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Background: Limited studies have compared graft-glenoid apposition and glenoid augmentation area between the Latarjet procedure and distal clavicle graft in glenohumeral stabilization. Additionally, preoperative planning is typically performed using computed tomography (CT), and few studies have used 3-dimensional (3D) magnetic resonance imaging (MRI) reformations to assess graft dimensions. Purpose: The purpose of this study was 2-fold: (1) to compare bony apposition, glenoid augmentation, and graft width among coracoid and distal clavicle bony augmentation techniques and (2) to determine the viability of 3D MRI to assess bone graft dimensions. Study Design: Controlled laboratory study. Methods: A total of 24 patients with recurrent glenohumeral instability and bone loss were included in this study. 3D CT and 3D MRI reformations were utilized to measure pertinent dimensions for 5 orientations of coracoid and distal clavicle autografts: (1) standard Latarjet procedure (SLJ), (2) congruent arc Latarjet procedure (CLJ), (3) distal clavicle attached by its posterior surface (DCP), (4) distal clavicle attached by its inferior surface (DCI), and (5) distal clavicle attached by its resected end (DCR). Glenoid augmentation was defined as the graft surface area contributing to the glenoid. Bone-on-bone apposition was defined as the graft-glenoid contact area for bone healing potential, and graft width was pertinent for fixation technique. Glenoid bone loss ranged from 0% to 34%. Paired t tests were used to compare graft sizes between patients and compare 3D CT versus 3D MRI measurements. Results: The CLJ had the largest graft surface area (mean, 318.41 ± 74.44 mm2), while the SLJ displayed the most bone-on-bone apposition (mean, 318.41 ± 74.44 mm2). The DCI had the largest graft width (mean, 20.62 ± 3.93 mm). Paired t tests revealed no significant differences between the Latarjet techniques, whereas distal clavicle grafts varied significantly with orientation. All 3D CT and 3D MRI measurements were within 1 mm of each other, and only 2 demonstrated a statistically significant difference (coracoid width: 13.03 vs 13.98 mm, respectively [ P = .010]; distal clavicle thickness: 9.69 vs 10.77 mm, respectively [ P = .002]). 3D CT and 3D MRI measurements demonstrated a strong positive correlation ( r > 0.6 and P < .001 for all dimensions). Conclusion: Glenoid augmentation, bony apposition, and graft width varied with coracoid or distal clavicle graft type and orientation. Differences between 3D CT and 3D MRI were small and likely not clinically significant. Clinical Relevance: 3D MRI is a viable method for preoperative planning and graft selection in glenoid bone loss.

To compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries.The MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sampleWe identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (Single-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured.Level III, retrospective cohort study.

To identify risk factors for shoulder and elbow injuries in high-school baseball position players and pitchers in the preseason history and physical examination.Retrospective cohort study.Community high-school baseball.Three hundred seventy-one male baseball players' mean age 15.0 ± 1.8 years.A preseason history and physical examination was performed on all athletes. Injury information was collected by weekly self-report and athletic trainer injury logs throughout the season. Comparisons between injured and noninjured players were performed using t tests and χ 2 analyses. Binary logistic regression models were developed to identify risk factors for injury.Seventy-six injuries were recorded over the season. In univariate analysis, the injured group had greater months of baseball participation ( P = 0.007) and shoulder visual analog scale for the past year ( P = 0.003). The injured group also had more olecranon tenderness ( P0.0001, odds ratio [OR] 2.9) and decreased elbow arc of motion. All other factors were not significantly different ( P0.05). In multivariable logistic regression, months per year of baseball participation was the only factor significantly associated with injuries ( P = 0.010, OR = 1.21).Baseball players who developed arm injuries during a season were more likely to play more months of baseball and report shoulder pain in the previous year. The presence of preseason olecranon tenderness was associated with nearly triple the risk of injury during the season. Every additional month of baseball participation in the previous year was associated with a 1.2× increased odds of injury. The presence of glenohumeral internal rotation deficit was not a predictor of injury.

Given the high volume of patient visits for foot and ankle complaints, developing a systematic approach to evaluation of foot and ankle pathology is important for orthopaedic providers. A thorough evaluation of weight-bearing radiographs is essential to differentiate acute and chronic injury from normal findings to dictate treatment. Radiographic changes and varying degrees of deformity can influence surgical considerations. The purpose of this article was to review and define radiographic measurements relevant to surgical decision making for common foot and ankle pathologies and treatment.

Background Stemless total shoulder arthroplasty (TSA) is aimed at better re-creating native anatomy, facilitating revision, and preserving bone. The purpose of this study is to determine which pre-operative patient characteristics or radiographic parameters were predictive of outcomes following stemless TSA. Methods This was a retrospective review of prospectively collected data. One hundred fifty-seven patients with glenohumeral osteoarthritis were prospectively enrolled as part of a multi-center FDA Investigational Device Exemption protocol in July 2011-November 2012. In the present study, one hundred forty-nine patients with minimum 2-year follow-up had imaging available for review and were included (107 men, 42 women). Mean age 65 years (range,37-84). Pre-operative patient demographics, baseline ASES and Constant scores, deltoid tuberosity index (DTI), combined cortical thickness, and postoperative glenoid version were analyzed to predict treatment success. Treatment success was defined by no revision procedures and an adjusted Constant score of >85% at final follow-up. Statistical analyses were performed using student T-test, multiple logistic regression, and Pearson correlation with a p-value of 0.05 defining significance. Intraclass correlation and kappa values were calculated to determine interrater reliability for radiographic measurements. Results Three patients (2.0%) underwent revision or explant due to infection, unstable implant, or glenoid loosening. Eleven (7.4%) had an adjusted Constant score Conclusion Patients younger than 60 years old had a 1.3x risk of suboptimal treatment outcome following stemless TSA, similar to what is seen with stemmed implants. Low radiographic bone density was not predictive of suboptimal constant score or reoperation at final follow-up. Older patients had decreased combined cortical thickness and deltoid tuberosity index, yet were more likely to have a successful outcome following stemless TSA compared to younger patients. Level of evidence Level III; Retrospective Cohort

Background and purpose — In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST. Patients and methods — This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty. Results — Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66–0.76) and 0.77 (CI 0.71–0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer’s perspective, or $1,035 from the societal perspective. Interpretation — IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources. publishedVersion

The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability.A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures.Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48%10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure.The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

Recent concepts are changing the management of ankle instability. These include concurrent medial and lateral instabilities, use of ankle arthroscopy, use of suture anchors, all-arthroscopic stabilization, synthetic augmentation, and early postoperative rehabilitation. Medial sided injuries occur in up to 72% of the lateral ankle sprains, and concomitant repair may provide greater stability. Suture anchors are equally as strong as transosseous tunnels, and the technique is simple, reproducible, and may decrease complications, but anchors do increase costs. Synthetic augmentation demonstrates greater strength than Brostrom alone in cadaver-based biomechanical testing. Although clinical studies of synthetic augmentation have demonstrated equivocal stability and pain compared with Brostrom alone, synthetic augmentation may expedite rehabilitation. All-arthroscopic ankle stabilization is gaining popularity with increasing publications. Early findings demonstrate comparable biomechanical and clinical data compared with open techniques. Early postoperative weight-bearing within 2 weeks seems to be safe and may shorten time to return to play. Surgeons may consider using these novel techniques in the management of lateral ankle instability.

Context: A strict rehabilitation protocol is traditionally followed after microfracture, including weightbearing restrictions for 2 to 6 weeks. However, such restrictions pose significant disability, especially in a patient population that is younger and more active. Evidence Acquisition: An extensive literature review was performed through PubMed and Google Scholar of all studies through December 2018 related to microfracture, including biomechanical, basic science, and clinical studies. For inclusion, clinical studies had to report weightbearing status and outcomes with a minimum 12-month follow-up. Study Design: Clinical review. Level of Evidence: Level 3. Results: Review of biomechanical and biology studies suggest new forming repair tissue is protected from shear forces of knee joint loading by the cartilaginous margins of the defect. This margin acts as a shoulder to maintain axial height and allow for tissue remodeling up to at least 12 months after surgery, well beyond current weight bearing restriction trends. A retrospective case-control study showed that weightbearing status postoperatively had no effect on clinical outcomes in patients who underwent microfracture for small chondral (2) defects. In fact, 1 survey showed that many orthopaedic surgeons currently do not restrict weightbearing after microfracture. Conclusion: This clinical literature review suggests that weightbearing restrictions may not be required after microfracture for isolated tibiofemoral chondral lesions of the knee. Strength of Recommendation Taxonomy: C.

