpose of this study was to characterize the MRI presentation of the distal tibiofibular
syndesmosis in both asymptomatic volunteers and injured patients to define the optimal MRI
sequencing image(s) for each structure and further improve clinical diagnostic sensitivity and reliability
of common syndesmotic injuries. Additionally, we correlated the presentation of individual structures
on MRI with anatomic investigations to assess the ability of MRI to reproducibly identify the individual
syndesmotic structures and common pathology.
Methods: This study was IRB approved. Age-matched volunteers deemed asymptomatic by selfreported subjective measures, objective physical exam, and morphological MRI exam were analyzed to
refine syndesmosis imaging and define the optimal MRI sequence(s) for the characterization of the
individual articular structures. Twenty patients from the practice of one foot and ankle fellowship
trained orthopaedic surgeon (initial blinded for review) between December 2009 through September
2013 were included. Preoperative 3.0 T ankle MR images (Magnetom Verio, Siemens Medical Solutions,
Erlangen, Germany) from patients with suspected syndesmotic injuries and subsequent arthroscopic
evaluation were retrospectively reviewed and analyzed. Patient MRI findings were correlated with
arthroscopic surgery to calculate the sensitivity, specificity, positive predictive value (PPV) and negative
predictive value (NPV). To further the understanding of the distal tibiofibular syndesmosis and
concomitant pathology, concurrent injuries to other structures of the ankle were recorded and
reported.
Results: Analysis of asymptomatic volunteers allowed for the successful identification of optimal MRI
sequences for the visualization of individual syndesmotic structures (Table 1). In the patient cohort,
sequence-optimized MRI diagnosed pathology correlated strongly with arthroscopic surgery reports
demonstrating excellent diagnostic sensitivity and specificity in the diagnoses of common clinically
observed syndesmotic injuries (Table 1)(Figure 1). Rarely (20%), were isolated injuries to the
syndesmosis reported either preoperatively on MRI or intraoperatively during arthroscopy. Concurrent
fractures (medial/lateral/bi/tri malleolar, proximal/distal/maisonneuve fibular fractures, and
attachment avulsions), additional ligamentous injury (deltoid sprains/tears), tendon tears (peroneus
brevis), osteochondral lesions (distal tibia, dorsal/medial/lateral talus), and synovitis were frequently
observed.
Conclusion: Accurate diagnosis and subsequent treatment are paramount when dealing with
syndesmotic injuries due to the chronic pain and instability that can result from misdiagnoses and
inappropriate treatment. In this MRI characterization of syndesmotic structures and retrospective
analysis of diagnostic accuracy, we demonstrate the capability of MRI to consistently visualize relevant
individual syndesmotic structures and to diagnose frequently observed syndesmotic injuries with a high
degree of sensitivity and specificity. We propose that the optimal MRI sequences/planes defined in this
study be clinically implemented to aid in future pre-operative planning, to facilitate anatomic repair of
the syndesmosis, and to assist in post-operative assessment of the ankle syndesmosis.
MRI Sequence-Optimized Visualization and Diagnostic Accuracy of Syndesmotic Injuries
Structure
MRI
Sequence(
MRI Appearance:
s) for
Normal/Scarred,Sprained,Synoviti
Optimal
s/Torn
Visualizati
on
Surgical
Findings: Sensitivi Specifici PP NP
Intact/To ty
ty
V V
rn
AITFL
Axial (PD
TSE FS,
T2W)
0 / 7 / 13
6 / 14
86.7
83.3
71. 92.
4 3
PITFL
Axial (PD
TSE FS,
T2W)
1 / 18 / 1
20 / 0
--
95.0
--
ITFL
Axial (PD
TSE FS,
T2W)
2 / 8 / 10
14 / 6
83.3
64.3
90. 50.
0 0
Interosseous
Membrane
Axial (PD
TSE FS,
T2W)
0 / 10 / 10
17 / 3
66.7
52.9
90. 20.
0 0
Synovial Recess
Sagittal
(PD TSE
FS, PD
TSE)
Coronal
(PD TSE
FS, PD
TSE)
15 / 5 / --
-- / --
-- / --
-- / --
-- / -- /
-- --
Tibial Cartilage
Coronal
(PD TSE
FS, PD
-- / --
-- / --
-- / --
-- / --
-- / -- /
-- --
100
TSE)
Coronal
(PD TSE
Fibular Cartilage
FS, PD
TSE)
-- / --
-- / --
-- / --
-- / --
-- / -- /
-- --
Coronal
(PD TSE
FS, PD
TSE)
-- / --
-- / --
-- / --
-- / --
-- / -- /
-- --
Talar Cartilage
*PD TSE FS,
Proton Density
Turbo Spin Echo
Fat Suppressed
PD TSE, Proton
Density Turbo
Spin Echo
T2W,T2
Weighted
--, Not
reported/applica
ble
Paper 54
The Effect Of Peroneus Brevis Tendon Anatomy On Stability Of Fractures At The Fifth Metatarsal Base
Lutul D. Farrow, MD1, Parisa M. Morris, MD2, Annie G. Francois, MD3, Randall E. Marcus, MD4.
1
The Cleveland Clinic Sports Health Center, Garfield Heights, OH, USA, 2Canyon Orthopaedic Surgeons,
Ltd, Phoenix, AZ, USA, 3University of Arizona College of Medicine, USA, 4University Hospitals Case
Medical Center, USA.
Objectives: Fractures of the fifth metatarsal base are not uncommon. Both fracture management and
outcomes can differ greatly depending on fracture location. The purpose of the present study is to
evaluate the influence of the peroneus brevis (PB) tendon on proximal fifth metatarsal fracture stability.
We hypothesize that proximal fifth metatarsal fractures distal to the PB tendon footprint are inherently
less stable than more proximal fractures.
