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Phytoestrogens, primarily isoflavones daidzein (DZ) and genistein (GE), are increasingly used by postmenopausal women as an alternative to hormone replacement therapy due to reports that estrogen therapy increases the risk of breast and endometrial cancers. These compounds, as estrogen receptor agonists, may influence chemical carcinogenesis in estrogen-responsive tissues such as the uterus. We utilized ovariectomized (OVX) rats to model menopause and assessed the effects of dietary DZ, GE, or 17beta-estradiol (E2) on carcinogen-induced mutagenesis and carcinogenesis in the rat uterus. Big Blue transgenic rats (derived from Fischer 344 strain) were exposed to 7,12-dimethylbenz[a]anthracene (DMBA) in the presence or absence of the supplements. At 16- or 20-wk sacrifice, the uteri were removed and processed to determine mutant frequencies (MFs) and immunohistochemical or histopathological parameters, respectively. In rats treated with DMBA alone, a significant increase in lacI MFs (P < 0.01) in both OVX and intact (INT) rats was observed. The DMBA-induced MFs were not significantly altered by dietary DZ, GE, or E2 in both OVX and INT rats. Although dysplasia was not induced in the uterus of OVX and INT rats treated with DMBA alone, it was detected in 55% of OVX rats fed E2 alone and in 100% of OVX rats fed E2 along with DMBA exposure. Cell proliferation also was significantly higher in OVX rats fed E2 and treated with DMBA. In rats fed the isoflavones and treated with DMBA, the incidence of dysplasia was either reduced or virtually absent in both OVX and INT groups. These results indicate that a high incidence of dysplasia was associated with E2 feeding with or without DMBA treatment in the OVX rats, whereas the incidence was low in rats fed DZ or GE and treated with DMBA, suggesting a weak estrogen receptor agonist of DZ or GE in the rat uterus. The absence of dysplasia in OVX rats exposed to DMBA alone also suggests, in part, a promotional mechanism via estrogen- or isoflavone-driven cell proliferation. [ABSTRACT FROM AUTHOR]

Objective: A goal of the DSM-IV revision is to increase clinical and research utility by improving diagnostic validity through reliance on empirical evidence. Currently defined eating disorder (ED) categories have limited validity and require refinement based on data. Method: The available scientific evidence is considered in evaluating the current ED nosology. Results: Specific recommendations include modifying ED classification by retaining categories but adding a dimensional component; removing the amenorrhea criterion for anorexia nervosa (AN); removing the subtypes for AN and bulimia nervosa (BN); making binge eating disorder (BED) an official diagnosis; and unifying the frequency and duration cut-points for BN and BED to once per week for 3 months. Priority research areas should include epidemiologic studies of full-range ED symptomatology and should focus on empirical validation for individual criterion. Conclusion: There are significant issues to address in revising ED nosology as we move toward a more valid and useful DSM-V. © 2007 by Wiley Periodicals, Inc. Int J Eat Disord 2007 [ABSTRACT FROM AUTHOR]

Over half of orthopedic surgeons will change jobs prior to their fifth year in practice. Commonly cited reasons behind the change include compensation, work-life balance, poor job fit, and dissatisfaction with management. Many of these factors are difficult to vet as a job applicant and are often only realized during the course of real-life practice. Possessing the tools and knowledge for effective self-reflection is crucial. It enables a clear understanding of why the current job may not be working and provides insights on how to transition to a different career path., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Fear is a taxonomically widespread behavioral response that functions to keep individuals out of danger. Empirical research has demonstrated that a diverse set of strategies are used in order to acquire a fear response across animals. Animals often use a mixed strategy: fear is acquired both innately and through learning. Despite the ubiquity of the fear response, and its established importance for shaping predator-prey interactions, little is known about why different fear acquisition strategies evolve or why mixed strategies appear common. Here, we model the evolution of fear acquisition (learning versus innate) under predation. We assume a tradeoff where individuals that learn fear are at higher risk from predators initially, but eventually obtain a lower risk as they survive predation attempts. We find that frequent predator encounters, predators that are not very dangerous, and effective learning favor the evolution of learned fear. Only pure strategies of fear acquisition evolve unless individuals suffer from either a cost to fear or, especially, a cost to learning, either of which can lead to the evolution of mixed strategies. Our results thus shed light onto the evolution of mixed fear acquisition strategies and open the door to further research on the evolution of fear acquisition., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Accurately determining the mutagenicity of small-molecule N-nitrosamine drug impurities and nitrosamine drug substance-related impurities (NDSRIs) is critical to identifying mutagenic and cancer hazards. In the current study we have evaluated several approaches for enhancing assay sensitivity for evaluating the mutagenicity of N-nitrosamines in the bacterial reverse mutagenicity (Ames) test. Preincubation assays were conducted using five activation conditions: no exogenous metabolic activation and metabolic activation mixes employing both 10% and 30% liver S9 from hamsters and rats pretreated with inducers of enzymatic activity. In addition, preincubations were conducted for both 60 min and 30 min. These test variables were evaluated by testing 12 small-molecule N-nitrosamines and 17 NDSRIs for mutagenicity in Salmonella typhimurium tester strains TA98, TA100, TA1535, and TA1537, and Escherichia coli strain WP2 uvrA (pKM101). Eighteen of the 29 N-nitrosamine test substances tested positive under one or more of the testing conditions and all 18 positives could be detected by using tester strains TA1535 and WP2 uvrA (pKM101), preincubations of 30 min, and S9 mixes containing 30% hamster liver S9. In general, the conditions under which NDSRIs were mutagenic were similar to those found for small-molecule N-nitrosamines., Competing Interests: Declaration of competing interest To the best of their knowledge, the authors are not aware that they have any of the conflicts of interests listed in the Instructions to Authors., (Published by Elsevier Inc.)

Background: Race- and ethnicity-based differences in treatment access and outcomes have been reported in the orthopaedic sports medicine literature. However, the rate at which race and ethnicity are reported and incorporated into the statistical analysis of sports medicine studies remains unclear., Purpose: To determine the rate at which race and ethnicity are reported and analyzed in athlete-specific sports medicine literature., Study Design: Systematic review; Level of evidence, 4., Methods: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, articles published by the 3 journals of the American Orthopaedic Society for Sports Medicine between 2017 and 2021 were considered for inclusion. Original sports medicine research studies that focused on athletes were included. Outcome measures included reporting and analysis of patient demographics (age, sex, race, ethnicity). Studies that included demographic variables in a multivariate analysis or that performed a race-/ethnicity-based stratified analyses were considered to have analyzed that variable. Studies that reported and/or analyzed patient demographics were examined. Chi-square tests were performed to determine statistical significance., Results: A total of 5140 publications were screened, and 842 met the inclusion criteria. Age and sex were well reported (84.1% and 87.0%, respectively), while race (3.8%) and ethnicity (2.0%) were poorly reported. There was no difference in rates of reporting age, sex, race, or ethnicity between the American Journal of Sports Medicine ( AJSM ), the Orthopaedic Journal of Sports Medicine ( OJSM ), or Sports Health: A Multidisciplinary Approach ( Sports Health ). The rate of analysis was also calculated as a percentage of the studies that reported that variable. Of the studies that reported age, 38.5% analyzed age. Using this method, 26.2% of studies analyzed sex, 40.6% analyzed race, and 17.6% analyzed ethnicity. Although there was no difference in the overall rate at which studies from the 3 journals analyzed ethnicity, Sports Health studies analyzed age ( P = .044), sex ( P = .001), and race ( P = .027) more frequently than studies published in AJSM and OJSM . Of the studies that analyzed race, most of those studies (8/13, 61.5%) found significant race-based differences in reported outcomes., Conclusion: This systematic review demonstrated that race and ethnicity are poorly reported and analyzed in athlete-specific sports medicine literature, despite the fact that a majority of studies analyzing race found significant differences between racial groups. Improved reporting of race and ethnicity can determine whether race- and ethnicity-based differences exist in patient interventions to ameliorate disparities in patient outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: F.P.T. has received consulting fees from DePuy Synthes Products and Medical Device Business Services; hospitality payments from MicroVention and Smith+Nephew; and holds stock options from Trice Medical. M.E.B. has received a grant from Arthrex; education payments from Gotham Surgical Solutions & Devices, Arthrex, and Smith+Nephew; and hospitality payments from Stryker. K.B.F. has received a grant from Vericel; education payments from Liberty Surgical; consulting fees from Vericel, Innocoll, and Medical Device Business Services; nonconsulting fees from Vericel; and honoraria from Vericel. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

