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Objectives: Some surgeons prefer reverse shoulder arthroplasty to total shoulder arthroplasty in elderly patients with osteoarthritis (OA) and without cuff tears because these patients may subsequently develop cuff tears. However, other studies have shown total shoulder arthroplasty provides good to excellent results in elderly patients with intact rotator cuffs, even in patients ≥ 80 years of age. We conducted the following studies to clarify potential rotator cuff degeneration in elderly OA patients, histologically analyzing the torn edges of ruptured rotator cuff tendons from patients with cuff tear arthropathy (CTA) with a proximal humeral fracture with an intact cuff (control) or en bloc cuff tendon remaining on the greater tuberosity from patients with OA after harvesting such tissues at the time of RSA. Then, we compared the clinical results of elderly patients undergoing total shoulder arthroplasty (TSA) and reversed shoulder arthroplasty (RSA) when these patients reached ≥ 80 years of age. We hypothesized that rotator cuff tendons were more severely degenerated microscopically in elderly patients with OA and intact cuff tendons compared with tendons in elderly patients with proximal humeral fractures, and comparable to those with CTA. Methods: We histologically evaluated torn rotator cuff tendon samples harvested from 13 samples in 11 shoulders in 9 patients with OA without cuff tears, 18 samples in 14 shoulders in 14 patients with CTA, and 2 shoulders in 2 patients with proximal humeral fractures using the Bonar score and electron microscopic analysis. In addition, we compared the clinical results of TSA in 7 shoulders in 6patients and RSA in 19 shoulders in 15 patients when these patients reached ≥ 80 years of age. Bonar scores were compared between the OA and CTA patients (OA and CTA groups), and Constant scores, and range of motion were compared between the two procedures (TSA and RSA groups). Two patients with proximal humeral fractures served as controls. We identified patients with secondary rotator cuff dysfunction by the presence of either moderate or severe superior subluxation of the humeral head base on radiographic assessment of humeral superior subluxation. Results: There were no significant differences in patients' age, sex, BMI, heart disease, DM, hyperlipidemia, sample site, and preoperative Constant and ASES scores (except regarding the number of affected dominant arms), between the CTA and OA groups. There were no significant differences in the distribution of each category for tenocytes, ground substance, and collagen; and vascularity (P =.227.107,.509,.848, respectively). In addition, there was no significant difference in the Bonar scores between the CTA and OA groups (P =.140). In the both groups, irregularly-orientated collagen fibers showing fiber separation and numerous blood vessels and inflammatory cells were observed in the sections with HE staining (Fig. 1A-C, A, OA patients; B and C, CTA patients). In the sections with AB/PAS staining, increase in alcianophilia indicating glycosaminoglycans among collagen fibers were observed (Figure 1, D, CTA patient). The control supraspinatus tendons from the patients of a four-part proximal humeral fracture demonstrated well-oriented collagen fibers with tightly cohesive well-demarcated bundles. The two control shoulders had 0 points and 2 points for the Bonar score, respectively (Figure 2). The ultrastructural analysis showed that collagen fibrils were arranged irregularly, with a heterogenous extracellular matrix, in the OA group. Similarly, in the CTA group, some collagen fibrils were oriented in different directions, and that there were empty spaces between the fibrils, representing non-collagenous extracellular matrix (Figure 3, A, C; OA patient, B,D; CTA patient). We found no significant difference in the fibril diameter (nm) between the two groups (mean,66.9 for the CTA group and 65.0 for the OA group) (P =.219) (Figure 3 C and D). There were significant improvements between preoperative and postoperative clinical scores in both groups. In addition, patients in the TSA group had significantly lower Constant scores, Constant ROM scores, and ROM in flexion and abduction at the final follow-up (P;.009, <.001,.003,.009, respectively). Upward migration of the prosthetic humeral head was observed in 7 shoulders (100%) overall and was graded as mild in 3 shoulders (42.9%), moderate in 4 shoulders (57.1%) as secondary cuff dysfunction. Conclusions: The most important finding in the present study was that rotator cuff tendons in elderly OA patients without cuff tears had relatively higher mean Bonar scores than the scores in the cuff tendons in two patients with proximal humeral fractures (control shoulders), and scores were comparable to the scores in cuff tendons in the elderly CTA patients. In addition, our clinical results showed that the TSA group had significantly lower clinical variables than those of the RSA group regarding the Constant score, Constant ROM score, and ROM in flexion and abduction in our cohort who were ≥ 80 years of age at the latest follow-up. Furthermore, 4 shoulders (57.1%) in the TSA group had moderate superior subluxation of the prosthetic humeral head as possible secondary cuff tendon dysfunction, at the final follow-up. Considering these histologic and clinical results, severe histological degeneration of rotator cuff tendons in elderly OA patients without cuff tears may be a risk of secondary rotator cuff dysfunction and poor clinical outcome after TSA. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to compare clinical outcomes between randomized groups who underwent MCL augmentation repair versus MCL autograft reconstruction. Methods: Patients were prospectively enrolled from 2013 to 2019 from 3 centers (United States, Norway, Denmark). Grade III superficial (sMCL) injuries were confirmed by stress radiography. Patients were randomized to an anatomic sMCL reconstruction versus an augmented repair with surgical treatment determined after examination under anesthesia confirmed sMCL incompetence. Post-operative visits occurred at 6 weeks and 6 months for repeat evaluation and repeat stress radiography at final follow-up. Patient reported outcome measures (PROMs) were obtained preoperatively and postoperatively at 6 months, 1 year, and at final follow-up. The two one-sided t-test (TOST) procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and Mann-Whitney U-test was used to compare postoperative PROMs between groups. Results: Fifty-four patients were prospectively enrolled from 3 centers. The average overall patient age was 38.0 years (standard deviation (SD = 14.2 years), average body mass index was 25.0 (SD = 3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (SD = 1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (SD = 1.46 mm) in the MCL augmentation group and 3.42 mm (SD = 0.55) in the MCL reconstruction group (p = 0.036). Postoperative valgus stress radiographs at an average of 6 months were 0.21 mm (SD = 0.81 mm) for MCL augmentation and 0.19 mm (SD = 0.67 mm) for MCL reconstruction (p = 0.940). At final follow-up (minimum 1-year), Lysholm scores were significantly higher in the reconstruction group (median 90, inter-quartile range 83–99) compared to the repair group (median 80, IQR 67-92; p=0.031). Final IKDC scores were significantly higher for the reconstruction group (median 85, IQR 68-89) compared to the repair group (median 72, IQR 60-78; p=0.039). Postoperative Tegner scores were not significantly different between the repair group (median 5, IQR 3.5-6) and the reconstruction group (median 5.5, IQR 4-7; p=0.123). Patient satisfaction was not significantly different between the repair (median 7.5, IQR 5.75–9.25) and reconstruction groups (median 9, IQR 7 - 10; p=0.184). There were no reported cases of DVT, infection, or arthrofibrosis in any patient in either group. There were no reported MCL graft ruptures in either the augmentation or reconstruction group as indicated from valgus stress radiographs (≥ 3.2 mm) and physical examination at 12 months postoperatively. Conclusions: There was no difference in objective outcomes between a sMCL augmentation repair versus a complete sMCL reconstruction at one year postoperatively. Patient reported clinical outcomes favored the reconstruction over repair. This randomized controlled trial demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had low risk of graft attenuation and complications. Table 1. Comparison of baseline covariates between MCL Treatment Groups.† Table A2. Comparison of baseline covariates between sites.† [ABSTRACT FROM AUTHOR]

Objectives: Significant anterior glenoid bone loss in the setting of recurrent instability may warrant a coracoid transfer (Latarjet). However, the amount of glenoid width that must be restored with a Latarjet in order to reestablish glenohumeral stability has not been studied. We hypothesize that restoration of greater than 90% of glenoid width with a Latarjet will be necessary to restore glenohumeral stability. We also hypothesize that there will be significant increases in anterior humeral head translation when 90% or less of the native glenoid width is restored and that contact pressures on the coracoid graft will increase. Methods: Seven cadaveric specimens were prepared and mounted on an established shoulder simulator, which loads shoulder tendons through a system of pulleys and weights. A motion tracking system to record glenohumeral translations was placed on the scapula and humerus and registered based on a computed tomography (CT) scan. Contact pressures were mapped and recorded using a TekScan secured to the glenoid face and coracoid graft transfer (Figure 1). The humerus was placed in 90 degrees of humerothoracic abduction. Coracoid osteotomy was performed, and the coracoid graft was sized to a depth of 10mm. A lesser tuberosity osteotomy (LTO) was performed to allow accurate removal of glenoid bone. The amount of bone loss needed to re-establish 110%, 100%, 90% and 80% of native glenoid width after Latarjet was calculated by directly measuring the widest point of the glenoid and confirming accuracy based on the CT scan. Glenoid bone loss was established using a burr and the coracoid graft transfer was secured to the anteroinferior glenoid with two screws. The conjoined tendon was passed through a subscapularis split and the LTO was repaired with multiple Kirshner wires prior to each testing condition (Figure 2). Additionally, the rotator interval was closed and the capsule was repaired prior to each testing condition. The supraspinatus, subscapularis, infraspinatus and conjoined tendons were each loaded with 22N. Testing conditions included native glenohumeral joint, LTO, Bankart tear, and then 110%, 100%, 90% and 80% of glenoid width restoration with Latarjet. Glenohumeral translations and contact pressures were recorded with an anteroinferior load of 0 or 44N at 0 degrees of glenohumeral external rotation. Results: Progressive increases in anterior humeral head translation occurred with an anteroinferior load as the amount of glenoid width restored decreased (Figure 3). An anteroinferior load created an average of 5.5mm, 9.6mm, 3.3mm, 3.6mm, 9.2mm and 10.2mm of anterior translation in the LTO, Bankart, 110%, 100%, 90% and 80% of glenoid restoration cohorts, respectively. Greater glenoid bone loss also led to more contact pressure on the coracoid graft after Latarjet (Figure 4). An anteroinferior load produced 26.4%, 46.9%, 86.2% and 94.4% of the contact pressures on the coracoid graft relative to the native glenoid with glenoid width restored to 110%, 100%, 90% and 80%, respectively. Conclusions: There is an increase in anterior humeral head translation and contact pressure on the coracoid graft when 90% or less of the native glenoid width is restored with Latarjet. By determining the goals for glenoid width restoration after Latarjet, the findings of this study may provide guidance for patient-specific size requirements for the coracoid based on preoperative imaging. When greater than 90% of glenoid width cannot be restored with a Latarjet, surgeons may consider alternative graft sources. [ABSTRACT FROM AUTHOR]

Objectives: Medial ulnar collateral ligament (UCL) repair utilization is increasing in recent years, bolstered by shorter rehabilitation and satisfactory clinical outcomes. While previous literature has illustrated the importance of tunnel position on restoring graft isometry in UCL reconstruction, there remains a paucity of literature guiding anchor placement in UCL repair. Herein, we describe a 3-dimensional (3D) elbow model to measure and optimize anchor location during UCL repair. Methods: A 3D computer model of a human elbow joint was created using CT and MRI images from a single patient. The humeral and ulnar attachments of the UCL were plotted using three distinct methodologies: 1) geometric cloud mapping; 2) quantitative measurements as described by the anatomical studies by Camp et al1; and 3) Frangiamore et al2. A 3.5mm-diameter clockface was placed on each attachment site which allowed for simulation of 12 distinct, 1.75mm deviations in anchor position. The three elbow models were then ranged through 0-120 degrees of flexion at 10-degree increments, and the 3D distances were measured between the two ligament centroids. The humeral and ulnar anchors were sequentially repositioned around the clockfaces, and ligament lengths were again measured to evaluate changes in isometry. An independent t-test was performed to determine if there was a significant difference in isometry between the humeral or ulnar anchor deviations. Results: Using method 1, the UCL length at 90 degrees of elbow flexion was 26.8mm. This ligament underwent 13.6mm of total excursion for a 46.4% change in length throughout arc of motion. Method 2 produced a 19.3mm ligament that underwent 0.8mm of excursion for a 3.9% length change throughout the arc. Method 3 produced a 24.5mm ligament that underwent 2.3mm of excursion for a 9.4% length change throughout arc. Identifying ligament footprints using the quantitative anatomical measurements as described by Camp et al1 and Frangiamore et al2 produced better ligament isometry through 120 degrees of flexion (ligament length changes of 3.9% and 9.4%, respectively) when compared to using the geometric cloud technique (46.4% length change). Humeral anchor deviations produced a statistically significant increase in ligament excursion when compared to ulnar anchor deviations (p < 0.001). Conclusions: When performing UCL repair, small deviations in humeral anchor position may significantly influence graft and ligament isometry. Anchor position was most isometric while using the quantitative measurements as described in Camp et al1. Particularly when addressing detachments of the humeral footprint, surgeons should be critical of the humeral anchor position in order to restore native anatomy and optimal biomechanics. [ABSTRACT FROM AUTHOR]

Objectives: The effect of platelet-rich plasma (PRP) treatment on recovery in acute hamstring injuries is controversial. Previous study results are inconsistent, and a standardized therapeutic approach has not been established yet. The objective of the study was to assess the treatment effect using a combination of hematoma aspiration and muscle strain PRP injection in partial hamstring muscle tears (grade 2 strains) in athletes. Methods: MRIs of athletes with grade 2 hamstring strains were reviewed from 2013 to 2018. From 2013 to 2015 athletes were treated conservatively and from 2016 to 2018 with a combination of ultrasound-guided hematoma aspiration and PRP muscle strain injection. The outcome, including return-to-play (in days) and recurrence rate, was compared retrospectively between both groups (conservative vs. aspiration/PRP) using ANOVA and Fisher's Exact test. There was no significant difference in age, type of sport, and muscle involvement (including injury grade/location, hamstring muscle type, and length/cross-sectional area of the strain). Results: Fifty-five athletes (28 treated conservatively, 27 with hematoma aspiration/PRP injection) were included. Average return-to-play time (mean) was 32.4 days in the conservative group and 23.5 days in the aspiration/PRP group (p<0.001). Recurrence rate of the hamstring strain was 28.6% (8/28) in the conservative treatment group and less than 4% (1/27) in the aspiration/PRP group (p=0.025). Conclusions: Athletes with grade 2 hamstring strains treated with a combination of hematoma aspiration and PRP injection had a significantly shorter return-to-play and a lower recurrence rate compared to athletes receiving conservative treatment. Axial T2-weighted fat saturated image in a 24-year-old athlete shows a grade 2 strain of the biceps femoris muscle with hemorrhage/hematoma (dashed arrow) surrounding the sciatic nerve (solid arrow). Corona STIR image of the thighs in a 27-year-old athlete with a grade 2 strain of the right biceps femoris muscle shows muscle edema and fluid (solid arrow). A feathery pattern of edema is also present (dashed arrow). Axial/cross-sectional ultrasound image of the right hamstring muscle in a 25-year-old athlete shows a grade 2 strain of the semitendinosus muscle (dashed arrow) and the adjacent normal portion of the muscle (solid arrow). Long axis ultrasound image in the same patient shows hemorrhage/hematoma (solid arrow) surrounding the sciatic nerve (asterisk). [ABSTRACT FROM AUTHOR]

Objectives: The timing for initiation of a throwing program following shoulder or elbow surgery in an overhead throwing athlete is dependent on a variety of factors, including surgical procedure performed, time from surgery, level of competition, and successful progression through a physical therapy program. Determining when it is safe for an athlete to begin a post-surgical throwing program is vitally important to ensure safe return to play, and objective data is often preferred to help accurately make such decisions. However, there is a paucity of objective data available to help guide the decision for the timing of initiation of a throwing program following shoulder and elbow surgery in overhead throwing athletes. Additionally, it is unknown what percentage of athletes typically achieve appropriate objective criteria at the presumed timepoint for initiation of a throwing program. Therefore, the objectives of the current study were the following: 1) to create a reproducible, objective return to throwing protocol, 2) to determine what percentage of post-surgical competitive baseball players successfully satisfied the objective return to throwing criteria at the presumed time of throwing program initiation, and 3) to determine what risk factors were most common in athletes who failed to meet objective criteria for return to throwing. Methods: Patients who were a competitive overhead throwing athlete and who underwent a shoulder or elbow surgery by one of the two senior authors were given the opportunity to perform an objective return to throwing evaluation at the presumed time of clearance by the treating physician. Figure 1 outlines the objective return to throwing criteria with the desired goal for each criterion. Each evaluation was performed by a single physical therapist with extensive experience in rehabilitation of overhead athletes. Patients who successfully accomplished all criteria at the time of evaluation were given a passing grade. Patients who failed the initial objective evaluation were re-tested two weeks later. Surgical procedure, level of play, and reason for failing were recorded for all players. Kinematic variables were compared between patients who passed versus those who failed using a two-tailed student's t-test. Relative odds and risks ratios were assessed for level of play and type of surgery with 95% confidence intervals. Significance was set at p<0.05 for all tests. Results: A total of 48 players were evaluated, and level of play was divided into high school (20 patients), college (19 patients), and professional (8 patients). A total of 36 players (75%) obtained a passing grade at the initial evaluation while 12 players received a failing grade (25%). The distribution of passing grades based on surgery type was the following: arthroscopic shoulder surgery: 4/7 patients, UCL reconstruction: 23/31 patients, UCL repair: 3/3 patients, and other elbow surgery (i.e. ulnar nerve decompression transposition, isolated elbow arthroscopy): 5/6 patients. Level of play, type of surgery, and reason for failing is summarized for all players who received a failing grade (Table 1). All players who failed were retested at two weeks and received a passing grade after focused physical therapy to address any insufficiencies. Players who received a failing grade demonstrated significantly more elbow extension, less dominant arm maximum shoulder internal rotation strength, and less dominant arm maximum shoulder external rotation strength (Table 2). Players with a level of play beyond high school and college each showed an elevated odds ratio and relative risk for receiving a failing grade, yet this did not reach statistical significance. Undergoing ulnar collateral ligament reconstruction demonstrated a trend towards having a smaller odds ratio for a failing grade, but this also did not reach statistical significance (Table 3). Conclusions: The most important finding of the current study is that 25% of competitive baseball players did not pass an objective return to throw evaluation at the time of presumed clearance based on time from surgical procedure and objective in-office evaluation by the treating surgeon. All patients who failed were able to achieve a passing grade two weeks later after directed physical therapy to address all insufficiencies. No specific factor reached statistical significance for increasing the odds ratio or relative risk for receiving a failing grade, though undergoing UCL reconstruction demonstrated an insignificant trend for having a lower risk of failing. Our findings demonstrate that not all competitive baseball players will be objectively ready to throw at the presumed time point following shoulder and elbow surgery, and insufficient shoulder strength and/or endurance was the most common reason for failure. Creating objective criteria to help determine when to start a post-surgical throwing program is a critical step to ensure safe rehabilitation after shoulder and elbow surgery in competitive baseball players. The current study provides a foundation for establishing such objective criteria, and it highlights areas of improvement in rehabilitation protocols. Further research is needed to validate the objective testing protocol and its applicability in a larger population. Figure 1. Checklist for objective return to throwing criteria. To obtain a passing score, the patient must achieve a "Yes" by attaining the minimum goal for each criterion. Table 1. Level of play, surgical procedure, and reason for failing for all patients who received an initial failing grade from objective return to throw testing Table 2. Descriptive statistics for time since surgery and throwing arm joint kinematics and kinetics for all players and within passing/failing groups Table 3. Relative odds and risk ratios for passing the return-to-throw test with respect to noted criteria [ABSTRACT FROM AUTHOR]