Methods: We utilized 5 matched pairs of fresh-frozen cadaveric specimens. We carefully exposed the
5th metatarsal and PB tendon. We measured the length of the PB insertion at the base of the fifth
metatarsal with calipers. The PB and Achilles tendons were then whip-stitched proximally to facilitate
loading. A custom leg holder was fabricated to allow loading and fluoroscopic evaluation. Two
conditions were utilized for biomechanical testing; (1) a simulated fracture distal to the PB insertion
(Jones equivalent) and (2) a simulated fracture within the footprint of the PB insertion (avulsion
equivalent). All fractures were carefully created with a narrow osteotome. Following fracture creation,
the plantar flexed foot was statically loaded through the Achilles and PB tendons. Oblique images with
and without loading and digital measurements were performed to evaluate for fracture separation. We
utilized a paired student T test and intraclass correlation coefficient (ICC) for all statistical analysis.
Results: The average length of the PB footprint was 15.2 mm. Compared to fractures within the PB
footprint, fractures distal to the PB tendon insertion demonstrated greater fracture widening following
loading of the PB tendon. Fractures within the PB footprint widened 0.4 mm on loading (Figure 1A to 1B)
compared to 1.1 mm of widening in the fractures distal to the PB insertion (Figure 1C to 1D). This
difference was significant (p = 0.02). Intraobserver reliability for all radiographic measurements showed
substantial agreement.
Conclusion: Avulsion fractures at the base of the fifth metatarsal have much better healing potential
than the so-called Jones fracture. Poor vascularity has been cited as a cause for poor healing potential
following Jones fractures. The principal findings of this study demonstrate that proximal fifth metatarsal
fractures distal to the PB insertion are significantly more unstable than more proximal fractures. In our
study, the PB exerts a deforming force on the proximal fragment of fractures distal to the PB footprint.
This deforming force was less pronounced in fractures within the PB footprint. Our findings help support
the notion that a mechanical component may contribute to the poor healing potential of Jones fractures
secondary to deformation exerted by the PB tendon. This would help explain why screw fixation is often
recommended to address Jones fractures. Further research is needed to evaluate the biomechanics of
these fractures.
Paper 55
Lumbar Spine Injury/Pathology as a Predictor of Outcomes in National Football League Athletes
Thomas Sean Lynch, MD1, Greg Schroeder, MD2, Daniel Gibbs, MD2, Ian Chow, BS2, Mark LaBelle, BS2,
Jason W. Savage, MD2, Alpesh Patel, MD2, Wellington Hsu, MD2, Gordon W. Nuber, MD3.
1
Cleveland Clinic Foundation Sports Medicine Program, Cleveland, OH, USA, 2Northwestern University
Department of Orthopaedic Surgery, Chicago, IL, USA, 3NorthShore University Health System
Department of Orthopaedic Surgery, Chicago, IL, USA.
Objectives: The purpose of this study is to determine if a pre-existing lumbar diagnosis such as
spondylosis, a herniated lumbar disc, or spondylolysis affects a football player’s draft status or his
performance and longevity in the NFL.
Methods: The written medical evaluations and imaging reports of
prospective professional American football athletes from 2003-2011 from one NFL franchise during the
NFL combine (annual college football player evaluation prior to the NFL draft) were compiled and
evaluated. All players were evaluated for a pre-existing lumbar diagnosis which were compiled from
previous injury/medical records including radiographic imaging reports. Those players with a lumbar
spine diagnosis and with appropriate radiograph, MRI and CT imaging were included in this study. These
athletes were then matched by age, position, year, and round drafted to control draftees without a
lumbar spine diagnosis. Career statistics were compiled including length of play and number of games
started. Additionally, a previously established “Performance Score” was calculated for all players
excluding offensive linemen. The continuous variables of each cohort were compared using a two-sided
(tailed) Student’s t-test for normally distributed data. A chi-squared analysis was performed to analyze
the categorical data. Statistical significance was accepted with a p < 0.05.
Results: Out of a total of 2,965 athletes evaluated from the NFL combine, 414 players were identified
with a pre-existing lumbar spine diagnosis. Athletes who attended the NFL combine without a lumbar
spine diagnosis were significantly more likely to be drafted than those with one (74% vs. 61%
respectively, p < 0.01). There was no difference between the investigational and control group with
regard to round drafted, age, year drafted, or position (Figure 2). Overall, athletes with a lumbar spine
injury compared to the control group had no difference in the number of years played (4.0 vs. 4.3 years,
respectively, p = 0.13), games played (46.5 vs. 50.7, respectively, p = 0.15), games started (28.1 vs. 30.6,
respectively, p = 0.39) or performance score (1.4 vs. 1.8, respectively, p = 0.3) (Figure 1).
Conclusion: The data in this study suggests that a pre-existing lumbar spine diagnosis was associated
with a significantly lower draft status for NFL athletes. However, the data in our study suggests that such
a diagnosis did not affect a player’s career longevity or performance. Further study will be required to
determine the individual effects of specific conditions on performance.
Figure 1: Comparison of players with a lumbar spine injury and the control group
Control (323)
L-Spine (253)
P Value
Round Drafted
3.68
3.66
0.93
Age
22.9
22.9
0.56
% of Players drafted in
2003
7.4%
6.7%
> 0.50
% of Players drafted in
2004
12.4%
10.7%
> 0.50
% of Players drafted in
2005
6.5%
7.1%
> 0.50
% of Players drafted in
2006
10.8%
10.3%
> 0.75
% of Players drafted in
2007
7.1%
8.7%
> 0.25
% of Players drafted in
2008
13.6%
13.4%
> 0.90
% of Players drafted in
2009
12.7%
14.6%
> 0.25
% of Players drafted in
2010
15.8%
15.8%
> 0.95
% of Players drafted in
2011
13.6%
12.6%
> 0.50
% Quarterbacks
4.6%
4.8%
> 0.90
% Running backs
5.0%
4.4%
> 0.50
% Wide Receivers or
Tight Ends
13.6%
12.7%
> 0.50
% Offensive Linemen
24.1%
26.2%
> 0.25
% Defensive Linemen
23.5%
25.0%
> 0.50
% Linebackers
11.5%
11.9%
> 0.75
% Defensive Backs
17.0%
14.3%
> 0.10
% Kickers
0.6%
0.8%
> 0.50
Average Years Played
4.25
3.96
0.13
Average Game Played
50.7
46.5
0.15
Average Game Started
30.6
28.1
0.39
Average Performance
Score
1.76
1.43
0.3
Paper 56
Supporting the Concept of Genetic Predisposition to Prolonged Recovery Following a Concussion
Jane McDevitt, PhD1, Ryan Tierney, PhD2, Jacqueline Phillips, MS2, John Gaughan, PhD2, Joseph S. Torg,
MD3, Evgeny Krynetskiy, PhD4.
