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Existing literature is varied in the methods used to make this determination in the treatment of athletes who have undergone recent anterior cruciate ligament (ACL) reconstruction. Some authors report using primarily time-based criteria, while others advocate for physical measures and kinematic testing to inform decision-making. The goal of this paper is to elucidate the most current medical evidence regarding identification of the earliest point at which a patient may safely return to sport. The present review therefore seeks to examine the evidence from a critical perspective-breaking down the biology of graft maturation, effect of graft choice, potential for image-guided monitoring of progression and results associated with time-based versus functional criteria-based return to play-to justify a multifactorial approach to effectively advance athletes to return to sport. The findings of the present study reaffirm that time is a prerequisite for the biological progression that must occur for a reconstructed ligament to withstand loads demanded by athletes during sport. Modifications of surgical techniques and graft selection may positively impact the rate of graft maturation, and evidence suggests that imaging studies may offer informative data to enhance monitoring of this process. Aspects of both functional and cognitive testing have also demonstrated utility in prior studies and consequently have been factored into modern proposed methods of determining the athlete's readiness for sport. Further work is needed to definitively determine the optimal method of clearing an athlete to return to sport after ACL reconstruction. Evidence to date strongly suggests a role of a multimodal algorithmic approach that factors in time, graft biology and functional testing in return-to-play decision-making after ACL reconstruction.Level of evidence: level V.

Background: Racquet sports, especially lawn tennis and badminton have been gaining popularity in Asian countries like India. With this increase in popularity, the injury rate in the sport has also increased. Objectives: The study will help detect the presence of gleno-humeral movement dysfunction and scapular resting position abnormality in asymptomatic racquet players, thus providing basis for screening the players and allow the clinician to determine if the asymmetry is a normal adaptation in the player or an abnormal change associated with injury. Materials and Methods: 46 asymptomatic professional players were divided into a study group of 23 players (16 tennis and 7 badminton) and control group of 23 football players. Assessment of passive gleno-humeral range of motion and distance of spine and inferior angle of scapula from corresponding spinous process were measured bilaterally and between groups. Results: There was statistically significant reduction in range of internal rotation (62.17 ± 8.09), extension (39.78 ± 4.12) and an increase in the external rotation (106.95 ± 7.49) of dominant compared to non-dominant arm of racquet players and a statistically significant decrease in internal rotation (78.69 ± 10.24), extension (44.78 ± 3.19), adduction (37.39 ± 6.54) and an increase in external rotation (102.6 ± 5.19) of dominant arm of racquet players compared to football players. Study also showed statistically significant increase in the spino-scapular distance at the level of inferior angle of scapula (10.23 ± 1.43) on dominant side compared to non-dominant. Conclusions: The dominant side scapula of asymptomatic racquet players showed increased external rotation and elevation as compared to the non-dominant side. Also, reduced shoulder internal rotation, extension and adduction and gain in shoulder external rotation was observed on the dominant side of racquet players when compared to the control group.

Background: Persistent infection, soft-tissue fibrosis, and damage to periosteum compound the treatment of children with a bone defect following osteomyelitis. We report on a series of twenty-six patients treated with nonvascularized fibular graft and intramedullary fixation. Methods: The series included eleven boys and fifteen girls (mean age, 6.8 years; range, three to twelve years) with gap nonunion after osteomyelitis. Initial treatment involved thorough debridement and sequestrectomy. When the infection was quiescent as indicated by inflammatory parameters, nonvascular fibular grafting with intramedullary Kirschner wire fixation (with or without additional external fixation) was performed. The time to union was noted, and a subgroup analysis was performed to correlate the size of the bone defect with the time to union. Results: The mean duration of follow-up was 3.02 ± 0.74 years (range, 1.3 to 4.2 years), and the mean time to union was 38.76 ± 12.02 weeks (range, fifteen to sixty weeks). There was a weak positive correlation between the time to union and the preoperative bone defect size (Pearson correlation coefficient, 0.699). The mean time to union was 31.7 ± 11.5 weeks for a defect of 6 cm. Delayed union was seen at one end of the fibular graft in four (15%) of the patients and was treated with plate fixation. One patient had recurrence of infection. Limb-length discrepancy (range, 2 to 5 cm) was seen in all patients in whom the lower limb was involved and was treated with a shoe lift. Conclusions: This series illustrates the potential benefits of staged sequestrectomy and nonvascular fibular grafting for the treatment of gap nonunion following osteomyelitis in children. The procedure is simple, does not require specialized training or equipment, and has a low complication rate. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.