Objectives: Though recognized as a risk factor, posterior glenoid bone loss has only recently been characterized and is distinctly different than anterior glenoid bone loss patterns. Existing biomechanical studies are limited by employment of anterior glenoid bone loss models which are different in both orientation and morphology than posterior glenoid bone loss, and testing in a single neutral arm position thus not fully accounting for the contribution of capsuloligamentous structures in various at-risk arm positions. The purpose of this study was to evaluate the biomechanical effectiveness of a posterior labral repair in the setting of a clinically relevant bone loss model using 3-dimensional computed tomography modeling of patients with recurrent posterior shoulder instability in various at-risk arm positions. Methods: Ten fresh-frozen cadaveric shoulders (mean age: 55.4 years, range: 39-65) were prepared by removing all tissue except the capsule and distal rotator cuff insertions. A joint coordinate frame was established, the specimens were potted, then mounted to a customized fixture on 6-degrees-of-freedom robotic arm. A posterior labral tear was created, then repaired with 3 horizontal mattress sutures and secured by drilling 6 transosseous holes along the peripheral glenoid face exiting the anterior glenoid neck. The sutures were secured for the labral repair states to the mounted fixture under maximal tension and released for the labral tear states and for creating the sequential bone loss models. Bone loss models were created based off a cohort of CT data on patients undergoing revision posterior labral repair surgery to develop 2 clinically relevant 3D models of glenoid bone loss: the first simulating the mean bone loss in this cohort and represented 7% or small bone loss; the second was the mean + 2SD representing 28% or large bone loss. The bone loss was created on each specimen with a 3mm round burr to match each respective 3D printed template (Figure 1). Each specimen was tested in 7 consecutive states: (1) native anatomy, (2) posterior labral tear (6-9 o'clock), (3) posterior labral repair, (4) mean posterior glenoid bone loss with labral tear, (5) mean posterior glenoid bone loss with labral repair, (6) large posterior glenoid bone loss with labral tear, and (7) large posterior glenoid bone loss with labral repair. Each state underwent 75N of posterior-inferior force and 75N of compression during the four tests at 60 and 90 degrees of flexion and 60 and 90 degrees of scaption. Posterior-inferior translation, lateral translation, and dislocation force were measured for each condition. Statistical analysis was performed using two-factor random-intercepts linear mixed-effects models. Results: Compared to the labral tear state, significant increases in dislocation forces occurred with labral repair independent of bone loss state or arm position with values as follows: 14.8N (60° scaption), 12.2N (90° scaption), 11.1N (60° flexion), and 10.1N (90° flexion) with mean 12.1 ± 2.0N across all arm positions (Figure 2). Dislocation force significantly decreased between no bone loss and small bone loss (mean 12.4 ± 0.7N) and between small bone loss and large bone loss (mean 11.8 ± 2.1N) regardless of labral state in all arm positions (table 1). Posterior-inferior translation significantly decreased with labral repair compared to labral tear states independent of bone loss state in all arm positions (Table 1). Lateral translation of the humeral head significant increased when the labrum was repaired independent of bone loss state in all arm positions except 90° scaption and decreased progressively in all bone loss states in all arm positions (table 1). In the native state, the shoulder significantly translated posterior-inferior in scaption at 60° and 90° elevation compared to flexion (p<0.017) and was most unstable in 60° scaption with 29.9 ± 6.1mm posterior-inferior translation (Figure 3). Conclusions: This is the first study to biomechanically evaluate posterior glenoid bone loss using a clinical model in various at-risk arm positions on a 6 degree-of-freedom robot and through a precise linear effects model has established values for the increase in dislocation force posterior labral repair provides regardless of bone loss. The most significant finding of the study is that independent of bone loss, labral repair reduced posterior dislocation forces by 12.1 ± 2.0N and significantly decreased posterior-inferior translation. With a mean decrease in dislocation force of 12.4 ± 0.7N with small (7%) bone loss, labral repair alone may be enough to restore shoulder stability in most individuals. However, significant increases in posterior bone loss may require bony augmentation for adequate stability based on individual factors such as age and activity level. Table 1. Summary of statistically significance among modeled effects for labrum state and bone loss state. Separate linear mixed-effects models were constructed for each combination shoulder position, elevation and measurement. Numeric results reflect the estimated effect of moving from State A -> State B, as indicated in the column header. Up arrows indicate an increasing effect in the measure of interest, while down arrows indicate a decreasing effect, n.s. represents not statistically significant. Figure 2. Bar plots indicating mean and standard deviation values, stratified by shoulder position, elevation, and experimental status of the labrum and glenoid bone loss. Figure 3. Linear mixed-effects model estimates for shoulder position and elevation upon posterior inferior translation among native shoulders. [ABSTRACT FROM AUTHOR]

Objectives: The deltoid ligament is frequently ruptured in association with ankle fractures and syndesmotic injuries. Despite the frequency of this ligamentous injury, surgical repair is not the current practice due to the belief that non-weightbearing during fracture recovery allows for adequate healing. However, conservative management has shown poor outcomes both acutely and over time with the development of arthritis. The contribution of the anterior and posterior bundles of the deltoid ligament to the stability of the ankle remains unknown, as does the effect of deltoid repair versus repair with augmentation. To determine the biomechanical role of the native anterior and posterior deltoid ligament in ankle stability and to determine the efficacy of simple suture vs augmented repair of each bundle. It was hypothesized that sectioning of the anterior and posterior deltoid ligaments would significantly increase ankle laxity in eversion, external rotation and anterior translation, repairing the anterior and posterior deltoid ligaments using suture anchors would significantly reduce ankle laxity compared to the sectioned states, and augmenting the repairs with an Internal Brace would further reduce ankle laxity compared to the suture anchor repair. Methods: Ten cadaveric ankles (50.9 mean age, male) were dissected free of soft tissue superficial to the medial ligamentous structures and mounted on a six-degrees-of-freedom robotic arm. The specimens underwent biomechanical testing in eight sequential states: 1) intact, 2) anterior deltoid cut, 3) anterior repair, 4) internal brace tibio-spring augmentation 5) internal brace tibio-calcaneal augmentation, 6) posterior deltoid cut, 7) posterior repair, 8) complete deltoid cut). Biomechanical testing consisted of three tests: 1) Anterior drawer 88 N, 2) Eversion 5 Nm, 3) External rotation 5 Nm, each run at 0° and 25° of plantarflexion under 100 N of joint compression. Anterior translation (mm) eversion (deg), external rotation (deg), were measured for each associated motion. A 1-factor random-intercepts linear mixed effect model was created for each test, and all pairwise comparisons were made between testing states, adjusting for multiple comparisons using Tukey's method. Results: The complete deltoid cut state had significantly higher anterior translation, eversion, and external rotation at 0⁰ and 25⁰ of plantar flexion compared to all other states (+8.6mm ATT p=0.01-9, +34.1⁰ Eversion p=0.01-9, +14.7⁰ p=0.01-9 ER compared to native at 0⁰ plantar flexion, respectively). The anterior Deltoid cut showed a significant increase in eversion at 25⁰ of plantarflexion compared to the native state (+6.65⁰ P=0.0007). The anterior deltoid repair alone showed no significant decrease from the anterior deltoid cut, however both augmented anterior repairs showed significant decreases in eversion (-5.1⁰, p=0.023; -5.0, p=0.026, respectively). No other significant differences were observed between any states. Conclusions: The most important finding of this study was that the complete deltoid tear caused major ankle instability in anterior translation, external rotation and eversion. Therefore, deltoid repair is strongly recommended in the clinical setting of a complete tear. The anterior deltoid tear alone caused significant eversion instability at 25⁰ of plantarflexion, which was significantly reduced by the first augmented repair, the addition of a second augmentation showed no additional benefit over a single augmentation. Cutting the posterior deltoid in the setting of an augmented anterior repair showed no effect on ankle kinematics, therefore an augmented anterior repair can be seen a sufficient to stabilize a complete deltoid tear. Our findings suggest that surgeons may need to reconsider non-operative treatment on complete anterior deltoid injuries and that repair with augmentation offers superior stability. Figure 1. * is significantly different from all cut, # is significantly different from negative, $ is significantly different from anterior deltoid cut Figure 2. Location of augmented repairs. Figure 3. Setup. [ABSTRACT FROM AUTHOR]

Objectives: To describe demographic and presenting clinical characteristics, diagnostic features, treatment approaches, and clinical outcomes of adolescent tarsal navicular BSI's. Methods: A retrospective chart review of patients with tarsal navicular BSIs was performed at eight academic centers. Diagnosis was confirmed by radiologic imaging in all cases. The following variables were collected utilizing a REDCap database and analyzed with basic descriptive and comparative statistics: age, sex, primary sport, physical exam (PE) findings, diagnostic imaging modality, treatment modalities, surgical technique (when applicable), time of protected weight-bearing, time to running, and time to return to sport. Results: 110 patients (mean age: 14.7 years +/-2.7 years; 65% female) met inclusion criteria, 103 (94%) of whom reported a primary sport, most commonly cross country/track and field (33%) and gymnastics/dance (27%). Common PE findings included navicular tenderness (96%), pain with walking (89%), and pain with resisted inversion (55%). Both x-ray and MRI were obtained in the majority of patients (91%), while CT was obtained for 30%. A radiologically detectable fracture line was present in 44%, most commonly on the dorsal navicular cortex. Non-operative treatment was successful in 85% of patients, consisting of protective boot (79%) or cast (21%). Operative treatment was pursued for 15% of patients, with 73% treated with open reduction internal fixation and 27% undergoing percutaneous screw fixation. All operative patients underwent fixation with either 1 (50%) or 2 screws (50%). Bone grafting was performed in 5 patients (31%). Significant differences between non-operative and operative cohorts included presence of fracture line (38% vs. 88%, P<0.001), age (14.3 years vs. 17.1, P<0.001), time of protected weightbearing (7 weeks vs 10 weeks, P=0.012), time to running (12 weeks vs 18 weeks, P=0.001), and time to return to sport (14 weeks vs 20 weeks, P=0.001). Conclusions: Adolescent tarsal navicular BSIs occur most commonly in sports involving repetitive loading, such as cross country, track and field, gymnastics, and dance. The most common PE findings are navicular tenderness to palpation, pain with walking, and pain with resisted inversion. Patients that ultimately require surgical treatment were more likely to have a radiologic fracture line, prolonged return to weightbearing, running and sport than those successfully treated non-operatively. Table 1: Total Cohort Demographics of patients with bone stress injury to the tarsal navicular bone from eight institutions across the United States from 2013 to 2021 Table 2: Demographic and clinical characteristics of non-operative vs. operative patients with tarsal navicular bone stress injuries from eight institutions across the United States from 2013 to 2021 [ABSTRACT FROM AUTHOR]

Objectives: Few studies have examined the viability of the quadriceps tendon autograft as a revision graft option following failed primary bone-patellar tendon-bone (PT) autograft reconstruction. Potential concerns include further disruption to the knee extensor mechanism, inhibition of the quadriceps muscle, and increased complication and reinjury rates. The purpose of this study was to assess knee extension strength, functional outcomes, patient reported outcomes, and return to play after revision ACL reconstruction using free quadriceps tendon autograft after a failed primary reconstruction using bone-patellar tendon-bone (PT) autograft. Methods: A retrospective case series was conducted in accordance with Strengthening the Reporting of OBservational Studies in Epidemiology (STROBE) guidelines using a prospective single surgeon ACL database (n = 1,514) that included 48 patients receiving revision ACL reconstruction using free QT autograft after failure of primary PT autograft ACL reconstruction from 2015-2019. Exclusion criteria are listed in Figure 1, and included ages <15 years or > 55 years, bi-cruciate ligament injuries, and meniscal allograft transplant. Baseline patient demographics and surgical variables were collected and included preinjury level of function (Marx Score). Functional and self-reported outcomes were obtained at the time of return to play and consisted of: single-leg squat symmetry, hip abduction strength, single-leg hop tests, agility testing, and isokinetic knee extension strength (60°, 180°, and 300°/sec). Self-reported outcomes at the time of return to play included the International Knee Disability Committee (IKDC-2000) scale and Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) psychological readiness survey. Return to play was defined as the time (mo) required to reach a threshold of 90% limb symmetry on objective functional testing compared to the contralateral extremity and ultimately, the surgeon's discretion. Injury and complication surveillance was conducted for 2-years postoperatively, and patients were contacted via email or phone survey at 24-months to obtain functional status and single answer numeric evaluation (SANE) scores. Descriptive statistics were calculated using SPSS (version 26, IBM Inc, NY, USA). Results: Baseline patient demographics are listed in Table 1 for the 48 patients (mean age 23.9 ±9.5 years; 14/34 female/male) enrolled in the study. Isokinetic knee extension strength was 84.3 ±17.1% at 60°/sec, 88.6 ±16.4% at 180°/sec, and 92.0 ±19.5% at 300°/sec. The mean knee function SANE score at 2-years was 88.9 ±12.2%. All patients went through return to play testing prior to returning to sport. The mean time to return to play was 8.9 ±1.8 mo, and the mean 24-month assessment was conducted at 24.6 ±2.3 mo. Limb symmetry index scores ranged from 94.1%-102.6% across all objective functional tests (Table 2), and self-reported knee function via the IKDC-2000 was 86.3±16.8. Three patients were lost to follow up (6.3%) at 2-years, and of the 45 patients remaining in the study, 3 sustained graft reinjuries (6.7%). Two-year complications are listed in Table 3, and included meniscal tear (2.2%), DVT (4.4%), loss of motion requiring surgical lysis of adhesions (4.4%), anterior knee pain (11.1%), and symptomatic removal of hardware (2.2%). Conclusions: Free quadriceps tendon autograft is a viable autograft option for revision ACL reconstruction for failed PT autograft allowing return to high function without compromising knee extension strength with a low failure and complication rate. Two-year graft reinjury rates for revision ACL reconstruction with free QT autograft are similar or favorable to other autograft options previously reported in the literature in a revision setting. Additionally, functional outcomes are comparable to revision reconstructions using PT autograft and good to excellent outcomes can be obtained Table 1. Patient Demographics Fig 1. Study Design Table 2. Level of Return to Sport Table 3. Return to Play Functional Performance Outcomes [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study is to evaluate the potential analgesic effects of buccal-absorbed cannabidiol (CBD) in patients that have undergone arthroscopic rotator cuff repair (ARCR). Methods: This is an FDA sanctioned, multi-center, placebo-controlled, randomized, double-blinded trial conducted in patients undergoing ARCR. Patients from 18 to 75 years of age undergoing an ARCR were prospectively enrolled. Patients were equally randomized to the control and experimental groups. The experimental group post-operatively received 25mg of CBD (Oravexx, Orcosa Pharmaceuticals, USA) TID if < 80kg and 50mg of CBD TID if > 80kg for 14 days, with control groups receiving an identical placebo. Patients were followed-up on Day 1, 2, 7, and 14, and Visual Analog Scale (VAS) for pain, opioid consumption, and satisfaction with pain control were recorded. Additionally, liver function tests (LFT) were done on Days 7 and 14 to assess safety, and nausea was monitored. A priori power analysis was performed based on the VAS score as primary endpoint, which revealed that a minimum of 39 patients would be required in each group to detect a clinically important difference in the VAS score (1.4) with a power of 0.8. A value of p < 0.05 was considered to be statistically significant. Results: Overall, 80 patients were recruited. There were no significant differences in age, sex, or BMI between the two groups. On Day 1, VAS pain score was significantly lower in those receiving CBD (4.1 ± 3.0 vs 6.0 ± 3.1, p = 0.01), which also meets VAS MCID for shoulder arthroscopy (1.2-1.4). Patient satisfaction with pain control trended towards significance favoring the CBD group (72% vs 60%, p = 0.072). However, there were no statistically significant differences in opioid consumption (16.4mme ± 12.7 vs 20.6mme ± 14.4, p = 0.186), which was relatively small in both groups. Notably, patients receiving 50 mg of CBD reported lower VAS scores at day 1 (3.9 ± 3.3 vs 4.6 ±2.5 ± 6.0 ± 3.1, p = 0.0394) and higher satisfaction with pain control at day 1 and 2 (8.1 ± 2.3, 5.8 ± 3.3, 5.9 vs 3.6, p = 0.0175 | 7.8 ± 1.8 vs 6.3 ± 3.0 6.0 ± 3.2, p = 0.05) compared to those receiving 25 mg of CBD and control group respectively. On Day 7 and Day 14, there were no statistically significant differences in VAS score, opioid consumption, or patient satisfaction with pain control (p>0.05 for all). There were no significant differences in nausea or LFTs post-operatively (p > 0.05). Conclusions: CBD is safe and effective in reducing pain in the immediate peri-operative period following ARCR and should be considered in post-operative multimodal pain control. Table 1. Summary of Major Kinematic Effects for LMORT Lesions and Repairs [ABSTRACT FROM AUTHOR]

