Background: Insufficiency of hip capsular structures has recently gained recognition as a cause o... more Background: Insufficiency of hip capsular structures has recently gained recognition as a cause of pre-arthritic hip pain, leading to hip joint instability and progressive chondrolabral injury. An accurate evaluation of capsular integrity can help orthopedic surgeons plan capsular management prior to hip arthroscopy. Indications: The proposed iliofemoral bounce test is meant to be applied preoperatively for identification of hip capsular integrity when microinstability is suspected or in the setting of revision hip arthroscopy. Technique Description: After induction of general anesthesia and complete muscle relaxation, the patient is placed in a supine figure-four position by placing the foot of the pathologic hip on the contralateral knee. Two examination techniques are performed: (1) The examiner places one hand on the patient’s contralateral anterior superior iliac spine and applies consecutive downward pressure in a “rocking” manner to the pelvis; (2) the examiner applies a prel...
North American journal of sports physical therapy, 2007
Over the past few years, arthroscopy of the hip joint is becoming more common as a technique in b... more Over the past few years, arthroscopy of the hip joint is becoming more common as a technique in both the diagnosis and treatment of hip pain. A frequent cause of hip and groin pain is a tear of the acetabular labrum. Patients with labral tears complain of pain in the groin region and pain with clicking in the hip without a history of pain prior to the original onset. Once a patient presents with signs and symptoms of hip pain that are greater than four weeks in conjunction with indicative findings of a labral tear by way of MRI, he or she may be considered a good candidate for arthroscopy of the hip joint. Little evidence exists in the current literature on rehabilitative procedures performed after arthroscopy of the acetabular labrum. The purpose of this clinical commentary is to suggest a rehabilitation protocol after acetebular labral debridement or repair.
The American journal of sports medicine, Jan 17, 2015
Few studies have compared outcomes after meniscus suture repair in patients younger than 40 years... more Few studies have compared outcomes after meniscus suture repair in patients younger than 40 years versus patients 40 years and older. To document failure rates and long-term outcomes after meniscus suture repair by a single surgeon, using the inside-out technique, at a minimum 10-year follow-up in patients younger than 40 years versus those 40 years and older. Cohort study; Level of evidence, 3. This study included all patients 18 years or older who underwent meniscus suture repair with the inside-out technique by a single surgeon between January 1992 and December 2003. Patients were divided into 2 cohorts according to age: <40 years (cohort 1) and ≥40 years (cohort 2). If patients underwent subsequent knee surgery, all subsequent reports, whether performed by the original treating surgeon or by a different surgeon elsewhere, were reviewed by 2 independent reviewers not involved in the primary care of the patients. Reviewers classified surgeries as failures if the subsequent surg...
Background: Athletes display persistent muscle deficits and altered limb-loading mechanics at the... more Background: Athletes display persistent muscle deficits and altered limb-loading mechanics at the time of return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR). Purpose: To compare an objective profile of adolescent athletes at RTS after ACLR to matched healthy controls. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were 124 participants; 62 patients who underwent ACLR (15.4 ± 1.7 years) and 62 healthy controls (15.3 ± 1.7 years). Motion capture and force plates were used to capture joint motions during jump landing (JL) and single-limb squat (SLS) tasks. Energy absorption contribution (EAC) was calculated, and repeated-measures analysis of variance was used to assess for EAC differences between groups. Participants completed an International Knee Documentation Committee (IKDC) Subjective Knee Form, and isokinetic quadriceps and hamstring strength testing was performed on each limb. Independent t tests were run to examine age, he...
Reconstruction is widely accepted as the gold standard treatment for anterior cruciate ligament [... more Reconstruction is widely accepted as the gold standard treatment for anterior cruciate ligament [ACL] injuries. This technique has been shown to usually restore the stability of a symptomatic ACL-deficient knee, but many patients continue to have problems, including graft failure, inability to return to sporting activities and the development of arthritis. Primary ACL repair was described more than a century ago, but was abandoned based on the science of the time and perceived unsatisfactory outcomes. During the last decade there has been a resurged interest in preserving ACL in an attempt to avoid some of the consequences following ACL reconstruction. Recent studies have reported promising outcomes in a well-defined subset of patients. The primary aims of this review are to summarize the current knowledge regarding ACL preservation surgery and discuss the newer techniques of ACL repair compared with the surgeries that were performed in the past. The pursuit of novel solutions for p...