Background: Although the incidence of osteochondritis dissecans (OCD) of the knee may be low, an overview and comparison of sports-related outcomes with current surgical management techniques are needed., Purpose: To summarize the available evidence regarding outcomes for different surgical treatment options for unstable OCD of the knee in both skeletally mature and immature patients by calculating the return to sports (RTS) rate, the mean RTS time, and other sports-related postoperative outcome measures., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review of studies on RTS after surgical correction of unstable OCD within the knee was conducted utilizing PubMed, Embase, and the Cochrane databases. Included were studies discussing the treatment of unstable OCD with minimum 1-year follow-up outcomes. Multivariate analysis was used to compare studies grouped together based on RTS and skeletal maturity., Results: Of 2229 articles, 6 studies (197 patients; 198 knees) met the inclusion criteria and were included in our analysis. The percentage of patients who returned to the previous level of sport ranged from 52% to 100%; those returning to any level of sport ranged from 87% to 100%. Clinical outcomes did not differ between patients with open versus closed physes. Osteochondral Autograft Transfer System (OATS) procedures had a 100% RTS rate across several studies with skeletally mature and mixed cohorts, and microfracture had the lowest overall RTS rate (52%). For skeletally immature patients, all examined studies that utilized either open or arthroscopic reduction and internal fixation, 77% and 78%, respectively, had acceptable RTS rates. Arthroscopic fixation had a higher rate of revision surgery in both skeletally mature and immature patients., Conclusion: Our analysis indicated that the treatment of unstable OCD lesions using the OATS technique demonstrated high RTS rates across several studies, while microfracture alone exhibited the lowest RTS rate. Both arthroscopic and open internal fixation utilizing bioabsorbable screws yielded satisfactory RTS rates for juvenile patients with OCD., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.B.F. has received grant support from Vericel; education payments from Liberty Surgical; consulting fees from Vericel, Innocoll, and Medical Device Business Services; nonconsulting fees from Vericel; and honoraria from Vericel. M.E.B. has received grant support from Arthrex; education payments from Arthrex and Smith+Nephew; and hospitality payments from Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

Background: Patient sex is known to affect patient outcomes in sports medicine. Historically, many studies on athletes have focused on male athletes and been generalized to female athletes., Hypothesis: Studies with female first or senior authors will isolate female athletes as study participants more frequently than studies with male first or senior authors., Study Design: Systematic review; Level of evidence, 4., Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocols, original research studies published between 2017 and 2021 that analyzed athletes were systematically screened from the 6 top sports medicine journals ( British Journal of Sports Medicine ; Arthroscopy: The Journal of Arthroscopic and Related Surgery ; Knee Surgery, Sports Traumatology, Arthroscopy ; American Journal of Sports Medicine ; Orthopaedic Journal of Sports Medicine ; Sports Health: A Multidisciplinary Approach ). Articles were included for analysis if they met the following criteria: (1) original sports medicine research study, (2) analysis involving athletes, and (3) inclusion of ≥10 participants. Exclusion criteria included (1) review articles of any type and (2) cadaveric studies. The determination of author sex was completed using the name-to-gender assignment algorithm Genderize.io (https://genderize.io/)., Results: A total of 1146 studies were included in quantitative analysis. There were 246 studies with a female first author (21.5%) and 191 studies with a female senior author (16.7%). When looking at all authors (first, senior, and intermediate), 19.9% were female. Female first authors were over 4 times more likely to isolate female athletes in clinical research than male first authors (17.5% vs 3.8%, respectively; P < .001). Female senior authors were approximately twice as likely to isolate female athletes compared with male senior authors (11.5% vs 5.8%, respectively; P < .001)., Conclusion: Female first authors were significantly more likely to perform research isolating female athletes. While improving the frequency of female athlete research is multifactorial, increasing the number of female researchers may have a direct effect on improving gender equality in sports medicine research., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.B.F. has received consulting fees from DePuy, Vericel, Medical Device Business Services, and Innocoll and support for education from Liberty Surgical. M.E.B. has received support for education from Gotham Surgical, Smith & Nephew, and Arthrex and research support from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Objectives: To describe injury frequency and characteristics in roundnet athletes and compare injury characteristics between elite and non-elite athletes., Methods: This cross-sectional study was performed by convenience sampling recreational and competitive roundnet athletes via a REDCap survey distributed through social media platforms. The custom survey evaluated athlete demographics, past sport participation, training workload and roundnet-related injuries throughout their whole playing career. Injury characteristics were reported for the full study cohort and compared between elite and non-elite athletes., Results: 166 athletes participated in the study, with 33.7% playing at the elite level. 279 injuries were reported, with 86.1% (n=143) of athletes reporting at least one injury throughout their playing career. Injuries most frequently involved the shoulder (20%), ankle (18%), knee (14%) and elbow (14%). 47% of reported injuries occurred due to overuse, and 67% resulted in missed competition time averaging 2.0 months. There were 10 injuries (3.6%) that required surgery. No differences were found in regards to injury frequency (1.9±1.5 vs 1.6±1.1 injuries per athlete, p=0.159) or any injury characteristics between elite and non-elite athletes., Conclusion: Roundnet athletes experienced a mean of 1.7±1.2 injuries while playing roundnet. Injuries most frequently involved the shoulder and ankle and often resulted in missed competition time. The level of competition does not significantly impact injury frequency or characteristics. Roundnet athletes may benefit from injury prevention programmes that include shoulder strengthening, maintaining shoulder range of motion and ankle stability., Competing Interests: Competing interests: RWP: none. RG: none. RM: none. SB: none. MEB: education payments from Smith & Nephew, and Gotham Surgical Solutions & Devices Inc, hospitality payments from Stryker and grant payments from Arthrex. KBF: education payments from Liberty Surgical Inc, honoraria and speaking fees from Vericel Corp, consulting fees from Medical Device Business Services Inc and personal fees from DePuy. American Orthopaedic Society for Sports Medicine: board or committee member., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Female sports participation continues to rise; however, inequalities between male and female athletes still exist in many areas and may extend into medical research., Purpose: The purpose of this study was to (1) compare the number of published studies evaluating male versus female athletes in various sports and (2) identify which co-ed sports currently underrepresent female athletes in the sports medicine literature., Study Design: Systematic review; Level of evidence, 4., Methods: All nonreview research studies published from 2017 to 2021 in 6 top sports medicine journals were considered for inclusion. Sports medicine studies were included that isolated athletes, reported study outcomes specific to male and/or female patients, provided study outcomes for specific sports, and evaluated ≤3 different sports. The total number of studies reporting on male and/or female athletes were compared for all sports, and odds ratios (ORs) were calculated. Comparisons of study design, level of sports participation, outcomes assessed, and study quality were also made according to participant sex., Results: Overall, 669 studies were included the systematic review. Most studies isolated male athletes (70.7%), while 8.8% isolated female athletes and 20.5% included male and female athletes. Female athletes were more frequently studied in softball and volleyball, while male athletes were more commonly researched in baseball, soccer, American football, basketball, rugby, hockey, and Australian football. Notably, male athletes were largely favored in baseball/softball (91% vs 5%; OR = 18.2), rugby (72% vs 5%; OR = 14.4), soccer (65% vs 15%; OR = 4.3), and basketball (58% vs 18%; OR = 3.2)., Conclusion: Sports medicine research has favored the evaluation of male athletes in most sports, including the majority of co-ed sports. Potential reasons for this inequality of research evaluation include availability of public data and database data, financial and promotional incentives, a high percentage of male sports medicine clinicians and researchers, and sex biases in sport. While the causes of these differences are multifaceted, researchers should consider both sexes for study inclusion whenever possible, and journals should support a more balanced representation of research publications regarding male and female athletes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.B.F. has received consulting fees from Medical Device Business Services and Innocoll Inc, support for education from Liberty Surgical, honoraria from Vericel, and personal fees from DePuy. M.E.B. has received support for education from Smith & Nephew and Gotham Surgical Solutions, hospitality payments from Stryker, and a grant from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Sex differences in sports medicine are well documented. However, no studies to date have reviewed the rate at which sex is reported and analyzed in the athlete-specific orthopaedic sports medicine literature., Purpose: To determine the rates of reporting and analyzing patient sex in athlete-specific sports medicine literature., Study Design: Systematic review; Level of evidence, 4., Methods: Articles published by the 3 journals of the AOSSM ( American Journal of Sports Medicine [ AJSM ], Orthopaedic Journal of Sports Medicine , and Sports Health: A Multidisciplinary Approach ) between 2017 and 2021 were considered for inclusion. Original sports medicine research studies that isolated athletes were included. Studies that isolated sports that are predominantly single sex at the college and/or professional levels (football, baseball, softball, and wrestling) were excluded., Results: Of the 5140 publications screened, 559 met the inclusion criteria. In total, 93.9% of all studies reported patient sex, and 34.7% of all studies analyzed patient sex. However, 143 studies only included males and 50 studies only included females (n = 193). When excluding these single-sex studies, analysis of the remaining 366 studies found that the rate of sex-specific analysis increased to 53.0%. Rates of reporting patient sex did not significantly differ by journal or by year. Similarly, rates of analyzing patient sex did not differ by year, but Sports Health analyzed sex the most frequently, and AJSM analyzed sex the least frequently ( P = .002). Studies that isolated college (84.1%), youth (66.7%), or recreational (52.6%) athletes analyzed sex at or above the overall rate of 53.0%, but studies of elite athletes (35.7%) tended to analyze sex less frequently., Conclusion: Patient sex is well reported in the athlete-specific sports medicine literature (93.9% of included studies reported sex), demonstrating that most studies include sex as a demographic variable. However, patient sex was analyzed only in 53.0% of studies that included both male and female patients. Given that athlete-specific sex differences are known to exist within the field of sports medicine, many studies that could benefit from using patient sex as a variable for analysis likely fail to do so.