Mood symptoms may be due to shoulder-related depression or anxiety or clinical anxiety/depression. The objective of this study was to evaluate the relationship of shoulder-related and pre-existing diagnosis of depression or anxiety with changes in American Shoulder and Elbow Surgeons (ASES) score after rotator cuff repair.A retrospective review of prospectively collected data on subjects undergoing arthroscopic rotator cuff repair was reviewed. Preoperative and postoperative ASES, questions from the Western Ontario Rotator Cuff index questions directed to feelings of depression/anxiety related to the shoulder, and pre-existing diagnoses of depression and/or anxiety were recorded. The Wilcoxon rank sum test was used to compare changes, and Spearman's correlation was used to correlate changes in mood and ASES between male and female subjects and those with and without anxiety and/or depression.One hundred seventy-one subjects (53 female; mean age, 58.0 years; standard deviation [SD], 8.5) who underwent arthroscopic rotator cuff repair were evaluated with the mean follow-up of 36.6 months (SD, 17.5). Forty-six subjects (mean age, 58.8 years; SD, 8.2) had pre-existing diagnoses of depression and/or anxiety and 125 subjects (mean age, 57.7 years; SD, 8.7) did not. Patients showed improvement in Western Ontario Rotator Cuff shoulder-related depression (Δ 22.3) and anxiety (Δ 24.7). There was a strong correlation between the change in mood symptoms and the change in ASES score, for depression (r = 0.74) and anxiety (r = 0.71). Patients with and without clinical diagnosis of anxiety or depression experienced similar changes in mood symptoms related to the shoulder and ASES scores (P = .65, P = .39). Patients' ASES scores were less correlated with changes in shoulder-related mood symptoms; however, if patients had clinical depression/anxiety compared with those without (r = 0.68 vs. 0.75, P.0001 for depression; r = 0.56 vs. r = 0.74, P.0001 for anxiety).After rotator cuff repair, symptoms of depression/anxiety related to the shoulder improved dramatically with or without pre-existing clinical diagnosis of depression or anxiety. As the patient-reported functional outcomes of those with pre-existing clinical diagnosis of anxiety/depression improved, they did not experience as strong as an improvement in their mood symptoms as those without prior diagnoses and may benefit from directed treatment of these symptoms. Patients with shoulder-related mood symptoms only, conversely, experience a strong relationship between their improvement in function with their mood symptoms and may be ideal candidates for rotator cuff surgery. It is important for clinicians to separate mood symptoms related to adjustment disorder from the rotator cuff injury from clinical depression and anxiety.

Proximal hamstring injuries are common, and open surgical repair with suture anchors has been the gold standard when surgical intervention is warranted. Endoscopic techniques offer the opportunity of surgical repair with smaller incisions to limit complications and expedite rehabilitation. The purpose of this technique guide is to describe a modified endoscopic technique that allows a safe and anatomic repair of proximal hamstring injuries. The patient is positioned prone with the feet at the head of the bed, table in reverse Trendelenburg, and knees flexed to 90°. Four portals are used, 3 in horizontal alignment within the gluteal fold and 1 directly superior to the ischial tuberosity. The sciatic nerve is identified, dissected, and mobilized away from the operative field. Retraction sutures help retract the gluteus maximus and further protect the sciatic nerve. Dissection is within the interval between the conjoint and semimembranosus tendons. The tendons are freed and mobilized, the ischial tuberosity is decorticated, and an anatomic repair is performed via 4 suture anchors, 2 at each tendon footprint. Advancements in arthroscopy have permitted adequate visualization and exposure of the hamstring footprint, thus allowing for an anatomic repair with increased protection of the sciatic nerve and decreased resources and cost.

Patient-reported outcomes continue to grow in importance. This study compared the Single Assessment Numeric Evaluation (SANE) score with the American Shoulder and Elbow Surgeons (ASES) score and Western Ontario Rotator Cuff (WORC) index score in patients before and after primary rotator cuff repair.This study was a retrospective review of a prospectively filled database of 333 subjects who underwent primary rotator cuff repair by a single surgeon between 2010 and 2017. The database included preoperative and postoperative SANE, ASES, and WORC evaluations. The mean follow-up time was 37.5 months. Spearman correlation coefficients were calculated comparing each score preoperatively and at least 1 year postoperatively.A strong correlation was found between the SANE and ASES scores of subjects in the preoperative period (r = 0.769, P.0001) and the follow-up period of at least 1 year (r = 0.781, P.0001). A similarly strong correlation was found between the SANE and WORC scores of subjects in the preoperative period (r = 0.757, P.0001) and the follow-up period of at least 1 year (r = 0.813, P.0001). On stratification analysis, correlation of SANE scores with ASES and WORC scores was found when subjects were grouped by sex, age, cuff tear size, and workers' compensation status.This study shows a significant correlation between the SANE, ASES, and WORC scores of primary rotator cuff repair subjects in the preoperative and long-term follow-up periods. We recommend the SANE score as an adjunct to clinical outcome data that can be used in patients regardless of sex, cuff tear size, or workers' compensation status.

Background: Psychological distress after orthopaedic surgery can lead to worse outcomes, including higher levels of disability and pain and lower quality of life. The 10-item Optimal Screening for Prediction for Referral and Outcome–Yellow Flag (OSPRO-YF) survey screens for multiple psychological constructs relevant to recovery from orthopaedic injury and may be useful to preoperatively identify patients who may require further psychological assessment and possible intervention after surgery. Purpose/Hypothesis: To determine the association between the OSPRO-YF and physiological patient-reported outcomes (PROs). It was hypothesized that higher OSPRO-YF scores (indicating worse psychological distress) would be associated with worse PRO scores at time of return to sport. Study Design: Case series; Level of evidence, 4. Methods: This study evaluated 107 patients at a single, academic health center who were assessed at a sports orthopaedics clinic and ultimately treated surgically for injuries to the knee, shoulder, foot, or ankle. Preoperatively, patients completed the OSPRO-YF survey as well as the following PRO measures: Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numeric Evaluation, numeric rating scale for pain; American Shoulder and Elbow Surgeons standardized shoulder assessment form for patients with shoulder injuries, the International Knee Documentation Committee score (for patients with knee injuries), and the Foot and Ankle Ability Measure (FAAM; for patients with foot or ankle injuries). At the time of anticipated full recovery and/or return to sport, patients again completed the same PRO surveys. Multivariable regression was used to evaluate the association between total OSPRO-YF score at baseline and PRO scores at the time of functional recovery. Results: The baseline OSPRO-YF score predicted postoperative PROMIS Physical Function and FAAM Sports scores only. A 1-unit increase in the OSPRO-YF was associated with a 0.55-point reduction in PROMIS Physical Function (95% CI, –1.05 to –0.04; P = .033) indicating worse outcomes. Among patients who underwent ankle surgery, a 1-unit increase in OSPRO-YF was associated with a 6.45-point reduction in FAAM Sports (95% CI, –12.0 to –0.87; P = .023). Conclusion: The study findings demonstrated that the OSPRO-YF survey predicts certain long-term PRO scores at the time of expected return to sport, independent of baseline scores.

Background: Combined injury of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) is a common injury pattern and accounts for 20% of all ligamentous knee injuries. Despite advancements in surgical technique, there is no up-to-date consensus regarding the superiority of nonoperative versus operative management in higher-grade MCL tears of combined ACL-MCL injuries. Purpose: To interpret recent literature on treatment options and to provide an updated evidence-based approach for management of combined ACL-MCL knee injuries. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: We performed a systematic review on outcomes following treatment of concomitant ACL and MCL injuries. A computerized search was conducted in PubMed, Embase.com , and Scopus.com . Authors independently assessed eligible studies and screened titles and abstracts. Articles reporting on patients with concomitant ACL and MCL injuries with or without concomitant procedures were included. Data regarding study design, sample size, patient age and sex, length of follow-up, timing of surgery, indications, surgical methods, concomitant procedures, outcomes, and complications were recorded. Patient-reported outcomes (PROs) and functional outcomes, including Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee scores, Lysholm and Tegner scores, and range of motion, were estimated via meta-analysis and compared statistically by surgical approach. Results: In total, 18 studies were included in the systematic review with level 1 to level 4 evidence, with a total of 1,534 cases, were included in the systematic review. Of these, 16 studies with sufficient statistical reporting including 997 cases with sufficient follow-up were included in meta-analysis. Three different approaches to combined ACL-MCL injuries were identified: ACL reconstruction with (1) nonoperative MCL, (2) MCL repair, and (3) MCL reconstruction. There was no statistical difference between nonoperative versus surgically managed MCL injuries for PROs, range of motion at final follow up, or quadriceps strength. Conclusion: Reconstruction of combined injury in a delayed fashion facilitates return of range of motion and may allow time for low-grade MCL tears to heal. If residual valgus or anteromedial rotatory laxity remains after a period of rehabilitation, then concomitant surgical management of ACL and MCL injuries is warranted. Avulsion MCL injuries and Stener-type lesions may benefit from early repair techniques.

