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Background: Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and future treatment. Hypothesis: Articular cartilage lesions and meniscus tears/treatment would predict International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level at 6 years after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 1. Methods: Between 2002 and 2004, a total of 1512 ACLR patients were prospectively enrolled and followed longitudinally, with the IKDC, KOOS, and Marx activity score completed at entry, 2 years, and 6 years. A logistic regression model was built incorporating variables from patient demographics, surgical technique, articular cartilage injuries, and meniscus tears/treatment to determine the predictors (risk factors) of IKDC and KOOS scores and Marx activity level at 6 years. Results: A minimum follow-up on 86% (1307/1512) of the cohort was completed at 6 years. The cohort was 56% male and had a median age of 23 years at the time of enrollment, with 76% reporting a noncontact injury mechanism. Incidence of concomitant injury at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 25%; lateral femoral condyle [LFC] 20%; medial tibial plateau [MTP], 6%; lateral tibial plateau [LTP], 12%; patella, 20%; trochlear, 9%) and meniscus (medial, 38%; lateral, 46%). Both articular cartilage lesions and meniscus tears were significant predictors of 6-year outcomes on the IKDC and KOOS. Grade 3 or 4 articular cartilage lesions (excluding patella) significantly reduced IKDC and KOOS scores at 6 years. The IKDC demonstrated worse outcomes with the presence of a grade 3 or 4 chondral lesion on the MFC, MTP, and LFC. Likewise, the KOOS score was negatively affected by cartilage injury. The sole significant predictor of reduced Marx activity level was the presence of a grade 4 lesion on the MFC. Lateral meniscus repairs did not correlate with inferior results, but medial meniscus repairs predicted worse IKDC and KOOS scores. Lateral meniscus tears left alone significantly improved prognosis. Small partial meniscectomies (50%) on either the medial or lateral menisci improved prognosis. Analogous to previous studies, other significant predictors of lower outcome scores were lower baseline scores, higher body mass index, lower education level, smoking, and anterior cruciate ligament revisions. Conclusion: Both articular cartilage injury and meniscus tears/treatment at the time of ACLR were significant predictors of IKDC and KOOS scores 6 years after ACLR. Similarly, having a grade 4 MFC lesion significantly reduced a patient’s Marx activity level score at 6 years.

Background Suspensory fixation use during anterior cruciate ligament reconstruction has increased due to ease of use and high pullout strength. We hypothesize that there are no significant differences in biomechanical performance among four types of suspensory fixation devices: Stryker VersiTomic G-Lok, Smith & Nephew Endobutton, Biomet ToggleLoc, and Arthrex RetroButton. Methods Forty fresh frozen porcine femurs and flexor digitorum profundus tendons were obtained. Each tendon graft was sized to 8.5 mm or 9.0 mm. Ten of each device were used to fix the grafts in the femur at the 2 o'clock (left) or 10 o'clock (right) position. The graft–femur complex was secured to a servohydraulic test machine in line with the femoral tunnel. The graft was cyclically loaded from 50 to 250 N for 1000 cycles at 1 Hz then loaded to failure at 20 mm/min. Actuator load and displacement were recorded. Data were analyzed with multiple one-way ANOVA and Tukey HSD post-hoc tests. Bonferroni correction was applied resulting in P ≤ 0.005 considered statistically significant for ANOVA, P ≤ 0.05 for Tukey. Findings There were no significant differences in cyclic displacement among any of the groups ( P = 0.43). The only significant difference in failure properties is the Endobutton exhibited at least 50% greater displacement at failure than the other three devices. Interpretation Suspensory femoral soft tissue fixation devices are biomechanically similar with respect to failure load but differ in failure displacement. However, there was no significant difference in displacement after cyclic loading. All four fixation devices should withstand the forces associated with daily activities without failure.

Purpose The purpose of this study was to investigate and validate the accuracy and safety of a technique using an anterior approach for non–image-guided intra-articular injection of the hip by use of anatomic landmarks. Methods We enrolled 55 patients. Injections were performed before supine hip arthroscopy after landmarking and before application of traction. After the needle insertion, success was confirmed with an air arthrogram and by direct visualization after arthroscope insertion. Accuracy and difficulty achieving correct needle placement were correlated with age, weight, height, body mass index, body type, gender, and surgical indication, as well as femoral and pelvic morphology. Forty-five patients who underwent injection in the office were followed up separately to document injection side effects. Needle placement accuracy was correlated to patients' demographics. All statistical tests with P values were 2 sided, with the level of significance set at P Results There were 51 correct needle placements and 4 misses, yielding a 93% success rate. The most common location for needle placement was the upper medial head-neck junction. Female gender was correlated with a more difficult needle placement and misses in relation to group size ( P = .06). The reasons for misplacements of the needle were a high-riding trochanter, increased femoral version, thick adipose tissue over the landmarks, and variant of ilium morphology. Of 45 patients in the side effect study arm, 3 reported sensory changes of the lateral femoral cutaneous nerve that resolved within 24 hours. Conclusions Hip injections by use of the direct anterior approach, from the intersection of the lines drawn from the anterior superior iliac spine and 1 cm distal to the tip of the greater trochanter, are safe and reproducible. Patient characteristics, such as increased subcutaneous adipose tissue or osseous anatomic variants, can lead to difficulty in placing the needle successfully. These characteristics can be predicted with the aid of physical examination and careful study of the pelvic radiographs. Level of Evidence Level IV, therapeutic case series.

Background The Western Ontario Rotator Cuff Index (WORC) is commonly used in orthopedic research to assess the effect of a rotator cuff injury. Questions in the WORC are presented in a visual analog scale format, which requires patients to place a pencil mark along a 10-cm line indicating their responses. The purpose of our study was to determine if a computerized version of a visual analog scale requiring patients drag a cursor along a line was comparable to data collected using the standard paper version of the WORC. Materials and methods Administration of the WORC was randomized, with the first version given in the waiting room before the office visit, and the second immediately after the office visit, to ensure the participant's shoulder function had not significantly changed. Results Thirty-five patients with rotator cuff injury completed the paper and computerized versions of the WORC. There was no significant difference in mean scores for the WORC between the paper (1040.3) and computerized versions (1021.2, P = .488). The intraclass correlation coefficient for the 2 versions was 0.94. Similarly, there were no significant differences in scores between the subset of scores within the WORC (Physical Activity, Work, Sports, Lifestyle, and Emotion, P > .05), and each subset was highly correlated (intraclass correlation coefficient >0.80). Conclusions There was no significant difference in scores for the WORC index when administered in a computerized format vs a paper format.