Background: Patella alta is a risk factor for recurrent patellar instability. Differences in chondral injury in patients with patellar instability between patella alta and patella norma have not been evaluated., Purpose: To analyze whether preoperative cartilage damage differs in severity and location between patellar instability patients with and without patella alta., Study Design: Cohort study; Level of evidence, 3., Methods: Patients with patellar instability who underwent patellar realignment surgery at a single institution with preoperative magnetic resonance imaging (MRI) scans were included. After measurement of Caton-Deschamps index (CDI) on MRI, patients were divided into patella alta (CDI ≥1.3) and patella norma groups. The area measurement and depth and underlying structures (AMADEUS) score was used to quantify cartilage defect severity on MRI., Results: A total of 121 patients were divided into patella alta (n = 50) and patella norma (n = 71) groups. The groups did not differ significantly in sex ratio, age at MRI, body mass index, mean reported number of previous dislocations, or mean interval between first reported dislocation and date of MRI. A total of 34 (68%) of the patella alta group and 44 (62%) of the patella norma group had chondral defects ( P = .625) with no significant between-group differences in defect size ( P = .419). In both groups, chondral injuries most affected the medial patellar facet (55% in patella alta vs 52% in patella norma), followed by the lateral facet (25% vs 18%), and lateral femoral condyle (10% vs 14%). A smaller proportion of patients had full-thickness defects in the patella alta compared with the patella norma group (60% vs 82%; P = .030). The overall AMADEUS score was higher for the patella alta versus the patella norma group (68.9 vs 62.1; P = .023), indicating superior articular cartilage status., Conclusion: Patients with patella alta had less severe cartilage injury after patellar instability, including a lower proportion with full-thickness defects and better overall cartilage grade. The location of injury when present was similar between alta and norma, with most defects affecting the medial facet, lateral facet, and lateral femoral condyle in descending frequency., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.R. has received education payments from Liberty Surgical and Medical Device Business Services. B.J.E. has received research support from Arthrex, DePuy, Linvatec, Smith & Nephew, and Stryker and consulting fees from Arthrex. F.P.T. has received consulting fees from DePuy/Medical Device Business Services, has stock/stock options in Trice Medical, and has received hospitality payments from Smith & Nephew. K.B.F. has received consulting fees from DePuy and Vericel. M.E.B. has received education payments from Gotham Surgical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications., Methods: A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted., Results: There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected ( P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified-a significantly lower complication rate than that reported in the literature ( P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature ( P < .0001; CI 0.067-1.94)., Conclusion: In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients' overall recovery, a significantly lower rate of complications existed compared to that reported in the literature., Level of Evidence: Level IV., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Purpose: It is unclear if an elevated tibial tubercle-trochlear groove (TT-TG) distance is a risk factor for poor outcomes following ACLR. Therefore, the purpose of this study was to determine whether patients with an elevated TT-TG have an increased risk of retear following primary ACLR compared to controls with a normal TT-TG., Methods: All patients who underwent primary ACLR between July 2018 and June 2019 with an available preoperative magnetic resonance imaging (MRI) were eligible for inclusion. TT-TG distance was measured on preoperative MRI scans by two independent investigators. Clinical outcomes, return-to-sport rates, and Lysholm scores were compared between patients with a TT-TG < 12.5 mm (normal) and those with a TT-TG ≥ 12.5 mm (elevated)., Results: Overall, 159 patients were included, 98 with normal TT-TG distance and 61 with elevated TT-TG distance. Patients with an elevated TT-TG distance had worse post-operative Lysholm scores than patients with a normal TT-TG distance (83.0 vs. 95.0, p = 0.010). In patients who received a bone-patellar tendon-bone (BTB) graft, an elevated TT-TG distance was associated with higher rates of subjective instability (13.0% vs. 3.0%, p = 0.041), reoperation (13.0% vs. 1.5%, p = 0.012), and post-operative complications (25.0% vs. 8.2%, p = 0.026), as well as lower ACL psychological readiness scores (324.1 vs. 446.7, p = 0.015)., Conclusion: Patients with an elevated pre-operative TT-TG distance have worse Lysholm scores than patients with normal TT-TG distance. Patients with an elevated pre-operative TT-TG distance who underwent ACLR with BTB grafts had significantly higher rates of subjective instability, reoperation, and post-operative complications., Level of Evidence: III., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Hypothesis and Background: Controversy exists as to the ideal management of young active patients with subcritical glenoid bone loss and an off-track Hill-Sachs lesion, and the Latarjet and arthroscopic Bankart with remplissage are effective surgical options. The purpose of this study was to compare rates of recurrent instability and reoperation, as well as patient-reported outcome measures, between Latarjet and arthroscopic Bankart repair with remplissage surgery patients. The authors hypothesized that there would be no difference in rates of recurrent instability, reoperation, and postoperative outcomes between patients who underwent Latarjet surgery and patients who underwent Bankart repair with concomitant remplissage postoperatively., Materials and Methods: All patients who underwent primary shoulder stabilization for shoulder instability from 2014 to 2019 were screened. Latarjet and Bankart repair with remplissage patients were included if arthroscopic surgery was performed in response to anterior shoulder instability. Recurrent instability, revision, shoulder range of motion, return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores) were compared between groups., Results: Overall, 43 Latarjet patients (age: 29.8 ± 12.1 years, 36 males 7 females) and 28 Bankart repair with remplissage patients (age: 28.2 ± 8.8 years, 25 males 3 females) were included with a mean follow-up of 3.3 ± 1.9 years. Patients who underwent Latarjet surgery had larger amounts of bone loss (19% vs. 11%, P < .001), a lower rate of off-track Hill-Sachs lesions (47% vs. 82%, P < .001), and more frequently had a history of chronic shoulder dislocations (88% vs. 43%, P < .001) compared to Bankart repair with remplissage patients. Latarjet patients less frequently reported feeling subjective shoulder instability after surgery (21% vs. 50%, P = .022), which was defined as feeling apprehension or experiencing a shoulder subluxation or dislocation event. There were no differences in rates of postoperative dislocation, revision, reoperation, or RTS, as well as patient-reported outcome scores, between groups (all P > .05)., Conclusion: Despite differences in osseous defects, Latarjet and Bankart repair with remplissage patients had similar rates of clinical, patient-reported, and RTS outcomes at a mean of 3.3 years postoperatively. Latarjet surgery patients may be less likely to experience subjective shoulder instability postoperatively than patients who undergo Bankart repair with concomitant remplissage., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Mentorship is a key part of the development of knowledge and skills in orthopedics. Mentorship at each of these different phases is important to preparing and enabling a competent, knowledgeable, and well-rounded surgeon. Although the mentor is generally the one in a senior position, experienced in their field, the mentee is the protégé or the trainee engaged in a relationship with the person with expertise. There should be mutual responsibility on both sides to develop a collaborative relationship in order to optimize value in the relationship for both parties., Competing Interests: Disclosure The authors have no relevant disclosures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to determine whether a preoperative Caton-Deschamps index (CDI) ≥ 1.30, as measured by magnetic resonance imaging, is associated with rates of postoperative instability, revision knee surgery, and patient-reported outcomes in patients undergoing isolated medial patellofemoral ligament (MPFL) reconstruction., Methods: Patients who underwent primary medial patellofemoral ligament reconstruction (MPFLR) between 2015 and 2019 at a single institution were assessed. Only those with at least 2 year follow up were included. Patients who had undergone a previous ipsilateral knee surgery, concomitant tibial tubercle osteotomy and/or ligamentous repair/reconstruction at the time of MPFL reconstruction were excluded from the study. CDIs were evaluated by three investigators based on magnetic resonance imaging measurement. Patients with a CDI ≥ 1.30 were included in the patella alta group, while those with a CDI between 0.70 and 1.29 served as controls. A retrospective review of clinical notes was used to evaluate the number of postoperative instability episodes and revisions. Functional outcomes were measured by the International Knee Documentation Committee (IKDC) and 12-Item Short Form Health Survey (SF-12) physical and mental scores., Results: Overall, 49 patients (50 knees, 29 males, 59.2%) underwent isolated MPFLR. Nineteen (38.8%) patients had a CDI ≥ 1.30 (mean: 1.41, range: 1.30-1.66). The patella alta group was significantly more likely to experience a postoperative instability episode (36.8% vs 10.0%; P  = .023) and was more likely to return to the operating room for any reason (26.3% vs 3.0%; P  = .022) compared to those with normal patellar height. Despite this, the patella alta group had significantly greater postoperative IKDC (86.5 vs 72.4; P  = .035) and SF-12 physical (54.2 vs 46.5; P  = .006) scores. Pearson's correlation showed a significant association between CDI and postoperative IKDC ( R 2  = 0.157; P  = .022) and SF-12P ( R 2  = .246; P  = .002) scores. There was no difference in postoperative Lysholm (87.9 vs 85.1; P  = .531). and SF-12M (48.9 vs 52.5; P  = .425) scores between the groups., Conclusion: Patients with preoperative patella alta, as measured by CDI had higher rates of postoperative instability and return to the OR with isolated MPFL reconstruction for patellar instability. Despite this, higher preoperative CDI was associated with greater postoperative IKDC scores and SF-12 physical scores in these patients., Level of Evidence: Retrospective cohort study, Level IV., (© 2023 The Authors.)