1
Temple University, Philadelphia, PA, USA, 2USA, 3Temple University Hospital, Philadelphia, PA, USA,
4
Temple University School of Pharmacy, USA.
Objectives: During a concussion, mechanical forces cause neuron cell strain that initiates dysfunction
through the indiscriminate movement of ions through protein channels. Receptors of extracellular
glutamate exacerbate the Ca2+ ion influx, and prolong neuron dysfunction. Genetic variations in the
NMDA NR2A subunits (i.e., NR2A & NR2B) are likely to modulate the severity and/or recovery from
concussion. Therefore, we hypothesized that genetic variability (e.g., repeat polymorphism) within the
GRIN2A (i.e., gene that produces the NR2A subunit) promoter region was associated with concussion
recovery time.
Methods: Fifty-one athletes with a diagnosed concussion from a hospital concussion program
completed a standardized initial evaluation. Concussion injury characteristics, acute signs and symptoms
followed by an objective screening, which included the vestibular ocular assessments, the BESS test, and
an ImPACT exam were assessed. Enrolled participants provided salivary samples for isolation of DNA.
The number of (GT) variable nucleotide tandem repeats (VNTR) within the promoter region (i.e., region
of the gene involved in transcription) of GRIN2A was genotyped. The long (L) allele was defined as an
allele with ≥ 25 dinucleotide repeats in the GT tract. The short (S) allele was defined as an allele with <
25 dinucleotide repeats in the GT tract. Based on the results of genetic analysis, participants were
genotyped as LL homozygotes, SS homozygotes, or LS heterozygotes. Participants’ concussion recovery
time was followed prospectively until the full return to play clearance date determined by the treating
physician. Participant’s recovery time was categorized as normal (≤ 20 days) or prolonged (greater than
20 days). The DNA region surrounding position (-975 to -776) in the promoter of GRIN2A was amplified
by PCR, and was analyzed by capillary electrophoresis. Fragment length polymorphism analysis was
performed by measuring the migration time of a PCR product, and extrapolation to the known
fragments in the DNA standard ladder using computer software. The number of GT dinucleotide repeats
was calculated using the following equation: n(GT)=(L - 167)/2, where L is the length of the PCR
fragment estimated in base pairs.
Results: There was a significant association (x2 = 4.01, p = 0.045) between the GT VNTR (recessive
model: LL versus SS + LS) and recovery, where the chance of prolonged recovery was 4.3 times greater
(95% CI1.03-18.04) for homozygous carriers of the long allele.
Conclusion: This was the first study to investigate and demonstrate the association of the (GT)n VNTR
within GRIN2A with concussion recovery in athletes. Athletes carrying the long allele genotype were
predisposed to prolonged recovery following a concussive injury. We believe that genetic influence on
concussion recovery will aid in future development of genetic counseling in athletes and individuals
exposed to concussive head impacts. The clinical relevance of genotyping athletes could help improve
monitoring and management of athletes who experience concussion injuries.
Paper 57
Treatment of Concussion in High School Athletes: A Proposed Protocol for Athletic and Academic Return
to Activity
Benton E. Heyworth, MD1, Kaitlin M. Carroll, BS2, Andrew J. Rizza, MS, ATC, LAT3, Kelly C. McInnis, DO4,
Thomas J. Gill, MD4.
1
Children's Hospital Boston, Division of Sports Medicine, Boston, MA, USA, 2Hospital for Special Surgery`,
New York, NY, USA, 3Weston High School, Weston, MA, USA, 4Massachusetts General Hospital, Boston,
MA, USA.
Objectives: Growing evidence suggests that there may be significant long term sequellae of cumulative
concussions, which may include prolonged cognitive deficits and physical symptoms. There are a
growing number of concussions each year in high school athletes that occur during sports. The objective
of this study is to investigate the impact of cerebral concussions on athletes to gain a deeper
understanding of sports related cerebral concussions that will ultimately lead to development of better
management and prevention strategies. The hypothesis of the current study is that adolescent athletes
who suffer from sports-related concussions demonstrate neurocognitive and neuropsychological deficits
that affect both athletic and academic performance. To date, no current guidelines exist for return to
academic activities, such as classroom attendance and schoolwork.
Methods: A review of prospectively collected data of all student athletes who suffered a concussion
during athletics in a single high school from 2006 to 2010. The following validated patient-reported
outcome scores were used to assess function and symptom scores pre- and post-injury: Impact Score,
and SAC score. Concussed athletes completed baseline and post injury Immediate Post-concussion
Assessment and Cognitive Test (ImPACT), and SAC testing on the same day. Athletes then followed the
Zurich consensus guidelines for RTP. Documented concussions were categorized by time missed from
participation using severity outcome intervals (same-day return, 1- to 2-day return, 3- to 6-day return, 7to 9-day return, 10- to 21-day return, >21-day return, no return). All clinical notes from a single athletic
trainer were reviewed for each athlete. The clinical data collected included patient demographics,
history of concussions/migraine headaches/ depression/ anxiety, current concussion components,
sideline (SAC) and computer-based (ImPact) neurocognitive testing, physical exertion post-concussion,
and the total number of days to return to play.
