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This case series describes the rate and time to return to sport following nonoperative management of abdominal muscle strain in the National Collegiate Athletic Association Division I. Twenty-seven overhead athletes were included, and each participated in a rehabilitation flexibility program as well as interventions addressing hip and thoracic rotational deficits. To our knowledge, this is the first study to report on the rates of abdominal injury in overhead athletes and their return to sport at a National Collegiate Athletic Association Division I institution. Volleyball athletes were disproportionately affected by abdominal injuries in the present study, and these injuries have been reported to account for up to 22.2% of muscle injuries in elite volleyball athletes. Similar to the finding in the present study, two baseball studies demonstrated that the abdominal musculature on the opposite side of the dominant arm (lead side) was usually affected.

Platelet-rich plasma (PRP) is an autologous mixture produced by centrifugal separation of whole blood. Understanding the clinical efficacy of PRP remains a challenge in the field of sports medicine, including the treatment of various shoulder conditions. Animal studies have examined the biologic actions of PRP on the rotator cuff tendon and shoulder capsule. Human studies have reported the outcomes of PRP in the management of subacromial impingement syndrome, rotator cuff tears, frozen shoulder, and glenohumeral osteoarthritis. These studies highlight the role of PRP in the nonsurgical management of these conditions and its utilization in the perioperative setting to augment tissue healing and optimize the surgical outcomes. The role of PRP as an adjunct therapy in patients undergoing rotator cuff repair has been in the spotlight during the last decade; however, a limited number of studies have examined the role of PRP in the management of non-rotator cuff shoulder conditions. This article aims to provide an overview of the biologic actions of PRP on shoulder tissues and to summarize the outcomes of PRP injection in patients with rotator cuff and non-rotator cuff disease of the shoulder. We sought to organize the existing literature and to provide recommendations on the use of PRP in various shoulder conditions, based on the existing evidence.

Small, preliminary studies and the systematic reviews on superior capsular reconstruction (SCR) that collate data are at increased risk spin. This study's primary objective was to identify, describe, and account for the incidence of spin in systematic reviews of SCR. This study's secondary objective was to characterize the studies in which spin was identified to determine whether identifiable patterns of characteristics exist among studies with spin.This study was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using a predetermined protocol. A search was conducted on the PubMed and Embase databases for systematic reviews and meta-analyses on SCR. Screening and data extraction were conducted independently by 2 authors. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. General data that were extracted included study title, authors, publication year, journal, level of evidence, study design, funding source, reported adherence to PRISMA guidelines, preregistration of the study protocol, and primary and secondary outcome measures. Full texts were used in the assessment of study quality per AMSTAR 2.We identified 53 studies during our search, of which 17 met the inclusion criteria. At least 1 form of spin was observed in all 17 studies. The most common types of spin were type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") and type 9 ("Conclusion claims the beneficial effect of the experimental treatment despite reporting bias"), both of which were observed in 11 studies (11 of 17, 65%). A statistically significant association between lower level of evidence and type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") was observed (P = .0175). A statistically significant association was also found between more recent year of publication and the spin category misleading interpretation (P = .0398), and between lower AMSTAR 2 score and type 13 ("Failure to specify the direction of the effect when it favors the control intervention") (P = .0260). No other statistical associations between other study characteristics were observed.Spin is highly prevalent in abstracts of SCR systematic reviews and meta-analyses. An association was found between the presence of spin and lower level of evidence, year of publication, and AMSTAR 2 ratings.

Tranexamic acid (TXA) effectively reduces blood loss and transfusion risk during total joint arthroplasty. Additionally, intraoperative irrigation with various antiseptic solutions is often utilized for the management and prevention of surgical site infection. However, interactions between various antiseptic solutions and TXA have not been investigated. The purpose of this in vitro study is to evaluate the stability of TXA in the presence of common orthopedic antiseptic solutions. Five antiseptic solutions-0.1% chlorhexidine (CHX) gluconate, 10% povidone-iodine (BTD), 0.5% sodium hypochlorite (Dakin's), 3% hydrogen peroxide (H

Context: It is important to examine hip injury characteristics in baseball athletes in order to develop injury-specific prevention protocols. There is currently a lack of literature regarding collegiate baseball athletes. Objective: To report the hip injury characteristics and time missed from sport participation in National Collegiate Athletic Association Division I baseball players over a period of 5 years. Results: Forty-seven hip–groin injuries were recorded in 30 National Collegiate Athletic Association Division I baseball players. Pitchers had the highest number of hip–groin injuries (24/47, 51%), and outfielders had the longest time missed from baseball participation (33 days on average). The two most common types of hip–groin injuries were femoroacetabular impingement syndrome (14/47, 30%) and hip adductor strain (14/47, 30%). Days missed from baseball participation was 4.5 days (range: 4–7) for short-term injuries and 90 days (range: 46–131) for long-term injuries. Interpretations: Femoroacetabular impingement syndrome and adductor muscle strain were the predominant diagnoses in National Collegiate Athletic Association Division I baseball players with hip–groin injury; short-term injuries resulted in ∼5 days missed but recovery from a long-term injury took ∼3 months. Pitchers had the highest number of injuries (including adductor strain and femoroacetabular impingement syndrome).

To comprehensively review and report the outcomes of ankle syndesmotic injury management in elite athletes.Three databases were searched for articles reporting the rate of return to sport following treatment of ankle syndesmotic injuries in elite athletes (collegiate or professional level). Ten articles and 440 athletes were included. Articles reporting the rate of return to sport following high ankle sprain injury in elite athletes. Data collected included demographics, type of treatment received, and return to sport (RTS) information. A random effects model was used.The estimated overall rate of RTS was 99% (95% CI, 95.5-99.9). The mean time to RTS was 38 ± 18 (range, 14-137) days. Of the 440 athletes, 269 (269/440%, 61%) were treated nonoperatively (nonoperative group); the rate of RTS was 99.6%, and the athletes returned at a mean time of 29 ± 14 (range, 13-45) days. A total of 171 athletes (171 of 440%, 39%) underwent surgical treatment (operative group). All (171 of 171%, 100%) athletes returned at a mean time of 50.3 ± 13 (range, 41-137) days. Almost all athletes who underwent surgery had suture button fixation (164 of 171 athletes, 96%), and the mean time to RTS was 7 weeks with 9.1% complication rate.Elite athletes with ankle syndesmosis injury return to sport at an extremely high rates, following operative or nonoperative treatment. Return to the preinjury level of competition should be expected at 4 weeks and 7 weeks in high-level athletes who undergo nonoperative and operative management, respectively. Suture button fixation was used by the majority of studies reporting surgical management of ankle syndesmosis injuries in athletes.

Knee fibrosis is characterized by the presence of excessive connective tissue due to dysregulated fibroblast activation following local or systemic tissue damage. Knee fibrosis constitutes a major clinical problem in orthopaedics due to the severe limitation in the knee range of motion that leads to compromised function and patient disability. Knee osteoarthritis is an extremely common orthopedic condition that is associated with patient disability and major costs to the health-care systems worldwide. Although knee fibrosis and osteoarthritis (OA) have traditionally been perceived as two separate pathologic entities, recent research has shown common ground between the pathophysiologic processes that lead to the development of these two conditions. The purpose of this review was to identify the pathophysiologic pathways as well as key molecules that are implicated in the development of both knee OA and knee fibrosis in order to understand the relationship between the two diagnoses and potentially identify novel therapeutic targets.

Chronic rotator cuff pathology is often complicated by fatty degeneration of the rotator cuff (FDRC) muscles, an insidious process associated with poor prognosis with or without surgical intervention. Currently there is no treatment for FDRC, and many studies have described a natural course for this disease almost always resulting in further degeneration and morbidity. Recapitulating FDRC using animal injury models, and using imaging-based studies of human FDRC, the pathophysiology of this disease continues to be further characterized. Researchers studying mesenchymal stem cell–derived progenitor cells and known fibrogenic and adipogenic signaling pathways implicated in FDRC seek to clarify the underlying processes driving these changes. While new cell- and molecular-based therapies are being developed, currently the strongest available avenue for improved management of FDRC is the use of novel imaging techniques which allow for more accurate and personalized staging of fatty degeneration. This narrative review summarizes the evidence on the molecular and pathophysiologic mechanisms of FDRC and provides a clinical update on the diagnosis and management of this condition based on the existing knowledge. We also sought to examine the role of newer biologic therapies in the management of RC fatty degeneration and to identify areas of future research.

Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.

Ulnar collateral ligament (UCL) reconstruction has been successfully utilized to treat symptomatic UCL insufficiency in overhead athletes. Despite the overall success of the procedure, attempts have been made to improve upon the original technique with the goal of hastening return to sport. Most recently, there has been interest in repairing or reconstructing the native ligament with internal brace (IB) augmentation. Biomechanical cadaveric studies assessing UCL repair with IB augmentation have attempted to evaluate the efficacy of this treatment; however, the literature is seemingly divided on its benefit. Preliminary clinical studies suggest internal bracing may allow a faster return to sport than conventional techniques. The purpose of this review was to provide an analysis of the current evidence on IB augmentation in UCL repair of the elbow as it pertains to biomechanical advantages/disadvantages, reported surgical techniques, and clinical outcomes in comparison with traditional UCL reconstruction techniques.

The global pandemic caused by SARS-CoV-2, or COVID-19, continues to impact all facets of daily life. Clinical manifestations of COVID-19 commonly include musculoskeletal symptoms such as myalgias, arthralgias, and neuropathies/myopathies. The inflammatory response and its impact on the respiratory system have been the focus of most studies. However, the literature is more limited regarding the inflammatory response and its implications for other organ systems, specifically the musculoskeletal system. Previous studies have described how systemic inflammation may play a role in bone and joint pathology. Furthermore, it is important to understand the effects current therapeutics used in the treatment of COVID-19 may have on the musculoskeletal system. In this study, we will review the current understanding of the effect COVID-19 has on the musculoskeletal system, provide an overview of musculoskeletal symptoms of patients infected with the virus, and address key issues for clinicians to address during the care of COVID-19 patients.

Background: Evidence, mainly from animal models, suggests that exercise during periods of pubertal growth can produce a hypertrophied anterior cruciate ligament (ACL) and improve its mechanical properties. In humans, the only evidence of ACL hypertrophy comes from a small cross-sectional study of elite weight lifters and control participants; that study had methodological weaknesses and, thus, more evidence is needed. Purpose: To investigate bilateral differences in the ACL cross-sectional area (CSA) for evidence of unilateral hypertrophy in athletes who have habitually loaded 1 leg more than the other. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We recruited 52 figure skaters and springboard divers (46 female and 6 male; mean age, 20.2 ± 2.7 years) because the former always land/jump on the same leg while the latter always drive the same leg into the board during their hurdle approach. Sport training for all participants began before puberty and continued throughout as well as after. Using oblique axial– and oblique sagittal–plane magnetic resonance imaging, we measured the ACL CSA and the anteroposterior diameter of the patellar tendon, respectively. In addition, isometric and isokinetic knee extensor and flexor peak torques were acquired using a dynamometer. Bilateral differences in the ACL CSA, patellar tendon diameter, and knee muscle strength were evaluated via 2-sided paired-samples t tests. Correlations between the bilateral difference in the ACL CSA and age of training onset as well as between the bilateral difference in the ACL CSA and years of training were also examined. Results: A significantly larger ACL CSA (mean difference, 4.9% ± 14.0%; P = .041), as well as patellar tendon diameter (mean difference, 4.7% ± 9.4%; P = .002), was found in the landing/drive leg than in the contralateral leg. The bilateral difference in the ACL CSA, however, was not associated with the age of training onset or years of training. Last, the isometric knee flexor peak torque was significantly greater in the landing/drive leg than the contralateral leg (mean difference, 14.5% ± 33.8%; P = .019). Conclusion: Athletes who habitually loaded 1 leg more than the other before, during, and after puberty exhibited significant unilateral ACL hypertrophy. This study suggests that the ACL may be able to be “trained” in athletes. If done correctly, it could help lower the risk for ACL injuries.

Background: No previous systematic reviews have reported on athletes who fail to return to sports after arthroscopic Bankart repair. Purpose: To review the literature on athletes who fail to return to sports after arthroscopic Bankart repair to determine the rate of athletes who did not return to sports and to identify the specific reasons for failure to return to sports by nonreturning athletes. Study Design: Systematic review and meta-analysis. Methods: A meta-analysis was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Three electronic databases (PubMed, Scopus, Web of Science) were queried for articles meeting the inclusion criteria. Studies were considered eligible only if reporting the rate of failure for return to sports and providing the specific reasons why athletes were unable to return to sports. All records were screened by title, abstract, and full text by 2 authors independently, with any discrepancies resolved by a third senior author. For articles selected for inclusion, data were collected on the number of athletes, average age, average follow-up time, type of sport played, rate of failure to return to sports, and specific reasons for failure to return. A random-effects model was used to conduct the meta-analysis. Results: Seventeen studies were selected for inclusion reporting on a total of 813 athletes. The calculated weighted rate of failure to return to sports after arthroscopic Bankart repair was 15.6% (95% CI, 10.9%-21.1%). A significantly higher proportion of athletes cited shoulder-dependent versus shoulder-independent reasons for failure to return to sports (81.7% vs 18.3%; P < .0001). The most cited reasons for failure to return included recurrent or persistent instability (33.3%), fear of reinjury (17.7%), apprehension (9.9%), changes in priorities or personal interest (8.5%), lack of time (7.1%), and discomfort or pain with sports (6.4%). Conclusion: Our study estimated the rate of failure to return to sports after arthroscopic Bankart repair to be 15.6%, with most athletes citing shoulder-related reasons as the primary factor precluding return. Identifying the potential reasons preventing successful return to sports can guide surgeons in counseling athletes regarding postoperative expectations and addressing hesitations for returning to sports.

Purpose: (1) To compare the pre- and postoperative driving performance in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS); (2) to examine the differences in driving performance between patients with versus without capsular repair. Methods: Patients who underwent arthroscopic hip surgery for FAIS were included. Driving performance of participating patients was collected using a driving simulator preoperatively and at 2 weeks, 4–6 weeks and 8–12 weeks postoperatively. Data collected included demographics, surgery laterality, intraoperative procedures, left and right turn reaction time, total turn reaction time, gas off time (GOF), and break reaction time (BRT). Repeated measures analysis of variance (ANOVA) was used for statistical analysis. Results: 21 subjects (9 males, 12 females) with a mean age of 30 ± 9 years were included and 57.1% of the subjects had right-sided surgery. There was no difference between the mean preoperative and the 2-week postoperative left (0.72 seconds and 0.75 seconds, respectively) right (0.77 seconds and 0.75 seconds, respectively), and total (0.74 seconds and 0.75 seconds, respectively) turn reaction times as well as GOF (0.62 seconds and 0.60 seconds, respectively) and BRT (0.92 seconds and 0.93 seconds, respectively), indicating that the patients’ driving performance returned to the preoperative level as early as 2 weeks following hip arthroscopy for FAIS. There was no significant difference amongst any of the driving variables between patients who underwent capsular repair (50%) and those who did not. There was no significant difference amongst any of the driving variable s between patients who underwent left versus right hip arthroscopy. Conclusions: Patients’ driving performance returns to the preoperative level as early as 2 weeks after hip arthroscopy for FAIS. Surgery laterality nor capsular repair make any significant difference in the time for driving abilities to return to baseline. The impact of intraoperative procedures performed, and the analgesic medications used postoperatively on the driving ability of patients undergoing hip arthroscopy warrants further investigation in larger patient populations.

