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Objectives: Jones’ fractures, 5th metatarsal metaphyseal-diaphyseal junction fractures, are a debilitating injury for the elite athlete, particularly in cutting/pivoting sports. These injuries are usually managed surgically due to the high rate of nonunion and re-fracture. Despite primary screw fixation, delayed union and nonunion are not uncommon. Bone marrow aspirate concentrate (BMAC), an autologous source of hematopoietic and mesenchymal stem cells, has been used to augment healing due to the poor healing potential in the watershed region. We hypothesize that open reduction internal fixation (ORIF) augmented with BMAC will improve patient-reported outcome measures following Jones’ fractures in athletes. Methods: This study was a prospectively collected and maintained review of elite athletes that underwent intramedullary screw fixation augmented with BMAC for Jones’ fractures at an academic medical institution. All patients were evaluated preoperatively and postoperatively to assess differences in patient reported outcomes including VAS, PROMIS, FAAM, SF-12 scores, return to play, and complications. Student’s t test was used in statistical comparison of the preoperative and postoperative outcome scores. P < 0.05 was considered significant. Results: A total of 41 elite athletes were treated with ORIF with BMAC for a Jones fracture with a mean age of 25.59 years (range 19-42). There were 26 (63%) males and 15 females included in the study. Type of athlete ranged across the following sport activities: football, basketball, soccer, volleyball. Of note, patients had significantly improved with lower visual analog score for pain (mean Δ3.56, p= 0.001), higher FAAM scores (mean Δ 43.6, p< 0.001), and PASS scores (increased from 11% to 85%, p< 0.001) at 6 months. Additionally, patients showed improvement in SF12, PROMIS10, and FAAM scores at 12 months, although this was not statistically significant due to insufficient follow up at this time. The average numbers of days lost to competition was 131 days. All patients that have returned to elite competitive sport activity report minimal to no pain. Conclusion: Intramedullary screw fixation of Jones’ fractures with BMAC results in optimal surgical outcomes in the elite athlete. The use of patient reported outcomes continues to be a focus of quality measures and should guide clinical decision making for surgical intervention, return to play, and to assess impact of treatment. A higher powered and long-term study with validated patient-reported outcomes is needed to confirm our observations.

Objectives: A randomized clinical trial was conducted to compare knee kinematics during gait and running 24 months after ACL reconstruction, using either single-bundle (SB) or double-bundle (DB) quadriceps tendon grafts. We hypothesized that DB reconstruction would better restore kinematics than SB reconstruction, in comparison to the uninjured, contralateral knee. Methods: Subjects were between 14 and 50 years of age, participated in at least 100 hours of Level 1 or 2 sports activities and presented within 12 months of injury to both bundles of the ACL (with or without meniscal injury). Exclusion criteria included prior injury or surgery of the ipsilateral or contralateral knee or greater than a grade 1 concomitant knee ligament injury. Subjects were randomized to undergo SB or DB ACL reconstruction with a 10 mm quadriceps tendon autograft harvested with a patellar bone block. A single, anatomically placed femoral tunnel was used for all cases. For DB ACL reconstruction, the soft tissue portion of the graft was split and passed through two anatomically placed tibial tunnels. Biplane radiographic images were acquired 24 months after surgery while subjects performed downhill running on a treadmill (3.0 m/s, 10 degree slope, 150 images/s) and level gait (1.3 m/s, 100 images/s). Subject specific bone models were generated from computed tomography images and matched to the biplane radiographs using a previously validated model-based tracking process to determine tibiofemoral kinematics. Rotations of the tibia relative to the femur were calculated using the rotational component of the Joint Coordinate System originally described by Grood and Suntay. Displacements of the tibia relative to the femur were expressed in an orthogonal anatomical coordinate system fixed to the tibia. Primary outcome variables were based on previous findings of abnormalities in knee kinematics after ACL injury/reconstruction, and included peak knee external rotation, adduction and anterior translation during heelstrike to mid-stance. Three trials were collected for each limb and each task, and averaged for statistical analysis. Differences between SB and DB kinematics were determined using Wilcoxon Signed Rank tests, with significance level p < 0.05. Results: No significant differences were found in any of the primary kinematic variables between single and double bundle anatomic ACL reconstruction (Table). Differences between reconstructed and contralateral (uninjured) limbs were small, averaging less than 2 degrees in rotation and 2 mm in translation. Rotational differences were smaller during gait than during downhill running. Conclusion: Conclusions: Contrary to the study hypothesis, DB reconstruction was not found to be superior to SB reconstruction. While some abnormalities remained (particularly during the more stressful downhill running evaluation), both anatomical reconstructions were equally effective at restoring normal knee kinematics. kinematic differences between limbs (affected-contralateral) during gait and downhill running Single Bundle Single Bundle Single Bundle Double Bundle Double Bundle Double Bundle N Mean Std Dev N Mean Std Dev Wilcoxon p Running Peak Knee Adduction 25 -0.23 1.12 21 -0.21 1.16 0.71 Running Peak External Rotation 25 -1.56 4.04 21 -0.17 3.12 0.20 Running Peak Anterior Translation 25 0.57 2.62 21 2.02 2.75 0.13 Gait Peak Knee Adduction 26 -0.06 1.19 21 -0.05 1.11 0.83 Gait Peak External Rotation 26 -0.44 4.34 21 -0.11 3.55 0.77 Gait Peak Anterior Translation 26 0.83 2.97 21 2.00 2.56 0.20

Background: The quadriceps tendon is a versatile graft option, and the clinical implications of a quadriceps tendon harvest need to be further defined. Purpose: To review surgical considerations for the safe harvest of a quadriceps tendon autograft for anterior cruciate ligament (ACL) reconstruction, with a focus on the risk of patellar fractures. Study Design: Case series; Level of evidence, 4. Methods: A series of 57 patients underwent ACL reconstruction with a quadriceps tendon autograft with a patellar bone block from March 2011 to December 2012 at a single institution. Patients who sustained a patellar fracture were identified. The clinical course for each patient was reviewed with International Knee Documentation Committee (IKDC) subjective knee form scores through 2-year follow-up. Results: The incidence of patellar fractures was 3.5% intraoperatively and 8.8% at 2 years. This included 2 intraoperative fractures, 1 fracture during strength testing, and 2 occult fractures detected on computed tomography (CT) performed 6 months postoperatively for research purposes in asymptomatic participants. For the 5 patients with a patellar fracture with 24-month follow-up, the IKDC scores were 91.95, 91.95, 100.00, 100.00, and 64.37. Conclusion: Careful consideration of the quadriceps tendon and patellar anatomy is needed to safely harvest the bone plug from the superior pole of the patella. The consequences of a quadriceps tendon autograft harvest, specifically with regard to the risks associated with fractures of the patella during the harvest, demand full consideration. Postoperative imaging with CT may identify abnormalities in patients who are otherwise asymptomatic.