High-demand Athletes Research Articles

Locked Posterior Shoulder Dislocation with Accompanying Fracture: A Debilitating Rare Injury for Athletes?

Shoulder dislocation is undoubtedly one of the most common injuries in traumatology. Posterior dislocation of the shoulder is regarded as comparatively rare compared to anterior dislocation, whilst it is strikingly extraordinary for this type of injury to be accompanied by a concomitant fracture. Accurate diagnosis and appropriate treatment can be considerably demanding, while being vitally important in this exceedingly rare condition. These injuries are broadly considered to be under-reported in the existing literature, especially among high-demand athletes. We present a rare case of a high-demand athlete sustaining a traumatic locked posterior shoulder dislocation with an accompanying fracture treated in our Institution. A detailed clinical examination and plain radiography revealed the peculiar condition, and a CT scan was subsequently performed for more thorough evaluation of the injury. The patient underwent surgery on the day following admission for repair of the extensive shoulder damage, and a deltopectoral approach was utilized. Reduction of the metaphyseal fracture and the dislocation was accomplished with gentle manipulations, and stabilization was obtained with an anatomic plate. A modified McLaughlin procedure was carried out to address the reverse Hill-Sachs lesion. The postoperative period was uneventful, followed by a painstaking physical rehabilitation program, and the patient returned successfully to his sporting activities 6 months postoperatively. By presenting this thought-provoking case, we stress the challenging nature of these immensely infrequent injuries while also highlighting the requirement for more sensitive factor-specific studies regarding their optimal treatment.

Glenoid Bone Loss - A Retrospective Evaluation of Functional Outcomes after Bone Block Surgery for Anterior Shoulder Instability in High-demand Athletes.

Objective This study assesses the relationship between the glenoid bone loss size and range of motion, functional outcomes, and complications in high-performance athletes undergoing bone block surgery for anterior shoulder instability. Methods This retrospective study evaluated postoperative outcomes in athletes submitted to bone block surgery for anterior shoulder instability. In 5 years, 41 shoulders underwent the procedure; 20 had bone losses up to 15%, and 21 shoulders presented bone losses ranging from 15% and 25%. Results There was no statistically significant difference regarding postoperative complications, new dislocations, and the rate of return to sports. In addition, the quantitative criteria evaluated, i.e., ranges of motion and functional scores, showed no statistically significant difference between groups. Conclusion The size of the bone loss per se does not seem to affect functional outcomes and complications from these procedures, which are safe techniques for small and large bone losses.

Return to Play After Surgical Treatment for Acromioclavicular Joint Dislocation: A Systematic Review

Background: Acromioclavicular (AC) joint dislocation is a common clinical problem among young and athletic populations. Surgical management is widely used for high-grade dislocations (Rockwood III-VI) and in high-demand athletes at high risk of recurrence. Purpose: To systematically review the evidence in the literature to ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after surgical treatment for AC joint dislocation. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted in the PubMed database. Clinical studies were eligible for inclusion if they reported on RTP after surgical treatment for AC joint dislocation. Statistical analysis was performed with SPSS. Results: We found 120 studies including 4327 cases meeting our inclusion criteria. The majority of patients were male (80.2%), with a mean age of 37.2 years (range, 15-85) and a mean follow-up of 34.5 months. Most were recreational athletes (79%), and the most common sport was cycling. The overall rate of RTP was 91.5%, with 85.6% returning to the same level of play. Among collision athletes, the rate of RTP was 97.3%, with 97.2% returning to the same level of play. In overhead athletes, the rate of RTP was 97.1%, with 79.2% returning to the same level of play. The mean time to RTP was 5.7 months (range, 1.5-15). Specific RTP criteria were reported in the majority of the studies (83.3%); time to return to play was the most commonly reported item (83.3%). Type III Rockwood injuries had the highest RTP rate at 98.7% and the earliest RTP at 4.9 months. Among the different surgical techniques, Kirschner wire fixation had the highest rate of RTP at 98.5%, while isolated graft reconstruction had the earliest RTP at 3.6 months. Conclusion: The overall rate of RTP was reportedly high after surgical treatment for AC joint dislocation, with the majority of patients returning to their preinjury levels of sport. There is a lack of consensus in the literature for what constitutes a safe RTP, with further focus on this topic required in future studies.

Management of lumbar bone stress injury in cricket fast bowlers and other athletes.