Background: No consensus exists regarding the superiority of operative versus nonoperative management for Achilles tendon ruptures, as multiple randomized controlled trials conducted since the advent of early mobilization protocols have found outcomes for these 2 interventions to be more similar than were previously held. Purpose: To use a large national database to (1) compare reoperation and complication rates between operative and nonoperative treatment of acute Achilles tendon ruptures and (2) evaluate trends in treatment and cost over time. Study Design: Cohort study; Level of evidence, 3. Methods: The MarketScan Commercial Claims and Encounters database was used to identify an unmatched cohort of 31,515 patients who sustained primary Achilles tendon ruptures between 2007 and 2015. Patients were stratified into operative and nonoperative treatment groups, and a propensity score—a matching algorithm—was used to establish a matched cohort of 17,996 patients (n = 8993 per treatment group). Reoperation rates, complications, and aggregate treatment costs were compared between groups with an alpha level of .05. A number needed to harm (NNH) was calculated from the absolute risk difference in complications between cohorts. Results: The operative cohort experienced a significantly larger total number of complications within 30 days of injury (1026 vs 917; P = .0088). The absolute increase in cumulative risk was 1.2% with operative treatment, which resulted in an NNH of 83. Neither 1-year (1.1% [operative] vs 1.3% [nonoperative]; P = .1201) nor 2-year reoperation rates (1.9% [operative] vs 2% [nonoperative]; P = .2810) were significantly different. Operative care was more expensive than nonoperative care at 9 months and 2 years after injury; however, there was no difference in cost between treatments at 5 years. Before matching, the rate of surgical repair for Achilles tendon rupture remained stable, from 69.7% to 71.7% between 2007 and 2015, indicating little change in practice in the United States. Conclusion: Results indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures. Operative management was associated with an increased risk of complications and higher initial costs, which dissipated over time. Between 2007 and 2015 the proportion of Achilles tendon ruptures managed operatively remained similar despite increasing evidence that nonoperative management of Achilles tendon rupture may provide equivalent outcomes.

The athlete with shoulder instability poses a unique challenge to the sports medicine team. Clinical studies support surgical intervention followed by a phased approach to rehabilitation. In the latter phases, it is important to tailor this program to the individual’s specific athletic needs, which requires ongoing qualitative assessment and objective measurement. Passing a return-to-sport testing battery has been shown to decrease the risk of recurrent instability. What is lacking in the literature is a consensus for how to best measure shoulder performance when the required athletic demands are widely varied by hand dominance, sport played, and playing position. Multiple upper-extremity tests have been described in the literature, but there is no consensus on which tests should be used to direct rehabilitation and to safely return the athlete to unrestricted athletic exposure. Using available evidence, we suggest a framework for return-to-play testing that integrates traditional rehabilitation phases with performance testing and graduated sports exposure. Level of Evidence: Level V, expert opinion.

Background: The adoption of telehealth visits for physical therapy (PT) has accelerated because of the COVID-19 pandemic. Patient reception of virtual PT at the outbreak of the pandemic was positive, but it is unclear how telehealth visits compare to in-person visits in the postpandemic era. Purpose: To evaluate utilization trends and patient satisfaction with virtual PT compared with in-person PT during and after the COVID-19 pandemic. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We identified 59,461 in-person and 2016 telehealth visits at a single physical rehabilitation center between March 2020 and December 2021. Patient socioeconomic and demographic variables, including insurance status, were compared between telehealth users and in-person visitors. A total of 1012 patient satisfaction surveys were available and analyzed using the top-box method. Univariable statistics ( t test or Mann-Whitney U and chi-square tests) were used for group comparisons. Results: Overall, telehealth users when compared with in-person visitors were older (median age, 47 vs 42 years, respectively; P < .001), and a higher proportion was female (60.6% vs 54.8%; P < .001), was White (69.7% vs 66.6%; P = .023), spoke English as their primary language (99.2% vs 98.1%; P = .001), and had Medicare insurance (20.3% vs 16.1%; P < .001). Telehealth patients more often lived out-of-county (50.7% vs 45.8%; P < .001) and in small towns rather than in urban areas (1.0% vs 0.3%; P < .001). When we compared telehealth use before and after official reopening of the PT center in September 2020, telehealth users in the postpandemic era had an out-of-county rate of 58.7%, and 68.7% were female. Patient satisfaction survey results demonstrated that telehealth patients compared with in-person patients were less likely to recommend visits to others (75.0% vs 89.1%, respectively; P = .008) and had lower overall assessment of their visits (71.7% vs 88.6%; P = .001). Accordingly, there was a significant reduction in telehealth visits from 2020 to 2021 (from 6.9% to 0.9% of visits; P < .001). Conclusion: We noted a decline in telehealth PT use during the postpandemic era, consistent with reduced patient satisfaction when compared with in-person visits. Telehealth is a useful option for populations with limited time or access to care and may serve a role in a hybrid care model. Further studies on long-term outcomes after telehealth PT are warranted to evaluate its efficacy.

Background: Osteochondral lesions of the tibial plafond (OLTPs) remain less common than osteochondral lesions of the talus (OLTs), but recognition of the condition has increased. Purpose: To systematically evaluate the literature on lesion locations and treatment outcomes of OLTPs, whether in isolation or in combination with OLTs. Study Design: Systematic review; Level of evidence, 4. Methods: A search was performed using the PubMed, Embase, and CINAHL databases for studies on lesion locations or with imaging or treatment outcomes of OLTPs. Case reports and reports based on expert opinion were excluded. Lesion locations as well as outcome measure results were aggregated. The Methodological Index for Non-randomized Studies score was used to assess methodological quality when applicable. Results: Included in this review were 10 articles, all published in 2000 or later. Most studies were evidence level 4, and the mean Methodological Index for Non-randomized Studies score was 8.6 (range, 8-10). Overall, 174 confirmed OLTP cases were identified, and the mean patient age was 38.8 years. Of the 157 lesions with confirmed locations, the most common was central-medial (32/157; 20.4%). Of 6 studies on treatment outcomes, all but 1 evaluated bone marrow stimulation techniques. Microfracture of small lesions (2) was the most common treatment utilized. Imaging and functional outcomes appeared favorable after treatment. The data did not support differences in outcomes between isolated OLTPs and OLTPs with coexisting OLTs. Conclusion: Osteochondral lesions of the distal tibia most commonly occurred at the central-medial tibial plafond. Microfracture of small lesions was the most common treatment utilized, and clinical and magnetic resonance imaging results were favorable, although data were heterogeneous. Areas for future research include the following: the effect of patient factors and additional pathologies on outcomes; larger or deeper lesion treatment; more direct comparisons of outcomes between kissing or coexisting lesions and isolated lesions; and head-to-head comparison of treatments, such as microfracture, bone marrow–derived cell transplantation, and osteochondral autografts/allografts.

Background: Revision shoulder stabilizations are becoming increasingly common. Returning to play after revision shoulder stabilizations is important to patients. Purpose: To evaluate the return-to-play rate after revision anterior shoulder stabilization using arthroscopic, open, coracoid transfer, or free bone block procedures. Study Design: Systematic review; Level of evidence, 4. Methods: All English-language studies published between 2000 and 2020 that reported on return to play after revision anterior shoulder stabilization were reviewed. Clinical outcomes that were evaluated included rate of overall return to play, level of return to play, and time to return to play. Study quality was evaluated using the Downs and Black quality assessment score. Results: Eighteen studies (1 level 2; 17 level 4; mean Downs and Black score, 10.1/31) on revision anterior shoulder stabilization reported on return to play and met inclusion criteria (7 arthroscopic, 5 open, 3 Latarjet, and 3 bony augmentation), with a total of 564 revision cases (mean age, 27.9 years; 84.1% male). The weighted mean length of follow-up was 52.5 months. The overall weighted rate of return to play was 80.1%. The weighted mean rate of return to play was 84.0% (n = 153) after arthroscopic revision, 91.5% (n = 153) after open revision, 88.1% (n = 149) after Latarjet, and 73.8% (n = 65) after bone augmentation. The weighted mean rate of return to same level of play was 69.7% for arthroscopic revision, 70.0% for open revision, 67.1% for Latarjet revision, and 61.8% after bone block revision. There were 5 studies that reported on time to return to play, with a weighted mean of 7.75 months (4 arthroscopic) and 5.2 months (1 Latarjet). The weighted mean rates of complication (for studies that provided it) were 3.3% after arthroscopic revision (n = 174), 3.5% after open revision (n = 110), 9.3% after Latarjet revision (n = 108), and 45.8% after bone block revision (n = 72). Conclusion: Revision using open stabilization demonstrated the highest return-to-play rate. Revision using Latarjet had the quickest time to return to play but had higher complication rates. When evaluated for return to same level of play, arthroscopic, open, and Latarjet had similar rates, and bone block had lower rates. The choice of an optimal revision shoulder stabilization technique, however, depends on patient goals. Higher-quality studies are needed to compare treatments regarding return to play after revision shoulder stabilization.

