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Objectives: To determine if UCL Reconstruction (UCLR) results in a decrease in ulnohumeral joint space gapping as measured on postoperative Stress Ultrasound (SUS) examination. Methods: Patients were identified from an existing IRB-approved single-blinded, prospective, randomized controlled trial designed to assess treatment outcomes after modified Jobe or Docking ulnar collateral ligament reconstructions (UCLR). This population consisted of overhead throwing athletes (any level-recreational, high school, collegiate & professional). Patients all met the following inclusion criteria: age 16-30 years of age, diagnosis of ulnar collateral ligament (UCL) instability involving either a complete UCL tear or a partial UCL tear that failed non-operative management. Any patients with a history of a previous ipsilateral elbow surgery (UCL reconstruction, ulnar nerve transposition, flexor-pronator debridement, posteromedial impingement debridement, or elbow fracture fixation) were excluded. All patients were randomized to UCLR by either the modified Jobe or the Docking technique utilizing a uniform surgical approach and contralateral gracilis autograft. Technique allocation was disclosed to the surgeon on the morning of surgery, but the patient remained blinded. All UCLR were performed by a board-certified, Sports Medicine fellowship-trained orthopedic surgeon who performs a high volume of UCLR. All patients were treated with a uniform postoperative rehabilitation and were followed for a minimum of 2 years for clinical outcomes. All patients underwent uniform pre- and post-operative radiographic assessment, including magnetic resonance imaging/arthrography (MRI/MRA) and stress ultrasound (SUS). All postoperative imaging was performed at a minimum of 1 year after surgery. All SUS exams were performed or directly supervised by experienced musculoskeletal radiologists well-versed in this technique. SUS provides a quantitative, dynamic assessment of ulnohumeral joint space gapping and has been previously validated. Patients who lacked any SUS data were excluded. All SUS exams were conducted using a 13-MHz linear-array transducer measuring the magnitude of ulnohumeral joint gapping at rest and with application of a valgus stress. Patients were positioned seated with the elbow at approximately 30 degrees of flexion. Ulnohumeral joint space gapping was assessed by first orienting the probe along the longitudinal axis of the UCL such that the sublime tubercle and the trochlea could be identified, being separated by the hypoechoic shadowing of the joint space and fluid. All measurements were taken using electronic calipers from the hyperechoic peak of the trochlea to the hyperechoic peak of the proximal-most ulna at the sublime tubercle. In addition, the static resting UCL graft length was recorded, as were the presence and size of any calcifications or hypoechoic foci within the UCL substance. Analysis was conducted using SPSS (IBM, Corp), utilizing two-tailed independent t-tests to compare population means, two-tailed paired student's t-tests for assessments of subjects over two different time points, and two-tailed one sample t-tests to compare the impact of UCLR to a reference population mean. Results: Of the 80 patients that were randomized in the prospective trial, 57 patients with SUS data were available. Of the 57 UCLR, 26 were reconstructed by the Modified Jobe technique and 31 by the Docking technique. The mean age was 19.3 ± 1.8 years, and all were overhead athletes (93% baseball). SUS findings available for the 57 patients included: 100% (57/57) preoperative baseline SUS exam, 87.8% (50/57) 1-year post-UCLR SUS exam, 40/57 (71.9%) reference preoperative SUS exam on contralateral un-injured elbow. The amount of joint space gapping as a result of the stress exam (delta) was 0.83 ± 0.53mm for the contralateral reference elbow, 2.11 ± 1.21 for pre-operative affected elbow baseline, and 0.62 ± 0.41mm for 1-year post-UCLR. Figures 1 and 2 show scatter plots of postoperative delta values compared to the preoperative baseline, and the preoperative contralateral reference, respectively. UCLR resulted in approximately 340% decrease in the magnitude of joint gapping measured on SUS, representing a mean 1.49mm decrease. UCLR restored delta gapping to values comparable to those of the native elbow. There was significantly less delta gapping on SUS examination at 1-year post UCLR (0.61 ± 0.42mm) compared to the preoperative SUS examination time point (2.11 ± 1.21; p<0.001). This was true irrespective of the procedure, with the docking technique decreasing from 2.17 ± 1.3mm to 0.57 ± 0.39mm (p<0.001), and the Jobe technique decreasing from 1.82 ± 0.87mm to 0.67 ± 0.46mm (p<0.001) on paired analyses. Considering all UCLR patients, two-tailed one sample t-testing found less joint gapping present in the minimum 1-year postoperative cohort (0.61 ± 0.42mm; p=0.003) compared to the reference contralateral mean (0.83mm), which was also true for the docking (p=0.007) but not Modified Jobe (p=0.193). When delta gaps for the contralateral reference were paired with post-UCLR in the same patients, there was no significant difference seen (0.61 ± 0.42mm vs 0.83 ± 0.53mm; p=0.187). Conclusions: UCLR returned average ulnohumeral joint gapping to normal values on postoperative SUS. UCLR results in an average decrease of joint space gapping from 2.11 ± 1.21mm to 0.61 ± 0.42mm. Regardless of technique, UCLR restored delta values comparable to those of the contralateral unaffected elbow (0.83 ± 0.53mm). Both techniques yielded mean gapping values less than 1.0mm. These findings provide surgeons with the expected change in joint gapping following UCLR as measured on SUS. By providing a reference, surgeons can better assess patients with concern for recurrent injury following previous UCLR in situations where MR alone may be challenging to interpret. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to compare the rates of secondary knee surgery for patients undergoing meniscus repair with or without concurrent anterior cruciate ligament reconstruction (ACLr). Methods: Utilizing a large national database, patients with meniscal repair with or without concurrent arthroscopic ACLr were identified. The two cohorts were then queried for secondary surgical procedures of the knee within the following 2 years. Frequency, age distribution, rates of secondary surgery, and type of secondary procedures performed were compared. Results: In total, 1,585 patients were identified: meniscus repair with ACLr was performed for 1,006 (63.5%) and isolated meniscal repair was performed for 579 (36.5%). Minimum of two year follow up was present for 487 (30.7% of the overall study population). Secondary surgery rates were not significantly different between meniscus repair with concurrent ACLr and isolated meniscus repairs with an overall mean follow up of 13 years (1.5–24 years) (10.6% vs. 13.6%, p = 0.126). For the 2 year follow up cohort, secondary surgery rates were not significantly different (19.3% vs. 25.6%, p = 0.1098). There were no differences in survivorship patterns between the two procedures, both in the larger cohort (p = 0.2016), and the cohort with minimum 2-year follow-up (p = 0.0586). Conclusion: The current study assessed secondary surgery rates in patients undergoing meniscus repair with or without concurrent ACLr in a large patient database. Based on this data, no significant difference in rates of secondary knee surgery was identified. [ABSTRACT FROM AUTHOR]

