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Collaboration between military and civilian investigators is necessary to develop strategies for optimizing treatments to diminish the sequelae of non–battle-related musculoskeletal injuries, which are highly prevalent among servicemembers. The 2024 Extremity War Injuries Symposium provided a forum whereby a diverse group of clinicians and researchers could develop strategies for optimizing treatments and diminishing the sequelae of conditions that are highly prevalent among active individuals. Key points were as follows: 1. The value of collaborations between military and civilian investigators cannot be overemphasized. These synergies can leverage the capabilities of established infrastructures in order to answer important questions pertaining to short-term outcomes—for example, warrior readiness of anterior cruciate ligament reconstructions among servicemembers and long-term posttraumatic osteoarthritis (PTOA) outcomes among civilian cohorts. 2. Current and future prospective trials will inform future treatment decisions related to multiligamentous knee injuries and glenohumeral instability. 3. Novel approaches to addressing PTOA in the acute postinjury period will need longitudinal surveillance to measure their impact on improving clinical outcomes and diminishing residual functional deficits. [ABSTRACT FROM AUTHOR]

Context: Many clinicians, trainers, and athletes do not have a true understanding of the effects of commonly used performance-enhancing drugs (PEDs) on performance and health. Objective: To provide an evidence-based review of 7 commonly used pharmacological interventions for performance enhancement in athletes. Data Sources: PubMed and Scopus databases were searched on April 8, 2022. Study Selection: Systematic reviews (SRs) and meta-analyses (MAs) assessing the performance-enhancing effects of the following interventions were included: androgenic anabolic steroids (AAS), growth hormone (GH), selective androgen receptor modulators (SARMs), creatine, angiotensin-converting enzyme (ACE)-inhibitors, recombinant human erythropoietin (rHuEPO), and cannabis. Study Design: Umbrella review of SRs and MAs. Level of Evidence: Level 4. Data Extraction: Primary outcomes collected were (1) body mass, (2) muscle strength, (3) performance, and (4) recovery. Adverse effects were also noted. Results: A total of 27 papers evaluating 5 pharmacological interventions met inclusion criteria. No studies evaluating SARMs or ACE-inhibitors were included. AAS lead to a 5% to 52% increase in strength and a 0.62 standard mean difference in lean body mass with subsequent lipid derangements. GH alters body composition, without providing a strength or performance benefit, but potential risks include soft tissue edema, fatigue, arthralgias, and carpel tunnel syndrome. Creatine use during resistance training can safely increase total and lean body mass, strength, and performance in high-intensity, short-duration, repetitive tasks. Limited evidence supports rHuEPO benefit on performance despite increases in both VO2max and maximal power output, and severe cardiovascular risks are documented. Cannabis provides no performance benefit and may even impair athletic performance. Conclusion: In young healthy persons and athletes, creatine can safely provide a performance-enhancing benefit when taken in controlled doses. AAS, GH, and rHuEPO are associated with severe adverse events and do not support a performance benefit, despite showing the ability to change bodily composition, strength, and/or physiologic measures. Cannabis may have an ergolytic, instead of ergogenic, effect. [ABSTRACT FROM AUTHOR]

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. Summary: 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The importance of several scapulothoracic muscles, including trapezius and serratus anterior, in maintaining physiological scapula kinematics has been highlighted in the past. However, the relationship between the scapula and the latissimus dorsi muscle remains unclear. Our clinical surgical observation is that the latissimus dorsi does not directly attach but rather runs superficial to the inferior angle of the scapula. Based on this observation, we hypothesise that the latissimus dorsi creates a dynamic track on which the scapula glides under the muscle belly during elevation of the arm, creating the latissimus-scapula overlap (LSO). Methods: All consecutive patients who had a whole-body computed tomography scan (CT) in case of polytrauma evaluation between 2018 and 2021, with complete depiction of the scapula and latissimus dorsi muscle, were analysed. 150 shoulders in 90 patients with arms up were matched according to their age (within five years), gender, and affected side with 150 shoulders in 88 patients with arms down. Patients with pathologies of the upper extremities or thorax that potentially could alter LSO measurements were excluded. LSO was calculated as a ratio of the measured area of the latissimus dorsi projection on the scapula and the total scapula area. Results: The mean age of the 178 patients (48 females; 13 males) was 60 years. The arms-up group showed a significantly higher LSO than the arms-down group (19.9 ± 6.3% vs. 2.7 ± 2.2%; p < 0.0001). In the arms-up group, approximately one fifth of the scapula was overlapped inferiorly by the muscle belly of the latissimus dorsi, contrary to the almost non-existing LSO in the arms-down group. Conclusion: With arms up, humans show a significantly higher LSO in comparison to arms down indicating that the latissimus dorsi indeed creates a dynamic track on which the scapula is forced to travel during abduction of the arm. This finding of increased LSO during the elevation of the arm warrants further consideration of the role of the latissimus dorsi in scapula kinematics and potentially scapular dyskinesis. Level of evidence: Level two diagnostic study. [ABSTRACT FROM AUTHOR]

Purpose: Anterior cruciate ligament tears and anterior cruciate ligament reconstruction (ACLR) are common in young athletes. The modifiable and non-modifiable factors contributing to ACLR failure and reoperation are incompletely understood. The purpose of this study was to determine ACLR failure rates in a physically high-demand population and identify the patient-specific risk factors, including prolonged time between diagnosis and surgical correction, that portend failure. Methods: A consecutive series of military service members with ACLR with and without concomitant procedures (meniscus [M] and/or cartilage [C]) done at military facilities between 2008 and 2011 was completed via the Military Health System Data Repository. This was a consecutive series of patients without a history of knee surgery for two years prior to the primary ACLR. Kaplan–Meier survival curves were estimated and evaluated with Wilcoxon test. Cox proportional hazard models calculated hazard ratios (HR) with 95% confidence intervals (95% CI) to identify demographic and surgical factors that influenced ACLR failure. Results: Of the 2735 primary ACLRs included in the study, 484/2,735 (18%) experienced ACLR failure within four years, including (261/2,735) (10%) undergoing revision ACLR and (224/2,735) (8%) due to medical separation. The factors that increased failure include Army Service (HR 2.19, 95% CI 1.67, 2.87), > 180 days from injury to ACLR (HR 1.550, 95% CI 1.157, 2.076), tobacco use (HR 1.429 95% CI 1.174, 1.738), and younger patient age (HR 1.024, 95% CI 1.004, 1.044). Conclusion: The overall clinical failure rate of service members with ACLR is 17.7% with minimum four-year follow-up, where more patients are likely to fail due to revision surgery than medical separation. The cumulative probability of survival at 4 years was 78.5%. Smoking cessation and treating ACLR patients promptly are modifiable risk factors impacting either graft failure or medical separation. Level of evidence: Level III. [ABSTRACT FROM AUTHOR]

