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Background: Persistent mildly abnormal knee kinematics after anterior cruciate ligament (ACL) reconstruction (ACLR) is an ongoing clinical problem., Purpose: To compare the clinical outcomes of revision ACLR (rACLR), rACLR and lateral extra-articular tenodesis (LET), or isolated LET in patients with a grade ≥2 pivot shift after ACLR with an intact or partially torn graft and a new, symptomatic medial meniscal tear., Study Design: Cohort study; Level of evidence, 3., Methods: A retrospective review of all patients with a new, symptomatic medial meniscal tear diagnosed after a primary ACLR was performed. Patients were included if they demonstrated a grade ≥2 pivot shift on physical examination with an intact or partially torn ACL graft. Exclusion criteria included complete graft rupture. The senior author's management evolved in a practice change design from rACLR to rACLR with LET, to isolated LET over the study period. The primary outcomes were the International Knee Documentation Committee (IKDC), Lysholm, and Tegner patient-reported outcomes (PROs) at 2 years postoperatively., Results: A total of 47 patients, with 16 in the rACLR group, 12 in the rACLR and LET group, and 19 in the isolated LET group were included. Baseline characteristics between groups were similar. At 2 years, the rACLR group IKDC score was 86.1 ± 6.6 and was lower than the rACLR and LET group (91.9 ± 4.4; P = .009; 95% CI, -10.4 to -1.2) and the isolated LET group scores (91.7 ± 3.0; P = .004; 95% CI, -9.7 to -1.6). The Lysholm score was lower in the rACLR group (85.8 ± 6.3) when compared with the rACLR and LET group (91.8 ± 4.6; P = .03; 95% CI, -11.8 to -0.39). There was no difference in any Tegner scores at 2 years ( P = .09)., Conclusion: In patients with grade ≥2 pivot shift after an ACLR with an intact or partially torn graft and a new, symptomatic medial meniscal tear, the addition of an LET with or without rACLR led to improved PROs compared with an isolated rACLR. An isolated LET in this patient population should be considered an acceptable treatment option., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.J.H. has received hospitality payments from Arthrex. J.C.B. has received hospitality payments from Stryker and education payments from ImpactOrtho. S.V.T. has received hospitality payments from Stryker and education payments from ImpactOrtho. K.J.E. has received education payments from Goode Surgical and hospitality payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained from Western Copernicus Group institutional review board (ref No. 20216101)., (© The Author(s) 2025.)

Background: Medicare (MCR) reimbursement for arthroplasty procedures has been declining, but little has been reported on Medicaid (MCD) reimbursement. We sought to determine MCD reimbursement rates using state MCD data for nine arthroplasty procedure codes and compare them to MCR rates., Methods: The Centers for Medicare & Medicaid Services physician fee schedule was used to collect MCR reimbursement rates, and state MCD fee schedules were accessed to collect MCD rates for nine procedures encompassing primary and revision hip and knee arthroplasty surgery. State MCR and MCD rates were compared to determine the mean dollar difference and dollar difference per relative value unit. A cost of living adjustment was performed using the Medicare Wage Index for each state. Coefficients of variation were calculated for each state to determine overall variability between the two systems., Results: The mean reimbursement rates for MCD were lower for eight of the nine codes used in the study. Medicaid reimbursed physicians an average of 11.3% less overall and 23.1% less when adjusted for cost of living. The amount of variability in the MCR rates was low with a consistent coefficient of variation of 0.06, but was higher in the MCD rates with a range of 0.26 to 0.29 in the unadjusted rates and 0.34 to 0.37 in the adjusted rates. There was a mean $6.73 decreased reimbursement per relative value unit for MCD procedures., Conclusions: For the most common arthroplasty procedures, MCD reimbursed physicians less than MCR on average. MCD also demonstrated increased variability when compared to MCR rates between states., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: It has been demonstrated that an athlete's psychological readiness contributes to one's ability to successfully return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction. However, the effect of graft choice on psychological readiness is not yet understood., Purpose/hypothesis: The purpose of this study was to evaluate the association between graft choice and an athlete's psychological readiness to RTS. It was hypothesized that similar ACL-Return to Sport after Injury (ACL-RSI) scores would be achieved among patients who underwent ACL reconstruction with quadriceps autograft (QA), hamstring tendon autograft (HA), and bone-patellar tendon-bone (BTB) autograft., Study Design: Cohort study; Level of evidence, 3., Methods: Patients who underwent primary ACL reconstruction at a single institution between January 2017 and December 2018 were placed into separate cohorts depending on graft type (HA, BTB, or QA; n = 30 patients in each group), and the ACL-RSI, International Knee Documentation Committee subjective form, and Lysholm scores were compared between the different graft cohorts at 6 months postoperatively, at RTS, and at 2 years postoperatively. Also, the rate of patients who achieved an ACL-RSI score of ≥65 (predictive of return to preinjury sport at 2 years postoperatively) was calculated, as was the RTS rate and time., Results: The QA group demonstrated significantly higher ACL-RSI scores than both the HA and BTB groups at 6 months postoperatively ( P < .0001) and RTS ( P = .011). The QA group also had a higher rate of achieving ≥65 on ACL-RSI than the other groups at 6 months postoperatively ( P = .002) and RTS ( P = .024). There was no significant difference in the RTS rate between the 3 groups, although the QA group demonstrated a significantly quicker return (QA, 8.1 months; BTB, 9.6 months; HA, 10.5 months; P < .001)., Conclusion: Athletes undergoing primary ACL reconstruction with QA achieved a higher mean ACL-RSI score and more often achieved a score of ≥65 at the 6-month and RTS time points compared with the HA and BTB groups. QA may afford an advantage over other grafts in terms of improved psychological readiness to RTS., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.C.B. has received education payments from ImpactOrtho and hospitality payments from Stryker and Medtronic. J.D.H. has received grant support from Arthrex and DJO; education payments from Smith & Nephew, Gemini Mountain Medical, ImpactOrtho, Medical Device Business Services, and Goode Surgical; and hospitality payments from Stryker, Zimmer Biomet, Avanos Medical, Heraeus Medical, and DePuy Synthes. S.V.T. has received education payments from ImpactOrtho and hospitality payments from Stryker and Avanos Medical. J.M.H. has received education payments from ImpactOrtho and hospitality payments from Stryker, Medtronic, and NuVasive. J.L.M. has received education payments from Arthrex, Smith & Nephew, ImpactOrtho, Davol, Stryker, Vericel, DePuy Synthes, and Goode Surgical. K.J.E. has received education payments from Goode Surgical; nonconsulting fees from Goode Surgical and Arthrex; and hospitality payments from Stryker, Zimmer Biomet, Smith & Nephew, Desert Mountain Medical, and Trice Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2025.)

