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Importance Arthroscopic suprapectoral biceps tenodesis (ABT) and open subpectoral biceps tenodesis (OBT) are two surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior to posterior (SLAP) tears. There is insufficient knowledge regarding the clinical superiority of one technique over the other. Objective To systematically review the literature in order to compare the clinical outcomes and safety of ABT and OBT for treatment of LHBT or SLAP pathology. Evidence review A systematic review was performed by searching PubMed, the Cochrane Library and Embase to identify studies that compared the clinical efficacy of ABT versus OBT. The search phrase used was: (bicep OR biceps OR biceps brachii OR long head of biceps brachii OR biceps tendinopathy) AND (tenodesis). Patients were assessed based on the American Shoulder and Elbow Surgeons Score, the visual analogue scale, the Single Assessment Numeric Evaluation, Constant-Murley Score, clinical failure, range of motion, bicipital groove pain and strength. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and both the Cochrane Collaboration’s and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) risk of bias tools were used to evaluate risk of bias. Findings Eight studies (one level I, seven level III) met inclusion criteria, including 326 patients undergoing ABT and 381 patients undergoing OBT. No differences were found in treatment failure rates or patient-reported outcome scores between groups in any study. One study found OBT patients to experience significantly increased range of shoulder forward flexion when compared with ABT patients (p=0.049). Two studies found ABT patients to experience significantly more postoperative stiffness when compared with OBT patients (p Conclusions Patients undergoing ABT and OBT can be expected to experience similar improvements in clinical outcomes at latest follow-up without differences treatment failure or functional performance. ABT patients may experience an increased incidence of stiffness in the early postoperative period. Level of evidence III.

PURPOSE To compare the biomechanical properties of the knotted versus knotless transosseous-equivalent (TOE) techniques for rotator cuff repair (RCR). METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and the Cochrane Library to identify studies that compared the biomechanical properties of knotted and knotless TOE RCR techniques. The search phrase used was as follows: (Double Row) AND (rotator cuff) AND (repair) AND (biomechanical). Evaluated properties included ultimate load to failure, cyclic displacement, stiffness, footprint characteristics, and failure mode. RESULTS Eight studies met the inclusion criteria, including a total of 67 specimens in each group. Of 6 studies reporting on ultimate load to failure, 4 found tendons repaired with the knotted TOE technique to experience significantly higher ultimate load to failure compared with knotless TOE repairs (knotted range, 323.5-549.0 N; knotless range, 166.0-416.8 N; P < .05). Of 6 studies reporting on failure stiffness, 2 found knotted TOE repairs to have significantly higher failure stiffness compared with knotless TOE repairs (knotted range, 30.0-241.8 N/mm; knotless range, 28.0-182.5 N/mm; P < .05), whereas 1 study found significantly higher failure stiffness in knotless TOE repairs compared with knotted TOE repairs (P = .039). Cyclic gap formation favored the knotted TOE group in 2 of 3 studies (knotted range, 0.6-5.2 mm; knotless range, 0.4-9.1 mm; P < .05). The most common mode of failure in both groups was suture tendon tear. CONCLUSIONS On the basis of the included cadaveric studies, rotator cuff tendons repaired via the knotted TOE technique display superior time-zero biomechanical properties, including greater ultimate load to failure, compared with rotator cuffs repaired via the knotless TOE technique. Suture tearing through the tendon remains a common failure method for both techniques. CLINICAL RELEVANCE The results of this systematic review provide helpful insight into the biomechanical differences between 2 popular techniques for RCR. Although these results should be carefully considered by surgeons who are using either of these techniques in the operating room, they should not be mistaken for direct clinical applicability because cadaveric studies may not directly correlate to clinical outcomes.

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery. Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores ( P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized ( P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts ( P = .87) or between BTB autografts and soft tissue allografts ( P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft ( P = .010; OR, 0.56; 95% CI, 0.36-0.87). Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Purpose To evaluate the quality and content of internet-based information available for some of the most common orthopaedic sports medicine terms. Methods A search of the PubMed, Embase, and Cochrane databases following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines was performed. All English-language literature published from 2010 to 2020 discussing information quality pertaining to orthopaedic sports medicine terms was included. Outcomes included the search engines used, number and type of websites evaluated, platform, and quality scoring metrics. Descriptive statistics are presented. Results This review includes 21 studies. Of these, 3 evaluated both the upper and lower extremity. Twelve focused on either the upper or lower extremity, most commonly rotator cuff tears (3 of 12) and/or anterior cruciate ligament pathologies (7 of 12). The most common engines were Google (18 of 21), Bing (16 of 21), Yahoo (16 of 21), YouTube (3 of 21), Ask (3 of 21), and AOL (2 of 21). The average number of media files assessed per study was 87 ± 55. Website quality was assessed with DISCERN (7 of 21), Flesch-Kincaid (9 of 21), Health on the Net (7 of 21), and/or Journal of the American Medical Association Benchmark (7 of 21) scores. YouTube was evaluated with Journal of the American Medical Association Benchmark scores (1.74 ± 1.00). Image quality was reported in 2 studies and varied with search terminology. Conclusions The results of this systematic review suggest that physicians should improve the quality of online information and encourage patients to access credible sources when conducting their own research. Clinical Relevance Doctors can and should play an active role in closing the gap between the level of health literacy of their patients and that of most common online resources.

Purpose To identify factors predictive of a large labral tear at the time of shoulder instability surgery. Methods As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. Results After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). Conclusions Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. Level of Evidence I, prognostic study.

Purpose To perform an updated systematic review of the anatomy, biomechanics, function of the anterolateral ligament (ALL), and the clinical outcomes of anterolateral ligament reconstruction (ALLR) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR). Methods A systematic search of the literature was performed by searching PubMed, the Cochrane Library, and Embase with the search phrase anterolateral ligament for articles published from February 2017 to May 2020. Inclusion criteria included studies that evaluated the anatomy, function, or biomechanics of the ALL; surgical technique articles on ALLR; clinical articles reporting outcomes of ALLR; studies published in English; and full-text articles. Exclusion criteria included studies published before February 2017. A subjective synthesis was performed, in which ranges were reported, and individual study data were presented in forest plots. Results Overall, 40 articles were included in this systematic review, with 11 articles describing ALL anatomy, 14 articles analyzing ALL function and biomechanics, 7 articles discussing the surgical technique of combined ACLR and ALLR (ACLR/ALLR), and 8 articles describing the clinical outcomes of ACLR/ALLR. The addition of ALLR in combination with ACLR (ACLR+) results in lower graft failure rates for ACLR/ALLR (0.0%–15.7%) when compared with isolated ACLR (I-ACLR) patients (7.4%–21.7%). Three of 5 studies using the Subjective International Knee Documentation Committee score, 2 of 5 studies using the Lysholm score, and 1 of 2 studies using the Tegner score reported significantly better scores at latest follow-up among ACLR+ patients compared with I-ACLR (P Conclusions The ALL acts as a secondary stabilizer to the anterior cruciate ligament and helps resist internal knee rotation and anterior tibial translation. Based on the current literature, combined ACLR with ALLR may result in lower graft failure rates and improved patient-reported outcomes when compared with I-ACLR in patients with specific indications, although several studies have shown equivalent outcomes between these 2 cohorts. Clinical Relevance The contents of this review provide great insight for orthopaedic surgeons who are performing ACLR and considering additional procedures to increase overall knee stability and decrease likeliness for re-rupture. The postoperative functional and clinical outcomes shown in patients undergoing ACLR+ compared with I-ACLR should be given proper consideration when evaluating available treatment courses.

Background: Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy. Purpose: To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption. Study Design: Systematic review. Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was “hip arthroscopy fascia iliaca randomized.” Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption. Results: Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; P = .054), IAR (7.7 vs 7.9; P = .72), control group (no FIB: 4.1 vs 3.8; P = .76); or saline placebo (difference, –0.2 [95% CI, –1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; P = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; P = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities. Conclusion: In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.

Background The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability. Methods Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient’s home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery. Results Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%. Conclusion We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.