Background The purpose of this study was to describe trends in the incidence of open versus arthroscopic management of posterior shoulder instability (PSI) as well as the patients undergoing these procedures in the United States over time. Methods The PearlDiver Patient Records Database was utilized for this study. Cases of PSI and surgery were identified via the appropriate ICD-10-CM and CPT codes. Linear regression and two-sample Student's t-test were used to analyze incidence rates, procedure type, number of instability events, and patient age. Results A total of 5655 patients were identified as having PSI, undergoing a total of 686 capsulorraphies. The incidence of PSI treated surgically increased across the years of the study at a rate of 0.0293 per 100,000 person-years with an incidence in 2019–2020 greater than in 2016–2018 ( p = 0.0151). Patients undergoing arthroscopic capsulorrhaphy were on average younger than those undergoing open capsulorrhaphy ( p = 0.0021). Patients experienced a higher number of posterior instability events before open surgery compared to arthroscopic ( p = 0.0274). Discussion The incidence of surgical treatment of PSI in the United States is steadily rising, with greater than 90% of cases being treated arthroscopically. Those undergoing arthroscopic posterior stabilization are both younger and face fewer instability events prior to surgery.

Background: The COVID-19 pandemic has changed the practice of orthopaedic sports medicine. The threat of COVID-19 persists, and future restrictions to elective procedures are possible. It is important to understand how sports surgeons are prioritizing surgical cases during elective case restrictions and how telehealth is being incorporated into practice. Purpose: To understand how orthopaedic sports surgeons have triaged surgical sports cases and how telehealth is being utilized in response to COVID-19. Study Design: Cross-sectional study. Methods: A survey was presented to participants of the American Orthopaedic Society for Sports Medicine (AOSSM) webinar “Handling Sports and COVID-19” and distributed through email to all members of the AOSSM. The survey consisted of 25 questions with 3 sections: demographics, clinical practice, and telehealth. Descriptive statistics were performed. Results: Overall, 104 respondents participated. Respondents varied with respect to their location, type of clinical practice, and years in practice. The cases with the highest priority during triage included infections, fractures, and traumatic tendon ruptures (eg, quadriceps tendon). Before COVID-19, Conclusion: Telehealth has seen rapid adoption during the COVID-19 pandemic, and the majority of respondents plan to continue using it. It is being used more for established patients rather than new patient visits. For surgical cases, there was a clear triage priority of sports medicine cases, including infections, fractures, and traumatic tendon ruptures. Lower extremity cases had higher priority than upper extremity.

Background:Treatment of a first-time anterior shoulder dislocation (FTASD) is sensitive to patient preferences. The operative or nonoperative management debate provides an excellent opportunity to learn how surgeons apply patient preferences in treatment decisions.Purpose:To determine how patient preferences (repeat dislocation risk, recovery difficulties, fear of surgery, treatment costs) and surgeon factors influence a surgeon’s treatment plan for FTASD.Study Design:Cross-sectional study.Methods:Eight clinical vignettes of hypothetical patients with FTASD (including age, sex, and activity level) were presented to members of the Magellan Society. A second set of matched vignettes with patient preferences and clinical variables were also presented. The vignettes represented scenarios in which evidence does not favor one treatment over another. Respondents were asked how they would manage each hypothetical case. Respondents also estimated the risk of redislocation for the nonoperative cases for comparison with the published rates. Finally, respondents completed a Likert-scale questionnaire to determine their perceptions on factors influencing their decisions.Results:A total of 103 orthopaedic surgeons completed the survey; 48% practiced in an academic hospital; 79% were in practice for 10 years or longer; and 75% had completed a sports medicine fellowship. Patient preferences were the single most important factor influencing treatment recommendation, with activity type and age also important. Just 62% of the surgeon estimates of the risk of redislocation were consistent with the published rates. The inclusion of patient preferences to clinical variables changed treatment recommendations in 62.5% of our hypothetical cases. Respondents rated patient treatment preference as the leading factor in their treatment decision making.Conclusion:Patient preferences were important when deciding the appropriate treatment for FTASD. Respondents were inconsistent when applying evidence in their decision making and estimates of recurrent instability. Decision support tools that deliver patient preferences and personalized evidence-based outcome estimates improve the quality of decision making at the point of care.

Purpose To evaluate the short-term outcomes of endoscopic proximal hamstring repair including clinical outcomes, patient-reported outcomes, and complications. Methods A retrospective analysis was performed on consecutive patients who underwent endoscopic proximal hamstring repair from 2013–2018 by a senior sports medicine orthopaedic surgeon. Demographic, operative, clinical data, complications, and patient-reported outcomes were collected and analyzed including the International Hip Outcome Tool-12 (iHOT-12), Single Assessment Numeric Evaluation (SANE), modified Harris Hip Score (mHHS), and the Hip Outcome Score activities of daily living scale (HOS-ADL). Results Thirty patients were included with a minimum 24.0- and average 44.0-month follow-up. The average age was 52.0 years (standard deviation [SD], 14.2), and 80.0% (n = 24) were women. Most patients presented with a history of refractory insertional tendinosis (83.3%, n = 25) and an average of 34.0 months of symptoms prior to surgical intervention. Two-year patient-reported outcomes were clinically acceptable with a postoperative iHOT-12 of 81.9 (SD, 21.1), SANE 78.8% (SD, 20.0), mHHS 89.6 (SD 13.4), and HOS-ADLs 87.2% function (SD, 15.9). Nine patients (30%) had available preoperative iHOT-12 scores. Among these patients, the mean increase in iHOT-12 was 46.3 (P = .0005; n = 9). Eighty percent (n = 24) of patients achieved the iHOT-12 patient acceptability symptomatic state. Complications (3%) included 1 atraumatic rerupture. Four patients participated in an organized sport and 18 in recreational sport with a return to play of 100% and 72.2%, respectively. All patients returned to work. Some 76.7% (n = 23) of patients reported return to their baseline level of physical activity, and 73.3% (n=22) of patients reported complete resolution of pain at last follow-up. There was a 90.0% (n=27) satisfaction rate. Conclusions Short-term follow-up for endoscopic proximal hamstring repair shows high patient satisfaction (90.0%) and clinically significant patient-reported outcomes with minimal residual pain and a low complication rate (3%). Level of Evidence IV, retrospective case series.

Background: Osteochondral lesion of the talus (OLT) may be caused by osteochondritis dissecans, osteochondral fractures, avascular necrosis, or focal arthritic changes. For certain focal cartilage defects, bone marrow stimulation (BMS) has been a widely used technique to restore a fibrocartilage substitute overlying the defect. There are various postoperative weightbearing protocols for this procedure, with no single gold standard method. Purpose: To retrospectively review the outcomes of patients undergoing ankle arthroscopy with concomitant BMS to determine outcomes based on postoperative weightbearing status. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively reviewed the records of patients who underwent ankle arthroscopy with BMS for OLTs between 2015 and 2018. Patients were placed into 2 cohorts based on postoperative immobilization status: the nonweightbearing (NWB) group and the weightbearing-as-tolerated (WBAT) group. Patient characteristics obtained included age, sex, comorbidities, and etiology of talar pathology. Outcomes included the pain visual analog scale (VAS), range of motion (ROM), complications, time to first weightbearing, and the method and length of immobilization. Patients who were lost to follow-up before 30 days were excluded. The chi-square test was used to compare categorical variables between cohorts, and the t test was used for continuous variables. Results: A total of 69 patients met the inclusion criteria for this study, 18 in the WBAT group and 51 in the NWB group. The mean lesion size was 9.48 × 9.21 mm (range, 3-15 mm × 2-20 mm) for the NWB group and 9.36 × 9.72 mm (range, 5-14 mm × 6-20 mm) for the WBAT group ( P > .05). The VAS scores improved from 4.40 to 0.67 for the WBAT group and from 6.33 to 2.55 for the NWB group, with the difference in final values reaching statistical significance ( P = .0002). Postoperative ROM was not significantly different between the groups. There were 4 repeat operations within the NWB cohort. Conclusion: The surgical management of OLTs can be challenging, and the postoperative weightbearing protocol can be an extra obstacle for the patient to navigate. We found no difference in pain, ROM, or complications when allowing immediate, full WBAT.