Purpose: To compare the surgical outcomes of anterior cruciate ligament (ACL) reconstruction using hamstring autograft (HA) plus lateral extra-articular tenodesis (LET), isolated all-soft tissue quadriceps autograft (QA), and isolated HA., Methods: A retrospective review was performed comparing high-risk patients undergoing ACL reconstruction with isolated HA, isolated QA, or HA + LET from August 2013 to January 2023. High-risk patients, as determined by high-grade pivot shift or generalized ligament laxity, with at least a 2-year follow-up, were included. Lysholm and International Knee Documentation Committee scores were compared at 3, 6, 12, and 24 months postoperatively. Retear rate, postoperative pivot-shift grade, return to sport, and complications were recorded., Results: In total, 159 patients (56 HA, 47 HA + LET, and 56 QA) were included. At 6 months postoperatively, the HA International Knee Documentation Committee score was significantly lower than that of the HA + LET and QA groups (P < .0001). Similarly, the Lysholm score was significantly lower in the HA cohort at 6 months, 1 year, and 2 years postoperatively (P < .0001-.02). There was no difference in the rate of achieving the minimally important clinical difference between the cohorts for either of these outcome scores. The retear rate was significantly higher in the HA group (17.9%) compared to the HA + LET (4.3%) and QA (1.8%) cohorts (P = .01). The rate of postoperative pivot shift of grade 2 or more was also higher in the isolated HA group (P = .04)., Conclusions: The use of an all-soft tissue QA or HA + LET for ACL reconstruction resulted in a lower retear rate and postoperative pivot-shift grade compared to an isolated HA graft in high-risk patients at 2 years postoperatively. There was no difference in the rate of achieving the minimal clinically important difference between the cohorts. The QA and HA + LET reconstruction options may improve stability and decrease the failure rate compared with HA reconstruction alone., Level of Evidence: III, retrospective cohort study., (Copyright © 2025 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze and quantify the change in United States of America Medicare reimbursement rates for the 30 most commonly performed spinal imaging procedures., Materials and Methods: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was utilized to find and extract the 28 most billed spinal imaging procedures. All data was adjusted for inflation and listed in 2020 US dollars. Percent change in reimbursement and Relative Value Units between 2005 and 2020, both unadjusted and adjusted, were calculated and compared. Additionally, percent change per year and compound annual growth rate were calculated and compared., Results: After adjusting for inflation, the average reimbursement for all analyzed spinal imaging procedures between the years 2005 and 2020 decreased by 45.9%. The adjusted reimbursement rate for all procedures decreased at an average 4.3% per year and experienced an average compound annual growth rate (CAGR) of - 4.4%. Magnetic resonance imaging (MRI) had the most substantial adjusted decline of all imaging modalities at - 72.6%, whereas x-ray imaging had the smallest decline at - 27.33%. The average total RVUs per procedure decreased by 50.1%, from 7.96 to 3.97., Conclusion: From the years 2005 to 2020, Medicare reimbursement significantly decreased for all advanced imaging modalities involving the most common spinal imaging procedures. Among all practices, imaging procedures may be experiencing some of the largest decreases from Medicare reimbursement cutbacks., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Purpose: To compare Medicaid and Medicare rates for the 20 most commonly billed orthopaedic sports medicine procedures., Methods: Medicaid reimbursement rates were obtained from state-specific fee schedules. Medicare rates were collected from the Centers for Medicare & Medicaid Services Physician Fee Schedule, along with relative value units for each procedure. State rates were compared using averages and dollar differences. Reimbursement rates were adjusted for cost of living using the Medicare Wage Index. Variability between states and between procedures was assessed using coefficients of variation., Results: Mean Medicaid reimbursement was lower than that of Medicare for 19 of the 20 procedures. In total, Medicaid reimbursed surgeons 14.9% less when data were unadjusted and 26.0% less when data were adjusted for cost of living. Variation in Medicare rates between states was constant, with a coefficient of variation of 0.06. For Medicaid, the coefficients of variation ranged from 0.27 to 0.70 for unadjusted data and from 0.35 to 0.69 for adjusted data., Conclusions: On average, Medicaid reimburses orthopaedic sports medicine specialists less than does Medicare, with substantial variability between states. Adjustment for cost of living increases the percentage difference and the variability between states' Medicaid reimbursement rates., Level of Evidence: Level IV, economic analysis., Competing Interests: Disclosures The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A.C. reports a consulting or advisory relationship with Arthrex, Smith & Nephew, and Zimmer Biomet; receives speaking and lecture fees from Arthrex; and receives publishing royalties and financial or material support from Wolters Kluwer Health–Lippincott Williams & Wilkins. All other authors (A.P.H., M.L.M., D.W.B., P.R.V.S., J.C.B., J.M.H.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: Sliding hip screw (SHS) and intramedullary (IMN) constructs are commonly utilized treatments for intertrochanteric (IT) femur fractures. The aim of this study was to assess the economic and utilization trends in the management of IT fractures among the Medicare population over the last 21 years., Methods: A review of the publicly available Medicare Part B National Summary Data File for years 2000-2021 was performed. Collected data included true physician reimbursement and utilization numbers for all CPT codes pertaining to fixation of IT fractures with either SHS or IMN., Results: A total of 1,361,112 IMN implants and 739,032 SHS implants were billed to Medicare for intertrochanteric femur fractures during the studied timeline. In this 21-year span, utilization of IMN increased 695% (9648-76,667), while utilization of SHS decreased by 96% (94,223-4224). After adjusting for inflation, the average physician reimbursement for SHS decreased by 34%, while IMN decreased by 41%. Absolute physician reimbursement was found to be $943.36 for SHS and $999.88 for IMN constructs., Conclusion: Intramedullary implants are being increasingly utilized while sliding hip screw, and intramedullary construct reimbursement continues to decrease for intertrochanteric femur fracture fixation. These trends suggest that opting for a sliding hip screw may be more cost-effective when the fracture pattern allows for either construct., Competing Interests: Declarations. Conflict of interest: The authors declare no conflict of interest., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: To characterize the relationship between testosterone replacement therapy (TRT) and anterior cruciate ligament (ACL) injuries., Methods: A retrospective cohort study using a large insurance database was conducted. Patients who were prescribed TRT for at least 3 months were matched with controls who were not prescribed TRT. Rates of ACL tears were compared between the cohorts. Multiple subgroups were created based on age (<25, 25-35, 36-45, 46-55, 56-65, and 65+ years). Multivariable logistic regressions were performed to determine the association of TRT with ACL tears while accounting for demographic variables and comorbidities., Results: After matching, there were 160,839 patients in both the TRT cohort and the control cohort. The incidence of ACL injuries was 17.8 per 10,000 person-years (95% confidence interval [CI]: 16.4-19.2) for patients who were prescribed TRT and 4.9 per 10,000 person-years (95% CI: 4.1-5.7) for controls (P < .001). Within 2 years of filling a testosterone prescription for at least 3 months, 572 (0.35%) patients experienced an ACL injury compared to only 157 (0.10%) controls during the same follow-up period (odds ratio: 2.77; 95% CI: 2.26-3.42, P < .001). When stratified by age, all groups except the <25 years of age group demonstrated a significantly higher rate of ACL tears (odds ratio 3.91-12.3, P < .001-.009). When separated by sex, males on TRT were 3.13 (95% CI: 2.50-3.93, P < .001) times more likely while females on TRT were 1.94 (95% CI: 1.13-3.41, P = .018) times more likely to experience an ACL injury compared to controls., Conclusions: This study found that patients prescribed at least 3 months of TRT had a significantly higher incidence of ACL injuries compared to controls within a 2-year follow-up period., Level of Evidence: Level III, retrospective comparative study., Competing Interests: Disclosures The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A.C. is a consultant and member of the Speaker’s Bureau for Arthrex; and a consultant for Zimmer Biomey and Trice Medical. All other authors (J.C.B., A.M.H., B.R.P., C.S.P. S.V.T., J.M.H.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Loss of shoulder function can be a complex condition to manage. Specifically, the definition between the terms pseudoparalysis and pseudoparesis remains inconsistent in the literature based on various factors including chronicity, present pathology, and the role of pain in the loss of function. There is also debate as to the optimal management strategies for these challenging conditions. In the setting of advanced glenohumeral arthritis or arthropathy in the correct patient, arthroplasty provides consistent and reliable results. However, in younger patients or the patient without arthritis, arthroplasty may not be the best option. In some cases, addressing pain with biceps procedures, balloon spacer placement, débridement, or others may be appropriate. However, other instances may require attempts at improving shoulder kinematics with procedures such as rotator cuff repair, superior capsular reconstruction, and tendon transfer. In this review, we discuss current definitions for pseudoparalysis and pseudoparesis, in addition to reviewing the indications for the various treatment options and their respective outcomes., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Objectives: This study seeks to evaluate the variability of Medicaid reimbursement and compare it with Medicare reimbursement using the 20 most commonly billed orthopaedic trauma Current Procedural Terminology (CPT) codes nationwide. The authors anticipate significant variability between states and hypothesize that Medicaid payment will be significantly less than Medicare payment., Methods: The top 20 most common orthopaedic trauma surgery procedural codes were identified from a previous analysis performed by Haglin et al. The Centers for Medicare and Medicaid Services Physician Fee Schedule was used to determine reimbursement rates from Medicare, and state Medicaid fee schedules were used to determine reimbursement rates for Medicaid. State Medicaid rates were compared with their corresponding Medicare rates to determine a dollar difference. In addition, the dollar difference for each CPT code was divided by its respective physician relative value unit. This was used to acknowledge the possible variability in the complexity of orthopaedic procedures and the related physician effort. The Medicare Wage Index was used to adjust Medicaid rates based on the cost of living for the state as well. Coefficients of variation were calculated to represent overall variability in Medicaid and Medicare reimbursement rates., Results: The mean reimbursement rates for Medicaid were lower for all 20 procedures compared with Medicare. On average, Medicaid reimbursed 16.0% less than Medicare and 29.6% less when adjusting for cost of living. MCD reimbursed at a higher rate than MCR for all procedures in only 9 states (Alaska, Arizona, Arkansas, Montana, Nebraska, New Jersey, New Mexico, North Dakota, and South Dakota) while 38 states reimbursed at a lower rate than MCR, on average. The coefficient of variation ranged from 0.24 to 0.34 for the Medicaid unadjusted group and from 0.35 to 0.46 for the Medicare Wage Index-adjusted group. By contrast, the Medicare group was consistent at 0.06 for all 20 procedures. The average dollar difference across the 20 CPT codes for Medicaid reimbursement compared with Medicare reimbursement ranged from -$76.89 to -$225.17, and the dollar difference per relative value unit ranged from -$5.96 to -$15.16., Conclusions: This study found a high amount of variation between state Medicaid reimbursement rates and average rates that were significantly lower than Medicare reimbursement rates for the top 20 most used orthopaedic trauma CPT codes as identified by Haglin et al. The discrepancy in reimbursement was increased when Medicaid rates were adjusted for state cost of living., Level of Evidence: Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Anterior glenohumeral instability is one of the most common injuries suffered from sport. Despite padding and conditioning, the shoulder joint remains particularly vulnerable to injury, especially in the setting of contact. The overall rate of anterior instability is reported to be 0.12 injuries per 1000 athlete exposures, although this is increased up to 0.40 to 0.51 in the contact athlete. Successful treatment requires consideration of restoring stability while minimizing loss of glenohumeral motion. Common treatment strategies involve addressing the pathology that results from anterior shoulder dislocation including labral detachment as well as bony defects to the humeral head and glenoid., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effects of this graft preparation technique on histologic evidence of tenocyte mechanical damage., Methods: A consecutive series of patients undergoing biceps tenodesis for shoulder pathology were evaluated. After suprapectoral tenodesis, 27 mm of the long head of the biceps was secured for compression into the patch. The remaining length of the residual tendon was longitudinally split, resulting in 2 equal lengths of remnant tendon from the same zone. One sample was sent to pathology with no preparation, and the other was prepared as a compressed biceps autograft patch according to the manufacturer's recommendations. Both grafts were sent to pathology for evaluation of tenocyte morphology. Records were reviewed to determine if compression resulted in mechanical damage to the tenocytes at the time of biceps augmentation., Results: Fifty-five shoulder procedures and 110 samples were sent for pathology analysis. Forty-two of the 55 (76%) specimens demonstrated morphologically normal tenocytes in both the compressed and noncompressed groups, and 7 (13%) cases showed evidence of tenocyte necrosis or mechanical damage in both groups. The difference in abnormal tenocyte morphology between the compressed and native groups was not statistically significant (P = .625)., Conclusions: Autograft biceps compression into a point-of-care patch did not result in mechanical damage to tenocyte morphology at the time of insertion for augmentation of rotator cuff pathology., Clinical Relevance: Free proximal biceps tendon compression can result in a patch that does not mechanically damage the tenocyte. The patch can be used as a biologic autograft to enhance shoulder rotator cuff repair, as well as subscapularis repair in the setting of shoulder arthroplasty., Competing Interests: Disclosures The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: J.C.B. is a member of the Editorial Board for Arthroscopy. P.J.D. received educational support and consultant fees from Arthrex. G.P.C. received educational support from Smith & Nephew and Peerless. J.M.T. received consultant fees from Arthrex and educational support from Arthrex, DePuy, Supreme Orthopedic, Impact Ortho, and Stryker. All other authors (J.L.M., J.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to assess the relationship between risk and reimbursement for both surgeons and hospitals among Medicare patients undergoing primary total joint arthroplasty (TJA)., Methods: The "2021 Medicare Physician and Other Provider" and "2021 Medicare Inpatient Hospitals" files were used. Patient comorbidity profiles were collected, including the mean patient hierarchal condition category (HCC) risk score. Surgeon data included all primary TJA procedures (inpatient and outpatient) billed to Medicare in 2021, while hospital data included all such inpatient episodes. Surgeon and hospital reimbursements were collected. All episodes were split into a "sicker cohort" with an HCC risk score of 1.5 or more and a "healthier cohort" with HCC risk scores less than 1.5. Variables were compared across cohorts., Results: In 2021, 386,355 primary total hip and knee arthroplasty procedures were billed to Medicare and were included. The mean surgeon reimbursement among the sicker cohort was $1,021.91, which was less than for the healthier cohort of $1,060.13 (P < .001). Meanwhile, for the hospital analysis, 112,012 Medicare TJA patients were admitted as inpatients and included. The mean reimbursement to hospitals was significantly greater for the sicker cohort at $13,950.66, compared to the healthier cohort of $8,430.46. For both analyses, the sicker patient cohorts had a significantly higher rate of all comorbidities assessed (P < .001)., Conclusions: This study demonstrates that mean surgeon reimbursement was lower for primary TJA among sicker patients in comparison to their healthier counterparts, while hospital reimbursement was higher for sicker patients. This represents a discrepancy in the incentivization of care for complex patients, as hospitals receive increased remuneration for taking on extra risk, while surgeons get paid less on average for performing TJA on sicker patients. Such data should inform future policy to assure continued access to arthroplasty care among complex patients., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Aseptic revisions are the most common reason for revision total knee arthroplasty (rTKA). Previous literature reports early periprosthetic joint infection (PJI) rates after aseptic rTKA to range from 3 to 9.4%. Intraosseous (IO) regional administration of vancomycin has previously been shown to produce high local tissue concentrations in primary and rTKA. However, no data exist on the effect of prophylactic IO vancomycin on early PJI rates in the setting of aseptic rTKA. The aim of this study was to determine the following: (1) what is the rate of early PJI during the first year after surgery in aseptic rTKA performed with IO vancomycin; and (2) how does this compare to previously published PJI rates after rTKA., Methods: A consecutive series of 117 cases were included in this study who underwent rTKA between January 2016 and March 2022 by 1 of 2 fellowship-trained adult reconstruction surgeons and received IO vancomycin at the time of surgery in addition to standard intravenous antibiotic prophylaxis. Rates of PJI at 3 months, 1 year, and the final follow-up were evaluated and compared to prior literature., Results: Follow-up at 3 months was available for 116 of the 117 rTKAs, with 1 lost to follow-up. The rate of PJI was 0% at 3 months postoperatively. Follow-up at 1 year was obtained for 113 of the 117 rTKAs, and the PJI rate remained 0%. The rate of PJI at the final follow-up of ≥ 1 year was 0.88% (95% confidence interval: -0.84 to 2.61). Previous literature reports PJI rates in aseptic rTKA to range from 3 to 9.4%., Conclusions: Dual prophylactic antibiotics with IO vancomycin in conjunction with intravenous cephalosporins or clindamycin were associated with a substantial reduction in early PJI compared to prior published literature. These data supplement the early evidence about the potential clinical benefits of IO vancomycin for infection prevention in high-risk cases., Level of Evidence: Level III, therapeutic study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Patella baja is a known complication of total knee arthroplasty (TKA). There is a limited understanding of the association between patellar resurfacing and the incidence of patella baja. We aimed to compare rates of patella baja between unresurfaced and resurfaced patellas in patients undergoing TKA., Methods: A retrospective review of patients who underwent TKA between October 2009 and January 2020 was performed. Patients were included if they had at least one preoperative radiograph and a 1-year follow-up radiograph. Blackburne-Peel index (BPI) and Insall-Salvati ratios (ISRs) were measured on preoperative and 1-year postoperative radiographs and were used to define patella baja vs pseudopatella baja. Statistical analysis was performed using a linear model analysis of variance and the Fisher's exact test., Results: Three hundred eighteen TKAs were included, with 176 being resurfaced and 142 unresurfaced patellas. Of the resurfaced group, 4% (7/176) had true patella baja, compared to 5.6% (8/142) of the unresurfaced patellas. Of the resurfaced patellas, 8% (14/176) had pseudopatella baja, compared to 7% (10/142) in the unresurfaced group. Patellar resurfacing was not associated with a higher incidence of patella baja ( P  = .60) or pseudopatella baja ( P  = .83). Lower preoperative ISRs ( P  = .04) and BPIs (0.03) were highly predictive of a higher incidence of patella baja post-TKA., Conclusions: Patellar resurfacing in TKA is not associated with a higher incidence of patella baja in TKA when compared to unresurfaced patellas. Lower preoperative ISRs and BPIs are highly predictive of a higher incidence of postoperative patella baja., (© 2024 The Authors.)