Background: Marrow stimulation (MST) surgery, which includes microfracture, subchondral drilling, and abrasion arthroplasty, and autologous chondrocyte implantation (ACI) are 2 surgical options to treat articular cartilage lesions in the knee joint. Recent studies have suggested worse outcomes when ACI is used after failed MST. Purpose: To investigate the failure rates and clinical outcomes of primary knee ACI versus ACI after failed MST surgery (secondary ACI). Study Design: Systematic review. Methods: A systematic review was performed by searching the PubMed, Embase, and Cochrane Library databases to identify studies evaluating clinical outcomes of patients undergoing primary versus secondary ACI of the knee joint. The search terms used were as follows: “knee” AND (“autologous chondrocyte implantation” OR “osteochondral allograft”) AND (microfracture OR “marrow stimulation”). Patients undergoing primary ACI (group A) were compared with those undergoing secondary ACI (group B) based on treatment failure rates and patient-reported outcomes (PROs). Results: Seven studies (2 level 2 studies, 5 level 3 studies) were identified and met inclusion criteria, including a total of 1335 patients (group A: n = 838; group B: n = 497). The average patient age in all studies was 34.2 years, and the average lesion size was 5.43 cm2. Treatment failure occurred in 14.0% of patients in group A and 27.6% of patients in group B ( P < .00001). Four studies reported PROs. One study found significantly better Subjective International Knee Documentation Committee scores ( P = .011), visual analog scale (VAS) pain scores ( P = .028), and VAS function scores ( P = .005) in group A. Another study found significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) Pain scores ( P = .034), KOOS Activities of Daily Living scores ( P = .024), VAS pain scores ( P = .014), and VAS function scores ( P = .032) in group A. Two studies found no significant difference in PROs between groups A and B ( P < .05). Conclusion: Patient-reported improvement can be expected in patients undergoing primary or secondary ACI of the knee joint. Patients undergoing secondary ACI have a significantly higher risk of treatment failure and may have worse subjective outcomes compared with patients undergoing primary ACI.

Purpose: To determine whether range of motion (ROM) varies with the location and extent of labral tear seen in patients undergoing arthroscopic anterior shoulder stabilization. Methods: Consecutive patients undergoing arthroscopic anterior shoulder stabilization who were enrolled in the Multicenter Orthopaedic Outcomes Network Shoulder Instability database underwent a preoperative physical examination and intraoperative examination under anesthesia in which ROM was recorded. Intraoperatively, the location and extent of the labral tear was recorded using conventional clock-face coordinates. Patients were grouped by combinations of quadrants involved in the labral tear (G1-G7): G1 = anterior only, G2 = anterior + inferior, G3 = anterior + inferior + posterior, G4 = all quadrants, G5 = superior + anterior, G6 = superior + anterior + inferior, and G7 = posterior + superior + anterior. Statistical analyses were performed with the Kruskal–Wallis rank-sum test. When P < .05, a post-hoc Dunn’s test was performed. For categorical variables, the χ2 test was performed. We performed a series of bivariate negative binomial regression models testing pairwise combinations of ROM parameters predicting the count of labral tear locations (possible: 0-5) within each quadrant. Results: A total of 467 patients were included, with 13 (2.8%) in G1, 221 (47.3%) in G2, 40 (8.6%) in G3, 51 (10.9%) in G4, 18 (3.9%) in G5, 121 (25.9%) in G6, and 3 (0.6%) in G7. Multiple statistically significant differences were noted in ROM, specifically active internal rotation at side (IRS) (P = .005), active abduction (P = .02), passive IRS (P = .02), and passive external rotation in abduction (P = .0007). Regression modeling revealed a positive correlation between passive abduction and predicted count of labral tear locations in the superior quadrant and between passive IRS and predicted count of labral tear location in the inferior quadrant. Conclusions: In patients undergoing arthroscopic shoulder stabilization for anterior instability, ROM varies with location and extent of labral tear. However, the clinical relevance of such small ROM differences remains undetermined. Level of evidence: II, prospective comparative study.

Anterior shoulder (glenohumeral joint [GHJ]) dislocations are relatively common injuries in sports. Previous studies have evaluated clinical outcomes of operative and nonoperative management for primary traumatic anterior GHJ dislocations. The purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing closed reduction of a traumatic anterior GHJ dislocation, particularly among the athletic population. Two independent reviewers performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. Unfortunately, the quantity and quality of published articles on this subject is very limited. In many studies, younger age (between 21 and 30 years) was associated with greater risk for recurrence of GHJ dislocations. Twelve studies (total N = 753) directly compared outcomes of operative versus nonoperative management. It seems that operative management significantly reduces recurrence rates with patients treated operatively among the young and active population. Operative management should be considered as a treatment option for young and athletic patients presenting with a first-time anterior GHJ dislocation.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon- dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting post-operative infections. Allografts had a higher risk of infection than autografts (odds ratio=6.8; 95% CI: 0.9-54.5; p=0.045). Diabetes (odds ratio=28.6; 95% CI: 5.5-149.9; p=0.004) was a risk factor for infection. Patient age, sex, BMI and smoking status were not associated with risk of infection after rACLR. STATEMENT OF CLINICAL SIGNIFICANCE: While there is a low rate of infection following rACLR, use of allograft and comorbidity with diabetes are associated with a higher risk of infection following this surgery.

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented. Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting. Study Design: Case-control study; Level of evidence, 3. Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment. Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction. Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both

Background: The cause of subsequent surgery after anterior cruciate ligament (ACL) reconstruction varies, but if risk factors for specific subsequent surgical procedures can be identified, we can better understand which patients are at greatest risk. Purpose: To report the incidence and types of subsequent surgery that occurred in a cohort of patients 6 years after their index ACL reconstruction and to identify which variables were associated with the incidence of patients undergoing subsequent surgery after their index ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients completed a questionnaire before their index ACL surgery and were followed up at 2 and 6 years. Patients were contacted to determine whether any underwent additional surgery since baseline. Operative reports were obtained, and all surgical procedures were categorized and recorded. Logistic regression models were constructed to predict which patient demographic and surgical variables were associated with the incidence of undergoing subsequent surgery after their index ACL reconstruction. Results: The cohort consisted of 3276 patients (56.3% male) with a median age of 23 years. A 6-year follow-up was obtained on 91.5% (2999/3276) with regard to information on the incidence and frequency of subsequent surgery. Overall, 20.4% (612/2999) of the cohort was documented to have undergone at least 1 subsequent surgery on the ipsilateral knee 6 years after their index ACL reconstruction. The most common subsequent surgical procedures were related to the meniscus (11.9%), revision ACL reconstruction (7.5%), loss of motion (7.8%), and articular cartilage (6.7%). Significant risk factors for incurring subsequent meniscus-related surgery were having a medial meniscal repair at the time of index surgery, reconstruction with a hamstring autograft or allograft, higher baseline Marx activity level, younger age, and cessation of smoking. Significant predictors of undergoing subsequent surgery involving articular cartilage were higher body mass index, higher Marx activity level, reconstruction with a hamstring autograft or allograft, meniscal repair at the time of index surgery, or a grade 3/4 articular cartilage abnormality classified at the time of index ACL reconstruction. Risk factors for incurring subsequent surgery for loss of motion were younger age, female sex, low baseline Knee injury and Osteoarthritis Outcome Score symptom subscore, and reconstruction with a soft tissue allograft. Conclusion: These findings can be used to identify patients who are at the greatest risk of incurring subsequent surgery after ACL reconstruction.

Background: The number of golfers aged ≥65 years has increased in recent years, and shoulder arthritis is prevalent in this age group. Guidelines for return to golf (RTG) after shoulder arthroplasty have not been fully established. Purpose: To review the data available in the current literature on RTG after shoulder arthroplasty. Study Design: Systematic review. Methods: A systematic review based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Two independent reviewers searched PubMed, Embase, and the Cochrane Library using the terms “shoulder,”“arthroplasty,”“replacement,” and “golf.” The authors sought to include all studies investigating RTG after total shoulder arthroplasty (TSA), shoulder hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA). Outcomes of interest included indications for shoulder arthroplasty, surgical technique, rehabilitation protocol, amount of time between surgery and resumption of golf activity, and patient-reported outcome measures. Results: A total of 10 studies were included, 2 of which reported on golf performance after shoulder arthroplasty. The other 8 studies described return to sports after shoulder arthroplasty with golf-specific data for our analysis. Three studies that included patients who underwent TSA reported RTG rates ranging from 89% to 100% after mean follow-up periods of 5.1 to 8.4 months. Two studies included patients who underwent TSA and HA and reported RTG rates of 77% and 100% after mean intervals of 5.8 and 4.5 months, respectively. Two studies included patients who underwent RSA, with RTG rates of 50% and 79% after mean postoperative intervals of 5.3 and 6 months, respectively. One study included only patients undergoing HA, with an RTG rate of 54% and a mean RTG time of 6.5 months. Varying surgical procedures and baseline patient characteristics precluded our ability to draw conclusions regarding surgical technique, rehabilitation protocol, or patient-reported outcome measures among studies reporting these data. Conclusion: Most patients who undergo a shoulder arthroplasty procedure can expect to resume playing golf approximately 6 months after the index procedure. The rate of return may be lower after RSA and HA as compared with anatomic TSA. The data presented in our review can help physicians counsel patients who wish to continue golf participation after a shoulder arthroplasty procedure.