Objectives: Distal biceps tendon tears, although rare, significantly impair patient's elbow mobility and function. There is a paucity of literature reporting outcomes of partial thickness tears to inform management strategies. Therefore, the authors sought to identify magnetic resonance imaging (MRI) confirmed partial thickness distal biceps tears and report on (1) demographics and treatment strategies, (2) outcomes and complications, and (3) any identifiable risk factors for progression to surgery or full thickness tear. Methods: Patients who experienced a partial thickness distal biceps tear confirmed on MRI from 1996 to 2016 were identified by a musculoskeletal radiologist through an institutional image database. Patients were included if they had complete medical records and at least one visit of clinical follow-up. Patients with inflammatory arthritis and enthesitis, polytrauma, or incidental findings without clinical assessment were excluded. Medical records were reviewed to confirm the diagnosis and obtain study details. Multivariate logistic regression models were created using baseline characteristics, injury details and physical exam findings in order to predict operative intervention. Results: Overall, 111 patients (22F, 89M, age: 53.6 years ± 13) were identified and included. Baseline injury characteristics and patient demographics including weakness in elbow flexion, forearm supination, and patient reported sensation at time of injury were all found to be statistically different between treatment groups (Table 1). Patients were followed to a mean of 10 years of clinical follow up. Within the cohort, 57 patients were treated non-operatively, while 54 were treated operatively. Patients who received surgical intervention were more likely to report missing time from work and greater loss of productivity due to missed time (Table 2); however, almost 90% of patients returned to work without restrictions, regardless of treatment modality (88% vs 88%, Table 2). For surgical patients, there were 5 re-operations (9%), 3 re-ruptures (6%), and overall, 31% of the operatively treated cohort experienced a complication. Results of the final multivariate logistic regression model are included in Table 3; final model variables included age at initial consult, tenderness to palpation tendon insertion on exam, and supination weakness. Of these, s upination weakness at initial consult was found to be a statistically significant predictor for surgical intervention (p=.001, OR=24.8). Conclusions: Operative patients tended to be male with more profound supination weakness; these patients tended to report increased loss of productivity due to time missed after treatment. At 10 year clinical follow up 31% experienced some complication and 9% underwent a re-operation. However, patients demonstrated uniform ability to return to work without modification and no statistical differences in functional outcomes, regardless of treatment modality. Patients who suffer from a partial distal biceps tear should be counseled that operative management represents a balance of returning function with potential complications and increased loss of productivity. Table 1. Cohort Baseline Characteristics Table 2. Operative and Nonoperative Outcomes Table 3. Multivariate Logistic Regression Model Identifies Risk Factors for Progression to Surgery [ABSTRACT FROM AUTHOR]

Objectives: Microfracture (MFx) technique is the most commonly used first-line treatment for cartilage injuries; however, it has been shown to have inferior long-term clinical outcomes as the repaired tissue is predominantly fibrocartilage. Bone Marrow Aspirate Concentrate (BMAC) treatment has been shown to enhance the healing ability of cartilage repair, superior to MFx treatment alone, although chondral defect filling was achieved with fibrocartilage or "hyaline-like" cartilage. Therefore, new therapeutic strategies to further improve cartilage healing following defects are in need. Fisetin (FIS) is a compound with antioxidant, anti-inflammatory, and senolytic activity capable of eliminating senescent cells systemically. Previous studies have reported that FIS attenuates the progression of osteoarthritis and osteoporosis in aged mice, however, whether FIS treatment improves the quality of repaired cartilage in MFx-treated acute osteochondral defects augmented with BMAC has not yet been investigated. We hypothesized that FIS or autologous BMAC, or a combination of the two, would enhance MFx procedure both histologically and mechanically in the repair of osteochondral defects in a rabbit model. Methods: All surgical procedures were performed by an experienced orthopaedic surgeon and followed Institutional IACUC approved protocols. Sixty-four skeletally mature New Zealand White rabbits at seven months old were used in this study. Animal procedure: Before surgery, bone marrow aspirate was collected through the iliac crests in each rabbit under anesthesia and processed via a two-step centrifugation method to prepare BMAC. After exposing the bilateral knee joints through the medial parapatellar approach, osteochondral defects (diameter: 5 mm, depth: 2 mm) were created bilaterally in the patellar groove of each rabbit, followed by the MFx procedure (5 holes with 2 mm depth) to allow bleeding at each MFx hole as previously described (Fig.1). BMACs were injected into the left knee joint as an autograft immediately after closing the joint capsule in all rabbits, with the right knee as a control (no BMAC transplantation). Rabbits were then randomly divided into 4 groups (N=8/group): MFx alone, MFx+FIS, MFx+BMAC and MFx+FIS+BMAC. FIS-treated rabbits were given FIS orally via drinking water at a dose of 20 mg/kg/day daily from immediately after surgery until euthanasia. Rabbits were sacrificed at 6 and 12 weeks post-op. The macroscopic appearance was evaluated using the International Cartilage Repair Society (ICRS) macroscopic assessment grading. ΜicroCT and histology: Microcomputed tomography (μCT) was performed to evaluate subchondral bone healing. Cartilage healing was assessed histologically on de-calcified tissue at 6 and 12 weeks post-op (H&E, Safranin O, and Alcian blue) and with immunohistochemistry for collagen II and p16. Regenerated cartilage was scored using the Modified O'Driscoll ICRS grading system (max 27 points). Biomechanical tests: The strength of the regenerated cartilage was analyzed by measuring the instantaneous elastic modulus of the regenerated cartilage in each group of samples collected at 12 weeks. (N=6/group). Results: Macroscopic assessment and μCT : At both 6 and 12 weeks postoperatively, MFx+BMAC and MFx+FIS+BMAC groups scored significantly higher than MFx alone group in the ICRS macroscopic evaluation. (p < 0.01, Fig. 2 A, D and Fig. 3 A, D). At both 6- and 12-week time points after surgery, μCT showed favorable healing of the bone defect in MFx+FIS, MFx+BMAC, and MFx+FIS+BMAC groups compared to MFx alone group. (Fig. 2 B and Fig. 3 B). Histology : At both 6- and 12- week time points, the Modified O'Driscoll score was significantly higher in the MFx+BMAC and MFx+FIS+BMAC groups than in the MFx alone group (p <0.01), and at 12 weeks, the MFx+FIS group had a significantly higher score than the MFx alone group. (p <0.05, Fig. 2E and Fig. 3E). In addition, immunohistochemistry showed stronger staining of type II collagen (brown) in the MFx+FIS, MFx+BMAC, and MFx+FIS+BMAC groups than in the MFx alone group at both time points, with a stronger reduction in staining of the cellular senescence marker p16 (brown) in FIS-treated group compared to MFx alone or MFx+BMAC group. (Fig. 2C and Fig. 3C). Biomechanical analysis: The instantaneous elastic modulus (cartilage's strength) was significantly increased in the MFx+FIS+BMAC group compared to MFx alone group. (p < 0.05, Fig. 4). Gene expression analyses : qPCR showed the expression level of SOD1 in synovium was significantly higher in the MFx+FIS group at 6 weeks (p < 0.01) and in the MFx+FIS+BMAC group at 12 weeks (p < 0.05) compared to the MFx alone group. Conclusions: Our results showed that BMAC treatment enhanced the healing of MFx-treated osteochondral defects, macroscopically, biomechanically, and histologically, compared to MFx alone. Furthermore, FIS treatment improved MFx-treated cartilage repair, and its combined use with BMAC led to significantly higher quality cartilage regeneration with stronger mechanical properties. Oxidative stress, which is one of the inducers of cell senescence, has been noted as the primary factor contributing to age-related changes in cartilage homeostasis, function, and response to injury. Given the increase in SOD1 expression commensurate with p16 reduction in the FIS-treated group (Figs 2-3), our results suggest that FIS may improve cartilage healing via reducing cellular senescence. These results support the clinical use of FIS combined with BMAC to enhance the effect of MFx in the repair of osteochondral defects and highlight cellular senescence as a novel therapeutic target for cartilage repair following injury. Figure 1: Acute osteochondral defect microfracture rabbit model Figure 2: Macroscopy, MicroCT, and Histological findings at 6 weeks postoperatively A: Macroscopic findings. B: Micro CT showed better subchondral bone healing in the MFx+FIS, MFx+BMAC, and MFx+FIS+BMAC group. C: In the MFx+BMAC and MFx+FIS+BMAC groups, the ICRS macroscopic score was significantly increased compared to the MFx alone group. (D) In the MFx+BMAC and MFx+FIS+BMAC groups, the Modified O'Driscoll score increased significantly compared to the MFx alone group (E), indicating primarily hyaline-like cartilage regeneration. In addition, strong staining of type II collagen was observed in the MFx+FIS+BMAC groups, and there was a strong decrease in p16 (cellular senescence marker) staining in the FIS-treated group. * p <.05, ** p <.01. Figure 3: Macroscopy, MicroCT, and Histological findings at 12 weeks postoperatively A: Macroscopic findings. B: Micro CT showed better subchondral bone healing in the MFx+FIS, MFx+BMAC, and MFx+FIS+BMAC group. C: In the MFx+BMAC and MFx+FIS+BMAC groups, the ICRS macroscopic score was significantly increased compared to the MFx alone group. (D) In the MFx+FIS, MFx+BMAC, and MFx+FIS+BMAC groups, the Modified O'Driscoll score increased significantly compared to the MFx alone group (E), indicating primarily hyaline-like cartilage regeneration. In addition, strong staining of type II collagen was observed in the MFx+FIS, MFx+BMAC, and MFx+FIS+BMAC groups, and there was a strong decrease in p16 (cellular senescence marker) staining in the FIS-treated group. * p <.05, * * p <.01. Figure 4: Biomechanical findings at 12 weeks postoperatively Instantaneous elastic modulus (cartilage's strength) measurements for each group are shown, with a significant increase in the MFx+FIS+BMAC group compared to MFx alone group. * * P <.05 [ABSTRACT FROM AUTHOR]

Objectives: Patients with anterior cruciate ligament (ACL) injury are at high risk for the development of post-traumatic osteoarthritis (PTOA), despite ACL reconstruction (ACLR). ACL injuries are frequently associated with damage of other structures within the knee, such as the meniscus. The meniscus is an important structure that provides protection for articular cartilage and stabilization of the joint. Long-term studies of PTOA after ACLR mainly used radiographs. Conventional magnetic resonance imaging (MRI) has been used in a limited number of studies to evaluate structural damages, but this only provides information on morphologic changes that occur at relatively late stages of the disease. In this study, we aim to use quantitative MRI (qMRI) to evaluate cartilage and meniscus degeneration in patients at 10 years after ACLR. Methods: This is a multi-site multi-vendor study that involves three sites and two MR platforms (Siemens 3T and Philips 3T). MRI protocols have been harmonized between sites and cross validation data were collected using phantoms. The patients are from a nested cohort within Multicenter Orthopaedic Outcomes Network (MOON) Onsite Cohort at 10 years after ACLR. Inclusion/Exclusion criteria were: 22-50 years old; ACL tear during a sport; no previous knee injury; no graft rupture during follow-up. In this preliminary report, 51 patients (age 32.8 ± 6.4 years; 25 females; body mass index [BMI] 25.7 ± 5.7 kg/m2; 40 hamstring autograft, 9 bone-patellar tendon-bone autograft, and 2 allograft) and 17 healthy control participants (age 30.8 ± 7.8 years; 10 females; BMI 23.8 ± 5.6 kg/m2) were studied. The MRI protocol included high-resolution Dual-Echo Steady State (DESS), and combined gradient echo MAPSS T1ρ and T2 mapping. Cartilage and meniscus were automatically segmented on DESS images using an in-house developed deep-learning model into medial/lateral femoral condyle (MFC/LFC), medial/lateral tibia (MT/LT), trochlear (TRO), and patellar cartilage (PAT), and medial and lateral menisci (MM/LM). Each cartilage compartment was further divided into sub-regions based on a modified MRI Osteoarthritis Knee Score (MOAKS) definition: central and posterior for MFC/LMC (cMFC/cLMC, pMFC/pLMC); anterior, central, and posterior for MT/LT (aMT/aLT, cMT/cLT, pMT/pLT); medial, central, and lateral for PAT/TRO (mPAT/mTRO, cPAT/cTRO, lPAT/lTRO). Menisci were further divided into anterior horn (aMM, aLM), central (body) (cMM, cLM), and posterior horn (pMM, pLM) subregions. These cartilage and menisci subregions were then transformed and overlaid onto the T1ρ and T2 parameter maps after co-registering the DESS image to the first echo of the 3D MAPSS sequence using the Elastix toolbox. T1ρ and T2 parameter maps were obtained by a voxel-wise two-parameter monoexponential fitting. The mean and standard deviation for each subregion was recorded and compared between three knee groups: operated and contralateral knees from patients, and control knees from healthy controls, using a mixed-effects regression model, adjusted for age, sex, and BMI. Results: For cartilage, compared to contralateral knees, operated knees in patients had significantly higher T1ρ and T2 values in MFC, MT, and TRO compartments. Looking into subcompartments, for MFC, MT, and TRO, most of the subcompartments (cMFC, pMFC; cMT, pMT; mTRO, cTRO) showed significantly higher T1ρ and T2 values compared to contralateral knees. For LFC and LT, only the posterior subcompartments showed significantly higher T1ρ and T2 values compared to contralateral knees. For PAT, no significant differences were observed between operated and contralateral knees. Compared to healthy control knees, operated knees in patients had significantly higher T1ρ and T2 values in all the six compartments. Besides, contralateral knees also showed higher T1ρ and T2 values in LFC, LT and PAT compartments compared to healthy control knees (Figure 1 for T1ρ, T2 with similar trend was not shown). For meniscus, no significant differences in T1ρ and T2 values were observed between injured and contralateral knees. Compared to healthy control knees, both operated and contralateral knees in patients had significantly higher T1ρ values in LM and significantly higher T2 values in MM (Figure 2). Conclusions: Cartilage T1ρ and T2 values were higher in operated knees compared to contralateral knees at 10 years after ACLR, except for patellar compartment. In patellar cartilage, no significant differences were observed between sides in patients, but both sides were significantly higher than control knees. Our data showed that contralateral knees after ACLR may not represent 'healthy controls' as there might be compensatory changes and early degeneration in contralateral knees as a result of injury and surgery to their other knee. Although we observed this general trend of higher cartilage T1ρ and T2 values in the operated knees compared to contralateral knees, no significant differences were observed in meniscus T1ρ and T2 values between sides in patients, suggesting the timing of cartilage and meniscus degeneration may be different for patients after ACLR. Meniscus T1ρ and T2 values in both sides are higher than control knees, suggesting early degeneration in meniscus in patients in both sides. The results will be confirmed with more patient data being collected in the ongoing study. The relationship between qMRI, morphological tissue changes, and patient-reported outcomes after ACLR will also be evaluated in future work. Figure 1. T1p comparisons of cartilage among operated, contralateral, and healthy control knees. *P < 0.05, **P < 0.01. ***P < 0.001. Figure 2. T1p and T2 comparisons of menisci among operated, contralateral, and healthy control knees. *P < 0.05. **P < 0.01. ***P < 0.001. [ABSTRACT FROM AUTHOR]

Objectives: There has been a hesitation by surgeons to operate on shoulder instability patients with maladaptive psychopathological traits, especially those with volitional instability, as these may portend a poor prognosis. The purpose of this study was to investigate the prevalence of maladaptive psychopathological traits, volitional instability, and their effect on two-year outcomes in patients undergoing shoulder stabilization surgery. Methods: A prospective multi-center cohort study led by the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group targeted all subjects having surgical shoulder stabilization and collected patient-reported outcomes at baseline and at two years postoperatively. Psychopathological traits were assessed using the Personality Assessment Screener (PAS), a validated personality assessment tool. Longitudinal analyses were performed using multivariable regression models to determine predictors of two-year outcomes adjusting for confounders measured at index such as age, sex, smoking, BMI, volitional instability, and intraarticular pathology. Results: The cohort (n = 890) was 80% male with a median age of 21.5 years. The prevalence of psychopathological traits was 20%. While all patients improved between baseline and 2 years, with adjusted analyses, the presence of maladaptive psychological traits present at the time of index surgery were predictive of lower WOSI (p = 0.001), ASES (p = 0.016), SANE (p = 0.03), and SF-36 MCS (p = 0.001) scores as well as a higher risk of failure (p = 0.04) at two years. As a main effect, volitional instability was not a predictor of WOSI, ASES, SANE, SF-36 or failure at two years. However, all models allowed for the interaction between volitional instability and the PAS, and this interaction was significant for WOSI (p = 0.006), SANE (p = 0.03), and SF-36 MCS (p = 0.003) scores at two years. In other words, the effect of volitional instability on the WOSI, SANE, and SF-36 MCS scores depends on the value of the PAS, and with high PAS scores it is associated with worse outcomes. This data is depicted in Figures 1-3. Conclusions: While all patients improved, the presence of maladaptive psychopathological traits at the time of index surgery was a predictor of poorer outcomes at two years. Voluntary dislocators did similarly as non-voluntary dislocators up to a PAS score of ˜ 20, where above this they had worse WOSI, SANE, SF-36 MCS and higher failure rates at 2 years post-operatively. Figure 1. Adjusted effects of PAS score and volitional instability on WOSI score at 2 years Figure 2. Adjusted effects of PAS score and volitional instability by gender on predicted MCS Score at two years Figure 3. Adjusted effects of PAS score and volitional instability on probability of failure [ABSTRACT FROM AUTHOR]