Background: Surgical techniques and associated outcomes in treating acute and chronic extra-articular ligament knee injuries are in evolution, and there is question as to whether repair or reconstruction is optimal. Purpose/Hypothesis: The purpose of this study was to compare the subsequent surgery rate between surgical repair versus reconstruction for all extra-articular ligament injuries of the knee utilizing a large database. Our hypothesis was that overall surgical repair of both lateral and medial extra-articular knee injuries would have a higher revision rate than those treated by reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner data set (2010-2019), with 122 million patients, was utilized to generate 2 patient cohorts: those who underwent surgical repair and those who underwent surgical reconstruction of a knee extra-articular ligament injury. All patients had a minimum of 2 years follow-up. Rates of concomitant or subsequent cruciate ligament reconstruction and rates of secondary procedures were assessed and compared between the 2 cohorts. Results: In total, 3563 patients were identified: extra-articular ligament reconstruction was performed for 2405 (67.5%), and repair was performed for 1158 (32.5%). Cruciate ligament reconstruction was performed for 986 (27.7%), of which 888 of 986 (90.1%) were performed on the same day as their extra-articular ligament procedure. At 2-year follow-up, the reconstruction cohort had higher rates of revision surgery compared with the repair cohort (8.2% vs 2.5%; P <.001). Conclusion: Using a large national database, knee extra-articular ligamentous reconstructions (those on both the lateral and the medial side) had a 3.3 times higher rate of revision surgery compared with repair at 2-year follow-up. Further study is needed to investigate the causes leading to revision surgery and to determine the optimal surgical treatment for both medial and lateral extra-articular knee ligament injuries. [ABSTRACT FROM AUTHOR]

