Lateral Extra-Articular Tenodesis via an All-Suture Anchor

Background: In young patients, anterior cruciate ligament (ACL) reconstruction often results in graft failure. This may be due, in part, to concomitant injury to anterolateral complex (ALC) of the knee leading to rotatory laxity. The modified Lemaire lateral extra-articular tenodesis (LET) technique is intended to address the anterolateral rotatory instability due to injury to the ALC and to protect the ACL graft and meniscus. Indications: The International Anterolateral Complex Consensus Group Meeting identified 4 appropriate indications for the modified Lemaire LET procedure: revision ACL, high-grade pivot shift, generalized ligamentous laxity/genu recurvatum, and young patients returning to pivoting activities. Technique Description: The technique consists of harvesting an 8-cm long by 1-cm wide graft from the iliotibial band. The graft is released proximally and remains attached distally to Gerdy’s tubercle. The graft is then passed deep to the lateral collateral ligament (LCL) from distal to proximal. The graft is then affixed to a point proximal and posterior to the lateral femoral epicondyle with an all-suture button. The graft is then tensioned with knee at 30° of flexion and neutral rotation, and then secured in place. Results: With the modified Lemaire LET, there was previously concern for overconstraint and lateral compartment degeneration. However, recent studies have shown that there is no increased risk for these complications with the LET procedure. The STABILITY trial found that the addition of LET to ACL reconstruction significantly reduces re-rupture and residual laxity when compared with ACL reconstruction alone. Moreover, the addition of LET to ACL reconstruction can restore native knee kinematics. Conclusion: The addition of the modified Lemaire LET technique to traditional ACL reconstruction is a safe and effective adjunct that reduces the occurrence of graft rupture, addresses residual rotational laxity, and can restore native knee kinematics in appropriately indicated patient populations. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.</p

Lateral Collateral Ligament Reconstruction With Tensionable Loops and Suture Tape Reinforcement

Background: The posterolateral corner (PLC) is an important knee stabilizer that resists varus stress, external tibial rotation, and posterior tibial translation. Untreated PLC injuries have been shown to increase failure rates of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstructions and lead to degenerative changes. Our modified Arciero technique reconstructs the femoral insertion site and functionality of the lateral collateral ligament (LCL) and popliteal fibular ligament, components of the PLC, with an internal brace and tensionable loops. Indications: The primary indication for PLC reconstruction is identified PLC injury. Patients often have a feeling of knee instability and a varus thrust gait. PLC injury should be confirmed with imaging. Technique Description: We employed a modified Arciero technique via LCL reconstruction with tensionable loops and internal brace. We used a semitendinosus allograft truncated at 240-millimeters to avoid the graft bottoming out. A suture augment was incorporated into the graft to reinforce the LCL reconstruction construct during graft tensioning and early rehabilitation. The graft construct was then passed through the transfibular tunnel to femoral sockets at the LCL and popliteus insertions. The graft construct is then affixed to the opposite femoral cortex. The graft was then tensioned with the knee in approximately 30° of flexion, neutral to 10° of internal rotation, and a valgus force applied. This restored excellent valgus stability. Results: Fibular and tibiofibular-based constructs are common procedures for PLC reconstruction. Our LCL reconstruction with tensionable loops technique and the Arciero technique are fibular-based constructs. The fibular-based construct and the tibiofibular-based construct have been found to be biomechanically equivalent at restoring knee stability. However, fibular-based constructs, such as our LCL reconstruction with tensionable loops, were found to be less technically demanding than tibiofibular-based constructs, used fewer grafts, and required a smaller surgical approach. Conclusion: Given similar clinical outcomes, it was concluded that fibular-based constructs, such as our modified Arciero technique, may be more advantageous because of the ability to avoid some of the pitfalls of tibiofibular-based constructs. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.</p

Lower Extremity Stress Fractures in the National Basketball Association, 2013-2014 Through 2018-2019

