Orthopedic Sports Medicine Board Review

Orthopedic Sports Medicine Board Review

• Trey Remaley, DO

• Assistant Professor

• Department of Orthopedics and Sports Medicine

• University of South Florida

Conflicts

• I have no conflicts of interest for this lecture or topic

Content

• Upper Extremity

• Lower Extremity

• Sports Physician Topics

SHOULDER

Upper Extremity

• Shoulder

• Instability

• SLAP/Labral tears

• Thrower’s shoulder

Shoulder Anatomy

• Glenohumeral complex• Humeral head retroverted 30o

• Greater tuberosity

• Lesser tuberosity

• Posterior humeral circumflex artery

• Scapula• Glenoid 5o retroverted

• Upward tilt 5o-10o

• Pear shaped

• Coarcoid tip

• Clavicle is S-shaped

• First to ossify last to calcify

Shoulder

• Static restraints to stability• Glenohumeral ligaments

• Glenoid labrum

• Articular congruity and version

• Negative intraarticular pressure

• Dynamic restraints• Rotator cuff musculature

• Biceps

• Periscapular muscles

Shoulder Stabilizing Ligaments

• SGHL: limits inferior translation in adduction• MGHL: limits anterior translation at 45o

• IGHL• Anterior band: limits anterior translation at 90o

• Posterior band: aids internal rotation

Relate Age to Common injuries

• Young• Shoulder instability

• AC joint injuries

• Distal clavicle osteolysis

• Old• Rotator cuff tears

• Glenohumeral arthritis

• Proximal humerus fracture

• Mechanism• Directs blow: AC joint

• Arm in ABD/ER position: Instability

• Night pain/Overhead pain: Rotator cuff tears

Evaluation

• Visual inspection

• ROM

• Palpation

• Special tests• Impingement: Neer’s, Hawkins

• Cuff: Empty can, ER strength, Hornblower’s

• Subscap: Inc ER, Lift off, Belly press

• Pec: Resisted Adduction

• Anterior Instability: Apprehension/Relocation, Load and Shift

• Posterior Instability: Jerk test, Load and Shift

• MDI: Remember Beighton’s criteria, Sulcus sign

• Bicep tendon: Crank, Speed’s, O’Brien

Imaging of the Shoulder

• Xrays – Always for initial evaluation• AP

• True AP (Grashey)

• Axillary – Never forget• Valpeau

• Scap Y

• CT Scan• Fracture characteristics

• Glenoid version or bone loss

• MRI• Rotator cuff

• Labrum – needs to be an arthrogram

Radiographs

CT/MRI

Shoulder Instability

Shoulder Instability

• TUBS

• Traumatic

• Unilateral/Unidirectional

• Bankart

• Surgical

• AMBRI

• Atraumatic

• Multidirectional

• Bilateral

• Rehabilitation

• Inferior capsular shift

Shoulder

• Multidirectional Instability

• AMBRI

• Generally seen in the 2nd to 3rd decade of life

• Microtrauma or overuse

• Baseball throwers, swimmers, volleyball, gymnasts

• May have an underlying connective tissue disorder – Ehler’s Danlos

• Generalized ligamentous laxity

MDI

• Patients present with pain and instability with easy activities

• Shoulder comes out while sleeping

• Clinically must have instability in two planes to be defined

as MDI

• Keep in mind that cuff impingement in <20 y/o may be a

sign of MDI

MDI

• Ligamentous laxity

• Beighton’s criteria (out of 9 points)

• Palms to floor

• Genu recurvatum

• Elbow hyperextension

• MCP hyperextension

• Thumb to forearm

MDI Workup

• X-rays

• Likely normal in MDI

• MRI

• Consider arthrogram to eval for enlarged capsule volume

• +/- Bankart lesion

• +/- Kim lesion

• Patulous capsule

MDI Workup

• Positive load and shift

• Anterior and Posterior

• Apprehension and relocation

• Sulcus sign

MDI Treatment

• Non-operative management



• 3-6 months of conservative

• Dynamic stabilization PT• Closed kinetic chain exercises to stimulate co-contraction of

muscle groups

MDI Treatment

• Avoid voluntary dislocators

• Capsular shift

• Capsular plication

• Rotator interval closure• Produces the biggest loss of motion in external rotation with the arm at

the side

• Make sure to address any labral pathology as well

• Address any bony deficiency?

MDI Treatment

• Open treatment

• Subscap Tenotomy (Neer)

• Longitudinal tenotomy

• Labral repair

• Humeral based shift (anteroinferior)

• More powerful – hyperlaxindividuals

• Subscap split (Jobe)

• Horizontal capsulotomy

• Labral repair

• Glenoid based shift

• Tailored – overhead athletes

Traumatic Shoulder Instability

• Most common shoulder injury

• 1.7% among the general population

• High recurrence rate in younger population

• 90% in patients under 20 years of age

• Position of vulnerability – abducted and ER

TUBS

• Injury can range from soft tissue only to including bony lesions on glenoid, humerus, or both

• Lesions• Bankart – anterior inferior lesion involving the anterior band of the IGHL

• 80—90% of patients with TUBS

• HAGL

• Higher recurrence rate if missed/not diagnosed

• You may not have seen it, but is has seen you

• Open repair?

• GLAD

• Sheared cartilage with labral tear

• ALPSA

• Anterior labral tear periosteal sleeve avulsion

• Labrum can heal along medial aspect of glenoid neck

• Higher failure rate after arthroscopic repair

• Rotator cuff tears• 30% of TUBS >40 years

• 80% of TUBS >60 years

TUBS

• Bony injuries• Bony Bankart

• Anterior inferior glenoid fracture

• Present in up to 50% of recurrent cases

• 20%-25% is known as critical bone loss*

• Need to address bony stabilization

• Hill-Sachs defect• Posterior humeral head impaction fracture

• 80% of traumatic dislocations, 25% of subluxations

• Engaging versus non-engaging

• Greater tuberosity fracture

• Lesser tuberosity fracture

TUBS Treatment

• Treatment of first time dislocators in controversial

• Sling and rehab as initial treatment

• Age <20 years

• Male

• Contact athletics

• Hyperlaxity

• Glenoid bone loss (critical bone loss)

TUBS Operative Treatment

• Arthroscopic Bankart repair• 1st time dislocators with Bankart lesion in athlete under 25 years of age

• High demand athletes

• +/- Remplissage with engaging Hill-Sachs lesion

• Similar outcomes with open repair, less pain and greater restoration of motion

• Minimum of three abchors

• Remplissage• Engaging Hill-Sachs deficits

• Off-track lesions

• Posterior capsule and infraspinatus sutured into Hill-Sachs defect

TUBS Operative Treatment

• Bony loss 20%-25%*

• Latarjet (Triple effect)

• Bony – coracoid bone restores glenoid loss

• Sling – conjoined tendon across subscap

• Capsule reconstruction– coracoacromial ligament

• Autograft/allograft

• Iliac crest tricortical graft

• Tibial allograft

TUBS Recurrence/Complications

• Soft tissue only procedures with critical bony loss 25%*

• Increased risk with young patients, contact athletes, male patients, unrecognized bony or soft tissue lesions (HAGL, off-track lesions, etc.)