Recent guidelines (including a special series in The Lancet) have emphasised a minimal role for imaging when assessing low back pain in adults, as the majority of patients will have non-specific findings on imaging that do not correlate well with pain. To assess whether the diagnosis of lumbar bone stress injuries in young athletes should be considered an exception to the recommendation to avoid imaging for low back pain in adults. Narrative review. Early lumbar bone stress injury diagnosis has been available via traditional MRI sequences (and its precursor Single Photon Emission Computed Tomography (SPECT)) for 25-30 years. MRI assessments using bone window sequences (such as Volumetric Interpolated Breath-hold Examination (VIBE)) have allowed a better understanding of the diagnosis and prognosis of lumbar bone stress injury in young athletes. MRI with bone sequences has allowed non-radiating scans to serially follow the healing of unilateral stress fractures. In the majority of cases, non-chronic unilateral fractures can heal; however, this takes three-six months rather than the six-ten weeks that would be the typical unloading period if using symptoms (only) as a guide. The use of MRI to provide evidence of bony healing (as opposed to fibrous union, which creates the pars defect that predisposes to further bone stress lesions) can lead to better long-term outcomes in athletes. There is evidence to flag this as a structural lesion which is both painful and, more importantly, can heal/resolve if managed correctly. Therefore it represents an important 'specific' diagnostic subset within adult low back pain. Structural (rather than functional) management of bone stress injuries in high-demand athletes, such as cricket pace bowlers, is in contrast to the recommendation of functional management for general back pain in adults. Structural management is justified when there are demonstrable superior outcomes of having better structure. Although this has not yet been shown in randomised trials of elite athletes, apparent lengthier Test cricket careers of pace bowlers who do not have pars defects suggest better athletic outcomes if bony healing is achieved. For lower demand young adults, or athletes with established bilateral pars defects, functional management may be more pragmatic.

Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review.

Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.

Management of Vertical Sternal Fracture Nonunion in Elite-Level Athletes.

Background:Sternal fractures are rare, and they can be treated nonoperatively. Vertical sternal fractures have rarely been reported.Purpose:To describe the management and surgical treatment of a series of elite-level athletes who presented with symptomatic nonunions of a vertical sternal fracture.Study Design:Case series; Level of evidence, 4.Methods:Patients with an established symptomatic nonunion of a vertical sternal fracture, as diagnosed by computed tomography (CT) or magnetic resonance imaging (MRI), underwent open reduction and internal fixation using autologous bone graft and cannulated lag screws. The patients were assessed preoperatively and at the final follow-up using the Rockwood sternoclavicular joint (SCJ) score; Constant score; and shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. Bony union was confirmed on postoperative CT scan.Results:Five patients (4 men and 1 woman) were included; all were national- or international-level athletes (rugby, judo, show-jumping, and MotoGP). The mean age at surgery was 23.4 years (range, 19-27 years), the mean time from injury to referral was 13.6 months (range, 10-17 months), and the mean time from injury to surgery was 15.8 months (range, 11-20 months). The mean follow-up was 99.4 months (range, 25-168 months). There was a significant improvement after surgery in the mean Rockwood SCJ score (from 12.6 to 14.8 [P < .05]), Constant score (from 84 to 96.4 [P < .05]; 80% met the minimal clinically important difference [MCID] of 10.4 points), and QuickDASH (from 6.8 to 0.98 [P < .05]; 0% met the MCID of 15.9 points). Four of the patients were able to return to sport at their preinjury level, and 1 patient retired for nonmedical reasons. All of the fractures had united on the postoperative CT scan. There were no postoperative complications.Conclusion:Vertical fractures of the sternum are very rare and tend to behave clinically like an avulsion fracture injury to the capsuloligamentous structure of the inferior SCJ. The requirement of advanced imaging to diagnose this injury means that the actual incidence and natural history are not known. For high-demand athletes, early identification, surgical reduction, and fixation are likely to achieve the best outcome.

