Melugin, Heath P.

Objective The purpose of this systematic review was to determine (1) treatment options for bipolar cartilage lesions of the knee, (2) patient-reported outcomes following various surgical treatments, and (3) complication and failure rates following surgery. Design A literature search of PubMed, the Cochrane Library, and CINHAL was performed using PRISMA guidelines. Patients were included if they had bipolar cartilage lesions of the knee treated surgically. Lesion characteristics, surgical technique, patient-reported outcomes, complication rates, failure rates, and survivorship were recorded. Results Fourteen studies yielded 301 knees treated surgically. Patient age ranged from 15 to 74 years. Surgical techniques included 138 autologous chondrocyte implantation (ACI), 156 osteochondral allograft transplantation (OCA), and 7 osteochondral autograft transfer system (OATS). Seven studies reported a concomitant procedure rate that ranged from 0% to 88%. Eight studies reported that both reciprocal lesions received surgical treatment, while 6 studies did not specify. Lesion size ranged from 1 to 41 cm 2 . All reported postoperative improvements in patient-reported outcomes, but the measures were very heterogeneous. There were no major complications and the rate of minor complications ranged from 0% to 50%. Survivorship ranged from 40% to 100% for OCA, 76% to 95% for ACI, and 100% for the 1 study evaluating OATS. Conclusions Bipolar cartilage lesions of the knee typically involve a large surface area and are most commonly treated with ACI or OCA, while OATS may be an option for smaller lesions. Improvements in mid-term patient-reported outcomes were reported for all surgical procedures and they can be performed safely with a low rate of major complications.

Context: Hockey is a skillful contact sport with an elevated injury risk at higher levels of play. An understanding of injury incidence, type, mechanism, and severity at various levels of competition aids the clinician treating these athletes. The purpose of this clinical review is to discuss the epidemiology of hockey injuries at various levels of participation, including youth, high school, junior, college, and professional. Evidence Acquisition: A literature search was performed by a review of PubMed, Embase, and Cochrane databases and included articles published from 1988 to 2017. Studies were included in this review if determined to be of high quality and containing injury data relevant to the levels of competition. Pertinent data regarding ice hockey injury epidemiology and prevention at various levels of competition were analyzed. Study Design: Clinical review. Level of Evidence: Level 4. Results: Youth, high school, junior, college, and professional hockey players have unique injury patterns. Injuries occur much more often in a game compared with a practice, and injury risk increases with each level of competition. Preventative measures, such as mandatory facial protection and delayed body checking in games until age 13 years, are proven strategies to reduce the risk of facial injury and concussion. Conclusion: An understanding of common injury types and mechanisms according to age and level of play aids the clinician in diagnosis and management. This information can also guide preventative strategies in the areas of education, coaching, rule enforcement, rule modifications, equipment improvement, and sportsmanship.

Background: During rehabilitation throwing programs, baseball players are commonly asked to throw at reduced levels of effort (ie, 50% effort, 75% effort, etc) to moderate stress to healing tissues. It is currently unknown how changes in players’ perceived exertion compares with changes in actual exertion during structured long-toss programs. Purpose: To determine whether decreased effort correlates with decreased throwing metrics, whether metrics decrease proportionally with reductions in perceived effort, and to quantify intrathrower variability. Study Design: Descriptive laboratory study. Methods: Sixty male high school and collegiate baseball pitchers participated in a structured throwing program. A motusBASEBALL sleeve was worn by all players, which measured elbow varus torque, arm velocity, arm slot, and shoulder rotation. Ball velocity was measured with a radar gun. Each pitcher threw 5 throws a distance of 120 ft with 3 efforts: maximum effort, 75% effort, and 50% effort. Throwing metrics were compared among the 3 levels of effort to see if each 25% decrease resulted in proportional decreases in elbow varus torque and ball velocity. Intrathrower variability was determined for each throwing metric at each degree of effort. Results: All throwing metrics decreased as players decreased their perceived effort ( P < .001). However, these observed decreases were much smaller in magnitude than the decreases in perceived effort. During the 75% effort throws, elbow varus torque was only reduced to 93% of maximum and velocity dropped to 86% of maximum. Similarly, for the 50% effort throws, elbow varus torque remained 87% of max effort torque, while velocity remained 78% of max. Intrathrower reliability was considered excellent for most metrics (intraclass correlation coefficient, >0.75). Conclusion: For every 25% decrease in perceived effort, elbow varus torque only decreased 7% and velocity only decreased 11%. Thus, when players throw at what they perceive to be reduced effort, their actual throwing metrics do not decrease at the same rate as their perceived exertion. Clinical Relevance: Measured effort decreased with decreasing perceived effort, but these were not proportional. This has significant implications for physical therapists, physicians, trainers, coaches, and athletes to understand and monitor elbow stress during the rehabilitation process.