Background Outcomes of knee arthroscopy (KA) after total knee arthroplasty (TKA) have been limited to small case series with short-term follow-up. The purpose of this study is to report the outcomes of patients who undergo a KA after a TKA using a large longitudinal database. Methods The PearlDiver Medicare database was queried for patients who underwent a KA procedure after a TKA on the ipsilateral extremity. A randomly selected control group was created by matching controls to cases in a 3:1 ratio based on age, gender, year of procedure, and Elixhauser Comorbidity Index. Revision for infection and all-cause revision were used as end points. Results A total of192 TKA patients who underwent a subsequent KA (TKA + KA group) were compared to 571 TKA patients who did not have a subsequent KA (TKA − KA group). The incidence of revision for infection was 6.3% in the TKA + KA group compared to 2.2% in the TKA − KA group (odds ratio, 2.87; P = .009). The incidence of all-cause revision was 18.8% in the TKA + KA group compared to 5.1% in the TKA − KA group (odds ratio, 4.34; P Conclusion KA after TKA was associated with increased infection-related and all-cause revision. The association between KA and subsequent infection requires further investigation.

For irreparable rotator cuff tears, superior capsular reconstruction (SCR) has become an option for restoring glenohumeral joint stability and reversing proximal humeral migration. Signs of irreparable rotator cuff tears include pain from subacromial impingement, muscle weakness, and pseudoparalysis. In biomechanical studies, Mihata et al. showed SCR with fascia lata graft and side-to-side suturing to remaining infraspinatus tendon restored superior stability of the shoulder joint. Adding acromioplasty decreased the subacromial contact area without altering the humeral head position, superior translation, or subacromial peak contact pressure. The same research group showed that using an 8-mm thick fascia lata graft attached at 15° to 45° of shoulder abduction optimized superior stability of the shoulder joint. Adams et al. performed SCR using a dermal allograft and found that greater glenohumeral abduction angle (60°) decreased applied deltoid force. SCR can be performed with the patient in the lateral decubitus or beach chair position. Arthroscopic exploration, debridement, and infraspinatus and supraspinatus repair attempt is completed before proceeding with SCR. To restore the superior capsule of the shoulder, the graft (fascia lata autograft, dermal allograft) can be attached to the superior glenoid medially and the rotator cuff footprint on the greater tuberosity of the humerus laterally, after debriding bone to enhance healing. SCR with side-to-side suturing to the remnant rotator cuff yields promising clinical results. Using a fascia lata autograft, Mihata et al. showed a reversal of pseudoparalysis in 93% to 96% of patients and mean active elevation, external rotation, and acromiohumeral distance on radiography all improved. Using a dermal allograft and a unique graft delivery technique, Burkhart et al. reversed pseudoparalysis in 9 of 10 patients and 70% of patients had completely intact grafts. Recommendations for rehabilitation and return to activity vary, but adequate time for graft healing is recommended.

To provide an updated review of the literature on the use of orthobiologics as a potential treatment option to alleviate symptoms associated with osteoarthritis (OA), slow the progression of the disease, and aid in cartilage regeneration. A comprehensive review of the literature was performed to identify basic science and clinical studies examining the role of orthobiologics in the diagnosis and management of osteoarthritis. Certain molecules (such as interleukin-6 (IL-6), interleukin-8 (IL-8), matrix metalloproteinase (MMPs), cartilage oligomeric matrix protein (COMP), and tumor necrosis factor (TNF), microRNAs, growth differentiation factor 11 (GDF-11)) have been recognized as biomarkers that are implicated in the pathogenesis and progression of degenerative joint disease (DJD). These biomarkers have been used to develop newer diagnostic applications and targeted biologic therapies for DJD. Local injection therapy with biologic agents such as platelet-rich plasma or stem cell–based preparations has been associated with significant improvement in joint pain and function in patients with OA and has increased in popularity during the last decade. The combination of PRP with kartogenin or TGF-b3 may also enhance its biologic effect. The mesenchymal stem cell secretome has been recognized as a potential target for the development of OA therapies due to its role in mediating the chondroprotective effects of these cells. Recent experiments have also suggested the modification of gut microbiome as a newer method to prevent OA or alter the progression of the disease. The application of orthobiologics for the diagnosis and treatment of DJD is a rapidly evolving field that will continue to expand. The identification of OA-specific and joint-specific biomarker molecules for early diagnosis of OA would be extremely useful for the development of preventive and therapeutic protocols. Local injection therapies with HA, PRP, BMAC, and other stem cell–based preparations are currently being used to improve pain and function in patients with early OA or those with progressed disease who are not surgical candidates. Although the clinical outcomes of these therapies seem to be promising in clinical studies, future research will determine the true role of orthobiologic applications in the field of DJS.

Background: Previous studies have established a classification of sports based on hip mechanics: cutting, impingement, contact, endurance, flexibility, and asymmetric/overhead. No previous review has compared the outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) using this classification. Purpose: To determine whether the rate of return to sport differs among cutting, impingement, contact, endurance, flexibility, and asymmetric/overhead athletes who undergo hip arthroscopy for FAIS. We also aimed to identify differences in patient characteristics, intraoperative procedures performed, and time to return to play among the 6 sport categories. Study Design: Systematic review and meta-analysis. Methods: Three electronic databases were searched for eligible articles. Two reviewers independently screened the titles, abstract, and full-text articles using prespecified criteria. Eligible articles were those that reported the rate of return to sport (defined by the number of hips) after hip arthroscopy for FAIS in athletes of all levels. Data collected were patient age, sex, body mass index, type of sport, rate and time to return to sport, and intraoperative procedures performed. A mixed effects model was used for meta-analysis. Results: A total of 29 articles and 1426 hip arthroscopy cases were analyzed with 185 cutting, 258 impingement, 304 contact, 207 endurance, 116 flexibility, and 356 asymmetric/overhead athletes. The mean age was similar among the 6 subgroups ( P = .532), but the proportion of female athletes was significantly higher in flexibility, endurance, and asymmetric/overhead sports as compared with impingement and contact athletes. Flexibility athletes had the highest rate of return to sport after hip arthroscopy for FAIS (94.8%), whereas contact athletes had the lowest rate (88%). The longest mean ± SD time (8.5 ± 1.9 months) to return to sport was reported in cutting sports, while endurance athletes returned faster than the rest (5.4 ± 2.6 months). The difference in rate and time to return to sport, as well as the intraoperative procedure performed, did not reach statistical significance among the 6 subgroups. There was evidence of publication bias and study heterogeneity, and the mean Methodological Index for Non-randomized Studies score was 13 ± 2.6. Conclusion: Flexibility athletes had the highest rate of return to sport after hip arthroscopy for FAIS, while endurance athletes returned the fastest. The difference in rate and time to return to sport and intraoperative procedures performed did not reach statistical significance among the 6 subgroups. These results are limited by the evidence of publication bias and should be interpreted with caution. Laboratory-based studies are necessary to validate the classification of sports based on hip mechanics.

Aims The aim of the study was to determine the incidence of oesophageal lesions after radiofrequency ablation (RFA) of atrial fibrillation (AF) with or without the use of oesophageal temperature probes. Methods and results Two hundred patients were prospectively randomized into two groups: the OPERA+ group underwent RFA using oesophageal probes (SensiTherm™); the OPERA− group received RFA using fixed energy levels of 25 W at the posterior wall without an oesophageal probe. All patients underwent post-interventional endoscopy and Holter-electrocardiogram after 6 months. (Clinical.Trials.gov: NCT03246594). One hundred patients were randomized in OPERA+ and 100 patients in OPERA−. The drop-out rate was 10%. In total, 18/180 (10%) patients developed endoscopically diagnosed oesophageal lesions (EDEL). There was no difference between the groups with 10/90 (11%) EDEL in OPERA+ vs. 8/90 (9%) in OPERA− (P = 0.62). Despite the higher power delivered at the posterior wall in OPERA+ [28 ± 4 vs. 25 ± 2 W (P = 0.001)], the average EDEL size was equal [5.7 ± 2.6 vs. 4.5 ± 1.7 mm (P = 0.38)]. The peak temperature did not correlate with EDEL size. During follow-up, no patient died. Only one patient in OPERA− required a specific therapy for treatment of the lesion. Cumulative AF recurrence after 6 (3–13) months was 28/87 (32%) vs. 34/88 (39%), P = 0.541. Conclusion This first randomized study demonstrates that intraoesophageal temperature monitoring using the SensiTherm™ probe does not affect the probability of developing EDEL. The peak temperature measured by the thermoprobe seems not to correlate with the incidence of EDEL. Empiric energy reduction at the posterior wall did not affect the efficacy of the procedure.

