Author: Elaine He

Abstract

BACKGROUND:

Shoulder instability has been well described in young men; however, few studies have specifically evaluated the pathoanatomy and unique spectrum of injuries in women with shoulder instability.

PURPOSE:

To describe the pathoanatomy of operative shoulder instability in a collegiatefemale cohort.

STUDY DESIGN:

Case series; Level of evidence, 4.

METHODS:

The authors performed a retrospective analysis of a consecutive series of female students at a National Collegiate Athletic Association Division I military service academy treated operatively for shoulder instability by a single surgeon between September 2008 and September 2014. Preoperative data collected included patient age, sport, mechanism of injury, number and frequency of dislocations, direction of instability, and co-occurring surgical abnormalities at the time of arthroscopy. Outcome variables included recurrent instability after surgery and need for revision.

RESULTS:

Thirty-six female student athletes with an average age of 20 years (range, 18-22 years) were included. The majority of instability events were traumatic in nature (69%), and 61% of the total events were subluxations. Rugby was the most common sport for experiencing instability (7 patients), followed by obstacle course training (6 patients). Thirty-two patients (89%) reported multiple instability events, averaging 4 per shoulder. The primary direction of instability was anterior in 26, combined anterior and posterior in 7, and 3 met criteria for multidirectional instability. At the time of surgery, 26 patients (72%) had a Bankart tear, 9 (25%) had a posterior labral tear, and 5 (14%) had superior labrum anterior to posterior tears. Nine patients (25%) were found to have humeral avulsion of the glenohumeral ligament (HAGL) lesions, 7 (19%) had partial-thickness articular-sided rotator cuff tears, and only 1 patient (3%) had evidence of true attritional glenoid bone loss. Hill-Sachs lesions were found in 16 patients (44%). Recurrent instability occurred in 9 patients (25%) following arthroscopic stabilization, and revision surgery was performed in 6 (17%).

CONCLUSION:

Shoulder instability in female athletes presents commonly as multiple subluxation events. While soft tissue Bankart lesions were found in numbers equal to those in previous studies include both sexes, bony Bankart lesions were less common in women. Finally, the presence of combined anterior and posterior labral tears and HAGLs in women was more common than previously reported.

 

To read the full article, please go to the journal website here.

Abstract

BACKGROUND:

The rotator cuff muscles are critical secondary stabilizers in the shoulder. Increased glenoid retroversion and rotator cuff strength have been associated with the risk of posterior shoulder instability; however, the effect of increased glenoid retroversion on rotator cuff strength remains unclear.

PURPOSE/HYPOTHESIS:

The purpose was to examine the association between glenoid version and rotator cuff strength in the shoulder in a young and healthy population with no history of shoulder instability. The hypothesis was that increased glenoid retroversion would be associated with increases in rotator cuff muscle strength.

STUDY DESIGN:

Cross-sectional study; Level of evidence, 3.

METHODS:

A prospective cohort study was conducted over a 4-year period within a high-risk population to identify the risk factors for shoulder instability. Analyzed participants included 574 freshmen entering a United States service academy. Baseline data collected upon entry into the study included magnetic resonance imaging measurements of glenoid version. Rotator cuff strength was also assessed at baseline using a handheld dynamometer. Internal and external rotation strength were assessed with the glenohumeral joint positioned in neutral and in 45° of abduction. The current study represents an analysis of the baseline data from this cohort.

RESULTS:

The mean age, height, and weight of participants was 18.77 ± 0.97 years, 176.81 ± 8.48 cm, and 73.80 ± 12.45 kg, respectively. The mean glenoid version at baseline was 7.79°± 4.85° of retroversion. Univariate linear regression analyses demonstrated that increased glenoid retroversion was associated with increased internal and external rotation strength of the rotator cuff in neutral and 45° of abduction (P < .001). Similar results were observed in multivariable models controlling for important confounding variables.