• Seizure disorder – exhaust all medical management prior to surgical intervention

• Shoulder pain

• Nerve injury• Musculocutaneous*

• Axillary

• Stiffness – ER

• Infection

• Graft lysis

• Hardware complications

• Chondrolysis

Thrower’s Shoulder

• Large forces

• GIRD• Increased ER, decreased IR – Same total ARC of motion

• Tight posterior capsule, loose anterior capsule

• Increased humeral and glenoid retroversion

• Posteroinferior capsular tightness leads to posterosuperior humeral translation • Internal Impingement

• Rest

• Posterior capsular stretches

Phases of Throwing

• Wind up• Minimal forces

• Cocking• Early – Deltoid

• Late – elbow valgus stress is greatest

• Supraspinatus, infraspinatus, teres minor

• Acceleration• Triceps; Pec major, Latissimus dorsi, Serratus anterior

• Deceleration• Most harmful phase of throwing

• Eccentric contraction of all muscles

• SLAP tear, biceps tendon injury, brachialis injury, teres minor injury

• Follow Through• Body rebalances

Phases of Throwing

GIRD

• Increased external rotation

• Decreased internal rotation

• Remember – The total ARC of motion is the same

• Increased humeral retroversion

• Treatment• Posterior capsular stretch

• Pec minor stretch

• Subscap strengthening

• Posterior inferior capsular release versus anterior capsular imbrication

Internal Impingement

• Late cocking/early acceleration phase

• Posterior superior capsule, labrum, and cuff get entrapped

• SLAP tear – peel back lesion

• Bennett lesion – glenoid exostosis

• Partial articular sided cuff tear near junction of supraspinatus

and infraspinatus


• Treatment• Rest, stop throwing

• NSAID

• Posteroinferior capsular stretch

• Pec minor

• SICK scapula

• Injection• Ultrasound guided glenohumeral or subacromial


• Treatment

• Failed non-op: 3-6 month minimum

• Arthroscopy• Debridement

• SLAP repair*

• Posterior capsular release – uncommon

• Anterior capsular repair – rare

• Concomitant rotator cuff repair – avoid if possible

Little Leaguer’s Shoulder• Salter Harris I epiphyseal injury

• Males > females

• 11-16 years of age

• Number of pitches is biggest indicator, breaking pitches are an associated culprit

• Hypertrophic zone of the growth plate

• Treatment

• Rest

• NSAID’s

• Return after progressive throwing program and evaluation of mechanics

• PITCH COUNT*

Pitch Count

SLAP Tears

• Mechanism• Traumatic

• Attritional/aging

• Internal impingement

• Risk factors• GIRD


• Rotator cuff tears – usually articular sided

• Shoulder instability

• Scapular dyskinesis

• Tight P-IGHL may cause increased shear force of superior labrum due to the shift of the glenohumeral contact point posterosuperiorly

• SLAP lesion increases strain on the A-IGHL which results in shoulder instability

SLAP Tears

• Treatments have been controversial

• Evolved over time

• Used to fix every one of them

• Now either treat non-op or tenodesis

• General outcomes OK if indication is appropriate

• RTP not as predictable, overhead throwers less predictable

SLAP Tears

• Classification

SLAP Tears

SLAP Tears

• Non-op management• First line

• Address GIRD/SICK scapula

• Cuff strengthening

• Operative management• Controversial

• Type II in overhead athletes

• Anchor placement• Refrain from anterior anchors – increase stiffness

• Tenotomy vs. tenodesis?

SLAP Tears

• Stiffness• Especially with concomitant rotator cuff repair in patients >45 years

• 78% of patients report some level of stiffness

• Return to play• Variable, especially in elite throwers

• Suprascapular nerve injury• Overdrilling the glenoid

• Failure• Better outcome for tenodesis in patients >36 years

Adhesive Capsulitis

• Functional loss of passive and active motion

• More common among women• 40-60 years of age

• Types• Idiopathic

• Post-traumatic

• Post-operative

• Fibroblastic proliferation of joint capsule leading to thickening, fibrosis, and adherence of the capsule to itself and humerus• Essential lesion involves the rotator interval and coracohumeral ligament

Adhesive Capsulitis

• Associated conditions• Diabetes

• Worse outcome in diabetics

• Stiffness is sometimes the first manifestation of DM and may require further workup

• Thyroid disorders (autoimmune etiology)

• Dupuytren’s

• Atherosclerotic disease

• Cervical spine involvement

Adhesive Capsulitis

• Self limiting• Can take 1-2 years

• Freezing

• Frozen

• Thawing

• Non-op• Daily stretching

• Supervised PT or HEP for competent patients

• +/- injections: Steroid, saline?

• Operative• Only after extensive non-op failure

• MUA - ~50% failure in diabetics

• Arthroscopic release – extensive capsular release, rotator interval, CHL, SAD/bursectomy

• Immediate PT

Rotator Cuff Tear

• Common aspect of aging

• Middle age to elderly

• Young patients with acute tears are treated more aggressively

• Prevelance• Increased incidence with age

• 1995 JBJS: 34% of asymptomatic individuals had cuff tears

• 2006 JBJS: 35% of people presenting with unilateral pain had asymptomatic tears in contralateral shoulder

• >60 years: 28% have full thickness tears

• >70 years: 65% have full thickness tears

Rotator Cuff

• Natural progression to increase in size and symptoms after

2-3 years

• 50% of tears enlarge by ~3 years

• In symptomatic tears, there is direct correlation between

symptoms and tear progression

Rotator Cuff

• Supraspinatus (Suprascapular nerve)• 12.7mm

• Infraspinatus (Suprascapular nerve)• 13.4mm

• Teres minor (Axillary nerve)• 13.9mm

• Subscapularis (Nerve to subscapularis) • 17.9mm

• Cuff to articular margin distance is 1.6-1.9mm

• AP dimension is 20mm

Rotator Cuff

Rotator Cuff

• Assist in initiating motion

• Balance the force couples around the joint

• Maintains a stable fulcrum for glenohumeral motion

Rotator Cuff

• Consists of 5 layers

• Articular side is less vascular and is half as strong as bursal side

• Higher rate of articular sided tears

• Anatomic components

• Rotator interval

• Rotator crescent

• Rotator cable

Rotator Cuff

• Crescent• Relatively avascular area of the more distal portion of the blended

supraspinatus and infraspinatus tendons

• Cable• Transmits forces across the rotator cuff complex

• Extension of the coracohumeral ligament and thickening of the supraspinatus and infraspinatus

• Rotator interval

Rotator Cuff

Pathology of a Cuff Tear

• Spans from acute trauma to chronic degenerative changes

• Depends on both intrinsic and extrinsic factors• Extrinsic


• Acromion Type

• Coracoid morphology

• Bicep tendon subluxation

• Inctrinsic• Aging

• Vascularity

• Genetics

Cuff Presentation

• Weakness• Active motion is limited, Passive motion is near full

• Functional ROM

• Pain• Lateral arm pain (deltoid)

• Night pain – usually a poor indicator of non-op management

• Deep toothache type pain

• Overhead activities painful

Cuff Exam

• Neer’s

• Hawkin’s

• Drop arm

• Hornblower’s

• Atrophy

• Strength

• Belly press

• Lift off

• Bear hug

Rotator Cuff Imaging

• X-rays• AP, Grashey, Scap-Y, Axillary

• GH joint arthritis, AC joint arthritis

• MRI• Gold standard for cuff imaging

• Eval bicep tendon, labrum, muscle atrophy

• Ultrasound• Just as accurate as MRI in cuff visualization

• Is there utility in using for post-op management?

Cuff Tear

• MRI Findings

• Tear extent

• Level of retraction

• Fatty atrophy

• Tangent sign

• Medial subluxation of the bicep tendon

• Subscap tear?