Purpose To systematically review the literature to compare the adductor canal block (ACB) with the femoral nerve block (FNB) following primary anterior cruciate ligament reconstruction (ACLR) in terms of early postoperative analgesic requirements and postoperative quadriceps strength. Methods A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to August 2019 to identify randomized controlled trials that compared postoperative pain and functional outcomes in patients following primary ACLR with ACB versus FNB. The search phrase used was: adductor canal femoral nerve anterior cruciate ligament. Patients were evaluated based on analgesic consumption and quadriceps muscle strength. Study quality and risk of bias were evaluated with the Modified Coleman Methodology Score and Cochrane risk-of-bias tool respectively. Results Five studies (all Level I evidence) were identified that met inclusion criteria, including 221 patients undergoing primary ACLR with ACB (mean age 26.8 years, 68.3% male) and 221 with FNB (mean age 28.2 years, 67.0% male). Statistical assessment for heterogeneity found for opioid consumption of ACB versus FNB groups was I2 = 97% (P Conclusions In patients undergoing ACLR, the ACB may provide similar analgesic requirements, and the included studies suggest a potential advantage in preserving muscle strength at short-term (24-48 hours) follow-up when compared with FNB. However, the differences in muscle strength assessments between studies do not allow for strong conclusions. Level of Evidence I, systematic review and meta-analysis of Level I studies.

Purpose To systematically review the literature in an effort to compare the demographics and clinical outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with a hamstring tendon autograft (HT) versus an irradiated or nonirradiated hybrid autograft-allograft. Methods A systematic review of the PubMed, Cochrane Library, and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All English-language literature that reported general demographics and compared the clinical outcomes of patients undergoing primary ACLR with autograft versus hybrid graft (HG) with a minimum 2-year follow-up was reviewed by 2 independent reviewers. Search terms used were “anterior cruciate ligament” and “hybrid graft.” Patients were assessed based on graft failure, anteroposterior laxity, and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, visual analog scale, Subjective International Knee Documentation Committee score, Lysholm, and Tegner scores). Study quality was evaluated with the Modified Coleman Methodology Score and ROBINS-I risk of bias tool. Results Twelve studies (1 level II, 11 level III) met inclusion criteria (follow-up, 2.0-8.9 years), including 471 patients undergoing ACLR with an irradiated hybrid graft (IH), 89 patients with a nonirradiated hybrid graft, and 829 patients with HT. Graft diameter ranged from 7.5 to 10.0 mm and from 6.5 to 10.0 mm in HG and HT patients, respectively. Overall, graft failure ranged from 0% to 30.0% and from 0% to 28.3% in HG and HT patients, respectively (I2 = 35.9%; 95% confidence interval 0%-74.8%). Among HG patients, graft failure ranged from 0%-30.0% and from 2.4%-4.2% in IH and nonirradiated hybrid graft groups, respectively (I2 = 33.6%; 95% confidence interval, 0%-71.8%). Results for postoperative anteroposterior laxity and patient-reported outcomes were also inconsistent. Conclusions Patients undergoing ACLR with HT demonstrate inconsistent differences in clinical outcomes at midterm follow-up compared with IH patients. Level of Evidence III, systematic review of level II and III studies.

Background: Patients with posterior shoulder instability may have bone and cartilage lesions (BCLs) in addition to capsulolabral injuries, although the risk factors for these intra-articular lesions are unclear. Hypothesis: We hypothesized that patients with posterior instability who had a greater number of instability events would have a higher rate of BCLs compared with patients who had fewer instability episodes. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group instability patient cohort were analyzed. Patients aged 12 to 99 years undergoing primary surgical treatment for shoulder instability were included. The glenohumeral joint was evaluated by the treating surgeon at the time of surgery, and patients were classified as having a BCL if they had any grade 3 or 4 glenoid or humeral cartilage lesion, reverse Hill-Sachs lesion, bony Bankart lesion, or glenoid bone loss. The effects of the number of instability events on the presence of BCLs was investigated by use of Fisher exact tests. Logistic regression modeling was performed to investigate the independent contributions of demographic variables and injury-specific variables to the likelihood of having a BCL. Significance was defined as P < .05. Results: We identified 271 patients (223 male) for analysis. Bone and cartilage lesions were identified in 54 patients (19.9%) at the time of surgical treatment. A glenoid cartilage injury was most common and was identified in 28 patients (10.3%). A significant difference was noted between the number of instability events and the presence of BCLs ( P = .025), with the highest rate observed in patients with 2 to 5 instability events (32.3%). Multivariate logistic regression modeling indicated that increasing age ( P = .019) and 2 to 5 reported instability events ( P = .001) were significant independent predictors of the presence of BCLs. For bone lesions alone, the number of instability events was the only significant independent predictor; increased risk of bone lesion was present for patients with 1 instability event (OR, 6.1; P = .012), patients with 2 to 5 instability events (OR, 4.2; P = .033), and patients with more than 5 instability events (OR, 6.0; P = .011). Conclusion: Bone and cartilage lesions are seen significantly more frequently with increasing patient age and in patients with 2 to 5 instability events. Early surgical stabilization for posterior instability may be considered to potentially limit the extent of associated intra-articular injury. The group of patients with more than 5 instability events may represent a different pathological condition, as this group showed a decrease in the likelihood of cartilage injury, although not bony injury.

Background: Articular cartilage and meniscal damage are commonly encountered and often treated at the time of anterior cruciate ligament reconstruction (ACLR). Our understanding of how these injuries and their treatment relate to outcomes of ACLR is still evolving. Hypothesis/Purpose: The purpose of this study was to assess whether articular cartilage and meniscal variables are predictive of 10-year outcomes after ACLR. We hypothesized that articular cartilage lesions and meniscal tears and treatment would be predictors of the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level outcomes at 10-year follow-up after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 1. Methods: Between 2002 and 2008, individuals with ACLR were prospectively enrolled and followed longitudinally using the IKDC, KOOS, and Marx activity score completed at entry, 2, 6, and 10 years. A proportional odds logistic regression model was built incorporating variables from patient characteristics, surgical technique, articular cartilage injuries, and meniscal tears and treatment to determine the predictors (risk factors) of IKDC, KOOS, and Marx outcomes at 10 years. Results: A total of 3273 patients were enrolled (56% male; median age, 23 years at time of enrollment). Ten-year follow-up was obtained on 79% (2575/3273) of the cohort. Incidence of concomitant pathology at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 22%; lateral femoral condyle [LFC], 15%; medial tibial plateau [MTP], 4%; lateral tibial plateau [LTP], 11%; patella, 18%; trochlea, 8%) and meniscal pathology (medial, 37%; lateral, 46%). Variables that were predictive of poorer 10-year outcomes included articular cartilage damage in the patellofemoral ( P < .01) and medial ( P < .05) compartments and previous medial meniscal surgery (7% of knees; P < .04). Compared with no meniscal tear, a meniscal injury was not associated with 10-year outcomes. Medial meniscal repair at the time of ACLR was associated with worse 10-year outcomes for 2 of 5 KOOS subscales, while a medial meniscal repair in knees with grade 2 MFC chondrosis was associated with better outcomes on 2 KOOS subscales. Conclusion: Articular cartilage injury in the patellofemoral and medial compartments at the time of ACLR and a history of medial meniscal surgery before ACLR were associated with poorer 10-year ACLR patient-reported outcomes, but meniscal injury present at the time of ACLR was not. There was limited and conflicting association of medial meniscal repair with these outcomes.

The role of graft selection on clinical and functional outcomes following anterior cruciate ligament (ACL) reconstruction has gained significant attention in the orthopaedic sports medicine community in recent years. Bone-patellar tendon-bone (BPTB) and semitendinosus/gracilis hamstring tendon (HT) autografts are 2 of the most commonly used grafts, given their low failure rates, predictable outcomes, and ability to incorporate appropriately at the graft site. However, multiple studies have recently shown each of these graft options to have some potentially less-desirable characteristics in regards to outcomes in specific patient populations. More specifically, in 14- to 25-year-old athletes, HT autografts have been shown to result in decreased rotational stability, decreased return to sport rates, and increased graft failure rates. On the other hand, BPTB autografts can require a prolonged recovery period and have been associated with increased postoperative pain and long-term kneeling pain. HT and BPTB grafts are both excellent grafts; however, it is important to understand the differences in clinical and functional outcomes between these graft options for ACL reconstruction. The characteristics of the graft need to be considered and individualized for each patient who is being treated for an ACL injury.