Objectives: Recent studies suggest that similar results can be achieved via arthroscopic and open biceps tenodesis techniques. The purpose of this investigation was to quantify and compare the behavior of the biceps tenodesis construct in arthroscopic suprapectoral (ASPBT) and open subpectoral (OSPBT) techniques performed with either interference screw or suture anchor fixation, with radiostereometric analysis (RSA). Methods: A prospective cohort study was performed comparing migration of the biceps tendon after suprapectoral and subpectoral biceps tenodesis (BT) with Polyetheretherketone (PEEK) interference screw vs. all-suture suture anchor (ASSA) fixation. Patients with symptomatic biceps tendinopathy, anterior intertubercular groove tenderness, and positive biceps tension tests were included in the investigation. A tantalum bead, functioning as a radiostereometric marker, was sutured to the biceps tendon before final fixation of tendon tissue with either an interference screw or suture anchor. Following final fixation, AP radiographs were obtained intraoperatively. Follow up single view AP radiographs were obtained at one week and 3-months post-operatively. The distance from the center of the tantalum bead to the most proximal aspect of the humeral head was measured. Results: Of 128 patients enrolled, 120 (93.8%) were available for follow-up. The average age was 52.05±10.5 years, average BMI 30.8±5.4, and 29% of the patients were females. Groups were similar concerning patient demographics and concomitant procedures. At final follow up, there was no difference in distal migration between the OSPBT and ASPBT performed with an interference screw (4.31 vs. 4.02 mm, respectively, P=0.418). BT performed with a single ASSA demonstrated significantly more migration than BT performed with double ASSA (27.24 vs. 9.73 mm, respectively, P=0.005) and significantly more migration than the interference screw (27.24 26 vs. 4.31 mm, respectively, P<0.001). BT performed with the double ASSA technique demonstrated significantly more migration than the interference screw (9.73 vs. 4.02 mm, respectively, P=0.041). Three patients (11.1%) in the open single ASSA group, one patient in the arthroscopic double ASSA group (4.0%) suffered Popeye deformities. None of the patients in the interference screw cohorts experienced Popeye deformities. Conclusions: OSPBT and ASPBT demonstrate similar construct stability with use of interference screws as assessed by RSA. BT performed with single ASSA fixation resulted in more distal migration compared to double ASSA and interference screw fixation. Interference screw fixation provided more construct stability compared to a single and double ASSA, whether performed arthroscopically or with an open approach. These findings are the first in vivo results to characterize and quantify the biceps tenodesis construct in the post-operative period. Table 1. Patient Demographics and Other Characteristics. Table 2. Intraoperative Findings. Table 3. Tantalum bead migration at 1 week, 3 months and between 1 week and 3 months for arthroscopic and open techniques. Figure 1. Comparison of postoperative construct migration for the four studied techniques of biceps tenodesis measured by radiostereometric analysis. [ABSTRACT FROM AUTHOR]

Objectives: (1) To report minimum 2-year patient reported outcome scores (PROs) and return to sport for elite female athletes undergoing hip arthroscopy for femoroacetabular impingement (FAI) and (2) to compare clinical results with a matched control group of elite male athletes. Methods: Data on all consecutive female athletes who underwent primary hip arthroscopy performed by the senior author (X.X.X.) between March 2009 and July 2018 were collected. Patients were considered eligible if they underwent hip arthroscopy for labral tears or FAI and participated in collegiate or professional athletics within 1 year of surgery. Minimum 2-year PROs were collected for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), visual analog scale (VAS) for pain, and RTS status. The percentage of patients achieving minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) were also recorded. These patients were then matched to elite male athletes for comparison. Results: Seventy-three female athlete hips were included with a mean follow-up of 65.1 ± 27.9 months. They demonstrated significant improvement from preoperative to latest follow-up for mHHS, NAHS, HOS-SSS, and VAS (P <.05). When outcomes were compared to a control group of male athletes, female athletes demonstrated lower preoperative scores, similar postoperative scores, and significantly greater magnitude of improvement (delta value) for mHHS, NAHS, and VAS. Female athletes also achieved MCID at higher rates than male athletes for HOS-SSS (85.1% vs 70.0%, P =.035) and NAHS (79.1% vs 62.9%, P =.037). RTS rates were similar between the two groups (Females: 67.1%, Males: 67.1%, P > 0.999). Conclusions: Elite female athletes undergoing primary hip arthroscopy for FAI demonstrated significant improvement in PROs and high rates of return to play, which were similar to a matched group of male athletes. Female athletes exhibited greater improvement in PROs (mHHS, NAHS, VAS) and achieved MCID (HOS-SSS, NAHS) at higher rates when compared to a control cohort of male athletes. Figure 1. Patient Selection Flowchart Figure 2. Return to sport rate comparison between males and females. (Lifestyle transition: did not return to sport due to a lifestyle transition; Hip pain: did not return to sport due to hip pain) Table 1. Rate of MCED and PASS achievement between the male and female cohorts at minimum 2 years. [ABSTRACT FROM AUTHOR]

Objectives: The number of anterior cruciate ligament (ACL) injuries and reconstructions observed in the adolescent population continues to rise. While the use of quadriceps tendon autograft has increased in popularity in this population, there remains no consensus on the ideal graft for pediatric ACL reconstruction. The objective of this study was to compare three commonly used ACL graft types with respect to i) performance on return to sport assessments and ii) timing to clearance for return to sports in an adolescent population. Methods: All patients, less than or equal to 19 years of age, who underwent reconstruction for ACL tears between 2016 and 2020 at a large, urban, academic institution were identified. Graft choice was made in a shared decision-making model with patient, parents, and surgeon. Patient demographics, laterality, graft type, time from surgery to clearance, number of physical therapy (PT) visits, and presence of concomitant meniscus injuries were collected from the electronic medical record. At a minimum of 6 months postoperatively, patients completed a formal return to sport test (RTS) including isometric strength assessments, Y- balance testing, and hop testing. Treatment cohorts based on graft type were compared with respect to RTS performance and timing to clearance. Associations between patient demographics and return to sport timing and performance were also assessed. Clearance for return to sport was determined by the treating surgeon with limb symmetry index of 90% on RTS as the goal for clearance. Results: A total of 110 adolescents, 44 female (40%), with a mean age of 16.3 years (SD, 1.7; range, 10-19) met our inclusion criteria (Table 1). Average time to first RTS assessment was 280 days (9.3 months) and average time to clearance was 371 days (12.2 months) after surgery. ACL grafts included 58 (52.7%) hamstring autografts, 26 (23.6%) bone-patellar tendon-bone (BPTB) autografts, 21 (19.1%) bone quadriceps (BQT) autografts, and 5 (4.6%) iliotibial band (ITB) autografts. ITB patients were younger on average (12.5 years old) than those receiving hamstring, BPTB or BQT grafts. There were no significant differences between groups with respect to laterality, number of physical therapy visits, or rate of concurrent meniscus surgery. Patients receiving BQT grafts were more likely to be cleared within 1 year of surgery compared to hamstring graft patients (82.4% vs. 39.6%, p=0.002) and had similar rates of clearance within 1 year compared to BPTB patients (82.4% vs. 65.2%, p=0.230). Patients with BQT and BPTB grafts both demonstrated significantly better hamstring strength symmetry compared to hamstring graft patients (5.8% strength deficit compared to healthy side vs. 1.3% vs. 29.3%, p<0.001) (Table 2). There were no differences in quadriceps strength or hop test asymmetry between graft types. Multivariate regression with age, gender, and number of PT sessions included as covariates demonstrated that hamstring graft choice was associated with decreased odds of clearance at 1 year. Conclusions: In this study of 110 adolescent ACL reconstruction patients who underwent return to sport evaluations, we found no significant difference between BPTB and BQT autografts with respect to RTS performance and time to clearance. Hamstring autograft was associated with significantly worse hamstring strength asymmetry and significantly lower rates of clearance within 1 year. Concurrent meniscus surgery, age, gender, and number of PT sessions completed prior to RTS evaluation were not significantly associated with timing of clearance or performance on the RTS assessment. Table 1. Patient Demographics and Surgical Characteristics Table 2. Patient Demographics and Performance by 3 Common Graft Types [ABSTRACT FROM AUTHOR]

Objectives: There is significant controversy regarding ideal medial patellofemoral ligament reconstruction (MPFLR) femoral tunnel position in the pediatric setting. The authors identified 3 main gaps in knowledge. First, the position of the radiographic MPFLR start point (Schottle's point) relative to the medial distal femoral epiphysis is not well defined. Second, although anatomic studies have suggested tunnel trajectories that avoid physeal contact, these trajectories are not based upon the widely used Schottle's point, providing limited intraoperative utility. Third, prior studies provide conflicting data regarding position of the MPFL origin relative to the distal femoral physis, particularly in younger patients. The purpose of this study was to determine the proximity of Schottle's point to the medial distal femoral physis and the medial epicondyle using a digitally reconstructed radiographs (DRR) and three-dimensional computed tomography (CT) models. Methods: The institutional picture archiving and communication system (PACS) was queried for CT imaging studies of pediatric knees with open physes. CT data were imported to a Python based, open-source image processing software and were transformed to create true lateral digitally reconstructed radiographs (DRR) (Figure 1) and 3-dimensional (3D) renderings of the distal femur (Figure 2). Schottle's point and the medial epicondyle were registered using fiducial markers and 3D distance measurements were then obtained from Schottle's point on the medial cortex to 1) the medial epicondyle, 2) the physeal point directly superior to Schottle's point, and 3) the shortest distance to the medial physis on the cortical surface. A 6-millimeter circle was used to simulate reaming diameter and physeal intersections were tabulated. Results: 49 pediatric knee CT scans with open physes were included in the data. Average patient age was 13.0 ± 2.3 years (range: 6-17 years). Mean minimum distance from the medial physis to Schottle's point was 9.9 mm ± 3.0mm (range: 3.4-16.1 mm) (Figure 3). In 49 of 49 cases (100%), Schottle's point was distal to the physis. Schottle's point was localized at a mean distance of 7.5mm ± 3.14mm posterior to the medial epicondyle and 6.1mm ± 2.9mm superior to the medial epicondyle. Using a 6mm reaming diameter, 3 (6%) femurs in our study would have violation of the medial distal femoral physis. Moving the start point 3mm distally would result in 0 of 49 (0%) having physeal injury. Conclusions: Historically, characterizing the position of the origin of the MPFL on the medial condyle relative to the medial distal femoral physis has been challenging. Prior cadaveric studies have suggested the MPFL originates proximal to the physis in younger patients (<7 years). However, more recent cadaveric studies have challenged this idea, finding the bony landmarks of the MPFL origin to be distal to the physis. Although these studies have sparked significant discussion regarding the pediatric MPFL origin, they have small numbers of specimens. Using a more surgically relevant approach, the present study demonstrates that Schottle's point is consistently distal to the distal femoral physis. Prior studies have suggested anterior and distal drill trajectories that may minimize physeal injury. Although useful, these studies do not assess drilling path relative to the commonly used radiographically identified starting point, Schottle's point. The present study complements this prior work by addressing the radiographic start point upon which the drill trajectory is based intraoperatively. Based on the present study, the use of Schottle's point without distalization would lead to physeal injury in 6% of cases. Further, prior cadaveric anatomic studies are subject to limitations of the availability and expense of pediatric specimens and are therefore limited to small sample sizes. The methodology of the present study, by using readily available fine cut CT data, is not subject to such constraints. The present investigation offers a larger sample size than any previously published pediatric MPFL anatomic study and uses a highly accurate and repeatable methodology. This unique methodology may be more broadly applicable to the study of pediatric procedures near the physis. The radiographically defined surgical start point for MPFL femoral tunnel placement (Schottle's point), is consistently distal to the medial distal femoral physis. Mean minimum distance from Schottle's point to the physis on the medial cortex is 9.9mm. Using Schottle's point for the start of tunnel drilling leads to physis violation in 6% of cases, when using a 6mm reamer. Distalization of the start point by 3mm leads to avoidance of physeal injury in all cases. Figure 1. Digitally Reconstructed Radiograph with Identification of Schottle's Point Figure 2. 3D Rendering with Physeal Distance Measurement Figure 3. Saggital Plane Plot of Schottle's Point and Closest Point on Medial Physis [ABSTRACT FROM AUTHOR]

Objectives: Osteochondral allograft transplantation for cartilage defects of the knee has demonstrated excellent long-term clinical outcomes and survival, which largely depends on successful graft osseointegration. Biologics have been suggested as a viable adjunct to enhance successful healing in several musculoskeletal applications. In the context of OCA, early results have suggested that BMAC may improve cellular repopulation and viability within the osseus portion of an implanted graft. However, few clinical studies to date have investigated the impact of BMAC on patient outcomes following OCA. The purpose of this study was to investigate the effect of bone marrow aspirate concentrate (BMAC) on osseointegration and patient-reported outcome metrics (PROMs) after osteochondral allograft transplantation in a prospective, randomized controlled single-blinded trial. Methods: Patients undergoing osteochondral allograft transplantation of the knee were consented and enrolled. Prior to surgery, patients were randomized into either the BMAC or sham incision groups. In the BMAC group, the osteochondral allograft plug was soaked in BMAC for a minimum of 2 minutes prior to implantation. All patients underwent postoperative computed tomography (CT) scanning at 6 months postoperatively and completed PROMs preoperatively, 6 months, and 1 year postoperatively. Two board-eligible orthopaedic surgeons blinded to treatment allocation independently assessed and graded each CT according to the ACTOCA system proposed by Gelber et al. Results: Thirty-six patients enrolled between April 2018 to December 2020 (17 female, 19 male) were included for analysis. There were no significant differences between the BMAC and non-BMAC groups in graft signal density (Grader 1: p=0.283, Grader 2: p=0.467), osseous integration (both graders: p=0.489), surface percentage with discernible cleft (Grader 1: 0.287, Grader 2: 0.469), or intra-articular fragments (Grader 1: p=0.617, Grader 2: p=0.810) (Table 1). A significantly greater number of patients receiving BMAC demonstrating cystic changes <3 mm (Grader 1: p=0.015, Grader 2: p=0.05) (Figure 1). At 1 year, BMAC patients reported significantly better WOMAC Pain (87.82±14.26 vs 75.80±15.56, p=0.043) and trended towards improved PROMIS Pain (54.14±8.31 vs 61.79±5.24, p=0.09). Conclusions: Patients receiving BMAC soaked OCA grafts demonstrated no difference from controls with respect to graft signal intensity, osseous integration, intra-articular fragments, or discernible graft-host clefts at 6-months postoperatively. BMAC patients had a significantly greater occurrence of small (<3 mm) cystic changes. At 1 year, BMAC patients reported significantly less pain than controls on WOMAC Pain, with similar trends on PROMIS Pain Interference. Table 1. Postoperative Imaging Characteristics (ACTOCA) by Grader. Figure 1. Distribution of cystic changes between BMAC and control groups. [ABSTRACT FROM AUTHOR]

Objectives: The incidence of long head of the biceps tendon (LHBT) procedures is increasing, yet the role of the LHBT in glenohumeral stability is not fully understood. People lift most objects in the sagittal plane with forward flexion, which stresses the posterior aspect of the unconstrained glenohumeral joint. Determining the mechanism by which the shoulder maintains stability with functional motions is important to understanding the pathoanatomy of degenerative shoulders. We hypothesize that the LHBT resists posterior translation of the humeral head (HH) during forward flexion by tensioning the posterior capsuloligamentous complex. Methods: Ten fresh-frozen cadaveric shoulders were tested using an established shoulder simulator, which loads the rotator cuff, deltoid and LHB tendons through a system of pulleys and weights. A motion tracking system recorded glenohumeral translations with an accuracy of ±0.2mm. In each subject, the scapula was fixed and the humerus was tested in 6 positions: 30 and 60 degrees of glenohumeral forward flexion at i) maximum internal rotation (IR), ii) neutral rotation and iii) maximum external rotation (ER) (Figure 1). The deltoid was loaded with 100N, and the infraspinatus and subscapularis were loaded with 22N each. The difference in glenohumeral translation was calculated at each position comparing the LHBT loaded with 45N or unloaded. Results: When comparing the two states of LHBT loading vs unloading, unloading the LHBT led to an overall increase in posterior and superior translation of the humeral head (Figure 2) in all tested positions (neutral, maximum internal rotation, maximum external rotation in both 30 and 60 degrees of forward flexion). At 30 degrees of glenohumeral forward flexion, unloading the LHBT increased HH posterior translation by 2.46mm (±0.92mm) (p<0.001), 1.71mm (±1.02mm) (p<0.001) and 1.02mm (±0.88mm) (p=0.014) at maximum ER, neutral rotation, and maximum IR, respectively (Figure 3). At 60 degrees of glenohumeral forward flexion, unloading the LHBT increased HH posterior translation by 2.77mm (±1.16mm) (p<0.001), 2.43mm (±1.56mm) (p<0.001) and 1.66mm (±1.42mm) (p<0.001) at maximum ER, neutral rotation and maximum IR, respectively (Figure 4). Unloading the LHBT led to more posterior translation at 60 degrees of glenohumeral forward flexion compared to 30 degrees (p=0.013). Conclusions: LHBT loading resists posterior translation of the humeral head during forward flexion. This data supports the role of the LHBT as a posterior stabilizer of the shoulder, specifically when a person is carrying objects in front of them. Biceps tenotomy or tenodesis may contribute to microinstability of the glenohumeral joint and shift contact pressure posteriorly. Further work is needed to determine if unloading the LHBT, as is done with biceps tenotomy or tenodesis, may eventually contribute to the posterior glenoid wear seen with osteoarthritis. [ABSTRACT FROM AUTHOR]