Posterolateral rotatory instability of the elbow is a recently described condition resulting from... more Posterolateral rotatory instability of the elbow is a recently described condition resulting from insufficiency of both the static lateral collateral ligament complex and the dynamic supporting muscular structures of the elbow. The lateral ulnar collateral ligament is the essential component of the lateral collateral ligament complex, linking the humerus and ulna and acting as the principle static restraint preventing external rotation of the ulna on the humerus, thus preventing posterolateral elbow instability. Ligament insufficiency permits the proximal ulna and the radial head to externally rotate posterior when the forearm is positioned in supination and slight flexion. Recent studies have characterized this condition as posterolateral instability of the elbow, and have portrayed the continuum that exists between posterior lateral rotatory instability and elbow dislocation. For patients whose instability symptoms persist despite conservative measures, repair or reconstruction of...
Hamstring injuries are the most common pathology reported in professional soccer players and repr... more Hamstring injuries are the most common pathology reported in professional soccer players and represent about 10-30% of all injuries. This study’s primary purpose was to identify specific injury patterns, location, and severity on MRI following acute hamstring injuries in a group of Major League Soccer (MLS) players. The secondary purpose was to present a new MRI classification protocol for identifying the location of hamstring injuries.
To describe the ‘mini-Max’ approach to labrum repair using non-absorbable 2.4-mm knotless suture ... more To describe the ‘mini-Max’ approach to labrum repair using non-absorbable 2.4-mm knotless suture anchors and report objective clinical outcomes with a large single-surgeon cohort. Level 3 retrospective case series. A retrospective review was conducted to report the use and allocation of non-absorbable 2.4-mm knotless suture anchors during ‘mini-Max’ labral repair from 2015 to 2018. Descriptive analysis of the labral damage severity, size and number of anchors used to arthroscopically repair the acetabular labrum was performed. Paired-samples t-tests were performed to evaluate whether preoperative and 1-year follow-up patient-reported outcomes (PROs) were statistically significant. An analysis of variance was performed comparing PROs with categorized number of labral anchors. A total of 390 patients were queried in this study, with 330 (85%) diagnosed intraoperatively with acetabular labral tears. A total of 245 patients (137 females and 108 males) with a mean age of 30.1 ± 11.6 year...
Background: A relatively new technology for the treatment of high grade articular cartilage lesio... more Background: A relatively new technology for the treatment of high grade articular cartilage lesions is the implantation of particulated articular cartilage obtained from a juvenile allograft donor (PJAC).1-2 Previous studies have reported the ability of juvenile chondrocytes to migrate from cartilage explants after being secured in a cartilage defect.3 There is little in the literature to use as a reference with respect to the use of PJAC for high grade articular cartilage lesion of the lateral femoral condyle after a failure of treatment with a microfracture in the high level athlete. Objective: The aim of this report is to describe the technique of PJAC transplantation for the treatment of chondral lesions of the lateral femoral condyle and to report the short term outcomes in the high performance athlete. Methods: We present a case report of two patients who were treated in our clinic in December 2014. Case 1: 16 year old female Division 1 university soccer player, who one year p...
Background: Quadriceps strength and knee extension are believed to be important in the ability to... more Background: Quadriceps strength and knee extension are believed to be important in the ability to effectively load the knee after anterior cruciate ligament (ACL) reconstruction (ACL-R). Purpose: To compare quadriceps strength (QUADS), side-to-side knee extension difference (ExtDiff), and knee energy absorption contribution (EAC) in patients preoperatively, 12 weeks postoperatively, and at return to sport (RTS). A secondary aim was to determine how the factors of QUADS and ExtDiff contributed to the ability to load the knee (knee EAC) at each of the 3 time points. Study Design: Case series; Level of evidence, 4. Methods: Overall, 41 individuals (mean ± SD age, 15.95 ± 1.63 years) were enrolled in this study. QUADS, ExtDiff, and knee EAC during a double-limb squat were collected preoperatively, 12 weeks postoperatively, and at RTS. Isokinetic QUADS was collected at 60 deg/s, normalized to body mass, and averaged across 5 trials. Knee extension was measured with a goniometer, and ExtD...