The primary goal of this study was to compare the utilization of plate versus intramedullary nail (IMN) in the treatment of humerus fractures. Secondarily, we sought to examine whether any differences in demographics and clinical course of patients who receive a nail versus plate affect the procedure selection process.The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients surgically treated for a humeral shaft fracture from the years 2007-2015, using current procedural terminology (CPT) code. Patients with overlapping procedures, nonunion, polytrauma, and malignancy were excluded. The Charlson Comorbidity Index (CCI) was calculated to compare preoperative comorbidities. A two-sample Wilcoxon rank-sum (Mann-Whitney U) test was used to compare numerical values, whereas the Fisher exact and Chi-squared analyses were performed to compare categorical variables. A p value 0.05 was considered significant. Preoperative variables with a p value 0.05 and a clinical prevalence 1%, indicating statistical and clinical significance, were included in a logistic regression for multivariate analysis to identify any independent predictors for procedure selection (IMN versus PF) based on preoperative patient characteristics.During the study period plate fixation increased from 7 cases per year to 272 cases per year, while IMN increased from 8 cases per year to 80 cases per year. IMNs were mostly in older patients (63.85 vs 56.19 years, p 0.001), and patients with a higher Charlson Comorbidity Index (CCI) (4.64 vs 2.79, p 0.001). IMN was associated with shorter operation times (104 min vs 128 min, p 0.001) and longer lengths of hospital stay (3.43d vs 2.78d, p 0.001). No significant differences in overall complication rates were seen between patients who received IMN versus PF. However, the postoperative mortality rate was higher in patients who received IMN compared to PF (2.19% vs 0.40%, p 0.01). Based on the regression analysis, patient age was the only independent patient factor demonstrated to predict the utilization of IMN over PF in older patients with humeral shaft fractures p = 0.043).According to this NSQIP-based analysis, the rate of PF and IMN utilization increased in the treatment of humeral shaft fractures over a period of 8 years, but PF was performed at an overall a higher rate than IMN. Intramedullary nailing was preferred over PF in older patients with more comorbidities. The last possibly contributed to the higher 30-day mortality rate observed in patients who received IMN compared to PF.Retrospective comparative study.

Over the last decade, there has been a marked increase in attention to, and interest in, femoroacetabular impingement syndrome (FAIS). Despite continued efforts by researchers and clinicians, the development, progression, and appropriate treatment of FAIS remains unclear. While research across various disciplines has provided informative work in various areas related to FAIS, the underlying pathomechanics, time history, and interaction between known risk factors and symptoms remain poorly understood. The purpose of this perspective is to propose a theoretical framework that describes a potential pathway for the development and progression of FAIS. This paper aims to integrate relevant knowledge and understanding from the growing literature related to FAIS to provide a perspective that can inform future research and intervention efforts.

Hip osteoarthritis (OA) can be idiopathic or develop secondary to structural joint abnormalities of the hip joint (alteration of normal anatomy) and/or due to a systemic condition with joint involvement. Early osteoarthritic changes to the hip can be completely asymptomatic or may cause the development hip symptomatology without evidence of OA on radiographs. Delaying the progression of hip OA is critical due to the significant impact of this condition on the patient's quality of life. Pre-OA of the hip is a newly established term that is often described as the development of signs and symptoms of degenerative hip disease but no radiographic evidence of OA. Advanced imaging methods can help to diagnose pre-OA of the hip in patients with hip pain and normal radiographs or aid in the surveillance of asymptomatic patients with an underlying hip diagnosis that is known to increase the risk of early OA of the hip. These methods include the delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC), quantitative magnetic resonance imaging (qMRI- T1rho, T2, and T2* relaxation time mapping), 7-Tesla MRI, computed tomography (CT), and optical coherence tomography (OCT). dGEMRIC proved to be a reliable and accurate modality though it is limited by the significant time necessary for contrast washout between scans. This disadvantage is potentially overcome by T2 weighted MRIs, which do not require contrast. 7-Tesla MRI is a promising development for enhanced imaging resolution compared to 1.5 and 3T MRIs. This technique does require additional optimization and development prior to widespread clinical use. The purpose of this review was to summarize the results of translational and clinical studies investigating the utilization of the above-mentioned imaging modalities to diagnose hip pre-OA, with special focus on recent research evaluating their implementation into clinical practice.

Category: Sports; Ankle Introduction/Purpose: No meta-analysis has been conducted to examine the clinical outcomes following operative and nonoperative management of high ankle sprain injuries in elite athletes. the purpose of this systematic review was (1) To report the rate and time to return to sport (RTS) following high ankle syndesmotic injury in elite athletes (2) To examine the rate and time of RTS as well as the postoperative complications in elite athletes who underwent surgical treatment of high ankle syndesmotic injury with screw versus suture button fixation. Methods: Three electronic databases were searched for eligible articles. Two reviewers independently screened the titles, abstract and full-text articles using pre-specified criteria. Eligible articles were those that reported the rate of return to sport following operative and nonoperative treatment of ankle syndesmotic injuries in elite athletes (collegiate or professional level). Data collected were type of sport, type of treatment received (operative versus nonoperative), surgical technique (screw versus suture button fixation), rate and time to return to the preinjury level of competition, and complications. A random-effects model was used for meta-analysis. Results: The estimated overall rate of RTS was 99% (95% CI 95.5-99.9). The mean time to RTS was 38 +- 18 (range: 14-137) days. Of the 440 athletes, 269 (269/440,61%) were treated nonoperatively (nonoperative group); the rate of RTS was 99.6% and the athletes returned at a mean time of 29+-14 (range: 13-45) days. A total of 171 athletes (171/440,39%) underwent surgical treatment (operative group); All (171/171,100%) athletes returned at a mean time of 50.3+-13 (range:41-137) days. Almost all athletes who underwent surgery had suture button fixation (164/171 athletes,96%) and the mean time to RTS was 7 weeks with 9.1% complication rate. Conclusion: Elite athletes with ankle syndesmosis injury return to sport at an extremely high rates, following operative or nonoperative treatment. Suture button fixation remains the gold standard technique in elite athletes with syndesmotic injury requiring surgical treatment. Return to the preinjury level of competition should be expected at 4 weeks and 7 weeks in high-level athletes who undergo nonoperative and operative management, respectively.

New actively shielded asymmetric vertical field split-coil superconducting magnet with maximal field of 8 T has been recently procured and implemented on the beam line POLI at Maier-Leibnitz Zentrum (MLZ). The magnet is designed in order to facilitate the single crystal diffraction with polarised neutrons. In order to provide high neutron polarisation in the vicinity of the new strong magnet a dedicated compact-size solid-state supermirror bender polariser optimised for the short neutron wavelength on POLI has been built. A Mezei flipper, which had been previously developed for lower field, could be upgraded with additional guide fields in order to be used in combination with new polarizer and magnet. All components are discussed and the performance test for the entire setup is presented. High efficiency of the new polarised neutron diffraction setup on POLI is demonstrated. Polarized neutron diffraction experiments in the fields up to 8 T are now available at MLZ.

Femoroacetabular impingement syndrome is a motion-related clinical disorder resulting from abnormal hip joint morphology. Mechanical impingement, in which the aspherical femoral head (cam morphology) abuts with the acetabular rim, is created with simultaneous hip flexion, internal rotation, and adduction. Impaired function of the gluteal muscles may be contributory to femoroacetabular impingement syndrome progression. The purpose of this study was to assess the influence of gluteal muscle recruitment on acetabular contact pressure during squatting in persons with cam femoroacetabular impingement syndrome.Eight individuals (4 males, 4 females) with a diagnosis of cam femoroacetabular impingement syndrome underwent CT imaging of the pelvis and proximal femora, and a biomechanical assessment of squatting (kinematics, kinetics, and electromyography). Two maximal depth bodyweight squat conditions were evaluated: 1) non-cued squatting; and 2) cued gluteal activation squatting. Utilizing subject-specific electromyography-driven hip and finite element modeling approaches, hip muscle activation, kinematics, bone-on-bone contact forces, and peak acetabular contact pressure were compared between squat conditions.Modest increases in gluteus maximus (7% MVIC, P 0.0001) and medius (6% MVIC, P = 0.009) activation were able to reduce hip internal rotation on average 5° (P = 0.024), and in doing so reduced acetabular contact pressure by 32% (P = 0.023). Reductions in acetabular contact pressure occurred despite no change in hip abduction and increased bone-on-bone contact forces occurring in the cued gluteal activation condition.Our findings highlight the importance of gluteal activation in minimizing mechanical impingement and provide a foundation for interventions aimed at preventing the development and progression of femoroacetabular impingement syndrome.