Background: Osteochondral allograft transplant (OCA) and osteochondral autograft transfer (OAT) replace damaged cartilage with a plug of bone and overlying articular cartilage; however, limited research is available regarding the survival of these osteoarticular grafting procedures. Hypothesis: We hypothesized that patients who underwent OCA would have a higher rate of subsequent surgery over the course of 5 years compared with patients who underwent OAT. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner administrative database was used to identify patients 10 to 59 years old who had undergone OCA or OAT between 2010 and 2018. All included patients were assessed for subsequent knee surgeries, defined by the occurrence of a subsequent osteochondral procedure (OCA or OAT) or any type of knee arthroplasty for the duration of the time they were included in the data set (maximum of 10 years). Analyses were performed for the total population and those with allograft versus autograft (compared using the Fisher exact test). The 5-year Kaplan-Meier survival curves for operation-free survival were compared using a Mantel-Cox log-rank test. Results: In total, 2598 patients were identified: 1631 patients who underwent OCA (34.5 ± 12.1 years old; 51.6% female) and 967 patients who underwent OAT (32.1 ± 12.9 years old; 51.0% female). Both groups had similarly high rates of subsequent knee surgeries (23.9% vs 21.9%, respectively; P =.249), with no statistical differences in rates of subsequent surgery between groups. Kaplan-Meier survival curves comparing operation-free survival at 5 years indicated no significant difference between the groups (OCA, 88.0% vs OAT, 89.5%; P =.235). Conclusion: Both osteochondral grafting procedures carried a relatively high rate of secondary surgery, which increased with time. The 5-year survival analysis revealed similarly high rates of subsequent surgery. [ABSTRACT FROM AUTHOR]

Background: Common classification schemes, measurements, and surgical planning for trochlear dysplasia are predicated on 2-dimensional imaging views. Purpose: To investigate patellofemoral joint osseous anatomy using 3-dimensional (3D) printed models to describe osseous anatomic trochlear variations in patients with recurrent patellar dislocation. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Computed tomography scans were obtained from 20 patients with recurrent patellar dislocation and 10 healthy control knees, and 3D prints generated from these computed tomography scans were studied with respect to mediolateral positioning of the proximal trochlear groove and groove obliquity as well as changes in the appearance, height, and orientation of the medial and lateral trochlear ridges. Each trochlea was centered with respect to a vertical line perpendicular to the distal femoral condyles and through the central intercondylar notch roof, with the 3D models resting on their posterior femoral condyles. A novel 3D measurement method was devised to assess groove obliquity, termed the entry point–transition point (EP-TP) angle. The EP was defined as the midpoint of the flattened region of the proximal trochlea where the lateral and medial ridges of the proximal trochlea meet, and the TP was the point along the trochlear groove at which the groove shape changes from an oblique orientation proximally to one more vertical distally. Measurements were obtained by 3 reviewers, and reliability analyses were performed. Results: With the dysplastic knees arranged according to flattening of the trochleas, increased obliquity of the trochlear grooves was observed, as reflected by increased EP-TP angles as well as more lateral patellar EPs into the proximal trochleas of these recurrent patellar dislocation knees when compared with the control knees. The degree of trochlear dysplasia (according to the Dejour classification and trochlear flatness in the frontal and axial planes) was associated with diminished prominence of the lateral trochlear convexity, increasingly lateralized proximal trochlear EPs, increased trochlear groove obliquity, lateral trochlear curvature, and progressive medial ridge deformity. Conclusion: The 3D reproductions enabled unique conceptualization of trochlear deformity associated with recurrent patellar dislocation. [ABSTRACT FROM AUTHOR]

Background: Previous studies have suggested that surgical repair of the posterolateral corner (PLC) may be inferior to reconstruction. Hypothesis: We hypothesized that acute repair (<3 weeks) of avulsion-type PLC multiligament knee injuries with no midsubstance injury would lead to lower failure rates than previously reported for PLC repair. Study Design: Case series; Level of evidence, 4. Methods: A total of 28 patients with multiligament knee injuries who underwent acute repair between January 2007 and June 2018 of a PLC avulsion injury with no evidence of midsubstance tearing were included. All PLC avulsion injuries were treated using a transosseous Krackow suture pull-through technique without graft augmentation. Outcome metrics included lateral joint-space widening with varus stress, patient-reported clinical varus instability, patient-reported outcome measures (PROMs), and any subsequent revision or salvage procedure. Results: The mean time from injury to repair was 8.1 ± 5 days. At a mean follow-up of 2 years (range, 3-90 months), clinical varus stress examination at 30° demonstrated a significant reduction in lateral compartment opening, from 9 ± 3 mm preoperatively to 0 ± 3 mm (P <.0001). The failure rate was calculated to be 10.7% (3/28), which was significantly lower than the failure rate from a 2016 systematic review (38%, 17/45; P =.015). Of the 28 patients, 21 (75%) had PROM scores. Patients who underwent staged bi-cruciate reconstructions (n = 5) had significantly higher subjective International Knee Documentation Committee (IKDC) (87.2 vs 65.5; P =.014) and Lysholm (90.5 vs 75.2; P =.029) scores compared to patients with untreated bi-cruciate injuries (n = 9). Patients with peroneal nerve injury (n = 4) had significantly lower IKDC (58.2 vs 80.8; P =.0045) and Tegner (3.2 vs 5.4; P =.047) scores than those without peroneal nerve injury (n = 17). The mean IKDC and Lysholm scores at final follow-up were 73.4 ± 24.0 and 80.8 ± 23.1 at 7.1 years (range, 2.3-10.6 years) of follow-up. Conclusion: Repair of acute grade 3 combined PLC avulsion injuries using a transosseous Krackow suture pull-through technique demonstrated a failure rate of 10.7%. Patients who underwent a staged cruciate reconstruction(s) had higher subjective outcome scores than those who had cruciate injuries left untreated. Peroneal nerve injury was associated with lower outcome scores. [ABSTRACT FROM AUTHOR]