Cuff Tear

• Classification

• Size

• Thickness

• Shape/Tendons involved

Cuff Tear

• Management

• Non-op

• Tendinitis

• Partial thickness tears <1cm – more aggressive with bursal sided tears

• Chronic full thickness tears in older patients >65-70 years

• Operative

• Acute, full thickness tears

• Chronc full thickness tears in a young age <65 years

Cuff Tear

• Non-op management• NSAIDs

• Subacromial injection

• Therapy – cuff strengthening, scapular stabilization

• Re-evaluate at 6-12 weeks

• MOON Shoulder study showed that 75% of patients did not have shoulder surgery by 2 years • 452 full thickness asymptomatic cuff tears

• Initial treatment with PT

• The majority that did go on to surgery failed non-op treatment by 12 weeks

Cuff Repair

• Arthroscopic versus open/mini-open

• Scope repair has equivalent outcomes with less pain, better

visualization, and less risk

• Traditional saber incision – Deltoid dehiscence

• Mini-open – axillary nerve at risk (5cm)

Cuff Tear

• Repair Techniques• Margin convergence

• Interval slide• Anterior, posterior

• Subscap repair• Difficult through scope, but shown improved pain and motion

• Comma sign – SGHL and CHL attach to subscap

• Long head biceps tendon• Tenotomy versus tenodesis

• Most studies show no to little difference after rotator cuff repair

• Footprint restoration• Lower retear rate with double row versus single row

• More anatomic footprint restoration

Cuff Tear

• Complications• Retear – most common cause of failure

• Study dependent: small tears 10%-20%, large tears – 50%• Cuff tissue healing to tuberosity

• Age >65

• Large tear >5cm

• Muscle atrophy

• Diabetes

• Smokers

• Non-compliance with therapy

• Treatment of retear• Revision rotator cuff repair

• Reverse total shoulder arthroplasty

Cuff Tear

• Tendon transfers

• Massive and irreparable tears• Pec major tendon – massive subscap tears

• Latissimus dorsi transfer

• Young laborer is best candidate

• Large supraspinatus and infraspinatus tears

• Radial nerve at risk

• Posterior branch of axillary nerve

• Graft augmentation – limited studies with limited outcomes, but promising?

• Biologics in cuff repair• PRP – most studies show no benefit

• BMAC – more promising, but limited studies

Cuff Tear

• Complications • Deltoid detachment – open repair? Overaggressive lateral acromion

debridement?

• AC pain

• Axillary nerve injury – mini-open procedure?

• Suprascapular nerve injury – over aggressive mobilization

• Infection• <1%

• P. acnes – ensure lab keeps samples for at least 21-day hold

• Stiffness – no difference at 1 year with early versus delayed motion

• Pneumothorax

Calcific Tendinitis

• Associated with subacromial impingement

• More common in women

• Endocrine disorders• Diabetes

• Hypothyroidism

• Unknown etiology

• Three stages• Precalcific

• Calcific• Formative phase

• Resting phase

• Resporptive phase – most painful

• Postcalcific

Calcific Tendonitis

• Calcium hydraxyapetite deposition

• Presents similar to impingement

• Catching, locking

• Atraumatic pain

• Mechanical block

• Reduced active ROM

• Reduced rotator cuff strength?

Calcific Tendinitis

• Imaging• X-Ray

• CT – rarely used

• Ultrasound

• MRI

• PT, injections, NSAIDs• Resolution in 60-70% after 6 months

• Shock wave therapy

• Ultrasound guided needle aspiration, barbotage

• Surgical decompression +/- cuff repair and subacromial decompression• Good results in short term studies

Scapular Winging

• Imbalance and abnormal motion of the scapula

• Direction

• Defined by the superomedial corner of the scapula

• Medial – serratus anterior: Long thoracic nerve

• Weak protraction, excessive retraction by rhomboids and elevation by trapezius

• Lateral – trapezius: spinal accessory nerve (XI)

• Weak retraction/elevation, excessive protraction by serratus and pecs

• Less common than medial

Winging

Medial Scapular Winging

• Deficit in serratus anterior

• Traction nerve injury >50% of cases• Head tilted away during overhead activity

• Baseball, volleyball, weight lifters

• Compressive nerve injury

• Direct nerve injury • 10% of patients had prior surgery


• Inferior medial scapula elevates, protrudes medial and posterior

• Manual stabilization of the scapula often reduces pain and improves motion• Active elevation and abduction limited to about 90o

• EMG assess long thoracic nerve

• Observe for a minimum of 6 months

• PT for serratus anterior strengthening

• Most resolve and return to full function in about 2 years


• Operative techniques

• Serratus avulsion repair

• Neurolysis of long thoracic nerve

• Muscle transfer – split pectoralis tendon

• Nerve transfer

• Scapulothoracic fusion

Lateral Scapular Winging

• Poor trapezius function secondary to spinal accessory nerve

• Iatrogenic

• Cervical lymph node dissection

• Radical neck dissection

• Traction injury

• Blunt trauma


• Superior medial scapula drops downward and protrudes

lateral and posterior

• Weakness of forward flexion and abduction

• EMG can show CN XI injury


• Observation

• Limited utility because most injuries are direct injuries and warrant

surgical intervention

• Exploration of the long thoracic nerve with repair or release

• Eden-Lange transfer of rhomboids and levator scapulae

from medial border of scapula to lateral border

• Scapulothoracic fusion

Suprascapular Neuropathy

• Entrapment of suprascapular nerve • Suprascapular notch

• Effects both supraspinatus and infraspinatus

• Spinoglenoid notch• Effects only infraspinatus

• C5-C6 nerve roots• Superior trunk of brachial plexus

• Supracapular ligament – Artery above, Nerve below

• Spinoglenoid ligament


• Scapular notch • Ganglion cyst from labral tears

• Fracture callus

• Transverse scapular ligament entrapment

• Effects both supraspinatus and infraspinatus

• Spinoglenoid notch• Posterior labral tears causing a cyst

• Traction injury (~45% of volleyball players)

• Spinoglenoid notch ganglion

• Effects only the infraspinatus


• Try non-operative management

• PT

• NSAIDs

• Activity modifications

• Operative management

• Cyst decompression with labral repair

• Spinoglenoid notch decompression and nerve release

AC Joint Injury

• Direct blow to shoulder or a fall onto the shoulder

• Injury to AC joint capsule or CC ligaments• Posterior and superior ligaments are most important for stability

• Conoid – Medial, 4.5cm medial to lateral edge

• Trapezoid – Lateral, 3cm medial to lateral edge

• Keep in mind osteolysis of the distal clavicle in weightlifters• Arthroscopic resection has best outcome after failed conservative