Background Prior studies have analyzed the quality of information available on the Internet regarding common orthopaedic surgical procedures. The purpose of the present study was to evaluate the quality of information available for reverse total shoulder arthroplasty (rTSA). Methods Websites were identified using the search term 'reverse total shoulder arthroplasty' and the first 50 websites from three separate search engines (Google, Yahoo, and Bing) were selected for evaluation of authorship and quality of information using the DISCERN instrument (www.discern.org.uk). After disregarding duplicated or overlapping websites within and among search engines, 90 of the total 150 websites were evaluated. A one-way analysis of variance test was used to compare differences in DISCERN scores between three categories of authorship (academic, private, other). Results The majority of the websites evaluated were authored by academic (43%) and private institutions (36%). These were the most credible sources, providing overall better quality and reliability than other sources. DISCERN reliable (p = 0.017) and overall scores (p = 0.020) were significantly higher for academic institutions compared to other websites. Conclusions The information available on the Internet pertaining to reverse total shoulder arthroplasty is highly variable and provides moderate quality information about treatment choices with some limitations based on the DISCERN instrument.

The Association of American Medical Colleges publishes residency match data and reports through the National Resident Matching Program (NRMP) every year. The purpose of this study was to analyze trends in orthopaedic surgery residency matching data and characteristics of successful applicants to counsel medical students with regard to their chances of matching.The annual reports of the NRMP were searched annually from 2006 to 2014 to determine the number of orthopaedic surgery residency positions available, the number of applicants, and the match rate among applicants. Comparisons were performed between matched applicants and unmatched applicants with regard to the number of contiguous ranks and distinct specialties, United States Medical Licensing Examination (USMLE) scores, number of research experiences and research products (abstracts, presentations, posters, publications), and proportion of Alpha Omega Alpha (AOA) Honor Medical Society members and students at a top-40, National Institutes of Health (NIH)-funded medical school.The number of orthopaedic surgery positions available and number of applicants increased at a mean rate of 9 positions and 65 applicants per year (p = 0.11). The mean number of contiguous ranks for U.S. senior medical students was 11.5 for those who matched and 5.5 for those who did not match (p0.0001). The USMLE scores for applicants who matched were significantly greater than for those who did not match in each category: Step-1 scores for U.S. seniors (p0.001) and independent applicants (p = 0.039), and Step-2 scores for U.S. seniors (p0.01) and independent applicants (p = 0.026). The mean number of research products was significantly greater for matched U.S. seniors compared with unmatched U.S. seniors (p = 0.035). A significantly higher proportion of matched U.S. seniors compared with unmatched U.S. seniors were AOA members and students at a top-40, NIH-funded medical school (both p0.0001).Successful applicants in the Match for orthopaedic surgery residency have higher USMLE Step-1 and 2 scores, number of research experiences and research products, and contiguous ranks. A higher proportion of successful applicants are AOA members and students at a top-40, NIH-funded medical school.

Acute ruptures of the long head of the biceps (LHB) tendon typically occur in patients 40–60 years of age. The two main causes are a natural degeneration and fraying of the tendon that occurs slowly over time as part of the aging process and an acute traumatic event such as excessive weight lifting. Clinical history and a physical examination can raise suspicion for LHB rupture. Sharp, anterior shoulder pain, significant ecchymosis over the proximal arm extending toward the elbow, cramping in the biceps with use, a bulging biceps muscle (“Popeye” sign), and a visible indentation in the bicipital groove represent classic findings of a proximal biceps rupture. Magnetic resonance imaging should be performed to confirm the diagnosis and evaluate for any concomitant pathology, the most common of which is a rotator cuff tear.

We conducted a study to identify and contrast patterns in the treatment of common injuries that occur in National Football League (NFL) players and National Collegiate Athletic Association (NCAA) Division I football players. Orthopedic team physicians for all 32 NFL and 119 NCAA Division I football teams were asked to complete a survey regarding demographics and preferred treatment of a variety of injuries encountered in football players. Responses were received from 31 (97%) of the 32 NFL and 111 (93%) of the 119 NCAA team physicians. Although patellar tendon autograft was the preferred graft choice for both groups of team physicians, the percentage of NCAA physicians who allowed return to football 6 months or less after anterior cruciate ligament reconstruction was significantly (P = .03) higher than that of NFL physicians. Prophylactic knee bracing, which may prevent medial collateral ligament injuries, was used at a significantly (P.0001) higher rate by NCAA teams (89%) than by NFL teams (28%). Ketorolac injections were given by a significantly (P.01) higher percentage of NFL teams (93%) than of NCAA teams (62%). Understanding the current trends in the management of these injuries is beneficial in designing studies that may help improve the treatment and prevention of injuries in football players.

AB Purpose: Diabetes has been associated with adverse outcomes after various types of surgery. There are no previously published data regarding the effect of diabetes on outcomes from anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to test the hypotheses that diabetes is associated with worse clinical outcomes and a higher prevalence of subsequent surgeries after ACLR. Methods: Anterior cruciate ligament-deficient patients (n = 2198) undergoing unilateral ACLR from a multicenter prospective study were included. Patients who self-reported diabetes on the basis of comorbidity questions before surgery were identified from the database. They were compared with the remainder of the cohort who did not self-report diabetes. All patients were followed up for a minimum of 2 yr after their index surgery. A minimum 2-yr follow-up was attained on 1905/2198 (87%) via completed outcome questionnaires and 2096/2198 (95%) regarding subsequent surgery. The primary outcome measures were three validated outcome instruments. The secondary outcome measure was the incidence of additional surgery on the ipsilateral and contralateral knees. Results: Patients with diabetes had a significantly higher activity level at 2 yr (OR = 2.96; 95% CI, 1.30-6.77; P = 0.01), but otherwise slightly worse clinical outcomes, compared with patients without diabetes (OR range = 0.42-0.59). The prevalence of subsequent surgeries in patients with diabetes was not significantly different from the prevalence in patients without diabetes. Conclusions: Patients with diabetes maintain a higher activity level after ACLR despite slightly lower patient-reported outcome scores compared with patients without diabetes and do not have a higher rate of subsequent surgery.