Purpose: To assess surgeon reimbursement for common arthroscopic procedures, including arthroscopic meniscal debridement and arthroscopic rotator cuff repair, in patients with differing risk profiles within the Medicare population., Methods: A publicly available Medicare database was used to identify all cases of arthroscopic meniscal debridement and arthroscopic rotator cuff repair procedures billed to Medicare from 2013 to 2020. The surgeon reimbursement from Medicare was collected and adjusted for inflation. All procedure episodes were split into 2 cohorts; those with a hierarchical condition category (HCC) risk score ≥1.5, and those with patient HCC risk scores <1.5. Reimbursement rates were compared between groups., Results: From 2013 to 2020, a total of 624,077 meniscal debridement procedures and 567,794 arthroscopic rotator cuff repairs were billed to Medicare Part B. During this time, the mean adjusted surgeon reimbursement for arthroscopic rotator cuff repair decreased by 9.2% from 2013 to 2020. During the same time period, the adjusted mean surgeon reimbursement for arthroscopic both compartment meniscal debridement and single compartment meniscal debridement decreased by 7.9% and 9.9%, respectively. Throughout the study period, the mean HCC risk score increased from 1.19 in 2013 to 1.31 in 2020 ( P < .001). Across all years in the study, the sicker cohort had a significantly greater rate of all comorbidities and a greater mean body mass index ( P < .001 for all variables). The mean reimbursement across this cohort was lower for both rotator cuff repair ( P  = .037) and meniscal debridement procedures ( P < .001) compared with the healthier cohort., Conclusions: This study demonstrates that from 2013 to 2020, inflation-adjusted surgeon reimbursement for arthroscopic rotator cuff repair and meniscal debridement decreased while patient complexity increased. Further, mean surgeon reimbursement was lower among patients with more complexity in comparison with their healthier counterparts for such procedures., Level of Evidence: Level III, retrospective cohort study., Competing Interests: All authors (J.M.H., J.C.B., E.L., S.V.T, K.S.M., K.A.P., and A.C.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Social determinants of health are implicated in the experience of knee osteoarthritis, a key component of which is access to care and healthcare utilization. The objective of this study was to describe difficulties in access to care and healthcare utilization in the United States knee osteoarthritis population., Methods: The publicly available All of Us Database was utilized to conduct a retrospective cohort study. Patients with a diagnosis of knee osteoarthritis were included and matched to a control group who did not have knee osteoarthritis. The association of knee osteoarthritis and patient-specific demographic features with self-reported domains of access to care was analyzed., Results: Among 15,718 patients with knee osteoarthritis, 27.6% reported delayed care (n = 4343), 25.6% reported inability to afford care (n = 4015), 12.8% reported skipped medications (n = 2011), and 1.6% reported not seeing a healthcare provider in over 1 year (n = 247). Patients with knee osteoarthritis were more likely to be unable to afford care (odds ratio 1.21, P < .001) or skip medications (odds ratio 1.12, P  = .004) in comparison to matched patients without knee osteoarthritis. Among the knee osteoarthritis cohort, low income and nonheterosexual orientation were both associated with increased rates of delayed care and an inability to afford care., Conclusions: Patients with knee osteoarthritis report significant challenges with delayed care, affordability of care, and medication adherence. Among patients with knee osteoarthritis, patients who are younger age, female sex, low-income, low-education, nonheterosexual orientation, or have poor physical and mental health are at increased risk of having decreased access to treatment., (© 2024 The Authors.)