Background: Players in the National Basketball Association (NBA) are at risk for lower extremity stress fractures, partly because of the sport’s high-intensity demand on the lower body. Purpose: To provide insight on the identification and management of potential risk factors associated with lower extremity stress fractures in NBA athletes. Study Design: Case series; Level of evidence, 4. Methods: A retrospective study was conducted using the NBA electronic medical record database for all players who were on an NBA roster for ≥1 game from the 2013-2014 through 2018-2019 seasons. Player characteristics, games missed, and treatment methodology were independently analyzed. Results were presented as incidence per 1000 player-games. Results: There were 22 stress fractures identified in 20 NBA players over the course of 6 years, with an average of 3.67 stress fractures per year and an incidence of 0.12 stress fractures per 1000 player-games. Most stress fractures occurred in the foot (17/22), and 45% (10/22) of stress fractures were treated surgically, with the most common site of operation being the navicular. On average, approximately 37 games and 243 days were missed per stress fracture injury. There was no significant difference in time to return to play between high-risk stress fractures treated operatively versus nonoperatively (269.2 vs 243.8 days; P = .82). Conclusion: The overall incidence of stress fractures in NBA players was 0.12 per 1000 player-games, and a high percentage of players returned to NBA activity after the injury. There was a relatively even distribution between high-risk stress fractures treated operatively and nonoperatively. When comparing high-risk stress fractures treated operatively to ones treated nonoperatively, no significant difference in average time to return to play in the NBA was found.</p

Are Oblique Views Necessary? A Review of the Clinical Value of Oblique Knee Radiographs in the Acute Setting

Introduction: The purpose of this study was to assess the added clinical value of oblique knee radiographs four-view (4V) compared to orthogonal anteroposterior (AP) and lateral radiographs in a two-view (2V) series. Methods: We obtained 200 adult, 4V knee radiographs in 200 patients in the ED and randomly divided them into two groups with 100 series in each group. Ten reviewers — three musculoskeletal radiologists and seven orthopedic surgeons — performed radiograph analyses. These reviewers were randomly divided evenly into group one and group two. Reviewers were blinded to patient data and first reviewed 2V radiographs (AP/lateral) only, and then reviewed 4V radiographs, including AP/lateral, and two additional oblique views for the same patients at least four weeks later. Acute pathology identification and the need for further imaging was assessed for all reviewers, and clinical decision-making (operative vs nonoperative treatment, need for admission, need for additional imaging) was assessed only by the seven orthopaedic surgeon reviewers.&nbsp; Results: Mean sensitivity for pathology identification was 79% with 2V and 81% with 4V (P =0.25). Intra-observer kappa value was 0.81 (range 0.54-1.00). Additional oblique radiographs led orthopaedic reviewers to change their treatment recommendations in 62/329 patients (18.84%) (P &lt;0.001). Eight of 329 radiographic series were identified as “critical misses.” (2.43%) (P =0.004), when pathology was reported as normal or reviewers recommended nonoperative treatment on 2V radiographs but changed their recommendation to operative management after the addition of oblique radiographs. The number needed to treat (NNT) for any treatment change and for “critical misses” was 83 and 643, respectively.&nbsp;&nbsp; Conclusion: Although the addition of oblique radiographs may improve a clinician’s ability to identify subtle pathologic findings not identified on 2V, it rarely leads to significant changes in treatment recommendations. Given the high NNT, limiting the usage of these oblique radiographs in the general patient population may reduce costs without significantly affecting patient care

Trends of Ulnar Collateral Ligament Reconstruction in the United States from 2003 to 2014: Analysis of 3,133 Patients