Background: Previous studies have determined the percentage of studies presented at national orthopaedic surgery meetings that are eventually published in peer-reviewed journals. Purpose: To determine the proportion of articles in The American Journal of Sports Medicine ( AJSM) that are presented at national or international meetings. Study Design: Descriptive epidemiology study. Methods: The AJSM archive of 2014 online issues was searched. All original research articles were searched for corresponding presentations as listed at the beginning of the manuscript. An email was sent to the corresponding author of all articles, including those with a presentation listed. Corresponding authors were asked if the published study was presented at a national or international meeting and, if so, at which meeting and year the study was presented. If the study was not presented at a national meeting, the corresponding author was asked why this was the case. Results: A total of 315 articles met the inclusion criteria. Presentation information was obtained for 264 of these articles (84%). Of these 264 studies, 218 (83%) were presented at national or international conferences. A total of 341 presentations were listed, including 144 (42%) at international conferences. The average time from first presentation to publication was 12.9 months. Seventy-two studies (72/218, 33%) were presented at more than 1 meeting. Of those studies presented at more than 1 meeting, the average number of presentations was 2.7 (range, 2-6). The most common conferences at which AJSM-published studies were presented were the American Orthopaedic Society for Sports Medicine (AOSSM) Annual Meeting (n = 56) and the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting (n = 43). Seven authors stated that their published studies were not presented because the study was not accepted for presentation at a national meeting. Conclusion: A high proportion of studies accepted for publication in AJSM are presented at national and international meetings. AOSSM and AAOS Annual Meetings are the most common conferences at which these studies are presented, although international conferences account for a substantial proportion of AJSM-published study presentations.

Injury to the anterior cruciate ligament (ACL) threatens an active lifestyle and exposes the patient to risk of early osteoarthritis (OA). ACL reconstruction is typically chosen by individuals to allow a return to their previous work and sports activities. Primary ACL reconstruction (ACLR) has in general been effective at restoring functional stability, but patients' modifiable predictors of both short- and long-term validated outcomes and OA are largely unknown. The Multicenter Orthopaedic Outcomes Network (MOON) consortium was established in 2002 to enroll and longitudinally follow a population cohort of ACL reconstructed patients. The objective was to establish patient-specific predictive models of clinically important outcomes. Over the past 10 years, the overarching aims of this NIAMS-funded prospective multicenter cohort of ACL reconstructions has been threefold: (1) to identify both short- and long-term prognosis and predictors of sports function, activity level, and general health through validated patient-reported outcomes, (2) to identify the symptoms and signs of OA, and (3) to quantify the incidence of ACL reconstruction graft and/or contralateral ACL failures and additional surgical procedures. This manuscript summarizes the Kappa Delta Ann Doner Vaughan Award paper and presentation at the 2012 ORS/AAOS Annual Meeting.

Background: Previous meta-analyses have been conducted to compare outcomes of various treatment injections for lateral epicondylitis (LE), including corticosteroid injection (CSI) and autologous blood products such as autologous blood (AB) and platelet-rich plasma (PRP). Purpose: To conduct a systematic review of overlapping meta-analyses comparing different injection treatments (CSI, AB, PRP) for LE to determine which meta-analyses provide the best available evidence. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic review was performed by searching PubMed, Embase, and the Cochrane Library to locate meta-analyses that compared clinical outcomes of CSI, AB, and PRP for the treatment of LE. Search terms included “injection,” “corticosteroid,” “platelet-rich plasma,” “autologous blood,” “tennis elbow,” “lateral epicondylitis,” and “meta-analysis.” Results were reviewed to determine study eligibility. Patient outcomes were extracted from these meta-analyses. Meta-analysis quality was assessed with the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad decision algorithm was then used to determine which meta-analyses provided the best level of evidence. Results: Nine meta-analyses (two level 1 studies, seven level 2 studies) containing 8656 patients met the eligibility criteria. Seven meta-analyses found that autologous blood products such as AB and PRP significantly improved pain and elbow function in the intermediate term (12-26 weeks), while 4 studies found that CSI effectively relieved pain and improved elbow function in the short term (

Background: Previous studies of the reliability of classifications for superior labral anterior and posterior (SLAP) lesions suggest that intraobserver/interobserver reliability is poor. Purpose: The goals were to (1) evaluate intraobserver/interobserver reliability of the Snyder classification of labrum tears among experienced surgeons, (2) determine the effect of simplifying that classification into normal versus abnormal labrums, (3) determine the reliability of subdividing type II SLAP lesions, and (4) evaluate the effect of videotape quality on diagnostic confidence. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: At 2 separate times, 5 experienced shoulder surgeons (all >10 years of practice) evaluated 90 videotapes of shoulder arthroscopy performed for SLAP lesions to identify lesion type, to grade video quality, and to determine degree of confidence in diagnosis. The results were compared for intraobserver reliability (κ analysis) and interobserver reliability (intraclass correlation coefficients) and effect of video quality on diagnostic confidence. Significance was set at P < .05. Results: When the choices were normal labrum or the 4 types of SLAP lesions, the intraobserver agreements (mean κ, 0.670) and interobserver agreements (mean correlation, 0.804) were substantial. When the labrums were divided into normal (normal and type I) and abnormal (types II-IV), the intraobserver agreements (mean κ, 0.792) and interobserver agreements (mean correlation, 0.648) were substantial. When the 3 type II SLAP lesion subvariants were evaluated, the intraobserver agreement (mean κ, 0.598) was moderate, and the interobserver agreement (mean correlation, 0.804) was substantial. The confidence of the diagnosis was highly correlated with the perceived video quality (average Pearson correlation, 0.718; P < .01). Repeated measures analysis showed a significant relationship between confidence and quality (parameter estimate, 0.732; standard error, 0.021; P < .01) adjusting for rater and review. Conclusion: For experienced shoulder surgeons, the Snyder classification is a reliable system for identifying SLAP lesions.

Background: Tearing an anterior cruciate ligament (ACL) graft is a devastating occurrence after ACL reconstruction (ACLR). Identifying and understanding the independent predictors of ACLR graft failure is important for surgical planning, patient counseling, and efforts to decrease the risk of graft failure. Hypothesis: Patient and surgical variables will predict graft failure after ACLR. Study Design: Prospective cohort study. Methods: A multicenter group initiated a cohort study in 2002 to identify predictors of ACLR outcomes, including graft failure. First, to control for confounders, a single surgeon’s data (n = 281 ACLRs) were used to develop a multivariable regression model for ACLR graft failure. Evaluated variables were graft type (autograft vs allograft), sex, age, body mass index, activity at index injury, presence of a meniscus tear, and primary versus revision reconstruction. Second, the model was validated with the rest of the multicenter study’s data (n = 645 ACLRs) to evaluate the generalizability of the model. Results: Patient age and ACL graft type were significant predictors of graft failure for all study surgeons. Patients in the age group of 10 to 19 years had the highest percentage of graft failures. The odds of graft rupture with an allograft reconstruction are 4 times higher than those of autograft reconstructions. For each 10-year decrease in age, the odds of graft rupture increase 2.3 times. Conclusion: There is an increased risk of ACL graft rupture in patients who have undergone allograft reconstruction. Younger patients also have an increased risk of ACL graft failure. Clinical Relevance: Given these risks for ACL graft rupture, allograft ACLRs should be performed with caution in the younger patient population.