Purpose Handheld ultrasound technology is increasingly used in health care. Its use for fracture care has not been adequately evaluated. The purpose of this study was to evaluate handheld, pocket-sized ultrasound in the diagnosis and assessment of reductions in distal radius fractures. Methods A total of 23 patients with distal radius fractures (average age, 53 years; 13 women) and 20 control patients (average age, 53 years; 10 women) were prospectively enrolled. All patients with distal radius fractures underwent standard, 3-view radiographic and ultrasonographic examinations of the wrist before and after closed reduction. Control patients had a one-time standard radiographic and ultrasonographic examination of the wrist. Radiographs were used as the reference standard. All images were assessed for the presence or absence of a fracture by a board-certified, hand fellowship–trained orthopedic surgeon and musculoskeletal fellowship–trained radiologist who were blinded to the study protocol. If a fracture was detected, the adequacy of reduction was assessed. Results The sensitivity of distal radius fracture diagnosis on ultrasound was 100% and specificity ranged from 90% to 95%. The sensitivity of identifying a satisfactory reduction ranged from 76% to 93% and specificity was 93% to 94%. Interrater reliability between the musculoskeletal radiologist and hand surgeon was κ = 0.86 for diagnosing the fracture and κ = 0.82 for identifying a satisfactory reduction. Intrarater reliability ranged from κ = 0.82 to 0.86. Conclusions A pocket-sized, handheld diagnostic ultrasound device demonstrates the ability to diagnose distal radius fractures and assess fracture reductions. Type of study/level of evidence Diagnostic II.

Background and purpose — Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods — Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results — Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation — Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN. publishedVersion

Injury to the anterolateral complex may be identified on advanced imaging and may manifest with a higher level of instability, in particular with pivot-shift testing.The anterolateral ligament reconstruction or modified Lemaire procedure may be used to reconstruct the anterolateral complex of the kn

Background:Few studies have considered the potential effect of depression or anxiety on outcomes after rotator cuff repair.Purpose:To evaluate the effect of a preexisting diagnosis of depression or anxiety, as well as the feeling of depression and anxiety directly related to the shoulder, on the American Shoulder and Elbow Surgeons (ASES) score.Study Design:Cohort study; Level of evidence, 3.Methods:This study is a retrospective review of prospectively collected data on patients who underwent arthroscopic rotator cuff repair and were evaluated by the ASES score preoperatively and at a minimum 12 months postoperatively as part of the senior author’s shoulder registry. Preexisting diagnoses of depression and/or anxiety were recorded, and questions from the Western Ontario Rotator Cuff Index directed at feelings of depression or anxiety related to the shoulder were also evaluated. The Wilcoxon rank sum test was used to compare ASES scores between patients with and without anxiety and/or depression. Spearman correlation was used to correlate questions on depression and anxiety with ASES scores.Results:A total of 187 patients (63 females, 124 males; mean age, 58.6 years, SD, 8.7 years) undergoing arthroscopic rotator cuff repair were evaluated with a mean follow-up of 47.5 months (SD, 17.4 months; range, 12-77 months). Fifty-three patients (mean age, 60 years; SD, 8.6 years) had preexisting diagnoses of depression and/or anxiety and 134 patients (mean age, 58.1 years; SD, 8.7 years) did not. Patients with depression and/or anxiety had significantly lower preoperative and postoperative ASES scores (60.7 vs 67.8, P = .014; and 74.6 vs 87.1, P = .008, respectively). The change in ASES scores from preoperative to postoperative, however, was not significantly different (18.0 vs 14.9). A higher score of depression or anxiety related to the shoulder had a negative correlation with the preoperative ( r = −0.76, P < .0001; and r = −0.732, P < .0001, respectively) and postoperative ( r = −0.31, P = .0001; and r = −0.31, P = .0003, respectively) ASES scores, but a positive correlation ( r = 0.50, P < .0001; and r = 0.43, P < .0001, respectively) with the change in ASES scores.Conclusion:Patients with a history of depression and/or anxiety have lower outcome scores preoperatively and postoperatively; however, they should expect the same amount of relief from arthroscopic rotator cuff repair as those without a history of depression or anxiety. Stronger feelings of depression or anxiety directly related to the shoulder correlated with lower preoperative and postoperative outcome scores, but a greater amount of improvement from surgery. The results from this study suggest that a preexisting diagnosis of depression or anxiety, as well as feelings of depression or anxiety directly related to the shoulder, should be considered during the management of patients with rotator cuff tears.

Background: The Single Assessment Numerical Evaluation (SANE) is a single-question outcome score that has been shown to be a reliable measure of outcomes for shoulder and knee injuries but has not been compared with other validated outcome scores in hip pathology managed arthroscopically. Purpose: To correlate SANE Activities of Daily Living (ADL) and Sport subscales with the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) ADL and Sport subscales before and after arthroscopic hip surgery. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A retrospective review of a prospectively filled database of patients undergoing arthroscopic hip surgery by a single surgeon was conducted. Inclusion criteria included patients scheduled for arthroscopic hip surgery for femoroacetabular impingement, labral tear, or gluteus medius tear. Exclusion criteria included previous surgery to the hip. Outcome scores, including the mHHS, HOS ADL and Sport, and SANE ADL and Sport, were measured preoperatively and postoperatively at 3 months, 1 year, and then annually. Pearson correlation coefficients between preoperative SANE ADL and Sport and the mHHS, HOS ADL, and HOS Sport were calculated. Pearson correlation coefficients between postoperative SANE ADL and Sport and the mHHS, HOS ADL, and HOS Sport were also calculated. Results: Eighty-five patients (mean age, 37.9 years; range, 14-66 years; 57 females, 28 males) underwent arthroscopic hip surgery for assorted pathology. Mean follow-up was 8 months (range, 3-64 months). Based on the Pearson correlation coefficient, preoperative SANE ADL and Sport had a moderate correlation with the mHHS ( r = 0.66; 95% CI, 0.47-0.79; P < .0001; r = 0.54; 95% CI, 0.31-0.71; P < .0001, respectively). Preoperative SANE ADL and Sport had a moderate correlation with HOS ADL ( r = 0.60; 95% CI, 0.39-0.75; P < .0001) and HOS Sport ( r = 0.65; 95% CI, 0.45-0.79; P < .0001). Postoperative SANE ADL and Sport had a strong correlation with the mHHS ( r = 0.69; 95% CI, 0.50-0.82; P < .0001; r = 0.78; 95% CI, 0.61-0.88; P < .0001). Postoperative SANE ADL and Sport had a strong correlation with HOS ADL ( r = 0.79; 95% CI, 0.65-0.88; P < .0001) and HOS Sport ( r = 0.88; 95% CI, 0.78-0.94; P < .0001). Conclusion: This study showed a significant correlation between SANE and mHHS in patients undergoing arthroscopic hip surgery both pre- and postoperatively. SANE ADL and Sport had a strong correlation with HOS ADL and Sport preoperatively and short-term postoperatively. SANE scores are more highly correlated with traditional subjective outcome measures during the short-term postoperative period than they are preoperatively. The SANE score provides an efficient method of assessing outcomes after hip arthroscopy.

Background Ankle fractures are a common orthopedic injury that frequently involves associated cartilage lesions, soft tissue damage, and a significant inflammatory burden. Despite studies revealing intra-articular pathology in up to 79% of ankle fractures, only 1% of open reduction and internal fixation (ORIF) procedures undergo arthroscopic evaluation. The primary purpose of this study was to determine the cost effectiveness of ankle arthroscopy performed at time of ORIF for ankle fracture. Methods An IRB approved retrospective review of patients who sustained ankle fractures and underwent ORIF with and without concomitant arthroscopic surgery between 2015 and 2020 were investigated. Patient demographics, fracture characteristics, outcomes, and cost data were collected and analyzed. Results There were 567 total ORIF and 28 ORIF and scope included for cost analysis purposes. Total surgical costs averaged $6,537.62 and $6,886.46 for the ORIF only and ORIF and scope procedures respectively. Total direct costs, including operating room time, for the same procedures were found to average $6,212.34 and $7,312.10 for the ORIF only and ORIF and scope procedures respectively. The cost difference between the ORIF only and with arthroscopy was not statistically significant (p = 0.1174). Twelve of the 28 arthroscopic patients (42.86%) had grade 3 or full thickness chondral lesions, and 11/28 (39.28%) arthroscopic patients were found to have grade 1–2 cartilage changes. Conclusion In the acute treatment of ankle fractures, concurrent arthroscopic evaluation does not add a significant cost to the procedure and may result in improved short and long term benefits for the patient. With improved arthroscopic efficiency, the cost differential can be further reduced. LOE IV.