Purpose: To compare outcomes of reverse total shoulder arthroplasty (RTSA) in patients with prior arthroscopic acromioplasty versus a control group of patients with no history of acromioplasty., Methods: We performed a retrospective matched-cohort study of patients from a single institution who underwent RTSA with a history of acromioplasty from 2009 to 2017 with a minimum 2-year follow-up period. Patients' clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons shoulder score and Simple Shoulder Test, visual analog scale, and Single Assessment Numeric Evaluation surveys. Postoperative radiographs and patient charts were reviewed to determine whether patients sustained a postoperative acromial fracture. Charts were reviewed to determine range of motion and postoperative complications. Patients were matched on a 1:1 basis to a cohort of patients who underwent RTSA without a history of acromioplasty, and comparisons were performed using t and χ 2 tests., Results: Forty-five patients who underwent RTSA with a history of acromioplasty met the inclusion criteria and completed the outcome surveys. There were no significant differences between cases and controls in post-RTSA American Shoulder and Elbow Surgeons, visual analog scale, Simple Shoulder Test, or Single Assessment Numeric Evaluation outcome scores. There was no difference in the postoperative acromial fracture rate between cases and controls ( P  = .577). Overall, more complications occurred in the study group (n = 6, 13.3%) compared with the control group (n = 4, 8.9%); however, this difference was not statistically significant ( P  = .737)., Conclusions: After RTSA, patients who have undergone a prior acromioplasty have similar functional outcomes without a significant difference in the rate of postoperative complications compared with patients with no history of acromioplasty. Furthermore, previous acromioplasty does not increase the risk of acromial fracture after RTSA., Level of Evidence: Level III, retrospective comparative study., (© 2022 The Authors.)