Massive, irreparable rotator cuff tears (MIRCTs) provide a significant dilemma for orthopaedic surgeons. One treatment option for MIRCTs is reverse total shoulder arthroplasty. However, other methods of treating these massive tears have been developed. A search of the current literature on nonoperative management, arthroscopic debridement, partial repair, superior capsular reconstruction (SCR), graft interposition, balloon spacer arthroplasty, trapezius transfer, and latissimus dorsi transfer for MIRCTs was performed. Studies that described each surgical technique and reported on clinical outcomes were included in this review. Arthroscopic debridement may provide pain relief by removing damaged rotator cuff tissue, but no functional repair is performed. Partial repair has been suggested as a technique to restore shoulder functionality by repairing as much of the rotator cuff tendon as possible. This technique has demonstrated improved clinical outcomes but also fails at a significantly high rate. SCR has recently gained interest as a method to prohibit superior humeral head translation and has been met with encouraging early clinical outcomes. Graft interposition bridges the gap between the retracted tendon and humerus. Balloon spacer arthroplasty has also been recently proposed and acts to prohibit humeral head migration by placing a biodegradable saline-filled spacer between the humeral head and acromion; it has been shown to provide good clinical outcomes. Both trapezius and latissimus dorsi transfer techniques involve transferring the tendon of these respective muscles to the greater tuberosity of the humerus; these 2 techniques have shown promising restoration in shoulder function, especially in a younger, active population. Arthroscopic debridement, partial repair, SCR, graft interposition, balloon spacer arthroplasty, trapezius transfer, and latissimus dorsi transfer have all been shown to improve clinical outcomes for patients presenting with MIRCTs. Randomized controlled trials are necessary for confirming the efficacy of these procedures and to determine when each is indicated based on specific patient and anatomic factors.

This article was migrated. The article was not marked as recommended. Background:Sports medicine is one of the most competitive orthopaedic subspecialties. Determining the most appropriate fellowship program is difficult for residents, due to limited information regarding research expectations, team coverage, and surgical exposure.Participants:An anonymous survey was distributed to the fellowship PDs of all Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic sports medicine fellowships in the United States. A complete list of accredited programs was obtained from the American Orthopaedic Society for Sports Medicine (AOSSM) website.Results:Thirty-eight of 95 PDs responded (40%). Twenty-three of the 38 programs (60.5%) were university-based, 6 (15.8%) were private practice, and 9 (23.7%) responded as "other". Research manuscript submission by the fellows is required at 28 of the 38 (73.6%) fellowship programs. Knee and shoulder arthroscopy were the most common areas of surgical exposure, with average scores of 9.18 and 9.08, respectively. Ankle arthroscopy had the lowest score (3.05), indicating minimal exposure in most programs. Non-athletes were the most common group treated, representing 25-50% of the patient population in 25 of 38 programs (65.8%) and 75-100% of patients seen in 7 of the 38 programs (18.4%). All programs reported that they treat professional athletes. College athletes accounted for 0-25% of the patient population in 81.6% of programs. With respect to team coverage, all programs covered football, while 21 out of 37 (56.8%) programs covered basketball.Conclusion There is variability among orthopaedic sports medicine fellowship programs with regard to research expectations, strength of surgical exposure, demographics of the patient population, and team coverage requirements. Most sports medicine fellowship programs are university-based, require some form of research with minimum publication submission, provide extensive exposure to shoulder and knee arthroscopy, and treat mostly non-athletes or high school athletes. This information may provide residents with a better understanding of some important components of orthopaedic sports medicine fellowship programs.

Background: Sports medicine is one of the most competitive fellowships in orthopaedic surgery. Despite its popularity, fellowship applicants have limited understanding of the orthopaedic sports medicine fellowship match process. Purpose: To define key outcomes in the orthopaedic sports medicine fellowship match, including the overall match rate, number of programs filled, and number of applicants ranked by programs that filled between 2010 and 2017. Study Design: Cross-sectional study. Methods: This study utilized data regarding the orthopaedic sports medicine fellowship match collected by the American Orthopaedic Society for Sports Medicine (AOSSM) from 2010 through 2017. Applicant data included number of applicants, number of matched and unmatched applicants, and percentage of applicants matching into their top choices. Fellowship program data included number of programs participating in the match and number of applicants ranked by filled and unfilled programs. Results: Between 2010 and 2017, the mean number of orthopaedic sports medicine fellowship applicants was 244.8. On average, 92.0% of applicants matched into a fellowship program. The mean number of programs participating in the fellowship match was 92.9, with a mean of 219.9 accredited positions and 5.4 nonaccredited positions. Over the time period studied, a mean of 75.8% of programs matched all available positions. Programs that matched fully ranked 9.0 applicants per position, on average, compared with a mean of 6.5 applicants ranked per position among programs that did not fully match ( P = .0016). Conclusion: From 2010 to 2017, the number of applicants, positions available, overall match rate, and number of programs participating in the orthopaedic sports medicine fellowship match have remained consistent. The mean number of applicants per position ranked by fully matched fellowship programs was 9.0 compared with a mean of 6.5 applicants per position ranked by programs that did not fully match. These data may be helpful as we look to the future of orthopaedic sports medicine fellowship positions and the match process. In addition, this study reveals characteristics that divide sports medicine fellowship programs that fully match from those that do not. Applicants and/or fellowship program directors may utilize this information to modify their approach to the match process going forward.

Background:Proper rehabilitation after matrix-associated autologous chondrocyte implantation (MACI) is essential to restore a patient’s normal function without overloading the repair site.Purpose:To evaluate the current literature to assess clinical outcomes of MACI in the knee based on postoperative rehabilitation protocols, namely, the time to return to full weightbearing (WB).Study Design:Systematic review; Level of evidence, 1.Methods:A systematic review was performed to locate studies of level 1 evidence comparing the outcomes of patients who underwent MACI with a 6-week, 8-week, or 10/11-week time period to return to full WB. Patient-reported outcomes assessed included the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity scale, Short Form Health Survey–36 (SF-36), and visual analog scale (VAS) for pain frequency and severity.Results:Seven studies met the inclusion criteria, including a total of 136 patients (138 lesions) who underwent MACI. Treatment failure had occurred in 0.0% of patients in the 6-week group, 7.5% in the 8-week group, and 8.3% in the 10/11-week group at a mean follow-up of 2.5 years ( P = .46). KOOS, SF-36, and VAS scores in each group improved significantly from preoperatively to follow-up ( P < .001).Conclusion:Patients undergoing MACI in the knee can be expected to experience improvement in clinical outcomes with the rehabilitation protocols outlined in this work. No significant differences were seen in failure rates based on the time to return to full WB.