Background: Autologous chondrocyte implantation (ACI) can be used to treat focal, full-thickness chondral defects of the knee. However, there is limited large-sample evidence available regarding the incidence, timing, and risk factors for revision surgery after ACI. Purpose: To assess the 5-year incidence, timing, and risk factors for revision surgery after ACI in a large national cohort. Study Design: Case series; Level of evidence, 4. Methods: The 2010-2020 PearlDiver database was queried for patients aged 20 to 59 years who underwent primary ACI of the knee without previous chondral procedures or knee arthroplasty. Revision surgery was defined as subsequent revision ACI, osteochondral allograft transplantation, osteochondral autograft transfer, unicompartmental knee arthroplasty, or total knee arthroplasty within 5 years. Kaplan-Meier analysis was used to assess both incidence and timing of revision surgery. Risk factors evaluated for revision surgery included patient age, sex, body mass index (BMI), Elixhauser Comorbidity Index (ECI) score, and previous or concomitant bony realignment procedures. Results: In total, 533 patients underwent primary ACI and met inclusion criteria. The 5-year incidence of revision surgery was 10.3%, with 63% of revisions occurring in the first 2 years after surgery. Risk factors associated with revision surgery included female sex (odds ratio, 2.58; 95% CI, 1.22-5.45; P =.013) and BMI ≥35 (odds ratio, 2.24; 95% CI, 1.01-4.94; P =.047). There was no relationship between age, ECI score, or previous or concomitant bony realignment procedures and revision surgery at 5 years (P >.05). Conclusion: In an analysis of 533 patients who underwent ACI, 10.3% required a subsequent articular cartilage procedure or conversion to knee arthroplasty in the first 5 postoperative years. Revision surgery was greatest in the first 2 postoperative years. Female sex and severe obesity (BMI, ≥35) were associated with increased risk of revision surgery, while age, ECI score, and previous or concomitant bony realignment procedures were not. These findings suggest that treatment of chondral defects of the knee with ACI is associated with durable outcomes at the 5-year follow-up. [ABSTRACT FROM AUTHOR]

Background: Open debridement (OD) of the extensor carpi radialis brevis tendon, both with and without repair to the lateral epicondyle, are effective treatments for recalcitrant lateral epicondylitis. However, few comparative studies exist within the literature. Purpose: To (1) compare the 5-year reoperation rates of patients who underwent OD alone versus OD with tendon repair (ODR) and (2) identify the 90-day adverse event rates, total same-day reimbursement amounts, and national usage trends for these 2 procedures from 2010 to 2019. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver MUExtr database was reviewed for patients diagnosed with lateral epicondylitis who underwent OD alone and ODR or reattachment between January 2010 and December 2019. These patients were stratified into 2 cohorts: the OD cohort and ODR cohort. The 5-year reoperation rates were assessed and compared, and the incidence of 90-day postoperative complications and risk factors were identified. The number of ODs and ODRs performed each year and the mean same-day reimbursement amounts (in US$) for both procedures were assessed. Results: Overall, 41,932 lateral epicondylitis patients who underwent debridement were identified, with 17,139 OD patients and 24,793 ODR patients. There were no significant changes in the proportion of OD versus ODR procedures performed during the study period (P =.18). A significantly higher incidence of hematoma was seen after OD compared with ODR (0.19% vs 0.12%; P =.04), but ODR had a significantly lower 5-year reoperation rate than OD (2.8% vs 3.9%; P =.006), with an absolute risk reduction of 1.1% and a number needed to treat of 91. Finally, ODR ($1683.17 ± $12.15) had a higher mean same-day reimbursement than OD ($1479.05 ± $15.78) (P =.001). Conclusion: Both OD and ODR had low complication rates. The 5-year reoperation rates were low for both procedures, but they were significantly higher for OD. Over the 10-year study period, there were no significant changes in the relative percentages of OD versus ODR performed. ODR had a significantly higher mean same-day reimbursement. [ABSTRACT FROM AUTHOR]