Purpose: To compare the results of patients who underwent Bankart repair with or without concomitant remplissage for treatment of shoulder instability., Methods: All patients who underwent shoulder stabilization for shoulder instability from 2014 to 2019 were evaluated. Patients who underwent remplissage were matched to those patients who received no remplissage based on sex, age, body mass index, and date of surgery. Glenoid bone loss and presence of an engaging Hill-Sachs lesion were quantified by 2 independent investigators. Postoperative complications, recurrent instability, revision, shoulder range of motion (ROM), return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons scores) were compared between groups., Results: Overall, 31 patients who underwent remplissage were identified and matched to 31 patients who received no remplissage at a mean follow-up of 2.8 ± 1.8 years. Glenoid bone loss was similar between groups (11% vs 11%, P  = .956); however, engaging Hill-Sachs lesions were more prevalent in the patients who underwent remplissage than the patients who received no remplissage (84% vs 3%, P < .001). There were no significant differences in rates of redislocation (remplissage: 12.9% vs no remplissage: 9.7%), subjective instability (45.2% vs 25.8%), reoperation (12.9% vs 0%), or revision (12.9% vs 0%) between groups (all P > .05). Also, there were no differences in RTS rates, shoulder range of motion, or patient-reported outcome measures (all P > .05)., Conclusions: If a patient is indicated for Bankart repair with concomitant remplissage, surgeons may expect shoulder motion and postoperative outcomes similar to those of patients without engaging Hill-Sachs lesions who undergo Bankart repair without concomitant remplissage., Level of Evidence: Therapeutic case series, level IV., (© 2022 The Authors.)

Background Collegiate electronic sports (esports) in the United States has grown from seven varsity programs in 2016 to over 200 today. Despite its growing success, little has been studied on the injuries of these athletes. In this study, we aimed to investigate the prevalence of injuries sustained by collegiate esports players and explore the injuries' impacts on their careers. The authors hypothesized that athletes who spend more time practicing and playing competitively in esports will report an increased history of musculoskeletal injury. Methodology This was a cross-sectional study, level IV evidence. A list of collegiate esports athletes was collected from publicly available sources. Athletes with available contact information were sent a self-reporting questionnaire. The questionnaire examined variables including length of time playing esports, hours/day playing esports, esports-related injury history, surgeries needed, and missed competition time. Results Overall, 153 collegiate esports athletes (88% male, aged 18-42 years) were included, with 41 (26.8%) having experienced at least one injury from esports. Of the 41 injured athletes, three (7.3%) required surgery, 17 (41.5%) had multiple injuries, and seven (17.1%) missed competition time for an average of 3.0 ± 2.3 weeks. Athletes who have been on their respective college team longer (2.0 ± 1.0 vs. 1.7 ± 0.9 years, p = 0.03) and who spent more hours per day practicing had a higher injury incidence (p = 0.01). There was no difference in the current age, sex, age at which athletes began competing in esports, and scholarship status between groups (all p > 0.05). When analyzing the 41 athletes who experienced an injury, the most common injury was to the wrist with 25 total injuries. There were 11 neck, 10 back, nine finger, eight hand, six elbow, and four thumb injuries. Conclusions Collegiate esports players who trained for more hours per day (31.7% of injured players vs. 10.7% of uninjured players practiced more than five hours/day, p = 0.01) and played competitive collegiate esports for more years (2.0 ± 1.0 vs. 1.7 ± 0.9 years, p = 0.03) were more likely to have experienced an esports-related injury. Fortunately, only a small portion of athletes who experienced an injury was forced to miss competition time or require surgery. With this being the largest investigation into collegiate esports-related injuries, future medical research regarding the incidence, management, and prevention of its injuries can help collegiate and professional programs place a greater emphasis on the health of their athletes., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2022, Clements et al.)

Background: Preoperative coracoid dimensions may affect the size of the bone graft transferred to the glenoid rim and thus the postoperative outcomes of Latarjet coracoid transfer., Purpose: To determine the effect of coracoid length and width as measured on preoperative magnetic resonance imaging (MRI) on outcomes after Latarjet treatment of anterior shoulder instability., Study Design: Cohort study; Level of evidence, 3., Methods: Included were patients who underwent primary Latarjet surgery between 2009 and 2019 and had preoperative MRI scans and minimum 2-year postoperative outcomes. Longitudinal coracoid length was measured on axial MRI sequences as the distance from the coracoclavicular ligament insertion to the distal tip. Comparisons were made between shorter and longer coracoids and between narrower and wider coracoids. The outcomes of interest were recurrent instability, reoperation, complications, return to sport (RTS), and American Shoulder and Elbow Surgeons (ASES) score. Independent-samples t test, Mann-Whitney test, chi-square test, and Fisher exact test were used to compare outcomes between groups, and univariate correlation coefficients were calculated to evaluate the relationships between demographics and coracoid dimensions., Results: Overall, 56 patients were included (mean age, 28.4 years). The mean ± SD coracoid length was 21.6 ± 2.4 mm and width 10.0 ± 1.0 mm. Relative to patients with a longer coracoid (≥22 mm; n = 26), patients with a shorter coracoid (<22 mm; n = 30) had similar rates of recurrent instability (shorter vs longer; 6.7% vs 3.8%), complications (10.0% vs 15.4%), reoperation (3.3% vs 7.7%), and RTS (76.5% vs 58.8%) and similar postoperative ASES scores (85.0 vs 81.6) ( P ≥ .05 for all). Likewise, relative to patients with a wider coracoid (≥10 mm; n = 27), patients with a narrower coracoid (<10 mm; n = 29) had similar prevalences of recurrent instability (narrower vs wider; 6.9% vs 3.7%), complications (17.2% vs 7.4%), reoperation (3.5% vs 7.4%), and RTS (66.7% vs 68.4%) and similar postoperative ASES scores (87.1 vs 80.0) ( P ≥ .05 for all)., Conclusion: Patients undergoing Latarjet coracoid transfer had similar postoperative outcomes regardless of preoperative coracoid dimensions. These findings should be confirmed in a larger cohort before further clinical recommendations are made., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.B.F. has received education payments from Liberty Surgical, consulting fees from DePuy/Medical Device Business Services, and speaking fees and honoraria from Vericel. M.E.B. has received grant funding from Arthrex, education payments from Arthrex and Smith & Nephew, and hospitality payments from Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Both beach-chair and lateral decubitus patient positioning are often utilized for shoulder arthroscopy, with each offering its unique advantages and disadvantages. The surgical position is often selected according to each surgeon's preference, with no clear superiority of one position over the other., Purpose/hypothesis: The purpose was to compare clinical and patient-reported outcomes between patients who underwent arthroscopic posterior labral repair in the beach-chair versus the lateral decubitus position. We hypothesized that patient positioning would not affect clinical and patient-reported outcomes., Study Design: Cohort study; Level of evidence, 3., Methods: A list of all patients diagnosed with the Current Procedural Terminology codes 29806 and 29807 between 2015 and 2019 was obtained from the medical records. Patients were only included if arthroscopic posterior labral repair with or without concomitant superior labral anterior to posterior repair was confirmed. Data collected for eligible patients included the number of anchors used, perioperative and postoperative complications, redislocations, subjective instability, reoperation, and revision. Patients were also contacted to complete several patient-reported outcome surveys. Preoperative data, perioperative data, and postoperative outcomes were compared between patients who underwent surgery in the beach-chair versus lateral decubitus position., Results: Overall, 126 patients were included-69 patients underwent surgery in the lateral decubitus position and 57 in the beach-chair position-with a mean follow-up of 2.6 ± 1.7 years. There were no significant pre- or perioperative differences between groups. Rates of postoperative dislocations, subjective instability, reoperations, revisions, all complications, and return to sports rates also did not differ between groups (all, P > .05). Finally, there was no difference between groups regarding postoperative pain, function, and subjective instability scores (all, P > .05). Results of the multivariate regression analysis showed that increased age was a weak independent risk factor for subjective recurrent posterior shoulder instability (odds ratio, 1.04; P = .036)., Conclusion: Surgical positioning for arthroscopic posterior shoulder labral repair did not affect postoperative clinical and patient-reported outcomes. Both beach-chair and lateral decubitus position provided good outcomes for posterior shoulder labral repair, with an overall recurrence rate of 8.7%. Increased age was a weak independent risk factor for subjective recurrent instability.