BACKGROUND: “Why try to convert other collagen substitutes into ligament if the original can be p... more BACKGROUND: “Why try to convert other collagen substitutes into ligament if the original can be preserved?” said Sherman1. Nowadays, reconstruction became the gold standard treatment for ACL injuries. Despite current treatment, secondary knee osteoarthritis has been described in more than 70% of the injured patients after 10 years follow up.2 Recent studies have reported that tears involving the proximal ACL have an intrinsic healing response. This response has been compared to the one observed in MCL injuries.3, 4. OBJECTIVE: The aim of this study is to initiate a scientific analysis of our experience in patients diagnosed with an acute, proximal ACL tear treated with a primary repair arthroscopic technique. We suggest the creation of a symposium that reconsiders the ACL repair as a tool for treatment, on a selected subset of patients. METHODS: We analyzed retrospectively the data of 12 consecutive patients diagnosed clinically and radiologically (MRI) with proximal ACL tears in ou...
Arthroscopy: The Journal of Arthroscopic & Related Surgery
PURPOSE To directly compare effectiveness of the inside-out and all-inside medial meniscal repair... more PURPOSE To directly compare effectiveness of the inside-out and all-inside medial meniscal repair techniques in restoring native contact area and contact pressure across the medial tibial plateau at multiple knee flexion angles. METHODS Twelve male, nonpaired (n = 12), fresh-frozen human cadaveric knees underwent a series of 5 consecutive states: (1) intact medial meniscus, (2) MCL tear and repair, (3) simulated bucket-handle longitudinal tear of the medial meniscus, (4) inside-out meniscal repair, and (5) all-inside meniscal repair. Knees were loaded with a 1,000-N axial compressive force at 5 knee flexion angles (0°, 30°, 45°, 60°, 90°), and contact area, mean contact pressure, and peak contact pressure were calculated using thin film pressure sensors. RESULTS No significant differences were observed between the inside-out and all-inside repair techniques at any flexion angle for contact area, mean contact pressure, and peak contact pressure (all P > .791). Compared with the torn meniscus state, inside-out and all-inside repair techniques resulted in increased contact area at all flexion angles (all P < .005 and all P < .037, respectively), decreased mean contact pressure at all flexion angles (all P < .007 and all P < .001, respectively) except for 0° (P = .097 and P = .39, respectively), and decreased peak contact pressure at all flexion angles (all P < .001, all P < .001, respectively) except for 0° (P = .080 and P = .544, respectively). However, there were significant differences in contact area and peak contact pressure between the intact state and inside-out technique at angles ≥45° (all P < .014 and all P < .032, respectively). Additionally, there were significant differences between the intact state and all-inside technique in contact area at 60° and 90° and peak contact pressure at 90° (both P < .005 and P = .004, respectively). Median values of intact contact area, mean contact pressure, and peak contact pressure over the tested flexion angles ranged from 498 to 561 mm2, 786 to 997 N/mm2, and 1,990 to 2,215 N/mm2, respectively. CONCLUSIONS Contact area, mean contact pressure, and peak contact pressure were not significantly different between the all-inside and inside-out repair techniques at any tested flexion angle. Both techniques adequately restored native meniscus biomechanics near an intact level. CLINICAL RELEVANCE An all-inside repair technique provided similar, native-state-restoring contact mechanics compared with an inside-out repair technique for the treatment of displaced bucket-handle tears of the medial meniscus. Thus, both techniques may adequately decrease the likelihood of cartilage degeneration.
The infrapatellar fat pad (IFP) is in the anterior knee compartment and may be a major pain gener... more The infrapatellar fat pad (IFP) is in the anterior knee compartment and may be a major pain generator. A PubMed database search using the terms Hoffas fat pad, anterior interval, and infrapatellar fat pad was performed from the years 1970 to 2015. Clinical review. Level 5. Limited research exists examining the role of the IFP in relation to potential treatment and rehabilitation implications. Alterations in IFP mobility, whether the result of postsurgical scarring or faulty movement patterns, result in pain and disability in a variety of patient populations. The majority of treatment approaches are driven by the surgical technique.