Purpose: To use Google trends to explore differences in public interest among types of anterior cruciate ligament (ACL) autografts, specifically quadriceps tendon, patellar tendon, and hamstring tendon autografts, between 2008 and 2019., Methods: Data were obtained by querying Google Trends for key terms and phrases for online search data ranging from January 2008 to December 2019. Relative search volumes were created based on searches related to ACL reconstruction with comparative analysis generated for search terms related to quadriceps ACL, patellar tendon ACL, and hamstring ACL autografts. Statistical analysis included linear regression analysis, comparison of quarterly search volume trends over time, and comparison of cumulative annual search volumes for 2008 versus 2019., Results: Linear models for respective search terms were statistically significant for the quadriceps ( P < .001) and patellar ( P  = .007) tendon autograft groups but not the hamstring group ( P  = .129). The quadriceps autograft group demonstrated a 12-year search volume trend change of 0.56, which was significantly greater than the hamstring (0.07; P < .001) and patellar tendon (0.168; P < .001) groups. There was no significant difference in the trend change between hamstring and patellar tendon groups ( P  = .20). Percent change in cumulative relative annual search volumes between 2008 and 2019 was 112% for the quadriceps tendon group, 12.9% for the hamstring group, and 18.6% for the patellar tendon group., Conclusions: This study indicates a consistently increasing public interest in quadriceps tendon autograft for ACL reconstruction. The quadriceps autograft group demonstrated a significantly greater 12-year online search volume, greater linear correlation, and larger percent change between 2008 and 2019 compared with patellar tendon or hamstring autograft groups., Clinical Relevance: Awareness of patient perceptions has value in informing shared decision-making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research., Competing Interests: The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (© 2024 The Authors.)

Patellar tendon ruptures can be debilitating injuries. When incomplete, partial tears can be managed nonsurgically with immobilization and progressive rehabilitation. Although complete ruptures remain a relatively uncommon injury, they portend a high level of morbidity. Ruptures typically result from an acute mechanical overload to the extensor mechanism, such as with forced quadriceps contraction and knee flexion. However, chronically degenerated tendons are also predisposed to failure from low-energy injuries. Diagnosis can often be made clinically with recognition of a palpable defect to the tendon, localized patellar tendon tenderness, and inability to actively extend the knee. Diagnosis and surgical planning can be established with radiograph, ultrasonography, or magnetic resonance imaging. Surgical repair is the mainstay of treatment, and there have been many recent advances in repair technique, optimal reconstruction strategies, and supplemental fixation. Time to surgery for complete tears remains the most important prognosticator for success. Direct primary repair can be completed with transosseous tunnels, suture anchor repair, or end-to-end repair. Tendon reconstruction can be achieved with or without mechanical or biologic augments. Rehabilitation programs vary in specifics, but return to sport can be expected by 6 months postoperatively., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Purpose of Review: Massive irreparable rotator cuff tears (MIRCTs) present treatment challenges. Recently, superior capsule reconstruction (SCR) and anterior cable reconstruction have emerged as surgical options, but no single approach is superior. This review provides an overview of SCR and cable reconstruction techniques, including biomechanical studies, clinical outcomes, and surgical considerations., Recent Findings: Biomechanical studies show SCR with autografts or allografts improves glenohumeral stability and mechanics. Clinical outcomes of SCR demonstrate improved range of motion, function scores, and pain relief in short-term studies. Anterior cable reconstruction reduces superior humeral head translation and subacromial pressures in biomechanical models. Early clinical studies report improved rotator cuff healing and outcomes for cable reconstruction in specific irreparable tear patterns. SCR and cable reconstruction are viable surgical options for MIRCTs based on early encouraging results. However, higher-level comparative studies with long-term follow-up are still needed. Careful consideration of tear pattern, patient factors, and surgical goals is required to optimize treatment of MIRCTs. Further research is necessary to determine the optimal role for these procedures., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: There is limited evidence related to the effects of autograft type on functional performance after anterior cruciate ligament reconstruction (ACLR)., Purpose/hypothesis: This study aimed to compare biomechanical outcomes during a drop vertical jump (DVJ) between patients with a hamstring tendon (HT) autograft, quadriceps tendon (QT) autograft with bone block, QT autograft without bone block, and bone-patellar tendon-bone autograft at 6 months postoperatively in an adolescent population. The authors' hypothesized there would be differences in DVJ biomechanics between athletes depending on the type of autograft used., Study Design: Controlled laboratory study., Methods: Patients aged 8 to 18 years who underwent primary ACLR were included for analysis. Kinematic and kinetic data collected during a DVJ using a 3-dimensional computerized marker system were assessed at 6 months after ACLR and compared with the uninjured contralateral limb., Results: A total of 155 participants were included. There were no significant differences in terms of age, sex, or affected leg ( P ≥ .1973) between groups. The HT group was significantly associated with a larger knee valgus moment at initial contact compared with the QT group (28 × 10 -2 vs -35 × 10 -2 N·m/kg, respectively; P = .0254) and a significantly larger maximum hip adduction moment compared with the QT with bone block group (30 × 10 -2 vs -4 × 10 -2 N·m/kg, respectively; P = .0426). Both the QT with bone block (-12 × 10 -2 vs -3 × 10 -2 N·m/kg, respectively; P = .0265) and QT (-13 × 10 -2 vs -3 × 10 -2 N·m/kg, respectively; P = .0459) groups demonstrated significantly decreased mean knee extension moments compared with the HT group., Conclusion: The findings of this study suggest that utilizing an HT autograft resulted in a significantly increased knee valgus moment at initial contact compared with a QT autograft without bone block at 6 months after ACLR in adolescent patients performing a DVJ. A QT autograft was found to be associated with significantly decreased extensor mechanism function compared with an HT autograft., Clinical Relevance: This study adds unique kinematic and kinetic information regarding various ACLR autograft options and highlights the biomechanical deficits that should be taken into consideration in rehabilitation., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: S.V.T. has received support for education from ImpactOrtho and hospitality payments from Stryker. J.V. has received support for education from ImpactOrtho and Goode Surgical and hospitality payments from Smith & Nephew. J.C.B. has received support for education from ImpactOrtho and hospitality payments from Stryker. A.C. has received consulting fees from Arthrex and Zimmer Biomet. J.M.T. has received consulting fees from Arthrex, DePuy Synthes, and Medical Device Business Services; royalties from Arthrex; and support for education from ImpactOrtho, Paladin Technology Solutions, Supreme Orthopedic Systems, and Goode Surgical. H.M. has received consulting fees from Medical Device Business Services and support for education from ImpactOrtho and Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Purpose: To determine clinical and radiographic outcomes of medial collateral ligament (MCL) pie-crusting during isolated medial meniscal root repair., Methods: A retrospective review was conducted between August 2013 and December 2019 in patients undergoing isolated medial meniscal root repair. Outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, re-tears, MCL laxity, and conversion to total knee arthroplasty (TKA), were compared between pie crust (PC) and non-pie crust (NPC) cohorts. Other assessments included subjective instability or stiffness, infection, and intra-operative chondromalacia. Additionally, radiographic outcomes were compared to determine progression of medial compartment arthrosis., Results: Final analysis included 97 knees, 45 in the PC, and 52 in the NPC group. IKDC and Lysholm scores were similar between both groups preoperatively and 3 months postoperatively. However, at the 6,12, and 24-month follow up, the PC group had a significantly higher measured IKDC and Lysholm scores than the NPC group. PASS percentages for the IKDC score were significantly higher in the PC group at 6 months, 1 year, and 2 years (96.2%; P = .02) follow-up compared to the NPC group. MCID percentages for the IKDC score were also significantly higher at the 1- and 2-year (100%; P = .05) follow-up in the PC group compared to the NPC group. There was also a significantly higher rate of recurrent medial meniscal root tears in the NPC group (4 [8.9%]) compared to the PC group (0 [P = .03]). No MCL laxity was observed at 6 months follow-up., Conclusions: MCL pie-crusting during isolated medial meniscal root repair can be used as an alternative surgical technique, as it leads to improved clinical and patient outcomes compared to patients who do not undergo MCL pie-crusting in the short term. Additionally, those that underwent MCL pie-crusting had a lower incidence of recurrent tears, and no patients experienced MCL laxity at 6 months., Level of Evidence: Level III, retrospective cohort/comparative study., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess outcomes of arthroscopic posterior capsular release among athletes for loss of terminal extension following anterior cruciate ligament (ACL) reconstruction., Methods: A retrospective review of prospectively collected data was performed for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction between January 2014 and December 2019. Procedure indications included extension loss greater than 10° at least 3 months after ACL reconstruction that was refractory to physical therapy. Patients were included if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least 2 years of follow-up. Prospectively collected outcomes included preoperative and postoperative measurement of knee extension, International Knee Documentation Committee score, Lysholm score, return to sport data, and complications., Results: Eighteen athletes with minimum 2 years of follow-up who underwent posterior capsular release following ACL reconstruction performed by a single surgeon were included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2 years' follow-up (prerelease mean extension deficit 15.1°, postrelease mean extension deficit 1.3°, P < .005). Improvements in the International Knee Documentation Committee score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant ( P < .001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively ( P < .001). In total, 77.8% returned to sport at an average of 9.8 months from their primary ACL surgery and 6.5 months following posterior capsular release surgery. No infections or neurovascular complications were observed. One patient required secondary release to achieve adequate extension., Conclusions: For athletes with persistent knee extension loss after ACL reconstruction, knee extension was significantly improved at 2 years following arthroscopic posterior capsular release. Substantial improvements in patient-reported outcomes also were seen. In addition, subjects demonstrated a high rate of return to sport and return to preinjury performance levels., Level of Evidence: Level IV, therapeutic case series., Competing Interests: All authors (J.C.B., J.M.I., M.L.M., J.H., A.T., J.M., K.J.E.) report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (© 2024 The Authors.)