Results: There were 120 concussions that occurred during athletics in a single high school between 2006
and 2011. There were 104 athletes (107 concussions) included in our study (64 males, 40 females). The
average age at time of injury was 16 ± 1.24 years (Range 14-20). There were 62 injuries with an on Field
SAC exam (Average 25 ± 3), 81 patients had a SAC exam 1 day after injury, 43 patients had both on field
and post day 1 injury SAC exams (Mean Difference in scores 3±4). The average time until asymptomatic
was 20 (Range 4-147) days, and average time for RTP was 39 (Range 6-147) days. In this cohort of high
school athletes, RTP within the first week after concussion was unlikely. There were 7 athletes who had
documented academic accommodations.
Conclusion: Athletes that suffered a concussion during athletic play were unlikely to return to sports in
less than a week. We found the Zurich consensus exertion protocol was important to differentiate
athletes that were asymptomatic at rest, but had return of symptoms with exertional stress. Based on
these results athletes were able to safely return to play without re-injury once the SAC and ImPACT test
returned to baseline. In addition, athletes subjectively had an improvement in symptoms when
academic accommodations were instituted as well.
Paper 58
Landing Error Scoring System (LESS) Items are Associated with the Incidence Rate of Lower Extremity
Stress Fracture
Kenneth L. Cameron, PhD, MPH, ATC1, Karen Y. Peck, MEd, ATC2, Brett D. Owens, MD1, Steven J.
Svoboda, MD1, Lindsay J. DiStefano, PhD, ATC3, Stephen W. Marshall, BSc, DAgrSc, PhD4, Sarah de la
Motte, PhD, MPH, ATC5, Anthony I. Beutler, MD6, Darin A. Padua, PhD, ATC7.
1
Keller Army Hospital, West Point, NY, USA, 2John A. Feagin Jr. Sports Medicine Fellowship, West Point,
NY, USA, 3University of Connecticuit, Storrs, CT, USA, 4University of North Carolina Department of
Epidemiology, Chapel Hill, NC, USA, 5Uniformed Services University of the Health Sciences, Bethesda,
MD, USA, 6Uniformed Services University, Bethesda, MD, USA, 7University of North Carolina, Chapel Hill,
NC, USA.
Objectives: Lower-extremity stress fracture injuries are a major cause of morbidity in physically active
populations. The ability to efficiently screen for modifiable risk factors associated with injury is critical in
developing and implementing effective injury prevention programs. The purpose of this study was to
determine if baseline Landing Error Scoring System (LESS) scores were associated with the
incidence rate of lower-extremity stress fracture during four years of follow-up.
Methods: To accomplish this objective we conducted a prospective cohort study at a US Service
Academy. A total of 1772 eligible subjects with complete baseline data and no history of lowerextremity stress fracture were included in this study. At baseline we conducted motion analysis during a
jump landing task using the LESS. Incident lower-extremity stress fracture cases were identified during
the four year follow-up period using the injury surveillance systems at our institution. The primary
outcome of interest was the incidence rate of lower-extremity stress fracture during follow-up. The
electronic medical records of each potential incident case were reviewed and case status was
determined by an adjudication committee consisting of two sports medicine fellowship-trained
orthopaedic surgeons who were blinded to baseline LESS data. The association between baseline LESS
scores and the incidence rate of lower-extremity stress fracture was examined for total LESS score and
for each individual LESS item. Univariate and multivariable Poisson regression models were used to
estimate the association between baseline LESS scores and the incidence rate of lower-extremity stress
fracture during follow-up. Results: During the follow-up period, 94 incident lower-extremity stress
fractures were documented in the study cohort and the cumulative incidence of stress fracture was
5.3% (95%CI: 4.3%, 6.5%). In univariate analyses total LESS score at baseline was associated with
the incidence rate of lower-extremity stress fracture during follow-up. For every additional movement
error documented at baseline there was a 15% increase in the incidence rate of lower-extremity
stress fracture during follow-up (IRR=1.15; 95%CI: 1.02, 1.31, p=0.025). Based on univariate analyses,
several individual LESS items at baseline were also associated with the incidence rate of stress fracture
during follow-up. Ankle flexion at initial contact (p=0.055), stance width at initial contact (p=0.026),
asymmetrical landing at initial contact (p=0.003), trunk flexion at initial contact (p=0.036), and overall
impression (p=0.021) were significantly associated with the incidence rate of stress fracture. In
multivariable analyses controlling for sex and year of entry into the cohort, subjects who consistently
landed flat-footed or heel-to-toe were 2.33 times (IRR=2.33; 95%CI: 1.36, 3.97, p=0.002) more likely to
sustain a lower-extremity stress fracture during follow-up. Similarly, subjects who consistently
demonstrated asymmetric landing at initial contact were 2.53 times (IRR=2.53; 95%CI: 1.34, 4.74,
p=0.004) more likely to sustain a stress fracture during follow-up. Conclusion: These data suggest that
specific LESS items may be predictive of lower-extremity stress fracture risk and may be helpful in injury
screening and prevention.
Paper 59
Eccentric Strengthening at Long Muscle Lengths Reduces Hamstring Strain Recurrences: Results of Long
Term Follow-up
Timothy F. Tyler, MS, PT, ATC1, Brandon Schmitt, DPT ATC2, Joshua M. Gellert, DPT3, Malachy P.
McHugh, PhD4.
1
PRO Sports Physical Therapy, Scarsdale, NY, USA, 2PRO Sports PT, Scarsdale, NY, USA, 3Nicholas Institute
of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York City, NY, USA, 4Nicholas Institute
of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, NY, USA.
Objectives: Hamstring injuries are among the most common injuries in sports involving sprinting and
have a high recurrence rate (20-33% recurrence rates reported in the literature). Rehabilitation
protocols that can prevent recurrences are needed. The purpose of this study was to determine if a
protocol emphasizing eccentric strength training with the hamstrings in a stretched position resulted in
a low recurrence rate after return to play.
