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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.

Collegiate athletes face rigorous physical, academic, and emotional demands. While significant attention has been paid to injury prevention among young athletes in the past two decades, orthopedic injury rates remain high among collegiate athletes, and a significant number will undergo surgical management for injuries each year. In this narrative review, we describe techniques for perioperative management of pain and stress after surgery in collegiate athletes. In particular, we outline pharmacologic and non-pharmacologic management of surgical pain, with a goal of minimizing opiate consumption. We emphasize a multi-disciplinary approach to optimizing post-operative recovery in collegiate athletes help minimize reliance on opiate pain medication. Additionally, we recommend that institutional resources should be harnessed to support athletes in their well-being, from a nutritional, psychological and sleep standpoint. Critical to success in perioperative pain management is the communication among the athletic medicine team members and with the athlete and family to address pain and stress management and encourage timely, safe return to play.

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.

BackgroundAnterior cruciate ligament (ACL) and meniscus tears are common knee injuries. Despite the high rate of post-traumatic osteoarthritis (PTOA) following these injuries, the contributing factors remain unclear. In this study, we characterized the immune cell profiles of normal and injured joints at the time of ACL and meniscal surgeries.MethodsTwenty-nine patients (14 meniscus-injured and 15 ACL-injured) undergoing ACL and/or meniscus surgery but with a normal contralateral knee were recruited. During surgery, synovial fluid was aspirated from both normal and injured knees. Synovial fluid cells were pelleted, washed, and stained with an antibody cocktail consisting of fluorescent antibodies for cell surface proteins. Analysis of immune cells in the synovial fluid was performed by polychromatic flow cytometry. A broad spectrum immune cell panel was used in the first 10 subjects. Based on these results, a T cell-specific panel was used in the subsequent 19 subjects.ResultsUsing the broad spectrum immune cell panel, we detected significantly more total viable cells and CD3 T cells in the injured compared to the paired normal knees. In addition, there were significantly more injured knees with T cells above a 500-cell threshold. Within the injured knees, CD4 and CD8 T cells were able to be differentiated into subsets. The frequency of total CD4 T cells was significantly different among injury types, but no statistical differences were detected among CD4 and CD8 T cell subsets by injury type.ConclusionsOur findings provide foundational data showing that ACL and meniscus injuries induce an immune cell-rich microenvironment that consists primarily of T cells with multiple T helper phenotypes. Future studies investigating the relationship between immune cells and joint degeneration may provide an enhanced understanding of the pathophysiology of PTOA following joint injury.

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.

Category: Sports; Basic Sciences/Biologics Introduction/Purpose: Syndesmosis injuries are common and frequently occur with deltoid injuries but optimal repair remains controversial. Prior biomechanical studies have demonstrated that 1 and 2 suture buttons are equivalent to screw fixation and that parallel or divergent suture buttons are equivalent to single suture button. Prior studies, however, created constructs with suture buttons within 1cm from each other (2-3cm from joint surface). Additionally, the role of deltoid injury and repair have not been evaluated in conjunction with syndesmosis injury and repair. The purpose of this study was to biomechanically compare a narrow vs spread 2-suture button construct with and without a deltoid repair. Methods: Four matched lower leg specimens (8 total specimens) aged mean 60.2 years (range 57-66 years; 6 females and 2 males; mean BMI 21.1) were tested. Ankle motion under cyclic loading was measured in multiple planes: first in the intact state, following simulated syndesmosis and deltoid injury, then following fixation with 1 of 2 randomly assigned constructs: 2 parallel suture buttons at 2 and 3cm from joint line (narrow); and 2 parallel suture buttons at 1 and 4cm from joint line (spread), and then finally following a deltoid repair with each construct. Each state was tested at a constant 750 N axial compressive force and 5N internal/external torque. Rotation position (degrees) and anterior-posterior displacement (mm) were collected throughout the testing to characterize relative spatial relationships of the tibiofibular articulation using 3D video capture technology. Results: Narrow and spread 2-suture button constructs improved rotation and translation compared to cut state (p0.05). There were no significant differences in rotation or translation between Narrow and Spread constructs (p>0.05). The addition of a deltoid repair did not improve rotation or translation compared to syndesmosis repair with either construct alone (p>0.05). Conclusion: The preliminary results of this study suggest that constructs with suture button placed close together or spread apart during fixation of combined syndesmosis and deltoid injury could improve rotation and translation equally. Additionally, in a combined syndesmosis and deltoid injury, the addition of a deltoid repair to a syndesmosis repair did not strengthen the construct. These findings suggest that repair of syndesmosis alone may be sufficient in combined syndesmosis and deltoid injuries. Additional matched samples will be tested to validate preliminary findings.

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: The Short Musculoskeletal Function Assessment (SMFA) tool measures function and quality of life in patients with musculoskeletal conditions. Objective: This study aimed to translate and adapt culturally the SMFA into Chichewa, and assess its clinimetric properties. Methods: The translated Chichewa version was administered to 53 patients with musculoskeletal disorders. To assess repeatability, an additional 20 patients answered the questionnaire twice over a time interval of two weeks. Internal consistency, floor and ceiling effects, and repeatability were tested; construct validity was assessed with the World Health Organization Quality of Life Assessment tool (WHOQOL-BREF). Results: There was good internal consistency for both Dysfunction and Bothersome indices (Cronbach’s alpha 0.90) and good construct validity between both indices with the WHOQOL-BREF. Pearson’s correlation coefficient and intraclass correlation coefficient (ICC) for repeatability for the Dysfunction Index were 0.941 and 0.922 (95% CI: 0.772, 0.971) respectively, and 0.877 and 0.851 (95% CI: 0.629, 0.941) for the Bothersome Index respectively. Conclusion: The translated Chichewa SMFA is a valid tool for populations that speak the Chichewa language. publishedVersion

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 Broström alone in cadaver-based biomechanical testing. Although clinical studies of synthetic augmentation have demonstrated equivocal stability and pain compared with Broström 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.

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.

Background: Modern techniques for graft choice, preparation, and fixation for anterior cruciate ligament (ACL) reconstruction demonstrate excellent longevity and return-to-play rates; however, up to 10% to 18% of cases continue to suffer reruptures, with even higher rates in specific subsets of patients. Indications: Normally, the posterior tibial slope is measured between 7° and 10°, with biomechanical and observational studies showing that posterior slope greater than 12° increases the risk of graft failure by 5× by allowing for increased anterior tibial translation, putting increased stress on the graft. The primary indication for a slope correction osteotomy with a revision ACL reconstruction is a patient with tibial slope greater than 12° who has failed prior ACL reconstruction. Technique Description: In our preferred technique, we illustrate a slope reducing anterior closing wedge proximal tibial osteotomy with concurrent revision ACL reconstruction rather than a staged ACL reconstruction. Results: The primary benefit of this technique is the ability to correct the tibial slope and reconstruct the ACL in one setting, which decreases recovery time, costs, and risks to the patients by eliminating an additional procedure. Discussion/Conclusion: In cases of ACL reconstruction failure, particularly in patients with multiple failures, an increased posterior tibial slope may be a contributing factor. Anterior closing wedge osteotomy has been shown to be an effective treatment, in patients with a native slope greater than 12°. A slope reducing anterior closing wedge proximal tibial osteotomy with concurrent revision ACL reconstruction rather than a staged ACL reconstruction has a wide array of benefits.