Background Cutibacterium (formerly Propionibacterium) acnes persists in the dermis despite standard skin antiseptic agents, prompting some surgeons to use topical antimicrobials such as benzoyl peroxide and clindamycin prior to shoulder arthroplasty surgery. However, the efficacy of these topical agents has not been established. Methods The upper backs of 12 volunteers were randomized into 4 treatment quadrants: topical benzoyl peroxide, topical clindamycin, combination topical benzoyl peroxide and clindamycin, and a negative control. The corresponding topical agents were applied to each site twice daily for 3 days. A 3-mm dermal punch biopsy specimen was obtained from each site and cultured for 14 days to assess for C acnes growth. Positive cultures were assessed for the hemolytic phenotype. The McNemar test was used to compare the proportion of positive cultures in each group. Results C acnes grew in 4 of 12 control sites (33.3%), 1 of 12 benzoyl peroxide sites (8.3%), 2 of 12 clindamycin sites (16.7%), and 2 of 12 combination benzoyl peroxide–clindamycin sites (16.7%). The C acnes hemolytic phenotype was present in 2 of 12 control specimens (16.7%) compared with 0 (0.0%) in the benzoyl peroxide group, 2 of 12 (16.7%) in the clindamycin group, and 2 of 12 (16.7%) in the combination benzoyl peroxide–clindamycin group. There were no statistically significant differences between treatment arms. Conclusion The topical application of benzoyl peroxide and clindamycin did not eradicate C acnes in all subjects. The clinical implications of these findings are yet to be determined.

The purpose of this systematic review was to determine the incidence of injuries among lacrosse athletes and the differences in rates of injury by location and gender.The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were implemented to conduct this systematic review.[1] The following variables were extracted from each of the included articles: location of injury, gender of patient, and incidence of injury among study population. The methodological quality of the included studies was assessed using mixed-methods appraisal tool (MMAT) version 2018.[2] Estimated rates were reported as pooled proportion with 95% CI. Rates of injury were calculated as a rate per 1000 athletic exposures (AEs), defined as an athlete participating in 1 practice or competition in which he or she was exposed to the possibility of athletic injury.This study found that the highest injury rate among lacrosse athletes was to the lower leg/ankle/foot with a rate of 0.66 injuries per 1000 AEs (95% CI, 0.51, 0.82). This injury pattern was also found to be the highest among both male and female lacrosse athletes. No statistical significance was detected when comparing rates of injury across gender, regardless of location. The injury pattern with the lowest rates of injury for female athletes being to the shoulder/clavicle and the neck for male athletes.The highest rate of injury among lacrosse athletes was to the lower leg/ankle/foot. As participation in lacrosse continues to rise, there is a greater need for understanding the rate of injury and injury characteristics for physicians and trainers to provide effective care to lacrosse athletes.

To evaluate the mid-term rate of revision arthroscopic rotator cuff repair as well as ipsilateral shoulder reoperations after index rotator cuff repair performed with or without acromioplasty in the United States.The Medicare Standard Analytic File, which encompasses the entire Medicare billing and payment data, was queried between 2005 and 2014. Patients undergoing arthroscopic rotator cuff repair were identified and stratified based on whether ipsilateral acromioplasty was concurrently performed using Current Procedural Terminology codes. Groups were matched by age, sex, year of index procedure, and Elixhauser index at a 2:1 ratio. Primary end point was defined as undergoing a repeat ipsilateral shoulder surgery related to the rotator cuff at 5 years of follow-up. Kaplan-Meier survival curves were constructed, and the 2 groups were compared using the log-rank test.After matching, 54,209 shoulders in the rotator cuff repair with acromioplasty group and 26,448 shoulders in the rotator cuff repair without acromioplasty group were identified. Shoulders undergoing concurrent acromioplasty at index rotator cuff repair had a significantly increased rate of repeat ipsilateral cuff repair at 5 years postoperatively (8.5% vs 6.8%,Using a large, national database, concurrent acromioplasty at the time of rotator cuff tear was found to be associated with both an increase rate of overall subsequent procedures and revision rotator cuff repair.III, retrospective comparative study.

Background Institutional academic productivity remains an influential factor in an applicant's selection of fellowship training. This study aimed to determine the quality and quantity of research in the United States orthopaedic sports medicine fellowship programs and identify those with highest productivity. Methods The Arthroscopy Association of North America Fellowship Directory was used to evaluate 88 fellowships in the United States. Publication data and Hirschberg indices (h-index) were collected from the Scopus database. Subanalysis was performed based on the number of publications and mean h-index. Results Total number of publications per faculty member ranged from 0 to 866, with a median of 20. The median h-index per faculty member was 9. The number of fellows was correlated with a higher mean average h-index of faculty members (P = 0.05). The five programs with the highest number of publications included Hospital for Special Surgery, Rush University, University of Pittsburgh Medical Center, Mayo Clinic in Rochester, and Boston Children's Hospital. Conclusions Most academic productivity in sports medicine is produced by a relatively small number of fellowship programs in the United States. Of interest, the number of fellows or faculty does not affect significantly the quality or quantity of research productivity at top institutions.

Background:The slope of the tibial plateau has been proposed as a reason for failure of anterior cruciate ligament reconstruction.Purpose:To evaluate the interobserver reliability of measurements of tibial slope on radiographs versus magnetic resonance imaging (MRI) scans and to assess whether the modalities can be used interchangeably for this purpose.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:This retrospective study included 81 patients aged 18 to 30 years who were evaluated in a sports medicine setting for knee pain and who had lateral knee radiographs as well as knee MRI scans on file. Medial and lateral tibial plateau slope measurements were made by 3 blinded reviewers from the radiographs and MRI scans using graphic overlay software. The paired t test was used to compare measurements of the medial tibial plateau slope (MTPS) and lateral tibial plateau slope (LTPS) from radiographs and MRI scans. Intraclass correlation coefficients (ICCs) were calculated to determine intra- and interobserver reliability of measurements within each imaging modality, and Pearson correlation coefficients were calculated to determine the relationship between measurements on radiographs versus MRI scans.Results:Imaging from 81 patients were included. The average MTPS was significantly larger on radiographs compared with MRI scans (8.7° ± 3.6° vs 3.7° ± 3.4°; P < .001), and the average LTPS was also significantly larger on radiographs compared with MRI scans (7.9° ± 3.4° vs 5.7° ± 3.7°; P < .001). ICC values indicated good to excellent intraobserver agreement for all imaging modalities (ICC, 0.81-0.97; P ≤ .009). The ICCs for interobserver reliability of MTPS and LTPS measurements were 0.92 and 0.85 for radiographs, 0.87 and 0.83 for MRI based off the subchondral bone, and 0.86 and 0.71 for MRI based off the cartilage, respectively ( P < .001). Medium correlation was noted between radiographic and MRI measurements; Pearson correlation coefficients for radiographic versus subchondral MRI measurements were 0.30 and 0.37 for MTPS and LTPS, respectively.Conclusion:The average MTPS and LTPS were significantly larger on radiographs compared with MRI scans. Although tibial slope measurements using radiography and those using MRI are reliable between individuals, the measurements from radiographs and MRI scans cannot be used interchangeably, and caution should be used when interpreting and comparing studies using measurements of the tibial slope.