Background: In a reverse total shoulder arthroplasty, the altered glenohumeral joint center of rotation subjects the glenoid baseplate to increased shear forces and potential loosening. Methods: This study examined glenoid baseplate micromotion and initial fixation strength with the application of direct shear force in a Sawbone model. The reverse total shoulder arthroplasty systems examined were the DJO Reverse® Shoulder Prosthesis, the Exactech Equinoxe® Reverse System, and the Tornier Aequalis TM Reverse Shoulder Prosthesis. Specimens were cyclically tested with increasing shear loads until 150 µm of displacement between the implant and glenoid was achieved, and subsequently until failure, classified as either 1 cm of implant/glenoid displacement or fracture. Results: The average load withstood for the 150 µm threshold for DJO, Tornier, and Exactech was 460 ± 88 N, 525 ± 100 N, and 585 ± 160 N, respectively. The average total load at device failure for DJO, Tornier, and Exactech was 980 ± 260 N, 1260 ± 120 N, and 1350 ± 230 N, respectively. Discussion: The Exactech implant design trended toward requiring more load to induce micromotion at each threshold and to induce device failure, most commonly seen as inferior screw pull out. This study proposes design features that may enhance fixation and suggests little risk of initial micromotion or failure during initial post-operative recovery. [ABSTRACT FROM AUTHOR]

Our advanced understanding of shoulder instability with bone loss has increased orthopaedic surgeons' interest in glenoid bone reconstruction procedures, of which the Latarjet procedure is the most well established [[10]]. Outcomes of the Latarjet procedure versus free bone block procedures for anterior shoulder instability: a systematic review and meta-analysis. Indeed, my bony glenoid reconstruction procedure of choice currently consists of a free bone block technique using either distal clavicle autograft (in cases of subcritical bone loss) or distal tibia allograft (for larger defects), done arthroscopically with suture anchor fixation [[18]]. i B Dr. Barth: b Currently, in my personal registry of anterior shoulder instability surgeries that I started in 2005, I have performed 710 open Latarjet procedures, 120 arthroscopic Bankarts, and 20 arthroscopic Latarjet techniques. [Extracted from the article]

Background: The primary objective of the present study was to investigate how preoperative imaging modalities including 3D computed tomography (CT) scans with preoperative planning software affect implant choice for shoulder arthroplasty. Methods: X-ray, uncorrected 2D CT scans, and 3D CT scans from 21 patients undergoing primary arthroplasty were reviewed by five shoulder surgeons. Each surgeon measured glenoid version, inclination and humeral head subluxation, and then selected an anatomic or reverse shoulder arthroplasty implant based only on these imaging parameters. Each surgeon virtually positioned the implant. Agreement between surgeons and changes in plan for individual surgeons between imaging modalities were assessed. Results: Average measurements of native version, inclination, and subluxation were similar across all imaging modalities with very good interobserver reliability. Overall, there was a high rate of variability in choice of implant depending on imaging modality. Agreement on implant selection between surgeons improved from 68.6% using x-ray to 80.0% with 3D CT. Introducing age added significant variability, reducing agreement on implant choice to 61.0% with 3D CT. Conclusions: The use of preoperative 3D planning changes implant choice in nearly one-third of cases compared to plain radiographs and improves surgeon agreement on implant choice compared to x-ray and 2D CT. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Background: Irreparable posterosuperior rotator cuff (PSRC) tears have been shown to result in shoulder pain and loss of function. Purpose/Hypothesis: The purpose of this study was to determine the effect of the loss of active or passive function of the PSRC on compensatory muscle loads in the deltoid and the remaining rotator cuff. It was hypothesized that both deactivation and resection of the PSRC would result in load increases in the remaining muscles and that resection of the PSRC would result in even higher required compensatory forces than would mere deactivation. Study Design: Controlled laboratory study. Methods: A total of 7 cadaveric shoulders were tested using a biomechanical shoulder simulator with 10 independently controlled actuators for various muscles (anterior, middle, and posterior deltoid; inferior and superior subscapularis; latissimus dorsi; pectoralis major; teres minor; supraspinatus; and infraspinatus) and 3-dimensional motion tracking. The muscle loads representing the latissimus dorsi and pectoralis major were each held constant, and the remaining muscle actuator forces required to abduct the arm in the scapular plane were determined. The actuator forces corresponding with arm elevation from 20° to 65° were compared at 5° increments for 3 testing conditions: (1) intact, active PSRC; (2) intact, deactivated PSRC; and (3) resected PSRC and shoulder capsule. Results: In both the deactivated and resected states, the teres minor showed a significant increase in required muscle forces through nearly the entire tested range of arm elevation compared to the active state. This was also the case for the subscapularis but only at higher elevation angles. The deltoid demonstrated increased muscle forces of at least 1 of its subunits between 25° and 55° of elevation when comparing the deactivated state or resected state to the active state. However, through nearly the entire range of elevation, no statistically significant differences were found between the deactivated and resected states for any of the actuator loads representing muscle forces. Conclusion: The loss of active function of the PSRC led to compensatory loads on the remaining rotator cuff and deltoid, regardless of the passive presence of the PSRC as a supposed subacromial spacer. Clinical Relevance: The findings encourage the exploration of treatment procedures that mimic the active function of the PSRC when the rotator cuff itself is irreparable. [ABSTRACT FROM AUTHOR]

Background: Although there is some evidence that cannabinoid (CBD) products may provide a therapeutic effect for musculoskeletal pain, little is known about the usage patterns or their prevalence of use in orthopaedic sports medicine patients. Purpose: To report the prevalence and perceived self-efficacy of CBD products in patients evaluated in an orthopaedic sports medicine clinic. Study Design: Descriptive epidemiology study. Level of evidence, 2. Methods: The study population consisted of new patients who visited an orthopaedic surgery sports medicine clinic at a large academic center for consultation with a surgeon between August 2020 and March 2021. All patients were asked to complete a survey that assessed perceived pain and effectiveness of CBD products and other nonsurgical treatment modalities using the Single Assessment Numeric Evaluation score (range, 0-100) and the Numeric Pain Rating Scale (NRS). Descriptive factors were collected via chart review. Descriptive statistics were used to characterize the data. Results: Overall, 823 patients completed the survey (45.4% female; mean age, 51 years [range, 18-87 years]; mean body mass index, 28.9 [range, 17.2-58.4]). Body areas involved included 285 shoulders, 44 elbows, 76 hips, 276 knees, 58 ankles, and 77 other. Of these patients, 19% (152/823) endorsed the use of CBD products before their initial evaluation. The mean NRS for pain was significantly different between non-CBD users and CBD users (5.6 vs 6.1; P = .029). CBD users were significantlymore likely to have tried other nonoperative modalities compared with nonusers, including nonsteroidal anti-inflammatory drugs (79.6% vs 69.8%; P = .032), bracing (44.7% vs 34.6%; P = .024), steroid injections (38.8% vs 21.6%; P < .001), and physical therapy (54% vs 36.1%; P < .001). In addition, 30.9% of CBD utilizers reported marijuana use compared with 2.8% of non-CBD users (P < .001) for management of their pain. Conclusion: In the current study, 19% of patients had used CBD products to manage joint-related issues. Sports medicine providers should be aware of this high incidence of usage and the potential interactions CBD products may have with other treatment modalities. Further studies are needed to assess the effectiveness of CBD as a therapeutic agent and the specific interactions it has with other drugs and other forms of treatment. [ABSTRACT FROM AUTHOR]