management

AC Joint Injury

• X-Rays

• AP views – get bilateral for comparison

• Axillary – required for Type IV

• Zanca view

• Cross body stress – Scap Y view

• Weighted stress views*

• Not done any more

• May help Type II vs Type III

AC Joint Injury

AC Joint Injury

• Non-op Management

• Type I, II, III*

• Sling and shoulder rehab

• Surgical Management

• Type III* - after non-op failure, still painful

• Type IV, V, VI

AC Joint Injury

• Technique• Bosworth screw fixation – clavicle to coracoid

• Fallen out of favor

• ORIF with suture fixation around coracoid

• ORIF with pin fixation across AC joint• High rate of pin migration

• ORIF with hook plate• Second surgery for plate removal, hook pullout

• CC ligament reconstruction with CA ligament• Weak repair, high failure

• CC ligament reconstruction with free graft• Allograft, autograft

• Best to recreate the CC ligament strength

AC Joint Injury

• Complications

• Hardware failure

• Coracoid fracture

• Coracoid tunnel drilling

• AC joint arthritis

• Residual pain at AC joint

• 30-50%

ELBOW

Elbow

• Anatomy• Distal humerus

• Proximal radius

• Proximal ulna

• Valgus carrying angle of 6-11o

• Ligament stability• Ulnar collateral ligament – medial

• Lateral collateral ligament - lateral

Elbow

• Ulnar collateral ligament• Anterior oblique

• Strongest and most important stabilizer to valgus stress

• 2.8mm distal to articular margin and inserts on sublime tubercle

• ~54mm

• Posterior oblique• Tighter in flexion

• Transverse ligament• No contribution to stability

UCL Anatomy

Ulnar Collateral Ligament

• Primary restraint to valgus stress from 30-120o

• Patients complain of feeling a pop• Decreased velocity and accuracy

• Pain during late cocking/early acceleration

• +/- ulnar nerve symptoms

• Overhead athlete, significance valgus stress

• Uncommon in skeletally immature• Little Leaguers Elbow

• Valgus stress test – 50% sensitive

• Milking maneuver

• Dynamic milking maneuver


• Risk factors for injury

• Increasing pitch count

• Not following throwing protocol

• Pitch velocity

• Poor kinetic chain/throwing mechanics

• Core weakness, shoulder weakness, lower extremity


• Imaging• Standard x-rays often are normal

• May see posterior olecranon osteophytes from valgus overload

• Gravity or manual stress views: can see gapping >3mm

• MRI arthrogram• Sensitivity 92%, specificity 100%

• Capsular T sign with dye extravasation

• Dynamic ultrasound• Ultrasound with dynamic milking maneuver observing for joint diastasis


• Treatment• Non-operative management as trial

• Avg 24 weeks has a 42% return to preinjury function

• Tommy John Reconstruction• Allograft vs autograft

• Docking technique has shown better outcomes with improved return to play, patient satisfaction, than Jobe, modified Jobe, or Figure-8 technique

• UCL Repair• Poor results and not clearly defined in the literature

• Ulnar nerve transposition• In situ release as part of surgical procedure

• Transpose only if neurological issues pre-procedure, subluxation of the nerve, or poor ulnar nerve motor function

UCL Complications

• Ulnar neuropraxia: up to 36%

• Fracture of ulna or medial epicondyle • Small bone bridge tunnel placement

• Stiffness• HO development

• Excise HO around 6 months if present

• Medial antebrachial cutaneous nerve injury

• Not able to return to pre-injury level of play• Higher risk with revision cases

Valgus Extension Overload

• Posteromedial stress secondary to shear stress and overload • Radiocapitellar compression

• Posterior extension overload

• Shear force on medial aspect of olecranon tip and fossa

• Stress along UCL

• Osteophytes along medial olecranon

• Chondromalacia

• Loose bodies

• Cubital tunnel in about 25% of cases

Valgus Extension Overload

• Loss of terminal extension

• Pain during deceleration phase

• Treatment• Rest, NSAIDs, PT

• Arthroscopic resection of osteophytes• Do not resect normal olecranon

• Increases stress to MCL

• Contraindication with resection only if UCL is incompetent

Posterolateral Rotatory Instability

• Posterolateral subluxation or dislocation of the radiocapitellar and ulnohumeral joints

• Insufficiency of the lateral ulnar collateral ligament

• Causes• Traumatic – elbow dislocation

• Forearm supination, axial load, valgus stress

• Iatrogenic• Aggressive arthroscopic debridement of lateral epicondylitis

• Stay anterior to equator of radial head during debridement

• Chronic attenuation

Lateral Ulnar Collateral Ligament

• 4 components of the ligament

• Annular ligament

• Lateral collateral ligament (radial)

• Lateral ulnar collateral ligament

• Primary lateral stabilizer to varus and ER stress

• Accessory collateral ligament

PLRI

• Varus instability

• Lateral pivot shift test

• Posterior drawer exam

• Apprehension test

• Chair rise test

• Table top relocation test

• Floor push up test

PLRI

• Reduce elbow and splint at 90o of flexion

• LCL disrupted but UCL intact

• Splint in pronation – tightens lateral structures

• LCL and UCL disrupted

• Splint in neutral

• Splint for 5-7 days

• Begin early ROM exercises after that

PLRI

• Bracing and progressing ROM and rehab• Low-demand patients

• Chronic PLRI

• LUCL repair, fracture fixation• Acute instability

• Graft reconstruction in chronic PLRI

• Complications• Stiffness

• Nerve injury – reduced with posterior approach

• Recurrent instability – 3-8% incidence

OCD of the Elbow

• Usually in patients over age 10

• Capitellum is most affected

• Boys > Girls

• Repetitive overhead activities• Gymnastics, Throwers

• Vascular insufficiency, repetitive microtrauma

• Capitellum is supplied by two end arteries• Radial recurrent

• Interosseous recurrent

OCD of the Elbow

• Panner’s disease• Prior to age 10

• Surgery contraindicated for Panner’s

• Self limiting

• Juvenile OCD has better prognosis than adult

• Prognosis is related to status of growth plate

• Usually heal between 6-18 months

• Up to 50% can develop elbow arthritis long term

OCD of the Elbow

• Classification

• Type I: Intact cartilage

• Type II: Cartilage fracture with bony collapse or displacement

• Type III: Loose bodies in joint

Type I Type II Type III

OCD of the Elbow

• Loss of extension

• Tenderness over lateral side of elbow

• Catching/locking – late signs of displaced fragment

• Type I – non-op with cessation of activities

• Slow return back to full activities after 6-12 weeks

• 90% success

OCD of the Elbow

• Scope with microfracture• Unstable Type I

• Type II

• Good outcomes after about 6 months of rehab and return to sports

• Fixation of lesion• Large lesions

• Throwing and lifting by 4-6 months

• Scope with debridement and loose body removal

• OATS procedure• Progressive throwing program by 5-7 months

• Stiffness

• Pain

• Arthritis

• Unable to return to sports

Lower Extremity

Hip Impingement

• Abnormal shape and mismatch between proximal femur

and acetabulum

• Femur based – CAM lesion

• Acetabulum based – Pincer lesion

• Most often asymptomatic in general population

Hip Impingement

• CAM lesion• Young athletic males most common

• Anterolateral neck is involved

• Decreased head to neck ratio

• Femoral neck anteversion

• Decreased femoral offset

• Aspherical femoral head

• Shearing of the chondro-labral junction • Cartilage delamination and separation of the labrum

Hip Impingement

• Pincer lesion• More common in females

• Large overhang of acetabular rim/wall• Anterosuperior quadrant

• Acetabular retroversion

• Acetabular protrusion

• Coxa profunda

• Intrasubstance labral degeneration

• Contrecoup lesions as the femoral head levers into the posteroinferior acetabulum

• Combined lesions are present in up to about 80% of patients

Hip Impingement

• Patients complain of activity related groin pain

• Worsened by hip flexion

• Difficulty sitting

• Gluteal or troch pain secondary to poor gait mechanics

• Pain with hip flexion up to 90o

• Worsened with hip internal rotation of >5o

• FADIR test elicits pain

Hip Impingement

• Radiographic measurement• AP pelvis

• True lateral Dunn or modified Dunn views

• False profile view• Standing position of 65o between pelvis and the film

• Signs• Pistol grip deformity in CAM lesions

• Crossover sign in Pincer lesions – acetabular retroversion

Hip Impingement

• Measurements• Alpha angle

• Frog leg lateral radiograph

• Line from center of femoral head to center of femoral neck

• Second line from center of femoral head extended to where femoral neck prominence begins