Data from large prospectively collected anterior cruciate ligament (ACL) cohorts are being utilized to address clinical questions regarding ACL injury demographics and outcomes of ACL reconstruction. These data are affected by patient and injury factors as well as surgical factors associated with the site of data collection. The aim of this article is to compare primary ACL reconstruction data from patient cohorts in the United States and Norway, demonstrating the similarities and differences between two large cohorts. Primary ACL reconstruction data from the Multicenter Orthopaedic Outcomes Network (MOON) in the United States and the Norwegian National Knee Ligament Registry (NKLR) were compared to identify similarities and differences in patient demographics, activity at injury, preoperative Knee injury and Osteoarthritis Outcome Score (KOOS), time to reconstruction, intraarticular pathology, and graft choice. Seven hundred and thirteen patients from the MOON cohort were compared with 4,928 patients from the NKLR. A higher percentage of males (NKLR 57%, MOON 52%; P < 0.01) and increased patient age (NKLR 27 years, MOON 23 years; P\0.001) were noted in the NKLR population. The most common sports associated with injury in the MOON cohort were basketball (20%), soccer (17%), and American football (14%); while soccer (42%), handball (26%), and downhill skiing (10%) were most common in the NKLR. Median time to reconstruction was 2.4 (Interquartile range [IQR] 1.2-7.2) months in the MOON cohort and 7.9 (IQR 4.2-17.8) months in the NKLR cohort (P < 0.001). Both meniscal tears (MOON 65%, NKLR 48%; P < 0.001) and articular cartilage defects (MOON 46%, NKLR 26%; P < 0.001) were more common in the MOON cohort. Hamstring autografts (MOON 44%, NKLR 63%) and patellar tendon autografts (MOON 42%, NKLR 37%) were commonly utilized in both cohorts. Allografts were much more frequently utilized in the MOON cohort (MOON 13%, NKLR 0.04%; P < 0.001). Significant diversity in patient, injury, and surgical factors exist among large prospective cohorts collected in different locations. Surgeons should investigate and consider the characteristics of these cohorts when applying knowledge gleaned from these groups to their own patient populations.

Background Meniscal repair is performed in an attempt to prevent posttraumatic arthritis resulting from meniscal dysfunction after meniscal tears. The socioeconomic implications of premature arthritis are significant in the young patient population. Investigations and techniques focusing on meniscus preservation and healing are now at the forefront of orthopaedic sports medicine. Hypothesis Concomitant meniscal repair with anterior cruciate ligament reconstruction is a durable and successful procedure at 2-year follow-up. Study Design Case series; Level of evidence, 4. Methods All unilateral primary anterior cruciate ligament reconstructions entered in 2002 in a cohort who had meniscal repair at the time of anterior cruciate ligament reconstruction were evaluated. Validated patient-oriented outcome instruments were completed preoperatively and then again at the 2-year postoperative time point. Reoperation after the index procedure was also documented and confirmed by operative reports. Results A total of 437 unilateral primary anterior cruciate ligament reconstructions were performed with 82 concomitant meniscal repairs (54 medial, 28 lateral) in 80 patients during the study period. Patient follow-up was obtained on 94% (77 of 82) of the meniscal repairs, allowing confirmation of meniscal repair success (defined as no repeat arthroscopic procedure) or failure. The overall success rate for meniscal repairs was 96% (74 of 77 patients) at 2-year follow-up. Conclusion Meniscal repair is a successful procedure in conjunction with anterior cruciate ligament reconstruction. When confronted with a “repairable” meniscal tear at the time of anterior cruciate ligament reconstruction, orthopaedic surgeons can expect an estimated >90% clinical success rate at 2-year follow-up using a variety of methods as shown in our study.

Triceps ruptures are relatively rare injuries. When they occur, primary surgical repair of the tendon to the proximal ulna is recommended. However, some patients require reconstruction using tendon grafting due to shortening or insufficiency of the native triceps tendon. Triceps ruptures associated with biological abnormalities (such as renal insufficiency or metabolic disease) or recurrence of rupture represent situations where a stout augmented repair is desirable. Multiple allograft and autologous tendons have been described for augmentation, but the use of gracilis and semitendinosus tendons provides superior length and size for use in triceps reconstruction. Using an illustrative case example, the evaluation of triceps insufficiency and the need for additional graft is shown. The technique of autologous hamstring augmentation for triceps insufficiency is described in detail. The importance of graded rehabilitation is emphasized with a complete program of triceps strengthening over time.

Anterior cruciate ligament (ACL) reconstruction is a common surgical knee procedure that requires intensive postoperative rehabilitation by the patient. A variety of randomized controlled trials have investigated aspects of ACL reconstruction rehabilitation. A systematic review of English language level 1 and 2 studies identified 54 appropriate randomized controlled trials of ACL rehabilitation. This part of the article discusses open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics.

BackgroundAlthough magnetic resonance imaging (MRI) is a standard method of assessing the extent and features of rotator cuff disease, the authors are not aware of any studies that have assessed the interobserver agreement among orthopaedic surgeons reviewing MRI scans for rotator cuff disease.HypothesisFellowship-trained orthopaedic shoulder surgeons will have good interobserver agreement in predicting the more salient features of rotator cuff disease such as tear type (full thickness versus partial thickness), tear size, and number of tendons involved but only fair agreement with more complex features such as muscle volume, fat content, and the grade of partial-thickness cuff tears.Study DesignCohort study (diagnosis); Level of evidence, 3.MethodsTen fellowship-trained orthopaedic surgery shoulder specialists reviewed 27 MRI scans of 27 shoulders from patients with surgically confirmed rotator cuff disease. The ability to interpret full-thickness versus partial-thickness tears, acromion type, acromioclavicular joint spurs or signal changes, biceps lesions, size and grade of partial-thickness tears, acromiohumeral distance, number of tendons involved and amount of retraction for full-thickness tears, size of full-thickness tears, and individual muscle fatty infiltration and atrophy were assessed. Surgeons completed a standard evaluation form for each MRI scan. Interobserver agreement was determined and a kappa level was derived.ResultsInterobserver agreement was highest (>80%) for predicting full- versus partial-thickness tears of the rotator cuff, and for quantity of the teres minor tendon. Agreement was slightly less (>70%) for detecting signal in the acromioclavicular joint, the side of the partial-thickness tear, the number of tendons involved in a full-thickness tear, and the quantity of the subscapularis and infraspinatus muscle bellies. Agreement was less yet (60%) for detecting the presence of spurs at the acromioclavicular joint, a tear of the long head of the biceps tendon, amount of retraction of a full-thickness tear, and the quantity of the supraspinatus. The best kappa statistics were found for detecting the difference between a full- and partial-thickness rotator cuff tear (0.77), and for the number of tendons involved for full-thickness tears (0.55). Kappa for predicting the involved side of a partial-thickness tear was 0.44; for predicting the grade of a partial-thickness tear, it was −0.11.ConclusionsFellowship-trained, experienced orthopaedic surgeons had good agreement for predicting full-thickness rotator cuff tears and the number of tendons involved and moderate agreement in predicting the involved side of a partial-thickness rotator cuff tear, but poor agreement in predicting the grade of a partial-thickness tear.

