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Background: Young athletes who specialize early in a single sport may subsequently be at increased risk of injury. While heightened injury risk has been theorized to be related to volume or length of exposure to a single sport, the development of unhealthy, homogenous movement patterns, and rigid neuromuscular control strategies may also be indicted. Unfortunately, traditional laboratory assessments have limited capability to expose such deficits due to the simplistic and constrained nature of laboratory measurement techniques and analyses. Methods: To overcome limitations of prior studies, the authors proposed a soccer-specific virtual reality header assessment to characterize the generalized movement regularity of 44 young female athletes relative to their degree of sport specialization (high vs low). Participants also completed a traditional drop vertical jump assessment. Results: During the virtual reality header assessment, significant differences in center of gravity sample entropy (a measure of movement regularity) were present between specialized (center of gravity sample entropy: mean = 0.08, SD = 0.02) and nonspecialized center of gravity sample entropy: mean = 0.10, SD = 0.03) groups. Specifically, specialized athletes exhibited more regular movement patterns during the soccer header than the nonspecialized athletes. However, no significant between-group differences were observed when comparing participants’ center of gravity time series data from the drop vertical jump assessment. Conclusions: This pattern of altered movement strategy indicates that realistic, sport-specific virtual reality assessments may be uniquely beneficial in exposing overly rigid movement patterns of individuals who engage in repeated sport specialized practice.

We aimed to objectively compare the effects of wearing newer, higher-ranked football helmets (HRank) vs. wearing older, lower-ranked helmets (LRank) on pre- to post-season alterations to neuroimaging-derived metrics of athletes' white matter. Fifty-four high-school athletes wore an HRank helmet, and 62 athletes wore an LRank helmet during their competitive football season and completed pre- and post-season diffusion tensor imaging (DTI). Longitudinal within- and between-group DTI metrics [fractional anisotropy (FA) and mean/axial/radial diffusivity (MD, AD, RD)] were analyzed using tract-based spatial statistics. The LRank helmet group exhibited significant pre- to post-season reductions in MD, AD, and RD, the HRank helmet group displayed significant pre- to post-season increases in FA, and both groups showed significant pre- to post-season increases in AD (p's < .05 [corrected]). Between-group analyses revealed the pre- to post-season increase in AD was significantly less for athletes wearing HRank compared to LRank (p < .05 [corrected]). These data provide in vivo evidence that wearing an HRank helmet may be efficacious for preserving white matter from head impact exposure during high school football. Future prospective longitudinal investigations with complimentary imaging and behavioral outcomes are warranted to corroborate these initial in vivo findings.

We aimed to objectively compare the effects of wearing newer, higher-ranked football helmets (HRank) vs. wearing older, lower-ranked helmets (LRank) on pre- to post-season alterations to neuroimaging-derived metrics of athletes' white matter. Fifty-four high-school athletes wore an HRank helmet, and 62 athletes wore an LRank helmet during their competitive football season and completed pre- and post-season diffusion tensor imaging (DTI). Longitudinal within- and between-group DTI metrics [fractional anisotropy (FA) and mean/axial/radial diffusivity (MD, AD, RD)] were analyzed using tract-based spatial statistics. The LRank helmet group exhibited significant pre- to post-season reductions in MD, AD, and RD, the HRank helmet group displayed significant pre- to post-season increases in FA, and both groups showed significant pre- to post-season increases in AD (p's.05 [corrected]). Between-group analyses revealed the pre- to post-season increase in AD was significantly less for athletes wearing HRank compared to LRank (p.05 [corrected]). These data provide in vivo evidence that wearing an HRank helmet may be efficacious for preserving white matter from head impact exposure during high school football. Future prospective longitudinal investigations with complimentary imaging and behavioral outcomes are warranted to corroborate these initial in vivo findings.

Background: The COVID-19 pandemic has led to changes to in-office orthopedic care, with a rapid shift to telemedicine. Institutions’ lack of established infrastructure for these types of visits has posed challenges requiring attention to confidentiality, safety, and patient satisfaction. Purpose: The aim of this study was to analyze the feasibility of telemedicine in orthopedics during the pandemic and its effect on efficiency and patient satisfaction. Methods: Patients seen by the Emory University Department of Orthopaedics Sports Medicine and Upper Extremity Divisions via telemedicine from March 23 to April 24, 2020, were contacted by telephone. Each patient was asked to respond to questions on satisfaction, ease of use, and potential future use; satisfaction with telemedicine and previous clinical visits were measured using a modified 5-point Likert scale. Results: Of the 762 patients seen, 346 (45.4%) completed the telemedicine questionnaire. Satisfaction varied by visit type, with average scores of 4.88/5 for in-office clinic visits versus 4.61/5 for telemedicine visits. There was no significant difference among age groups for satisfaction ratings. Patients 65 years old or older reported significantly longer visit times and decreased ease of use with the telemedicine platform. Conclusion: Telemedicine in a large orthopedics department was successfully implemented without compromising patient satisfaction. The use of telemedicine allows many patients to be seen quickly and efficiently without diminishing their musculoskeletal clinical experience.