Graft Preparation for Combined ACL and ALL Reconstruction With a Single Femoral Tunnel

Background: Combined reconstruction of the anterolateral ligament (ALL) and anterior cruciate ligament (ACL) has shown excellent results. It could potentially reduce graft failure and improve outcomes in high-risk patients. There are several surgical techniques described. Hamstrings are the most frequently used graft for ALL reconstruction. The distal portion of the iliotibial band is used for the modified Lemaire procedure. Indications: Anterior cruciate ligament reconstructions associated with the following risk factors: pivoting sports, high-demand athletes, high-grade pivot-shift, chronic ACL injury, lateral femoral condyle notch, Segond fractures, young patients (&lt;20 years), ACL revision, generalized hyperlaxity, and Lachman &gt;7 mm. Technique Description: Semitendinosus and gracilis tendons are harvested and their extremities are prepared with continuous suture. The semitendinosus graft is folded in 3 parts leaving the ends of the graft internalized. The triple semitendinosus will be the main component of the ACL and the single gracilis will be used for both ACL and ALL. Anterolateral ligament anatomical landmarks are proximal and posterior to the lateral epicondyle in the femur, and in the mid distance from the fibular head and the Gerdy tubercle in the tibia. The ALL is fixed in knee extension with interference screws. This video also includes a brief demonstration of graft preparation for the modified Lemaire procedure. Results: Results from our group using this technique have shown excellent clinical outcomes, minimal complications, and low failure rates in high-risk populations. This graft preparation shows excellent diameter and length for combined ACL and ALL reconstruction. Conclusion: This technique is easy to perform, with minimal complications, and should be considered in high-risk patients undergoing ACL reconstruction.

Bristow versus Latarjet in high-demand athletes with anterior shoulder instability: a prospective randomized comparison.

BackgroundTraumatic anterior shoulder instability is a common disease, especially in young athletes. The Latarjet and Bristow techniques are nonanatomical surgeries that involve the transfer of the coracoid process to the anterior border of the glenoid and are indicated in cases at a high risk for recurrence and in the presence of associated bone lesions. Studies have evaluated the recurrence and complications associated with these techniques, but they have important differences, and should not be considered synonymous. The objective of this study was to prospectively compare the Bristow and Latarjet techniques in high-demand athletes. Hypothesis: Bristow and Latarjet techniques lead to similar results.Patients and methodsThirty-seven athletes (41 shoulders; three athletes underwent bilateral surgery) with anterior recurrent dislocation of the shoulder that was surgically treated using the Bristow or Latarjet technique were prospectively analyzed. The follow-up time was 5 years. The mean age was 26.4 years (range: 16-46 years). In 17 cases (41.5%), the dominant side was not affected.ResultsElevation and external rotation (passive and active) decreased in the early postoperative period and achieved values in the final follow-up similar to those found in the preoperative period. The mean postoperative scores at 5 years were as follows: ASES, 79.1 (range: 66-95); ASORS, 77.8 (range: 60-100); WOSI, 52.6 (range: 18-77); and VAS, 1.88 (range: 0-6). All of the results presented statistical significance. There was a complication rate of 9.75% in the follow-up period. There were no new dislocations after the surgery. Most (75%) of the athletes returned to the sport after the surgery, and there was no correlation between poor results and any of the variables studied. There was a statistically significant difference in passive external rotation in favor of the Latarjet technique four weeks after surgery (P = .01). We also found a statistically significant difference in passive elevation in favor of the Latarjet technique eight weeks after the surgery (P = .04). When we compared the Bristow and Latarjet techniques regarding the ASES, ASORS, and WOSI scores, we found no statistically significant difference. In the comparison regarding whether the athletes returned to sports, we found no statistically significant difference.ConclusionThe Bristow and Latarjet techniques lead to good results in athletes with no new dislocation episodes and are suitable for treating patients with anterior recurrent dislocation of the shoulder. The Latarjet technique showed better results in some of the variables studied.

Cortical Button Fixation for Proximal Tibiofibular Instability: A Technical Report

Instability of the proximal tibiofibular joint (PTFJ) is a rare injury pattern than can affect high-demand athletes involved in twisting or pivoting movements on a flexed knee. Instability may produce painful subluxations during provocative activity and occasional neuritic symptoms from tethering of the common peroneal nerve at the fibular neck. There are several reports of reconstruction for symptomatic PTFJ instability; however, no optimal treatment has been elucidated in the literature. Use of a cortical button suspensory device for fixation of the PTFJ offers the advantage of stabilizing the joint without need for free graft harvest or rigid screw fixation. The present technical report illustrates the operative technique and the advantages, disadvantages, pearls, and pitfalls associated with this operation.

Hamstring Autograft for Lateral Ligament Stabilization.