Background: The purpose was to evaluate the relationship of component size and position to postoperative range of motion following reverse shoulder arthroplasty. The hypothesis was that increased lateralization, larger glenospheres, and a decreased acromiohumeral distance would be associated with excellent postoperative range of motion. Methods: A retrospective multicenter study was performed at a minimum of one year postoperatively on 160 patients who underwent primary reverse shoulder arthroplasty with a 135° humeral component. Outcomes were stratified based on postoperative forward flexion and external rotation into excellent (n = 42), defined as forward flexion >140° and external rotation > 30°, or poor (n = 36), defined as forward flexion <100° and external rotation < 15°. Radiographic measurements and component features were compared between the two groups. Results: A larger glenosphere size was associated with an excellent outcome (p = 0.009). A 2-mm posterior offset humeral cup (p = 0.012) and an increased inferior glenosphere overhang (3.1 mm vs 1.4 mm; p = 0.002) were also associated with excellent outcomes. Humeral lateralization and distalization were not associated with an excellent outcome. Conclusion: L arger glenosphere size and inferior positioning as well as posterior humeral offset are associated with improved postoperative range of motion following reverse shoulder arthroplasty. Level of Evidence: Level 3, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Background: With a hip abductor tendon tear, widening of the intergluteal space, or "fat stripe," is a characteristic change seen in and around the gluteus medius and minimus. Purpose: To determine the relationship of the intergluteal fat stripe in hips with pathologic abductor tears compared with the contralateral side and to evaluate the association of fat stripe size with hip-specific patient-reported outcome measures. Study Design: Case series; Level of evidence, 4. Methods: Of the 43 patients (42 female, 1 male; mean age, 56.6 years; range, 38-85 years) who underwent endoscopic gluteus medius repair, 19 met inclusion criteria of preoperative bilateral hip magnetic resonance imaging (MRI) scans and 2-year follow up. A single board-certified fellowship-trained orthopaedic surgeon (J.F.), who was blinded to outcomes, evaluated the MRI scans to measure the intergluteal fat stripe on the operative and nonoperative sides. The 2-year postoperative International Hip Outcome Tool (iHOT-12) and modified Harris Hip Score (mHHS) values were analyzed to determine their relationship to the size of the fat stripe. Statistical analysis was performed using a paired t test, and associations were determined using Pearson product correlation as well as nonparametric measurements. Results: The size of the intergluteal fat stripe differed significantly between the operative and nonoperative sides. The area of the fat stripe on the operative side was 645.73 ± 513.09 mm2, and on the nonoperative side it was 313.47 ± 360.71 mm2, an average of 332.36 mm2 greater than the nonoperative side (P =.02). The width of the fat stripe was 9.10 ± 4.60 mm on the operative side and 5.15 ± 3.87 mm on the nonoperative side, 3.95 mm greater than the nonoperative side (P <.01). There was no correlation between the width or area of the fat stripe on the operative side and iHOT-12 or mHHS values at 2-year follow-up. Conclusion: The study findings indicated that the intergluteal fat stripe is significantly wider and has a significantly larger area in hips with abductor tears compared with unaffected hips. This did not correlate with 2-year patient-reported outcomes. [ABSTRACT FROM AUTHOR]

This biomechanical study evaluates the performance of a solid titanium-alloy intra-medullary (IM) clavicular screw in torsion and cantilever bending in cadaveric clavicle specimens with simulated simple oblique and butterfly wedge midshaft fractures. Thirty-two fresh-frozen male clavicles were sorted into six experimental groups: Torsion Control, Torsion Simple Oblique Fracture, Torsion Butterfly Wedge Fracture, Bending Control, Bending Simple Oblique Fracture, and Bending Butterfly Wedge Fracture. The experimental groups were controlled for density, length, diameter, and laterality. All other samples were osteotomy-induced and implanted with a single 90 mm × 3 mm clavicle screw. All groups were tested to physiologically relevant cutoff points in torsion or bending. There were no statistically significant differences in the performance of the oblique and butterfly wedge fracture models for any torsion or bend testing measures, including maximum torsional resistance (p = 0.66), torsional stiffness (p = 0.51), maximum bending moment (p = 0.43), or bending stiffness (p = 0.73). Torsional testing of samples in the direction of thread tightening tended to be stronger than samples tested in loosening, with all groups either approaching or achieving statistical significance. There were no significant differences between the simple oblique or the butterfly-wedge fracture groups for any of the tested parameters, suggesting that there is no difference in the gross biomechanical properties of the bone-implant construct when the IM clavicle screw is used in either a simple midshaft fracture pattern or a more complex butterfly wedge fracture pattern. [ABSTRACT FROM AUTHOR]

Background: In-season return to play after anterior glenohumeral instability is associated with high rates of recurrent instability and the need for surgical stabilization. We are not aware of previous studies that have investigated in-season return to play after posterior glenohumeral instability; furthermore, as posterior shoulder instability in collision athletes occurs frequently, understanding the expected outcome of in-season athletes may improve the ability of physicians to provide athletes with a better understanding of the expected outcome of their injury and their ability to return to sport.Questions/purposes: (1) What proportion of athletes returned to play during the season after posterior instability in collegiate football players? (2) How much time did athletes lose to injury, what proportion of athletes opted to undergo surgery, and what proportion of athletes experienced recurrent instability after a posterior instability episode during a collegiate football season?Methods: A multicenter, prospective, observational study of National Collegiate Athletic Association (NCAA) Division 1 Football Bowl Subdivision athletes was performed at three US Military Service Academies. Ten athletes who sustained a posterior instability event during the regular football season and who pursued a course of nonoperative treatment were identified and prospectively observed through the subsequent season. All athletes in the observed cohort attempted an initial course of nonoperative treatment during the season. All athletes sustained subluxation events initially identified through history and physical examination at the time of injury. None of the athletes sustained a dislocation event requiring a manual reduction. Intraarticular pathology consisting of posterior labral pathology was further subsequently identified in all subjects via MRI arthrogram. Return to play was the primary outcome of interest. Time lost to injury, surgical intervention, and subsequent instability were secondary outcomes.Results: Of the 10 athletes who opted for a trial of initial nonoperative management, seven athletes were able to return to play during the same season. Although these seven athletes returned within 1 week of their injury (median of 1 day), 5 of 7 athletes sustained recurrent subluxation events with a median (range) of four subluxation events per athlete (0 to 8) during the remainder of the season. Seven athletes were treated surgically after the completion of their season, four of whom returned to football.Conclusion: This study suggests that although collegiate football players are able to return to in-season sport after a posterior glenohumeral instability event, they will likely sustain multiple recurrent instability events and undergo surgery after the season is completed. The results of this study can help guide in-season management of posterior shoulder instability by allowing more appropriate postinjury counseling and decision making through the identification of those athletes who may require additional attention from medical staff during the season and possible modifications to training regimens to minimize long-term disability. Further prospective studies involving a larger cohort over several seasons should be performed through collaborative studies across the NCAA that better assess function and injury risk factors before beginning collegiate athletics. This would better characterize the natural history and associated functional limitations that athletes may encounter during their collegiate careers.Level Of Evidence: Level IV, prognostic study. [ABSTRACT FROM AUTHOR]

Background: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. Purpose: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. Results: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R 2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. Conclusion: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians. [ABSTRACT FROM AUTHOR]