Biceps tenodesis has been proven to be an effective treatment for biceps tendon and superior labral pathology. Many techniques including both open and arthroscopic approaches have been reported. Open techniques afford management of the entire proximal biceps tendon but are limited by wound healing issues, increased bleeding, and increased surgical time. Arthroscopic tenodesis offers benefits in terms of surgical efficiency, cosmesis, and bleeding risk. However, standard arthroscopic tenodesis only addresses intra-articular biceps pathology. In this report we describe an all-arthroscopic biceps tenodesis technique at the suprapectoral region of the humerus using knotless suture anchor fixation., (© 2024 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.)

Objectives: Perform a comprehensive video analysis of all anterior cruciate ligament (ACL) injuries in National Basketball Association (NBA) athletes from 2006 to 2022 to determine the associated biomechanics, injury mechanism and game situation., Methods: NBA players diagnosed with an ACL tear from 2006 to 2022 were identified and videos of each injury evaluated by two reviewers. Visual evaluation included assessment of joint kinematics at three time points: initial contact of the injured leg with the ground (IC), 33 milliseconds later (IC+33) and 66 milliseconds later (IC+66). Game situation was assessed qualitatively., Results: Videos of 38 out of 47 (80.9%) ACL tears were obtained. 9 injuries were non-contact, while 29 involved indirect contact. Between IC and IC+33, average knee valgus increased from 5.1° to 12.0° and knee flexion increased from 12.6° to 32.6°. At all time points, the majority of injuries involved trunk tilt and rotation towards the injured leg, hip abduction and neutral foot rotation. The most common game situations for injury included the first step when attacking the basket following picking up the ball (n=13), landing following contact in the air (n=11) and jump stop (n=5)., Conclusion: Three major mechanisms predominate ACL tears in NBA players: the first step following picking up the ball when attacking, landing and jump stops. None of the injuries reviewed demonstrated direct contact to the knee, emphasising the importance of body kinematics in this injury pattern. The increase in knee valgus and knee flexion between IC and IC+33 should be noted as a possible precipitant to injury., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Shoulder and elbow function is essential to basic basketball actions. Outside of anterior shoulder instability, injuries in these joints are not well characterized in National Basketball Association (NBA) players., Purpose: To describe the epidemiology and associated risk factors of shoulder and elbow injuries in NBA players and identify factors that influence player performance upon return to play., Study Design: Descriptive epidemiology study., Methods: Historical injury data from the 2015-2020 NBA seasons were retrieved from Pro Sports Transactions, a public online database. An injury was defined as a health-related concern resulting in an absence of ≥1 NBA games. Primary measures included pre- and postinjury player efficiency rating (PER) and true shooting percentage (TS%) with interquartile ranges (IQRs), stratified by extremity dominance. Multivariate logistic regression analyses with stepwise regression were performed to identify risk factors associated with return-to-play performance., Results: A total of 192 shoulder and elbow injuries were sustained among 126 NBA athletes, with incidence rates of 1.11 per 1000 game exposures (GEs) and 0.30 per 1000 GEs, respectively. Sprain/strain and general soreness were the most common injury types in both the shoulder and the elbow. In the 2 years after injury, baseline PER was achieved in all groups, except for players with dominant shoulder injuries (baseline PER, 16 [IQR, 14-18] vs 2-year PER, 13 [IQR 11-16]; P = .012). Younger age was associated with quicker return to baseline PER (odds ratio, 0.77 [95% CI, 0.67-0.88]). Shoulder and elbow injuries did not negatively influence TS% upon return to play (baseline TS%, 0.55% [IQR, 0.51%-0.58%] vs 1-year TS%, 0.55% [IQR, 0.52%-0.58%]; P = .13)., Conclusion: Dominant shoulder injuries negatively influenced PER during the first 2 seasons upon return to play in NBA players. Therefore, expectations that players with this type of injury immediately achieve baseline statistical production should be tempered. Shooting accuracy appears to remain unaffected after shoulder or elbow injury., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: S.V.T. has received education payments from ImpactOrtho. A.C. has received consulting fees from Arthrex and Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was waived by Mayo Clinic (ref No. 21-009369)., (© The Author(s) 2023.)

Background: The optimal graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in the high-level cutting and pivoting athlete remains controversial. Studies have shown similar outcomes when directly comparing bone-patellar tendon-bone (BPTB) autograft versus quadriceps soft tissue (QST) autograft in the general population. However, no studies have directly compared these 2 grafts in athletes participating in cutting and pivoting sports., Hypothesis: It was hypothesized that, compared with BPTB autograft, the QST autograft would result in similar patient-reported outcomes and rates of retear, return to sport, and complications., Study Design: Cohort study; Level of evidence, 3., Methods: A retrospective review was performed on athletes participating in cutting and pivoting sports (soccer, American football, lacrosse, and basketball) who underwent primary ACLR with either BPTB autograft or QST autograft chosen by the athlete between January 2015 and January 2019. The International Knee Documentation Committee (IKDC) subjective knee evaluation and Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. Return-to-sport and complication rates were identified. Descriptive statistics were expressed using Mann-Whitney test or Student t test for continuous variables and the chi-square test for categorical variables., Results: A total of 68 athletes (32 QST, 36 BPTB) were included for analysis. The percentage follow-up was 89% (32/36) for the QST autograft group and 86% (36/42) for the BPTB autograft group. The 2-year IKDC score (QST, 90.5 ± 6.6 vs BPTB, 89.7 ± 7.8) and 2-year Lysholm score (QST, 91.3 ± 7.5 vs BPTB, 90.5 ± 8.6) were similar between groups. The percentage of athletes able to return to sport within the follow-up period was also similar (88% vs 83%; P  = .63). There were 2 retears requiring revision in the BPTB group (6%) and no retears in the QST group ( P  = .18). One contralateral ACL rupture occurred in the QST group (3%) and 4 in the BPTB group (11%) ( P  = .21)., Conclusion: The QST and BPTB autografts demonstrated similar patient-reported outcomes, return-to-sport rates, and complication rates after primary ACLR at 2-year follow-up. Both autografts appear to be reliable and consistent options for ACLR in the cutting and pivoting athlete., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: S.V.T. has received education payments from ImpactOrtho. K.J.E. has received education payments from Goode Surgical and nonconsulting fees from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained from WCG IRB (No. 20216101)., (© The Author(s) 2023.)

We report the case of an achondroplastic female who presented with acute neurologic decline following epidural anesthesia for an elective cesarean section. Achondroplasia presents unique anatomical challenges to anesthesiologists in perioperative management, and cesarean sections are standard for achondroplastic pregnancies. High rates of spinal stenosis and lumbar radiculopathy in this patient population make administration of epidural analgesia technically challenging and may increase the risk of neurologic injury. Ultrasound is an effective means of administering epidural anesthesia for most patients; however, its utility is user-dependent and more challenging for those with obesity and abnormal spinal anatomy, both of which are common in achondroplasia. Cephalic and thoracic anatomical features in achondroplasia can also make general anesthesia challenging. Therefore, preoperative imaging may help guide preoperative planning based on patient anatomy and individual risk factors to reduce the risks of complications in this patient population. This report includes details from the patient's prenatal care, cesarean section, and 18 months of follow-up., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Renfree et al.)