Objectives: The treatment for idiopathic adhesive capsulitis of the shoulder remains controversial. The pathophysiology of adhesive capsulitis supports the rationale for intra-articular glenohumeral joint corticosteroid injection to treat the synovial inflammation in stages 1 and 2, that results in capsular fibrosis in the later stages of adhesive capsulitis. We hypothesize that an intra-articular ultrasound-guided glenohumeral injection (USGI) of corticosteroid in patients diagnosed with stage 1 or stage 2 idiopathic adhesive capsulitis will result in timely functional recovery and resolution of pain and stiffness. Methods: This is a retrospective analysis of a cohort of patients with stage 1 or stage 2 idiopathic adhesive capsulitis, diagnosed using history and physical examination. A total of 61 patients met inclusion criteria. Range of motion (ROM) measurements documented in the patient charts were recorded in four planes: forward flexion, abduction, internal rotation, and external rotation in neutral abduction. All ROM measurements were performed pre-injection and at all subsequent post-injection visits by a single treating physician. All patients were treated with an ultrasound-guided intra-articular injection of local anesthetic and depomedrol. Recovery criteria were defined as forward flexion, abduction, and external rotation to within 15 degrees of the contralateral side and internal rotation to within three spinous process levels of the contralateral side. Results: A total of 11 patients with Stage 1 and 50 patients with Stage 2 adhesive capsulitis comprised the study cohort. The mean age was 55 years (SD=8, range: 38 to 72) and 49 (80%) patients were female. Within the stage 1 cohort, all 11 patients met recovery criteria for forward flexion (100%), 10 patients met recovery criteria for abduction (91%), 11 patients met recovery criteria for internal rotation (100%), and 8 patients met recovery criteria for external rotation (73%). Within the stage 2 cohort, 31 patients met recovery criteria for forward flexion (62%), 30 patients met recovery criteria for abduction (60%), 36 patients met recovery criteria for internal rotation (72%), and 24 patients met recovery criteria for external rotation (48%). Time to recovery in days for each ROM compared between the stage 1 and stage 2 cohorts was statistically significant in all ROM planes (forward flexion (p<0.0001), abduction (p<0.0001), internal rotation (p=0.0008), and external rotation (p=0.0096)), indicating a greater proportion of stage 1 patients had a shorter time to recovery after injection. Figures 1-4 depict cumulative survival functions between Stage 1 and Stage 2 patients for each individual ROM measurement. Conclusions: USGI for early adhesive capsulitis allows patients to recover ROM more rapidly. Importantly, Stage 1 patients recovered faster than Stage 2 patients in all ROM planes, with only forward flexion reaching statistical significance. This suggests that prompt recognition of early idiopathic adhesive capsulitis and subsequent USGI with corticosteroid and local anesthetic plays an important role in timely recovery of motion and symptom resolution thus shortening the natural history of this disease and preventing the development of significant fibrosis. Figure 1. Cumulative survival functions between Stage 1 and Stage 2 patients for Forward Flexion Figure 2. Cumulative survival functions between Stage 1 and Stage 2 patients for Abduction Figure 3. Cumulative survival functions between Stage 1 and Stage 2 patients for Internal Rotation Figure 4. Cumulative survival functions between Stage 1 and Stage 2 patients for External Rotation [ABSTRACT FROM AUTHOR]

Objectives: Mild to moderate glenohumeral osteoarthritis (GHOA) is a common finding among patients who are evaluated for rotator cuff (RC) tears. However, the impact of pre-operative shoulder joint degeneration on patient-reported outcomes (PROs) following RC repair (RCR) is not well-established. Certain studies have reported a negative association between radiographic findings of glenohumeral osteoarthritis (GHOA) and RCR PROs, while other studies have found no substantial association. The purpose of this study was to apply the MRI-based Shoulder Osteoarthritis Severity (SOAS) score to the evaluation of patients undergoing RCR and determine the relationship between pre-operative shoulder pathology present on MRI with post-operative PROMIS-UE scores. We hypothesized that patients with higher pre-operative SOAS scores, indicating greater shoulder pathology, would have lower post-operative PROMIS-UE scores following RCR. Methods: Seventy-one MRIs corresponding to 71 patients were analyzed by two independent reviewers and scored using the SOAS criteria. Intraclass correlation coefficients were calculated for total SOAS score as well as for each sub-score. Spearman's correlations were calculated between averaged SOAS scores, patient demographics, and PROMIS-UE scores. Linear regression analysis was performed between the independent variables of patient age, sex, BMI, and significant SOAS score components determined by univariate analysis with the dependent variable of PROMIS-UE score. Significance was defined as p<0.05. Results: The mean PROMIS-UE score of this cohort was 51.5 ± 7.5 (Table 1), while the average total SOAS score was 21.5 ± 8.4 (Table 2). There was a negative correlation between increasing total SOAS score and worsening post-operative PROMIS-UE score (r = -0.24, p = 0.04) (Table 3). Both cartilage wear (r = -0.33, p = 0.0045) and AC joint degeneration (r = -0.24, p = 0.048) individually demonstrated negative correlations with PROMIS-UE score (Table 3). SOAS cartilage score was an independent negative predictor of PROMIS-UE score in a multiple variable linear regression with patient age and sex (β = -1.05, p = 0.038) (Table 4). Conclusions: In this cohort of patients undergoing RCR, increasing pre-operative total SOAS score was predictive of lower post-operative PROMIS-UE scores. SOAS sub-scores with the strongest negative correlations with PROMIS-UE scores included cartilage wear and AC joint degeneration. Cartilage subscore was negatively correlated with PROMIS-UE scores independent of patient demographic factors in multivariate analysis. Pre-operative GH cartilage wear and AC joint degeneration may warrant particular attention and counseling in patients undergoing RCR. Table 1. Characteri&tici of Study Subject Table 2. ICCs and Average SQAS Scores Table 3. Summary of Correlations Table 4. Multivariate Regression of SOAS Variables to Predict PROMIS-UE [ABSTRACT FROM AUTHOR]

Objectives: Larger amounts of bipolar bone loss have a strong association with shoulder re-dislocation following arthroscopic labral repair. Development of the Glenoid Track (GT) concept has helped propose bone loss cut-offs for shoulders that should not be managed with arthroscopic labral repair alone. Recent literature has suggested the use of the glenoid track as a continuous variable rather than a binary "on-track/off-track" concept. The re-dislocation risk for "on-track" shoulders with smaller distances to dislocation (DTD), or "near-track" shoulders, has not been previously described. We hypothesized that decreasing DTD, or on-track lesions approaching an off-track lesion, would result in an increased risk of failure following arthroscopic Bankart repair alone. Methods: We performed a retrospective analysis of 197 patients who had undergone primary arthroscopic anterior labral repair between 2007 and 2019 with minimum 2-year follow-up. Glenoid bone loss using a perfect-circle method and Hills-Sachs (HS) interval, were measured from pre-operative MRIs. GT was calculated using previously described methods. Surgical failure was defined as a patient who re-dislocated their shoulder following surgery. DTD was calculated by subtracting the HS measurement from the GT calculation. Patients with "off-track" lesions (negative DTD), and those who had undergone a concomitant arthroscopic remplissage were excluded. We performed a logistical regression model to evaluate the relationship between surgical failure and DTD, glenoid bone loss, Hill-Sachs lesion size, number of anchors used, and patient age. We then created a risk estimator tool that calculates the risk of dislocation with DTD as a continuous variable. Results: Twenty-eight patients (14%) sustained recurrent shoulder dislocations following anterior shoulder labral repair. Average follow up was 7.8 years and there were no demographic differences between those with recurrence and those without (p>0.05). All patients had less than 25% glenoid bone loss (range 0-23%). Increased DTD (p < 0.0005) and glenoid bone loss (p < 0.0005) were independent predictors of surgical failure. After adjusting for glenoid bone loss and patient age, logistic regression modeling showed that for every 1mm decrease in DTD, there was an associated 13.6% increase in re-dislocation risk (p = 0.003). Patient age, Hill-Sachs length, participation in collision sports, and number of anchors used were not significantly associated with failure risk (p>0.05). A DTD <10mm had a 4.26 times greater odds of failure compared to those with DTD >10mm (OR 4.26; 95% CI 1.57-11.65; p = 0.005). The risk estimator tool developed using a logistic regression modeling demonstrated a 19% risk of failure for DTD 10mm, 26% risk for DTD 8mm, 36% risk for DTD 6mm, 49% risk for DTD 4mm, and 67% risk for DTD 2mm after adjusting for glenoid bone loss and patient age (Figure 1). Conclusions: The main finding of this study was that on-track lesions approaching off-track lesions, the so-called "near track" lesions, are associated with an exponentially increased risk of recurrent dislocation following primary arthroscopic anterior stabilization with labral repair alone. Furthermore, DTD values of <10mm were associated with the highest odds ratios for failure and were 4 times more likely to fail than for patients with DTD values >10mm. All of the patients included in this analysis had "on-track" shoulder lesions and <25% glenoid bone loss. Historically, these values have been identified as "cut-offs" used to identify patients who can be treated successfully with arthroscopic labral repair without a remplissage or other augmentation. DTD is a simple calculation for bipolar bone loss that can be used to predict risk of recurrent dislocation. Our results demonstrate potential pitfalls in making treatment decisions for bipolar bone loss using a binary "on-track, off-track" construct. Rather, the glenoid track concept applied as a continuum may be more useful for optimizing treatment. "On-track" shoulder lesions <10mm with diminishing DTD have a substantially higher risk of surgical failure with arthroscopic labral repair alone. As the DTD approaches 0mm ("off track lesion"), the risk of failure increases exponentially. When making treatment decisions for shoulder instability, bipolar bone loss should be viewed as a continuum rather than discreet "on-track, off-track" entities. For high-risk patients with a DTD approaching 0mm, additional augmentation with remplissage or open approaches should be considered. DTD can be used to estimate patient's risk of recurrent dislocation following primary arthroscopic anterior labral repair for treatment of anterior shoulder instability. Application of this calculation would help surgeons decide the best surgical treatment for patients following anterior shoulder dislocation and can be particularly valuable for high risk patients. Understanding the association between lower DTD values and failure can also help inform the surgeon and patient regarding the risks and benefits of available treatment options. [ABSTRACT FROM AUTHOR]

Objectives: In our previous trial of 86 patients randomized to undergo rotator cuff repair with or without acromioplasty, no differences in functional and quality-of-life indices at 24-months post-operative were observed. At that time point, four patients (9%) in the group without acromioplasty required reoperation due to persistent symptoms (1 with a type-II acromion and 3 with type-III acromion) while no patients that underwent acromioplasty had follow-up surgery. This is consistent with other short-term studies; however, no long-term follow-up of a randomized clinical trial has been conducted. The aim of this study was to re-evaluate the patients from the original trial determine the long-term efficacy of performing a subacromial decompression in cases of full thickness rotator cuff tears. Methods: This is a secondary study based on a previous multi-centre, double-blind, balanced randomization (1:1), parallel-group study with patients allocated to arthroscopic rotator cuff repair with (ACR) or without acromioplasty (No ACR). Recruitment for the original study was conducted between June 2003 and February 2009 with 24-month follow-up taking place between 2005 and 2011. This secondary study was conducted between April 2015 and March 2021 with all patients randomized in the main study comprising the study sample. Additional exclusion criteria were those who were unable or unwilling to provide informed consent. Patients from the original study were invited by a blinded assessor to return for a follow-up visit involving the same methodology as their previous visits. The visit included completion of a patient-reported outcome, the Western Ontario Rotator Cuff score (WORC) and clinical assessment. If a participant was unable to return for a clinical evaluation, they were asked to complete the WORC by mail. Results: Eighty-six patients were randomized in the original trial. Fifty-seven of those completed the long-term follow-up, 31 of 45 from the No ACR group and 25 of 41 from the ACR group. Sixty-one percent in the No ACR group and 64% in the ACR group were male. The mean (SD) duration of follow-up was 11.2 (2.4) years for No ACR and 11.5 (2.6) years for ACR, respectively. Mean (SD) age of patients at the time of initial surgery for the No ACR group was 58.5 (8.4) and for the ACR group was 56.2 (7.8), while mean age at the most recent follow-up was 69.0 (9.3) for No ACR and 67.7 (7.7) for ACR. Mean (SD) WORC scores at pre-operative, 24-months and long-term follow-up are presented by group in Table 1. There was no significant difference in WORC between the No ACR and ACR groups at the time of long-term follow-up (p=0.30). WORC score maintained a significant improvement from pre-operative scores in both groups (p < 0.001). In the initial study at 24-months post-operative, four patients were identified in the No ACR group who underwent revision surgery. Of those, 2 returned for long-term follow-up and 2 did not. In long term follow-up, another 6 patients were identified that underwent additional surgery on their study shoulder since the 24-month follow-up, including 3 rotator cuff revisions, 1 total shoulder arthroplasty, and 2 unknown shoulder surgeries (patient-reported). Therefore, 10 (22%) of the 45 patients in the No ACR group underwent further shoulder surgery. One participant, 2% of the initial 41 patients allocated to ACR, underwent a revision shoulder surgery. Conclusions: The main finding of this study was that at long-term (mean 11 years post-operative) follow-up of patients randomized to undergo rotator cuff repair with or without acromioplasty, there was no difference in patient-reported outcome, specifically WORC scores. Both groups maintained improved outcomes from their pre-operative status. However, revision rate was significantly higher in those that did not undergo acromioplasty at the time of their initial surgery. Figure 1. Patient flow through study. Figure 2. WORC scores over time by group. [ABSTRACT FROM AUTHOR]

Objectives: The rate of anterior cruciate ligament reconstruction (ACLR) in pediatric/adolescent populations has increased over time. However, there is less evidence to support the relative change in concomitant meniscus procedures over time. Demographics and socioeconomic (SES) factors may be implicated in the rate and usage of meniscectomy vs. meniscal repair as treatment. The purpose of this study is to assess if the rate of concomitant meniscus procedure with ACLR is increasing and what factors may be contributing to this rise. We hypothesize that age, sex, race/ethnicity, income, or insurance type may affect the rate of concomitant meniscus procedures. Methods: The Pediatric Health Information System (PHIS) Database was queried for all patients 18 years or younger who underwent ACLR with or without concomitant meniscus procedures based on CPT code from 2015-2019. Data from 39 out of 52 centers were included based on completeness of their data. Basic demographic information including age, sex, self-identified race/ethnicity, and insurance status was collected. Urban and rural designation was identified based on rural-urban commuting area (RUCA) codes. Based on the 2015 Department Health & Human Services Federal Poverty Guidelines (FPL), patients were stratified into lower (<199% of FPL) and higher (≥200% of FPL) income brackets. Linear regression was used to model trends and multiple logistic regression modeling was used to test for associations. Results: 14,398 patients underwent ACLR during the study period with 8,337 patients (58%) having concomitant meniscal procedures with a 1.24-fold increase over five years (Figure 1). Of the 8,337 patients with concomitant meniscus treatment, 46% had a meniscectomy and 54% had a meniscus repair. There was a 0.86-fold change in meniscectomy and a 1.70-fold increase in meniscus repair during the study period (Figure 2). Males, older patients, Black race, living in an urban area, and those with non-private insurance had increased odds of undergoing a concomitant meniscus procedure (all p<0.05). Patients of Black or other race and those with non-private insurance had increased odds of having a meniscectomy vs. meniscus repair (all p£0.01). There were no associations detected between income bracket and our outcomes. Conclusions: This study shows that in pediatric and adolescent patients undergoing ACLR, there is a rise in concomitant meniscus procedures from 2015-2019. In addition, patients of non-white race and those with non-private insurance have increased odds of undergoing meniscectomy vs. meniscus repair. This study identifies access and inequality issues in ACLR with concomitant meniscus procedures in pediatric and adolescent populations. Figure 1. ACL Reconstruction vs ACL Reconstruction with Concomitant Meniscus Procedures from 2015-2019 Figure 2. ACL Reconstruction with Concomitant Meniscus Procedures: Meniscectomy vs. Meniscus Repair [ABSTRACT FROM AUTHOR]

Objectives: The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation and is often disrupted with a lateral patellar dislocation. Surgical management for recurrent patellar instability focuses on restoring MPFL function with repair or reconstruction techniques. Recent studies have favored reconstruction over repair, but no long-term, comparative studies are available in the literature. Methods: A total of 55 patients (58 knees) with recurrent lateral instability were treated between 2005 and 2012 with either MPFL repair or MPFL reconstruction. Exclusion criteria included prior or concomitant tibial tubercle osteotomy or trochleoplasty, and follow-up less than 8 years. Pre- and post-operative demographic, surgical, imaging and clinical data were recorded for each patient. Results: MPFL repair was performed on 26 patients (29 knees; 14 females, 15 males) at a mean age of 19.1 years. MPFL reconstruction was performed on 29 patients (29 knees; 18 females, 11 males) at a mean age of 18.2 years. Mean follow-up was 12.0 years (range 8.3-18.9). The reconstruction group had a significantly lower rate of recurrent dislocation compared to the repair group (14% vs 41%, p=0.019) at final follow up. There were no differences in the number of pre-operative dislocations (greater than or less than 3), degree of patellar facet chondromalacia, TT-TG distance, or Tegner scores. The reconstruction group had significantly more time from injury to surgery compared to the repair group (median, 1,460 days vs 627 days, p =0.007). There were no differences in post-operative Tegner, Lysholm or Kujala scores at final follow-up. Additionally, there were no differences in return to play rates (repair 80.8% vs reconstruction 75.0%, p=0.610) or reoperation rates (repair 20.7% vs reconstruction 13.8%, p=0.487). Conclusions: Repair of the MPFL leads to nearly 3-fold higher rate of recurrent patellar dislocation (41% vs. 14%) at long term follow-up compared to MPFL reconstruction. However, MPFL repair and reconstruction provide similar clinical results, return to play rates and reoperation rates. [ABSTRACT FROM AUTHOR]

Objectives: (1) To report mid-term outcomes of HLA following primary hip arthroscopy and (2) to compare their results to a propensity-matched cohort of NA patients. Methods: Data were prospectively collected and retrospectively reviewed from February 2008 to November 2015 for HLA (professional, college, or high school) who underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome (FAIS). HLA were included if they had preoperative, minimum 2-year, and minimum 5-year follow-up data for the Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score Sports-Specific Subscale (HOS-SSS). Radiographic and intraoperative findings, surgical procedures, patient-reported outcome scores (PROs), the patient acceptable symptomatic state (PASS), the minimal clinically important difference (MCID) and the return to play were reported. The HLA study group was propensity-matched to a control group of NA patients for comparison. Results: A total 65 HLA (67 hips) were included in the final analysis with mean follow-up time of 74.6 ± 16.7 months. HLA showed significant improvement in all PROs recorded, achieved high rates of MCID and PASS for mHHS (74.6% and 79.4% respectively) and HOS-SSS (67.7% and 66.1% respectively), and returned to sport at high rates (80.4%). When compared to the propensity-matched NA control group, HLA reported higher baseline but comparable postoperative scores for the mHHS and NAHS. HLA patients achieved MCID and PASS for mHHS at similar rates as NA patients, but they achieved PASS for HOS-SSS at higher rates which trended toward statistical significance (66.1% vs 48.4%; P =.07). NA underwent revision arthroscopic surgery at similar rates compared to HLA patients (14.9% vs 9.0%; P =.424). Conclusions: Primary hip arthroscopy results in favorable mid-term outcomes in HLA. When compared to a propensity-matched NA control group, HLA demonstrated a tendency toward higher rates of achieving PASS for HOS-SSS but similar arthroscopic revision rates at minimum 5-year follow-up. Figure 1. Patient Selection Flowchart. HLA, High-Level Athletes; NA= Non-Athletes Figure 2. Patient-Reported Outcomes Scores for High Level Athletes (HLA) group and Non-Athletes (NA) group ait the preoperative, minimum 2-year and rninimum 5-year time points. * indicates statistically significant | difference between groups. Table 1. MCID and PASS of the Cohorts After Propensity Score Matchinsa [ABSTRACT FROM AUTHOR]