Background: Surgical positioning can affect both perioperative and postoperative complication rates. It is unclear whether beach-chair versus lateral decubitus positioning affects outcomes in patients undergoing arthroscopic anterior shoulder stabilization surgery., Purpose: The purpose of this study was to compare recurrent instability, complications, and patient-reported outcomes between patients who underwent arthroscopic anterior shoulder stabilization in the beach-chair versus the lateral decubitus positions. It was hypothesized that recurrent instability, complications, and patient-reported outcomes would not be affected by surgical positioning., Study Design: Cohort study; Level of evidence, 3., Methods: The authors reviewed the medical records of patients who underwent shoulder stabilization ( Current Procedural Terminology codes 29806 and 29807) from 2015 to 2019. Patients were included only if anterior instability was confirmed, arthroscopic surgery was performed in response to shoulder instability, and a minimum of 2 years of follow-up data were available. Data collected for eligible patients included perioperative and postoperative complications, recurrent instability, reoperation, and revision. Patients also completed surveys for the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Oxford Shoulder Instability (OSI) score, and a return to any level of sport (RTS) questionnaire., Results: Overall, 294 patients (162 lateral decubitus and 132 beach-chair positions) were included, with an average follow-up of 2.4 ± 1.6 years. There were no significant differences in demographics between groups, nor were there differences in the rates of postoperative dislocations, subjective instability, reoperations, revisions, or complications. There was a trend toward a higher revision rate in the beach-chair group (beach-chair, 6.1% vs lateral decubitus, 1.9%; P = .069). There was no significant difference between groups regarding RTS rates or postoperative ASES, SANE, and OSI scores at 3.3 ± 1.1 years postoperatively., Conclusion: Surgical positioning for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, and patient-reported outcomes. Both beach-chair and lateral decubitus positioning provided good outcomes for anterior shoulder stabilization, with an overall recurrent dislocation rate of 7.8% at a mean of 3.3 years after surgery., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.B.F. has received education payments from Liberty Surgical, consulting fees from Medical Device Business Services, and speaking fees and honoraria from Vericel. B.J.E. has received research support from Arthrex, DePuy, Linvatec, Smith & Nephew, and Stryker; education payments from Arthrex, DePuy, and Smith & Nephew; and consulting fees from Arthrex. S.H. has received education payments from Liberty Surgical and hospitality payments from Arthrex and Smith & Nephew and has stock/stock options in Johnson & Johnson. M.E.B. has received grant payments from Arthrex, education payments from Arthrex and Smith & Nephew, and hospitality payments from Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: The coronavirus 2019 (COVID-19) pandemic resulted in the cancellation of the 2020 National Football League (NFL) preseason and a decreased preseason roster size. The effect of this disruption on athlete injury rates is unknown., Purpose/hypothesis: The purpose was to quantify the rates of anterior cruciate ligament (ACL), Achilles tendon, and hamstring tendon injuries in NFL players before and after the COVID-19 pandemic. We hypothesized that injury rates in the 2020 season would be higher than those seen prepandemic., Study Design: Descriptive epidemiology study. Level of evidence, 4., Methods: An online search using publicly available data was carried out to identify all NFL players who sustained an ACL, Achilles tendon, or hamstring tendon injury between April 1, 2017, and March 31, 2021. Data collected included player characteristics as well as career and season of injury workloads., Results: The number of Achilles tendon (27 vs 20; P = .024) and hamstring tendon (186 vs 149; P < .001) injuries, respectively, in the 2020 NFL season were significantly higher than the average of the 2017 to 2019 seasons. However, the number of ACL injuries sustained remained constant (43 vs 46; P = .175). More than half (52.9%) of ACL injuries in the 2017 to 2019 seasons occurred in the preseason, while most of the injuries (34.9%) in the 2020 season occurred in weeks 1 to 4. There was no player characteristic or career workload variable collected that was significantly different for players who sustained an ACL, Achilles tendon, or hamstring tendon injury in the 2020 NFL season compared with the 2017 to 2019 seasons., Conclusion: In the 2020 NFL season, the number of Achilles tendon and hamstring tendon injuries rose while the number of ACL injuries remained constant compared with the 2017 to 2019 seasons. Injuries that occurred during the first 4 games of the 2020 NFL season were consistent, with higher rates of injuries seen in the preseason in previous years., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.E.B. has received grant support from Arthrex, education payments from Arthrex and Smith & Nephew, and hospitality payments from Stryker. B.J.E. has received education payments from Arthrex, DePuy, Pinnacle, and Smith & Nephew and consulting fees from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Biceps tendon pathology is common in patients with rotator cuff tears. Leaving biceps pathology untreated in rotator cuff repairs (RCRs) may lead to suboptimal outcomes., Purpose/hypothesis: The purpose was to compare clinical outcomes between patients who underwent isolated RCR versus patients who underwent RCR with concomitant biceps treatment. It was hypothesized that there would be no difference in clinical outcomes between groups., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 244 patients who underwent RCR in 2016 were included. Patient characteristics, presence of concomitant biceps pathology, pre- and postoperative American Shoulder and Elbow Surgeons (ASES) scores, rotator cuff failure, revision surgery, and complications were recorded., Results: There were no significant differences between patients who underwent isolated RCR (n = 143) and those who underwent RCR with biceps treatment (n = 101) at 2 years postoperatively in ASES scores (RCR, 81.5; RCR+biceps treatment, 79.5; P = .532), cuff failure rate (5.6% vs 4.0%; P = .760), revision RCR rate (3.5% vs 2.0%; P = .703), or complication rate (11.9% vs 5.0%; P = .102). Furthermore, when comparing concomitant biceps tenotomy (n = 30) versus concomitant biceps tenodesis (n = 71), there were no differences in ASES scores ( P = .149), cuff failure rate ( P > .999), revision RCR rate ( P > .999), or complication rate ( P > .999) postoperatively. Finally, when comparing arthroscopic biceps tenodesis (n = 50) versus subpectoral biceps tenodesis (n = 21), there were no differences in ASES scores ( P > .592), cuff failure rate ( P > .999), revision RCR rate ( P = .507), or complication rate ( P > .999) 2 years postoperatively., Conclusion: Addressing biceps pathology when performing RCR resulted in similar rates of cuff failure, revision RCR, and complications, as well as a similar improvement in patient-reported outcomes when compared with isolated RCR at 2 years postoperatively. Furthermore, when comparing tenotomy versus tenodesis and arthroscopic versus subpectoral tenodesis, comparable outcomes with regard to rate of rotator cuff repair failure, revision RCR, complications, and patient-reported outcomes were found.