Background: Meniscal root repair can improve patient outcomes significantly; however, several contraindications exist, including arthritic change to the medial or lateral tibiofemoral compartments., Purpose/hypothesis: The purpose of this study was to evaluate the outcomes of meniscal root repair in patients with advanced patellofemoral chondromalacia (PFC). It was hypothesized that the presence of advanced PFC would not significantly affect the postoperative outcomes., Study Design: Cohort study; Level of evidence, 3., Methods: A retrospective review was conducted of patients who underwent meniscal root repair with at least 2 years of follow-up data. Patients with chondromalacia as determined by arthroscopic visualization (defined as Outerbridge grade 3 or 4) were placed in the PFC group; patients with Outerbridge grade 0 to 2 chondromalacia were placed in the non-PFC group. Outcomes were measured by the Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) Subjective Knee Form. Clinical outcomes including complications were also recorded. Quantitative data between the groups were analyzed using the 2-tailed independent-samples t test., Results: Overall, this study included 81 patients (35 in the PFC group, 46 in the non-PFC group). The mean follow-up times were 25.1 months in the PFC group and 24.8 months in the non-PFC group. In both groups, Lysholm and IKDC scores improved significantly with 24-month Lysholm scores averaging 85.86 in the PFC group and 86.61 in the non-PFC group ( P = .62) and 24-month IKDC scores averaging 77.66 for the PFC group and 79.59 for the non-PFC group ( P = .45). The cohorts demonstrated similar rates of retear, arthrofibrosis, infection, and progression to total knee arthroplasty., Conclusion: The presence of advanced PFC was not associated with inferior outcomes in patients who underwent posterior meniscal root repair, and rates of recurrent tears, postoperative infection, arthrofibrosis, and conversion to total knee arthroplasty were similar between the study groups. These findings suggest that PFC may not significantly alter the results of meniscal root repair and should not be considered an absolute contraindication for this procedure., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: S.V.T. has received education payments from ImpactOrtho. K.J.E. has received education payments and nonconsulting fees from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: While previously used in other specialties, the preference signaling program (PSP) was implemented in the 2022 to 2023 orthopaedic surgery residency application process for the first time. The PSP allowed for 30 signaling tokens to be sent by applicants to programs of their choice to indicate particular interest in a program. It remains unknown how the PSP affects applicants and programs in the orthopaedic surgery residency match. Thus, this study's purpose was to assess the utility of preference signaling within the orthopaedic surgery residency application process in its inaugural year of use., Methods: An anonymous electronic survey was emailed to all orthopaedic surgery residency applicants who applied to the authors' institution during the 2022 to 2023 application cycle. The survey was sent after match lists were submitted and closed before the release of match results. The survey collected information regarding applicant demographics, preference signaling habits, and attitude toward preference signaling., Results: The survey was completed by 101 applicants. Applicants applied to a mean of 90 programs (range: 10-197) and received an average of 12 interview invitations (range: 0-39). Applicants almost uniformly used all 30 signals, with nearly two-thirds signaling their home programs (65%, 49/76), and nearly all applicants sending signals to programs at which they performed away rotations (95.7%, 88/92). Applicants received a mean of 9 invitations from programs they signaled, compared with 2 invitations from programs they did not signal. Applicants were significantly more likely to receive an interview invite at a program they signaled than one they did not (p < 0.01). Overall, 57% of applicants (57/101) found the PSP to be helpful, whereas 28% (28/101) found it to be unhelpful, and 16% (16/101) had a neutral opinion., Conclusions: This study reports that the PSP in the 2022 to 2023 orthopaedic surgery match was an effective method of expressing interest in a program because applicants were significantly more likely to receive interview invites to signaled programs. More than half of respondents felt PSP to be helpful; however, the effect on application numbers is still unclear., Level of Evidence: III., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A551)., (Copyright © 2023 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background  Patients often turn to online reviews as a source of information to inform their decisions regarding care. Existing literature has analyzed factors associated with positive online patient ratings among hand and wrist surgeons. However, there is limited in-depth analysis of factors associated with low patient satisfaction for hand and wrist surgeons. The focus of this study is to examine and characterize extremely negative reviews of hand and wrist surgeons on Yelp.com. Methods  A search was performed using the keywords "hand surgery" on Yelp.com for eight major metropolitan areas including Washington DC, Dallas, New York, Phoenix, Los Angeles, San Francisco, Boston, and Seattle. Only single-star reviews (out of a possible 5 stars) of hand and wrist surgeons were included. The complaints in the 1-star reviews were then categorized into clinical and nonclinical categories. Result  A total of 233 single-star reviews were included for analysis, which resulted in 468 total complaints. Of these complaints, 81 (18.8%) were clinically related and 351 (81.3%) were nonclinical in nature. The most common clinical complaints were for complication (24 complaints, 6%), misdiagnosis (16 complaints, 4%), unclear treatment plan (16 complaints, 4%), and uncontrolled pain (15 complaints, 3%). The most common nonclinical complaints were for physician bedside manner (93 complaints, 22%), financially related (80 complaints, 19%), unprofessional nonclinical staff (61 complaints, 14%), and wait time (46 complaints, 11%). The difference in the number of complaints for surgical and nonsurgical patients was statistically significant ( p  < 0.05) for complication and uncontrolled pain. Clinical Relevance  Patient satisfaction is dependent on a multitude of clinical and nonclinical factors. An awareness of online physician ratings is essential for hand and wrist surgeons to maintain and improve patient care and patient satisfaction. We believe the results of our study could be used to further improve the quality of care provided by hand and wrist surgeons., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Background: Ankle injuries are more common in the National Basketball Association (NBA) compared with other professional sports., Purpose/hypothesis: The purpose of this study was to report the incidence and associated risk factors of ankle injuries in NBA athletes. It was hypothesized that factors associated with an increased physiologic burden, such as minutes per game (MPG), usage rate, and associated lower extremity injury, would be associated with increased ankle injury risk and time loss., Study Design: Descriptive epidemiology study., Methods: Ankle injury data from the 2015-2016 through 2020-2021 NBA seasons were evaluated. The truncated 2019-2020 season due to the COVID-19 pandemic was omitted. The primary outcome was the incidence of ankle injuries, reported per 1000 game-exposures (GEs). Secondary analysis was performed to identify risk factors for ankle injuries through bivariate analysis and multivariable logistic regression of player demographic characteristics, performance statistics, injury characteristics, and previous lower extremity injuries. Factors influencing the time loss after injury were assessed via a negative binomial regression analysis., Results: A total of 554 ankle injuries (4.06 injuries per 1000 GEs) were sustained by NBA players over 5 NBA seasons, with sprain/strain the most common injury type (3.71 injuries per 1000 GEs). The majority of ankle injury events (55%) resulted in 2 to 10 game absences. The likelihood of sustaining an ankle injury was significantly associated with a greater number of games played ( P = .029) and previous injury to the hip, hamstring, or quadriceps ( P = .004). Increased length of absence due to ankle injury was associated with greater height ( P = .019), MPG ( P < .001), usage rate ( P = .025), points per game ( P = .011), and a prior history of foot ( P = .003), ankle ( P < .001), and knee injuries ( P < .001)., Conclusion: The incidence of ankle injuries was 4.06 per 1000 GEs in professional basketball players. Games played and prior history of hip, hamstring, or quadriceps injuries were found to be risk factors for ankle injuries. Factors associated with physiologic burden such as MPG and usage rate were associated with an increased time loss after injury., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: S.V.T. has received education payments from ImpactOrtho. K.P. has received education payments from ImpactOrtho and Arthrex and consulting fees from Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Purpose: To quantify and analyze public interest trends in platelet-rich plasma (PRP) therapy for shoulder pathology between 2011 and 2020 using Google Trends data., Methods: Google Trends data were queried for online search data ranging from January 2011 to December 2020. Various combinations of terms related to PRP and shoulder pathology were queried. Terms related to corticosteroid therapy in association with shoulder pathology were also generated for comparative analysis. Analyses were performed regarding trends in online search volumes., Results: Linear models were generated to evaluated trends in the volume of online searches for PRP and corticosteroid therapy for shoulder pathology. For both the PRP and steroid groups, linear models showed a statistically significant increase in search volume for the period studied ( P < .001). The PRP group showed a significantly greater growth rate than the steroid group ( P < .001). There were no statistically significant differences in online search volume when compared between different geographic and socioeconomic locations., Conclusions: This study indicates consistently increasing public interest in PRP injections in the shoulder. The rate of online search volume growth of PRP is significantly greater than that of corticosteroid injections for the period studied., Clinical Relevance: Awareness of patient perceptions has value in informing shared decision making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research., (© 2023 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.)