Background: There is little in vivo data that describe the relationships between patellar tendon orientation, patellar tendon strain, and anterior cruciate ligament (ACL) strain during dynamic activities. Quantifying how the quadriceps load the ACL via the patellar tendon is important for understanding ACL injury mechanisms. Hypothesis: We hypothesized that flexion angle, patellar tendon orientation, and patellar tendon strain influence ACL strain during a single-leg jump. Specifically, we hypothesized that patellar tendon and ACL strains would increase concurrently when the knee is positioned near extension during the jump. Study Design: Descriptive laboratory study. Methods: Models of the femur, tibia, ACL, patellar tendon, and quadriceps tendon attachment sites of 8 male participants were generated from magnetic resonance imaging (MRI). High-speed biplanar radiographs during a single-leg jump were obtained. The bone models were registered to the radiographs, thereby reproducing the in vivo positions of the bones, ligament, and tendon attachment sites. Flexion angle, patellar tendon orientation, patellar tendon strain, and ACL strain were measured from the registered models. ACL and patellar tendon strains were approximated by normalizing their length at each knee position to their length at the time of MRI. Two separate bivariate linear regression models were used to assess relationships between flexion angle and patellar tendon orientation and between ACL strain and patellar tendon strain. A multivariate linear regression model was used to assess whether flexion angle and patellar tendon strain were significant predictors of ACL strain during the inflight and landing portions of the jump. Results: Both flexion angle and patellar tendon strain were significant predictors ( P < .05) of ACL strain. These results indicate that elevated ACL and patellar tendon strains were observed concurrently when the knee was positioned near extension. Conclusion: Concurrent increases in patellar tendon and ACL strains indicate that the quadriceps load the ACL via the patellar tendon when the knee is positioned near extension. Clinical Relevance: Increased ACL strain when the knee is positioned near extension before landing may be due to quadriceps contraction. Thus, landing with unanticipated timing on an extended knee may increase vulnerability to ACL injury as a taut ligament is more likely to fail.

» Surgical decision-making should consider factors to help optimize return to play for athletes with foot and ankle injuries, including injuries to the syndesmosis, the Achilles tendon, the fifth metatarsal, and the Lisfranc complex. Understanding influential factors on return to play may help orthopaedic surgeons counsel athletes and coaches on expectations for a timeline to return to play and performance metrics. » Outcomes after rigid and flexible fixation for syndesmotic injuries are generally favorable. Some data support an earlier return to sport and higher functional scores with flexible fixation, in addition to lower rates of reoperation and a decreased incidence of malreduction, particularly with deltoid repair, if indicated. » Minimally invasive techniques for Achilles tendon repair have been shown to have a decreased risk of wound complications. Athletes undergoing Achilles repair should expect to miss a full season of play to recover. » Athletes with fifth metatarsal fractures have better return-to-play outcomes with surgical management and can expect a high return-to-play rate within approximately 3 months of surgery. » Percutaneous treatment of Lisfranc injuries may expedite return to play relative to open procedures.

Background:Primary shoulder stabilization is successful, but there continues to be a risk of recurrence after operative repair, particularly in the young athlete. It is important for surgeons to understand the outcomes after various revision stabilization techniques to best counsel patients and manage expectations.Purpose:To analyze recurrent instability and revision surgery rates in patients who underwent revision anterior glenohumeral stabilization procedures with either arthroscopic repair, open repair, coracoid transfer, free bone block, or capsular reconstruction.Study Design:Systematic review; Level of evidence, 4.Methods:We performed a systematic review of level 2 to 4 evidence studies using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical studies of revision anterior glenohumeral stabilization (arthroscopic repair, open repair, coracoid transfer, free bone block, or capsular reconstruction) with a minimum 2-year follow-up were analyzed. The rate of recurrent instability, rate of revision surgery, patient-reported outcomes, and range of motion were extracted and reported. Study methodological quality was evaluated using the Downs and Black quality assessment score.Results:A total of 37 studies met inclusion criteria and were available for analysis: 20 studies evaluated arthroscopic repair, 8 evaluated open repair, 5 evaluated Latarjet procedure, 3 evaluated bone block, and 2 evaluated capsular reconstruction. There was 1 study included in both arthroscopic and Latarjet procedures, for a total of 1110 revision cases. There was 1 level 2 study, and the remainder were level 3 or 4 with poor Downs and Black scores. Participants analyzed were most commonly young (weighted mean age, 26.1 years) and male (78.4%). The weighted mean clinical follow-up after revision surgery was 47.8 months. The weighted mean rate of recurrent instability was 3.8% (n = 245) after the Latarjet procedure, 13.4% (n = 260) after open repair, 16.0% (n = 531) after arthroscopic repair, 20.8% (n = 72) after bone block, and 31.0% (n = 35) after capsular reconstruction. The weighted mean rate of additional revision surgery was 0.0% after bone block, 0.02% after the Latarjet procedure, 9.0% after arthroscopic repair, 9.3% after open repair, and 22.8% after capsular reconstruction. Patient-reported outcomes and objective measures of range of motion and strength improved with all revision techniques.Conclusion:The current review identifies a deficiency in the literature pertaining to consistent meaningful outcomes and the effect of bone loss after revision shoulder stabilization. Published studies demonstrate, however, that revision shoulder stabilization using arthroscopic, open, coracoid transfer, or bone block techniques yielded satisfactory objective and patient-reported outcomes. The Latarjet procedure exhibited the lowest recurrent instability rate. This study confirms that recurrent instability remains a common problem, despite revision shoulder stabilization. The quality of research in revision shoulder stabilization remains poor, and higher quality studies are needed to establish best practices for treatment of this complex problem.

Partial meniscectomy for meniscus tears is one of the most common procedures performed by orthopaedic surgeons. Much research has been done to evaluate the biomechanical consequences and clinical outcomes from meniscus debridement. Biomechanically, as the portion of the meniscus that is removed increases, greater contact pressures are experienced by the cartilage, which leads to altered knee mechanics. The use of partial meniscectomy to manage degenerative meniscus tears in knees with mild preexisting arthritis and mechanical symptoms may be beneficial; however, its routine use in the degenerative knee over physical therapy alone is not supported. In younger populations, partial meniscectomy may provide equal long-term symptom relief, earlier return to play, and lower revision surgery rate compared with meniscal repair. Partial meniscectomy may result in earlier development of osteoarthritis. Treatment should be patient specific in a shared-decision making process with the patient after discussion about known outcomes.

Introduction The purpose of our study is to prospectively evaluate the cost effectiveness of intramedullary nailing compared with skeletal traction in a resource-limited setting where traction remains the most common definitive treatment. Methods This multicenter, prospective multicenter investigation was conducted in Malawi at 2 central hospitals and 3 district hospitals. The project was divided into phases. In phase 1, the EuroQol-5D and SMFA were translated and validated in Chichewa. In phase 2, adult patents with OTA/AO 32 femur shaft fractures were prospectively enrolled, and a comparison of quality of life and functional status was made. In phase 3, a cost-effectiveness analysis was performed between those treated with intramedullary nail and those treated with skeletal traction. Conclusion This study serves as an example of an economic study in orthopaedic surgery conducted in a resource-poor environment through academic collaboration.

Ankle sprains are the most common disorder in patients with lateral ankle pain; however, other pathologies can present similarly and can require different treatments.In the acute setting, it is important to evaluate for subtle fractures that may mimic an ankle sprain, including fractures of the late

Author(s): LaMartina, Joey A; Lau, Brian C; Miller, Liane; Salesky, Madeleine A; Feeley, Brian T; Ma, C Benjamin; Zhang, Alan L | Abstract: BackgroundThere is no standard method for the surgical treatment of acromioclavicular (AC) joint separations. Current techniques have associated complications, including need for device removal, coracoid fracture, and inadequate reduction.PurposeTo evaluate the clinical outcomes of an internal splint technique without graft augmentation or rigid fixation to treat acute Rockwood type IV and V AC joint injuries.Study designCase series; Level of evidence, 4.MethodsA retrospective analysis was performed of 26 patients who underwent a novel internal splint fixation technique between 2011 and 2016. Patients had type IV (n = 2) and type V (n = 24) acute AC separations. The mean time to surgery was 13.7 days (range, 1-28 days). The surgical technique included an open approach with coracoclavicular suture and tape fixation and AC suture fixation. Range of motion, strength, and radiographs were evaluated after surgery. Patient follow-up included the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire at a mean 3.3 years postoperatively (range, 6 months-8.6 years). DASH questionnaires were obtained for all patients via email. Patients were also surveyed on cosmetic appearance and willingness to undergo the operation again.ResultsAll patients regained full strength and range of motion following surgery. All postoperative radiographs demonstrated well-maintained reduction of the AC joint. The mean DASH score was 3.4 at final follow-up, and 23 of 26 respondents were satisfied with their postoperative shoulder appearance. There were no reoperations, and all patients stated that they would have the operation again given the same circumstances.ConclusionThe results of this study demonstrate a reliable new technique for acute fixation of type IV or V AC joint injuries via an internal splint construct. This technique enables reduction in the coronal and sagittal planes without the need for graft augmentation or a rigid implant, allowing healing of the coracoclavicular and AC ligaments.