The clinical efficacy of autologous chondrocyte implantation (ACI) versus microfracture (MFx) for repair of articular cartilage lesions in the knee has gained significant attention in the orthopaedic sports medicine community in recent years. Bone marrow stimulation with MFx often is considered a first-line treatment option, given the ease and low cost of the procedure, as well as the good short-term outcomes. However, multiple studies have recently shown the outcomes of knee MFx to worsen after 5 years postoperatively, particularly for larger lesions. Because of this, ACI has been proposed as a first-line rather than salvage procedure for focal chondral defects in the knee. Although it is important to understand the differences in clinical outcomes between ACI and MFx at mid-term follow-up, longer-term outcomes need to be further investigated. In addition, it may be more appropriate to focus on the comparison of MFx with newer-generation techniques of chondrocyte implantation matrix-associated ACI rather than a collation of historical 2-step ACI using periosteum and newer techniques.

PURPOSE OF REVIEW: Reverse total shoulder arthroplasty (RTSA) is a procedure that has been increasingly utilized since its inception over 20 years ago. The purpose of this review is to present the most up to date practice and advances to the RTSA literature from the last 5 years. RECENT FINDINGS: Recent literature on RTSA has focused on identifying complications, maximizing outcomes, and determining its cost-effectiveness. RTSA has become a valuable tool in the treatment of various shoulder pathologies from fractures to massive-irreparable rotator cuff tears. Maximizing outcomes, proper patient counseling, and limiting complications are vital to a successful procedure. SUMMARY: RTSA can be a difficult procedure; however, when utilized appropriately, it can be an invaluable tool in the orthopedic surgeon’s armament. Recent evidence suggests, more and more, that RTSA not only provides value to the patient, but it is also cost-effective.

It is imperative that surgeons educate their patients on what to expect following a meniscectomy.A high preinjury activity level, younger age, medial meniscectomy, and smaller meniscal resection play a role in reducing the time until patients are able to return to sport.Improved clinical outcomes ca

Background: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery. Hypotheses: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates. Results: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC ( P < .0001), KOOS-Symptoms ( P = .01), KOOS–Sports and Recreation ( P = .04), and KOOS–Quality of Life ( P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates. Conclusion: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Hypothesis and background Male sex has been identified as a risk factor for both primary shoulder dislocation and recurrent instability, and male patients more often undergo surgery for instability. Despite published discrepancies between sexes regarding the incidence and surgical rates of shoulder instability, there is little detail on the differences in presentation, mechanism of injury, and intraoperative findings. The purpose of this study was to explore these differences. Methods Prospective baseline data from 1010 patients in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were analyzed for sex-related differences using demographic characteristics, patient-reported outcomes, radiographic findings, intraoperative findings, and surgical procedures performed. Two-tailed t tests and χ2 tests were used to compare the continuous and categorical data, respectively. Patients were categorized using the Frequency, Etiology, Direction, Severity (FEDS) classification system. Results Male patients comprised 81.3% of the cohort. Male patients had a significantly higher rate of traumatic instability and rate of initial instability while playing sports, as well as significantly higher activity scores. Female patients had significantly lower preoperative American Shoulder and Elbow Surgeons, Western Ontario Shoulder Instability Index, 36-Item Health Survey, and Single Assessment Numeric Evaluation scores. No difference in the number of dislocations was found between male and female patients. Intraoperatively, male patients had higher rates of labral pathology and bone loss whereas female patients had higher rates of capsular laxity. These differences resulted in more Latarjet procedures for male patients and more soft-tissue procedures for female patients. Conclusion There are differences between male and female patients in the etiology of their instability, baseline patient-reported outcomes, and associated shoulder pathology, likely reflecting intrinsic and activity-related variation. These differences may influence clinical decision making and patient outcomes.

Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Study design: Systematic review. Methods: A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. PubMed, EMBASE, and the Cochrane Library were queried through use of the terms anterior cruciate ligament and revision to identify all studies reporting outcomes of bone tunnel grafting in 2-stage revision ACL reconstruction. Data extracted included indications for 2-stage surgery, surgical technique, graft material, time between surgeries, rehabilitation protocols, physical examination findings, patient-reported outcomes, and radiographic and histologic findings. Results: The analysis included 7 studies with a total of 234 patients. The primary outcome in 2 studies was graft incorporation (mean follow-up, 8.8 months), whereas the other 5 studies reported clinical outcomes with follow-up mean ± SD of 4.2 ± 2.1 years. The indication for bone grafting and between-stage protocol varied among studies. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). Finally, 1 study compared ICBG to a synthetic bone substitute. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. In 4 studies, the authors reported the time interval between first and second surgeries, with an average of 6.1 months for ICBG compared with 8.7 months for allogenic and synthetic grafts. Revision ACL graft failure rates were reported by 5 studies, including 1 study with ABM (6.1%), 1 study with AC (8.3%), 1 study with TBA (0%), and 2 studies with ICBG (0% and 2%). Conclusion: The indications for staged ACL reconstruction and the rehabilitation protocol between stages need to be clearly established. The available data indicate that autograft for bone tunnel grafting in 2-stage ACL revision may be associated with a lower risk of revision ACL reconstruction graft failure compared with allograft bone.

Background: Traumatic anterior shoulder instability is a common condition affecting sports participation among young athletes. Clinical outcomes after surgical management may vary according to patient activity level and sport involvement. Overhead athletes may experience a higher rate of recurrent instability and difficulty returning to sport postoperatively with limited previous literature to guide treatment. Purpose: To report the clinical outcomes of patients undergoing primary arthroscopic anterior shoulder stabilization within the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Consortium and to identify prognostic factors associated with successful return to sport at 2 years postoperatively. Study Design: Case series; Level of evidence, 4. Methods: Overhead athletes undergoing primary arthroscopic anterior shoulder stabilization as part of the MOON Shoulder Instability Consortium were identified for analysis. Primary outcomes included the rate of recurrent instability, defined as any patient reporting recurrent dislocation or reoperation attributed to persistent instability, and return to sport at 2 years postoperatively. Secondary outcomes included the Western Ontario Shoulder Instability Index and Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow questionnaire score. Univariate regression analysis was performed to identify patient and surgical factors predictive of return to sport at short-term follow-up. Results: A total of 49 athletes were identified for inclusion. At 2-year follow-up, 31 (63%) athletes reported returning to sport. Of those returning to sport, 22 athletes (45% of the study population) were able to return to their previous levels of competition (nonrefereed, refereed, or professional) in at least 1 overhead sport. Two patients (4.1%) underwent revision stabilization, although 14 (28.6%) reported subjective apprehension or looseness. Age ( P = .87), sex ( P = .82), and baseline level of competition ( P = .37) were not predictive of return to sport. No difference in range of motion in all planes ( P > .05) and Western Ontario Shoulder Instability Index scores (78.0 vs 80.1, P = .73) was noted between those who reported returning to sport and those who did not. Conclusion: Primary arthroscopic anterior shoulder stabilization in overhead athletes is associated with a low rate of recurrent stabilization surgery. Return to overhead athletics at short-term follow-up is lower than that previously reported for the general athletic population.

Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes than primary ACL reconstruction. The reasons remain varied and not completely understood. METHODS: Patients undergoing revision ACL reconstruction were prospectively enrolled. Data collected included baseline demographics, surgical technique and pathological condition, prescribed rehabilitation instructions, and a series of validated patient-reported outcome instruments. Patients were followed for 2 years and asked to complete a set of outcome instruments identical to those completed at baseline. Subsequent surgical procedures on the ipsilateral knee were recorded. Regression analysis was used to control for age, sex, activity level, baseline outcome scores, and the above-mentioned rehabilitation-related variables in order to assess the factors affecting clinical outcomes 2 years after revision ACL reconstruction. RESULTS: A total of 843 patients met the inclusion criteria and were successfully enrolled, and 82% (695) were followed for 2 years. Two rehabilitation-related factors were found to influence outcome. First, patients who were prescribed an ACL brace for their return to sports had a significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) for sports and recreational activities at 2 years (odds ratio [OR] =1.50, 95% confidence interval [CI] = 1.07 to 2.11; p = 0.019). Second, patients prescribed an ACL brace for the postoperative rehabilitation period were 2.3 times more likely to have subsequent surgery by 2 years (OR = 2.26, 95% CI = 1.11 to 4.60; p = 0.024). The odds of a graft rerupture were not affected by any type of brace wear. CONCLUSIONS: Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years. Weight-bearing and motion can be initiated immediately postoperatively. Bracing during the early postoperative period is not helpful. Use of a functional brace early in the postoperative period was associated with an increased risk of a reoperation. Use of a functional brace for a return to sports improved the KOOS on the sports/recreation subscale. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Purpose To systematically review high-quality studies in the literature to compare the postoperative radiographic incidence of knee osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) with a single-bundle (SB) versus double-bundle (DB) graft. Methods A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to locate randomized controlled trials that compared the postoperative progression of knee OA in SB versus DB ACLR patients. The search terms used were “anterior cruciate ligament reconstruction,” “single-bundle,” “double-bundle,” “randomized,” and “osteoarthritis.” Patients were assessed based on radiographic evaluation (Kellgren-Lawrence [K-L] and objective International Knee Documentation Committee scales) and graft failure. Results A total of 7 studies (5 Level I and 2 Level II) met the inclusion criteria, including 375 SB and 477 DB ACLR patients with a mean follow-up period of 5.3 years. Graft failure occurred in 3.2% of patients overall (27 of 852), with no significant difference between groups (P = .10). No significant difference in overall K-L grade distribution was found between groups (P = .90). Overall, 15.1% of patients (58 of 383) were given a K-L grade of 2 or greater, including 14.4% in the SB group (31 of 215) and 16.1% in the DB group (27 of 168) (P = .65). Using other, unconventional grading schemes, 2 studies found DB ACLR patients to have significantly fewer signs of radiographic knee OA at follow-up compared with SB ACLR patients (P Conclusions Patients undergoing ACLR with either an SB or DB graft can be expected to experience a similar incidence of postoperative knee OA at midterm follow-up according to the K-L grading system. Level of Evidence Level II, systematic review of Level I and II studies.

Purpose The purpose of this study was to systematically review the literature in order to compare the efficacy of platelet-rich plasma (PRP) and hyaluronic acid (HA) injections for the treatment of hip osteoarthritis (OA). Methods A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that compared the clinical efficacy of PRP and HA injections for hip OA. The search phrase used was hip osteoarthritis platelet-rich plasma hyaluronic acid randomized. Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Visual Analog Scale (VAS) for pain, and the Harris Hip Score (HHS). Sub-analyses were performed for any outcome score in which at least three studies reported results. Results Six studies (5 Level I, 1 Level II) met inclusion criteria, including 211 patients undergoing intra-articular injection(s) with PRP (mean age 60.0 years, mean follow-up 12.2 months) and 197 patients with HA (mean age 62.3 years, mean follow-up 11.9 months). No significant differences were found in the weighted improvement of any outcome score (WOMAC, VAS, HHS) from pre-injection to post-injection between groups. When excluding a study with the highest risk of bias to eliminate heterogeneity, pooled sub-analysis demonstrated no significant differences in WOMAC subscores between PRP and HA groups. Similarly, in a pooled sub-analysis that isolated patients treated with leukocyte-poor PRP, no significant differences in WOMAC subscores were found between PRP and HA groups. Conclusion Patients undergoing treatment for hip OA with either PRP or HA injections can expect to experience similarly beneficial short-term clinical outcomes.

Background: Arthroscopic shoulder capsulolabral repair using glenoid-based suture anchor fixation provides consistently favorable outcomes for patients with anterior glenohumeral instability. To optimize outcomes, inferior anchor position, especially at the 6-o’clock position, has been emphasized. Proponents of both the beach-chair (BC) and lateral decubitus (LD) positions advocate that this anchor location can be consistently achieved in both positions. Hypothesis: Patient positioning would be associated with the surgeon-reported labral tear length, total number of anchors used, number of anchors in the inferior glenoid, and placement of an anchor at the 6-o’clock position. Study Design: Cross-sectional study; Level of evidence, 3. Methods: This study was a cross-sectional analysis of a prospective multicenter cohort of patients undergoing primary arthroscopic anterior capsulolabral repair. Patient positioning in the BC versus LD position was determined by the operating surgeon and was not randomized. At the time of operative intervention, surgeon-reported labral tear length, total anchor number, anchor number in the inferior glenoid, and anchor placement at the 6-o’clock position were evaluated between BC and LD cohorts. Descriptive statistics and between-group differences (continuous: t test [normal distributions], Wilcoxon rank sum test [nonnormal distributions], and chi-square test [categorical]) were assessed. Results: In total, 714 patients underwent arthroscopic anterior capsulolabral repair (BC vs LD, 406 [56.9%] vs 308 [43.1%]). The surgeon-reported labral tear length was greater for patients having surgery in the LD position (BC vs LD [mean ± SD], 123.5°± 49° vs 132.3°± 44°; P = .012). The LD position was associated with more anchors placed in the inferior glenoid and more frequent placement of anchors at the 6-o’clock (BC vs LD, 22.4% vs 51.6%; P < .001). The LD position was more frequently associated with utilization of ≥4 total anchors (BC vs LD, 33.5% vs 46.1%; P < .001). Conclusion: Surgeons utilizing the LD position for arthroscopic capsulolabral repair in patients with anterior shoulder instability more frequently placed anchors in the inferior glenoid and at the 6-o’clock position. Additionally, surgeon-reported labral tear length was longer when utilizing the LD position. These results suggest that patient positioning may influence the total number of anchors used, the number of anchors used in the inferior glenoid, and the frequency of anchor placement at the 6 o’clock position during arthroscopic capsulolabral repair for anterior shoulder instability. How these findings affect clinical outcomes warrants further study. Registration: NCT02075775 (ClinicalTrials.gov identifier)

Purpose: To systematically review the literature to evaluate the biomechanical properties of the suture anchor (SA) versus transosseous tunnel (TO) techniques for quadriceps tendon (QT) repair. Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase using PRISMA guidelines to identify studies that evaluated the biomechanical properties of SA and TO techniques for repair of a ruptured QT. The search phrase used was “quadriceps tendon repair biomechanics”. Evaluated properties included ultimate load to failure (N), displacement (mm), stiffness (N/mm), and mode of failure. Results: Five studies met inclusion criteria, including a total of 72 specimens undergoing QT repair via the SA technique and 42 via the TO technique. Three of 4 studies found QTs repaired with SA to have significantly less elongation upon initial cyclic loading when compared to QTs repaired with the TO technique (P .05). The most common mode of failure in both groups was suture slippage. Conclusion: On the basis of the included cadaveric studies, QTs repaired via the SA technique have less initial displacement upon cyclic testing when compared to QTs repaired via the TO technique. However, final displacement and ultimate load to failure outcomes did not reveal differences between the two fixation strategies. Knot slippage remains a common failure method for both strategies.

Knee dislocations (KDs) are devastating injuries for patients and present complex challenges for orthopaedic surgeons. Although short-term outcomes have been studied, there are few long-term outcomes of these injuries available in the literature. The purpose of this study is to determine factors that influence mid- to long-term clinical outcomes following surgical treatment of KD. A review of the current literature was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies published from 2010 to 2019 with a minimum 2-year follow-up that reported outcomes following surgical treatment of KDs. Ten studies (6 level III, 4 level IV) were included. At mid- (2–10 y) to long-term (>10 y) follow-up, concomitant arterial, cartilage, and combined meniscus damage were predictive factors for inferior Lysholm and International Knee Documentation Committee (IKDC) scores when compared with patients without these associated injuries. Although concomitant neurological damage may influence short-term outcomes due to decreased mobility, at longer follow-up periods it does not appear to predict worse clinical outcomes when compared with patients without concomitant neurological injury. Frank and polytrauma KDs have been associated with worse mid- to long-term outcomes when compared with transient and isolated KDs. Patients who underwent surgery within 6 weeks of trauma experienced better long-term outcomes than those who underwent surgery longer than 6 weeks after the initial injury. However, the small sample size of this study makes it difficult to make valid recommendations. Lastly, female sex, patients older than 30 years at the time of injury and a body mass index (BMI) greater than 35 kg/m2 are factors that have been associated with worse mid- to long-term Lysholm and IKDC scores. The results of this review suggest that female sex, age >30 years, BMI >35 kg/m2, concomitant cartilage damage, combined medial and lateral meniscal damage, KDs that do not spontaneously relocate, and KDs associated with polytrauma may predict worse results at mid- to long-term follow-up.