CONCLUSION:

The results of this study demonstrate that as glenoid retroversion increases, internal and external rotation strength of the rotator cuff also increase in a young and healthy athletic population. These compensatory changes may contribute to increased glenohumeral dynamic stability in the presence of worse static stability with increasing retroversion.

To read the full article, please go to the journal website here.

Abstract

“BACKGROUND:

Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes than primary ACL reconstruction. The reasons remain varied and not completely understood.

METHODS:

Patients undergoing revision ACL reconstruction were prospectively enrolled. Data collected included baseline demographics, surgical technique and pathological condition, prescribed rehabilitation instructions, and a series of validated patient-reported outcome instruments. Patients were followed for 2 years and asked to complete a set of outcome instruments identical to those completed at baseline. Subsequent surgical procedures on the ipsilateral knee were recorded. Regression analysis was used to control for age, sex, activity level, baseline outcome scores, and the above-mentioned rehabilitation-related variables in order to assess the factors affecting clinical outcomes 2 years after revision ACL reconstruction.

RESULTS:

A total of 843 patients met the inclusion criteria and were successfully enrolled, and 82% (695) were followed for 2 years. Two rehabilitation-related factors were found to influence outcome. First, patients who were prescribed an ACL brace for their return to sports had a significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) for sports and recreational activities at 2 years (odds ratio [OR] =1.50, 95% confidence interval [CI] = 1.07 to 2.11; p = 0.019). Second, patients prescribed an ACL brace for the postoperative rehabilitation period were 2.3 times more likely to have subsequent surgery by 2 years (OR = 2.26, 95% CI = 1.11 to 4.60; p = 0.024). The odds of a graft rerupture were not affected by any type of brace wear.

CONCLUSIONS:

Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years. Weight-bearing and motion can be initiated immediately postoperatively. Bracing during the early postoperative period is not helpful. Use of a functional brace early in the postoperative period was associated with an increased risk of a reoperation. Use of a functional brace for a return to sports improved the KOOS on the sports/recreation subscale.

LEVEL OF EVIDENCE:

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.”

To read the full article, please go to the journal website here.

Abstract

BACKGROUND:

Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery.

HYPOTHESES:

Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level.

STUDY DESIGN:

Cross-sectional study; Level of evidence, 3.

METHODS:

A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates.

RESULTS:

Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC (P < .0001), KOOS-Symptoms (P = .01), KOOS-Sports and Recreation (P = .04), and KOOS-Quality of Life (P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates.

CONCLUSION:

Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

To read the full article, please go to the journal website here.

Abstract

Background:

Pectoralis major ruptures are rare injuries that can occur at several parts of the muscle. Little is known of the pathoanatomic process and performance following pectoralis major ruptures in young athletes.

Purpose/Hypothesis:

The objective of this study was to describe a series of pectoralis major ruptures in military academy athletes at the US Military Academy and US Naval Academy. We hypothesized that military academy athletes will demonstrate a different rupture location than previously reported in older patients.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective case series was performed by analyzing all electronic medical records and imaging software for consecutive pectoralis major ruptures undergoing surgical repair within the student population at 2 military academies. The primary outcome of interest was rupture pattern and location. We also assessed functional recovery following surgery by analyzing push-up performance on the biannual Army Physical Fitness Test and Navy Physical Readiness Test.

Results:

From 2005 to 2017, a total of 19 cases of pectoralis major ruptures occurred in military academy cadets. Patients ranged in age from 19 to 23 years, with a mean age of 20 years. All injuries occurred during sports activity, with bench press as the most common mechanism of injury (n = 10; 53%). The most common rupture location was the musculotendinous junction (n = 10; 53%), followed by pectoralis major tendon insertion (n = 8; 42%), and only 1 bony avulsion was noted. Physical activity performance following the rupture was negatively affected. The mean ± SD number of push-ups preinjury was 73.20 ± 12.10, which decreased following injury and surgery (66.50 ± 11.98; P = .037).