Background: Avulsion fractures involving the tibial eminence are considered equivalent in etiology to anterior cruciate ligament tears, however there is limited data comparing outcomes of adolescent patients undergoing surgical fixation of tibial eminence fractures to those undergoing anterior cruciate ligament (ACL) reconstruction. Purpose: The purpose of this study was to compare clinical outcomes, subsequent ACL injury rates, and activity levels between adolescent patients who underwent tibial eminence fracture fixation to patients with mid-substance ACL tears who required acute ligament reconstruction. Methods: This study included a group of patients with tibial eminence fractures treated with surgical fixation matched to a group of similar patients with ACL tears treated with reconstruction between the years of 2001 and 2015. Data regarding initial injury, surgical intervention, ACL/ACL graft injury rates, and physical examination findings were recorded. Clinical and functional outcomes were obtained using physical examination, IKDC subjective scores, Lysholm scores, and Tegner Activity levels. Results: Sixty patients with a mean follow-up of 57.7 (24-206) months were included. 20 patients (11 M:9 F) who underwent surgical fixation for tibial eminence fractures (TEF) with a mean age of 11.9 (7-15) years were matched to a group of 40 patients (23 M:17 F) who underwent ACL reconstruction for ACL tears with a mean age of 12.5 (8-15) years. The TEF group demonstrated significantly lower postoperative IKDC (TEF group: 94.0, ACL group: 97.2 (p=0.04)) and Lysholm scores (TEF group: 92.4, ACL group: 96.9 (p=0.02)). The TEF group returned to sport 121 days sooner (p<0.01), but there was no difference in postoperative Tegner scores (TEF group: 7.3, ACL group: 7.6 (p=0.16)). The TEF group demonstrated increased postoperative anterior laxity (p=0.02) and a higher rate of postoperative arthrofibrosis (p=0.04). There was no difference in subsequent ACL injury (p=0.41). Conclusion: Patients with tibial eminence fractures demonstrated lower mean clinical outcome scores compared to patients with ACL tears at minimum 2-year follow up. Additionally, they experienced more postoperative anterior laxity and had a higher rate of postoperative arthrofibrosis. There was no difference in subsequent ACL injury rate. The TEF group returned to sport sooner than the ACL group, but the postoperative activity level was similar.

Purpose: The goal of this study was to evaluate patient and surgical factors predictive of excellent functional and isokinetic test results 6-months following anterior cruciate ligament (ACL) reconstruction in a group of pediatric patients with open physes. Methods: We retrospectively reviewed the records of all patients 14 years of age or younger that underwent ACL reconstruction from 2000 to 2015. An excellent 6-month outcome was defined as greater than 85% in isokinetic strength and greater than 90% in functional tests when compared to the non-operative extremity. We then utilized univariate and multivariate statistical models to identify patient and/or surgical factors associated with excellent 6-month outcomes. Results: Eighty-six patients (46 male, 42 female) with open physes on preoperative radiographs were included in the study, with a mean age of 13.6 (range, 8.4-14.9), body mass index (BMI) of 22.1 (range, 15.6-36.0), Tegner activity score of 8.8 (6.0-9.0). Thirty-four patients (40%) met the criteria for the excellent 6-month group, which left 52 (60%) in the delayed 6-month group. In univariate analysis, no single preoperative factor correlated with excellent 6-month outcome. The two groups were statistically similar in terms of age, BMI, time to surgery, preoperative arc of motion, presence of concomitant meniscal tear, cartilage damage, graft size, use of a nerve block or tourniquet, operative time, and tourniquet time. Use of a nerve block trended towards delayed outcomes (p = 0.051). Conclusion: Children undergoing ACL reconstruction only have a 40% chance of achieving an excellent rehabilitation result at 6 months. We found no statistically significant patient or surgical characteristics that could predict this outcome. Utilizing a nerve block is a factor which will need to be further evaluated. Significance: Studies in the adult population have identified preoperative patient and surgical factors associated with excellent 6-month isokinetic and functional test results. This pediatric cohort did not find similar results as many of these children were young, healthy and fit. However, the variability of the outcome casts doubts on applying adult rehabilitation protocols to children.