Background: Insufficiency of hip capsular structures has recently gained recognition as a cause o... more Background: Insufficiency of hip capsular structures has recently gained recognition as a cause of pre-arthritic hip pain, leading to hip joint instability and progressive chondrolabral injury. An accurate evaluation of capsular integrity can help orthopedic surgeons plan capsular management prior to hip arthroscopy. Indications: The proposed iliofemoral bounce test is meant to be applied preoperatively for identification of hip capsular integrity when microinstability is suspected or in the setting of revision hip arthroscopy. Technique Description: After induction of general anesthesia and complete muscle relaxation, the patient is placed in a supine figure-four position by placing the foot of the pathologic hip on the contralateral knee. Two examination techniques are performed: (1) The examiner places one hand on the patient’s contralateral anterior superior iliac spine and applies consecutive downward pressure in a “rocking” manner to the pelvis; (2) the examiner applies a prel...
North American journal of sports physical therapy, 2007
Over the past few years, arthroscopy of the hip joint is becoming more common as a technique in b... more Over the past few years, arthroscopy of the hip joint is becoming more common as a technique in both the diagnosis and treatment of hip pain. A frequent cause of hip and groin pain is a tear of the acetabular labrum. Patients with labral tears complain of pain in the groin region and pain with clicking in the hip without a history of pain prior to the original onset. Once a patient presents with signs and symptoms of hip pain that are greater than four weeks in conjunction with indicative findings of a labral tear by way of MRI, he or she may be considered a good candidate for arthroscopy of the hip joint. Little evidence exists in the current literature on rehabilitative procedures performed after arthroscopy of the acetabular labrum. The purpose of this clinical commentary is to suggest a rehabilitation protocol after acetebular labral debridement or repair.
The American journal of sports medicine, Jan 17, 2015
Few studies have compared outcomes after meniscus suture repair in patients younger than 40 years... more Few studies have compared outcomes after meniscus suture repair in patients younger than 40 years versus patients 40 years and older. To document failure rates and long-term outcomes after meniscus suture repair by a single surgeon, using the inside-out technique, at a minimum 10-year follow-up in patients younger than 40 years versus those 40 years and older. Cohort study; Level of evidence, 3. This study included all patients 18 years or older who underwent meniscus suture repair with the inside-out technique by a single surgeon between January 1992 and December 2003. Patients were divided into 2 cohorts according to age: <40 years (cohort 1) and ≥40 years (cohort 2). If patients underwent subsequent knee surgery, all subsequent reports, whether performed by the original treating surgeon or by a different surgeon elsewhere, were reviewed by 2 independent reviewers not involved in the primary care of the patients. Reviewers classified surgeries as failures if the subsequent surg...
Background: Athletes display persistent muscle deficits and altered limb-loading mechanics at the... more Background: Athletes display persistent muscle deficits and altered limb-loading mechanics at the time of return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR). Purpose: To compare an objective profile of adolescent athletes at RTS after ACLR to matched healthy controls. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were 124 participants; 62 patients who underwent ACLR (15.4 ± 1.7 years) and 62 healthy controls (15.3 ± 1.7 years). Motion capture and force plates were used to capture joint motions during jump landing (JL) and single-limb squat (SLS) tasks. Energy absorption contribution (EAC) was calculated, and repeated-measures analysis of variance was used to assess for EAC differences between groups. Participants completed an International Knee Documentation Committee (IKDC) Subjective Knee Form, and isokinetic quadriceps and hamstring strength testing was performed on each limb. Independent t tests were run to examine age, he...
Reconstruction is widely accepted as the gold standard treatment for anterior cruciate ligament [... more Reconstruction is widely accepted as the gold standard treatment for anterior cruciate ligament [ACL] injuries. This technique has been shown to usually restore the stability of a symptomatic ACL-deficient knee, but many patients continue to have problems, including graft failure, inability to return to sporting activities and the development of arthritis. Primary ACL repair was described more than a century ago, but was abandoned based on the science of the time and perceived unsatisfactory outcomes. During the last decade there has been a resurged interest in preserving ACL in an attempt to avoid some of the consequences following ACL reconstruction. Recent studies have reported promising outcomes in a well-defined subset of patients. The primary aims of this review are to summarize the current knowledge regarding ACL preservation surgery and discuss the newer techniques of ACL repair compared with the surgeries that were performed in the past. The pursuit of novel solutions for p...