Background: COVID-19 is a severe respiratory virus that spreads via person-to-person contact through respiratory droplets. Since being declared a pandemic in early March 2020, the World Health Organization had yet to release guidelines regarding the return of college or professional sports for the 2020-2021 season. Purpose: To survey the head orthopedic surgeons and primary care team physicians for the National Collegiate Athletic Association (NCAA) Football Bowl Subdivision (FBS) football teams so as to gauge the management of common COVID-19 issues for the fall 2020 college football season. Study Design: Cross-sectional study. Methods: The head team orthopaedic surgeons and primary care physicians for all 130 FBS football teams were surveyed regarding their opinions on the management of college football during the COVID-19 pandemic. A total of 30 questions regarding testing, return-to-play protocol, isolating athletes, and other management issues were posed via email survey sent on June 5, 2020. Results: Of the 210 team physicians surveyed, 103 (49%) completed the questionnaire. Overall, 36.9% of respondents felt that it was unsafe for college athletes to return to playing football during fall 2020. While the majority of football programs (96.1%) were testing athletes for COVID-19 as they returned to campus, only 78.6% of programs required athletes to undergo a mandatory quarantine period before resuming involvement in athletic department activities. Of the programs that were quarantining their players upon return to campus, 20% did so for 1 week, 20% for 2 weeks, and 32.9% quarantined their athletes until they had a negative COVID-19 test. Conclusion: While US Centers for Disease Control and Prevention guidelines evolve and geographic regions experience a range of COVID-19 infections, determining a universal strategy for return to socialization and participation in sports remains a challenge. The current study highlighted areas of consensus and strong agreement, but the results also demonstrated a need for clarity and consistency in operations, leadership, and guidance for medical professionals in multiple areas as they attempt to safely mitigate risk for college football players amid the COVID-19 pandemic.

Rotator cuff tears are some of the most common injuries in the field of orthopedics, with over 4.5 million patient visits per year and $3 to $5 billion annual economic burden in the United States (Baumer et al., Orthop J Sports Med. 4:2325967116666506, 2016). With a large increase in the number of physically active aging individuals, rotator cuff disease is quickly becoming a major medical complication (Seida et al. AHRQ Comp Eff Rev, 2010). The unpredictability of cuff tear progression, the possibility that a reparable tear will become irreparable, and the time and cost of unsuccessful nonoperative management add complexity to the treatment strategy. As a result, knowledge of basic rotator cuff tendon anatomy is helpful in understanding its injury patterns and provides a good starting point to begin thinking about repair or reconstruction (Blevins et al., Orthop Clin North Am. 28:1–16, 1997).

Background: Posttraumatic osteoarthritis (PTOA) after injury to the anterior cruciate ligament (ACL) is common. Purpose: To perform a systematic review of basic science and animal studies to determine the effect of doxycycline treatment on the prevention of PTOA after ACL rupture/transection. Study Design: Systematic review. Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify basic science and animal studies evaluating the effect of doxycycline treatment on the prevention of PTOA of the knee joint after ACL/cranial cruciate ligament (CCL) injury. The search phrase used was “doxycycline cruciate ligament.” Inclusion criteria were basic science and animal studies evaluating the effect of oral administration of doxycycline in ACL/CCL-deficient animals with or without a control group. Results: Seven studies met inclusion criteria and were included in this systematic review. Five studies were performed in dogs, 1 in rabbits, and 1 in mice. Overall, the effects of doxycycline treatment on the prevention of PTOA after ACL/CCL rupture/transection were mixed. In dogs, no significant effects of doxycycline treatment were found in terms of matrix metalloproteinase (MMP) activity, while a mouse study found significantly lower MMP-13 expression on the tibia in doxycycline-treated animals, suggesting that doxycycline may protect against proteoglycan loss and decrease osteoarthritis progression. Cartilage nitric oxide concentrations were lower in doxycycline-treated dogs compared with untreated dogs, suggesting decreased cartilage degradation among doxycycline-treated dogs, although there were no significant effects on cartilage stromelysin levels with no significant effects in terms of physiological remodeling or catabolism of cartilage. Bone formation or resorption was not found to be affected by doxycycline treatment. One study demonstrated a substantial beneficial effect of doxycycline on gross morphology of the medial femoral condyle. Doxycycline was found to conserve bone strain energy density and appeared to limit subchondral bone loss in 1 study. Conclusion: Based on the limited available animal studies, doxycycline appears to demonstrate some benefits in the prevention of PTOA after ACL/CCL rupture/transection. Additional studies are needed to further characterize the potential benefits, side effects, dosage, and duration of this treatment after ACL injury in human patients.

Biceps tenodesis and tenotomy are 2 surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior-to-posterior (SLAP) tears. The purpose of this systematic review was to compare the clinical outcomes and complications of biceps tenodesis and tenotomy for the treatment of LHBT or SLAP pathology during shoulder arthroscopy.We performed a systematic review by searching PubMed, the Cochrane Library, and Embase to identify level I randomized controlled trials that compared the clinical outcomes of biceps tenodesis vs. tenotomy. The search phrase used was as follows: biceps tenodesis tenotomy randomized. Patients were assessed based on the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Constant-Murley score, as well as postoperative range of motion, strength, and cosmetic deformity.Five studies (all level I) met the inclusion criteria, including 236 patients undergoing biceps tenodesis (mean age, 60.3 years) and 232 patients undergoing biceps tenotomy (mean age, 59.7 years). The mean follow-up period was 23.0 months. Overall, 6.8% of tenodesis patients experienced cosmetic deformity at latest follow-up compared with 23.3% of tenotomy patients (P.001). No differences in Constant-Murley, visual analog scale, or American Shoulder and Elbow Surgeons scores were found between groups in any study, and of all the studies evaluating strength and range of motion at latest follow-up, only 1 found a significant difference between groups, in which tenodesis patients demonstrated significantly increased forearm supination strength (P = .02). One study found tenodesis patients to experience significantly more biceps cramping at 6-month follow-up compared with tenotomy patients (P = .043), although no differences in complication rates at latest follow-up were found in any study.Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes. There is an increased rate of cosmetic deformity in patients undergoing biceps tenotomy compared with tenodesis.

Background: No study in the orthopaedic literature has analyzed the demographic characteristics or surgical training of sports medicine fellowship directors (FDs). Objective determinations as to what makes a physician qualified for this leadership position remain unclear; thus, it is important to identify these qualities as future physicians look to fill these roles. Purpose: To illustrate characteristics common among sports medicine FDs. Study Design: Cross-sectional study. Methods: The 2020 Accreditation Council for Graduate Medical Education Fellowship Directory was used to identify the FDs for all orthopaedic sports medicine fellowship programs in the United States. The characteristics and educational background data for FDs were gathered by 2 independent reviewers from up-to-date curricula vitarum, Web of Science, and institutional biographies and consolidated into 1 database. Data points gathered included age, sex, residency/fellowship training location and graduation year, name of current institution, length of time at current institution, time since training completion until being appointed FD, length of time in current FD role, and personal research H-index. Results: We identified 90 current orthopaedic sports medicine FDs. The mean Scopus H-index was 24.1 (median, 17). The mean age of FDs was 55.4 years; 87 of 90 (96.7%) were male and 3 (3.3%) were female; and 79/90 (87.8%) were White and 3/90 (3.3%) were African-American. The mean time to complete residency was 5.1 years (range, 5.0-6.0 years), and the most attended residency programs were the Hospital for Special Surgery (n = 9), the Harvard Combined Orthopaedic Residency Program (n = 5), and Duke University Medical Center (n = 4). The mean time required to complete a fellowship was 1.1 years (range, 1.0-2.0 years), and the fellowship programs that produced the most future FDs were the American Sports Medicine Institute (n = 11), the Steadman Hawkins Clinic (Vail) (n = 8), the Kerlan-Jobe Orthopaedic Clinic (n = 7), and the Hospital for Special Surgery (n = 7). The mean time from completion of fellowship to appointment as a FD was 12.8 years (range, 1-39 years). Conclusion: Women and minority groups are largely underrepresented among leadership positions in the field of orthopaedic sports medicine.