Background: Functional bracing is often used as an adjunct to nonoperative treatment of anterior shoulder instability, but no study has evaluated the effectiveness of in-season bracing. The purpose of this study was to examine successful return to play in a nonoperative cohort of adolescent athletes with in-season shoulder instability and compare those athletes treated with bracing to those who were not. Hypothesis: The use of functional bracing will improve success rates in a cohort of athletes treated nonoperatively for in-season shoulder instability. Study Design: Cohort study. Level of Evidence: Level 3. Methods: A total of 97 athletes with anterior shoulder instability were followed for a minimum of 1 year. The mean age was 15.8 ± 1.4 years (range, 12.0-18.0 years). All athletes were treated with initial nonoperative management. Twenty athletes (21%) were also treated with bracing while 77 (79%) were not. The athlete completing the current season and 1 subsequent season without surgery or time lost from shoulder injury was defined as a successful outcome. Results: There was no statistical difference in nonoperative success rates between the braced and nonbraced athletes (P = 0.33). Braced athletes (n = 20) returned to play 80% of the time, while nonbraced athletes (n = 77) returned at a rate of 88%. Of the braced athletes, 85% were football players (n = 17). A football-only comparison demonstrated no difference between braced failures (26%) and nonbraced failures (16%) (P = 0.47). Conclusion: This is the first study to evaluate the utility of functional bracing in returning an athlete to sport and completing a full subsequent season without surgery or time loss due to injury of the shoulder. In adolescent athletes with shoulder instability treated nonoperatively, functional bracing did not result in increased success rates when compared with no bracing. Clinical Relevance: The data from this study indicate that functional bracing may not improve success rates for athletes with shoulder instability. [ABSTRACT FROM AUTHOR]

Background: The management of the adolescent athlete after initial shoulder instability remains controversial. Hypothesis: Individual risk factors in athletes with shoulder instability who are managed nonoperatively can be integrated into a scoring system that can predict successful return to sport. Study Design: Retrospective cohort study. Level of Evidence: Level 4. Methods: A total of 57 scholastic athletes with primary anterior shoulder instability who were managed nonoperatively were reviewed. Success was defined as a return to index sport at the same level and playing at least 1 subsequent season without missed time as a result of the shoulder. Patient-specific risk factors were individually evaluated, and odds ratios were calculated. A 10-point Nonoperative Injury Severity Index Score (NISIS) incorporated the risk factors for failure. This score was then retrospectively applied with regression analysis and a chi-square analysis to determine the overall optimal score that predicted failure of nonoperative management. Results: In total, 6 risk factors for failure were included in the NISIS: age (>15 years), bone loss, type of instability, type of sport (contact vs noncontact), male sex, and arm dominance. Overall, 79% of patients treated nonoperatively were able to successfully return to sport. Nearly all (97%) low-risk patients (NISIS <7) successfully returned to sport, while only 59% of high-risk patients returned to sport, a relative risk of 12.2 (P = 0.001). High-risk patients with unipolar bone loss successfully returned (100%), but 67% of high-risk patients with bipolar bone loss failed. Conclusion: The NISIS is a simple and effective clinical tool to determine successful nonoperative management following anterior shoulder instability and may be helpful in guiding decision making when presented with the unstable shoulder in the scholastic athlete. [ABSTRACT FROM AUTHOR]

Background: Ultrasound-guided fascia iliaca blocks have been used for pain control after hip arthroscopy. There is little evidence regarding their effectiveness in comparison with other pain control modalities in patients who have undergone hip arthroscopy. Purpose: To compare the efficacy of ultrasound-guided fascia iliac block with intra-articular ropivacaine in controlling pain after hip arthroscopy. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Between 2015 and 2017, patients (N = 95) undergoing hip arthroscopy were randomly assigned to 2 groups. The first group received an ultrasound-guided fascia iliaca block with 50 to 60 mL of 0.35% ropivacaine. The second group received an intra-articular injection of 20 mL of 0.5% ropivacaine at the completion of the surgical case. Primary outcomes were postoperative pain scores in the recovery room; at postanesthesia care unit (PACU) discharge; and at 2 weeks, 6 weeks, and 3 months. Secondary outcomes included intraoperative and PACU narcotic usage (converted to morphine equivalent use) as well as readmission rates, PACU recovery time, and postoperative nausea and vomiting. Results: Postoperative pain across all points did not significantly differ between the groups. Intraoperative and PACU narcotics did not differ significantly between the groups. Readmission rates, PACU recovery time, and postoperative nausea and vomiting did not significantly differ between the groups. There were no associated complications in either group. Conclusion: Ultrasound-guided fascia iliaca block for hip arthroscopy had no clinical advantage when compared with onetime intra-articular ropivacaine injection. Registration: NCT02365961 (ClinicalTrials.gov identifier). [ABSTRACT FROM AUTHOR]

Purpose of Review: Glenohumeral internal rotation deficit (GIRD) is a term used in the literature to describe the physiological adaptation that occurs in the dominant arm of the overhead-throwing athlete. The meaning of this term and the clinical significance and the rationale for its treatment have all been described with some ambiguity within the literature. GIRD as a measurement is multivariate. There is an adaptive bony component in humeral retroversion (HR) and muscular contributions in the form of thixotropy which can confound the capsular component of GIRD. Emerging diagnostic tools such as ultrasound can help differentiate between the bony and soft tissue contributions as well as provide a dynamic assessment in the throwing shoulder. The purpose of this review is to describe and differentiate between anatomical GIRD (aGIRD) and pathological GIRD (pGIRD), discuss the clinical significance of pGIRD and values reported within the literature, and describe its measurement and clinical treatment. Recent Findings: Recent literature has demonstrated that GIRD alone is not associated with injury risk of the upper extremity in the overhead athlete. Although past literature has demonstrated pGIRD as increasing injury risk, other variables such as external rotation (ER) deficit, horizontal adduction deficit, and shoulder flexion deficit have been associated with injury of the upper extremity while GIRD did not. Further, an appreciation for the difference between adaptive GIRD and pathologic GIRD has recently been emphasized to ensure optimal treatment addresses the pathologic portion of GIRD. The recent focus on early treatment approaches to pGIRD may play a role in its diminished risk association. Summary: This review offers the term humeral retroversion (HR) Corrected GIRD as a more clinically sensitive value that may provide the clinician a more precise rationale for the treatment of pGIRD. Currently, diagnostic ultrasound is a reliable and valid method for measuring HR in the overhead-throwing athlete. Future research that validates clinical methods for assessing HR could provide utility for clinical decision-making in the absence of diagnostic ultrasound. [ABSTRACT FROM AUTHOR]

Context: Sport specialization is thought to be a primary contributor to the throwing-related injury risk in youth baseball players. Objective: To (1) establish arm-injury incidence in a cohort of male youth (9-12 years old) baseball players and (2) examine sport specialization and the frequency of arm injuries in the same cohort. Design: Cohort study. Setting: Greenville, South Carolina, youth baseball programs and tournaments. Patients or Other Participants: A total of 159 asymptomatic youth baseball players (age = 11.1 ± 1.1 years) were physically assessed and then were prospectively followed for 6.7 ± 1.5 months. Main Outcome Measure(s): Athlete demographics and playing and injury histories were initially recorded. Athleteexposures and presence of arm injury were prospectively tracked. All injuries were physically confirmed by a licensed physical therapist. Results: Youth players demonstrated an arm-injury incidence rate of 2.22 per 1000 athlete-exposures. Parents and players underestimated sport-specialization status based on the standard research definition (self versus research based: 31% versus 83%, respectively; P = .001). The frequency of arm injuries was higher in specialized players (100%) than in nonspecialized players (80%, P=.03) but did not differ between pitchers and position players (13.2% each, P = 1.00). Conclusions: Sport specialization was associated with throwing-related arm injuries in a small cohort of youth baseball players. It is concerning that 57.9% of parents and specialized players were unaware of the athletes' status. Larger studies with longer follow-up periods are needed to further evaluate injury-risk profiles in physically developing youth populations. [ABSTRACT FROM AUTHOR]