Posterolateral rotatory instability of the elbow is a recently described condition resulting from... more Posterolateral rotatory instability of the elbow is a recently described condition resulting from insufficiency of both the static lateral collateral ligament complex and the dynamic supporting muscular structures of the elbow. The lateral ulnar collateral ligament is the essential component of the lateral collateral ligament complex, linking the humerus and ulna and acting as the principle static restraint preventing external rotation of the ulna on the humerus, thus preventing posterolateral elbow instability. Ligament insufficiency permits the proximal ulna and the radial head to externally rotate posterior when the forearm is positioned in supination and slight flexion. Recent studies have characterized this condition as posterolateral instability of the elbow, and have portrayed the continuum that exists between posterior lateral rotatory instability and elbow dislocation. For patients whose instability symptoms persist despite conservative measures, repair or reconstruction of...
Hamstring injuries are the most common pathology reported in professional soccer players and repr... more Hamstring injuries are the most common pathology reported in professional soccer players and represent about 10-30% of all injuries. This study’s primary purpose was to identify specific injury patterns, location, and severity on MRI following acute hamstring injuries in a group of Major League Soccer (MLS) players. The secondary purpose was to present a new MRI classification protocol for identifying the location of hamstring injuries.
To describe the ‘mini-Max’ approach to labrum repair using non-absorbable 2.4-mm knotless suture ... more To describe the ‘mini-Max’ approach to labrum repair using non-absorbable 2.4-mm knotless suture anchors and report objective clinical outcomes with a large single-surgeon cohort. Level 3 retrospective case series. A retrospective review was conducted to report the use and allocation of non-absorbable 2.4-mm knotless suture anchors during ‘mini-Max’ labral repair from 2015 to 2018. Descriptive analysis of the labral damage severity, size and number of anchors used to arthroscopically repair the acetabular labrum was performed. Paired-samples t-tests were performed to evaluate whether preoperative and 1-year follow-up patient-reported outcomes (PROs) were statistically significant. An analysis of variance was performed comparing PROs with categorized number of labral anchors. A total of 390 patients were queried in this study, with 330 (85%) diagnosed intraoperatively with acetabular labral tears. A total of 245 patients (137 females and 108 males) with a mean age of 30.1 ± 11.6 year...
Background: A relatively new technology for the treatment of high grade articular cartilage lesio... more Background: A relatively new technology for the treatment of high grade articular cartilage lesions is the implantation of particulated articular cartilage obtained from a juvenile allograft donor (PJAC).1-2 Previous studies have reported the ability of juvenile chondrocytes to migrate from cartilage explants after being secured in a cartilage defect.3 There is little in the literature to use as a reference with respect to the use of PJAC for high grade articular cartilage lesion of the lateral femoral condyle after a failure of treatment with a microfracture in the high level athlete. Objective: The aim of this report is to describe the technique of PJAC transplantation for the treatment of chondral lesions of the lateral femoral condyle and to report the short term outcomes in the high performance athlete. Methods: We present a case report of two patients who were treated in our clinic in December 2014. Case 1: 16 year old female Division 1 university soccer player, who one year p...
Background: Quadriceps strength and knee extension are believed to be important in the ability to... more Background: Quadriceps strength and knee extension are believed to be important in the ability to effectively load the knee after anterior cruciate ligament (ACL) reconstruction (ACL-R). Purpose: To compare quadriceps strength (QUADS), side-to-side knee extension difference (ExtDiff), and knee energy absorption contribution (EAC) in patients preoperatively, 12 weeks postoperatively, and at return to sport (RTS). A secondary aim was to determine how the factors of QUADS and ExtDiff contributed to the ability to load the knee (knee EAC) at each of the 3 time points. Study Design: Case series; Level of evidence, 4. Methods: Overall, 41 individuals (mean ± SD age, 15.95 ± 1.63 years) were enrolled in this study. QUADS, ExtDiff, and knee EAC during a double-limb squat were collected preoperatively, 12 weeks postoperatively, and at RTS. Isokinetic QUADS was collected at 60 deg/s, normalized to body mass, and averaged across 5 trials. Knee extension was measured with a goniometer, and ExtD...