Conclusion:

Military academy athletes in our study cohort demonstrated a different type of rupture location than has been reported in older cohorts, with the majority experiencing tearing at a location other than the tendon itself. Performance was also negatively affected immediately following repair, but moderate improvement was observed as time from surgery increased.

To read the full article, please go to the journal website here.

Abstract

“PURPOSE:

To quantify the effect of saline solution injections on patient-reported outcome measures (PROMs) and to determine whether this effect is clinically relevant by comparing it with minimal clinically important difference (MCID) criteria.

METHODS:

A systematic search identified randomized controlled trials of lateral epicondylitis interventions comparing saline solution injections with nonsurgical injection therapies. Among included studies, saline solution was compared with platelet-rich plasma, autologous conditioned plasma, corticosteroid, and botulinum toxin injections. By use of data from included studies, a random-effects model was used to calculate overall mean differences (MDs) in pre- and post-injection PROMs in a pair-wise fashion. Calculated MDs were then compared with MCID criteria.

RESULTS:

Of 458 identified studies, 10 met the inclusion criteria and encompassed 283 patients. At 1, 3, 6, and 12 months, statistically significant improvements in MDs in visual analog scale (VAS) scores were noted as follows: MD of 16.11 (95% confidence interval [CI], 8.29-23.93) at 1 month; MD of 22.50 (95% CI, 11.45-33.55) at 3 months; MD of 40.40 (95% CI, 27.48-53.32) at 6 months; and MD of 47.04 (95% CI, 39.43-54.66) at 12 months. At 6 months, Disabilities of the Arm, Shoulder and Hand scores showed a statistically significant improvement (MD, 23.92; 95% CI, 9.47-38.37).

CONCLUSIONS:

Improvements in Disabilities of the Arm, Shoulder and Hand scores at 6 months (23.92) surpassed MCID criteria for conservatively managed upper-extremity musculoskeletal pathology (10.83)-suggesting that saline solution injections have a clinically relevant effect. VAS MCID criteria are poorly established, but VAS scores at 6 and 12 months surpassed MCID criteria for conservative treatments for common orthopaedic conditions. In all but 1 study, no statistically significant difference in PROMs was found between saline solution and non-saline solution injections.”

To read the full article, please visit the journal website here.

Abstract:

Posterior glenoid bone deficiency can occur with recurrent glenohumeral instability. Glenoid reconstruction with a distal tibial allograft (DTA) has been reported to successfully restore contact pressures that occur during posterior glenohumeral translation. However, there are concerns regarding the risk of allograft resorption, availability, and costs. Extracapsular reconstruction using a scapular spinal autograft (SSA) has been reported as an alternative technique secondary to its anatomic location relative to the posterior shoulder and preferable autograft properties. There are no known prior biomechanical studies evaluating the scapular spine as an effective extracapsular graft choice.

Reconstruction of a large posterior glenoid defect with either a DTA or an SSA can effectively restore glenohumeral stability.

This study supports the use of a DTA or SSA in posterior glenoid defect reconstruction. Clinical studies are needed to determine the long-term effects of utilizing such grafts.

For the full journal article, please visit the journal website here.

Dr. Brett Owens discusses the pros and cons of including wearable devices in orthopedic research. For the full article, please go to the Healio article web page here.

BACKGROUND: Examination of the incidence of shoulder season-ending injury (SEI) in the collegiate athlete population is limited.
PURPOSE: To determine the incidence of shoulder SEI in the National Collegiate Athletic Association (NCAA) and to investigate the risk factors for a shoulder injury ending an athlete’s season.

CONCLUSION: Injury to the shoulder of an NCAA athlete, while somewhat infrequent, can have significant implications on time lost from play. Incidence of these injuries varies widely by sport and injury, with a number of associated risk factors. Athletes sustaining potentially season-ending shoulder injuries, with their coaches and medical providers, may benefit from these data to best manage expectations and outcomes.

For more information about this study, please visit the American Journal of Sports Medicine website.