Objectives: Background: The volume of hip arthroscopy for femoroacetabular impingement syndrome(FAIS) has dramatically risen, and data increasingly supports early intervention from symptom onset. In an increasingly value-conscious environment, the practice of routinely acquiring preoperative MRIs for primary hip arthroscopy patients in the setting of FAIS defined by concordant history, physical exam, and radiographs may offer questionable clinical utility, waste healthcare resources, and negatively impact patient outcomes by delaying access to care. Hypothesis/Purpose: The primary purpose of the present study was to determine whether preoperative MRI provided clinical utility for patients aged 40 or under with FAIS undergoing primary hip arthroscopy. A secondary purpose was to quantify the delay in care due to ordering the preoperative MRI. Methods: A cohort of 1,786 consecutive patients who underwent hip arthroscopy between August 27, 2015, and December 31, 2020, were reviewed from the practice of a single fellowship-trained hip arthroscopist at a quaternary referral center. Our inclusion criteria were as follows: primary hip arthroscopy for FAIS and age 40 years or under. Patients were excluded if they presented to the office already with an MRI, had a contraindication to undergo MRI, elected to reattempt a second round of conservative management, or underwent a concomitant periacetabular osteotomy. The interpretation of the preoperative MRI was subsequently compared to the in-office evaluation, consisting of history, physical exam, and plain radiographs, as well as the intraoperative findings at the time of hip arthroscopy to assess for agreement. In addition to baseline demographic data, time from initial office evaluation to MRI completion and time from MRI to hip arthroscopy were recorded. Results: A total of 198 patients met the criteria for evaluation, 70% of which were female. Mean BMI and age were 25.6 and 24.8, respectively. All 198 patients had MRI findings demonstrating anterosuperior labral tears that were again re-demonstrated and repaired intraoperatively during hip arthroscopy. Of the three patients with questionable articular cartilage pathology noted on MRI, none required surgical treatment or reoperations to address cartilage pathology. No patients underwent primary labral reconstruction. The mean time from in-office FAIS diagnosis to noncontrast MRI acquisition was 15.0 days. The mean time from MRI to hip arthroscopy was 73.0 days. Conclusions: Preoperative MRI for patients with FAIS aged 40 or under undergoing primary hip arthroscopy provides little to no actionable clinical information with respect to the labrum or cartilage and may in turn negatively impact outcomes by delaying access to care unnecessarily by at least two weeks. Whether driven by practice dogma from referring physicians or arbitrary insurance preauthorization standards, the necessity of routine preoperative MRI in the young hip population with FAIS indicated for primary hip arthroscopy should be challenged by all relevant stakeholders from both clinical and value-based perspectives. FAIS. Time from initial visit to MRI and MRI to procedure. Table 1. Demographic data for cohort of included patients [ABSTRACT FROM AUTHOR]

Objectives: Sex mismatch between donor and recipient has been considered a potential contributor to adverse outcomes following solid organ transplantation. However, the influence of sex mismatching in osteochondral allograft (OCA) transplantation is yet to be determined. Therefore, the objective of this study was to evaluate whether donor-recipient sex mismatching impacts graft survival after OCA transplantation. Methods: In this review of prospectively collected data, patients who underwent OCA transplantation between November 2013 and November 2017 by a single surgeon were analyzed. Cumulative survival was performed through the Kaplan–Meier method using log-rank tests to compare patients with similar donor groups. Multivariable Cox regression analysis adjusted for patient age, graft size and body mass index (BMI) were used to evaluate the influence of donor–recipient sex on graft survival. Results: A total of 154 patients were included, 102 (66.2%) who received OCAs from a same sex donor, and 52 (33.8%) from a different sex donor. At 5 years follow-up, a significantly lower graft survival rate was observed for different sex donor transplantation in comparison to same sex donor (63% versus 92%, p = 0.01). (Figure 1.) When correcting for age, graft size and BMI, donor-recipient sex mismatching demonstrated a 2.9 times greater likelihood to fail at 5 years compared to donor-recipient same sex (p = 0.03). A subgroup analysis showed no significant difference in graft survival between female-to-female and female-to-male groups (91% and 84%, respectively). (Figure 2.) Conversely, male-to-male demonstrated a significant higher cumulative 5-year survival (94%, p = 0.04), whereas a lower survival was found in the male-to-female group (64%, p = 0.04). Multivariable Cox regression indicated a 2.6 times higher likelihood of failure for male-to-female in comparison with other groups (p = 0.04). Male-to-male had a tendency toward decreased likelihood of OCA failure (0.33 hazard ratio), although without statistical significance. Conclusions: Mismatch between donor and recipient sex has a negative effect on OCA survival following transplantation, particularly in those cases when male donor tissue was transplanted into a female recipient. [ABSTRACT FROM AUTHOR]

Objectives: The main objective of this study was to determine if hyaluronic acid (HA) injected at the same time as leukocyte-poor platelet rich plasma LP-PRP would improve the performance compared to LP-PRP alone in the treatment of symptomatic knee osteoarthritis. We hypothesized that the addition of hyaluronic acid would improve the efficacy of LP-PRP. Methods: Patients between the ages of 30 and 80 who had symptomatic Kellgren-Lawrence grades 1-4 were eligible for the study. Patients were offered enrollment and screened with inclusion and exclusion criteria. The participants were randomized into two study groups and scheduled to receive a three-injection series. Group 1 [LP-PRP] received 3 intra-articularinjections of LP-PRP dosed at one week intervals. Group 2 [LP-PRP/HA] received 3 intra-articular injections of LP-PRP dosed at one week intervals, with hyaluronic acid (Hymovis) injected concomitantly for the first two injections. The Arthrex Autologous Conditioned Plasma system was used to prepare all LP-PRP injections. Participants were blinded to injection randomization and wore a blind fold for the first two injections. Participants completed patient reported outcome questionnaires prior to their injections and at 1, 3, 6, 12, 18, and 24 months after the final injection. The questionnaires included the Western Ontario and McMaster Universitys Osteoarthritis Index (WOMAC), International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS). Results: The study population included 63 total subjects, 32 subjects were randomized to Group 1 (ACP) with average age 55.8 +/- 11.4, 31 subjects were randomized to group 2 (ACP+HA) with average age 60.4 +/- 9.0. Both groups demonstrated improvement over baseline at 1 and 3 months, with improvement plateauing at 3 months. Both groups demonstrated improvement over baseline out to 24 months. The LP-PRP/HA group demonstrated increased improvement compared to group 1 at 1 and 3 months but consistently trended down in both the WOMAC, IKDC, and KOOS scores however statistical significance was not reached. The LP-PRP groups improvement was consistent until the 18 month time point. Complete patient reported outcome data is included in Table 1. Change in WOMAC, IKDC and KOOS scores over time are represented in Figures 1, 2, and 3 respectively. Conclusions: Both groups demonstrated improvement over baseline at 1 and 3 months, with improvement plateauing at 3months. Both groups demonstrated improvement over baseline out to 24 months. The LP-PRP/HA group demonstrated increased improvement compared to the LP-PRP group at 1 and 3 months, however statistical significance was not reached and the improvement diminished after the 12 month time point. The LP-PRP group did not see a diminishing improvement until the 18 month time point. Figure 1. IKDCScore. Figure 2. WOMAC Score. Figure 3. KOOS Scores. [ABSTRACT FROM AUTHOR]

Objectives: Ulnar collateral ligament (UCL) tears are prevalent in Major League Baseball (MLB) pitchers and cause significant loss of time with varying reports of impact on performance. Revision UCL reconstruction (UCLR) is increasingly common, with little known about the effects on both fastball (FB) velocity and usage (%) in this setting. The purpose of this study was to evaluate the effect of revision UCLR on MLB pitchers with respect to post-operative FB % and velocity at one and two years after return-to-play. The hypothesis was that post-operative FB usage (FB%) and velocity would significantly decrease versus pre-injury levels in the revision UCLR group, and that revision UCLRs would result in significantly decreased FB % and velocity in comparison to a matched group of MLB pitchers after primary UCLRs. Methods: Public records were used to identify MLB pitchers from 2008 to 2020 who underwent a revision UCLR. The PITCHf/x system, which was installed in 2007 and is a standardized recording of all pitches thrown in MLB stadiums, collected FB velocity for four-seam (4FB) and two-seam (2FB) fastballs and total FB % for pitchers in the pre-injury year as well as the first two years after return. A matched control group of pitchers who underwent primary UCLR was used for comparison. Results: Nineteen pitchers fit the study criteria. There were no significant differences in the revision UCLR group in FB velocity between pre-injury levels (4FB 92.87 mph, 2FB 91.43 mph) and years one (4FB 92.55 mph, p=.375) (2FB 91.2 mph, p=0.448) and two (4FB 93.38 mph, p=.695) (2FB 91.59 mph, p=0.806) after return (Table 1). There were also no significant differences in FB % usage between the pre-injury season (60.4) and first (56.5, p=.095) or second years (52.5, p=.053) after return (Table 1). In terms of walks and hits per innings pitched (WHIP), strikeouts per 9 innings (K/9), and walks per 9 innings (BB/9), the only significant difference between pre-injury and post-injury outcomes was a significant higher K/9 in the first season after return (p=0.031) (Table 1). There were no significant differences between FB velocity or % usage between the revision and primary UCLR groups at any time point (Tables 2-4). There were also no significant differences in the revision and primary UCLR groups between WHIP, K/9, or BB/9 with the exception of lower WHIP (p=0.015) and K/9 (p=0.001) in the pre-injury season (Tables 2-4). Conclusions: In pitchers that return to the MLB level, there were no significant differences in FB velocity versus their pre-injury levels or in comparison to pitchers after primary UCLR. While not statistically significant, a trend was demonstrated that there was a clinically relevant decrease in FB % usage, potentially suggesting less confidence in their FB. Table 1. Comparison of major league baseball (MLB) revision ulnar collateral ligament reconstruction (UCLR) between pre-injury and post-operative performance. The pre-injury performance was collected for the year prior to injury while the post-operative performance was collected for the first and second years after return-to-play. Statistical comparisons were made between pre-injury performance versus the performance at 1 and 2 years after return to the MLB. Fastball (FB) velocity reported as a mean in miles-per-hour (mph). WHIP- walks and hits per inning pitched, BB/9-walks per 9 inning, K/9- strikeouts per 9 innings, *-statistically significant Table 2. Comparison of major league baseball (MLB) pitchers with revision ulnar collateral ligament reconstruction (UCLR) versus a group of primary UCLR (controls) in their pre-injury season prior to their respective surgical intervention. Fastball (FB) velocity reported as a mean in miles-per-hour (mph).. WHIP- walks and hits per inning pitched, BB/9-walks per 9 inning, K/9- strikeouts per 9 innings, *-statistically significant Table 3. Comparison of major league baseball (MLB) pitchers with revision ulnar collateral ligament reconstruction (UCLR) versus a group of primary UCLR (controls) in their first season after return to play. Fastball (FB) velocity reported as a mean in miles-per-hour (mph). WHIP- walks and hits per inning pitched, BB/9-walks per 9 inning, K/9- strikeouts per 9 innings, *-statistically significant Table 4. Comparison of major league baseball (MLB) pitchers with revision ulnar collateral ligament reconstruction (UCLR) versus a group of primary UCLR (controls) in their second season after return to play. Fastball (FB) velocity reported as a mean in miles-per-hour (mph). WHIP- walks and hits per inning pitched, BB/9-walks per 9 inning, K/9- strikeouts per 9 innings, *-statistically significant [ABSTRACT FROM AUTHOR]

Objectives: Substantial differences in throwing metrics, like velocity, spin rate and pitcher break, have been observed between left and right-handed pitchers. Elite pitchers have demonstrated significant changes in glenohumeral range of motion and humeral torsion compared to the normal population. Differences in these anatomical parameters between left and right-handed pitchers may explain these performance trends. Furthermore, changes in shoulder range of motion measurements have been associated with different injury risks and challenges in assessing rehabilitation progress. This study seeks to determine if differences in glenohumeral range of motion and humeral torsion exist between left-handed and right-handed pitchers. Methods: 217 MLB pitchers from a single organization were evaluated over a 7-year period from 2013-2020. Range of motion was evaluated by three trained examiners using a Standard Goniometer. Ultrasound scanning was used to determine neutral position of the shoulder and the degree of humeral torsion was measured with a goniometer. The mean and standard deviation were assessed for normality using Shapiro Wilk. Differences between right and left-handed pitchers were assessed using one-way ANOVA. Arm effects were assessed using paired samples t-tests. Results: Right-handed pitchers showed, on average, 13.9 degrees more shoulder external rotation range in their dominant arm compared with their non-dominant arm, whereas left-handers averaged only 2.2 degrees. RHPs showed greater asymmetries in shoulder internal rotation range (13.9 vs 4.8 degrees) and humeral torsion (-23.1 vs -2.2 degrees). Left-handed pitchers showing significantly greater range of non-dominant shoulder flexion (165.8 vs 160.7 degrees) leading to greater flexion deficits in the dominant arm compared to their right-handed counterparts, (7.5 vs 0.0 degrees). Conclusions: Right-handed pitchers demonstrate significantly greater measures of external rotation, humeral retrotorsion, and shoulder flexion compared to left-handed counterparts. The correlation between humeral retrotorsion and increased external rotation indicate that osseus adaptations are a major contributor to range of motion differences associated with handedness. Additionally, these findings may explain observed differences in several throwing metrics between right and left-handed pitchers. Furthermore, knowledge of these differences can inform rehabilitations programs and shoulder maintenance regimens. Table 1. Range of Motion Variables for Right Handed (RHP) and Left Handed (LHP) Professional Baseball Pitchers.* Table 2. Average Velocity in Miles per Hour by Pitch Type and Pitcher Handedness, 2017-2020.a Figure 1. Scatter chart showing the correlation between dominant-arm retrotorsion and external rotation gain in the throwing arm of all pitcher's studied. As retrotorsion increased, the degree of external rotation also increased. Right-handed pitchers were more likely to have higher degrees of both retrotorsion and external rotation gain. Negative values indicate retrotorsion. Figure 2. Box and whisker plot showing the difference in dominant-arm retrotorsion in the dominant throwing arm in left and right-handed pitchers. Dominant-arm| retrotorsion is the difference in torsion between the dominant throwing and non-throwing arm. Right-handed pitchers demonstrated significantly more retrotorsion (negative torsion) in the dominant throwing arm compared to left-handed pitchers. [ABSTRACT FROM AUTHOR]

Objectives: During the 21st century, opioid medication prescription and consumption has increased, which has led to an increase in opioid abuse, dependence, and fatal overdoses. Health care providers, particularly surgeons, have recently focused on decreasing the amount of opioids prescribed, as overprescribing is a known cause contributing to the opioid epidemic. Patients undergoing anterior cruciate ligament reconstruction (ACLR) would especially benefit for the identification of an ideal opioid prescription amount for post-op pain, as the average age of patients undergoing ACLR is 29.8 years old, which falls within the age group that experienced the largest increase in opioid related deaths between 2001 and 2016. It is unknown if prescribing patterns change patient behavior related to opioid consumption. The purpose of this randomized, prospective trial was to evaluate the effects of different quantities of prescribed opioid tablets on opioid utilization by patients, post-operative pain, and patient satisfaction following ACL reconstruction. Methods: This study was a prospective, randomized trial enrolling patients undergoing primary ACLR following ACL tear. Patients were randomly assigned to one of 3 prescription groups pre-operatively: 15 tablets, 25 tablets, or 35 tablets of oxycodone-5mg. Standard of care nerve blocks were utilized in all patients in addition to general anesthesia for the surgical procedure. Patients were instructed to take acetaminophen and NSAIDs as needed with the opioid medication to be used for "breakthrough" pain. Exclusion criteria included concomitant procedure other than meniscectomy or meniscal repair, ACL revision, history of chronic pre-operative opioid use, history of substance abuse, pregnancy, or workman's compensation claims. Patients in all 3 groups were asked to complete pain and medication logs 2 times a day for the first 14 days post-operatively, along with an opioid medication satisfaction survey at 2 weeks, and IKDC questionnaires before surgery and up to 6 months post-operatively. Demographics and complication information were gathered from the medical record. Requests for prescription refills were recorded as well. Analysis assessed for statistical differences in post-op pain and medication usage. All usage of narcotics was verified with the state database monitoring system for narcotic pain medication. Results: One hundred thirty patients were included in the analysis (41 who received 15 oxycodone tablets, 40 who received 25 oxycodone tablets, and 49 who received 35 oxycodone tablets). There were no significant differences between the two groups in mean age at surgery (33.6 vs. 31.6 vs 33.3; P=0.328), BMI (27.7 vs 26.1 vs 25.7; P=0.525), or sex ratio (24M/17F, 20M/19F, 25M/24F; P=0.735). There were also no significant preoperative differences in subjective pain and function, as measured by IKDC scores (46.8 vs 48.7 vs 46.5; P=0.794). There were no significant differences in mean total morphine milligram equivalents (MME) consumed between the three groups (72.3 in the 15 tablet group, 61.9 in the 25 tablet group, 78.1 in the 35 tablet group; P>0.05). There was a significant difference between those who received 15 tablets and those who received 25 and 35 tablets when asked if they thought they were prescribed too few/too many narcotics, with a greater percentage of the 15 tablet group reporting that they felt they received too few at 20.6%, (P=0.05) as depicted in Figure 1. Despite this difference, there was no significant difference between the three groups on subjective morning or afternoon pain for the first 14 days after surgery, total opioid pills consumed, patient satisfaction on ability of the narcotic to treat their condition, patient satisfaction on amount of pain relief they experienced since surgery, or patient satisfaction regarding the amount of narcotics initially prescribed after surgery. Finally, there was no difference between the three groups on postoperative function at 2 weeks, 6 weeks, 3 months, and 6 months, as measured by IKDC scores (Figure 2). Conclusions: Despite a significantly larger portion of the group who received 15 oxycodone tablets reporting that they felt they received too few opioid tablets, there was no difference between those who received 15, 25, or 35 oxycodone-5mg tablets in reported pain levels, opioid consumption, or any satisfaction metrics. In addition, there was no difference between the three groups in pain and function as reported in the IKDC surveys. Given these results, giving lower quantities of opioid medication appears to be as effective in appropriately controlling post-operative pain as higher quantities, and may help to limit amount of opioids prescribed and possible diversion of unused prescription opioid medication. [ABSTRACT FROM AUTHOR]