Methods: Forty-eight athletes (age 35±16 yr; 31 men, 17 women) with unilateral hamstring strains (3
G1, 41 G2, 4 G3; 27 recurrent injuries) followed a 3-phase rehabilitation protocol (phase 1: isometric and
isotonic strengthening at short to intermediate muscle lengths; phase 2: eccentric strengthening at short
to intermediate lengths; phase 3: eccentric strengthening in a stretched position). Athletes progressed
to the next phase when pain free with maximum contractions and were discharged to sports when pain
free with maximal eccentric contractions in a stretched position and with functional tests. Prior to
discharge, isometric strength was assessed bilaterally at 80º, 60º, 40º and 20º knee flexion in sitting with
the thigh flexed to 40º above horizontal. Eight athletes chose to return to play prior to completing the
rehabilitation and were categorized as noncompliant (5 completed phase 2, 3 completed phase 1).
Reinjury rates and hamstring strength were compared between compliant and noncompliant athletes
using Fisher exact tests and analysis of variance.
Results: None of the 40 compliant athletes had sustained a reinjury at an average of 20±13 months after
returning to sports (18>2yr, 7 1-2yr, 15<1yr). Three of the 8 noncompliant athletes sustained reinjuries
between 3 and 5 months after return to play (P<0.01 vs. compliant athletes). At time of return to sport,
noncompliant athletes had significant hamstring weakness, which was progressively worse at longer
muscle lengths (20% deficit at 80º, 23% at 60º, 31% at 40º, 43% at 20º; Angle effect P<0.001). Compliant
athletes had symmetrical strength at all angles (P=0.99). Compliant athletes averaged 17±7 treatments
over 11±7 wks versus 12±7 treatments over 13±11 wks for noncompliant athletes (P=0.11, P=0.53).
Conclusion: Rehabilitation with an emphasis on eccentric strength training with the hamstrings in a
stretched position resulted in zero recurrent injuries at an average of 1.7 years after return to play.
Paper 60
The Efficacy Of The Fifa 11+ Injury Prevention Program In The Collegiate Male Soccer Player
Holly J. Silvers, MPT1, Bert R. Mandelbaum, MD2, Ola Adeniji, MS1, Stephanie Insler, BA1, Mario Bizzini,
PT3, Jiri Dvorak, MD4.
1
Santa Monica Sports Medicine Foundation, Santa Monica, CA, USA, 2Santa Monica Orthopaedic and
Sports Medicine, Santa Monica, CA, USA, 3Schulthess Clinic, Zurich, Switzerland, 4Schulthess KlinikSpine
Unit, Zurich, Switzerland.
Objectives: To examine the efficacy of the FIFA 11+ injury prevention program in Men’s NCAA collegiate
soccer
Methods: A prospective randomized controlled trial was conducted in Division I and Division II NCAA
men’s soccer teams during the Fall, 2012 season. Every athletic director, head soccer coach and head
athletic trainer from each Divion I and Division II member institution with a men’s collegiate soccer
program (N=411) was contacted via a formal letter, email and phone call. Sixty-one member institutions
consented to participate. Human ethics review board approval was obtained through Quorum IRB,
Seattle, WA, USA. After randomization was completed, the intervention group received an instructional
DVD, teaching manual and exercise placards thoroughly describing the FIFA 11+ intervention. An injury
surveillance database was utilized (HealtheAthleteTM, Overland Park, Kansas). Every athletic exposure,
injury incurred, utilization of the 11+ program and compliance data was entered weekly. Sixty-one
institutions completed the study: 34 control institutions (N=850 athletes) and 27 intervention
institutions (N=675 athletes). The FIFA 11+ program served as the intervention program over the course
of one collegiate season. The warm-up was utilized two to three times per week for the duration of the
season.
Results: In the intervention Group (IG), 285 Injuries were reported (mean=10.56 injuries/team+/-3.64)
compared to 665 Injuries (mean=20.15 injuries +/- 11.01) in the control group (CG). The number of
athletic exposures was 35,226 (Games: 10,935 AE, Practice: 24,291 AE) for the IG and 44,212 (Games:
13,624 AE, Practice: 30,588 AE) in the CG). The incidence rate (IR) was 8.09/1,000 AE (95% CI) in the IG
compared to 15.04/1000 AE (CI=95%) in the CG (p=0.00117). Total days missed due to injury was 2824
(mean=9.94) in the IG compared to 8776 days (mean =13.20) in the CG.
Conclusion: The FIFA 11+ was shown to significantly reduce injury rates and time loss in the competitive
male collegiate soccer player in a statistically significant manner. There was a significant reduction in
ACL injuries, hamstring injuries and ankle sprains in the intervention group compared to the control
group. A biomechanical analysis has been planned in order to fully understand the neuromuscular
changes imparted onto the participating athlete by the FIFA 11+ program.
Paper 61
The Effect of Femoral Nerve Block on Strength and Patient-reported Outcomes Following ACL
Reconstruction
Robert A. Magnussen, MD1, Kristy Pottkotter, PT, SCS2, Stephanie DiStasi2, Mark V. Paterno, PhD, PT,
ATC3, Samuel Clayton Wordeman, BS4, Laura Schmitt, PhD, PT5, David C. Flanigan, MD6, Christopher C.
Kaeding, MD7, Timothy E. Hewett, PhD, FACSM8.