This paper seeks to review the current literature and trends regarding use of hamstring autograft for lateral ankle instability. Reconstruction of the lateral ankle ligaments using hamstring autograft has been found to be an effective method to treat ankle instability in terms of patient-reported outcomes and objective measures. Biomechanically, reconstruction has been shown to be stronger (load to failure) when compared with the Broström procedure. Clinical studies have demonstrated non-inferiority when compared with the Broström procedure, with one synthetic reconstruction technique demonstrating superior outcomes. Reconstruction of the lateral ankle ligaments using hamstring autograft is especially useful in patients who are at high risk of failure (insufficient soft tissue available for repair, ligamentous laxity, previous failed ligament repair, ossicle > 1cm, or in the heavier, high-demand athletes).

Return to Play After the Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review

Background: Traumatic anterior shoulder instability is a common clinical problem among athletic populations. The Latarjet procedure is a widely used treatment option to address shoulder instability in high-demand athletes at high risk of recurrence. However, rates and timing of full return to sports have not been systematically analyzed. Purpose: To systematically review the evidence in the literature to ascertain the rate and timing of return to play and the availability of specific criteria for safe return to play after the Latarjet procedure. Study Design: Systematic review. Methods: A systematic literature search was conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using the EMBASE, MEDLINE, and Cochrane Library databases. Eligible for inclusion were clinical studies reporting on return to play after the Latarjet procedure. Statistical analysis was performed by use of SPSS. Results: Our review found 36 studies including 2134 cases meeting our inclusion criteria. The majority of patients were male (86.9%), with a mean age of 25.4 years (range, 15-59 years) and a mean follow-up of 83.5 months. The overall rate of return to play was 88.8%, with 72.6% returning to the same level of play. Among collision athletes, the overall rate of return to play was 88.2%, with 69.5% returning to the same level of play. In overhead athletes, the overall rate of return to play was 90.3%, with 80.6% returning to the same level of play. The mean time to return to play was 5.8 months (range, 3.2-8 months). Specific return to play criteria were reported in the majority of the studies (69.4%); time to return to sport was the most commonly reported item (66.7%). Conclusion: The overall rate of return to play was reportedly high after the Latarjet procedure. However, almost a fifth of athletes returning to sports were not able to return at the same level. Further development of validated criteria for safe return to sports could potentially improve clinical outcomes and reduce recurrence rates.

Surgical Repair of Acute TFCC Injury.

Triangular fibrocartilage complex tears are a common source of ulnar-sided wrist pain and distal radioulnar joint instability. Symptoms recalcitrant to conservative management or injuries in high-demand athletes may indicate surgical management. Both open and arthroscopic techniques offer improvements in objective measures, patient-centered outcome scores, and return to work, but may be complicated by nerve irritation, persistent wrist instability, and pain. Recently developed knotless arthroscopic techniques are not well studied but may limit morbidity.

Anatomical Arthroscopic Anterior Talofibular Ligament and Calcaneofibular Ligament Reconstruction Using an Autogenic Hamstring Tendon: Safe Creation of Anatomical Fibular Tunnel

Ankle sprains are the most common lower extremity injuries associated with sports activity. Although ligament repair techniques are popular, reconstruction methods using free tendons are considered when the ligament remnant is insufficiently strong, when high-demand athletes sustain repeat ankle sprains, or in revision cases after repair. Recently, some arthroscopic reconstruction techniques have been reported. The distal fibular end is thin; therefore, surgeons must be careful while drilling the fibular tunnel. This report indicates the safe creation method of an anatomical fibular tunnel during anatomical arthroscopic reconstruction of the anterior talofibular ligament and calcaneofibular ligament. This also provides a stronger reconstruction using a 2-strand tendon graft for the anterior talofibular ligament substitute, which is thought to have less risk for postoperative graft failure.

Rotational stability after ACL reconstruction using anatomic double bundle technique versus anatomic single bundle technique plus anterolateral ligament augmentation