BACKGROUND: “Why try to convert other collagen substitutes into ligament if the original can be p... more BACKGROUND: “Why try to convert other collagen substitutes into ligament if the original can be preserved?” said Sherman1. Nowadays, reconstruction became the gold standard treatment for ACL injuries. Despite current treatment, secondary knee osteoarthritis has been described in more than 70% of the injured patients after 10 years follow up.2 Recent studies have reported that tears involving the proximal ACL have an intrinsic healing response. This response has been compared to the one observed in MCL injuries.3, 4. OBJECTIVE: The aim of this study is to initiate a scientific analysis of our experience in patients diagnosed with an acute, proximal ACL tear treated with a primary repair arthroscopic technique. We suggest the creation of a symposium that reconsiders the ACL repair as a tool for treatment, on a selected subset of patients. METHODS: We analyzed retrospectively the data of 12 consecutive patients diagnosed clinically and radiologically (MRI) with proximal ACL tears in ou...
Arthroscopy: The Journal of Arthroscopic & Related Surgery
PURPOSE To directly compare effectiveness of the inside-out and all-inside medial meniscal repair... more PURPOSE To directly compare effectiveness of the inside-out and all-inside medial meniscal repair techniques in restoring native contact area and contact pressure across the medial tibial plateau at multiple knee flexion angles. METHODS Twelve male, nonpaired (n = 12), fresh-frozen human cadaveric knees underwent a series of 5 consecutive states: (1) intact medial meniscus, (2) MCL tear and repair, (3) simulated bucket-handle longitudinal tear of the medial meniscus, (4) inside-out meniscal repair, and (5) all-inside meniscal repair. Knees were loaded with a 1,000-N axial compressive force at 5 knee flexion angles (0°, 30°, 45°, 60°, 90°), and contact area, mean contact pressure, and peak contact pressure were calculated using thin film pressure sensors. RESULTS No significant differences were observed between the inside-out and all-inside repair techniques at any flexion angle for contact area, mean contact pressure, and peak contact pressure (all P > .791). Compared with the torn meniscus state, inside-out and all-inside repair techniques resulted in increased contact area at all flexion angles (all P < .005 and all P < .037, respectively), decreased mean contact pressure at all flexion angles (all P < .007 and all P < .001, respectively) except for 0° (P = .097 and P = .39, respectively), and decreased peak contact pressure at all flexion angles (all P < .001, all P < .001, respectively) except for 0° (P = .080 and P = .544, respectively). However, there were significant differences in contact area and peak contact pressure between the intact state and inside-out technique at angles ≥45° (all P < .014 and all P < .032, respectively). Additionally, there were significant differences between the intact state and all-inside technique in contact area at 60° and 90° and peak contact pressure at 90° (both P < .005 and P = .004, respectively). Median values of intact contact area, mean contact pressure, and peak contact pressure over the tested flexion angles ranged from 498 to 561 mm2, 786 to 997 N/mm2, and 1,990 to 2,215 N/mm2, respectively. CONCLUSIONS Contact area, mean contact pressure, and peak contact pressure were not significantly different between the all-inside and inside-out repair techniques at any tested flexion angle. Both techniques adequately restored native meniscus biomechanics near an intact level. CLINICAL RELEVANCE An all-inside repair technique provided similar, native-state-restoring contact mechanics compared with an inside-out repair technique for the treatment of displaced bucket-handle tears of the medial meniscus. Thus, both techniques may adequately decrease the likelihood of cartilage degeneration.
The infrapatellar fat pad (IFP) is in the anterior knee compartment and may be a major pain gener... more The infrapatellar fat pad (IFP) is in the anterior knee compartment and may be a major pain generator. A PubMed database search using the terms Hoffas fat pad, anterior interval, and infrapatellar fat pad was performed from the years 1970 to 2015. Clinical review. Level 5. Limited research exists examining the role of the IFP in relation to potential treatment and rehabilitation implications. Alterations in IFP mobility, whether the result of postsurgical scarring or faulty movement patterns, result in pain and disability in a variety of patient populations. The majority of treatment approaches are driven by the surgical technique.
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Papers by Steven B Singleton