1
The Ohio State University Sports Medicine Center, Columbus, OH, USA, 2The Ohio State University, USA,
3
Sports Medicine Biodynamics Ctr, Cincinnati, OH, USA, 4University of Cincinnati, Cincinnati, OH, USA,
5
Cincinnati, OH, USA, 6OSU Sports Medicine Center, Columbus, OH, USA, 7Columbus, OH, USA, 8The Ohio
State U. Sports Health & Performance Inst., Columbus, OH, USA. Objectives: Femoral nerve block (FNB)
has been proposed for pain control following anterior cruciate ligament (ACL) reconstruction. Although
numerous high level studies have assessed the efficacy of FNB’s, there has been little to no research into
the effect of such blocks on post-operative strength and patient-reported outcomes. Exacerbation of
post-operative quadriceps weakness by a FNB could negatively impact recovery, particularly in the early
post-operative period. We hypothesized that performance of a FNB would result in decreased
quadriceps strength and poorer patient-reported outcome score in the first three months following ACL
reconstruction. Methods: Thirty patients scheduled to undergo hamstring autograft ACL reconstruction
following an acute ACL injury were randomized to a single shot FNB group or a control group. The
surgical procedure and post-operative rehabilitation were performed identically in both groups. Preoperatively, all patients completed a KOOS and isokinetic quadriceps strength testing at 60 deg/s. At 6
weeks post-operative, all patients completed a KOOS and isometric quadriceps strength testing at 90
deg. At 12 weeks post-operative, all patients but three completed a KOOS and isokinetic strength
testing. Quadriceps strength limb symmetry indices (LSI) were calculated at all time points by dividing
the strength of the involved limb by the strength of the uninvolved limb. LSI and KOOS subscales for
Activities of Daily Living (ADL), Pain, and Symptoms at 6 weeks and 12 weeks were compared with preoperative values. Results: Patients who underwent nerve block demonstrated a significant decrease in
their LSI from pre-operative (0.80 ± 0.14) to 6 weeks post-operative (0.67 ± 0.29) (p = 0.05). Patients
who did not undergo nerve block demonstrated no significant difference in the pre-operative (0.77 ±
0.23) and 6-week post-operative (0.78±0.28) LSI (p = 0.99). At 12 weeks post-operative, both groups
demonstrated LSI values that were not statistically different from pre-operative. Patients who had a FNB
demonstrated no change in their KOOS subscales from pre-op to 6 weeks post-op, while those patients
who did not undergo FNB demonstrated a statistically significant increase in KOOS ADL, pain, and
symptoms subscales from pre-operative to 6 weeks post-operative (Figure 1). All patients, regardless of
group, demonstrated significant increases in KOOS subscales at 12 weeks relative to pre-operative
(Figure 1). Conclusion: Femoral nerve block is associated with decreased quadriceps strength at 6
weeks post-operative, slowing the post-operative improvement in patient-reported outcome scores.
While strength returns to pre-operative levels at 12 weeks post-operative, the effect of early quadriceps
weakness on movement patterns and functional outcome at later time points has yet to be determined
Paper 62
Incidence and Characterization of Injury to the Infrapatellar Branch of the Saphenous Nerve after ACL
Reconstruction: A Prospective Study
Steven B. Cohen, MD1, Michael C. Ciccotti, BA2, Christopher C. Dodson, MD2, Fotios P. Tjoumakaris, MD3,
John P. Salvo, MD4, Paul A. Marchetto, MD4, Ryan A. Watson, BA5, Matthew Robert Salminen, BS2,
Russell R. Flato, BA2, Daniel Francis O'Brien, BA2.
1
Rothman Institute, Media, PA, USA, 2Rothman Institute, Philadelphia, PA, USA, 3The Rothman Institute,
Egg Harbor Township, NJ, USA, 4Rothman Institute, Marlton, NJ, USA, 5The Rothman Institute,
Philadelphia, PA, USA.
Objectives: The infrapatellar branch of the saphenous nerve is commonly injured in anterior cruciate
ligament reconstruction (ACLR) causing sensory deficits around the knee. The primary purpose of this
prospective study was to determine the incidence of patient reported sensory deficits around the knee
following ACLR. The secondary purpose was to determine if sensory deficits caused by intraoperative
injury present at 6 weeks changed in severity and total area after 6 months and 1 year postoperatively.
Methods: Two-hundred and fifty patients that underwent ACLR with or without meniscal repair were
prospectively enrolled. Variables for each patient included: type of graft, direction of tibial incision,
number of portals, and length of surgical incision. The grafts used were categorized into three types:
Allograft (allo), hamstring autograft (HS), or patella tendon autograft (BTB). At 6 weeks, patients
completed a questionnaire to ascertain any sensory deficits over their knee. Patients rated their sensory
deficit on a scale from 0-10 (“0” = (no deficit) to “10” (complete lack of sensation) and shaded areas on a
picture of a knee split into nine rectangular segments (3 by 3 grid) to determine the location of any
numbness. Patients completed the same questionnaire at 6 months and 1 year. Any patient that was
noted to have no stated numbness at 6 weeks or 6 months was noted to have completed the study. A
mixed effects linear regression model was used to identify variables which were predictors for the
patient-reported severity of numbness.
Results: Overall, 67/221 (30.3%) patients who underwent ACLR stated that they had no numbness at 6
weeks. Of those patients who reported numbness at 6 weeks, 16.6% (25/151) considered their
numbness completely resolved by six months. At 1 year, 73.2% (90/123) reported their numbness had
gotten better and 14.2% (18/123) considered their numbness resolved. The most common location of
numbness was along the inferolateral aspect of the knee. The mean numbness rating for allografts was
2.73 +/- 0.32 (mean +/- standard error) at 6 weeks, decreasing to 1.04 +/- 0.26 at 6 months and 0.64 +/0.26 at 1 year for oblique and vertical incisions combined. A statistical model, controlling for time and
incision direction, indicated that HS patients were 1.94 +/- 0.52 points higher than allograft patients
across all time points, and BTB patients were 1.57 +/- 0.51 points higher than allo. However, there were
no significant difference in mean numbness score between BTB and HS patients (p=0.521). Time had a
negative impact on the patient reported severity of numbness score for all graft types. At 6 months this
effect was -0.95 +/- 0.17 and at 1 year, -1.21 +/- 0.18. The use of BTB increased the mean numbness of
affected segments by 0.67 +/- 0.23, while the use of a HS increased the mean numbness of segments by
0.39 +/- 0.21. The mean number of segments decreased slightly with time, down by 0.20 +/- 0.08 at 6
months (p=0.008) and 0.28+- 0.08 at 1 year (p=<0.001).