BackgroundA residual pivot shift seen in up to quarter of ACL reconstructions using anatomic single bundle (ASB) technique. Light has been thrown on the importance of the Posterolateral (PL) bundle and its role in rotational stability, hence the concept of anatomic double bundle (ADB) reconstruction. Anterolateral ligament (ALL) reconstruction; an added extra-articular procedure, is proposed to be responsible for rotational knee stability. The aim of this study was to assess functional outcomes and rotational stability of the knee after ADB versus ASB reconstruction plus ALL augmentation. Patients and methodsBetween January 2015 and December 2015, a randomized controlled trial (RCT) was conducted on 40 patients suffering from chronic ACL injuries or acute injuries with high grade knee jerk or are high demand athletes. Twenty patients (group A) were treated with ASB ACL reconstruction and ALL augmentation. The other 20 patients (group B) underwent ADB ACL reconstructions. All patients were assessed pre and post-operatively using the Lysholm and IKDC (international knee documentation committee) scores and KT-1000 arthrometer. At the final follow-up, internal rotation kinematics of the knee was assessed using motion analysis in a gait lab. ResultsAll were followed-up for a mean of two years. At the final follow-up, there was no statistically significant difference regarding the total Lysholm score, IKDC score and KT-1000 side to side difference; P-values 0.821, 0.732, 0.533 respectively. Group ‘A’ demonstrated better rotational stability than group ‘B’ as measured from internal tibial rotation angle with a p-value of 0.001. ConclusionALL augmentation is an added extra-articular procedure that superseded ADB reconstruction in achieveing better knee internal rotation kinematics. Level of evidence: II.

Fifteen-Year Audit of Anterior Cruciate Ligament Reconstructions in the Australian Football League From 1999 to 2013: Return to Play and Subsequent ACL Injury

Background: Anterior cruciate ligament (ACL) injury has been a major cause of missed game time among Australian Football League (AFL) players. Return to play after ACL reconstruction is not always achieved, even among elite athletes. The rate of subsequent ACL injury in the AFL from 1990 to 2000 was high as compared with that of other elite sports. Purpose: To determine the rates of return to play and subsequent ACL injury after ACL reconstruction among AFL players from 1999 to 2013 and to explore factors associated with differing rates of return to play and subsequent ACL injury. Study Design: Case series; Level of evidence, 4. Methods: A total of 158 AFL players who underwent ACL reconstruction were identified from a prospectively maintained registry of AFL player injuries. Further data were gathered from official playing statistics, surgical records, and structured phone interviews. Results: The rate of return to play after an initial ACL injury was 77% (121 of 158 players). Greater preinjury playing experience and earlier selection in the AFL draft were associated with higher rates of return to play. The rate of subsequent ACL injury to either knee was 30% (48 of 158 players) and was especially high among players aged <21 years (23 of 46 players, 50%). After subsequent ACL injury, 34 of 48 players (71%) returned to play. In primary ACL reconstruction, the use of Ligament Augmentation and Reconstruction System grafts resulted in a faster return to play (P = .001) but had a higher risk of subsequent revision reconstruction (risk ratio = 2.8, P = .048). Family history of ACL injury was associated with an increased risk of subsequent contralateral ACL injury (risk ratio = 3.8, P = .002). Conclusion: Most AFL players who underwent ACL reconstruction returned to play at least 1 AFL match. The high rate of subsequent ACL injury among AFL players demonstrates the highly demanding nature of Australian football, particularly at the elite level. The risk factors for subsequent ACL injury should be considered carefully when treatment and rehabilitation decisions are made for these high-demand athletes.

Periosteal flap augmentation of the Modified Broström-Gould procedure for chronic lateral ankle instability.

Chronic lateral ankle instability occurs in up to 20% of ankle injuries. Most can be treated conservatively, but surgical reconstruction is required if conservative treatment fails. Modified Broström-Gould procedure is an effective surgical treatment and the augmentation of this procedure with a periosteal flap may confer additional stability. We report on the outcome of a technique combining a modified Broström-Gould procedure augmented with a periosteal flap in patients with chronic lateral ankle instability. Twenty-four males aged 18-42 (mean, 24) with chronic lateral ankle instability affecting 24 ankles underwent the modified Broström-Gould procedure augmented with a periosteal flap, and these surgeries were performed by a single surgeon. The mean follow-up period was 28.7 months. Patients were assessed pre- and post-operatively with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hind foot score. Preoperatively, the mean AOFAS ankle and hind foot score was 67.38. Post-operatively, significant improvement was seen, with a score of 88.71 ( p < 0.05). None of the patients reported surgical or wound complications. The technique of modified Broström-Gould procedure with periosteal flap augmentation appears to be a simple and safe operation for chronic lateral ankle instability. Patients with poor quality local ligamentous tissue, obese patients or high demand athletes generally benefit from this procedure. It allows effective augmentation of the reconstruction without causing any harm to local tendons or using additional costly implants.