Purpose: The purpose of this study is to investigate the trends concerning ulnar collateral ligament (UCL) reconstruction (UCLR) for athletic injuries within the United States over the years 2003 to 2014. Methods: A retrospective review of the Truven Health Marketscan® Commercial Database was conducted for patients undergoing UCLR. Data was reviewed for patients treated between 2003 and 2014, and the cohort of patients undergoing UCLR was queried using Common Procedural Terminology code 24346. Patients ages 11 to 40 years were included and divided into 6 different age groups, with the rate of UCLR calculated for each group. RESULTS: The overall rate of UCLR increased from 4.4 per million in 2003 to 11.9 per million in 2014 (p \u3c .01). Throughout the same time period, the rate per million increased from 3.3 to 22.1 in 11- to 15-year-olds (p \u3c .01), from 105.4 to 293.2 in 16- to 20-year-olds (p \u3c .01), from 23.1 to 67.0 in 21- to 25-year-olds (p \u3c .01), and from 2.1 to 5.7 in 31- to 35-year-olds (p \u3c .01). There was no significant increase in the rate of UCLR in the age groups of 26 to 30 and 36 to 40 years. Conclusion: UCLR was mostly performed in patients aged 11 to 25 years (96.6%), and specifically most common in those patients aged 16 to 20 years (67.4%). The rate of UCLR procedures increased over time for younger age groups significantly more than for their older counterparts. Clinical Relevance: UCLR rates are increasing in young patients despite efforts addressing injury risk reduction strategies and education for coaches, players, and parents regarding risk factors for UCL injury

Neural EGF-like protein 1 (NELL-1): Signaling crosstalk in mesenchymal stem cells and applications in regenerative medicine

Bone tissue regeneration holds the potential to solve both osteoporosis and large skeletal defects, two problems associated with significant morbidity. The differentiation of mesenchymal stem cells into the osteogenic lineage requires a specific microenvironment and certain osteogenic growth factors. Neural EGF Like-Like molecule 1 (NELL-1) is a secreted glycoprotein that has proven, both in vitro and in vivo, to be a potent osteo-inductive factor. Furthermore, it has been shown to repress adipogenic differentiation and inflammation. NELL-1 can work synergistically with other osteogenic factors such as Bone Morphogenic Protein (BMP) −2 and −9, and has shown promise for use in tissue engineering and as a systemically administered drug for the treatment of osteoporosis. Here we provide a comprehensive up-to-date review on the molecular signaling cascade of NELL-1 in mesenchymal stem cells and potential applications in bone regenerative engineering

Sox9 augments BMP2-induced chondrogenic differentiation by downregulating Smad7 in mesenchymal stem cells (MSCs)

Cartilage injuries caused by arthritis or trauma pose formidable challenges for effective clinical management due to the limited intrinsic proliferative capability of chondrocytes. Autologous stem cell-based therapies and transgene-enhanced cartilage tissue engineering may open new avenues for the treatment of cartilage injuries. Bone morphogenetic protein 2 (BMP2) induces effective chondrogenesis of mesenchymal stem cells (MSCs) and can thus be explored as a potential therapeutic agent for cartilage defect repair. However, BMP2 also induces robust endochondral ossification. Although the precise mechanisms through which BMP2 governs the divergence of chondrogenesis and osteogenesis remain to be fully understood, blocking endochondral ossification during BMP2-induced cartilage formation may have practical significance for cartilage tissue engineering. Here, we investigate the role of Sox9-donwregulated Smad7 in BMP2-induced chondrogenic differentiation of MSCs. We find that overexpression of Sox9 leads to a decrease in BMP2-induced Smad7 expression in MSCs. Sox9 inhibits BMP2-induced expression of osteopontin while enhancing the expression of chondrogenic marker Col2a1 in MSCs. Forced expression of Sox9 in MSCs promotes BMP2-induced chondrogenesis and suppresses BMP2-induced endochondral ossification. Constitutive Smad7 expression inhibits BMP2-induced chondrogenesis in stem cell implantation assay. Mouse limb explant assay reveals that Sox9 expands BMP2-stimulated chondrocyte proliferating zone while Smad7 promotes BMP2-intitated hypertrophic zone of the growth plate. Cell cycle analysis indicates that Smad7 induces significant early apoptosis in BMP2-stimulated MSCs. Taken together, our results strongly suggest that Sox9 may facilitate BMP2-induced chondrogenesis by downregulating Smad7, which can be exploited for effective cartilage tissue engineering