Posterior shoulder instability is becoming an increasingly diagnosed and treated entity especially recognized in the contact athlete. Historically, the open technique of addressing posterior shoulder labral and capsular pathology has had marginal results and unacceptable high rates of recurrence. Arthroscopic posterior stabilization has become more popular recently, given its ability to address labral and capsular pathology, as well as deal with pathology that is encountered intraoperatively. It has also been postulated that the arthroscopic approach may lead to less postoperative morbidity and decreased time to return to athletic activity. The surgical technique presented is an arthroscopic approach to posterior labral tears and capsular laxity has been successful in dealing with this challenging entity.

Background Six classification systems have been proposed for describing rotator cuff tears designed to help understand their natural history and make treatment decisions. Purpose To assess the interobserver variation for these classification systems and identify the method with the best interob-server agreement. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods Six rotator cuff tear classification systems were identified in a literature search. The components of these systems included partial-thickness rotator cuff tears and classification by size, shape, configuration, number of tendons involved, and by extent, topography, and nature of the biceps. Twelve fellowship-trained orthopaedic surgeons who each perform at least 30 rotator cuff repairs per year reviewed arthroscopy videos from 30 patients with a random assortment of rotator cuff tears and classified them by the 6 classification systems. Interobserver variation was determined by a kappa analysis. Results Interobserver agreement was high when distinguishing between full-thickness and partial-thickness tears (0.95, [UNKNOWN]=0.85). The investigators agreed on the side (articular vs bursal) of involvement for partial-thickness tears (observed agreement 0.92, [UNKNOWN]= 0.85) but could not agree when classifying the depth of the partial-thickness tear (observed agreement 0.49, [UNKNOWN]= 0.19). The best agreement for full-thickness tears was seen when the tear was classified by topography (degree of retraction) in the frontal plane (observed agreement 0.70, [UNKNOWN]= 0.54). Conclusion With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. Researchers should consider describing full-thickness rotator cuff tears by topography (degree of retraction) in the frontal plane.

Excision of the distal clavicle has become the mainstay of surgical treatment for acromioclavicular joint arthritis and osteolysis refractory to nonoperative management. Surgical options for symptomatic acromioclavicular joint abnormalities refractory to nonoperative treatment are the classic open distal clavicle excision, direct (superior) arthroscopic excision, and indirect (bursal) arthroscopic distal clavicle excision. We asked whether any of these three procedures provided a better result. We systematically reviewed the medical literature (Medline, EMBASE), assigned a level of evidence for available studies, and critically identified the flaws and biases in the studies to provide comparisons between the published reports. We limited the literature review to clinical reports in the English language published in peer-reviewed journals. The literature supports surgical excision, but the reports are all Level III or IV evidence consisting largely of retrospective case series. Arthroscopic distal clavicle resection has provided more "good or excellent" results than has the open procedure, but is comprised of low-level evidence. Distal clavicle resection has provided satisfactory results when combined with other procedures. Simple distal clavicle resection may have worse outcomes when performed after preceding trauma. The published reports of the removal of medial acromial and inferior distal clavicle osteophytes when performing subacromial decompression are conflicting and may increase post-operative acromioclavicular symptoms.

Arthroscopic treatment of glenohumeral arthritis has become an increasingly popular treatment option particularly in young patients that are active and wish to either delay or avoid total shoulder replacement. The optimal treatment remains to be determined. However, multiple studies have shown improved outcomes, pain scores, range of motion, and patient satisfaction with arthroscopic debridement and a capsular release. In addition, microfracture has been shown to be helpful for isolated cartilage lesions. Capsular release reliably increases range of motion. Bipolar lesions, a joint space less than 2 mm on radiographs, and a biconcave glenoid have been associated with inferior outcomes. The goal of this chapter is to review the role of debridement, microfracture, and capsular release in treating glenohumeral arthritis. The authors’ preferred operative technique will be discussed along with technical pearls.

Long head biceps tendon is a common cause of anterior shoulder pain. Failure of conservative treatment may warrant surgical intervention. Surgical treatment involves long head biceps tenotomy or tenodesis. Several different techniques have been described for biceps tenodesis, including arthroscopic versus open and suprapectoral versus subpectoral. Most studies comparing tenodesis to tenotomy are limited by the level of evidence and confounding factors, such as concomitant rotator cuff tear. Many studies demonstrate similar outcomes for both procedures. Surgeon preference is likely more influential in choosing between tenotomy and tenodesis. Higher-powered studies are necessary to elucidate any differences in outcomes if present.

The purpose of this study is to help define the indications for rotator cuff repair by identifying predictors of failure of nonoperative treatment.A prospective, multicenter, cohort study design was used. All patients with full-thickness rotator cuff tears on magnetic resonance imaging were offered participation. Baseline data from this cohort were used to examine risk factors for failing a standard rehabilitation protocol. Patients who underwent surgery were defined as failing nonoperative treatment. A Cox proportional hazards model was fit to determinethe baseline factors that predicted failure. The dependent variable was time to surgery. The independent variables were tear severity and baseline patient factors: age, activity level, body mass index, sex, Single Assessment Numeric Evaluation score, visual analog scale score for pain, education, handedness, comorbidities, duration of symptoms, strength, employment, smoking status, and patient expectations.Of the 433 subjects in this study, 87 underwent surgery with 93% follow-up at 1 year and 88% follow-up at 2 years. The median age was 62 years, and 49% were female patients. Multivariate modeling, adjusted for the covariates listed previously, identified patient expectations regarding physical therapy (P .0001) as the strongest predictor of surgery. Higher activity level (P = .011) and not smoking (P = .023) were also significant predictors of surgery.A patient's decision to undergo surgery is influenced more by low expectations regarding the effectiveness of physical therapy than by patient symptoms or anatomic features of the rotator cuff tear. As such, patient symptoms and anatomic features of the chronic rotator cuff tear may not be the best features to use when deciding on surgical intervention.