• >42o – suggestive of head neck offset deformity

• 50o-55o – indicated CAM deformity

• Lateral center edge angle• <40o

• Anterior center edge angle• >20o

• Acetabular index/Tonnis roof angle• Normal above 0o

• Cross over sign

• Ischial spine sign

AB

C

D

A: Lateral Center Edge Angle

B: Alpha Angle

C: Acetabular Index/Tonnis Roof Angle

D: Anterior Center Edge Angle

Hip Impingement

• CT scan

• Aids in assessing bony deformity

• 3D recons can be used for pre-surgical planning

• MRI/Arthrogram

• Evaluate for articular cartilage and labral injury

• Assess femoral head/neck junction

• Make sure the MRI is formatted to be in line with the femoral neck

Hip Impingement


• At least 3-6 months

• Rest

• NSAIDs

• Intraarticular steroid injections

• PT to work on hip mechanics, gait, and kinetic chain

Hip Impingement

• Operative intervention• Failure of non-op treatment in non-arthritic hip

• Tonnis grade 1 or higher have poorer outcomes

• Arthroscopic osteoplasty• CAM resection, acetabular resection

• Labral repair?

• Similar outcomes with less morbidity compared to open procedures

• Open osteoplasty• Reserved for severe deformities

• Periacetabular osteotomy• Acetabular deformity with severe retroversion

• Hip arthroplasty• Hip OA

• Resurfacing vs Total hip?

Hip Impingement

• Inadequate resection about 68% of the time

• Isolated labral debridement without bony work will not

resolve the pathology

• Ensure labral repair/refixation if destabilized to resect

acetabular pathology

• Return to play - successful ~80%

Hip Impingement

• Complications• Femoral neck fracture

• Reduce the risk by resecting <30% of the femoral neck diameter during femoral osteoplasty

• Heterotopic ossification

• Residual deformity• Ensure appropriate use of multiplanar fluoroscopy during procedure

• Remeasure alpha angle to ensure appropriate resection was performed

• Neuropraxias from hip scope

Hip Arthroscopy

• Indications• FAI

• Labral tear

• Loose bodies

• Iliopsoas disorders

• Synovitis/Infection

• Capsulotomy• Improves visualization

• Interportal vs T-Cut• Controversy on closure

• Resection of iliofemoral ligament will result in increased external rotation

• Iatrogenic instability with capsular deficiency

Hip Arthroscopy

• Portals• Anterolateral portal

• Primary viewing portal

• Posterolateral portal

• Posterior hip joint access

• Anterior portal

• Anterior hip joint access

• Distal anterolateral portal

• Peripheral compartment access

Hip Arthroscopy

• Compartments• Central

• Intra-articular

• Labral repair

• Chondroplasty

• Acetabuloplasty

• Peripheral• CAM resection

• Lateral• Gluteus medius repair

• IT band release

• Peritrochanteric lesions

Hip Arthroscopy

• Contraindications – Do Not Scope• Extensive Pincer lesion – circumferential

• Open dislocation with osteoplasty

• Moderate to severe DDH• Periacetabular osteotomy

• Instability after prior capsulotomy• Open allograft reconstruction

• Degenerative joint disease• Joint space <2mm

• Tonnis grade 2

Tonnis Grading

Hip Arthroscopy

• Complications• Most common is associated chondral injuries

• Neurovascular injury• Traction related – most common

• Pudendal nerve injury

• Peroneal nerve

• Anterolateral portal• Superior gluteal nerve

• Posterolateral nerve• Sciatic nerve

• Anterior portal• Lateral femoral cutaneous nerve

• Femoral neurovascular bundle

• No instruments medial to the ASIS

• Ascending branch of the lateral femoral circumflex artery

Hip Arthroscopy

• Conversion to total hip arthroplasty

• Female gender

• Obesity

• Age >60

• Low case volume surgeon

• Tobacco use

• Pre-existing hip arthritis

Ischifemoral Impingement

• Pain with passive extension

• Involves the quadratus femoris

• Edema seen on MRI

• Impingement with lesser trochanter and lateral border

ischium

• Local injection is diagnostic

Athletic Pubalgia

• Males >> Females

• Lower abdominal pain with excessive exertion• Abdominal hyperextension

• Thigh hyper abduction

• PE• Adductor longus pain

• Pain with adduction

• Pain with Valsalva/sit ups

• Tx• Conservative management

• Pelvic floor repair

• Adductor/Rectus resection

Sports Hernia

• Groin pain

• Heavy weight training, Valsalva

• Adductor tightness

• Fasical defect

• Imaging not helpful - difficult to visualize

• Hernia repair?

Sports Hernia

• Rectus femoris tightness• Modified Thomas test

• Adductor strain• Hockey

• Adduction to abduction strength <80%

• Steroid injection is diagnostic and therapeutic

• Osteitis pubis• Adductor longus inflammation

• Gait disturbance

• Self limited

Snapping Hip

• Coxa Saltans

• Internal (You will hear this)• Ballet dancers

• Pelvic rim or proximal femur

• Extend hip from FABER position

• Conservative treatment, iliopsoas lengthening

• External (You will see this)• ITB over GT

• Hip adduction and knee flexion

• Conservative, IT band z-lengthening

• Intra-articular• Loose body

• Labral tear

Other Hip Disorders

• Greater trochanteric bursitis• ~60% long term relief with steroid injections

• Hip osteoarthritis• Common in runners

• Loss of internal rotation

• Hip dislocation/subluxation• 90% are posterior

• Pay attention for posterior acetabular fracture

• 10-20% hip osteonecrosis

• Iliac wing contusion• Hip pointer - conservative

Lower Extremity

• Hamstring Avulsion

• Water skiing

• Sudden hip flexion with knee extension

• Early repair indicated

• Avulsion fractures

• Adolescents

• ASIS – sartorius

• AIIS – Rectus

• Ischial tuberosity – Hamstring

• Fix if >2cm displacement, high level athlete

• Minimally displace treated with rest and NSAIDs x4 weeks then PT indicated

Lower Extremity• Thigh

• Hamstring muscle tear

• Musculotendinous junction

• Satellite cells play a role in muscle injury healing

• Conservative management

• Quad strain

• Patient often describes a “Dead Leg”

• 2:1 male:female

• Football, soccer, rugby – most common

• Splint early with the knee flexed – 120o, 24-48 hours after injury

• Myositis ossificans

• Only operate on mature lesions – 6-12 months

Adductor Strain

• “Pulled groin”

• 10-30% soccer and hockey players

• Adductor compartment• All obturator nerve innervation

• Adductor longus – most commonly injured

• Adductor magnus

• Adductor brevis

• Gracilis

• Obturator externus

• Pectineus

Adductor Strain

• X-Ray

• AP pelvis and hip

• Most often normal

• May see a fleck sign with avulsion injury

• MRI

• Tendon avulsion, retraction from pubic ramus

• Muscle edema and hemorrhage

Adductor Strain

• Non-operative management• Rest, NSAIDs, protected weight bearing

• PT

• Open repair• Avulsion

• Retraction

• Not a lot of data showing open repair better than conservative treatment

KNEE

ACL Injury

• +/- 400,000 ACL reconstructions every year

• Females>>Males

• Age of incidence

• Females are younger than their male counterparts when they

sustain an ACL injury

• Several factors as to why

• Anatomic, Biomechanical, Neuromuscular, Hormonal, Genetic

ACL Injury

• Women vs Men

• Anatomic

• Hypermobility or joint laxity

• Smaller notch leading to ACL impingement

• Smaller size ACL

• BMI

• Previous ACL injury

• Biomechanical

• Decreased hip and knee flexion with landing

• Increased knee valgus with landing

• Fatigue reistance

• Neuromuscular

• Quad dominant – poor hamstring strength and strength programs

• Lower hamstring recruitment

• Core stability is weaker

• Hormonal

• Pre-ovulatory – affect coordination, relaxin hormone?