Background: The increased focus on patient satisfaction has led to growth in the use of physician rating websites., Purpose: To analyze the factors associated with online 5-star patient reviews for orthopaedic sports medicine surgeons., Study Design: Cross-sectional study., Methods: A total of 70 orthopaedic sports medicine surgeons were randomly selected from the AOSSM website. A search was performed for these surgeons on Yelp.com. All reviews other than 5 stars (of a possible 5 stars) were excluded from the study. Each review was categorized as referring to a surgical or nonsurgical aspect of care, and each comment within the review was categorized as being clinically or nonclinically related. Comments were further subcategorized by specific features such as bedside manner, clinical outcomes, and patient education. Categorical variables were analyzed using the chi-square test., Results: Overall, 400 five-star reviews were included in the study, comprising 1225 total positive comments. Of the 400 five-star reviews, 200 (50%) were from surgically treated patients, and 200 (50%) were from nonsurgically treated patients. Of the 1225 positive comments, 505 (41%) were clinically related, and 720 (59%) were nonclinical. The most common positive clinical comments were for clear treatment plans (191 reviews [48%]), good outcomes (173 reviews [43%]), and providing alternative treatment plans (55 reviews [14%]). The most common positive nonclinical comments were for good physician bedside manner (287 reviews [72%]), friendly/professional staff (194 reviews [49%]), and ease of scheduling (68 reviews [17%])., Conclusion: The majority of 5-star patient reviews left positive comments regarding nonclinical aspects of care such as physician bedside manner and friendly staff. The most common positive comments regarding clinical aspects concerned good outcomes and clear treatment plans. The overall most common positive comment, in both surgically and nonsurgically treated patients, referred to good bedside manner., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: S.T. has received education payments from ImpactOrtho. A.C. has received education payments from Arthrex and consulting fees from Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: There is a wide range of literature on patellar tendon injury, making it increasingly difficult to stay informed on the most influential studies in this field. It is essential to be familiar with the foundational articles of patellar tendon injury research to understand the current state of the literature and deliver high quality care., Purpose: To objectively identify the 50 most influential articles relating to patellar tendon injury and conduct a bibliometric analysis to identify key features of these articles., Study Design: Cross-sectional study., Methods: The Clarivate Analytics Web of Knowledge database was utilized to gather metrics on the 50 most cited articles on patellar tendon injury on June 27, 2022. The information extracted from each article included publication year, number of citations, author information, article type, level of evidence, country of origin, journal name, study focus, and industry influence., Results: The top 50 studies were cited a total of 8543 times and published between 1977 and 2015. The majority of articles were published after 2003, and the majority of citations were accrued after 2011. The most prevalent article types were cohort studies (n = 23), and the majority of studies were of evidence level 2 (n = 14) or 4 (n = 13). Australia and the United States (US) each published the most studies (n = 11). Only 4 (8%) studies focused on patellar tendon rupture, and 12 (24%) of the top 50 studies were associated with industry., Conclusion: The majority of the top 50 most influential articles in patellar tendon injury were published and accumulated citations in the past 10 to 20 years. Non-US countries, institutions, and journals published many of the top 50 studies, reflecting a global interest and commitment to research in this field. Patellar tendon rupture and surgical repair represents a minority of research in the top 50 studies and could be a point of growth in the future., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.M.H. has received education payments from ImpactOrtho. A.C. has received consulting fees from Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: The purpose of this study was to assess surgeon reimbursement among total joint arthroplasty (TJA) patients who had differing risk profiles within the Medicare population., Methods: The "2019 Medicare Physician and Other Provider" file was utilized. In 2019, 441,584 primary total hip and knee arthroplasty procedures were billed to Medicare Part B. All episodes were included. Patient demographics and comorbidity profiles were collected for all patients. Additionally, mean patient hierarchal condition category (HCC) risk scores and physician reimbursements were collected. All procedure episodes were split into 2 cohorts; those with an HCC risk score of 1.5 or greater, and those with patient HCC risk scores less than 1.5. Variables were averaged for each cohort and compared., Results: The mean reimbursement across all procedures was $1,068.03. For the sicker patient cohort with a mean HCC risk score of 1.5 or greater, there was a significantly higher rate of all comorbidities compared to the cohort with HCC risk score under 1.5. The mean payment across the sicker cohort was $1,059.21, while the mean payment among the cohort with HCC risk score under 1.5 was 1,073.32 (P = .032)., Conclusion: This study demonstrates that for Medicare patients undergoing primary TJA in 2019, the mean surgeon reimbursement was lower for primary TJA among sick patients in comparison to their healthier counterparts, although it is difficult to ascertain the impact of this discrepancy. As alternative payment models continue to undergo evaluation and development, these data will be important for the potential advancement of more equitable reimbursement models in arthroplasty care, specifically regarding surgeon reimbursement and possible risk adjustment within such models., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The use of robotics in arthroplasty surgery has increased substantially in recent years. The purpose of this study was to objectively identify the 100 most influential studies in the robotic arthroplasty literature and to conduct a bibliometric analysis of these studies to describe their key characteristics., Methods: The Clarivate Analytics Web of Knowledge database was used to gather data and metrics for robotic arthroplasty research using Boolean queries. The search list was sorted in descending order by the number of citations, and articles were included or excluded based on clinical relevance to robotic arthroplasty., Results: The top 100 studies were cited a total of 5770 times from 1997 to 2021, with rapid growth in both citation generation and the number of articles published occurring in the past 5 years. The top 100 robotic arthroplasty articles originated from 12 countries, with the United States being responsible for almost half of the top 100. The most common study types were comparative studies (36) followed by case series (20), and the most common levels of evidence were III (23) and IV (33)., Conclusions: Research on robotic arthroplasty is rapidly growing and originates from a wide variety of countries, academic institutions, and with significant industry influence. This article serves as a reference to direct orthopaedic practitioners to the 100 most influential studies in robotic arthroplasty. We hope that these 100 studies and the analysis we provide aid healthcare professionals in efficiently assessing consensus, trends, and needs within the field., (© 2023 The Authors.)

Background: The development of Achilles tendon treatment modalities has been rapid, and it is increasingly difficult for clinicians to stay up to date with the most influential studies in this field. In order to fully understand the current state of the literature regarding Achilles tendon injury, it is invaluable to be familiar with the foundational articles and studies upon which the field is built., Purpose: To objectively determine the 50 most frequently cited studies in Achilles tendon pathology and to conduct a bibliometric analysis., Study Design: Cross-sectional study., Methods: The Clarivate Analytics Web of Knowledge database was used to gather data and metrics of Achilles tendon research. The 50 most cited articles were selected for analysis from an initial 17,244 identified articles. The information extracted for each article included author name, publication year, country of origin, journal name, study type, and level of evidence., Results: For these 50 studies, the total number of citations was calculated to be 13,159, with a mean of 263.2 citations per paper. The most cited article collected 657 citations. The publication dates of the 50 studies included in this analysis spanned 41 years (1972-2013). The largest number of articles were published by Swedish authors (n = 14); however, many other countries were represented, including Canada and Finland (n = 6 articles each). The most prevalent study designs were cohort studies (n = 13) with level 4 evidence studies being the most common (n = 14)., Conclusion: Among the 50 most influential articles in Achilles tendon pathology, the study designs most commonly used were cohort studies and review articles. Sweden was the country of origin for the most studies included on this list, which reflects this country's interest and commitment to researching Achilles tendon injuries and treatments., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.A.P. has received education payments from Arthrex and ImpactOrtho. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Purpose: To determine the most frequently cited articles relating to ice hockey since 2000 and conduct a bibliometric analysis of these publications., Methods: The Clarivate Web of Knowledge database was used to gather data and generate a list of publications relating to "ice hockey" on June 20, 2022. Articles were filtered by the total number of citations accrued and were included or excluded on the basis of relevance to ice hockey; no date of publication, language, or journal restrictions. After the 50 most highly cited articles were identified, articles published before the year 2000 were excluded to avoid bias. The information analyzed from each article included author name (first and last), publication year, country of origin, institutional affiliation (of the first and last author), journal name, research design, main research topic, competition level, and the level of evidence., Results: Ultimately, 46 studies were included in this analysis. The total number of citations was 8,267 times with an average of 179.7 citations per article. The most cited article was cited 926 times. The articles came from 5 different countries, with the United States and Canada comprising 27 and 13 articles, respectively. All articles were published in English. The American Journal of Sports Medicine published the greatest number of articles. The most studied topic was concussion/traumatic brain injury (n = 26). Professional hockey was the most studied level of competition (n = 15), while college followed (n = 13). Three institutions, University of Calgary, Dartmouth School of Medicine, and University of North Carolina at Chapel Hill were responsible for 32.6% of the top articles (n = 15)., Conclusions: The majority of the most cited articles relating to ice hockey are cohort studies, review articles, and epidemiological studies originating from the United States or Canada. The majority of publications included in the analysis focused on concussion and traumatic brain injury prevalence, identification, diagnosis, outcomes, and prevention, as well as the most studied level of competition was professional, but the greatest number of participants arose from the youth and high school level., Level of Evidence: Level IV, cross-sectional study., (© 2023 The Authors.)