Introduction: It is unknown whether functional and isokinetic testing at 6 months following ACL reconstruction in patients with open-physes correlates with longer term outcomes. The purpose of this study was to compare subsequent ACL rupture risk, knee function, and activity level in patients with open-physes who had excellent 6-month testing to those who did not. Methods: Between the years of 2000 and 2015, 86 patients with open-physes underwent ACL reconstruction and had functional and isokinetic testing performed at 6-months post-operatively. Thirty-four (40%) tested in the excellent range in all categories of both functional and isokinetic testing and were labeled the excellent group. The remaining 52 (60%) patients were labeled the delayed testing group. Data regarding patient, injury, and surgical characteristics were retrospectively collected. The rate of second ACL injury as well as clinical outcome scores were collected postoperatively. Results: Graft rupture rate was 23.4% (n = 8) in the excellent group and 15.4% (n = 8) in the delayed group (p = 0.51). In the excellent group, 20.5% (n = 7) had a contralateral ACL tear versus 11.5% (n = 6) in the delayed group (p = 0.40). Five patients in the excellent group and 4 patients in the delayed group sustained both graft failure and contralateral ACL tear. The overall prevalence of second ACL injury was 29% in the excellent group and 23% in the delayed group. The delayed group returned to sport at an average of 8.8 months whereas the excellent group returned at an average of 6.6 months (p < 0.01). At mean follow up of 3.59 years, the excellent group had a higher Tegner activity level (8.9 versus 8.3) than the delayed group (p < 0.02). Conclusion: Pediatric patients with open-physes who had excellent isokinetic strength and functional testing 6-months postoperatively returned to sport sooner than those who did not. There was no statistical difference in either graft failure or contralateral ACL disruption between these groups. However, both groups had unacceptably high rates of second ACL injury (29% for the excellent group and 23% for the delayed group). Significance: Excellent 6 month return of strength and function was not protective of subsequent ACL disruption, the rate of which remains dismal within this pediatric population. Development of more sensitive functional measures for children could help to change these poor outcomes and guide clinicians when to allow return to sport.

Background Adductor canal block (ACB) is an alternative method to femoral nerve block (FNB) for post-operative analgesia for anterior cruciate ligament reconstruction (ACLR) in pediatric and adolescent patients. Prior studies have suggested that FNB is associated with persistent strength deficits at 6 months after ACLR in this population. Proponents of the ACB consider that this method may result in a decreased incidence of quadriceps strength deficits during post-operative rehabilitation. The purpose of this study was to compare knee strength and function at 6 and 9 months after ACLR in pediatric and adolescent patients who received FNB versus ACB peri-operatively. Methods Patients 18 years or younger who underwent primary ACLR between 2002 and 2017 at a single institution were identified. ACLR was performed with either a patellar tendon autograft or hamstring autograft. A transphyseal ACLR was performed in patients with open physes. All patients participated in a comprehensive rehabilitation program which included isokinetic strength testing and functional testing at 6 and/or 9 months postoperatively. Patients were excluded if they underwent multiligamentous knee reconstruction, concomitant cartilage restoration procedures, did not receive perioperative FNB or ACB, or if they did not complete isokinetic strength and functional testing at 6 or 9 months. The included cohort was separated into FNB group and ACB group for comparison. Isokinetic extension and flexion strength deficits and functional deficits in vertical jump, single hop, and triple hop between the two groups were compared at both time points. A strength deficit of 15% or less and a functional deficit of 10% or less compared to the contralateral side were considered satisfactory. Univariate analysis was performed to assess for differences in patient demographics and surgical variables. A 1:1 matched subgroup analysis between the two groups was performed to account for possible differences in outcomes associated to graft types, concomitant meniscus repair, and BMI. Results Of the 240 patients identified, 85 patients (64 FNB, 21 ACB) with a mean age of 15.9 years (Range: 11-18) met inclusion criteria for comparison at 6 months and 76 patients (40 FNB, 36 ACB) with a mean age of 15.5 years (Range: 12-17) met inclusion criteria for comparison at 9 months. Univariate analysis showed significantly greater deficits at 6 months in the FNB with respect to fast isokinetic flexion strength (7.7% vs. -4.9%; p = .03). There were no differences in slow isokinetic flexion (10.5% vs. 6.8%; p = .79) and fast isokinetic extension (11.9% vs. 13.9%; p = .68) strength deficits between the groups. There were clinically relevant greater deficits in the FNB group with respect to slow isokinetic extension (19.3% vs. 12.0%; p = .24), but this did not reach statistical significance. This clinical difference in satisfactory scores between the groups with respect to slow isokinetic extension was accentuated with the 1:1 matched outcome trial (23.9% vs. 12.1%; p = .20). With respect to function, there were no differences in deficits for vertical jump (8.4% vs. 4.3%; p = .55), single hop (7.4% vs. 9.3%; p = .65), or triple hop (6.0% vs. 7.1%; p = .77) between the two groups. Univariate analysis showed significant greater deficits at 9 months in the FNB with respect to slow isokinetic flexion strength (9.6% vs. 0.4%; p = .01). There were no differences in fast isokinetic flexion (-0.2% vs. 0.7%; p = .87) and fast isokinetic extension (6.0% vs. 2.7%; p = .51) strength deficits between the groups. There were clinically relevant greater deficits in the FNB group with respect to slow isokinetic extension (17.3% vs -14.0%, p = .19), but this did not reach statistical significance. With respect to function, there were no differences in deficits for vertical jump (5.2% vs. 6.5%, p = .85), single hop (7.7% vs. 6.2%; p = .79), or triple hop (1.9% vs. 3.9%; p = .35) between the two groups. Conclusion Because previous studies have shown a significant delay in return of strength with FNB, ACB began to be employed at our center for post-operative pain control following ACLR in pediatric and adolescent patients. This study showed that pediatric and adolescent patients treated with FNB as a method of post-operative analgesia after ACLR had significantly greater deficits in fast isokinetic flexion at 6 months and slow isokinetic flexion at 9 months compared to those who received ACB. These differences may or may not have clear clinical relevance. However, patients treated with FNB showed clinically relevant greater deficits in slow isokinetic extension strength at 6 and 9 months postoperatively compared to those who received ACB if 85% strength return is used as criteria to return to sport. Pediatric and adolescent patients could benefit from undergoing perioperative analgesia with ACB instead of FNB, but comparison between these two methods of regional anesthesia may require a prospective trial. Level of Evidence Retrospective cohort study, Level IV [Table: see text][Table: see text]