Background: Female surgeons, representing 6.5% of the American Academy of Orthopaedic Surgeons, are particularly vulnerable to work-family conflict. This conflict may deter women from considering orthopaedic surgery as a specialty. The study objective was to identify differences in work-family integration between female and male orthopaedic surgeons in the United States., Methods: An anonymous survey collecting data within the domains of work, family, and satisfaction was completed by 347 orthopaedic surgeons (153 female, 194 male). Differences in responses between males and females were identified., Results: Female surgeons were younger than males (mean, 41.1 versus 50.1 years; p < 0.001) and earlier in their careers, with 60.3% of males in practice >10 years compared with 26.1% of females (p < 0.001). Consulting (7.8% versus 31.4%; p < 0.001), course faculty positions (19.0% versus 39.2%; p < 0.001), and academic and leadership titles (30.7% versus 47.4%; p = 0.002) were significantly less common among females. There was a significant income disparity between females (mean yearly income, $300,000 to $400,000) and males (mean, $400,000 to $500,000; p < 0.001). Females were more likely to have never married (12.4% versus 2.6%; p < 0.001), or they married at a later mean age (30.2 ± 4.7 versus 28.3 ± 3.9 years; p < 0.001). Females were more likely to have no children (29.4% versus 7.8%; p < 0.001), require fertility treatment (32.0% versus 11.9%; p < 0.001), and not have children until after completing their medical training (63.0% versus 31.1%; p < 0.001). Female surgeons reported more responsibility in parenting (p < 0.001) and household duties (p < 0.001) than males. Work-family balance satisfaction was 72.3% in females and 82.1% in males (p = 0.081)., Conclusions: This study highlights deficiencies in work-family integration that appear to uniquely impact female orthopaedic surgeons. Female surgeons delay starting a family, more frequently require fertility treatments, carry more responsibility at home, have fewer academic and leadership roles, earn lower incomes, and are less satisfied with work-family balance relative to males. The discrepancy in work-family integration must be addressed to attract, support, and retain women as successful orthopaedic surgeons., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G812)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is one of the key tobacco-specific nitrosamines that plays an important role in human lung carcinogenesis. Repeated dose inhalation toxicity data on NNK, particularly relevant to cigarette smoking, however, is surprisingly limited. Hence, there is a lack of direct information available on the carcinogenic and potential non-carcinogenic effects of NNK via inhalational route exposure. In the present study, the subchronic inhalation toxicity of NNK was evaluated in Sprague Dawley rats. Both sexes (9-10 weeks age; 23 rats/sex/group) were exposed by nose-only inhalation to air, vehicle control (75% propylene glycol), or 0.2, 0.8, 3.2, or 7.8 mg/kg body weight (BW)/day of NNK (NNK aerosol concentrations: 0, 0, 0.0066, 0.026, 0.11, or 0.26 mg/L air) for 1 h/day for 90 consecutive days. Toxicity was evaluated by assessing body weights; food consumption; clinical pathology; histopathology; organ weights; blood, urine, and tissue levels of NNK, its major metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and their glucuronides (reported as total NNK, tNNK, and total NNAL, tNNAL, respectively); tissue levels of the DNA adduct O 6 -methylguanine; blood and bone marrow micronucleus (MN) frequency; and bone marrow DNA strand breaks (comet assay). The results showed that NNK exposure caused multiple significant adverse effects, with the most sensitive endpoint being non-neoplastic lesions in the nose. Although the genotoxic biomarker O 6 -methylguanine was detected, genotoxicity from NNK exposure was negative in the MN and comet assays. The Lowest-Observed-Adverse-Effect-Level (LOAEL) was 0.8 mg/kg BW/day or 0.026 mg/L air of NNK for 1 h/day for both sexes. The No-Observed-Adverse-Effect-Level (NOAEL) was 0.2 mg/kg BW/day or 0.0066 mg/L air of NNK for 1 h/day for both sexes. The results of this study provide new information relevant to assessing the human exposure hazard of NNK., (Published by Elsevier Ltd.)

Multidirectional instability (MDI) of the shoulder is characterized by generalized shoulder capsular laxity and symptomatic shoulder instability in more than one direction with one direction of instability as inferior. Generalized ligamentous laxity and specifically shoulder laxity, has been associated with female athletes. While males are at a higher risk of shoulder instability due to a number of extrinsic risk factors including participation in higher risk contact/collision activities, females are particularly susceptible to MDI due to their association with increased joint laxity. Patients with MDI often have a loose patulous capsule and display altered glenohumeral and scapulothoracic mechanics. The mainstay of treatment is physical therapy focusing on strengthening the dynamic stabilizers of the shoulder. In cases of failed rehabilitation, operative management most frequently includes either open or arthroscopic capsular shift with reasonably good outcomes and return to sport. Sex-related differences concerning shoulder instability risk and pathophysiology may influence treatment decisions and outcome measures. An understanding of the factors concerning shoulder instability specific to the female athlete is important in management and prevention of injury., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/aoj-20-33). The series “Sports Related Injuries of the Female Athlete” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2022 Annals of Joint. All rights reserved.)

Purpose: To retrospectively investigate the clinical and functional outcomes of patients who underwent knotted medial-row rotator cuff repair (KT-RCR) compared with patients who underwent knotless medial-row rotator cuff repair (KL-RCR)., Methods: A retrospective chart review of patients who underwent double-row transosseous-equivalent rotator cuff repair in 2016 was performed at a single institution with 2-year follow-up. Information regarding demographic characteristics, preoperative tear size (magnetic resonance imaging), surgical variables (including method of suture stabilization), preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) scores, and all complications (e.g., cuff failure, adhesive capsulitis, and persistent pain) was compiled., Results: A total of 189 patients met the inclusion criteria: 72 in the KL-RCR group and 117 in the KT-RCR group. No significant difference in preoperative ASES scores was found between the KL-RCR and KT-RCR groups (48.3 vs 45.4, P  = .327). Postoperative ASES scores did not differ between the groups (82.4 for KL-RCR vs 78.8 for KT-RCR, P  = .579). We found no significant difference in cuff failure rates after 2 years, determined by magnetic resonance imaging (5.6% for KL-RCR vs 6.1% for KT-RCR, P > .999), or complication rates (11.1% for KL-RCR vs 8.6% for KT-RCR, P  = .743)., Conclusions: The knotted approach and knotless approach to double-row rotator cuff repair showed similar outcome scores, cuff failure rates, and complication rates at minimum 2-year follow-up., Level of Evidence: Level III, retrospective therapeutic comparative trial., (© 2021 The Authors.)