Musculoskeletal ultrasound imaging is increasingly being used for static and dynamic imaging of tendons, muscles, ligaments, and bones. New, hand-held, pocket-sized ultrasounds are more portable and affordable. The purpose of this study was to evaluate the feasibility of pocket-sized ultrasound to diagnose shoulder pathology.Prospective cohort study.Tertiary Care Hospital.Ten consecutive patients (mean age 54; range 42-68 years) referred for a shoulder ultrasound for evaluation of shoulder pain were recruited. A diagnostic ultrasound was performed first with a pocket-sized ultrasound machine (VScan; General Electric, Northville, MI) and cine images saved for later review. Next, standard diagnostic ultrasound by a radiology technician specialized in musculoskeletal ultrasound was performed using (LOGIQ; General Electric, Northville, MI) ultrasound. The radiology report from the standard diagnostic ultrasound was used as the gold standard for diagnoses. Two independent evaluators, a musculoskeletal-trained radiologist and a sports-medicine-trained physician with over 8 years of experience with musculoskeletal ultrasound, reviewed the images from the pocket-sized ultrasound.Nine of the studies were diagnosed with a pathologic entity during the standard diagnostic ultrasound and 1 was found to be normal. Diagnoses ranged from biceps tendinopathy, calcific tendonitis, and partial-articular-sided rotator cuff tear. Evaluator 1 correctly identified 7/10 diagnoses and evaluator 2 correctly identified 8/10 diagnoses. The evaluators also rated their confidence in diagnosis as 4.2/5 and the image quality as 3.7/4 from the pocket-sized ultrasound.The findings from this study demonstrate that pocket-sized, hand-held ultrasound machines may be used to identify shoulder pathology.

Background: Convergence insufficiency (CI) is a common binocular vision deficit after a sport-related concussion (SRC). CI may result in visual discomfort and vision-mediated functional difficulties such as slowed reading and compromised attention, leading to impaired academic, work, and sport performance. Purpose: To test the reliability of repeated near point of convergence (NPC) measurements in a sample of athletes after an SRC; compare the symptoms and cognitive impairment of athletes with normal NPC to those with CI after an SRC; and explore the relationship among age, sex, learning disability, migraine history, and CI. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 78 athletes (mean age, 14.31 ± 2.77 years) who were seen a mean 5.79 ± 5.63 days after an SRC were administered 3 trials of an NPC assessment, along with neurocognitive (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]) and symptom assessments. Patients were divided into normal NPC (NPC ≤5 cm; n = 45) and CI (NPC >5 cm; n = 33) groups. Intraclass correlation coefficients (ICCs) and repeated-measures analyses of variance (ANOVAs) assessed the consistency of NPC across the 3 trials. The ANOVAs were employed to examine differences on neurocognitive composites and symptoms between the normal NPC and CI groups. Stepwise regressions (controlling for age and symptom scores on the Post-Concussion Symptom Scale [PCSS]) were conducted to evaluate the predictive utility of the NPC distance for neurocognitive impairment. Results: Groups did not differ on demographic or injury characteristics. NPC differed between trial 1 and trials 2 ( P = .02) and 3 ( P = .01) for the CI group but not the normal NPC group. Internal consistency was high across NPC measurements (ICC range, 0.95-0.98). Patients with CI performed worse on verbal memory ( P = .02), visual motor speed ( P = .02), and reaction time ( P = .001, η2 = .13) and had greater total symptom scores ( P = .02) after the injury. Results of hierarchical regression revealed that the NPC distance contributed significantly to the model for reaction time ( P < .001). Conclusion: CI was common (~42%) in athletes evaluated within 1 month after an SRC. Athletes with CI had worse neurocognitive impairment and higher symptom scores than did those with normal NPC. Clinicians should consider routinely screening for NPC as part of a comprehensive concussion evaluation to help inform treatment recommendations, academic accommodations, and referrals for vision therapy.

Objective The incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) after pediatric knee arthroscopy is unknown. The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after knee arthroscopy in the pediatric and adolescent population in a high-volume center. Design Retrospective cohort study. Setting Tertiary care children's hospital. Patients All patients who underwent arthroscopy of the knee for a sports-related injury by 2 surgeons were reviewed. Chief complaint, past medical/surgical history, medications, procedure performed, intraoperative findings, intraoperative complications, and postoperative recovery were reviewed. The incidences of postoperative VTE within 30 days after the procedure were reviewed. Results Seven hundred forty-six (358 male and 388 female patients) knee arthroscopies performed from September 2011 to October 2016 by 2 pediatric orthopedic surgeons specializing in sports-related injuries were included. The average age was 15.2 ± 2.72 years. Five patients were suspected to have either DVT or PE postoperatively (0.67%). The overall incidence of symptomatic confirmed VTE after knee arthroscopic procedures was 0.27% (one DVT after a partial lateral meniscectomy and one PE after fixation of an osteochondral lesion). Conclusions The incidence of VTE after pediatric sports medicine knee arthroscopies is low, 0.27%. Patients who present with calf swelling or pain, chest pain, or shortness of breath after arthroscopic surgery should be examined closely. Level of evidence Level III.

Background Musculoskeletal ultrasonography is a tool that is being used increasingly. However, the interpretation of ultrasound images of fractures is not incorporated into orthopaedic training programs. This paper presents the results of an initiative to train orthopaedic surgery residents to accurately interpret images of distal radial fractures in adults and to assess their confidence levels and attitudes regarding their future use of ultrasonography. Methods Six junior residents were given a pretest with 100 distal radial images that had been made with a pocket-sized ultrasound device; they were asked to determine fracture versus nonfracture cases (50 cases) as well as reduced fracture versus nonreduced fracture cases (50 cases). Following the pretest, residents completed a 30-minute tutorial (didactic and practical) on distal radial ultrasonography. The residents then completed a period of self-practice during 2 separate trauma rotations (a total of 14 to 16 weeks in a single academic year). Following completion of their second trauma rotation, the residents completed a posttest. Comfort level using a pocket-sized ultrasound device also was assessed during pretesting and posttesting. Results The median number of days from the pretest to the posttest was 212 days (range, 175 to 225 days). Residents demonstrated an overall improvement in positive predictive value (PPV) of identifying a fracture from the pretest (86.0%; range, 77.5% to 93.1%) to the posttest (93.5%; range, 91.4% to 94.2%). The overall negative predictive value (NPV) for identifying a fracture also improved from the pretest (69.4%; range, 60.0% to 76.9%) to the posttest (81.0%; range, 76.4% to 86.7%; p = 0.04). The overall PPV for detecting a reduced fracture improved from 67.1% with the pretest (range, 54.2% to 82.4%) to 88.9% with the posttest (range, 83.3% to 94.1%; p = 0.04). The comfort level with using the ultrasound device also increased between pretesting and posttesting, and the residents felt that ultrasonography would be useful in the care of distal radial fractures. Conclusions After a focused training session and a period of self-practice, orthopaedic residents improved their interpretation of ultrasound images and their comfort level using pocket-sized ultrasound devices with adult patients with distal radial fractures. Residents felt that a pocket-sized ultrasound device was useful for fracture diagnosis and evaluation of reduction.