Background: Young age and contact sports have been postulated as risk factors for anterior shoulder instability. Management after shoulder instability is controversial, with studies suggesting that nonoperative management increases the risk of recurrence. Several studies examined return to play after an in-season instability episode, and few followed these patients to determine if they were able to successfully compete in a subsequent season. No study has evaluated this question in a high school athlete population. Purpose: To compare the likelihood of return to scholastic sport and complete the next full season without an additional time-loss injury among athletes with anterior shoulder instability in terms of treatment, instability type, and sport classification. Study Design: Cohort study; Level of evidence, 2 Methods: Athletes were included in this study as identified by a scholastic athletic trainer as experiencing a traumatic time-loss anterior shoulder instability injury related to school-sponsored participation. The cohort was predominantly male (n = 108, 84%) and consisted mostly of contact athletes (n = 101, 78%). All athletes had dislocation or subluxation diagnosed by a board-certified physician who determined the athlete's course of care (nonoperative vs operative). Successful treatment was defined as completion of care and return to the athlete's index sport, with full participation for the following season. Chi-square and relative risk analyses were completed to compare success of treatment (nonoperative vs operative care) and instability type. Separate logistic regressions were used to compare the effect of sex and sport classification on the athletes' ability to return to sport. Statistical significance was set a priori as α = .05. Results: Scholastic athletes (N = 129) received nonoperative (n = 97) or operative (n = 32) care. Nonoperatively treated (85%) and operatively treated (72%) athletes successfully returned to the same sport without injury for at least 1 full season (P = .11). Players sustaining a dislocation were significantly more likely to fail to return when compared with those sustaining a subluxation (26% vs 89%, P = .013). Sex (P = .85) and sport classification (P = .74) did not influence the athlete's ability to return to sport, regardless of treatment type. Conclusion: A high percentage of athletes with shoulder instability achieved successful return to sport without missing any additional time for shoulder injury. Those with subluxations were at almost 3 times the odds of a successful return compared with those sustaining a dislocation. [ABSTRACT FROM AUTHOR]

Background: Movement toward a value-based health-care system necessitates the development of performance measures to compare physicians, hospitals, and health-care systems. Patient-reported outcomes (PROs) are a potential metric. However, valid use of PROs hinges on the ability to risk-adjust for baseline patient differences across a surgeon's panel of patients. The purpose of this study was to propose an approach for baseline risk adjustment and evaluate the importance of risk adjustment when comparing surgeons' performance of rotator cuff repair.Methods: Patients (n = 995) treated with arthroscopic rotator cuff repair by 34 surgeons from 2010 to 2017 were identified from a large sports medicine clinical data registry. A linear regression model was used to adjust for baseline PROs, patient demographics, and clinical characteristics to predict American Shoulder and Elbow Surgeons (ASES) change scores for each surgeon. A risk-adjusted performance measure was calculated as the difference between the average unadjusted ASES change scores and the risk-adjusted predicted ASES change scores across all patients treated by a surgeon.Results: The differences between unadjusted and risk-adjusted performance scores varied widely across surgeons (range, -13.8 to 10.3 ASES points). Use of the risk-adjusted performance scores resulted in a dramatic change in the relative ranking of surgeons, compared with the ranking based on the observed ASES change scores, with 31 of the 34 surgeons' rank changing following risk adjustment. On average, the observed ASES scores improved from 49.5 ± 17.5 at baseline to 78.0 ± 22.5 at 6 months across all surgeons. In the risk-adjustment model (R = 0.44), male sex, Workers' Compensation status, higher scores on the Veterans RAND 12-item Health Survey (VR-12), lower baseline ASES scores, fair and poor tendon quality, and night pain all had a significant effect on the predicted ASES change scores (p < 0.05).Conclusions: Our results show wide variation of nearly 25 points in the risk-adjusted 6-month ASES performance difference from the highest to the lowest-performing surgeons. Additionally, 91% of surgeons' rank changed following risk adjustment. This suggests that performance measurement that does not account for baseline patient characteristics would likely result in incorrect conclusions about a surgeon's relative performance based on PROs.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose of Review: This review discusses the current literature regarding the use of platelet-rich plasma (PRP) in the treatment of muscle strain injuries. Case series as well as experimental trials for both human and animal models are covered.Recent Findings: Multiple studies have examined outcomes for the use of PRP in the treatment of muscle strain injuries. PRP has been shown to promote muscle recovery via anabolic growth factors released from activated platelets, and in doing so, potentially reduces pain, swelling, and time for return to play.Summary: In vitro studies support the regenerative potential of PRP for acute soft tissue injuries. Multiple clinical case series for PRP injections in the setting of muscle strains demonstrate imaging evidence for faster healing, less swelling, which can decrease time for return to play. These studies, however, are retrospective in nature, and few randomized controlled studies exist to demonstrate a clear clinical benefit. Additionally, there is tremendous heterogeneity regarding the injectant preparation, optimum platelet concentration, presence of leukocytes, and volume of PRP which should be administered as well as number of and timing of treatments. [ABSTRACT FROM AUTHOR]

Background: There is an ever-increasing demand for widespread implementation of patient-reported outcomes. However, adoption is slow owing to limitations in clinical infrastructure and resources within busy orthopaedic practices. Prior studies showed the single alpha-numeric evaluation (SANE) score to correlate at a single point in time with the American Shoulder and Elbow Surgeons (ASES) score. However, no study has validated the SANE in terms of test-retest reliability, responsiveness, or clinical utility. Purpose: To validate SANE with the ASES across a sample of patients with common orthopaedic shoulder diagnoses. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients undergoing rotator cuff repair (n = 77), total shoulder replacement (n = 55), or physical therapy (n = 80) for signs and symptoms of subacromial impingement syndrome (n = 61) or adhesive capsulitis (n = 19) were administered the SANE and ASES at baseline and again at their 3-month follow-up from initial care or surgery (N = 212, mean ± SD age = 52.6 ± 1.2 years, n = 145 women). Interclass correlation coefficient (ICC2,1) and standard error of the measurement (SEm) were used to evaluate the test-retest reliability of the SANE and the validity between the SANE and ASES scores. Analysis of variance (treatment group × time) was used to evaluate the responsiveness to treatment, and a receiver operating characteristic curve was used to establish the minimal clinically important difference (MCID) for the SANE as compared with the ASES (α = .05). Floor and ceiling effects were evaluated as the percentage of patients who scored the highest or lowest score on each tool. Results: The SANE demonstrated good pretreatment reliability (ICC2,1 = 0.84, SEM = 3.8), similar to the ASES (ICC2,1 = 0.82, SEM = 3.4). The SANE also showed good agreement with the ASES before and after treatment across all treatment groups (rotator cuff repair, ICC2,1 = 0.85, SEM = 3.4; total shoulder replacement, ICC2,1 = 0.72, SEM = 5.2; physical therapy: ICC2,1 = 0.82, SEM = 2.9). The SANE and ASES displayed similar responsiveness after treatment, with similar mean change and SD within each treatment group. The receiver operating characteristic curve revealed an area under the curve of 0.79 (SE, 0.62; P < .001) and a cutoff of 15% on the SANE, with a sensitivity of 85% to establish the MCID. Acceptable and similar floor and ceiling effects were observed for the ASES (4%) and SANE (9%). Conclusion: The study demonstrates that the SANE is valid for a range of common shoulder diagnoses to assess patient outcomes across operative and nonoperative treatment for shoulder complaints. The MCID of 15% is similar to that of the ASES (11%), suggesting that the SANE is a simple and efficient tool to assess treatment effects for shoulder disorders. Future studies are warranted to confirm these results and compare across other body parts and diagnoses. [ABSTRACT FROM AUTHOR]