Background: No previous systematic review to our knowledge has examined the reasons that athletes fail to return to sport (RTS) after ulnar collateral ligament (UCL) surgery. Purpose: To report the rate of failure to RTS after UCL surgery and identify reasons that preclude an athlete’s ability to successfully RTS. Study Design: Systematic review; Level of evidence, 4. Methods: This study was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, Scopus, and SPORTDiscus databases for studies on athletes who underwent either UCL reconstruction or repair that reported RTS rates and identified reasons for failure to RTS. Data were collected on the number of athletes included, average age, sport played, operative technique, average follow-up, rate of failure to RTS, and reasons for failure to return. A random-effects model was used to conduct the meta-analysis. Results: Included were 26 studies reporting on 1019 athletes. Primary or revision UCL reconstruction was performed in 913 patients (89.6%), while the remaining 106 patients (10.4%) underwent UCL repair. The pooled rate of failure to RTS after UCL reconstruction or repair was calculated to be 11.4% (95% CI, 8.4-14.7). A significantly higher estimated proportion of athletes failed to return because of elbow-related reasons compared with non–elbow-related reasons (55.3% vs 40.6%; P = .0352). Persistent pain (29/103; 28.2%) was the most common reason for failure to return, followed by elbow limitations and other unspecified elbow problems (19/103; 18.4%). There was moderate evidence for publication bias and study heterogeneity across the included studies. Conclusion: This meta-analysis estimated the rate of failure to RTS after UCL surgery as 11.4%, with the majority of athletes unable to return because of elbow pain. Future studies reporting outcomes and providing details as to why athletes are unable to RTS can better inform sport surgeons on factors precluding RTS and can guide clinical practice to better help athletes achieve their postoperative goals.

Shoulder instability is a relatively common injury especially in the young athletic population and its surgical management continues to remain a controversial topic in sports medicine orthopedics. Anterior instability is the most common type encountered and is estimated to have an incidence rate of 0.08 per 1000 person–years in the general population; however, this figure is likely higher in the young athletic population. While in recent practice, arthroscopic surgery has become the new gold standard for management, reported failure rates as high as 26% and high recurrence rates in specific subpopulations such as young men in high collision sports have led to the consideration of alternative open procedures such as open Bankart repair, Latarjet, capsular shift, and glenoid bone grafting. These procedures may be preferred in specific patient subgroups such as young athletes involved in contact sports and those with Hill–Sachs defects and multidirectional instability, with postoperative recurrence rates of instability as low as 10%. The purpose of this review is to provide an overview of different open surgical techniques in the management of shoulder instability and summarize patient outcomes including recurrence rates for shoulder instability, return to sport, range of motion (ROM), muscle strength, and complications either individually by procedure or in comparison with other techniques, with special focus on their impact in the athletic population.

Anterior cruciate ligament reconstructions (ACLR) are a relatively common procedure in orthopedic sports medicine with an estimated 130,000 arthroscopic operations performed annually. Most procedures are carried out on an outpatient basis, and though success rates of ACLR are as high as 95%, pain remains the most common postoperative complication delaying patient discharge, and thereby increasing the costs associated with patient care. Despite the success and relative frequency of ACLR surgery, optimal and widely accepted strategies and regimens for controlling perioperative pain are not well established. In recent years, the paradigm of pain control has shifted from exclusively utilizing opiates and opioid medications in the acute postoperative period to employing other agents and techniques including nerve blocks, intra-articular and periarticular injections of local anesthetic agents, NSAIDs, and less commonly, ketamine, tranexamic acid (TXA), sedatives, gabapentin, and corticosteroids. More often, these agents are now used in combination and in synergy with one another as part of a multimodal approach to pain management in ACLR, with the goal of reducing postoperative pain, opioid consumption, and the incidence of delayed hospital discharge. The purpose of this review is to consolidate current literature on various agents involved in the management of postoperative pain following ACLR, including the role of classically used opiate and opioid medications, as well as to describe other drugs currently utilized in practice either individually or in conjunction with other agents as part of a multimodal regimen in pain management in ACLR.

One emerging technology with the potential to improve and further transform the field of orthopaedic surgery is virtual reality (VR). VR has been explored and used in many different specialties with clinical applications, such as psychiatric therapy, pain management, rehabilitation, and traumatic brain injury. Recent studies have suggested that the use of VR during the training of orthopaedic surgery residents produces similar or improved surgical performance by residents. This is an area where VR can provide a tremendous benefit to the field of orthopaedic surgery, as it offers a safe and accessible complement to orthopaedic surgical training outside of the operating room (OR) and without involving patients directly. This review will elucidate the current state of virtual reality use in the training of orthopaedic surgeons and highlight key benefits and challenges in its application as a training resource.

Background: Knee injection using either bone marrow aspirate concentrate (BMAC) or stromal vascular fraction (SVF) from adipose tissue has been shown to result in symptomatic improvement in patients with knee osteoarthritis (OA). It is still unclear whether one of these therapies is superior over the other. Purpose: To systematically report the clinical studies evaluating BMAC and SVF in the treatment of knee OA and to compare the clinical efficacy of these 2 injection therapies. Study Design: Meta-analysis; Level of evidence, 4. Methods: This meta-analysis was performed per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Studies were included if they reported the clinical outcomes after a single BMAC or SVF injection in the knee joint of patients with OA. Studies evaluating preparations of culture-expanded stem cells were excluded. A random effects model was used; the clinical efficacy of BMAC or SVF injection was assessed using the standardized mean difference (SMD) and compared. Visual analog scale (VAS) scores for pain and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) knee index were the primary outcomes. The level of statistical significance was set at P < .05. Results: Ten studies and 472 patients with knee OA who received either BMAC (233 patients) or SVF (239 patients) were included. Patients who received an injection had improved VAS outcomes (mean ± SD): from 5.8 ± 1.3 to 2.6 ± 17 for BMAC and from 6.4 ± 1.4 to 3.4 ± 0.5 for SVF. They also experienced significantly reduced pain (SMD [VAS], 2.6 for BMAC and 3.4 for SVF) and improved function (SMD [WOMAC], 1.4 for BMAC and 1.2 for SVF). However, the SVF injection had a significantly greater effect on pain reduction than did the BMAC injection ( P < .0001). Based on WOMAC, the clinical effect of BMAC versus SVF knee injection in patients with knee OA was equivalent ( P = .626). Results were limited by the presence of publication bias as well as variability in the preparation methods utilized in the BMAC and SVF injection protocols. Complications were reported in 50% of the BMAC studies (knee stiffness, persistent knee swelling) and 67% of the SVF studies (knee swelling, knee pain, positive SVF cultures without symptoms of infection, and bleeding at the abdominal harvest site). Conclusion: A single BMAC or SVF injection into the knee joint of patients with OA resulted in symptomatic improvement at short-term follow-up. However, SVF seemed to be more effective than did BMAC in the reduction of knee pain. There was significant variation in the BMAC and SVF injection preparation techniques used across the studies and a lack of stratification of outcomes based on the radiologic classification of OA. Therefore, these results should be taken with caution.

(1) To report the distribution of injuries per body site and time lost from participation in female NCAA Division I rowers and (2) to present an updated summary of the existing evidence regarding the analysis of injuries per body site in rowers.Case series: The distribution of injuries per body site in female NCAA Division I rowers and the time lost from participation were retrieved from an institutional registry. Injuries per body site were reported as number of athletes with site-specific injury per total number of injured athletes. Systematic review: Based on the PRISMA guidelines for systematic reviews, three electronic databases were searched for studies reporting the epidemiology of injuries per body site in rowers and analyzed.Case series: One-hundred and thirty-seven injuries were recorded in 92 female rowers over 5 years. The risk of injury (number of injured athletes over total number of athletes on roaster) was 52% (92/176). Among the 92 injured athletes, 38% sustained injury to the lower back, while 23% and 16% of these athletes sustained injury to the ribs and hip-groin area, respectively. Systematic review: Ten studies were included. The level of evidence was IV and the mean MINORS score was 13.2(9-15) (fair quality). Most studies reported injuries to the lower spine (8/10,80%) whereas injuries to the ribs or other anatomic sites were reported in ≤4 (40%) studies. Significant heterogeneity of the injury reporting methodologies (injury definition; measures of injury occurrence; description of the injury site) was detected and precluded meta-analysis.Most injuries recorded in a single team of female NCAA Division I athletes occurred in the lower back followed by injuries to the ribs and the hip. The existing injury epidemiology literature in mostly focuses on injuries to the lower back, while injuries to other anatomic sites were less frequently analyzed. No conclusions can be made regarding the most common injuries in rowers based on the current evidence due to substantial heterogeneity of injury reported methodologies which warrants further investigation.