Purpose To compare bipolar bone loss by evaluating the degree of glenoid bone loss, Hill-Sachs lesion size, and glenoid track in adolescents and adults with shoulder dislocations. Methods We performed a retrospective review between 2012 and 2016 of surgical and nonsurgical patients with a history of anterior shoulder dislocations (primary or recurrent) who underwent magnetic resonance imaging of the affected shoulder. The exclusion criteria included multidirectional instability, prior surgery, and posterior dislocation. Patients were grouped into 2 groups: adolescents (aged 10-19 years) and adults (aged ≥20 years). The groups were compared regarding measures of glenoid bone loss (best-fit circle technique) and Hill-Sachs lesion size (medial margin of rotator cuff footprint to medial margin of Hill-Sachs lesion). If the medial margin of a Hill-Sachs lesion was within the glenoid track, it was defined as on track; if it was more medial than the glenoid track, it was defined as off track. Results We identified 45 adolescents (mean age, 16.1 years) and 30 adults (mean age, 28.9 years) with anterior shoulder dislocations. There was no significant difference in percentage of bone loss between adolescents (mean, 8.4%) and adults (mean, 9.9%; P = .23). There was no significant difference in Hill-Sachs lesion size between adolescents (mean, 12.7 mm) and adults (mean, 9.9 mm; P = .12). There were 12 patients with off-track lesions. Off-track lesions were present in 11 of 45 adolescents (24.4%) and 1 of 30 adults (3.3%). Adolescents had an increased risk of having an off-track lesion (odds ratio, 9.38; 95% confidence interval, 1.14-77.1). A subgroup analysis identified multiple dislocations as an independent risk factor for an off-track lesion (odds ratio, 4.15; 95% confidence interval, 0.85-20.23). Conclusions This study shows that adolescence and a history of multiple dislocations are independent risk factors for a greater likelihood of glenoid off-track lesions. The findings support the use of bipolar assessment of shoulder dislocators, especially in adolescents and multiple dislocators. Level of Evidence Level III, retrospective comparative study.

Background There are excellent data supporting recommendations to prevent elbow injuries (osteochondritis dissecans [OCD] and ulnar collateral ligament [UCL] injuries), such as pitch count and pitch type in baseball, but anatomic risk factors have not been thoroughly examined. This study aimed to evaluate radiographic measurements in adolescents with elbow OCD lesions or UCL injuries and controls. Methods We retrospectively identified adolescent patients between 2011 and 2016 with isolated capitellum OCD, UCL tear, or normal elbows based on magnetic resonance imaging. Nineteen patients (mean age, 13.5 years) had isolated OCD defects of the capitellum, 8 patients (mean age, 16.9 years) had isolated UCL complete tear, and the remaining 16 patients (mean age, 14.6 years) were normal controls. Radiographic measurements from corresponding anterior-posterior elbow radiographs were taken, including carrying angle, distal humeral articular surface angle, and radial neck-shaft angle. On the lateral radiograph, anterior angulation of the articular surface of distal humerus was measured. Results Significant differences were observed in carrying angle between controls (15.7°) and OCD patients (11.6°; P = .03) as well as between controls and UCL patients (10.3°, P = .02), with the OCD and UCL patients tending to be in more varus. Significant differences were also found between controls (88.5°) and OCD patients (93.6°; P = .01) and between controls and UCL patients (93.3°; P = .03) in distal humeral articular surface angle, with OCD and UCL patients with increased valgus at the distal humerus articular surface. There were no significant differences between groups in radial neck-shaft angle or anterior angulation of articular surface of distal humerus. Conclusions Patients with OCD and UCL injuries have anatomic differences compared with normal controls that can be measured radiographically.

Background: There has been increasing attention and understanding of sport-related concussions. Recent studies show that neurocognitive testing and symptom clusters may predict protracted recovery in concussed athletes. On-field signs and symptoms have not been examined empirically as possible predictors of protracted recovery. Purpose: This study was undertaken to determine which on-field signs and symptoms were predictive of a protracted (≥21 days) versus rapid (≤7 days) recovery after a sports-related concussion. On-field signs and symptoms included confusion, loss of consciousness, posttraumatic amnesia, retrograde amnesia, imbalance, dizziness, visual problems, personality changes, fatigue, sensitivity to light/noise, numbness, and vomiting. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: The sample included 107 male high school football athletes who completed computerized neurocognitive testing within an average 2.4 days after injury, and who were followed until returned to play as determined by neuropsychologists using international clinical concussion management guidelines. Athletes were then grouped into rapid (≤7 days, n = 62) or protracted (≥21 days, n = 36) recovery time groups. The presence of on-field signs and symptoms was determined at the time of injury by trained sports medicine professionals (ie, ATC [certified athletic trainer], team physician). A series of odds ratios with χ2 analyses and subsequent logistic regression were used to determine which on-field signs and symptoms were associated with an increased risk for a protracted recovery. Results: Dizziness at the time of injury was associated with a 6.34 odds ratio (95% confidence interval = 1.34-29.91, χ2 = 5.44, P = .02) of a protracted recovery from concussion. Surprisingly, the remaining on-field signs and symptoms were not associated with an increased risk of protracted recovery in the current study. Conclusion: Assessment of on-field dizziness may help identify high school athletes at risk for a protracted recovery. Such information will improve prognostic information and allow clinicians to manage and treat concussion more effectively in these at-risk athletes.

Background: Concussions affect an estimated 136 000 high school athletes yearly. Computerized neurocognitive testing has been shown to be appropriately sensitive and specific in diagnosing concussions, but no studies have assessed its utility to predict length of recovery. Determining prognosis during subacute recovery after sports concussion will help clinicians more confidently address return-to-play and academic decisions. Purpose: To quantify the prognostic ability of computerized neurocognitive testing in combination with symptoms during the subacute recovery phase from sports-related concussion. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: In sum, 108 male high school football athletes completed a computer-based neurocognitive test battery within 2.23 days of injury and were followed until returned to play as set by international guidelines. Athletes were grouped into protracted recovery (>14 days; n = 50) or short-recovery (≤14 days; n = 58). Separate discriminant function analyses were performed using total symptom score on Post-Concussion Symptom Scale, symptom clusters (migraine, cognitive, sleep, neuropsychiatric), and Immediate Postconcussion Assessment and Cognitive Testing neurocognitive scores (verbal memory, visual memory, reaction time, processing speed). Results: Multiple discriminant function analyses revealed that the combination of 4 symptom clusters and 4 neurocognitive composite scores had the highest sensitivity (65.22%), specificity (80.36%), positive predictive value (73.17%), and negative predictive value (73.80%) in predicting protracted recovery. Discriminant function analyses of total symptoms on the Post-Concussion Symptom Scale alone had a sensitivity of 40.81%; specificity, 79.31%; positive predictive value, 62.50%; and negative predictive value, 61.33%. The 4 symptom clusters alone discriminant function analyses had a sensitivity of 46.94%; specificity, 77.20%; positive predictive value, 63.90%; and negative predictive value, 62.86%. Discriminant function analyses of the 4 computerized neurocognitive scores alone had a sensitivity of 53.20%; specificity, 75.44%; positive predictive value, 64.10%; and negative predictive value, 66.15%. Conclusion: The use of computerized neurocognitive testing in conjunction with symptom clusters results improves sensitivity, specificity, positive predictive value, and negative predictive value of predicting protracted recovery compared with each used alone. There is also a net increase in sensitivity of 24.41% when using neurocognitive testing and symptom clusters together compared with using total symptoms on Post-Concussion Symptom Scale alone.

UPDATE This article was updated on April 26, 2018, because of a previous error. On pages 1 and 14, the author name that had read "Alan Z. Zhang, MD" now reads "Alan L. Zhang, MD."

BackgroundPatellar maltracking is a leading cause of patellofemoral pain syndrome (PFPS). The aim of this study was to determine the inter- and intra-rater reliability of a semi-automated program for magnetic resonance imaging (MRI) based patellofemoral kinematics.MethodsSixteen subjects (10 with PFPS [mean age 32.3; SD 5.2; eight females] and six controls without PFPS 19 [mean age 28.6; SD 2.8; three females]) participated in the study. One set of T2-weighted, fat-saturated fast spin-echo (FSE) MRIs were acquired from each subject in full extension and 30° of knee flexion. MRI including axial T1ρ relaxation time mapping sequences was also performed on each knee. Following image acquisitions, regions of interest for kinematic MRI, and patellar and trochlear cartilage were segmented and quantified with in-house designed spline- based MATLAB semi-automated software.ResultsIntraclass Correlations Coefficients (ICC) of calculated kinematic parameters were good to excellent, ICC > 0.8 in patellar flexion, rotation, tilt, and translation (anterior -posterior, medial -lateral, and superior -inferior), and contact area translation. Only patellar tilt in the flexed position and motion from extended to flexed state was significantly different between PFPS and control patients (p=0.002 and p=0.006, respectively). No significant correlations were identified between patellofemoral kinematics and contact area with T1ρ relaxation times.ConclusionsA semi-automated, spline-based kinematic MRI technique for patellofemoral kinematic and contact area quantification is highly reproducible with the potential to help better understand the role of patellofemoral maltracking in PFPS and other knee disorders.Level of evidenceLevel IV.