• OCP protective?

• Genetic

• COL5A1 gene shows a link to reduced risk of injury in women

ACL Injury

• Non-contact• Pivot and shift mechanism

• Anterior tibial translation while knee is in slight flexion and valgus moment arm

• Associated injuries• Meniscal involvement

• Lateral meniscal tears in 54% of acute ACL injuries

• Medial meniscal tears are seen in chronic ACL deficient knees

• Other ligament injuries• PCL, LCL, PLC

• Chondral injuries seen

Biomechanics

• Diarthrodial

• Simultaneous rotation and translation

• Articular cartilage

• Type II

• Mostly water

• Increased water and decreased proteoglycans with

osteoarthritis

ACL Anatomy

• Anteromedial bundle

• Tight in flexion

• Limits translation

• Posterolateral bundle

• Tight in extension

• 33mm x 11mm

• Tibia -> Femur

• Middle geniculate artery

• 90% Type I cartilage

• 10% Type III

• 2200 N strength regarding tibial translation

AM

PL

ACL Anatomy

• Anteromedial bundle• Limits tibial translation

• Posterolateral bundle• Limits rotation primarily (pivot shift test)

• Lateral intercondylar ridge is the anterior extent of the ACL footprint on the femur• Bifurcate ridge delineates the two bundles different attachments on the femur

• Tibial attachment is between the intercondylar spines

• 85% contribution to tibial translation

• Secondary stabilizer to tibial rotation and varus/valgus rotation

ACL Injury

• Describe feeling/hearing a “pop”

• Immediate swelling, hemarthrosis

• Feelings of instability

• Immediate ROM is limited, loss of motion due to effusion

and pain

ACL Exam• Lachman

• Most sensitive

• A = Firm endpoint : B= soft/no endpoint

• I = 3-5mm translation

• 2 = 5-10mm translation

• 3 = >10 mm translation

• Keep in mind that a concomitant PCL tear may give confusing Lachman due to the already posterior translated position of the tibia

• Keep in mind that displaced bucket handle meniscal tear can give confusing Lachman exam due to meniscus blocking translation

• Pivot shift

• Extension to flexion with valgus and internal rotated tibia

• IT band will reduce tibia at 20-30o flexion

ACL Imaging

• X-ray

• Sulcus terminalis sign

• Depression along the lateral femoral condyle at the terminal sulcus

• Segond fracture

• Fragment from anterolateral proximal tibia

• Avulsion of the Anterolateral ligament

ACL Imaging

• MRI • Discontinuity of ACL fibers on sagittal T2

• Not parallel to Blumensaat’s line

• Bone bruising is seen in more than half of ACL tears• Pivot shift: middle 1/3 of lateral femoral condyle and posterior 1/3 of lateral

tibial plateau

• Coronal imging shows discontinuity of ACL fibers and fluid against the femoral wall – “empty wall sign”

• CT• Used for revision settings to evaluate for bony tunnel sizing/position

ACL Treatment

• PT and lifestyle modifications for non-operative management• Low demand patients

• Increased arthritis development

• ACL reconstruction • Young, active athletic patient

• Lack of pre-operative motion is a risk factor for post-op arthrofibrosis

• Noted instability with daily activities

• Prior ACL reconstruction

• Return to play encompasses:• Psychological

• Demographic

• Functional instability

ACL Treatment

• Goal is to restore anatomic position and function of the knee

• Tunnel placement • Femur

• Sagittal plane - 1-2 mm of back wall

• Coronal plane – left knee 2 o'clock , right knee 10 o’clock

• Tibia

• 10-11 mm anterior to PCL

• 9mm posterior to intermeniscal ligament

• Tunnel trajectory <75o from horizontal – in the coronal plane

ACL Treatment

• Pre-condition the graft

• Level I study showed no difference between 20N or 40N

• Fix the graft in 20o-30o

• Fixation

• Interference screw

• Cortical button – suspensory fixation

ACL Graft

• BTB• Most common graft source

• Load to failure 2600N

• 10-30% of patients experience anterior knee pain kneeling and squatting

• Patella fracture

• Quad graft• Minimal anterior knee pain

• Load to failure 2200N

• Often used in revision setting

• Hamstring • Load to failure 4000N

• Decreased peak flexion strength at 3 years

• Can see windshield wiper effect with tunnel widening

ACL Graft

• Allografts• Longer incorporation of graft

• Increased risk of re-rupture in young athletes • Risk of re-tear is 4.3x higher in young athletes 10-19

• Graft processing• Fresh frozen grafts have lower re-rupture rates compared to

chemically treated or irradiated grafts

ACL – Pediatric Considerations

• Age of menarche is best determinant of skeletal maturity in females

• <14 years of age with open physis

• Avoid the physis• Large tunnel >12mm is biggest risk component to injury of the physis

• 8mm tunnel is about 3% cross sectional area of physis

• 12mm tunnel is >7-9% of physeal cross sectional area

• No instrumentation across physis

• No bony block across the physis

• Oblique tunnel position

• High speed reaming

• Suture near the tibial tubercle

• Lateral extra-articular tenodesis

• Dissection close to the Ring of LaCroix

• Physeal disruption with growth disturbance ~10%

ACL Rehab

• Early range of motion

• Aggressive swelling control• Ice

• Compression

• Obtain passive full extension early

• Early exercises• Eccentric strengthening to improve quad strength and volume

• Isometric hamstring contractions

• Isometric quad contractions

• Active knee motion 35o-90o

• Core and gluteal exercises

• Closed chain exercises

ACL Rehab

• Pitfalls to avoid• Early isokinetic strengthening of the quads

• Open chain exercises

• Injury prevention• Jumping and landing mechanics

• Less valgus with more knee flexion

• Neuromuscular training

• Improve hamstring strength to try and normalize the quad dominance

• Psychological factors play a major role in return to play

ACL Failure

• Graft failure due to femoral tunnel malposition • Almost 70% of failures

• Vertical femoral tunnel placement• Will still have pivot shift on exam

• Anterior tunnel placement • Tight in flexion

• Loose in extension

• Don’t get posterior to resident’s ridge

• Posteiror tunnel placement• Loose in flexion

• Tight in flexion

ACL Failure

• Tibial tunnel malposition

• Anterior tunnel

• Roof impingement in extension

• Tight flexion

• Posterior tunnel

• Impingement on the PCL

ACL Failure

• Other causes

• Hardware failure

• Tunnel/screw divergence >30o

• Small graft <8mm

• Femoral bone plug dislodgement

• Missed concomitant ligament injuries

• Posterolateral corner

• Over aggressive rehab, not following protocol

ACL Infection

• Septic arthritis <1%• S. epidermidis is most common

• S. aureus is second

• Pre-soaking in vancomycin may lower this risk

• Effusion, increase pain 2-14 days post-op• Knee aspiration with gram stain and cultures

• Immediate arthroscopic irrigation and debridement• Can try and save the graft with multiple I&D’s with at least 6 weeks of

antibiotics

Other ACL Failures

• Arthrofibrosis

• <12 weeks – aggressive PT and progressive splinting

• >12 weeks – knee scope with lysis of adhesions, MUA

• Pre-hab - gain full pre-op ROM and wait for inflammatory phase to subside before surgery