Background: There is controversy regarding which patient-reported outcome measures (PROMs) should be used for proximal hamstring tendon injuries. Hypothesis: It was hypothesized that (1) most (>50%) of the questions on the 13 most common PROMs for proximal hamstring injuries would demonstrate extensive overlap in the health domains and question categories and (2) each of the PROMs would contain a variable distribution of questions within each health domain. Study Design: Systematic review. Methods: We conducted a literature review through PubMed, Scopus, and CINAHL and identified the 13 most common PROMs for proximal hamstring injuries: Lower Extremity Functional Scale (LEFS), Marx activity rating scale (MARS), 12-item Short Form Survey (SF-12), Tegner activity scale (TAS), Single Assessment Numeric Evaluation (SANE), Perth Hamstring Assessment Tool (PHAT), Proximal Hamstring Injury Questionnaire (PHIQ), modified Harris Hip Score (mHHS), University of California, Los Angeles activity score (UCLA), International Hip Outcome Tool (iHOT-12), Hip Outcome Score (HOS), Sydney Hamstring Origin Rupture Evaluation (SHORE), and Non-Arthritic Hip Score (NAHS). All PROM questions were sorted into 5 health domains (pain, symptoms, activities of daily living, sports, and mindset) and further divided into question categories if they referred to similar tasks or aspects of health. Questions in the same health domain and question category were considered overlapping, and those within a health domain that did not fit into a question category were considered unique. For each PROM, we analyzed the distribution of questions within particular health domains and question categories as well as the amount of overlapping and unique questions. Results: Of the 165 questions evaluated, 116 (70.3%) were overlapping, and 49 (29.7%) were unique. The SF-12 contained the most unique questions (9/12 [75.0%]). The MARS, TAS, SANE, and UCLA had 0 unique questions. The PHIQ and iHOT-12 contained questions in all 5 health domains. The PHAT, SHORE, and NAHS contained questions in every health domain except mindset. The LEFS, MARS, SF-12, TAS, mHHS, SANE, UCLA, and HOS contained questions in ≤3 health domains. Conclusion: The evaluated PROMs had a high degree of overlapping questions (≥50%) and demonstrated a statistically significant variance in the distribution of questions within each health domain. [ABSTRACT FROM AUTHOR]

Background: Tibiofemoral bone bruise patterns seen on magnetic resonance imaging (MRI) are associated with ligamentous injuries in the acutely injured knee. Bone bruise patterns in multiligament knee injuries (MLKIs) and particularly their association with common peroneal nerve (CPN) injuries are not well described. Purpose: To analyze the tibiofemoral bone bruise patterns in MLKIs with and without peroneal nerve injury. Study Design: Case series; Level of evidence, 4. Methods: We retrospectively identified 123 patients treated for an acute MLKI at a level 1 trauma center between January 2001 and March 2021. Patients were grouped into injury subtypes using the Schenck classification. Within this cohort, patients with clinically documented complete (motor and sensory loss) and/or partial CPN palsies on physical examination were identified. Imaging criteria required an MRI scan on a 1.5 or 3 Tesla scanner within 30 days of the initial MLKI. Images were retrospectively interpreted for bone bruising patterns by 2 board-certified musculoskeletal radiologists. The location of the bone bruises was mapped on fat-suppressed T2-weighted coronal and sagittal images. Bruise patterns were compared among patients with and without CPN injury. Results: Of the 108 patients with a MLKI who met the a priori inclusion criteria, 26 (24.1%) were found to have a CPN injury (N = 20 complete; N = 6 partial) on physical examination. For CPN-injured patients, the most common mechanism of injury was high-energy trauma (N = 19 [73%]). The presence of a grade 3 posterolateral corner (PLC) injury (N = 25; odds ratio [OR], 23.81 [95% CI, 3.08-184.1]; P =.0024), anteromedial femoral condyle bone bruising (N = 24; OR, 21.9 [95% CI, 3.40-202.9]; P <.001), or a documented knee dislocation (N = 16; OR, 3.45 [95% CI, 1.38-8.62]; P =.007) was significantly associated with the presence of a CPN injury. Of the 26 patients with CPN injury, 24 (92.3%) had at least 1 anteromedial femoral condyle bone bruise. All 20 (100%) patients with complete CPN injury also had at least 1 anteromedial femoral condyle bone bruise on MRI. In our MLKI cohort, the presence of anteromedial femoral condyle bone bruising had a sensitivity of 92.3% and a specificity of 64.6% for the presence of CPN injury on physical examination. Conclusion: In our MLKI cohort, the presence of a grade 3 PLC injury had the greatest association with CPN injury. Additionally, anteromedial femoral condyle bone bruising on MRI was a highly sensitive finding that was significantly correlated with CPN injury on physical examination. The high prevalence of grade 3 PLC injuries and anteromedial tibiofemoral bone bruising suggests that these MLKIs with CPN injuries most commonly occurred from a hyperextension-varus mechanism caused by a high-energy blow to the anteromedial knee. [ABSTRACT FROM AUTHOR]