Background: Glenoid bone loss is a well-accepted risk factor for failure after arthroscopic stabilization of anterior glenohumeral instability. Glenoid bone loss in posterior instability has been noted relative to its existence in posterior instability surgery. Its effect on outcomes after arthroscopic stabilization has not been specifically evaluated and reported. Purpose: The purpose was to evaluate the presence of posterior glenoid bone loss in a series of patients who had undergone arthroscopic isolated stabilization of the posterior labrum. Bone loss was then correlated to return-to-duty rates, complications, and validated patient-reported outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review was conducted at a single military treatment facility over a 4-year period (2010-2013). Patients with primary posterior instability who underwent arthroscopic isolated posterior labral repair were included. Preoperative magnetic resonance imaging was used to calculate posterior glenoid bone loss using a standardized “perfect circle” technique. Demographics, return to duty, complications, and reoperations, as well as outcomes scores including the Single Assessment Numeric Evaluation and the Western Ontario Shoulder Instability Index (WOSI) scores, were obtained. Outcomes were analyzed across all patients based on percentage of posterior glenoid bone loss. Bone loss was then categorized as below or above the subcritical threshold of 13.5% to determine if bone loss effected outcomes similar to what has been shown in anterior instability. Results: There were 43 consecutive patients with primary, isolated posterior instability, and 32 (74.4%) completed WOSI scoring. Mean follow-up was 53.7 months (range, 25-82 months) The mean posterior glenoid bone loss was 7.3% (0%-21.5%). Ten of 32 patients (31%) had no appreciable bone loss. Bone loss exceeded 13.5% in 7 of 32 patients (22%), and 2 patients (6%) exceeded 20% bone loss. Return to full duty or activity was nearly 90% overall. However, those with >13.5%, subcritical glenoid bone loss, were statistically less likely to return to full duty (relative risk = 1.8), but outcomes scores, complications, and revision rates were otherwise not different in those with no or minimal bone loss versus those with more significant amounts. Conclusion: Posterior glenoid bone loss has not previously been evaluated independently relative to patients with shoulder instability repairs. Sixty-nine percent of our patients had measurable bone loss, and 22% had greater than 13.5%, or above subcritical bone loss. While these patients were statistically less likely to return to full duty, the reoperation rate, complications, and patient-reported outcomes between groups were not different. [ABSTRACT FROM AUTHOR]

Background: Bone loss in shoulder instability is a well-recognized cause of failure after stabilization surgery. Many approaches have been described to address glenoid bone loss, including coracoid transfer. This transfer can be technically difficult and has been associated with high complication rates. An ideal alternative to coracoid transfer would be an autologous source of fresh osteochondral graft with enough surface area to replace significant glenoid bone loss. The distal clavicle potentially provides such a graft source that is readily available and low-cost. Purpose: To evaluate distal clavicular autograft reconstruction for instability-related glenoid bone loss, specifically comparing the width of the clavicular autograft with the width of an ipsilateral coracoid graft as prepared for a Latarjet procedure. Further, we sought to compare the articular cartilage thickness of the distal clavicle graft with that of the native glenoid. Study Design: Controlled laboratory study. Methods: Twenty-seven fresh-frozen cadaver specimens were dissected, and an open distal clavicle excision was performed. The coracoid process in each specimen was prepared as has been described for a classic Latarjet coracoid transfer. In each specimen, the distal clavicle graft was compared with the coracoid graft for size and potential of glenoid articular radius of restoration. The distal clavicle graft was also compared with the native glenoid for cartilage thickness. Results: In all specimens, the distal clavicle grafts provided a greater radius of glenoid restoration than the coracoid grafts (P < .0001). On average, the clavicular graft was able to reconstruct 44% of the glenoid diameter, compared with 33% for the coracoid graft (P < .0001). The articular cartilage of the glenoid was significantly thicker (1.4 mm thicker, P < .0001) than that of the distal clavicular autograft (average ± SD, 3.5 ± 0.6 mm vs 2.1 ± 0.8 mm, respectively). When specimens with osteoarthritis were excluded, this difference decreased to 0.97 mm when compared with the clavicular cartilage (P = .0026). Conclusion: The distal clavicle autograft can restore a significantly greater glenoid bone deficit than the Latarjet procedure and has the additional benefit of restoring articular cartilage to the glenoid. The articular cartilage thickness of the distal clavicle is within 1.4 mm of that of the native glenoid. Clinical Relevance: The distal clavicular autograft may be a suitable option for reconstruction of instability-related glenoid bone loss. This graft provides a structural osteochondral autograft with a broader radius of reconstruction than that of a coracoid graft, is locally available, has minimal donor site morbidity, is anatomic, and provides articular cartilage. [ABSTRACT FROM AUTHOR]

Case: Chronic massive irreparable rotator cuff tears remain challenging to treat. We present the case of a 70-year-old active and healthy woman who presented with 6 months of worsening shoulder pain and function; she had experienced considerable deterioration over the past 2 months. Nonoperative management of the massive rotator cuff tear was not successful. Superior capsule reconstruction (SCR) was performed with a partial rotator cuff repair. Conclusion: SCR is an exciting advancement for the chronic massive irreparable rotator cuff tear, one of the more challenging problems encountered by shoulder surgeons. Our patient was doing well at the 1-year follow-up and was very satisfied with the outcome. [ABSTRACT FROM AUTHOR]