Background: There remains a paucity of literature comparing clinical outcomes after anterior cruciate ligament reconstruction (ACLR) between skiers and non-skiers, particularly in older patient populations. Purpose: To compare clinical outcomes after ACLR between skiers and non-skiers, with a subanalysis based on age. Study Design: Cohort study; Level of evidence, 3. Methods: A nested cohort of 128 patients from the Multicenter Orthopaedic Outcomes Network cohort who underwent primary ACLR completed a series of patient-reported outcomes pre- and postoperatively at 2 and 6 years including the Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, and subjective International Knee Documentation Committee (IKDC) score. Data including patient sex, age at surgery, graft type, and sport participation were analyzed. Patients were stratified by participation in skiing (skiers vs non-skiers) and by age subgroup (≤29, 30-39, and ≥40 years). Student t tests and analysis of variance were used to compare mean improvement between pre- and postoperative outcomes. Results: A total of 44 skiers (female, 59.1%; age, 35.3 ± 11.6 years) and 84 non-skiers (female, 34.5%; age, 27.7 ± 11.3 years) were included. ACLR was performed using allograft in 36.7% (22 skiers, 25 non-skiers), autograft in 58.6% (19 skiers, 56 non-skiers), or hybrid autograft-allograft in 4.7% (3 skiers, 3 non-skiers). Although both non-skiers and skiers demonstrated improvements in outcomes from baseline to 2 and 6 years, non-skiers demonstrated significantly less overall improvement from 2 to 6 years postoperatively in KOOS Symptoms ( P = .01), KOOS Pain ( P = .002), and KOOS Activities of Daily Living ( P = .03) subscales compared with skiers. There were 15 skiers who were 29 years or younger (34.1%), 14 skiers between 30 and 39 years (31.8%), and 15 skiers 40 years or older (34.1%). Skiers 40 years and older demonstrated significantly greater mean improvement in KOOS Symptoms ( P = .02) and KOOS Quality of Life (QoL) ( P = .01) subscales at 2 years and KOOS QoL ( P = .01) at 6 years postoperatively compared with skiers 29 years or younger. Conclusion: Compared with non-skiers, skiers demonstrated significantly greater mean improvements in KOOS scores between 2 and 6 years after ACLR. In addition, skiers 40 years or older showed greater improvement in KOOS QoL compared with younger skiers. This information can be used to counsel skiers, especially those older than 40 years, as to their expected outcomes after ACLR.

Background: Guidelines for return to driving after anterior cruciate ligament reconstruction (ACLR) have not been established. Purpose: To review the literature pertaining to driving after ACLR and provide evidence-based guidelines to aid clinicians in counseling patients about driving after ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two independent reviewers searched PubMed, EMBASE, and the Cochrane Library using the terms anterior cruciate ligament, ACL, drive, and driving. Studies reporting on functional recovery after ACLR were included when data regarding return to driving were reported. Results: Five studies were included. Two studies included patients who underwent right-sided ACLR. Of these, 1 study evaluated bone-patellar tendon-bone autograft and reported that brake response time (BRT) returned to normal approximately 4 to 6 weeks postoperatively. The other study found that BRT returned to normal 3 weeks after allograft ACLR, but 6 weeks elapsed after autograft ACLR before values were not significantly different than controls. One study reported that patients who underwent left-sided hamstring tendon autograft ACLR demonstrated BRTs similar to controls within 2 weeks, while those with right-sided ACLR had significantly slower BRTs until 6 weeks postoperatively. Another study including patients who underwent either right- or left-sided ACLR and employed a manual transmission simulator found that 4 to 6 weeks should elapse after ACLR with hamstring tendon autograft. Survey data from 1 study demonstrated that the mean time for patients to resume driving was 13 and 10 days after right- and left-sided ACLR, respectively. Conclusion: BRT returned to normal values approximately 4 to 6 weeks after right-sided ACLR and approximately 2 to 3 weeks after left-sided ACLR. According to 1 study in this review, ACLR laterality should be disregarded for patients who drive manual transmission automobiles, as a 4- to 6-week time period was required for driving ability to reach the level of healthy controls. Future studies should aim to elucidate the influence of graft choice and transmission type on return to driving after ACLR.

Background: Few studies have investigated the relationship between the Patient-Reported Outcomes Measurement Information System (PROMIS) and legacy patient-reported outcome (PRO) measurements. Purpose: To compare patient-reported outcomes from the PROMIS physical function (PF) and upper extremity (UE) platforms against one another and against legacy PRO measurements to assess the potential strengths and weaknesses of the National Institutes of Health PROMIS initiative and expand on the use of PRO measurements in clinical orthopaedic practice. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic search of the PubMed, Embase, and Cochrane Library databases was conducted following PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. All English-language studies published between 2017 and 2019 using PROMIS to evaluate patients for shoulder surgery were analyzed. PROs were compared based on survey administered and the shoulder condition being investigated. Study quality was evaluated using the Modified Coleman Methodology Score and the Methodological Index for Non-Randomized Studies score. Results: We included 9 studies (5 studies were level 2; 3 studies were level 3; 1 study was level 4) encompassing a total of 1130 patients (60.2% male; mean age, 52.6 ± 16.5 years; mean BMI, 29.8 ± 2.8 kg/m2). Of these, 6 studies administered the PROMIS PF, and 6 studies administered the PROMIS UE. The strongest correlation was between PROMIS PF computer adaptive test and the 36-Item Short Form Health Survey Global Health (SF-36 GH) ( r = 0.75). The highest overall correlation with the PROMIS UE was found with the American Shoulder and Elbow Surgeons (ASES) Shoulder Score ( r = 0.70). The lowest correlations were found between PROMIS PF and the Marx Shoulder Activity Scale ( r = 0.08) and the PROMIS UE and the Marx Shoulder Activity Scale ( r = 0.18). Conclusion: From available data, the PROMIS PF and PROMIS UE were most closely correlated with outcomes measured by the SF-36 GH. The PROMIS UE alone was most correlated with ASES Shoulder Score. Thus, either PROMIS PF or UE may provide a possible alternative to legacy PRO measurements but with a lower overall number of questions and higher generalizability. Future research should compare the time and question burden of the various PROMIS platforms with a more consistent evaluation of standard PRO measurements.

Background The Frequency, Etiology, Direction, and Severity (FEDS) system was developed as a simple but reliable method for classifying shoulder instability based on 4 factors attainable by history and physical examination: frequency (solitary, occasional, or frequent); etiology (traumatic or atraumatic); direction (anterior, posterior, or inferior); and severity (subluxation or dislocation). This study investigated the epidemiology and 2-year surgical outcomes for the FEDS categories in the prospective Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. Methods At the time of surgery, 1204 patients were assigned to the FEDS categories. Follow-up data were available for 636 of 734 patients (86.6%) who had undergone surgery at least 2 years prior to analysis. The most common categories were further analyzed by patient-reported outcomes (PROs) (American Shoulder and Elbow Surgeons, Western Ontario Shoulder Instability index, Single Assessment Numeric Evaluation scores) and rates of recurrent subluxation, recurrent dislocation, and revision surgery. Results Of the 36 FEDS categories, 16 represented at least 1% of patients. Occasional traumatic anterior dislocation (OTAD) was the most common category, with 16.4% of patients. Five other anterior categories (solitary traumatic anterior subluxation, occasional traumatic anterior subluxation [OTAS], frequent traumatic anterior subluxation [FTAS], solitary traumatic anterior dislocation, and frequent traumatic anterior dislocation) and one posterior category (solitary traumatic posterior subluxation [STPS]) represented at least 5% of patients. PROs improved significantly for each category. The highest rates of recurrent subluxation occurred in FTAS, OTAS, and OTAD cases; dislocation, OTAS and FTAS cases; and further surgery, OTAD cases. The lowest rates of failure occurred in STPS cases. Downward trends in PROs and higher failure rates were noted with an increasing number of preoperative dislocations. Conclusion Different FEDS categories showed varying degrees of improvement and failure rates, indicating that the system can be used to provide prognostic insight for presurgical education. Overall, outcomes decreased with a higher number of preoperative dislocations.

Background: The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss. Purpose: (1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and Results: Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) ( P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02). Conclusion: A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.