Conclusion: Sensory deficits after ACLR follow the direction of the infrapatellar branch of the saphenous
nerve. Patients who underwent ACLR with allo were less likely to develop sensory deficits compared to
BTB or HS. Sensory deficits in allo patients were on average, less severe. Surprisingly, there was no
significant difference in numbness between HS and BTB grafts. Surgeons should counsel their patients
that sensory deficits are common postoperatively after ACLR, but that this sensory disturbance is likely
to dissipate with time.
Paper 63
Femoral Nerve Blockade is Associated with Persistent Strength Deficits at Six Months Post ACL
Reconstruction in Pediatric and Adolescent Patients.
Amy L. McIntosh, MD1, Diane L. Dahm, MD1, Ali Ashraf, MD2, Tianyi David Luo1.
1
Mayo Clinic, Rochester, MN, USA, 2Mayo Clinic, MN, USA.
Objectives: Femoral nerve blockade has become a popular method of postoperative analgesia for
anterior cruciate ligament (ACL) reconstruction in pediatric and adolescent patients. Successful
rehabilitation after ACL reconstruction involves return of quadriceps and hamstring strength and
dynamic knee stability. The objective of this study was to compare strength and function six months
after ACL reconstruction in pediatric and adolescent patients who received a femoral nerve block versus
a control group of patients with no nerve block
Methods: A search of our institutional database was performed to identify patients 17 years of age or
younger who underwent primary ACL reconstruction between 2001 and 2010. Revision ACL surgeries
and previous contralateral and ipsilateral knee surgeries were excluded. Based on institutional protocol,
the patients participated in a comprehensive rehabilitation program and underwent isokinetic strength
testing (slow and fast activation) and functional testing (vertical jump, single hop, triple hop) at six
months after ACL reconstruction.
Results: There were 127 patients that met the inclusion criteria, including 63 patients in the NB group
(32 males, 31 females) and 64 patients in the control group (26 males, 38 females). There were no
significant differences between the NB group and the control group with respect to age (15.7 ± 1.4 vs.
15.5 ± 1.4, p = 0.26), sex (p = 0.29), BMI (23.7 ± 3.6 vs. 23.8 ± 3.6, p = 0.91), or type of graft used (67%
patellar tendon autograft, 33% hamstring autograft vs. 70% patellar tendon autograft, 30% hamstring
autograft, p = 0.85). Univariate analysis showed a significantly higher deficit at six months in the NB
group with respect to fast isokinetic extension strength (17.6% vs. 11.3%, p = 0.008), as well as fast
(12.8% vs. 8.3%, p = 0.029) and slow (9.9% vs. 5.5%, p = 0.029) isokinetic flexion strength. There was no
difference in slow extension isokinetic strength deficit between the two groups (NB 22.1% vs. control
18.9%, p = 0.246).. With respect to function, there were no differences in deficit for vertical jump (NB
9.3% vs. control 11.3%, p = 0.267), single hop (NB 7.5% vs. control 7.6%, p = 0.970), or triple hop (NB
7.9% vs. control 6.5%, p = 0.375) between the two groups. A higher percentage of patients in the control
group met criteria for return to sports at six months. (88.9% vs. 68.3%, p = 0.008).
Conclusion: Pediatric and adolescent patients treated with a femoral nerve block for postoperative pain
control after ACL reconstruction had significant isokinetic deficits in knee extension (quadriceps) and
flexion (hamstring) strength at six months when compared to patients who did not receive a nerve
block. No differences in the results of functional testing were observed between the two groups. A
significantly higher percentage of patients in the group who did not receive a block were cleared to
return to sports at six months following ACL reconstruction.
Table 1. Isokinetic and Functional Testing Six Months after ACL Reconstruction
Slow extension deficit
Slow flexion deficit
Fast extension deficit
Fast flexion deficit
Vertical jump deficit
Single hop deficit
Triple hop deficit
Cleared for sports
NB (n=63)
Control (n=64)
P-value
22.1%
18.9%
0.246
12.8%
8.3%
0.029
17.6%
11.3%
0.008
9.9%
5.5%
0.029
9.3%
11.3%
0.267
7.5%
7.6%
0.970
7.9%
6.5%
0.375
68.3%
88.9%
0.008
Paper 64
ACL Fibers Inserting on the Lateral Intercondylar Ridge Carry the Greatest Loads - Are Modern Anatomic
Femoral Tunnel Positions Too Low?
Danyal H. Nawabi, MD1, Carl Imhauser, PhD2, Scott Tucker, BA1, Joseph Nguyen, MPH3, Thomas L.
Wickiewicz, MD1, Andrew Pearle, MD4.
1
Hospital for Special Surgery, New York, NY, USA, 2Hospital for Special surgery, New York, NY, USA,
3
Hospital for Speical Surgery, New York, NY, USA, 4Hospital for Special Surgery Program, New York, NY,
USA.
Objectives: Histological studies have shown that the ACL has a direct and indirect insertion on the femur
[1]. The direct insertion is located along the lateral intercondylar ridge and the indirect insertion is
located ‘lower’ on the lateral wall of the notch. The trend towards anatomic ACL reconstruction using
the anteromedial (AM) portal technique has resulted in ‘lower’ non-isometric femoral tunnel positions
and increased graft failures [2]. To our knowledge, the load transfer properties of the direct and indirect
ACL insertions have not been studied. This information may help in understanding the increased failures
reported with AM portal drilling. The purpose of this study was, 1) to compare the load transferred
across the native ACL at the direct and indirect femoral insertions and, 2) to determine the strain
behavior of ACL grafts placed at different tunnel locations within the direct and indirect insertions.
Methods: Ten fresh-frozen cadaveric knees (mean age, 52.5 years; range, 29-65) were mounted to a six
degree of freedom robot. A 134N anterior load at 30 and 90° flexion and a combined valgus (8Nm) and
internal (4Nm) rotational moment at 15° flexion were applied. The ACL was subsequently sectioned at
the femoral footprint by detaching either the direct or indirect insertion (partially sectioned state),
followed by the remainder of the ACL (completely sectioned state) (Figure 1). The kinematics of the
intact knee were replayed after each stage of sectioning to determine the loads transferred across the
direct and indirect ACL fibers. Loads were expressed as a percentage of the total load borne by the ACL.