Background: The processing of allograft tissues in anterior cruciate ligament (ACL) reconstruction continues to be controversial. While high-dose irradiation of grafts has received scrutiny for high failure rates, lower dose irradiation and “proprietary-based” nonirradiated sterilization techniques have become increasingly popular, with little in the literature to evaluate their outcomes. Recent studies have suggested that the specifics of allograft processing techniques may be a risk factor for higher failure rates. Purpose: To assess these proprietary processes and their clinical outcomes and biomechanical properties. Study Design: Systematic review. Methods: A systematic review was performed using searches of PubMed, EMBASE, Google Scholar, and Cochrane databases. English-language studies were identified with the following search terms: “allograft ACL reconstruction” (title/abstract), “novel allograft processing” (title/abstract), “allograft anterior cruciate ligament” (title/abstract), “anterior cruciate ligament allograft processing” (title/abstract), or “biomechanical properties anterior cruciate ligament allograft” (title/abstract). Duplicate studies, studies not providing the allograft processing technique, and those not containing the outcomes of interest were excluded. Outcomes of interest included outcome scores, complication and failure rates, and biomechanical properties of the processed allografts. Results: Twenty-four studies (13 clinical, 11 biomechanical) met inclusion criteria for review. No demonstrable difference in patient-reported outcomes was appreciated between the processing techniques, with the exception of the Tutoplast process. The clinical failure rate of the Tutoplast process was unacceptably high (45% at 6 years), but no other difference was found between other processing techniques (BioCleanse: 5.4%; AlloTrue: 5.7%; MTF: 6.7%). Several studies did show an increased failure rate, but these studies either combined processing techniques or failed to delineate enough detail to allow a specific comparison for this study. The biomechanical studies showed overall maintenance of satisfactory biomechanical properties throughout multiple testing modes with normalization to the percentage of control specimens. Conclusion: A comparison of proprietary allograft processing techniques is difficult because of the variability and lack of specificity of reporting in the current literature. Among the available literature, except for the Tutoplast process, no notable differences were found in the clinical outcomes or biomechanical properties. Future study with a longer follow-up is necessary to determine the role and limitations of these grafts in the clinical setting. [ABSTRACT FROM AUTHOR]

Background: The debate continues regarding the optimal treatment of intercollegiate contact athletes with in-season anterior shoulder instability. Purpose: To examine return to sport and recurrent instability in the season after the index in-season anterior instability event. Study Design: Cohort study; Level of evidence, 2. Methods: Forty-five contact intercollegiate athletes treated nonoperatively or with arthroscopic stabilization were prospectively followed in a multicenter observational study to evaluate return to play (RTP) and recurrent instability in the season after an initial in-season anterior glenohumeral instability event. Baseline data collection included sport played, previous instability events, direction of instability, type of instability (subluxation or dislocation), and treatment method (nonoperative management or arthroscopic stabilization). All nonoperatively treated athletes underwent a standardized accelerated rehabilitation program without shoulder immobilization. Surgical stabilization was performed arthroscopically in all cases, and successful RTP was evaluated during the next competitive season after complete rehabilitation. Results: Thirty-nine of 45 intercollegiate contact athletes had remaining National Collegiate Athletic Association eligibility and were followed through the subsequent competitive season after the index instability event. Of the 10 athletes electing nonoperative treatment, 4 (40%) successfully returned to play without recurrence during the subsequent season. Of the 29 athletes treated surgically, 26 (90%) were able to successfully return to play without recurrence the following season (recurrence: n = 1; inadequate function: n = 2). Athletes who underwent surgical reconstruction before the next season were 5.8 times (95% CI, 1.77-18.97; P = .004) more likely to complete the subsequent season without recurrent instability. Of the 29 athletes electing surgical stabilization, there was no difference (risk ratio, 0.95; 95% CI, 0.10-9.24; P > .99) in RTP between the 9 stabilized after a single instability event (90% RTP rate) and the 20 stabilized after multiple in-season recurrent instability events (89% RTP rate). Conclusion: Collegiate contact and collision athletes with in-season anterior shoulder instability are significantly more likely to successfully return to sport without subsequent instability events the next season if they undergo surgical repair in the off-season. [ABSTRACT FROM AUTHOR]

Background: Glenoid and humeral bone loss are well-described risk factors for failure of arthroscopic shoulder stabilization. Recently, consideration of the interactions of these types of bone loss (bipolar bone loss) has been used to determine if a lesion is "on-track" or "off-track." The purpose of this study was to study the relationship of the glenoid track to the outcomes of arthroscopic Bankart reconstructions.Methods: Over a 2-year period, 57 shoulders that were treated with an isolated, primary arthroscopic Bankart reconstruction performed at a single facility were included in this study. The mean patient age was 25.5 years (range, 20 to 42 years) at the time of the surgical procedure, and the mean follow-up was 48.3 months (range, 23 to 58 months). Preoperative magnetic resonance imaging was used to determine glenoid bone loss and Hill-Sachs lesion size and location and to measure the glenoid track to classify the shoulders as on-track or off-track. Outcomes were assessed according to shoulder stability on examination and subjective outcome.Results: There were 10 recurrences (18%). Of the 49 on-track patients, 4 (8%) had treatment that failed compared with 6 (75%) of 8 off-track patients (p = 0.0001). Six (60%) of 10 patients with recurrence of instability were off-track compared with 2 (4%) of 47 patients in the stable group (p = 0.0001). The positive predictive value of an off-track measurement was 75% compared with 44% for the predictive value of glenoid bone loss of >20%.Conclusions: The application of the glenoid track concept to our cohort was superior to using glenoid bone loss alone with regard to predicting postoperative stability. This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Context: Posterior shoulder instability has become more frequently recognized and treated as a unique subset of shoulder instability, especially in the military. Posterior shoulder pathology may be more difficult to accurately diagnose than its anterior counterpart, and commonly, patients present with complaints of pain rather than instability. "Posterior instability" may encompass both dislocation and subluxation, and the most common presentation is recurrent posterior subluxation. Arthroscopic and open treatment techniques have improved as understanding of posterior shoulder instability has evolved.Evidence Acquisition: Electronic databases including PubMed and MEDLINE were queried for articles relating to posterior shoulder instability.Study Design: Clinical review.Level Of Evidence: Level 4.Results: In low-demand patients, nonoperative treatment of posterior shoulder instability should be considered a first line of treatment and is typically successful. Conservative treatment, however, is commonly unsuccessful in active patients, such as military members. Those patients with persistent shoulder pain, instability, or functional limitations after a trial of conservative treatment may be considered surgical candidates. Arthroscopic posterior shoulder stabilization has demonstrated excellent clinical outcomes, high patient satisfaction, and low complication rates. Advanced techniques may be required in select cases to address bone loss, glenoid dysplasia, or revision.Conclusion: Posterior instability represents about 10% of shoulder instability and has become increasingly recognized and treated in military members. Nonoperative treatment is commonly unsuccessful in active patients, and surgical stabilization can be considered in patients who do not respond. Isolated posterior labral repairs constitute up to 24% of operatively treated labral repairs in a military population. Arthroscopic posterior stabilization is typically considered as first-line surgical treatment, while open techniques may be required in complex or revision settings. [ABSTRACT FROM AUTHOR]

Context: Given its young, predominately male demographics and intense physical demands, the US military remains an ideal cohort for the study of anterior shoulder instability.Evidence Acquisition: A literature search of PubMed, MEDLINE, and the Cochrane Database was performed to identify all peer-reviewed publications from 1950 to 2016 from US military orthopaedic surgeons focusing on the management of anterior shoulder instability.Study Design: Clinical review.Level Of Evidence: Level 4.Results: The incidence of anterior shoulder instability events in the military occurs at an order of magnitude greater than in civilian populations, with rates as high as 3% per year among high-risk groups. With more than 90% risk of a Bankart lesion and high risk for instability recurrence, the military has advocated for early intervention of first-time shoulder instability while documenting up to 76% relative risk reduction versus nonoperative treatment. Preoperative evaluation with advanced radiographic imaging should be used to evaluate for attritional bone loss or "off-track" engaging defects to guide comprehensive surgical management. With complex recurrent shoulder instability and/or cases of clinically significant osseous lesions, potential options such as remplissage, anterior open capsular procedures, or bone augmentation procedures may be preferentially considered.Conclusion: Careful risk stratification, clinical evaluation, and selective surgical management for at-risk military patients with anterior shoulder instability can optimize the recurrence risk and functional outcome in this population. [ABSTRACT FROM AUTHOR]