INTRODUCTION Preoperative opioid use has recently been associated with increased perioperative pain. This study evaluates the effect of preoperative opioid use on postoperative pain and duration of opioid use after total shoulder arthroplasty (TSA). METHODS We retrospectively identified 138 TSAs (69.1% reverse and 30.9% anatomic) between January 2013 and April 2017 that met inclusion criteria. Patients were stratified into two groups based on opioid usage within the 4 weeks before surgery. Primary outcome was resting pain at 3 months postoperatively using a 10-point numerical rating scale system. Duration of postoperative opioid consumption was also recorded and compared between cohorts. RESULTS The opioid cohort (n = 50) reported significantly greater resting pain and pain with activity at 3 months postoperatively, at which time the reported numerical rating scale pain scores were 1.6 and 2.8 points greater in the opioid cohort compared with the non-opioid cohort (P < 0.001). Preoperative opioid use strongly predicted postoperative opioid use at all follow-up time points (P < 0.0001). DISCUSSION Preoperative opioid consumption is associated with higher pain and increased duration of opioid use after TSA.

Purpose: To use mirror imaging to identify the location and magnitude of difference in acetabular rim morphology between the symptomatic and unaffected acetabula in patients with symptomatic unilateral pincer-type or mixed femoroacetabular impingement syndrome (FAIS) using 1-dimensional models created with computed tomography (CT). Methods: CT scans of bilateral hips in 33 patients diagnosed with unilateral pincer-type or mixed FAIS were obtained. Three-dimensional bilateral hip models were constructed, and the unaffected hemipelvis was superimposed onto the symptomatic side to compare acetabular thickness. Protrusion of the symptomatic side was recorded, and rim morphology was divided into clock face quadrants to analyze the location of greatest magnitude of difference between affected and unaffected acetabula. Analysis of the quadrants was performed using analysis of variance with post hoc Bonferroni correction. Results: The study group consisted of more females (51.6%) than males, with an average age of 35.72 ± 7.8 years and an average body mass index of 24.3 ± 4.1 kg/m2. Of the 33 hips included, 14 were isolated pincer-type FAIS and 19 were mixed. The average preoperative symptomatic side lateral center edge angle was 37.5° ± 7.2° compared with 29° ± 5.1° on the asymptomatic side (P = .001). The symptomatic acetabular rim was on average 0.43 ± 0.18 mm thicker than the corresponding location on the unaffected rim. When the acetabulum was divided into clock face quadrants, the 12 to 3 o'clock position showed the greatest difference between symptomatic and unaffected sides (0.55 ± 0.18 mm) compared with the 3 to 6 o'clock position (0.4 ± 0.28 mm; P = .006), 6 to 9 o'clock (0.34 ± 0.07 mm; P < .001), and 9 to 12 o'clock (0.38 ± 0.03; P = .001). Conclusions: Patients with unilateral, symptomatic pincer-type or mixed FAIS show statistical differences in rim thickness between the affected and unaffected acetabula. Small changes in acetabular rim morphology on the order of ≤0.5 mm may be the difference between symptomatic FAIS and the unaffected hip. Level of Evidence: IV, case series.

The structural integrity of rotator cuff repair (RCR) has been a primary focus for shoulder surgeons seeking long-term clinical and functional success. Improvements in surgical techniques have allowed for superior initial biomechanical fixation. However, tendon healing remains a significant clinical problem even after rigid time-zero repair. The lack of long-term healing has led to increased interest in biologic augmentation to improve tendon-to-bone healing. This interest has led to a rise in the investigation of small molecular therapies, cell-based strategies, and tissue-derived treatments offering surgeons a new therapeutic toolbox for potentially improving RCR long-term outcomes. However, the delivery, efficacy, and safety of these treatments remain under investigation. Additional well-designed, high-level studies are of paramount importance in creating evidence-based guidelines for the implementation of new biologic solutions. This review article discusses the current preclinical, translational, and clinical experience with and rationale for biologic augmentation in RCR.

The advantages of upgrade to cardiac resynchronisation therapy (CRT) have not been explored as carefully as the outcomes of de novo CRT implantations. Furthermore selection criteria for patients with the potential to benefit the most from this therapy are unknown. Therefore, we analyzed the long term outcome and its predictors in a real-world cohort receiving a CRT upgrade from previous pacemaker (PM) and defibrillator devices (ICD). We analyzed 86 patients (mean age 68 ± 9 years; 89% male) undergoing CRT upgrade procedures. Response to CRT as well as long term patient outcome was analyzed. NYHA class improved in majority of the patients during short term period (61%), and this trend remained constant during long term follow-up (54%). The observed all-cause mortality was 54% with mean survival of 49 ± 4 months. 11 patients underwent left ventricular assist device implantation or heart transplantation. In the multivariate analysis, only kidney function assessed by GFR (HR 0.97; 95% CI 0.95-0.99; p = 0.009) and LVEF (HR 0.92; 95% CI 0.87-0.97; p = 0.002) remain predictors for mortality. Patients who undergo an upgrade procedure to CRT demonstrate a significant response rate assessed by improvement in NYHA class, with initial baseline parameters such as LVEF and kidney function remaining significant predictors for mortality.

The purpose of this study was to compare the cross-sectional area (CSA) of joint visualization between extended interportal and T-capsulotomies. Twenty fresh-frozen cadaveric hips were dissected to their capsuloligamentous complexes and fixed in a custom apparatus in neutral hip position. Ten hips underwent sequential interportal capsulotomies at lengths of 2, 4, 6, and 8 cm. Ten hips underwent sequential T-capsulotomies starting from a 4 cm interportal capsulotomy, creating a 2 cm T-capsulotomy (Half-T), and finally a 4 cm T-capsulotomy (Full-T). Following each sequential capsule change in both groups, a high-resolution digital photograph was taken to measure the visualized intra-articular cross-sectional area (CSA). Independent t-test was used to compare CSA interportal and T-capsulotomy groups. Analysis demonstrated a statistically significant increase in CSA visualization with each sequential increase in interportal capsulotomy length up to 6 cm (2cm: 0.6 ± 0.2 cm2; 4cm: 2.1 ± 0.5 cm2 (p

Background: Lateral collateral ligament (LCL) injuries are implicated in varus instability of the knee. Often, these accompany other ligamentous injuries including anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) tears, and injury to the anterolateral capsular complex (ALCC). Use of internal brace augmentation with anatomic repair is an alternative to reconstruction to improve patient outcomes and facilitate early range of motion and weight bearing. Indications: We present a case of an anatomic repair of a LCL and an ALCC injury with internal brace augmentation. Technique Description: A curvilinear incision centered over the lateral epicondyle is used. The avulsed LCL and biceps tendon was exposed and a placed #5 FiberWire was placed into the distal LCL, biceps tendon, and the popliteofibular ligament. A split was made in the iliotibial (IT) band and a second #5 FiberWire was placed proximally in the LCL/biceps tendon for additional fixation. A tunnel was made in the fibular head and tibia using a 2.4-mm beath pin and the two #5 FiberWires were passed to the anteromedial tibia. The FiberWires were fixed to the tibia using a 14-mm attachable button system (ABS) manhole cover for suspensory fixation. Repair and internal bracing of the anterolateral capsular complex was accomplished with 2 interlocked TightRopes and a #2 FiberTape. This fixation method achieved repair by compressing the anterolateral capsular complex onto its tibial origin. The suture devices also served to augment the repair and were fixed proximally to the femur using another 14-mm ABS manhole cover. The FiberTape was fixed to the anterolateral tibia distally with a 4.5 mm SwiveLock. The TightRopes were passed through a tunnel to the anterolateral tibia and secured using an ABS Dog Bone. The construct was tensioned in near full extension and gapping was matched fluoroscopically to the contralateral knee. Results: Patient was cleared for full return to sports 9 months postoperatively. At the final follow up visit, the patient had excellent strength, stability, and 135° range of motion on the operative knee. Patient had returned to exercise at home but was unable to return to sports due to COVID-19 restrictions. Conclusion: Anatomic repair of the LCL and the ALCC with internal brace augmentation can serve as an effective alternative to reconstruction and demonstrates excellent patient outcomes regarding restoring stability, ROM, and return to preoperative sports.