Arthroscopic posterior labral repairs for posterior shoulder instability can be challenging. Preparation of the capsulolabral tissue and glenoid bony surface is critical. Iatrogenic injury to the articular cartilage and unwarranted truncation of the capsulolabral tissue are concerns during preparation. As a result, several techniques have been described to potentially avoid these complications. We describe an additional technique for improving access and preparing the capsulolabral tissue and glenoid surface through a “sublabral window.” This technique approaches the posterior labrum and glenoid through an already established posterior portal and mitigates iatrogenic injury to the labrum and articular cartilage. The technique is rather simple and easily adaptable.

Stress fractures can occur in any active individual, from the weekend warrior to the elite athlete. As these injuries occur, it is important to understand how bones respond to the stresses placed on them. The understanding of potential intrinsic and extrinsic causes is important in treatment of these injuries. The proper identification and prevention of these stress injuries allows for athletes to return to activity expeditiously.

Background Acute and chronic cartilage injury of the knee has an important impact on prognosis. The validity of the classification of such injuries is critical for prospective multicenter studies. The agreement among multiple surgeons at different institutions for articular cartilage lesions has not been established. Hypothesis Arthroscopic classification of articular cartilage lesions is reliable and reproducible and can be used for multicenter studies involving multiple surgeons. Study Design Cohort study (diagnosis); Level of evidence, 1. Methods A total of 6 surgeons from 5 centers reviewed 31 videos of articular cartilage lesions. With grade 2 and grade 3 combined for the analysis, observed agreement ranged from 81% to 94%, and kappa ranged from 0.34 to 0.87. An additional 22 videos comprising grade 2 and grade 3 lesions were analyzed, and the observed agreement was 80%, with an overall kappa of 0.47. Conclusion Arthroscopic grading of articular cartilage lesions is reproducible among surgeons at different centers. Clinical Relevance Articular cartilage lesions can be reliably classified among surgeons at different sites. Such reliability is important for multicenter clinical research studies involving arthroscopic knee surgery.

Intra-articular chondral and meniscal injury in the multiligament-injured knee has not been examined. The purpose of this study was to determine the pattern of intra-articular chondral and meniscal damage in subjects with multiligament knee injuries undergoing surgery.Prospective cohort study.Analysis was performed on prospectively collected data for the presence of meniscal tears and significant chondral injury on subjects who underwent knee ligament surgery. Subjects were grouped by their multiligament injury combination. Chondral injury was graded using the Modified Outerbridge Classification system. Criteria for significant chondral defect were any grade 2 lesion involving 50% or more of condylar width and all grade 3 or 4 lesions. Groups with more than 10 subjects were compared against the anterior cruciate ligament (ACL)-only group.Data were collected on 2,265 subjects. The ACL/medial collateral ligament (MCL) injury pattern was the most common multiligament injury, comprising 70.5% of all multiligament injuries. Lateral meniscal damage was significantly higher in the ACL/MCL group (P.01). Medial meniscal damage was significantly lower in the ACL/MCL group (P.01). Medial and lateral meniscal damage was significantly lower in the ACL/lateral collateral ligament (LCL) group (P.01). Articular damage to the medial tibial plateau was significantly lower in the ACL/MCL group (P.01). All other multiligament injury patterns showed chondral damage similar to the ACL-only group. Ligament injuries repaired acutely had significantly less articular and medial meniscal damage than chronic repairs (P.01).The ACL/MCL injury pattern was the most common multiligament injury pattern and showed a high incidence of lateral meniscal tears. ACL/LCL injuries had fewer meniscal injuries. Multiligament-injured knees showed increased risk of a torn medial meniscus as chronicity increased.Level IV.

The synovial joints provide a unique environment in which to carry out their critical mechanical function. The complex architecture of the articular cartilage normally provides painless motion throughout a variety of activities. Fluids secreted by cells in the superficial layers of the articular cartilage as well as in the synovium provide an almost frictionless articulation. The synovium also helps to maintain the aseptic environment found within the joint. The cartilage and fluid provide critical protection to the underlying bone. If any of these structures are damaged, or lose their efficiency, the ensuing cascade of damage inflicted on the joint can lead to catastrophic failure.

The role of arthroscopy in the treatment of rotator cuff tears continues to evolve and expand. The arthroscope offers several advantages to open techniques. It provides clear visualization of the glenohumeral joint, smaller incisions, no deltoid detachment, less soft-tissue dissection, less pain, and more rapid rehabilitation. The past few decades have seen explosive technological advances in the availability of arthroscopic implants, as well as improvement in equipment designs that have made arthroscopy an effective and efficient treatment tool. The development of suitable arthroscopic implants has been critical to the success of arthroscopic tissue repair. These various suture anchors are often used to reattach torn tissue back to bone in the shoulder. The past decade has seen a proliferation in the designs and types of suture anchors available, and this proliferation in implant availability often presents a confusing plethora of options. Each anchor has individual characteristics that influence the appropriateness of its usage including size, shape, composition, and holding strength. In light of the prodigious and voluminous anchor options, we attempt to concisely discuss the individual characteristics and provide quantitative data for the various metal and plastic suture anchors. We divide the anchors into 5 groups based on composition and morphology consisting of metal screw anchors, nonscrew metal anchors, minianchors, plastic suture anchors, and newer anchor designs that have not yet been tested in comparative biomechanical studies.

Background There have been reports of axillary nerve palsy after thermal capsular shrinkage with radiofrequency energy-generating devices. The exact cause of this is unknown. Hypothesis The temperature of the axillary nerve increases during shoulder capsular shrinkage at various degrees of shoulder abduction. Study Design Laboratory study. Methods Fifteen cadaveric shoulders had fiberoptic thermometer probes placed at various points along the axillary nerve and major branches under the capsule. The shoulders underwent thermal capsular shrinkage with a radiofrequency energy-inducing device at various positions of abduction. Results With the arm at the side, temperatures above 50°C (56°-61°C) were evident along the teres minor branch of the axillary nerve in 4 of 6 specimens. The increase in temperature was noted in the middle to posterior aspect of the inferior capsule. At 45° of abduction, 4 of 5 shoulders demonstrated increases in temperature greater or equal to 50°. Three of 4 shoulders tested at 90° of abduction revealed similar temperature increases. Conclusions The arthroscopic technique of thermal capsular shrinkage causes an increase in the temperature of the axillary nerve and its branches in 11 of 15 cadaveric specimens tested at various arm positions—particularly affected is the teres minor branch. Clinical Relevance Orthopaedic surgeons using the radiofrequency device for thermal capsular shrinkage need to be aware of the possible increase in temperature along the axillary nerve and its branches during this procedure. The clinical effect of this type of increase on the nerve is unknown.