All-inside arthroscopic allograft reconstruction of the anterior talo-fibular ligament using an accesory transfibular portal

BackgroundAnatomic graft reconstruction of the anterior talo-fibular ligament is an alternative for patients who are bad candidates for standard procedures such as a Broström–Gould reconstruction (high-demand athletes, obesity, hyperlaxity or collagen disorders, capsular insufficiency or talar avulsions). The purpose of this study is to describe an all-inside arthroscopic technique for ATFL reconstruction, and the results in a series of patients with chronic ankle instability. MethodsWe reviewed patients with chronic ATFL ruptures treated with an all-inside arthroscopic allograft reconstruction of the ATFL, with a minimum 2-year follow-up. Twenty-two patients with lateral ankle instability were included. Mean follow-up was 34±2.5 months. ResultsThe mean AOFAS score improved from 62.3±6.7 points preoperatively to 97.2±3.2 points at final follow-up. Three patients suffered complications: one case each of ankle rigidity, superficial peroneal nerve injury and fibular fracture. ConclusionsChronic ATFL injuries are amenable to all-inside arthroscopic allograft reconstruction fixed with tenodesis screws. This procedure simplifies other reported techniques in that it facilitates identification and bone tunnel placement of the talar ATFL insertion.

Associated Reconstruction of Anterior Cruciate and Anterolateral Ligaments With Single Asymmetric Hamstring Tendons Graft

The anterior cruciate ligament (ACL) rupture is a common disease that accounts for 250,000 cases/year in the United States. The anterolateral ligament (ALL) has been suggested to be an important restraint for rotational instability, and its reconstruction provides a reinforcement to the ACL reconstruction in this aspect, especially in high-demand athletes and in knees with high-grade pivot shift. Different techniques for associated ACL and ALL reconstruction have been described, but the ideal technique remains unclear. Several facts of these techniques may entail a concern to the surgeon, such as the need for several grafts or several bone tunnels. A technique for associated ACL and ALL is presented, using a single hamstring tendons graft, which is prepared asymmetrically, leaving one-third of the length with single diameter and two-thirds with double diameter. A single femoral tunnel is created, using a screw for fixation and differentiation of the grafts. A suspension device is used for tibial fixation, allowing for length adjustment according to the graft's length. The objective of this Technical Note is to provide the orthopaedic surgeon with a resource for ACL and ALL reconstruction even with relatively short grafts, saving bone stock and avoiding the need for allografts.

Intra-articular Anterior Cruciate Ligament Reconstruction With Extra-articular Lateral Tenodesis of the Iliotibial Band

An increasing concern has been given to the rotation stability of the knee in the setting of an anterior cruciate ligament (ACL) reconstruction. This growing interest stems from a better understanding of the rotational stability of the knee afforded by the identification of the anterolateral ligament. Previously, a residual abnormal pivot-shift test had been found after an anatomic single-band reconstruction of the ACL because of a lack of rotational stability, which may lead to the development of osteoarthritis. Residual instability affects function, especially in high-demand athletes who perform many flexion-rotation movements during sporting activity. The purpose of this Technical Note is to describe our preferred method of intra-articular ACL reconstruction using a hamstring tendon autograft in combination with an extra-articular iliotibial band tenodesis for reinforcement of rotational stability.

Arthroscopic Surgical Technique for an Acute Talar Dome Osteochondral Lesion in a Professional Rugby League Player

Talar osteochondral lesions represent challenging clinical entities, particularly in high-demand athletes. Surgical treatment of large lesions often requires a 2-step procedure, or the use of osteotomy in the case of autologous osteochondral transfer, which can delay return to sport. A professional rugby league player underwent surgery for a complex injury to the ankle. A talar osteochondral lesion with a maximal diameter of 15 mm was treated in an arthroscopic fashion using the cartilage taken from the completely displaced osteochondral fragment. Cartilage was cut into chips and combined with bone graft product containing platelet-derived growth factor and a porous collagen scaffold. Autologous cartilage was then reimplanted arthroscopically. The patient was allowed full ankle motion from 2 weeks postoperatively, and weightbearing was commenced at 6 weeks. Follow-up imaging and functional outcomes, including return to sport, were assessed at regular intervals. The patient was able to return to professional rugby league by 23 weeks postoperatively. Magnetic resonance imaging at 16 months postoperatively showed restoration of the subchondral plate and osseous infill. At final follow-up, the patient remained pain free and was playing at preinjury level. This report describes good outcomes using a novel, 1-step cartilage repair technique to treat a large talar osteochondral lesion in a professional athlete. Level V: Expert opinion.