Background: Patients who have undergone shoulder instability surgery are often allowed to return to sports, work, and high-level activity based largely on a time-based criterion of 6 months postoperatively. However, some believe that advancing activity after surgery should be dependent on the return of strength and range of motion (ROM). Hypothesis: There will be a significant loss of strength or ROM at 6 months after arthroscopic Bankart repair with remplissage compared with Bankart repair alone. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 38 patients in a prospective multicenter study underwent arthroscopic Bankart repair with remplissage (33 males, 5 females; mean age, 27.0 ± 10.2 years; 82% with ≥2 dislocation events in the past year). Strength and ROM were assessed preoperatively and at 6 months after surgery. Results were compared with 104 matched patients who had undergone Bankart repair without remplissage, although all had radiographic evidence of a Hill-Sachs defect. Results: At 6 months, there were no patients in the remplissage group with anterior apprehension on physical examination. However, 26% had a ≥20° external rotation (ER) deficit with the elbow at the side, 42% had a ≥20° ER deficit with the elbow at 90° of abduction, and 5% had persistent weakness. Compared with matched patients who underwent only arthroscopic Bankart repair, the remplissage group had greater humeral bone loss and had a greater likelihood of a ≥20° ER deficit with the elbow at 90° of abduction ( P = .004). Risk factors for a ≥20° ER deficit with the elbow at 90° of abduction were preoperative stiffness in the same plane ( P = .02), while risk factors for a ≥20° ER deficit with the elbow at the side were increased number of inferior quadrant glenoid anchors ( P = .003), increased patient age ( P = .02), and preoperative side-to-side deficits in ER ( P = .04). The only risk factor for postoperative ER weakness was preoperative ER weakness ( P = .04), with no association with remplissage ( P = .26). Conclusion: Arthroscopic Bankart repair with remplissage did not result in significant strength deficits but increased the risk of ER stiffness in abduction compared with Bankart repair without remplissage at short-term follow-up.

Background: Arthroscopic capsular release (ACR) for the treatment of adhesive capsulitis of the shoulder can be performed in either the beach-chair (BC) or lateral decubitus (LD) position. Purpose: To determine the clinical outcomes and recurrence rates after ACR in the BC versus LD position. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed by searching PubMed, Embase, and the Cochrane Library databases for studies reporting clinical outcomes of patients undergoing ACR in either the BC or LD position. All English-language literature from 1990 through 2017 reporting on clinical outcomes after ACR with a minimum 3-month follow-up were reviewed by 2 independent reviewers. Recurrence rates, range of motion (ROM) results, and patient-reported outcome (PRO) scores were collected. Study methodological quality was evaluated using the modified Coleman Methodology Score (MCMS). Results: A total of 30 studies (3 level 1 evidence, 2 level 2 evidence, 4 level 3 evidence, 21 level 4 evidence) including 665 shoulders undergoing ACR in the BC position (38.1% male; mean age, 52.0 ± 3.9 years; mean follow-up, 35.4 ± 18.4 months) and 603 shoulders in the LD position (41.8% male; mean age, 53.0 ± 2.3 years; mean follow-up, 37.2 ± 16.8 months) were included. There were no significant differences in overall mean recurrence rates between groups (BC, 2.5%; LD, 2.4%; P = .81) or in any PRO scores between groups ( P > .05). There were no significant differences in improvement in ROM between groups, including external rotation at the side (BC, 36.4°; LD, 42.8°; P = .91), forward flexion (BC, 64.4°; LD, 79.3°; P = .73), abduction (BC, 77.8°; LD, 81.5°; P = .82), or internal rotation in 90° of abduction (BC, 40.8°; LD, 45.5°; P = .70). Significantly more patients in the BC group (91.6%) underwent concomitant manipulation than in the LD group (63%) ( P < .0001). There were significantly more patients with diabetes in the LD group (22.4%) versus the BC group (9.6%) ( P < .0001). Conclusion: Low rates of recurrent shoulder stiffness and excellent improvements in ROM can be achieved after ACR in either the LD or BC position. Concomitant manipulation under anesthesia is performed more frequently in the BC position compared with the LD position.

The purpose of this systematic review is to evaluate the current literature in an effort to investigate sleep quality and disturbances and the association with clinical outcomes of patients undergoing shoulder surgery.A systematic review of the PubMed, Embase, and Cochrane Library databases was performed according to PRISMA guidelines. All English-language literature reporting clinical outcomes and sleep quality and disturbance after shoulder surgery was reviewed by 2 independent reviewers. Outcomes assessed included patient-reported outcomes (PROs) and sleep quality. Specific PROs included the Pittsburgh Sleep Quality Index (PSQI), Visual Analog Scale (VAS) for pain, Simple Shoulder Test (SST), University of California Los Angeles (UCLA) Shoulder Rating Scale, and American Shoulder and Elbow Surgeons Score (ASES). Study methodology was assessed using the Modified Coleman Methodology Score. Descriptive statistics are presented.Sixteen studies (11 level IV, 2 level III, 3 level II) with a total of 2748 shoulders were included (age, 12-91 years; follow-up, 0.25-132 months). In total, 2198 shoulders underwent arthroscopic rotator cuff repair (RCR), 131 shoulders underwent arthroscopic capsular release, 372 shoulders underwent total shoulder arthroplasty (TSA), 18 shoulders underwent comprehensive arthroscopic management, and 29 shoulders underwent sternoclavicular joint procedures. All shoulder surgeries improved self-reported sleep and PROs from before to after surgery. In RCR patients, PSQI scores were significantly associated with VAS scores, SST scores (r = 0.453, r = -0.490, P.05, respectively), but not significantly associated with UCLA Shoulder rating scale or the ASES scores (r = 0.04, r = 0.001, P.05, respectively). In TSA patients, PSQI scores were significantly associated with ASES scores (r = -0.08, P.05). All 4 RCR studies and 1 TSA study using PSQI found significant improvements in mean PSQI scores within 6 to 24 months (P.05).Surgical intervention for rotator cuff tear and glenohumeral osteoarthritis significantly improves self-reported sleep in patients with shoulder pain. However, there remains a dearth of available studies assessing the effects of surgical intervention for adhesive capsulitis, sternoclavicular joint instability, and sternoclavicular osteoarthritis on sleep. Future studies should use sleep-specific PROs and quantitative measures of sleep to further elucidate the relationship between sleep and the effect of shoulder surgery.Level IV, systematic review of Level II-IV studies.

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. Methods A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. Conclusion Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. Level of Evidence Level V, expert opinion.

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. Methods A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. Conclusion Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. Level of Evidence Level V: expert opinion.

Background: The Knee injury and Osteoarthritis Outcome Score (KOOS) has demonstrated inferior psychometric properties when compared with the International Knee Documentation Committee (IKDC) subjective knee form when assessing outcomes after anterior cruciate ligament (ACL) reconstruction. The KOOS, Joint Replacement (KOOS, JR) is a validated short-form instrument to assess patient-reported outcomes (PROs) after knee arthroplasty, and the purpose of this study was to determine if augmenting the KOOS, JR with additional KOOS items would allow for the creation of a short-form KOOS-based global knee score for patients undergoing ACL reconstruction, with psychometric properties similar to those of the IKDC. Hypothesis: An augmented version of the KOOS, JR could be created that would demonstrate convergent validity with the IKDC but avoid the ceiling effects and limitations previously noted with several of the KOOS subscales. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Based on preoperative and 2-year postoperative responses to the KOOS questionnaires from a sample of 1904 patients undergoing ACL reconstruction, an aggregate score combining the KOOS, JR and the 4 KOOS Quality of Life subscale questions, termed the KOOSglobal, was developed. Psychometric properties of the KOOSglobal were then compared with those of the IKDC subjective score. Convergent validity between the KOOSglobal and IKDC was assessed with a Spearman correlation (ρ). Responsiveness of the 2 instruments was assessed by calculating the pre- to postoperative effect size and relative efficiency. Finally, the presence of a preoperative floor or postoperative ceiling effect was defined with the threshold of 15% of patients reporting either the worst possible (0 for KOOSglobal and IKDC) or the best possible (100 for KOOSglobal and IKDC) scores, respectively. Results: The newly developed KOOSglobal was responsive after ACL reconstruction and demonstrated convergent validity with the IKDC. The KOOSglobal significantly correlated with the IKDC scores (ρ = 0.91, P < .001), explained 83% of the variability in IKDC scores, and was similarly responsive (relative efficiency = 0.63). While there was a higher rate of perfect postoperative scores with the KOOSglobal (213 of 1904, 11%) than with the IKDC (6%), the KOOSglobal was still below the 15% ceiling effect threshold. Conclusion: The large ceiling effects limit the ability to use several of the KOOS subscales with the younger, more active ACL population. However, by creating an aggregate score from the KOOS, JR and 4 KOOS Quality of Life subscale questions, the 11-item KOOSglobal offers a responsive PRO tool after ACL reconstruction that converges with the information captured with the IKDC. Also, by offering the ability to calculate multiple scores from a single questionnaire, the KOOSglobal may provide the orthopaedic community a single PRO platform to be used across knee-related subspecialties. Registration: NCT00478894 ( ClinicalTrials.gov identifier).