Purpose The purpose of this study was to determine whether drilling the femoral tunnel when performing anterior cruciate ligament (ACL) reconstruction through the accessory medial portal, as opposed to drilling the tunnel transtibially, will lead to more frequent location of the anteromedial femoral tunnel within the anatomic anteromedial bundle insertion site. Methods Primary anatomic double-bundle reconstruction was performed on 113 patients. Intraoperatively, we placed a guide pin through the anteromedial and posterolateral tibial tunnels and accessory medial portal, attempting to reach the center of the native femoral anteromedial bundle insertion. For each approach, the position of the guide pin was classified as (1) within the center of, (2) off-center within, or (3) outside of the femoral anteromedial insertion. Results There were significant differences in the ability of each approach to reach the center of the femoral anteromedial bundle insertion. Through the tibial anteromedial tunnel, the femoral anteromedial insertion center was reached in 4.4% of cases, whereas it was off-center within and outside of the femoral anteromedial insertion in 23.0% and 72.6%, respectively. Through the tibial posterolateral tunnel, the femoral anteromedial insertion center was reached in 60.2% of cases, whereas it was off-center within and outside of the femoral anteromedial insertion in 23.9% and 15.9% of cases, respectively. When approached from the accessory medial portal, the center of the femoral anteromedial insertion was reached in 100% of the cases. Ultimately, the femoral anteromedial tunnel was drilled through the tibial anteromedial tunnel in 0.9%, through the posterolateral tunnel in 62.8%, and through the accessory medial portal in 36.3% of cases. Conclusions Drilling the femoral tunnel for the anteromedial graft through the accessory medial portal, as opposed to drilling the tunnel transtibially, leads to more frequent location of the anteromedial femoral tunnel within the anterior cruciate ligament anteromedial bundle anatomic footprint. Level of Evidence Level IV, therapeutic case series.

Background: Current trends in anterior cruciate ligament reconstruction (ACLR) have been toward anatomical reconstruction that restores the normal size and location of the anterior cruciate ligament insertions and its 2 bundles, the posterolateral (PL) and anteromedial (AM) bundles. This has resulted in a more individualized approach to ACLR. Several studies have shown that the size of the anterior cruciate ligament insertion sites is variable; however, these studies are limited by use of relatively small sample sizes and cadaveric specimens. Purpose: This study was undertaken to evaluate the in vivo size variability of the anterior cruciate ligament insertion sites and its AM and PL bundles during arthroscopy in a large series of patients and to correlate these findings with individuals’ physical characteristics (height, weight, and body mass index). Study Design: Cross-sectional study; Level of evidence, 3. Methods: In 137 patients undergoing ACLR during the first 6 months after injury, the femoral and tibial anterior cruciate ligament insertion sites and the 2 bundles were identified, marked with electrocautery, and measured with an arthroscopic ruler. Additionally, physical characteristics of the patients, including self-reported height, weight, and body mass index, were recorded. Results: The tibial anterior cruciate ligament insertion site had a mean length of 17.0 ± 2.0 mm. The tibial AM bundle length was 9.1 ± 1.2 mm and the width was 9.2 ± 1.1 mm. The tibial PL bundle insertion site length averaged 7.4± 1.0 mm and the width averaged 7.0 ± 1.0 mm. The femoral insertion sites had a mean length of 16.5 ± 2.0 mm. The length of the femoral AM bundle insertion site averaged 9.2 ± 1.2 mm and the width averaged 8.9 ± 0.9 mm. The femoral PL bundle insertion site length averaged 7.1 ± 1.1 mm and the width averaged 6.9 ± 1.0 mm. There were significant positive correlations between patient height and weight ( P < .05) with femoral and tibial anterior cruciate ligament insertion site length, tibial PL bundle insertion site length, femoral AM bundle insertion site length, and tibial AM bundle and PL bundle insertion site areas. However, the coefficients of determination values were low (1.0% to 19.4%). Conclusion: There is a large variation in size of the anterior cruciate ligament insertion sites and the AM and PL bundles. Additionally, there are significant but weak correlations between the size of the insertions and height, weight, and body mass index of the individual patient.