Background: Avulsion fractures involving the tibial eminence are considered equivalent in terms of the cause to anterior cruciate ligament (ACL) tears; however, there are limited data comparing the outcomes of adolescent patients undergoing surgical fixation of a tibial eminence fracture (TEF) with those undergoing ACL reconstruction. Purpose: To compare the clinical outcomes, subsequent ACL injury rates, and activity levels between adolescent patients who underwent TEF fixation with patients with midsubstance ACL tears who required acute reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: This study included a group of patients with TEFs treated with surgical fixation matched to a group of similar patients with ACL tears treated with reconstruction between the years 2001 and 2015. Data regarding the initial injury, surgical intervention, ACL/ACL graft injury rates, and physical examination findings were recorded. Clinical and functional outcomes were obtained using a physical examination, the International Knee Documentation Committee (IKDC) subjective score, the Lysholm score, and the Tegner activity score. Results: Sixty patients with a mean follow-up of 57.7 months (range, 24-206 months) were included; 20 patients (11 male, 9 female; mean age, 11.9 years [range, 7-15 years]) who underwent surgical fixation for a TEF were matched to a group of 40 patients (23 male, 17 female; mean age, 12.5 years [range, 8-5 years]) who underwent reconstruction for ACL tears. The TEF group demonstrated significantly lower postoperative IKDC scores (TEF group, 94.0; ACL group, 97.2; P = .04) and Lysholm scores (TEF group, 92.4; ACL group, 96.9; P = .02). The TEF group returned to sport 119 days sooner ( P < .01), but there was no difference in postoperative Tegner scores (TEF group, 7.3; ACL group, 7.6; P = .16). The TEF group demonstrated increased postoperative anterior laxity ( P = .02) and a higher rate of postoperative arthrofibrosis ( P = .04). There was no difference in subsequent ACL injuries ( P = .41). Conclusion: Both groups demonstrated quality outcomes at a minimum 2-year follow-up. Patients with TEFs demonstrated lower mean clinical outcome scores compared with patients with ACL tears, but the differences were less than reported minimal clinically important difference values. Additionally, the TEF group experienced more postoperative anterior laxity and had a higher rate of postoperative arthrofibrosis. There was no difference in the rate of subsequent ACL injuries. The TEF group returned to sport sooner than the ACL group, but the postoperative activity levels were similar.