Background: With the alarming statistics concerning the quality of national health care, it is hoped that electronic health records (EHRs) will reduce inefficiencies associated with medical delivery and improve patient safety. This study reports the results of a survey that demonstrates a pattern in EHR system implementation that indicates that health-care information technology decisions are based more on the preferences of information technology professionals (ITPs) and hospital administrators than clinicians.Methods: We present survey data highlighting the growing discrepancy in EHR-related satisfaction between clinicians and ITPs. We conducted a literature search to identify major barriers that must be overcome to achieve optimal EHR benefits. We summarize our recommendations in order to maximize the favorable impact of EHRs on the health-care system.Results: The existing gap in postimplementation EHR satisfaction ratings between ITPs and clinicians reveals an underlying systematic problem. Electronic medical record vendors perceive administrators and ITPs as the "buyers" for many EHR systems, and their needs are given higher priority than those of clinicians. This possibly may lead to the lack of clinically optimized EHRs, with systems often presenting as rigid and standardized with a limited exchange of health information.Conclusions: EHRs have the potential to become a powerful tool that may improve many processes related to health care, including quality, safety, and economical aspects. The involvement of physicians in every step of the process, from electronic medical record selection to acquisition, implementation, and ongoing optimization, is crucial for enabling the achievement of the medical organization's mission. [ABSTRACT FROM AUTHOR]

Background: The use of allografts for anterior cruciate ligament (ACL) reconstruction in young athletes is controversial. No long-term results have been published comparing tibialis posterior allografts to hamstring autografts. Purpose: To evaluate the long-term results of primary ACL reconstruction using either an allograft or autograft. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: From June 2002 to August 2003, patients with a symptomatic ACL-deficient knee were randomized to receive either a hamstring autograft or tibialis posterior allograft. All allografts were from a single tissue bank, aseptically processed, and fresh-frozen without terminal irradiation. Graft fixation was identical in all knees. All patients followed the same postoperative rehabilitation protocol, which was blinded to the therapists. Preoperative and postoperative assessments were performed via examination and/or telephone and Internet-based questionnaire to ascertain the functional and subjective status using established knee metrics. The primary outcome measures were graft integrity, subjective knee stability, and functional status. Results: There were 99 patients (100 knees); 86 were men, and 95% were active-duty military. Both groups were similar in demographics and preoperative activity level. The mean and median ages of both groups were identical at 29 and 26 years, respectively. Concomitant meniscal and chondral pathologic abnormalities, microfracture, and meniscal repair performed at the time of reconstruction were similar in both groups. At a minimum of 10 years (range, 120-132 months) from surgery, 96 patients (97 knees) were contacted (2 patients were deceased, and 1 was unable to be located). There were 4 (8.3%) autograft and 13 (26.5%) allograft failures that required revision reconstruction. In the remaining patients whose graft was intact, there was no difference in the mean Single Assessment Numeric Evaluation, Tegner, or International Knee Documentation Committee scores. Conclusion: At a minimum of 10 years after ACL reconstruction in a young athletic population, over 80% of all grafts were intact and had maintained stability. However, those patients who had an allograft failed at a rate over 3 times higher than those with an autograft. [ABSTRACT FROM AUTHOR]

Background: Glenoid bone loss is a common finding in association with anterior shoulder instability. This loss has been identified as a predictor of failure after operative stabilization procedures. Historically, 20% to 25% has been accepted as the "critical" cutoff where glenoid bone loss should be addressed in a primary procedure. Few data are available, however, on lesser, "subcritical" amounts of bone loss (below the 20%-25% range) on functional outcomes and failure rates after primary arthroscopic stabilization for shoulder instability. Purpose: To evaluate the effect of glenoid bone loss, especially in subcritical bone loss (below the 20%-25% range), on outcomes assessments and redislocation rates after an isolated arthroscopic Bankart repair for anterior shoulder instability. Study Design: Cohort study; Level of evidence, 3. Methods: Subjects were 72 consecutive anterior instability patients (73 shoulders) who underwent isolated anterior arthroscopic labral repair at a single military institution by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons. Data were collected on demographics, the Western Ontario Shoulder Instability (WOSI) score, Single Assessment Numeric Evaluation (SANE) score, and failure rates. Failure was defined as recurrent dislocation. Glenoid bone loss was calculated via a standardized technique on preoperative imaging. The average bone loss across the group was calculated, and patients were divided into quartiles based on the percentage of glenoid bone loss. Outcomes were analyzed for the entire cohort, between the quartiles, and within each quartile. Outcomes were then further stratified between those sustaining a recurrence versus those who remained stable. Results: The mean age at surgery was 26.3 years (range, 20-42 years), and the mean follow-up was 48.3 months (range, 23-58 months). The cohort was divided into quartiles based on bone loss. Quartile 1 (n = 18) had a mean bone loss of 2.8% (range, 0%-7.1%), quartile 2 (n = 19) had 10.4% (range, 7.3%-13.5%), quartile 3 (n = 18) had 16.1% (range, 13.5%-19.8%), and quartile 4 (n = 18) had 24.5% (range, 20.0%-35.5%). The overall mean WOSI score was 756.8 (range, 0-2097). The mean WOSI score correlated with SANE scores and worsened as bone loss increased in each quartile. There were significant differences (P < .05) between quartile 1 (mean WOSI/SANE, 383.3/62.1) and quartile 2 (mean, 594.0/65.2), between quartile 2 and quartile 3 (mean, 839.5/52.0), and between quartile 3 and quartile 4 (mean, 1187.6/46.1). Additionally, between quartiles 2 and 3 (bone loss, 13.5%), the WOSI score increased to rates consistent with a poor clinical outcome. There was an overall failure rate of 12.3%. The percentage of glenoid bone loss was significantly higher among those repairs that failed versus those that remained stable (24.7% vs 12.8%, P < .01). There was no significant difference in failure rate between quartiles 1, 2, and 3, but there was a significant increase in failure (P < .05) between quartiles 1, 2, and 3 (7.3%) when compared with quartile 4 (27.8%). Notably, even when only those patients who did not sustain a recurrent dislocation were compared, bone loss was predictive of outcome as assessed by the WOSI score, with each quartile's increasing bone loss predictive of a worse functional outcome. Conclusion: While critical bone loss has yet to be defined for arthroscopic Bankart reconstruction, our data indicate that "critical" bone loss should be lower than the 20% to 25% threshold often cited. In our population with a high level of mandatory activity, bone loss above 13.5% led to a clinically significant decrease in WOSI scores consistent with an unacceptable outcome, even in patients who did not sustain a recurrence of their instability. [ABSTRACT FROM AUTHOR]

The article focuses on the potential of in-season athletes who underwent treatment for treatment for anterior should instability to return to sport, with a focus on the role played by injury factors and patient-reported outcome scores. Topics discussed include the methodology and results of the author's cohort study of 45 contact intercollegiate athletes including percentage of athletes who were able to return to play and the state of their shoulder after their return.