An increasing number of methods are being used to extract rock discontinuities from 3D point cloud data of rock surfaces. In this paper, a new method for automatic extraction of rock discontinuity based on an improved Naive Bayes classifier is proposed. The method first uses principal component analysis to find the normal vectors of the points, and then generates a certain number of random point sets around the selected training points for training the classifier. The trained, improved Naive Bayes classifier is based on point normal vectors and is able to automatically remove noise points due to various reasons in conjunction with the knee point algorithm, realizing high-precision extraction of the discontinuity sets. Subsequently, the individual discontinuities are segmented using a hierarchical density-based spatial clustering method with noise application. Finally, the PCA algorithm is used to complete the orientation by plane fitting the individual discontinuities. The method was applied in two cases, Kingston and Colorado, and the reliability and advantages of the new method were verified by comparing the results with those of previous research, and the discussion and analysis determined the optimal values of the relevant parameters in the algorithm. [ABSTRACT FROM AUTHOR]

Objectives: Calcific tendonitis is a painful shoulder condition that occurs secondary to deposition and resorption of calcium deposits within the tendinous insertions of the rotator cuff musculature. Its prevalence within the population ranges from 2.7 to 20% and it can be a cause of acute and debilitating pain. The treatment for calcific tendinitis is classically self-limited, as the natural history of the disease is for it to resolve with time. Anti-inflammatory medications and steroid use therefore are a common first line treatment option. In certain instances secondary measures such as extracorporeal shock wave therapy and percutaneous barbotage have been utilized when initial therapies have failed, but prior to pursuing surgical intervention Surgical intervention with removal of the calcium deposit and possible rotator cuff repair as needed is utilized only once all prior treatment options have been exhausted. Percutaneous needle barbotage of calcium deposits has been demonstrated to provide pain relief and improved symptoms in patients suffering from calcific tendonitis, but continued research is necessary to determine which patients might benefit most from this procedure as opposed to continued conservative approach. The purpose of our study is to assess the demographics and outcomes of those patients with a diagnosis of shoulder calcific tendonitis who underwent needle barbotage procedure. We evaluated those that had success with the procedure, including if any required surgery for their calcific tendonitis. Methods: This study was performed at a single institution. All patients were first seen and evaluated by an orthopedic surgeon fellowship trained in either sports medicine or shoulder and elbow surgery. Once calcific tendonitis was confirmed as the diagnosis and etiology of their symptoms they were referred to a single, family medicine physician with fellowship training in sports medicine. With this physician they underwent needle barbotage procedure of their calcific tendonitis with injection of local anesthetic, aspiration of the calcium deposit, and injection of corticosteroid all under ultrasound guidance. These patients were then retrospectively reviewed for demographic information and procedure details then prospectively contacted to evaluate the current status of their shoulder, as well as, if they ever had to undergo any further or operative treatment of their shoulder for calcific tendonitis. Results: Since 2018, twenty-two patients who had undergone needle barbotage for calcific tendonitis were able to be prospectively reached while 19 opted in to the study after informed consent. Of these patients, 14 were female (73%) vs. 5 male (27%), 13 of the 19 (68%) had at least one significant medical comorbidity, an average BMI of 26.3 (range 20-42), and average age was 56.8 years (range 31-76). The follow-up from time to procedure until they were prospectively contacted by phone was avg. 12.6 mo (range 2-30mo). The average Sane score for the affected extremity was 81.05 (range 25-100) vs. the unaffected extremity avg 91.6 (range 60-100) (P=0.054). Of these 19 patients zero went on the have surgical treatment of their calcific tendonitis at the time of follow up, only one patient had a subsequent corticosteroid injection into the affected shoulder. Conclusions: Calcific tendonitis remains a severe and idiopathic cause of acute shoulder pain. Though the disease is self-limiting this may take up to 6 months to resolve on its own. Previously, operative management for severe disease after corticosteroid injection failure was a mainstay. In our study cohort all patients were able to avoid surgical intervention by undergoing needle barbotage of the lesion after an average of 1 year follow up. Needle barbotage appears to be an effective way to treat symptomatic calcific tendonitis while allowing patients to avoid surgical debridement. [ABSTRACT FROM AUTHOR]

Objectives: Recent studies have stressed the important role of the deltoid ligament in maintaining global ankle stability. However, controversy remains around whether deltoid ligament repair is necessary in addition to syndesmotic repair when addressing injuries that disrupt both the syndesmosis and deltoid ligament. The purpose of this study was to measure differences in tibiotalar joint contact pressures and tibio-talar torsional stability in the presence of deltoid ligament injury, syndesmotic injury, and after their respective repairs using a cadaveric model. Our hypotheseis were 1) injury to the syndesmoosis and deltoid would increase contact pressures and decrease torsional stability, 2) repaired injuries would restore biomechanics to near native state, and 3)that there would be similar tibiotalar contact pressures and torsional stability with syndesmosis repair alone compared to syndesmosis and deltoid ligament repair. Methods: Twelve fresh-frozen human cadaveric lower extremity specimens with intact ankle joints were randomized and tested under a series of conditions: 1) intact syndesmosis and deltoid, 2) sectioning of syndesmosis or deltoid, 3) sectioning of both the syndesmosis and deltoid, 4) repair of syndesmosis or deltoid, 5) repair of both the syndesmosis and deltoid. In one group, the syndesmosis was sectioned and repaired first and in the other the deltoid was sectioned and repaired first. The syndesmosis was repaired with a single high-tensile strength suture mechanism (TightRope, Arthrex), and deltoid ligament repairs were performed with a single suture anchor (FiberTak, Arthrex). Specimens were tested under each condition with 800 N axial compression load, followed by cyclic torsional preconditioning of 5 Nm internal tibial torque (i.e., external foot rotation) at a rate of 2.5 Nm/s, and then a single rotation test of 7.5 Nm internal tibial torque at 1 Nm/s under 800 N axial compression load on a servohydraulic mechanical testing system. Contact pressures within the tibiotalar joint were measured with a digitized pressure sensor film (Tekscan, Boston MA), and coronal plane motion about the tibia was measured in angular displacement. Results: There was no significant difference in peak contact pressures between conditions except when the comparing an isolated deltoid ligament injury to a combined deltoid and syndesmosis injury (4.43±1.33MPa vs 2.67±0.45MPa, p=0.038). Total contact area was less following syndesmosis repair in isolation (609.55±312.37mm2) and combined syndesmosis and deltoid repair (598.28±181.47mm2) compared to all other conditions (p<0.001). There was also a decrease in total contact area compared to native state when the deltoid was repaired in isolation (951.51±72.79mm2 vs 888.72±105.74mm2, p=0.027). The mean external rotation angle was greater when the syndesmosis (15.67±5.39°), deltoid (13.21±3.28°), and both injuries combined (16.59±4.01°) compared to native state (8.55±2.02°), however these values did not achieve statistical significance. Additionally, There was no statistically significant difference in external rotation angle between isolated syndesmosis, isolated deltoid, or combined repairs. Conclusions: These findings demonstrate that ankle contact pressures and torsional stability do not differ significantly when a deltoid ligament repair is performed in conjunction with a syndesmosis repair for a purely ligamentous injury. However, the change in contact area following syndesmosis repair may play a role in the development of post-traumatic arthritis. This finding reinforces the importance of striving for an anatomic syndesmotic reduction, and care should be taken not to over-reduce the syndesmosis during repair. [ABSTRACT FROM AUTHOR]

Objectives: Subtle syndesmotic instability (SSI) is a difficult albeit important diagnosis to make, as undiagnosed instability frequently leads to posttraumatic ankle arthritis. Stressed conventional radiographs, ultrasonography, bilateral comparative conventional computed tomography (CT) and magnetic resonance imaging (MRI) serve as important diagnostic tools, however, the current diagnostic gold-standard is arthroscopic assessment, an invasive surgical method. The advent of weight-bearing computed tomography (WBCT) is considered to be an important additional diagnostic tool for improved non-invasive SSI diagnosis, particularly by utilizing distal tibiofibular syndesmotic (DTFS) area and volume measurements. However, to date, no studies have assessed WBCT diagnostic accuracy for chronic SSI. The purpose of this study was to prospectively evaluate the diagnostic accuracy of WBCT area and volumetric measurements in patients with suspected chronic SSI, when compared to the gold-standard arthroscopic assessment. Methods: In this IRB-approved prospective comparative study, 11 patients with suspected SSI were enrolled from July 2019 to December 2020. Patients were assessed preoperatively by bilateral standing WBCT. Raw 3D WBCT was automatically segmented by dedicated software. WBCT measurements included semi-automatic DTFS area (1cm proximally to tibial dome apex) and DTFS volumes (1, 3 and 5cm proximally to tibial dome apex). Threshold values for WBCT abnormality were defined based on currently available data (area>105mm2 and volumes>796mm3, >3062 mm3, and >6733 mm3 for 1, 3 and 5cm, respectively). Subjects underwent surgical treatment including DTFS instability arthroscopic assessment, defined as positive when a 3mm diameter sphere could enter the syndesmotic incisura. Confirmed unstable cases were treated with open reduction/internal fixation. WBCT measurements sensitivity, specificity, positive and negative predictive values (PPV/NPV) and accuracy were calculated using confirmed arthroscopic instability as diagnostic gold standard. Paired t-tests/Wilcoxon analysis was used to compare measurements. P-values<0.05 were considered significant. Results: When compared to non-injured sides, DTFS area and volumes were significantly higher in injured ankles at 1cm (667 vs 554mm3) and 3cm (2331 vs 2038mm3). Medial gutter volumes were also increased in injured sides (398 vs 370 mm3). DTFS volumes at 5cm and lateral gutter volumes were not different. Nine of eleven patients had confirmed arthroscopic DTFS instability. Considering WBCT area measurements, 4/11 patients were found to be positive (>105mm2), including 3 true positives (+WBCT/+Arthroscopy), 1 false positive (+WBCT/-Arthroscopy), 6 false negatives (-WBCT/+Arthroscopy), and 1 true negative (-WBCT/-Arthroscopy), leading to a 33.3% sensitivity, 50%, specificity, 75% PPV 75%, 14.3% NPV and 36% accuracy. When analysing WBCT DTFS volumes (1cm), 3/11 patients were found positive (>796mm3), depicting 3 true positives, 0 false positives, 2 true negatives and 6 false negatives, with resultant diagnostic accuracy of: 33.3% sensitivity, 100% specificity, 100% PPV, 25% NPV 25%, and 45% accuracy. Conclusions: This is the first study to prospectively assess the diagnostic accuracy of WBCT area and volume measurements in detecting chronic SSI and to compare it to the arthroscopic diagnostic gold standard. When compared to uninjured side, DTFS area and volumetric measurements were significantly increased in injured sides of patients with suspected SSI, including medial gutter volumes, consistent with associated deltoid ligament instability. However, interestingly, we observed a diagnostic accuracy for WBCT area and volumetric measurements to be lower than initially expected. Further incorporation of additional patients, as well as introduction of an external rotational stress can potentially optimize the WBCT diagnostic accuracy for chronic SSI. [ABSTRACT FROM AUTHOR]

Objectives: Anterior shoulder instability (ASI) is a well-studied topic in young patients, however there is a dearth of knowledge about older patients with this pathology. The goals of this study were to describe patient demographics, injury characteristics and outcomes in patients >50 years old with anterior shoulder instability along with historical trends in diagnosis and treatment. Methods: An established geographic database was used to identify 179 patients who experienced new onset anterior shoulder instability after the age 50 between 1994-2016. Mean age was 59.7 years, mean BMI was 31.3 and 54.2% were female. The dominant arm was involved in 62.2% of instability events. 26.8% of our study population were laborers and 50% reported current or former smoking habits. The primary etiology for ASI involved trauma in 96.6% of cases. Comparative analysis was performed to identify differences between age groups. Mean follow up time was 11 years. Results: The overall incidence of ASI in our study population was 28.8/100,000 person years with the highest incidence in the age cohort 60-64 at 38.9/100,000 person years. At initial presentation, 73% of all patients were found to have a lesion apparent on either XR or MRI. Rotator cuff tears were found in 92.4% of all patients undergoing MRIs. 26.2% ultimately progressed to surgery at a mean time of 1.57 years after injury. 53% of all surgical procedures involved a rotator cuff repair whereas only 25% were performed for instability. In terms of historical trends, the one-year rate of obtaining an MRI after an ASI event has increased from 10% in the late 1990s to 46% in 2015-16. Similarly, the one-year rate of performing surgery has increased from 5.1% to 47% from 1994-1999 to 2015-2016. Conclusions: In our cohort, patients over the age of 50 with ASI were found to often have concomitant pathology on imaging, however only ¼ of all patients required surgery. Although the rate of ASI has stayed relatively stable over the last 20 years, the rate of obtaining an MRI and of surgical management has increased. Figure 1. Incidence of Anterior Instability by age [ABSTRACT FROM AUTHOR]

Objectives: Recent research suggests that the short- and long-term outcomes following Anterior Cruciate Ligament Reconstructions (ACLR) on knee joint health are worse than originally thought. The ACLR procedure may result in or expediate the arthritic process through a variety of factors including prolonged underloading of the knee joint following surgery. These recent findings have resulted in a renewed interest in the ACL repair (ACL-r) procedure as a potentially more joint "friendly" secondary to less surgical trauma with the preservation of the native ACL ligament. In several animal models and in human clinical data, ACL remnant preservation and ACL entire ligament repair/preservation has been shown to benefit lower extremity and knee biomechanics, proprioception, and short term clinical outcomes. However, there is limited data on the newer ACL-r techniques and their subsequent outcomes on knee joint loading. Therefore, the purpose of this study was to assess for differences in metrics of knee joint loading between individuals following a primary anterior cruciate ligament repair (ACL-r) surgery versus those who underwent a standard ACL reconstruction with a patella bone-tendon-bone autograft (ACLR). Methods: A total of 30 participants were enrolled into this study [ACL-r n: 15, age(yrs): 38.8±13.9, Ht(cm): 173.4±10.0, Wt(kg): 77.9±17.5; ACLR: n: 15, age(yrs): 25.60±1.7, Ht(cm): 173.5±10.3, Wt(kg): 75.4±15.6]. Participants in ACL-r group all sustained a proximal ACL disruption (Sherman Classification Type 1 or 2) that was amenable to repair and underwent primary ACL repair with suture fixation. ACL-r was performed under arthroscopic visualization with 2 or 3 standard portals in a technique similar to that described by van der list, MD (2017), but modified by the senior author to include only one 4.75mm swivelock (Arthrex) secured in the anterior aspect of the native footprint on the medial wall of the lateral femoral condyle. Participants in the ACLR group all underwent a primary ACLR with patella bone-tendon-bone autograft. The autograft bone blocks were crimped to 9mm and then two 10mm femoral and tibial tunnels created for the graft. An independent tunnel technique, utilizing the medial portal for creation of the femoral socket within the native ACL femoral attachment site, was performed in all ACLR patients. At 12 weeks following surgery participants in both groups completed the IKDC questionnaire and biomechanical testing with two AMTI force plates and a 10 camera Qualisys motion capture system. Peak knee extension moment (Nm/Ht*Wt) and total knee joint power (Watt/Ht*Wt) as a measure of eccentric loading (contraction) during the descent phase of a single-leg squat were calculated on the surgical limb and averaged across the middle three trials. Participants also completed quadriceps strength testing on both limbs (surgical and non-surgical) on an isokinetic dynamometer at 60 °/sec. The average peak torque of five repetitions were used to calculate a limb symmetry index (LSI) [Surgical/NonSurgical X100]. Independent t-tests were used to assess for differences between groups in three metrics. For descriptive purposes a separate independent t-test was used to assess for differences in age, height, mass, and IKDC scores. Statistical significance was set at P< 0.05 for all analyses. Results: There were no differences in height (p=0.996), mass(p=.678), or IKDC (p=0.886) scores between the groups; however, there was a significant difference in age (p=0.009). The ACL-r had a significantly greater peak knee extension moment (ACL-r: -0.078±0.02; ACLR: -0.059±.02; p=0.014) and total knee joint power (ACL-r-0.03±0.01; ACLR: -0.02±0.01, p=0.016) than the ACLR group. The ACL-r also had a significantly great quadriceps LSI than the ACLR group (ACL-r: 65.09±20.4, ACLR: 49.2±11.4, p=0.014). Conclusions: The results of this study indicate that those individuals following ACL-r demonstrate increased knee joint loading during a single leg squat task compared to those who underwent ACLR. Decreases in knee extension moment have been reported across a variety of tasks and across a variety of time points following ACLR. Furthermore, decreased knee extension moments have been associated with movement profiles that have been linked to cartilage degeneration following ACLR. The improved knee extension moment in the ACL-r group at this early time may indicate a positive change in joint loading and potentially a decreased rate of cartilage degeneration. Knee joint total power accounts for both knee moment and angular velocity, indicating improved knee loading throughout the entire eccentric movement in the ACL-r group and further supports the notion of improved knee joint loading following ACL-r compared to ACLR. Decreased quadriceps muscle strength has been associated with changes in cartilage structure and it has been suggested that maximizing muscle strength in the first 6 months following surgery may promote improved cartilage healing, thus the increased quadriceps LSI in the ACL-r may be protective early in the recovery process. [ABSTRACT FROM AUTHOR]