Objective This retrospective case series describes a hybrid fixation technique and determines the clinical outcomes, knee function, and activity level of patients at short-term follow-up. Design Seventeen patients (18 knees) with unstable osteochondritis dissecans (OCD) lesions involving the knee were treated with a hybrid fixation technique in which the salvageable fragment was fixed and osteochondral autograft transplantation system (OATS) was used for the unsalvageable fragment. Thirteen lesions involved the medial femoral condyle, 4 involved the lateral femoral condyle, and 1 involved the patella. Mean patient age was 17 years (range 12-28 years). All lesions were International Cartilage Repair Society (ICRS) grade III or IV. The patients were prospectively followed postoperatively. Outcome measures included the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Tegner activity scale. Results At mean follow-up of 36 months (range 24-67.2 months), the mean postoperative KOOS scores, given as mean (SD), were as follows: Quality of Life (QoL) 91.1 (17.0), Activities of Daily Living (ADL) 99.5 (1.5), Sport 94.5 (11.2), Pain 97.4 (5.8), and Symptoms 95.9 (6.5). Mean IKDC score was 96.2 (7.0). There was no significant difference between mean preinjury (7.95, SD = 1.1) and mean postoperative (7.45, SD = 1.5) Tegner scores ( P = 0.363). The mean Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was 87.5 at a mean 7.8 months (range 3-18 months) postoperation. There were no reported complications. Conclusion The results of this case series suggest that patients with partially salvageable OCD lesions involving the knee can have positive short-term outcomes and can expect a low complication rate when treated with a hybrid technique of fixation with osteochondral autograft transfer.

Background: There is a paucity of clinical information to guide the treatment of a combined anterior cruciate ligament (ACL) tear and Segond fracture. Purpose: To compare clinical outcomes, graft failure rates, and activity levels between patients undergoing ACL reconstruction (ACLR) with and without an untreated Segond fracture at a minimum 2-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: This study included a group of patients with a combined ACL tear/untreated Segond fracture that was matched based on age, sex, body mass index, and graft type to a control group of patients with an ACL tear and no Segond fracture. All patients were treated with ACLR alone between the years of 2000 and 2015. The diagnosis of a Segond fracture, or bony avulsion of the anterolateral complex, was made by radiographic analysis. Data regarding the initial injury, surgical intervention, and physical examination findings were recorded. Clinical and functional outcomes were obtained using physical examination results, International Knee Documentation Committee (IKDC) subjective scores, and Tegner activity levels. Results: Twenty patients (16 male, 4 female) with a combined ACL tear/untreated Segond fracture with a mean age of 26.3 years (range, 13-44 years) were matched to a control group of 40 patients (32 male, 8 female) with an ACL tear and no Segond fracture with a mean age of 26.4 years (range, 13-47 years). The study group was followed for a mean of 59.1 months (range, 24-180 months) and the control group for a mean of 55.5 months (range, 24-120 months). The mean IKDC score was 86.5 (range, 54-100) for the study group compared with 93.0 (range, 54-100) for the control group ( P = .03). The graft rupture rate was 10% for both groups ( P = .97). The mean time to rupture was 33.0 months (range, 21-45 months) in the study group and 63.5 months (range, 39-88 months) in the control group ( P = .24). Patients in the study group had significantly more anteroposterior instability by preoperative Lachman testing than those in the control group (control group: 0 normal, 3 grade 1+, 37 grade 2+, 0 grade 3+; study group: 0 normal, 1 grade 1+, 10 grade 2+, 9 grade 3+; P = .0001). There was no significant difference between the 2 groups in regard to postoperative Lachman testing (control group: 35 normal, 3 grade 1+, 2 grade 2+, 0 grade 3+; study group: 17 normal, 3 grade 1+, 0 grade 2+, 0 grade 3+; P = .31). Patients in the study group had significantly more instability by preoperative pivot-shift testing than those in the control group (control group: 0 normal, 7 grade 1+, 33 grade 2+, 0 grade 3+; study group: 1 normal, 1 grade 1+, 11 grade 2+, 7 grade 3+; P = .0003). No significant difference was found between the 2 groups for postoperative pivot-shift testing (control group: 36 normal, 2 grade 1+, 2 grade 2+, 0 grade 3+; study group: 18 normal, 1 grade 1+, 1 grade 2+, 0 grade 3+; P = .61) or final Tegner activity level (median, 6). Conclusion: At midterm follow-up, patients undergoing ACLR with and without a Segond fracture had similar pivot-shift test results, graft failure rates, and activity levels. The IKDC score was statistically worse in the patients with a combined ACL tear/untreated Segond fracture, but the difference was less than the minimal clinically important difference for the IKDC score. These findings suggest that patients with a combined ACL tear/untreated Segond fracture can have comparable outcomes to patients with an ACL tear and no Segond fracture when treated with ACLR alone.