Background: Concomitant cartilage injury is commonly associated with patellofemoral instability. While nonoperative treatment remains the gold standard for first time dislocators, there has been an increased trend toward addressing patellar instability when symptomatic cartilage disease is present. Indications: A healthy active 29-year-old woman >2 years of patellar instability and pain symptoms in the right knee. Imaging revealed tibial tubercle to trochlear groove (TT-TG) distance of 19.8 mm, and a Caton Deschamps Ratio of 1.54. Initial staging arthroscopy demonstrated a near full thickness cartilage defect of the lateral patellar facet measuring 2x2 cm. Technique Description: In the index procedure, a staging diagnostic arthroscopy is performed to evaluate the extent of the cartilage defect. Given the size of the lesion, a matrix-induced autologous chondrocyte implantation (MACI) biopsy is performed for later implantation. At the second stage procedure, a midline approach to the patella and tibial tubercle is performed. A 45° osteotomy is initiated with a cutting jig. The osteotomy is detached distally to allow for both anteromedialization and distalization to offload the cartilage defect and improve patellar articulation. The lateral patellar facet cartilage defect is prepared, and a combination of fibrin sealant and digital pressure is used to implant the pre-shaped MACI transplant. The osteotomy is then secured with 2 bicortical screws. A semitendinosus allograft is secured to the upper half of the medial border of the patellar and secured to its anatomometric point on the femur to reconstruct the medial patellofemoral ligament (MPFL). Results: Patient successfully returned to running and is currently working on return to other sports with no anterior knee pain or instability. Recent studies have demonstrated overall good clinical outcomes following MACI for patellofemoral lesions. Addressing underlying bony deformity and offloading patellofemoral cartilage lesions with tibial tubercle osteotomy in combination with MPFL reconstruction has improved patellar stability and good patient satisfaction. Discussion/Conclusion: Combined tibial tubercle osteotomy, MPFL reconstruction, and MACI in a comprehensive approach can successfully address symptomatic patellofemoral cartilage disease in the setting of patellar instability with underlying bony abnormalities.

AIM To explore the current evidence surrounding the administration of prophylactic antibiotics for arthroscopic knee surgery. METHODS Databases were searched from inception through May of 2018 for studies examining prophylactic antibiotic use and efficacy in knee arthroscopy. Studies with patient data were further assessed for types of arthroscopic procedures performed, number of patients in the study, use of antibiotics, and outcomes with the intention of performing a pooled analysis. Data pertaining to “deep tissue infection” or “septic arthritis” were included in our analysis. Reported data on superficial infection were not included in our data analysis. For the pooled analysis, a relative risk ratio was calculated and χ2 tests were used to assess for statistical significance between rates of infection amongst the various patient groups. Post hoc power analyses were performed to compute the statistical power obtained from our sample sizes. Number needed to treat analyses were performed for statistically significant differences by dividing 1 by the difference between the infection rates of the antibiotic and no antibiotic groups. An alpha value of 0.05 was used for our analysis. Study heterogeneity was assessed by Cochrane’s Q test as well as calculation of the I2 value. RESULTS A total of 49682 patients who underwent knee arthroscopy for a diverse set of procedures across 19 studies met inclusion critera for pooled analysis. For those not undergoing graft procedures, there were 27 cases of post-operative septic arthritis in 34487 patients (0.08%) who received prophylactic antibiotics and 16 cases in 10911 (0.15%) who received none [risk ratio (RR) = 0.53, 95% confidence interval (CI): 0.29-0.99, P = 0.05]. A sub-group analysis in which bony procedures were excluded was performed which found no significant difference in infection rates between patients that received prophylactic antibiotics and patients that did not (P > 0.05). All anterior cruciate ligament reconstruction studies used prophylactic antibiotics, but two studies investigating the effect of soaking the graft in vancomycin in addition to standard intravenous (IV) prophylaxis were combined for analysis. There were 19 cases in 1095 patients (1.74%) who received IV antibioitics alone and no infections in 2034 patients who received IV antibiotics and had a vancomycin soaked graft (RR = 0.01, 95%CI: 0.001-0.229, P < 0.01). CONCLUSION Prophylactic antibiotics are effective in preventing septic arthritis following simple knee arthroscopy. In procedures involving graft implantation, graft soaking reduces the rate of infection.

Aims Epicardial ablation has risen to an essential part of the treatment of ventricular tachycardias (VTs). In this study, we report the efficacy, risks, and current trends of epicardial ablation in structural heart disease as reported in a tertiary single centre over a 12-year period. Methods and results Two hundred and thirty-six patients referred for VT ablation underwent a successful epicardial access and were included in the analysis (89% non-ischaemic cardiomyopathy, 90% males, mean age 60 years, mean left ventricular ejection fraction 38.4%). After performing epicardial ablation the clinical VTs were eliminated in 87% of the patients and 71% of the cohort achieved freedom from VT during 22-month follow-up. Twelve patients (5%) suffered major procedure-related complications. Until the end of follow-up 47 (20%) patients died, 9 (4%) underwent a left ventricular assist device implantation and 10 (4%) patients received a heart transplantation. Antiarrhythmic drugs at baseline and during follow-up were independent predictors of VT recurrence. Atrial fibrillation, renal dysfunction, worse New York Heart Association class, and antiarrhythmic drugs at follow-up were associated with worse survival in our cohort. Conclusion In this large tertiary single-centre experience, percutaneous epicardial access was feasible in the large majority of the cohort with acceptably low complications rates. A combined endo-/epicardial approach resulted in 87% acute and 71% long-term success. Further studies are needed to clarify the role of routine combined endo-/epicardial ablation in these complex cardiomyopathies.

Background: Beach volleyball officially became a National Collegiate Athletic Association (NCAA) Division I sport in 2015-2016. Few studies have examined the epidemiology of injuries in indoor versus beach volleyball in NCAA Division I athletes. Purpose: To compare the epidemiology of injuries and time lost from participation between female NCAA Division I athletes who participate in indoor versus beach volleyball. Study Design: Cohort study; Level of evidence, 3. Methods: Injury surveillance data (2003-2020) were obtained using an institutional database for all NCAA Division I women’s beach or indoor volleyball athletes. The total injury rate was expressed per 1000 hours played. The injury rate per body site was calculated by dividing the number of injuries in each body region by the total number of injuries. The frequency of injury per body site was also expressed as number of injuries per 1000 hours of practice or number of injuries per 1000 hours of game. The injury rate (total and per body site) and time lost from participation were compared between indoor and beach volleyball athletes. Results: Participants were 161 female NCAA Division I volleyball athletes (53 beach volleyball and 108 indoor volleyball athletes). In total, 974 injuries were recorded: 170 in beach volleyball and 804 in indoor volleyball. The injury rates for beach versus indoor volleyball were 1.8 versus 5.3 injuries per 1000 hours played ( P < .0001). Indoor volleyball athletes had significantly higher injury rates compared with beach volleyball players for concussion (7.5% vs 6.5%; P < .0001) and knee injury (16.7% vs 7.6%; P = .0004); however, the rate of abdominal muscle injury was significantly higher in beach versus indoor volleyball (11.8% vs 4.7%; P = .0008). Time lost from sport participation was significantly longer in beach versus indoor volleyball for knee (24 vs 11 days; P = .047), low back (25 vs 17 days; P = .0009), and shoulder (52 vs 28 days; P = .001) injuries. Conclusion: Based on this study, injury was more likely to occur in indoor compared with beach volleyball. Sport-related concussion and knee injuries were more common in indoor volleyball, but the rate of abdominal muscle injury was higher in beach volleyball. Beach volleyball players needed longer time to recover after injuries to the knee, low back, and shoulder.