• Infrapatellar contraction

• Patella tendon rupture

• RSD

• Patella fracture

• Seen 8-12 weeks post-op

• Tunnel osteolysis

• Cyclops lesion

• Blocks extension

• Post-traumatic arthritis

• More likely with meniscal pathology

• Nerve irritation

• Saphenous from hamstring harvest

PCL Anatomy

• 30% larger than ACL• 38mm x13mm diameter

• Two bundles• Anterolateral – tight in flexion

• Posteromedial – tight in extension

• Posterior tibial sulcus below articular surface to the anterolateral medial femoral condyle

• Ligament of Humphrey (anterior) Ligament of Wrisberg (posterior)• From posterior horn of lateral meniscus

• Middle geniculate artery

• 2500N – 3000N

PCL Injury

• Dashboard injury

• Hyperflexion of knee with plantar flexed foot

• PCL deficient knee

• Increased contact pressures in the patellofemoral and medial

compartments due to varus malalignment

• Isolated injuries cause greatest instability at 90o

PCL Injury

• Always consider history of knee dislocation

• Exam• Posterior sag sign

• Posterior drawer exam

• Quad activation test• Flex knee 90o and actively straighten knee. Positive if tibia reduces under femur

• Dial test• >10o difference with external rotation at 30o and 90o – combined PCL and PLC

• >10o asymmetry at 30o is consistent with isolated PCL injury

• Varus/Valgus• Laxity at 30o alone is isolated MCL/LCL

• Laxity at 0o is combined MCL/LCL and PCL injury

PCL Injury

• Most can be treated non-op• Quad strengthening/knee extensor

• May return in 2-4 weeks• Grade I and complete isolated Grade II

• Immobilization in extension for 4 weeks• Grade III injuries

• Operative • Bony avulsions in young

• Combined ligamentous injuries

PCL Injury

• Techniques• ORIF of bony avulsion

• Transtibial method vs tibial onlay

• Single bundle vs double bundle

• Primary repair of bony avulsions show good outcomes

• Reconstruction not as successful as ACL

• Residual posterior laxity often seen

• No clear advantage with one technique over the other

• Concomitant HTO with PCL• Varus malalignment with PCL deficiency

• Open wedge osteotomy on medial side• Can shift the tibia anterior relative to the femur reducing posterior sag

PCL Rehab

• Position prone for motion

• Avoid resisted hamstring exercises since this creates a posterior pull on the tibia

• Immobilize in extension and protect against gravity

• Pearls• Popliteal artery is closest to the tibia in extension

• At risk with transtibial drilling or posterior screw placement with onlaytechnique

Other Knee Injuries

• Patellar tendinopathy• Jumper’s knee

• Males > females

• Most common in VB, basketball

• Poor quad and hamstring flexibility

• Histologically this seems to be more degenerative in nature and not inflammatory

• IT band friction syndrome• Pain along lateral femoral condyle as IT Band passes over

• 50-90% of patients improve over 4-6 weeks with conservative management

• Operative• Z-lengthening

• Ellipse the posterior border of IT band over LFC

Articular Cartilage Defects

• 5-10% of people over age 40 tend to have high grade cartilage

lesions

• Locations

• Chronic ACL deficiency - anterior aspect of LFC and posterior lateral

tibial plateau

• OCD – 70% are found in posterolateral aspect of MFC

• Impaction forces as little as 24MPa can disrupt normal cartilage

Articular Cartilage Grading

Grade Outerbridge Arthroscopic Grading

Grade 0 Normal cartilage

Grade I Softening, swelling

Grade II Fissuring, superficial

Grade III Deep fissure, no exposed bone

Grade IV Exposed subchondral bone

Grade International Cartilage Repair Society Grading

Grade 0 Normal cartilage

Grade I Near normal – superficial fissures

Grade II Abnormal – lesions <50% depth of cartilage

Grade III Severely abnormal – lesions >50% depth of cartilage

Grade IV Severely abnormal – lesions with exposed subchondral bone

Articular Cartilage Treatment

• Non-op management

• Unloader bracing

• Viscosupplementation

• May provide symptomatic relief, but not long-term solution

• Decision making algorithm

• Age, skeletal maturity, low vs high demand, tolerate extended rehab

• Size of defect, location, contained vs uncontained, presence or absence

of subchondral bone involvement

Articular Cartilage Treatment

• Femoral condyle lesions• Address limb malalignment, ligament deficiency, meniscal deficiency

• Size of defect• <4mm2 – microfracture or OATS

• >4mm2 – OATS, ACI, MACI

• Patellar lesions• Address patellar maltracking and malalignment

• Size of defect• <4mm2 – microfracture or OATS

• >4mm2 – ACI, MACI

Surgical Techniques – Articular Cartilage

• Debridement/Chondroplasty

• Remove loose flaps

• Limited benefits in 50-70%

• Loose fragment fixation

• Need adequate subchondral bone

• Best in patients with with unstable OCD and open physes

• Non-absorbable implants need removed by three months


• Marrow stimulating techniques • Allows access of marrow stimulating agents into the defect to fill in with reparative tissue

• Drill holes 3-4mm apart

• Non-weightbearing and CPM while mesenchymal stem cells develop fibrocartilage

• Limited outcomes on long-term

• OATS• Replace both bone defect and cartilage defect

• Remove from non- to low weightbearing area to transfer to defect

• Chondrocytes remain viable and the subchondral bone heals well, biopsy shows Type II collagen

• Limited by• Size

• Shape matching

• Fixation strength is initially decreased – avoid weight bearing for 3 motnhs


• ACI• 2-stage procedure

• Harvest of cartilage and then grown and expanded in the lab

• Replant of cartilage inside the defect and over sew a patch

• MACI• Similar 2-stage procedure

• Cartilage cells are grown onto a matrix membrane for implantation

• Limitations• Must have well contained lesion

• Prolonged recovery with protected rehab

• Expensive


• Tibial tubercle osteotomy• Marquet

• Anteriorize the tibial tubercle reducing stress across PFJ

• Indicated for only distal pole lesions

• Do not elevate more than 1cm – risk skin necrosis

• Poor outcomes if patella has superior pole lesions

• Fulkerson• Anteromedialize tubercle

• Lateral and distal pole lesions

• Increased Q-angle

• Do not perform in skeletally immature

OCD Lesions of the Knee

• Two phases

• Juvenile – 10-15 years with open physes

• Adult – past skeletal maturity

• Knee

• 70% of lesions are posterolateral aspect of MFC

OCD Lesions of the Knee

• Juvenile – prognosis is related to:

• Age – open physes show better prognosis

• LFC and patellar lesions have worse prognosis

• Sclerosis on xrays show poorer prognosis

• Fluid behind lesion shows evidence of poorer prognosis

Grade Clanton Classification of OCD

Type I Depressed osteochondral fracture

Type II Fragment attached by osseous bridge

Type III Detached, non-displaced fragment

Type IV Displaced fragment

OCD Treatment

• Non-op• Restricted weight bearing in stable lesions in patients with open physes

• 50-70% will heal without fragmentation of the lesion

• Operative• Diagnostic scope

• Retrograde drilling or transchondral

• Fix unstable lesions >2cm • 85% healing rates in juvenile OCD

• Chondral resurfacing• Large >2cm x 2cm

• Arthroplasty• Age over 60

Exertional Compartment Syndrome

• Reversible ischemia in a muscular compartment

• Second in incidence in exercise induced leg syndrome only

to medial tibial stress syndrome

• Males > Females

• Generally seen in runners

• 3rd decade of life


• Unknown etiology

• Muscular metabolism cannot catch up to eliminating exercise byproducts/waste from muscular compartment