Background: Traumatic hip dislocations are rare injuries that most commonly occur in motor vehicle accidents. There is a paucity of literature that describes sports-related hip dislocations. Purpose: To estimate the incidence of sports-related hip dislocations and determine any sport- or sex-related epidemiological trends using the National Electronic Injury Surveillance System (NEISS) database. Study Design: Descriptive epidemiology study. Methods: Data regarding sports-related hip dislocations from 2010 to 2019 were retrieved from the NEISS, a database that catalogs injury information during emergency department visits from 100 hospitals across the United States to produce nationwide estimates of the injury burden. The estimated number of injuries was calculated using weights assigned by the NEISS database. The injuries were then stratified by sport and sex to determine any epidemiological patterns. Results: A total of 102 hip dislocation injuries were identified over the surveyed 10 years, indicating 2941 estimated injuries nationwide. Overall, 10 (9.8%) of 102 sports-related hip dislocations presented with concomitant acetabular fractures, representing an estimated 288 injuries nationally over 10 years. Male athletes sustained more sports-related hip dislocations than female athletes, with a relative incidence of 12.51 (P <.001). Adolescents aged 15 to 19 years recorded the highest number of hip dislocations. There were 17 sports identified as having caused at least 1 hip dislocation over the 10-year period. More hip dislocation injuries were sustained from contact sports (91.2%) than noncontact sports (8.8%) (P <.001). Football (estimated 164 injuries per year; 55.6%), snowboarding (28 per year; 9.5%), skiing (26 per year; 8.8%), and basketball (21 per year; 7.1%) had the highest rates of hip dislocation. Additionally, 43 (82.7%) football-related injuries were caused by tackling mechanisms, and 9 (17.3%) were caused by nontackling mechanisms (P <.001). Conclusion: The incidence of traumatic sports-related hip dislocations was extremely low in the United States during the study period. Male adolescents, aged 15 to 19 years, sustained the greatest number of injuries during football. Significantly more hip dislocations occurred in contact sports, most commonly football, snowboarding, skiing, and basketball, compared with noncontact sports. As adolescent athletes may have limited treatment options if osteonecrosis occurs, these data serve to increase the clinical awareness of these injuries. [ABSTRACT FROM AUTHOR]

Background: Bone bruise patterns in the knee can aid in understanding the mechanism of injury in anterior cruciate ligament (ACL) ruptures. There is no universally accepted magnetic resonance imaging (MRI)mapping technique to describe the specific locations of bone bruises. Hypothesis: The authors hypothesized that (1) our novel mapping technique would show high interrater and intrarater reliability for the location of bone bruises in noncontact ACL-injured knees and (2) the bone bruise patterns reported from this technique would support the most common mechanisms of noncontact ACL injury, including valgus stress, anterior tibial translation, and internal tibial rotation. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were 43 patients who underwent ACL reconstruction between 2018 and 2020, with MRI within 30 days of the injury on a 3.0-T scanner, documentation of a noncontact mechanism of injury, and no concomitant or previous knee injuries. Images were retrospectively reviewed by 2 radiologists blinded to all clinical data. The locations of bone bruises were mapped on fat-suppressed T2-weighted coronal and sagittal images using a novel technique that combined the International Cartilage Repair Society (ICRS) tibiofemoral articular cartilage surgical lesions diagram and the Whole-Organ Magnetic Resonance Imaging Scoring (WORMS) mapping system. Reliability between the reviewers was assessed using the intraclass correlation coefficient (ICC), where ICC >0.90 indicated excellent agreement. Results: The interrater and intrarater ICCs were 0.918 and 0.974, respectively, for femoral edema mapping and 0.979 and 0.978, respectively, for tibial edemamapping. Significantlymore bone bruises were seen within the lateral femoral condyle compared with the medial femoral condyle (67% vs 33%; P < .0001), and more bruises were seen within the lateral tibial plateau compared with the medial tibial plateau (65% vs 35%; P < .0001). Femoral bruises were almost exclusively located in the anterior/central regions (98%) of the condyles as opposed to the posterior region (2%; P < .0001). Tibial bruises were localized to the posterior region (78%) of both plateaus as opposed to the anterior/central regions (22%; P < .0001). Conclusion: The combined mapping technique offered a standardized and reliable method for reporting bone bruises in noncontact ACL injuries. The contusion patterns identified using this technique were indicative of the most commonly reported mechanisms for noncontact ACL injuries. [ABSTRACT FROM AUTHOR]