Strain behaviour was tested by generating 3D models of the femur and tibia from CT scans of each knee.
Three tunnel locations (anteromedial bundle [AM], center [C], posterolateral bundle [PL]) each were
selected for the direct and indirect insertions and a virtual ACL graft was inserted. The isometry of the
virtual graft was calculated through a flexion path of 0 to 90°.
Results: Under an anterior tibial load at 30° flexion, the direct insertion carried 83.9% of the total ACL
load compared to 16.1% in the indirect insertion (p<0.001). The direct insertion also carried more load
at 90° flexion (95.2% vs 4.8%; p<0.001). Under a combined rotatory load at 15° flexion, the direct
insertion carried 84.2% of the total ACL load compared to 15.8% in the indirect insertion (p<0.001). A
virtual ACL graft placed at the AM position in the direct insertion demonstrated the best strain
behaviour with a mean 10.9% change in length. This value was significantly lower (p<0.001) than the
isometry at all 3 tunnel positions in the indirect insertion (AM = 18.5%; C = 24.9%; PL = 30.9%).
Conclusion: Fibers in the direct insertion of the ACL carry more load than fibers in the indirect insertion.
Virtual ACL grafts placed in the ‘higher’ direct location are more isometric than in the ‘lower’ indirect
location during range of motion testing.
Clinical Relevance: ‘Low’ ACL grafts in the indirect ACL insertion, resulting from AM portal drilling
techniques, may experience higher loads in-vivo due to unfavorable biomechanics. With the current
shift towards anatomic ACL reconstruction, it may be beneficial to create a ‘higher’ femoral tunnel
within the direct insertion at the lateral intercondylar ridge. This position remains anatomical but may
also be biomechanically favorable.
References:
[1] Sasaki N, et al. Arthroscopy 2012;28(8):1135-46.
[2] Rahr-Wagner L, et al. Arthroscopy 2013;29(1):98-105.
Paper 65
Aircast Award for Basic Science - The Effect of Dynamic Changes in ACL Graft Force on Soft Tissue ACL
Graft-Tunnel Incorporation
Richard Ma, MD1, Michael Schaer, MD2, Tina Chen, MS1, Marco Sisto, BS2, Clifford Voigt, MD2, Joseph
Nguyen, MPH2, Lilly Ying, VS2, Xiang-Hua Deng, MD2, Scott A. Rodeo, MD2.
1
Missouri Orthopaedic Institute, Columbia, MO, USA, 2Hospital for Special Surgery, New York, NY, USA.
Objectives: Anterior cruciate ligament grafts that are placed for reconstruction are subject to complex
forces with joint motion. Current “anatomic” ACL reconstructions result in greater in situ graft forces.
The biologic effect of changing magnitudes of ACL graft force on graft-tunnel osseointegration is not
completely understood. The objective of the present study is to determine the effects of dynamic
mechanical ACL graft tension or load on graft-tunnel incorporation.
Methods: One hundred male Sprague-Dawley rats underwent unilateral ACL resection followed by
reconstruction with a soft tissue autograft. The animals were allocated into one of three groups during
surgery: (1) ACL reconstruction followed by limb immobilization for the entire duration of the study, (2)
ACL reconstruction with a "high-tension" ACL graft and daily knee motion, or (3) ACL reconstruction with
an "isometric" low-tension ACL graft and daily knee motion. ACL graft isometry was assessed
intraoperatively. External fixators were used to eliminate graft load during cage activity. Daily knee
motion was then started on post-operative day 3 for all animals that were allocated to a knee motion
group using a custom computerized knee flexion device. Graft-tunnel healing was assessed at 3 and 6
weeks via biomechanical, micro-CT, and histologic analyses. Biomechanical and micro-CT data was
analyzed using ANOVA with significance set at p<0.05.
Results: Intraoperative ACL graft force measurements demonstrated two distinct ACL graft curves (hightension versus isometric ACL graft) were achieved with the two different femoral graft tunnel locations.
At 90 degrees of knee flexion, there is a 1.6 fold increase in ACL graft force between a high-tension ACL
graft and isometric ACL graft at the time of surgery.
High ACL graft force with joint motion appeared to be deleterious to early ACL graft-tunnel
incorporation. The load to failure for knees with high-tension ACL grafts (5.50 ± 2.30N) was significantly
lower when compared to immobilized (10.90 ± 2.78N, p<0.01) and isometric grafts (9.91 ± 3.36N,
p=0.01) at 3 weeks. At 6 weeks, isometric ACL grafts coupled with daily knee motion had greater load to
failure than immobilized knees (24.16 ± 5.72N versus 16.56 ± 3.51N, p=0.01). Immobilized and isometric
grafts had greater femoral bone volume fraction than knees with high-tension grafts at both 3 and 6
weeks (p<0.01 and p<0.001, respectively). Greater cellularity and collagen gaping were seen in loaded
ACL graft (those that underwent motion) versus immobilized grafts, particularly within the tibial tunnel.
Higher prevalence of osteoclasts were seen along the graft-tunnel interface in high-tension ACL grafts.
Conclusion: There is limited data on how the ACL graft mechanical environment affects its healing. We
were able to demonstrate that ACL graft-tunnel incorporation is sensitive to dynamic load from joint
motion using a novel small animal model. ACL soft tissue grafts that experience higher in situ force have
inferior early biomechanical properties. Maintaining graft isometry allows early joint motion without
deleterious biomechanical consequences when compared to immobilized grafts in this animal model.
Our findings regarding the effects of graft isometry may not only have clinical implications in terms of
post-operative rehabilitation with modern anatomic ACL reconstructions, but it also raises questions
regarding existing preclinical ACL healing studies where isometry may not have been considered.