• Can see fascial defect that my play a role

• Symptoms begin about 10 minutes into exercise, abate after about 30-40 minutes rest

• Decreased active ankle dorsiflexion

• Numbness in 1st dorsal web space


• Diagnostic test – compartment pressure measurements with exercise

• 1- resting pressure obtained

• 2- 1-minute post-exercise pressure

• 3- 5-minute post-exercise pressure

• Diagnostic criteria

• Resting pressure >15mmHg

• Immediate (1 minute) pressure >30mmHg

• Post-exercise (5 minute) pressure >20mmHg

• Post-exercise (15 minute) pressure >15mmHg

• Two incision fasciotomy

• 80% success for anterior compartment

• ~60% success for deep posterior compartment

• Complications

• SPN injury

• DVT

• Recurrence

• 20% at 2-years after fasciotomy

Muscle Exercises

Type Definition Example

Isotonic - Force remains constant through arc of motion- Improves motor performance

Bicep curls using free weights

Isometric - Constant muscle length and tension that is proportional to the external load

- Causes muscle hypertrophy

Pushing against an immovable object

Concentric - Shortened muscle, tension that is proportional to the external load Biceps curl with elbow flexing

Eccentric - Force remains constant as muscle lengthens- Most efficient method of strengthening muscle

Biceps curl with elbow extending

Isokinetic - Muscle contracts at a constant velocity through varied resistance- Often used to objectively evaluate muscle strength during injury

rehabilitation

Requires special machines (Cybex)

Plyometric - Rapid eccentric-concentric shortening- Good training for sports that require power

Box Jumps

Open Chain - Distal end of extremity moves freely Seated leg extension and curls

Closed Chain - Distal end of extremity is fixed Squats with planted foot

Energy Sources

Anaerobic Glycolytic Aerobic

Energy Source ATP-CP Lactic acid - Oxidative phosphorylation (Krebs cycle)

- Glycogen and fatty acids

Muscle Type Type II (A,B) muscle- Fast twitch

- Type I muscle- Slow twitch

Exercise Duration 10 seconds high intensity 2-3 minutes - Endurance

Note - Type IIA: aerobic and anerobic

- Type IIB: primarily anaerobic, last to be recruited

- Low ATP yield- Lactic acidosis after

several minutes

- High ATP yield- Requires O2- Slow red ox

muscles- First to be recruited

Exercise Programs

• Periodization• Planned variation in intensity and duration of a specific workout over a predefined duration

• Dynamic exercise• Improves cardiac output by increasing stroke volume

• Endurance training (Aerobic)• Changes in circulation and muscle metabolism

• Increased energy efficiency in muscle contractions

• Increase in size, number, and density of mitochondria

• Increase use of fatty acids > glycogen

• Increased oxidative capacity of Type I, Type IIA, Type IIB muscle fibers

• Strength training• High load : low reps

• Increased cross sectional area of muscle

• Increased motor recruitment

• Adolescents can safely participate in appropriate strength training

Exercise Programs

• Aquatic therapy• Reduces joint stress by lowering vertical component of ground reaction force

• Less abrupt increases in heart rate

• Increased oxygen consumption

• Prevents secondary injuries to the lower limb

• Weight training• Increased cross sectional area

• Increased strength

• Increased mitochondria

• Increased capillary density

• Thickened connective tissue

• Adult gains are related to muscle hypertrophy

• Adolescent gains are related to increased muscle efficiency and coordination

Nutrition

• Carbohydrate loading• Increase carb loads three days prior to event

• Decrease exercise output over same time period

• Increases the stores of glycogen in the muscle to provide improved endurance • Better plan is for the athlete to maintain a normal diet

• Fluid loading/replacement• The magnitude of the core temp and heart rate increase are both proportional to the amount

of water debt you have at the beginning of exercise

• Best practice is to maintain pre-practice weight with water replacement

• Fluid carbohydrate and electrolyte replacement• Best is low osmolarity fluids (<10%) of carbs and electrolytes which will enhance gut

absorption • Glucose polymers reduce osmolarity

Cardiac Conditions in the Athlete

• Cardiac pathology is the most common cause of sudden death in the young athlete

• History and PE is the best screening tool for HS athletes• Chest pain

• Palpitations

• Syncope• Red flag in a young athlete – requires complete medical work-up

• PE• Diastolic murmur warrants further work-up

• EKG normal findings in athletes• Ventricular hypertrophy

• Primary AV block

• Nonspecific STT wave changes in lateral leads

• Resting sinus bradycardia

Hypertrophic Cardiomyopathy

• Most common cause of sudden cardiac death in young athlete

• Dyspnea on exertion, chest pain, + Family history• II/VI systolic murmur

• Increases with Valsalva

• Evaluation with a cardiac echo – nondilated thickened left ventricle

• Avoid vigorous exercise • Absolute contraindication to vigorous exercise and sports

Commotio Cordis

• Rare but catastrophic even with sudden blunt force trauma

to the chest

• Chest protectors in baseball and hockey???

• Immediate cardiac defibrillation, or CPR if not available

Long QT Syndrome

• Abnormal ventricular repolarization• V-Tach

• Torsades de pointes

• Sudden cardiac death if not recognized and treated

• Syncope or near syncope with exercise• Often asymptomatic

• ECG is the gold standard

• Return to play• Need for a pacemaker?

Steroids

• Anabolic• Increase in muscle strength, increase in aggressive behavior

• Side effects• Hypertension

• Liver tumors

• Increased LDL

• Decreased HDL

• Hyhpercholesterolemia

• Abnormal level of HDL should alert the physician

• Exam• Increased body weight

• Testicular atrophy

• Irreversible of deep female voice

• Alopecia

• Reduction in estrogen and testosterone growth retardation

• gynecomastia

Steroids

• HGH• Pituitary gland hormone

• Androstenedione• Androgen produced in the adrenal glands and gonads

• Converted to testosterone in the liver

• DHEA• Produced by the adrenal cortex

• -> Androstenedione -> Testosterone

• EPO• Stimulates Hgb production increasing oxygen carrying capacity

• Increased blood viscosity: increase risk for stroke or MI

• Somatotropin• Hypertrophy of Type 1 muscle, atrophy of Type 2 muscles

• Glucagon – not a steroid• Has a catabolic effect on skeletal muscle

Supplements

• Creatine • Derived from AA – glycine, argenine, methionine

• Muscle and power building supplement – NOT an anabolic steroid

• -> phosphocreatine -> used to build ATP for muscle activity

• Used with off season workouts

• Pulls water from blood vessels into cells – dehydration?

• Risks• Cramps

• Increased muscle injury

• Renal insufficiency is rare occurrence

Stimulants

• Caffeine• 2-3mg/kg has been shown to improve performance

• Reduces fatigue and improves alertness

• Previously banned by IOC

• Allowed up to 12micrograms per mL of urine

• Epehdra

• Ephedrine

• Ma huang – energy drinks

• Amphetamines

• Risks• Dehydration

• Impaired heat management

• Hypertension

• Nervous system impairment

I truly hope this was beneficial. There is a lot of information covered in a very short amount of time. If you have nay questions or suggestions feel free to email me or text me. Good luck in your studies. Stay safe and socially distance.

Thank you for your time

Trey Remaley, [email protected]

Resources

• AOSSM

• AAOS

• JBJS

• www.orthobullets.com

• AJSM

• AANA

http://www.orthobullets.com/

Documents

Orthopedic Sports Medicine Board Review