Proximal hamstring avulsions from the ischium are becoming more frequently recognized, secondary to their disability when treated nonoperatively. The acute repair of these injuries is becoming prevalent given the improved outcomes reported in the literature. Anatomic studies have recently been conducted on the proximal hamstring origin; however, there are few reports on surgical techniques for repair in the setting of injury. The present article describes the technique for proximal hamstring avulsion repair, as performed by the senior author. More than 30 cases have been performed based on this technique, with excellent results.

The anatomic approach to anterior cruciate ligament (ACL) reconstruction has been a growing trend in orthopaedics. Progress made over the last 7 years has led to a greater understanding of the ACL anatomy and its 2 bundles. Surgeons are now more equipped to restore the native anatomy and knee kinematics than ever before. The University of Pittsburgh experience and technique have been described and have evolved to include several key principles. These include the restoration of native ACL anatomy, insertion sites, and double-bundle tension patterns with the utilization of an accessory medial portal to provide an individualized approach to ACL reconstruction. The purpose of this technical note is to provide surgeons with a technical update regarding the anatomic approach to ACL surgery. Most of this article will be focused on anatomic double-bundle ACL reconstruction, but it must be emphasized that this is a concept rather than just a technique and should be applied to all ACL reconstructions to provide a more anatomic and individualized result.

Objective. Although thoracotomy for removal of pulmonary metastasis is well documented in a wide variety of solid tumors, data are sparse regarding management of patients with gynecologic malignancies metastatic to the lung. Methods. We retrospectively reviewed the Roswell Park Cancer Institute experience between 1982 and 1999. Of 82 eligible patients with gynecologic tumors metastatic and confined to the lung, 25 underwent pulmonary resection. Results. There were 60 uterine and 22 cervix cancer patients with pulmonary metastases. Among patients with uterine cancer primaries undergoing pulmonary resection (n 5 19) median survival was 26 months. Uterine cancer patients who underwent surgical resection for leiomyosarcomas (n 5 11) had a median survival of 25 months compared to 46 months in patients with adenocarcinoma (n 5 6, P 5 0.02). Median survival in cervix cancer patients undergoing resection for pulmonary metastases (n 5 6) was 36 months. Conclusions. Pulmonary resection may provide a survival advantage for selected patients with uterine and cervical malignancies with metastases isolated to the lung. © 2001 Academic Press

Posterior cruciate ligament (PCL) tears with concomitant medial collateral ligament (MCL) or posteromedial injuries are a rare but recognized injury pattern. Unlike the posterolateral corner (PLC), the medial side generally has a higher potential to heal conservatively. Nevertheless, we have a low threshold to surgically address the medial side if significant instability exists in a PCL deficient knee. Bergfeld et al. showed that complete injuries to the superficial MCL in combination with the PCL led to increased laxity in internal tibial rotation and significant increases in posterior tibial translation (1). They recommended restoration of the MCL in combined PCL-MCL injuries to restore normal knee biomechanics.

Most patients with isolated acute PCL injuries do relatively well with conservative treatment. As a result of excessive posterior tibial translation, however, abnormal chondral wear may occur. Pain rather than instability becomes the major symptomatic issue. Conservative treatment of these injuries has been shown to lead to a high incidence of acute and chronic chondral injuries involving the medial femoral condyle and patellofemoral joint (1–4). Patients are also subject to acute and chronic meniscal tears (1,5,6). Consequently, there is an emerging consensus that isolated grade III PCL injuries are not as benign as previously thought (7). Many surgeons have thus elected to proceed with PCL reconstruction in patients with isolated grade III injuries, especially in the presence of instability and pain (8–17).

BackgroundThere are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the shoulder.HypothesisArthroscopic management of symptomatic multidirectional instability in an athletic population can successfully return athletes to sports with a high rate of success as determined by patient-reported outcome measures.Study DesignCase series; Level of evidence, 4.MethodsForty patients (43 shoulders) with multidirectional instability of the shoulder were treated via arthroscopic means and were evaluated at a mean of 33.5 months postoperatively. The mean patient age was 19.1 years (range, 14-39). There were 24 male patients and 16 female patients. Patients were evaluated with the American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability scoring systems. Stability, strength, and range of motion were also evaluated with patient-reported scales.ResultsThe mean American Shoulder and Elbow Surgeons score postoperatively was 91.4 of 100 (range, 59.9-100). The mean Western Ontario Shoulder Instability postoperative percentage score was 91.1 of 100 (range, 72.9-100). Ninety-one percent of patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% were able to return to their sport with little or no limitation.ConclusionArthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic population.