Introduction: The purpose of this study was to characterize factors that contribute to 1-star negative reviews regarding orthopaedic trauma surgeons., Methods: A search was done for Orthopaedic Trauma Association members on Yelp.com , Healthgrade.com , and Vitals.com in New York, Boston, San Francisco, Los Angeles, Dallas, Phoenix, Seattle, Baltimore, Denver, Houston, Philadelphia, and Washington, DC. All single-star reviews (out of a possible 5 stars) were included in this study. Reviews were categorized as either clinical or nonclinical and then further subcategorized. Categorical variables were analyzed using a chi-square test. The rate ratio (the ratio of the rate for nonsurgical divided by surgical reviews) was determined for each category., Results: Two hundred eighty-eight single-star reviews were included in the study, comprising 655 total complaints. Of all complaints, 274 (41.8%) were clinically related and 381 (58.2%) were nonclinical. Of the 288 single-star reviews, 96 (33.3%) were from surgically treated patients and 192 (66.7%) were from nonsurgical patients. Most complaints were in reference to nonclinical aspects of care such as physician bedside manner (173 reviews, 60%), not enough time spent with provider (58 reviews, 20%), and wait time (42 complaints, 15%). The most common clinical complaints were for complication (61 reviews, 21%), disagree with decision/plan (49 reviews, 17%), and uncontrolled pain (45 reviews, 16%). Surgical patients had a significantly higher rate of clinical complaints than nonsurgical patients (1.57 vs. 0.64 clinical complaints per review, P < 0.001). Nonsurgical patients had a significantly higher rate of nonclinical complaints than surgical patients (1.43 vs. 1.10 nonclinical complaints per review, P < 0.001)., Discussion: Most 1-star reviews referenced a nonclinical aspect of care with a physician's bedside manner being the most common complaint. Surgical patients were markedly more likely to reference a clinical aspect of care, such as complications or misdiagnosis compared with nonsurgical patients, who more commonly referenced nonclinical aspects of care., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Purpose: To compare the 5-year clinical and functional outcomes of the soft-tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft., Methods: A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft-tissue QT or double-tendon HT autograft with at least 5 years of follow-up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications., Results: A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2-years' postoperatively. At 5 years' postoperatively, the QT group demonstrated significantly greater IKDC (P = .018) and Lysholm (P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years' postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications., Conclusions: Although the QT autograft demonstrated increased patient-reported outcome scores when compared with the HT at 5 years' postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years' postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid-term follow-up., Level of Evidence: III, retrospective comparison study., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Medicare reimbursement is rapidly declining in many specialties. An in-depth analysis of Medicare reimbursement for routinely performed diagnostic imaging procedures in the United States is warranted., Purpose/hypothesis: The purpose of this study was to evaluate Medicare reimbursement trends for the 20 most common lower extremity imaging procedures performed between 2005 and 2020, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). We hypothesized that Medicare reimbursement for imaging procedures would decline substantially over the studied period., Study Design: Cohort study., Methods: The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was analyzed for reimbursement rates and relative value units associated with the top 20 most utilized Current Procedural Terminology (CPT) codes in lower extremity imaging from 2005 to 2020. Reimbursement rates were adjusted for inflation and listed in 2020 US dollars using the US Consumer Price Index. To compare year-to-year changes, the percentage change per year and compound annual growth rate were calculated. A 2-tailed t test was used to compare the unadjusted and adjusted percentage change over the 15-year period., Results: After adjusting for inflation, mean reimbursement for all procedures decreased by 32.41% ( P = .013). The mean adjusted percentage change per year was -2.82%, and the mean compound annual growth rate was -1.03%. Compensation for the professional and technical components for all CPT codes decreased by 33.02% and 85.78%, respectively. Mean compensation for the professional component decreased by 36.46% for radiography, 37.02% for CT, and 24.73% for MRI. Mean compensation for the technical component decreased by 7.76% for radiography, 127.66% for CT, and 207.88% for MRI. Mean total relative value units decreased by 38.7%. The commonly billed imaging procedure CPT 73720 (MRI lower extremity, other than joint, with and without contrast) had the greatest adjusted decrease of 69.89%., Conclusion: Medicare reimbursement for the most billed lower extremity imaging studies decreased by 32.41% between 2005 and 2020. The greatest decreases were noted in the technical component. Of the modalities, MRI had the largest decrease, followed by CT and then radiography., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: N.H. has received education payments from Goode Surgical and ImpactOrtho. K.P. has received education payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Introduction Subsequent anterior cruciate ligament (ACL) injury is more common in the pediatric population and encompasses graft failure and subsequent contralateral tears. Females are at a higher risk. The purpose of the present study was to compare the knee valgus angles at initial contact, knee extension moments, anterior and lateral knee joint forces, hip flexion angles, hip adduction moments, and ankle inversion during the drop vertical test in the uninjured extremity between adolescent males and females who had previously undergone an anterior cruciate ligament reconstruction (ACLR). Methods This IRB-approved retrospective chart review included patients aged 8-18 years who were seen at the five to seven month postoperatively following ACL reconstruction. A total of 168 patients met our inclusion criteria (86 girls and 82 boys.) Using three-dimensional motion capture technology (CORTEX software, Motion Analysis Corp., Rohnert Park, CA), data were collected while the subject performed the drop vertical test over floor-mounted force plates (FP-Stairs, AMTI, Watertown, MA) under the direct supervision of a pediatric physical therapist. The Wilcoxon rank sum was used, and p < 0.05 was considered statistically significant. Results Females demonstrated a larger average knee joint extension moment (0.31 vs 0.28 N*m/kg, p = 0.0408), a larger anterior knee joint force at initial contact (3.51 vs. 2.79, N/kg, p = 0.0458), larger average hip flexion angle (41.50° vs. 35.99°, p = 0.0005), a smaller maximum hip adduction moment (0.92 vs. 1.16, N*m/kg, p = 0.0497), and a smaller average ankle inversion angle (5.08° vs. 6.41°, p = 0.03231). No significant differences were found regarding knee abduction angle or lateral knee joint force. Conclusions The biomechanical profile of the contralateral extremity varies significantly between the genders after ACLR. In the uninjured extremity, females may have larger hip flexion angles, smaller hip adduction moments, larger anterior knee joint forces, larger knee extension moments, and smaller ankle inversion angles as compared to males after ACLR. These findings may explain the higher incidence of subsequent contralateral injury in female adolescent athletes. Further work is required to develop a composite score that determines at-risk athletes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Vij et al.)

A first-time shoulder dislocation is a challenging topic that requires consideration of anatomic and patient-specific factors. Initial management is predicated on determining functional demands, activity level, and expectations of the patient, in addition to assessing the risk of recurrent instability. When considering surgical indications, it is imperative to understand the biomechanical implications of injury to the glenohumeral joint complex and how specific surgical procedures can restore stability. It is important to provide an overview of the current treatment algorithm for management of first-time shoulder dislocation, with a special focus on diagnosis and intervention in the young athlete.

Background: Bibliometric citation analyses have been widely used in medicine to help researchers gain foundational knowledge about a topic and identify subtopics of popular interest for further investigations., Purpose: To identify the 50 most cited research publications related to American football., Study Design: Cross-sectional study., Methods: The Clarivate Analytics Web of Science database was used to generate a list of publications relating to football. Articles were filtered by the total number of citations, and the top 50 most cited articles studying the sport of football were selected for this analysis. Articles were analyzed by author, publication year, country of origin, institution affiliation, journal, article type, main research topic area, competitive level, and the level of evidence. A total of 247 articles were reviewed to reach the top 50 articles., Results: The most studied topic within the top 50 articles was concussion/chronic traumatic encephalopathy (n = 40). Collegiate football was the most studied level of competition (n = 25). The journal publishing the greatest number of top articles was Neurosurgery. Two institutions, the University of North Carolina at Chapel Hill and Boston University School of Medicine, produced over one-third of top 50 articles (n = 18)., Conclusion: Our analysis indicated that most of the top 50 publications related to the sport of football focused on concussion and CTE, were observational, and were published during or after 2000. The most studied level of competition was collegiate football., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.C. has received education payments from Arthrex and consulting fees from Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Physician review websites (PRWs) are increasing in usage and popularity. Our purpose is to characterize one-star reviews of orthopedic oncology surgeons to understand factors in healthcare that contribute to patient satisfaction., Methods: Orthopedic oncology surgeons were randomly selected from the Musculoskeletal Tumor Society. A search for one-star reviews was performed on Google Reviews, Healthgrades, and Vitals.com. Reviews were classified as clinical or nonclinical. Statistical analyses were performed regarding the frequency of reviews and complaints for each category., Results: Of the 7,733 reviews discovered, 908 (11.7%) were identified as one-star reviews. Of 907 usable complaints, 362 (40.8%) were clinical and 545 (59.2%) were nonclinical. The most common nonclinical complaints included bedside manner (65%) and limited time with providers (19%). The most common clinical complaints included complications (26%) and disagreements with the treatment plan (26%). There were 120 surgical and 221 nonsurgical reviews. Surgical patients had a higher rate of clinical complaints. Nonsurgical patients had a higher rate of total complaints., Conclusion: To the best of our knowledge, this is the first study examining PRWs regarding orthopedic oncology surgeons. Most one-star reviews were due to nonclinical complaints from nonsurgical patients. The most common factors are bedside manner, limited time with provider, phone communication issues, and rude/unprofessional conduct., Competing Interests: All authors declare that they have no conflicts of interest., (Copyright © 2022 Leeann Qubain et al.)

Background: Revision anterior cruciate ligament (ACL) reconstruction is being performed at an increasing rate. Previous literature has suggested that autograft ACL reconstruction is a better option than allograft in revision surgery, although the optimal autograft choice remains unknown. The all-soft tissue quadriceps tendon (ASTQT) autograft has been found to be an effective option for primary ACL reconstruction. However, few studies have evaluated ASTQT autograft in revision ACL reconstruction., Purpose/hypothesis: The purpose of this study was to evaluate the ASTQT autograft in revision ACL reconstruction in athletes compared with bone-patellar tendon-bone (BTB) autograft. We hypothesized that the ASTQT autograft would lead to similar return to play, time to return to play, retear rate, and patient-reported outcomes compared with BTB autograft., Study Design: Cohort study; Level of evidence, 3., Methods: A retrospective study was performed on all athletes undergoing revision ACL reconstruction between August 2013 and December 2019 at a single institution. Patients participating in high school or college athletics undergoing first-time revision with either ASTQT or BTB autograft with ≥2 years of follow-up were included. Demographic variables, complications, return to sports, and outcome scores including the International Knee Documentation Committee (IKDC) and Lysholm were collected and compared between the 2 cohorts., Results: A total of 58 revision ACL reconstructions were included, with 32 in the ASTQT cohort and 26 in the BTB cohort. Return to sports at the same level occurred in 62.5% of the ASTQT group and 53.8% of the BTB group. The ASTQT group returned to sports significantly faster than the BTB group (8.9 vs 10.3 months; P = .020). There was no difference in retear rates (3.1%, ASTQT; 7.7%, BTB) or other complications between the 2 groups. The IKDC scores were significantly higher at the 6- and 12-month follow-up for the ASTQT autograft group compared with the BTB group (6 months: ASTQT, 71.3; BTB, 61.7, P = .001; 12 months: ASTQT, 82.7; BTB, 78.6; P = .021). Lysholm scores were also greater in the ASTQT cohort at these time points (6 months: ASTQT, 75.1; BTB, 63.6; P < .001; 12 months: ASTQT, 82.0; BTB, 74.5; P < .001). However, IKDC and Lysholm scores were similar between both groups at final follow-up (IKDC: ASTQT, 82.9; BTB, 81.7; P = .344; Lysholm: ASTQT, 83.0; BTB, 81.0; P = .104) There was no significant clinical difference in the absolute difference in scores or rate of achieving clinical thresholds between the 2 cohorts., Conclusion: ASTQT autograft for revision ACL in athletes has similar outcomes compared with BTB autograft. However, the ASTQT may possibly afford quicker return to sports and better early improvements in patient-reported outcomes that normalize by 1 year. The soft tissue quadriceps autograft should be considered a viable graft option in revision ACL reconstruction in athletes.