Case. We report an 11-year-old male who sustained a lesser tuberosity avulsion fracture of the proximal humerus upon making contact with a baseball during an at-bat. This injury was neglected for 14 months and was eventually detected by an axillary radiograph and subsequent MRI. He successfully underwent an open surgical repair and regained full range of motion and level of activity at 1-year follow-up. Conclusion. In pediatric baseball players, lesser tuberosity avulsion fractures may occur upon striking a baseball with a bat. Even after being neglected for several months, these injuries can be treated successfully with an open surgical repair. [ABSTRACT FROM AUTHOR]

Anterior surgical approaches to the cervical spine have allowed for treatment of common and complex pathologies with excellent outcomes. During the approach, complications can result from injury to the surrounding structures. The transverse processes usually protect the vertebral artery (VA) as it enters at C6 and courses cranially through the transverse foramina to C2 (referred to as the V2 segment). This is a case report of a patient who presented with myeloradiculopathy attributed to a C4-C5 disc herniation, severe canal stenosis, and marked bilateral neural foraminal stenosis. Preoperative imaging showed the right VA entering the C4 transverse foramen. This anatomic variant on a routine MRI led to further imaging and precautions when performing an uneventful anterior cervical discectomy and fusion (ACDF) at C4-C5. A high VA entry point into the transverse foramen above C6 could increase the risk of iatrogenic vascular injury in anterior approaches to the cervical spine. Rarely reported, the currently presented case describes a patient with a C4 right VA entry variant and highlights the importance of proper surgical planning. [ABSTRACT FROM AUTHOR]

The article discusses the benefits of interdisciplinary care for older adult surgical patients. Four areas identified for care improvement are patient goals, cognition and delirium prevention, mobility and functional status, nutrition and hydration optimization. It identifies challenges in the interdisciplinary care outlined in the Geriatric Surgery Verification Program (GSVP) and calls for care coordination and management plans for older adult surgical patients.

Update: This article was updated on May 19, 2021 because of previous errors, which were discovered after the preliminary version of the article was posted online. In the legend for Figure 3-A, the phrase that had read "T1-weighted coronal MRI showing a right knee" now reads "T1-weighted coronal MRI showing a left knee." On page 924, in the section entitled "Materials and Methods," the sentence that had read "If there was no radiographic evidence or if there was a clinical note that documented visible deformity around the knee with no reduction maneuver being performed, then the patient was classified into the non-dislocated MLKI group." now reads "If there was no radiographic evidence or if there was no clinical note that documented visible deformity around the knee with no reduction maneuver being performed, then the patient was classified into the non-dislocated MLKI group." On page 925, in the section entitled "Analysis," the sentence that had read "Our study included 78 dislocated MLKIs and non-dislocated MLKIs, so both cohorts were adequately powered for the overall analysis." now reads "Our study included 45 dislocated MLKIs and 78 non-dislocated MLKIs, so both cohorts were adequately powered for the overall analysis." Finally, on page 927, in the section entitled "Discussion," the sentence that had read "Interestingly, we found that MLKIs with a documented knee dislocation had a substantially higher rate of vascular injury (23%) compared with those without (3%)." now reads "Interestingly, we found that MLKIs with a documented knee dislocation had a substantially higher rate of vascular injury (18%) compared with those without (4%)." [ABSTRACT FROM AUTHOR]

Case: A 29-year-old healthy woman, 19 weeks pregnant, sustained a right posterolateral knee dislocation with multiligamentous injury and a complete occlusive injury to the right popliteal artery yet had adequate distal perfusion. She declined operative management for both the knee dislocation and the arterial injury, and successful collaboration between obstetrical, vascular, and orthopaedic surgical services resulted in limb preservation and restoration of function. Conclusion: This is a unique case of traumaticcomplete popliteal artery occlusionwith adequate collateral arterial perfusion after a reducible posterolateral knee dislocation in a pregnant patient that resulted in limb preservation with nonoperative management. [ABSTRACT FROM AUTHOR]