Cryotherapy has been shown to decrease intraarticular temperature in all regions of the knee after arthroscopy. The purpose of our study was to determine if similar declines in intraarticular temperature were seen with the use of cryotherapy after anterior cruciate ligament reconstruction, a procedure which, unlike simple arthroscopy, produces postoperative hemarthrosis. Sixteen patients had intraarticular temperatures measured for 2 hours after anterior cruciate ligament reconstruction with cryotherapy instituted for only 1 of the 2 hours (eight patients for the first hour and eight patients for the second hour). Significant declines were seen in the suprapatellar pouch after either hour (-2.7 degrees C in Group 1, -2.7 degrees C in Group 2) but not in the lateral gutter. The difference between cryotherapy versus no cryotherapy in the first hour in the suprapatellar pouch was 6.0 degrees C, a clinically meaningful temperature difference. We hypothesize the swelling and hemarthrosis was more pronounced in the lateral gutter because of its dependent position and therefore blunted the effect of cryotherapy seen in the lateral gutter. Cooling of the intraarticular temperature should be considered in the clinical benefits of cryotherapy.

Background: Medial meniscal repairs are commonly performed with inside-out sutures and entirely arthroscopic with arrows, but few comparative evaluations on failures have been performed.Hypothesis: No differences in failure rates exist between medial meniscal repairs performed with inside-out suture or entirely arthroscopic at the time of anterior cruciate ligament reconstruction.Study Design: Prospective cohort study.Materials: A single surgeon performed 47 consecutive inside-out suture repairs from August 1991 to June 1996 and 98 consecutive entirely arthroscopic repairs with arrows from June 1996 to December 1999. All data were derived from a prospective database and rehabilitation was held constant (nonweightbearing 5 weeks). Clinical success was defined as no reoperation for failed medial meniscal repair. Statistical evaluation was by Kaplan-Meier curves and Cox proportional hazards model.Results: The inside-out suture group had 85% follow-up (40 of 47) with a median 68 months and the entirely arthroscopic group had 87% follow-up (85 of 98) with a median 27 months. There were seven failures in each group. Both Kaplan-Meier curves and the Cox proportional hazards model showed no difference in time to reoperation between techniques (P = 0.85). Three-year success rates (proportions with no reoperations) were 88% for sutures versus 89% for arrows.Conclusions: Repairs of the longitudinal posterior horn of the medial meniscus during an anterior cruciate ligament reconstruction with nonweightbearing for 5 weeks can be performed with an equivalent high degree of clinical success for both repair techniques.

Background: As participation in high school athletics increases, so does the number of adolescents experiencing sports-related injury. Understanding injury patterns is an important component to developing and evaluating prevention and rehabilitation programs. Purpose: To analyze recurrent injury rates and patterns among high school athletes, to compare recurrent injuries with new injuries, and to evaluate injury trends over time. Study Design: Descriptive epidemiology study. Methods: High school sports injury data on 24 sports were collected from 2005-2006 through 2015-2016 via the High School RIO (Reporting Information Online) surveillance system. Injury rates were calculated as number of injuries per 10,000 athletic exposures (AEs). Injury rate ratios and injury proportion ratios (IPRs) were calculated to compare differences among subgroups. Results: Overall, 78,005 injuries were sustained during 40,195,806 AEs, for an injury rate of 19.41 per 10,000 AEs. Of these, 69,821 (89.5%) were new injuries, and 8184 (10.5%) were recurrent. The ankle was the most commonly injured body part among recurrent injuries, while the head/face was the most common body part that sustained new injuries. Ligament sprains were more often recurrent, while concussions were more commonly diagnosed as new, although concussions represented 16.7% of recurrent injuries. Trends for recurrent injuries over time were relatively stable. The proportion of athletes who had >3 weeks of time loss or medical disqualification (15.8% vs 13.3%; IPR, 1.19; 95% CI, 1.13-1.26) or who voluntarily withdrew from sport (2.5% vs 1.1%; IPR, 2.33; 95% CI, 2.00-2.73) was significantly greater for recurrent injuries than new injuries. Furthermore, a greater proportion of recurrent injuries resulted in surgery (8.1% vs 6.0%; IPR, 1.34; 95% CI, 1.24-1.46). Conclusion: Although only 10.5% of all injuries were recurrent, they more frequently resulted in missing >3 weeks of playing time and were more often managed surgically when compared with new injuries. The rate of recurrent injuries has not increased over the past decade.

The meniscus plays an important role in the function of the knee. Preservation of the meniscus is preferred if possible when considering treatment of a meniscus tear. A thorough understanding of the anatomy of the meniscus, the structure, the mechanics, and other factors of meniscal healing are critical when evaluating the torn meniscus for a reparative procedure. Many options for meniscus repair exist for the orthopaedist. Options such as open repair or arthroscopically-assisted inside-out techniques have long-term favorable results. The all-inside techniques are attractive because of the decrease in operative time and ease of the technique. Short-term results are positive for the all-inside technique; however, good long-term data on these techniques are lacking. Few well-designed prospective studies exist on any of the meniscus repair techniques. Future directions include the potential use of growth factors and gene therapy to augment meniscus repair.

Background: Over the past few decades, there has been a trend toward an increasing subspecialization in orthopaedic surgery, with orthopaedic sports medicine being one of the most competitive subspecialties. Information regarding the application and interview process for sports medicine fellowships is currently lacking. Purpose: To survey orthopaedic sports medicine fellowship program directors (PDs) to better define the structure of the sports medicine fellowship interview and to highlight important factors that PDs consider in selecting fellows. Study Design: Cross-sectional study. Methods: A complete list of accredited programs was obtained from the American Orthopaedic Society for Sports Medicine (AOSSM) website. An anonymous survey was distributed to fellowship PDs of all Accreditation Council for Graduate Medical Education (ACGME)–accredited orthopaedic sports medicine fellowships in the United States. The survey included 12 questions about the fellowship interview and selection process. Results: Of the 95 orthopaedic sports medicine fellowship PDs surveyed, 38 (40%) responded. Of these, 16 (42.1%) indicated that they interview between 21 and 30 applicants per year. Eleven of the 38 fellowship programs (28.9%) have only 1 fellow per year at their respective program. Most programs (27/37, 73%) reported that between 0 and 5 faculty members interview applicants, and 29 of the 38 programs (76.3%) arrange for applicants to have ≥4 interviews during their interview day. Large group interviews are conducted at 36 of 38 (94.7%) sports medicine fellowship programs, and most programs (24/38, 63.2%) hold individual interviews that last between 5 and 15 minutes. The most important applicant criterion taken into account by PDs was the quality of the interview, with an average score of 8.68 of 10. Conclusion: The most significant factor taken into account by PDs when deciding how to rank applicants was the quality of the interview. Many orthopaedic sports medicine fellowship programs interview between 21 and 30 applicants per year, with each applicant participating in an average of 2 to 4 individual interviews per interview day and interviews commonly lasting between 5 and 15 minutes.