Objectives: Lateral extra-articular tenodesis (LET) is being performed more frequently with anterior cruciate ligament reconstruction (ACLR) to decrease graft failure rates. Posterior tibial slope (PTS) affects ACL graft failure rates.2 The impact of LET plus ACLR on tibial motion and graft forces with increasing PTS has not been elucidated. We hypothesized LET will decrease anterior tibial translation (ATT), tibial rotation, and ACL graft force versus ACLR alone with increasing tibial slope throughout knee range of motion. Methods: Twelve cadaveric knees (40.5 mean age, all female) were tested in four conditions (intact, ACL cut, ACLR, ACLR + LET) with varying PTS (5°, 10°, 15°, 20°) at three flexion angles (0°, 30°, 60°). Specimens were mounted to a load frame which applied a 500-N axial load with 1 Nm of internal rotation (IR) torque (Figure 1). The amount of tibial translation, IR, and graft forces were measured. Results: Increasing PTS revealed a linear and statistically significant increase in graft force at all flexion angles. LET reduced graft force by 8.3% (6N) compared to ACLR alone at 30° of flexion. At the same position, slope-correcting osteotomy reduced graft force by 17-22% per 5° of slope correction, with a 46% reduction seen from 20° to 5°slope correction. For ATT, ACLR returned tibial translation to pre-injury levels, as did ACLR + LET at all flexion angles, except full extension where ACLR + LET over-reduced ATT by 2.47mm (p<0.05). Conclusions: Increased PTS was confirmed to increase graft forces linearly. Additionally, while the ACLR + LET reduced graft force compared to ACLR alone, slope correcting osteotomies are a more powerful method to minimize graft force. No other clinically significant differences were noted between ACLR with or without LET in regards to graft force, ATT, or IR. Many authors have proposed LET in the setting of ACLR, revision surgery, hyperlaxity, high grade pivot shift and elevated PTS, but the indications remain unclear. The biomechanical performance of LET plus ACLR at varying PTSs may impact daily practice and provide clarity on these indications. [ABSTRACT FROM AUTHOR]

Objectives: We sought to identify pre-operative physical exam findings, imaging findings, and surgical management trends associated with humeral avulsion of the glenohumeral ligament (HAGL) lesions by utilizing a large, multicenter orthopedic outcomes database. Methods: Patients with anterior shoulder instability who underwent surgical management from 2012 to 2020 at 11 orthopedic centers were prospectively enrolled. Patients with a HAGL lesion identified intra-operatively were compared to patients without a HAGL lesion; patients with isolated posterior HAGL lesions were excluded from data analysis. Pre-operative patient demographics, physical examination, and imaging findings were collected; intra-operative findings and surgical procedures performed were also recorded. Student's T-test, Fisher Exact test and Chi Square test were used to compare groups and determine risk factors. Logistic regression analysis was performed to determine independent risk factors associated with need for an open stabilization procedure, and odds ratio (OR) and 95% confidence interval (95% CI) were calculated. Significance was set at p<0.05. Results: From 2012 to 2020, 22 HAGL lesions were identified in 1002 patients (2.2%). Baseline demographics, including age, gender, BMI, and number of lifetime shoulder dislocations, were similar between the HAGL and non-HAGL groups. As compared to non-HAGL patients, HAGL patients were less likely to have a Hill Sachs lesion (51.8% vs. 27.3%, p=0.02) or an anterior labral tear (81.7% vs. 63.6%, p=0.03) on pre-operative MRI. On pre-operative physical examination, HAGL patients demonstrated increased external rotation when their affected arm was positioned in 90° of abduction as compared to non-HAGL patients (90° vs. 85°, p=0.01). The most common procedure performed amongst all patients was an arthroscopic Bankart repair (45.5% of the HAGL patients and 78.9% of the non-HAGL group); however, HAGL patients were more likely than non-HAGL patients to undergo an open stabilization procedure (68.2% vs. 10.7%, p<0.001) and less likely to undergo an arthroscopic stabilization procedure (72.7% vs. 94.7%, p<0.001). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization procedure (OR 31.3, 95% CI 11.0 – 88.9, p<0.001). Conclusions: Patients with anterior shoulder instability and a HAGL lesion are less likely to exhibit classic pre-operative imaging findings associated with anterior shoulder instability, such as Hill Sachs lesions or anterior labral pathology. Increased external rotation at 90° of shoulder abduction on pre-operative physical exam may suggest presence of a HAGL lesion. Other demographic factors, including age, gender, BMI, and number of lifetime shoulder dislocations, do not differ significantly between patients with and without HAGL lesions. Patients with HAGL lesions undergo open stabilization procedures more frequently than patients without HAGL lesions. [ABSTRACT FROM AUTHOR]

Objectives: Based on findings from our multi-center, double-blinded randomized controlled trial comparing arthroscopic Bankart repair with/without remplissage for the treatment of traumatic recurrent shoulder instability there is a greater risk of postoperative recurrent instability in patients without a remplissage at two years follow-up. The objective of the current study is to determine whether our short-term findings change with medium-term follow-up. Methods: This was a double-blinded, randomized clinical trial with two 1:1 parallel groups conducted at two sites. Patients were randomized intra-operatively to an arthroscopic Bankart with remplissage (REMP) or isolated Bankart repair (NO REMP) between 2011 and 2017. Inclusion criteria were patients 14 years or older diagnosed with traumatic anterior shoulder instability with a glenoid defect >15% and the presence of a Hill-Sachs defect (of any size). Patients were contacted by telephone (Spring 2020) and asked standardized questions to determine whether any additional information regarding subluxations, dislocation or additional surgery occurred since their two-year follow-up. "Recurrent instability" was defined as patient-reported dislocation, or two or more episodes of subluxation. Kaplan-Meier survival analyses were performed to assess survival distribution between groups. For the time factor in the survival analysis, the number of months from time of surgery to outcome (either failure or no failure) was based on the time of the long-term follow-up phone call, or from the time of last reported outcome based on clinical or study follow-ups, whichever was the greatest. These were conducted for: 1) recurrent instability and 2) dislocations. Odds ratios with 95% confidence intervals were also calculated. Results: Study groups were similar at baseline with respect to age, gender and BMI. Fifty-four patients were randomized to each study group at the time of the original study., with 52 REMP and 50 NO REMP included in the analyses up to 24-months post-operative. Of those, 36 from each group were available for mid-term follow-up. Mean months (mean) from surgery to last follow-up was 53.8 for REMP and 49.3 for NO REMP. The rate of postoperative recurrent instability at medium term follow-up was 10% (5/52) in the REMP group at an average of 24 months and 30% (15/50) in NO REMP at an average of 19.5 months (p=0.010). The odds ratio of recurrent instability in the NO REMP group relative to the REMP group was 4.029 (1.337-12.135; p=0.010) and the survival curve was significantly different favouring REMP (χ2 = 6.958, P=0.008; Figure 1). With respect to dislocations only, the odds ratio in the NO REMP group relative to REMP was 3.385 (0.999-11.463; p=0.041) and the survival curve was also significantly different favouring the REMP (χ2 = 4.412, p=0.036; Figure 2). Conclusions: At medium-term follow-up, patients undergoing a Bankart repair with remplissage have a better rate of survival than those with an isolated Bankart repair. Figure 1. Survival curve for patients undergoing Bankart and remplissage or bankart only comparing time to recurrence of instability (dislocation and/or recurrent subluxation). Figure 2. Survival curve for patient undergoing Bankart and remplissage or Bankart only comparing time to dislocation. [ABSTRACT FROM AUTHOR]

Objectives: The phenomenon of bony remodeling of healed displaced clavicle midshaft fractures in adolescents remains poorly understood. The purpose of the current study was to evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures treated non-operatively to understand the factors that may influence this process. Methods: Patients were identified from the database(s) of a multi-center study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced mid-diaphyseal clavicle fractures that were treated non-operatively who had further imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Radiographic measurements were performed on the injury and final follow-up films. Fracture remodeling was subjectively classified as 'complete/near-complete', 'moderate', or 'minimal' (Figure 1) and subsequently analyzed quantitively and qualitatively to determine factors associated with deformity correction. Results: Ninety-eight patients (mean age of 14.4±2.2 years) were analyzed at a mean radiographic follow-up of 3.4± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 59%, 61%, and 30% respectively (p<0.001). Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrate more remodeling (p<0.001). Ninety-two percent of patients <14 years and 79% of patients ³14 years-old at time of injury with a minimum follow-up of four years underwent complete/near-complete remodeling. Conclusions: Significant clavicle remodeling occurs in adolescent patients with displaced fractures, including older adolescents and particularly when followed for longer time intervals. This finding may help explain why symptomatic malunions are so infrequently observed in adolescent patients, even in severely displaced fractures. [ABSTRACT FROM AUTHOR]

Objectives: Multidirectional Instability (MDI) of shoulder in adolescents is a clinical diagnosis and there are no defined objective criteria to validate the diagnosis. Most patients with MDI have no identifiable labral or capsular tear pattern on MR imaging. The objective of this study was to identify objective criteria for MDI diagnosis based on rotator interval and glenohumeral capsular dimensions on MR imaging in surgically confirmed adolescents with MDI. Methods: In a comparative retrospective study, the clinical records and MR arthrogram of adolescent patients treated for shoulder instability at our center between 2008 and 2019 were reviewed. Twenty-four adolescents with surgically confirmed MDI were age-matched to 25 control patients. The width and depth of the rotator interval and multiple linear dimensions of the glenohumeral capsule were measured on sagittal-oblique MR arthrography sequences, after controlling for glenoid size (Fig 1). The measurements that differed significantly were identified using unpaired t-tests. These values were plotted on receiver operator characteristic (ROC) curves, which were used to determine threshold values for identifying MDI. Power analysis showed a sample size of 16 in each group to be sufficient to detect 5 mm difference in average capsular dimension of 20 mm (power 0.8) Results: 24 patients (28 shoulders) 20 females, 4 males were in the MDI group; average age at time of surgery was 15.2 years (range, 8-20 yrs). The control group consisted of 25 patients (27 shoulders), 9 females, 16 males; average age was 15.4 years (range, 11-18 yrs). Rotator interval depth was significantly greater in the MDI group vs control (MDI 8.5mm; Control 6.1mm) (p <0.01), as were the inferior, posteroinferior, and posterior dimensions of the glenohumeral joint capsule (24.5 vs 20.4mm, 26.4 vs 21.9mm, and 22.5 vs 19.3mm, respectively; p <0.01) (Table 1). Rotator interval width and anterior capsular dimensions were not significantly different between groups. The ROC-derived threshold values for identifying MDI using MR arthrography were Rotator interval depth = 7.4mm; Posterior capsule = 20.9mm; Inferior capsule = 22.4mm; Posteroinferior capsule = 24.0mm. Conclusions: Rotator interval depth and dimensions of glenohumeral joint capsule in the inferior, posterior and posteroinferior quadrant on MR arthrography were significantly greater in adolescent patients with MDI. Measurement of rotator interval depth and glenohumeral capsular dimensions on MR arthrography can be used to supplement clinical diagnosis of MDI. Table 1. Glenohumeral joint capsule measurements (* statistically significant) [ABSTRACT FROM AUTHOR]

Objectives: Patellar dislocation is a common knee injury and up to 35% who dislocate can develop recurrent patellar instability. In the setting of recurrent instability, medial patellofemoral ligament reconstruction (MPFLR) often restores knee stability. There has been recent interest in the evaluation of patient and surgical factors that may influence the outcomes of isolated MPFLR. Much of the previous work has focused on influences of anatomical measures; however, patient and injury characteristics may also impact surgical outcomes. We hypothesize that patients who suffer > 2 patellar dislocations prior to MPFLR will demonstrate poorer patient-reported outcomes (PROs) than those who experience ≤ 2 prior dislocations. Methods: Records were reviewed to identify patients who underwent MPFLR at a single academic institution in the United States between 2008 and 2016. Patients were excluded if they underwent concomitant tibial tubercle osteotomy or fixation of an osteochondral fracture. Patient demographics (age, sex, BMI), number of prior patellar dislocations, and patient anatomical measures (Caton-Deschamps index, tibial tubercle-trochlear groove distance, and trochlear sulcus angle) were collected. PROs were assessed with Norwich Patellar Instability (NPI) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity score. Outcomes of those with > 2 or ≤ 2 patellar dislocations were compared using linear regression analysis. Results: A total of 160 patients were identified who underwent isolated MPFLR. Ninety-five patients (60%) were available to complete PROs at a mean follow-up of 4.8 years post-operation. Patients with < 2 dislocations were younger (≤ 2 dislocations: 20.7 ± 9.4yrs, > 2 dislocations: 27.4 ± 9.4yrs; p < 0.001), though there were no other differences between groups in terms of demographics or radiographic anatomical measures (Table 1). Controlling for age, sex, BMI, and anatomical factors linear regression analysis found that patients with > 2 dislocations had lower KOOS pain (p = 0.003), ADLs (p = 0.025), Sports/rec (p = 0.009), and knee related QOL (p = 0.008) subscales (Table 2). Conclusions: Patients who suffer > 2 patellar dislocations prior to MPFLR demonstrate poorer PROs at 4.8 years post-operation than those who suffer < 2 dislocations prior to surgery. To our knowledge, no other study has investigated the relationship between the number of pior patellar dislocations and outcomes following MPFLR. Our findings emphasize the role patient and injury factors may play in determining outcomes following MPFLR. Table 1. Comparison of patients based on number of prior dislocations controlling for age, sex, BMI, CDI, TT-TG distance, and sulcus angle Table 2. PROs for patients with ≤ 2 or > 2 patellar dislocations prior to MPFLR, controlling for age, sex, BMI, CDI, TT-TG distance, and sulcus angle [ABSTRACT FROM AUTHOR]

Objectives: Cam-type femoroacetabular impingement (FAI) is now well-established as a risk factor for intra-articular damage (labrum and articular cartilage) and secondary osteoarthritis. Long-term studies of FAI surgery are critical in understanding clinical outcomes, refining surgical treatments and predicting osteoarthritis progression. Nevertheless, studies beyond 15 years are uncommon. Although femoral osteoplasty is now common practice in treating cam FAI, long-term data supportive of this procedure and its ability to alter the natural history of FAI are not available. The purpose of this study was to analyze the long-term clinical outcomes and survivorship of symptomatic FAI treatment by arthroscopic correction of labral pathology alone or in combination with femoral osteoplasty (structural FAI correction). Methods: A retrospective comparative study was performed on two consecutive, longitudinal cohorts of patients with isolated cam-type FAI that underwent surgical treatment of labral pathology either with femoral osteoplasty (HSLO group, 23 hips) or without femoral osteoplasty (HS group, 17 hips). These cohorts were captured immediately prior to and after implementation of femoral osteoplasty into our practice and have been previously reported on at mean 2-year followup. The current study investigated clinical outcomes and survivorship at minimum 15-year followup. Patients with pincer or combined cam-pincer morphologies were excluded. Clinical outcomes were measured with the modified Harris hip score (mHHS). Kaplan-Meier survival was assessed for THA-free and reoperation-free survivorship. Results: The HSLO group included 23 hips followed for a mean of 16.0 ±0.6 years, and the HS group 17 hips followed for 19.7 ±1.2. The HSLO group had a significantly higher final mHHS (82.7 vs. 64.7, p=0.002) and mHHS improvement (18.4 vs. 6.1, p=0.02) compared to the HS group. The rate of THA conversion (22% vs. 59%, P=0.02) and overall reoperation (22% vs. 70%, P=0.003) were significantly lower in the HSLO group. THA conversion occurred at a mean of 5.8 ±2.5 years postoperatively in the HSLO group, and 7.1 ±4.0 years in the HS group. The HSLO group had significantly greater 15-year THA-free survivorship (78% vs 41%, p=0.02) and reoperation-free survivorship (78% vs. 29%, p=0.003) by Kaplan-Meier analysis. Conclusions: This study demonstrates better long-term clinical outcomes and survivorship with combined arthroscopy and femoral osteoplasty compared to arthroscopy alone. These long-term data strongly support the current practice of femoral osteoplasty in patients with cam FAI morphologies and suggest that this treatment alters the natural history of FAI. Figure 1. Comparative Survival [ABSTRACT FROM AUTHOR]

Objectives: Avulsion fractures of the sublime tubercle of the ulna have been reported as a cause of medial elbow pain and instability in overhead athletes in adolescence and early adulthood. While the management of ulnar collateral ligament (UCL) and medial epicondyle injuries have been extensively described and reported, little has been published on the treatment of the less common bony avulsion fracture of the sublime tubercle. The objective of this study was to characterize injury pattern, treatment, and outcomes for sublime tubercle avulsion fractures in adolescent throwing athletes. Methods: A multicenter retrospective review was conducted from July 2005 to December 2020. Sublime tubercle avulsion fractures were identified by surgeon records or a database query of radiology reports. Inclusion criteria included throwing athletes age ≤19 years old with a sublime tubercle avulsion fracture sustained from a throwing mechanism, identified on at least one radiologic study (radiograph, CT, or MRI). Data collected included demographics, clinical presentation including mechanism of injury, acuity, initial treatment; and outcomes including complications, final range of motion, patient reported symptoms, radiographic union, and return to activities or sport. Results: 14 baseball players were identified with sublime tubercle avulsion fractures with a median age of 16.5 years (range, 15-19). Median duration of follow up was 2.26 years. All athletes were initially managed non-operatively with either rigid immobilization (casting, n=7), or no rigid immobilization (activity modification alone, sling, or removable brace, n=7). Six of the seven athletes treated with casting had favorable outcomes and were able to return to sport; one suffered a reinjury at 10 months and was unable to return to his previous level of play, but declined operative management. Of the seven initially managed without rigid immobilization, two had success and were able to return to sport without additional intervention, one had persistent pain and associated UCL tear but declined surgery; four ultimately proceeded to UCL reconstruction. For the athletes that underwent surgery, two did so for continued pain and associated tearing of the UCL, one for nonunion of displaced sublime tubercle, and one for a reinjury 10 months after full healing of the initial fracture and return to sport. All were able to return to their previous level of throwing postoperatively. Conclusions: As the largest case series of adolescent throwing athletes with sublime tubercle avulsion fractures to date, this study expands our understanding of management of this rare injury. Our results challenge the historical findings that the majority of sublime tubercle avulsion fractures fail non-operative management, and highlight the role for a diligent non-operative protocol with rigid immobilization, which has much better success than removable forms of immobilization or activity modification alone. Unlike purely ligamentous injuries, bony avulsions may be treated nonoperatively with good results and return to high level throwing in adolescent patients. Figure 1. AP radiographs of a simple sublime tubercle fracture on initial presentation (left) and after 3 weeks of immobilization in a long arm cast (right). [ABSTRACT FROM AUTHOR]