Background: A description of the precise locations of ligamentous and myotendinous injury patterns of acute posterolateral corner (PLC) injuries and their associated osseous and neurovascular injuries is lacking in the literature. Purpose: To characterize the ligamentous and myotendinous injury patterns and zones of injury that occur in acute PLC injuries and determine associated rates of peroneal nerve palsies and vascular injuries, as well as fracture and dislocation. Study Design: Case series; Level of evidence, 4. Methods: We retrospectively identified all patients treated for an acute multiligament knee injury (MLKI) at our level 1 trauma center from 2001 to 2018. From this cohort, all patients with PLC injuries were identified. Demographics, involved ligaments and tendons, neurovascular injury, and presence of fracture and dislocation were compared with the larger multiligament knee cohort. Incidence and location of injury of PLC structures—from proximal to midsubstance and distal injury—were recorded. Results: A total of 100 knees in 100 patients were identified as having MLKIs. A total of 74 patients (74%) had lateral-sided ligament injuries. Of these, 23 (31%) had a peroneal nerve palsy associated with their injury; 10 (14%), a vascular injury; and 23 (31%), a fracture. Patients with PLC injuries had higher rates of peroneal nerve injury as compared with those having acute MLKIs without a PLC injury (31% vs 4%; P =.005). Patients with a complete peroneal nerve palsy (n = 17) were less likely to regain function than those with a partial peroneal nerve palsy (n = 6; 12% vs 100%; P <.0001). Complete injury to the lateral collateral ligament (LCL) occurred in 71 of 74 (96%) PLC injuries, with 3 distinct patterns of injury demonstrated. Fibular avulsion of the LCL was the most common zone of injury (65%), followed by femoral avulsion (20%) and midsubstance tear (15%). Location of injury to the LCL was associated with the rate of peroneal nerve injury, with midsubstance tears and fibular avulsions associated with higher rates of peroneal nerve injury. Conclusion: MLKIs with involvement of the PLC are more likely to suffer peroneal nerve injury. The LCL is nearly always involved, and its location of injury is predictive of peroneal nerve injury. Patients with a complete peroneal nerve palsy at presentation are much less likely to regain function. [ABSTRACT FROM AUTHOR]

Background: Musculoskeletal urgent care centers are a new development in the urgent care landscape. Anecdotally, these centers are known to screen patients based on their insurance status, denying care to those with Medicaid insurance. It is important to know whether the practice of denying musculoskeletal urgent care to patients with Medicaid insurance is widespread because this policy could exacerbate existing musculoskeletal healthcare disparities.Questions/purposes: (1) Do musculoskeletal urgent care centers in Connecticut provide access for patients with Medicaid insurance? (2) Do musculoskeletal urgent care centers have the same Medicaid policies as the entities that own them? (3) Are musculoskeletal urgent care centers more likely to be located in affluent neighborhoods?Methods: An online search was conducted to create a list of musculoskeletal urgent care centers in Connecticut. Each center was interviewed over the telephone using a standardized list of questions to determine ownership and Medicaid policy. Next, the entities that owned these musculoskeletal centers were called and asked the same questions about their Medicaid policy. Medicaid policy was compared between musculoskeletal urgent care centers and the practices that owned them. The median household income for each ZIP code containing a musculoskeletal urgent care center was compared with the median household income for Connecticut. The median household income was also compared between the ZIP codes of musculoskeletal urgent care centers that accepted or denied patients with Medicaid insurance.Results: Of the 29 musculoskeletal urgent care centers in Connecticut, only four (13%) accepted patients regardless of their insurance type, 19 (66%) did not accept any form of Medicaid insurance, and six (21%) required that certain requisites and stipulations be met for patients with Medicaid insurance to receive access, such as only permitting a patient for an initial visit and then referring them to a local hospital system for all future encounters, or only permitting patients with Medicaid insurance who lived in the same town as the clinic. All 29 musculoskeletal urgent care centers were owned by private practice groups and nine of 14 of these groups had the same policy towards patients with Medicaid insurance as their respective musculoskeletal urgent care centers. All 29 musculoskeletal urgent care centers were co-located in a private practice clinic office. Musculoskeletal urgent care centers were located in areas with greater median household incomes than the Connecticut state median (95% CI, USD 112,322 to USD 84,613 versus the state median of USD 73,781; p = 0.001).Conclusions: Most musculoskeletal urgent care centers in Connecticut do not accept patients with Medicaid insurance and have similar or stricter Medicaid policies as the groups that own them. Additionally, musculoskeletal urgent care centers were located in affluent neighborhoods. These findings are important because they suggest private practices are using musculoskeletal urgent care centers to capture patients with more favorable insurance. This is likely a result of the relatively low Medicaid reimbursement rates in Connecticut and reflects a need for an increase in either reimbursement or incentives to treat patients with Medicaid insurance. The financial impact of capturing well-insured patients from public and academic medical centers and directing Medicaid patients to these urgent care centers is not known. Additionally, although most of these 29 musculoskeletal urgent care clinics denied care to patients with Medicaid, the specific healthcare disparities caused by decreased access to care must be further studied. [ABSTRACT FROM AUTHOR]