Introduction: There has been recent interest in throwing from flat-ground versus the mound regarding stress on the elbow. Typical throwing progression programs begin with flat-ground work and progress to mound work., Methods: All baseball pitchers of ages 10 to 17 years who completed a 15-week pitching mechanics and velocity-training program were included. Players' pitch velocity was tested at four time points during training. Average velocity and maximum velocity of pitches from flat-ground were compared with those of mound, and change in velocity between testing sessions was also compared., Results: Thirty-six male pitchers (average age: 14.4 ± 1.6 years) were included. Fastball velocity increased by an average of 5.2 mph (95% confidence intervals 2.0 to 8.8 mph) at the end of the training program. When change in average and maximum velocity was compared between the four testing sessions, the most notable increase in velocity occurred between the third and fourth testing sessions. Both sessions were thrown from the mound., Conclusion: The 15-week baseball pitcher-training program markedly improved pitching velocity. Throwing from a mound compared with flat-ground resulted in the largest velocity increase. Therefore, when attempting to increase a pitcher's velocity, throwing from the mound should be an integral part of any velocity program., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is one of the key tobacco-specific nitrosamines that plays an important role in human lung carcinogenesis. However, repeated inhalation toxicity data on NNK, which is more directly relevant to cigarette smoking, are currently limited. In the present study, the subacute inhalation toxicity of NNK was evaluated in Sprague Dawley rats. Both sexes (9-10 weeks age; 16 rats/sex/group) were exposed by nose-only inhalation to air, vehicle control (75% propylene glycol), or 0.8, 3.2, 12.5, or 50 mg/kg body weight (BW)/day of NNK (NNK aerosol concentrations: 0, 0, 0.03, 0.11, 0.41, or 1.65 mg/L air) for 1 h/day for 14 consecutive days. Toxicity was evaluated by assessing body and organ weights; food consumption; clinical pathology; histopathology observations; blood, urine, and tissue levels of NNK, its major metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and their glucuronides (reported as total NNK, tNNK, and total NNAL, tNNAL, respectively); O6-methylguanine DNA adduct formation; and blood and bone marrow micronucleus frequency. Whether the subacute inhalation toxicity of NNK followed Haber's Rule was also determined using additional animals exposed 4 h/day. The results showed that NNK exposure caused multiple significant adverse effects, with the most sensitive endpoint being non-neoplastic histopathological lesions in the nose. The lowest-observed-adverse-effect level (LOAEL) was 0.8 mg/kg BW/day or 0.03 mg/L air for 1 h/day for both sexes. An assessment of Haber's Rule indicated that 14-day inhalation exposure to the same dose at a lower concentration of NNK aerosol for a longer time (4 h daily) resulted in greater adverse effects than exposure to a higher concentration of NNK aerosol for a shorter time (1 h daily)., (Published by Oxford University Press on behalf of the Society of Toxicology 2021.)

Background: The coronavirus disease of 2019 (COVID-19) pandemic led to the suspension and shortening of the 2020 Major League Baseball (MLB) season from 162 to 60 regular season games. The effect of this disruption on injury rates, specifically injury to the ulnar collateral ligament (UCL), has not been quantified., Purpose/hypothesis: The purpose of this study was to compare the rate of UCL reconstruction (UCLR), surgery timing, and pitching workload in MLB pitchers from before and after the COVID-19 pandemic lockdown. We hypothesized that UCLR rates relative to games played would be increased and pitching workload would be decreased in 2020 compared with previous seasons., Study Design: Cohort study; Level of evidence, 3., Methods: An extensive online search using publicly available data was conducted to identify all MLB pitchers who underwent UCLR between January 1, 2017, and December 31, 2020. Only pitchers who were competing at the MLB level when undergoing reconstruction were included. Player characteristics and surgery date, as well as career and season of surgery pitching workload, were collected for all included pitchers. All data were compared as a pooled sample (2017-2019 vs 2020)., Results: A similar number of pitchers underwent UCLR during or after the 2020 regular season (n = 18) compared with the 2017-2019 seasons (n = 16, 20, and 16, respectively). However, after accounting for the decrease in games played during the 2020 regular season, an MLB pitcher was 2.9 times more likely to undergo surgery per game after the COVID-19 lockdown compared with the previous years ( P < .001). MLB pitchers who underwent surgery in 2020 threw fewer preseason innings than did pitchers who underwent surgery between 2017 and 2019 (5.98 vs 9.39; P = .001)., Conclusion: MLB pitchers were almost 3 times more likely to undergo UCLR per game after the COVID-19 lockdown. A decreased preseason pitching workload because of the COVID-19 lockdown may have had an effect on per game UCLR rates., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.E.B. has received grant support from Arthrex; education payments from Arthrex and Smith & Nephew; and hospitality payments from Stryker. B.J.E. has received education payments from Arthrex, DePuy, and Smith & Nephew and consulting fees from Arthrex. F.G.A. has received speaking fees from Integra LifeSciences. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Purpose: To compare the measurements of the Caton-Deschamps index on preoperative magnetic resonance imaging and radiographs of patients undergoing operative management of patellar instability., Methods: Patients who underwent primary medial patellofemoral ligament reconstruction and/or tibial tubercle osteotomy between January 2015 and November 2019 were assessed. Caton-Deschamps indices were measured by 3 independent reviewers on both radiographs and magnetic resonance imaging. Intra- and interclass correlation coefficients and a Bland-Altman analysis were calculated to assess inter-rater reliability and measurement agreement between radiographic and magnetic resonance imaging., Results: Seventy-two patients (73 knees) were identified. The average Caton-Deschamps index was 1.23 ± 0.18 on radiograph and 1.26 ± 0.18 on magnetic resonance imaging. Strong inter-rater reliability was observed between reviewers for both radiographic and magnetic resonance imaging Caton-Deschamps indices (intraclass correlation coefficients 0.700 and 0.715, respectively). Pooled observer measurements revealed a moderate agreement between radiographic and magnetic resonance imaging for patella to tibia distance, weak agreement for patellar articular cartilage distance, and strong agreement for the Caton-Deschamps index (intraclass correlation coefficients 0.687, 0.485, and 0.749, respectively). Bland-Altman analysis demonstrated a mean difference in Caton-Deschamps index of -0.03 ± 0.15 (95% limits of agreement: -0.29 to 0.23) between radiographic and magnetic resonance imaging, meaning that Caton-Deschamps indices were on average 0.03 lower on radiographic than on magnetic resonance imaging., Conclusions: The Caton-Deschamps index has strong agreement between radiographic and magnetic resonance imaging in patients undergoing patellar stabilization surgery. Either modality can be reliably used to preoperatively assess patellar height., Level of Evidence: Level IV, diagnostic case series., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Case: This report describes a case of bilateral femoral head avascular necrosis during pregnancy with a subsequent anterior dislocation of the femoral head during labor in a 40-year-old woman., Conclusions: Many physiologic and hormonal changes occur during pregnancy. Although rare, hip pathologies may cause life-changing health outcomes, demonstrating a need for more research and careful monitoring throughout pregnancy., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B613)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

The tobacco-specific nitrosamine NNK [4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone] is found in tobacco products and tobacco smoke. NNK is a potent genotoxin and human lung carcinogen; however, there are limited inhalation data for the toxicokinetics (TK) and genotoxicity of NNK in vivo. In the present study, a single dose of 5 × 10-5, 5 × 10-3, 0.1, or 50 mg/kg body weight (BW) of NNK, 75% propylene glycol (vehicle control), or air (sham control) was administered to male Sprague-Dawley (SD) rats (9-10 weeks age) via nose-only inhalation (INH) exposure for 1 h. For comparison, the same doses of NNK were administered to male SD rats via intraperitoneal injection (IP) and oral gavage (PO). Plasma, urine, and tissue specimens were collected at designated time points and analyzed for levels of NNK and its major metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and tissue levels of DNA adduct O6-methylguanine by LC/MS/MS. TK data analysis was performed using a non-linear regression program. For the genotoxicity subgroup, tissues were collected at 3 h post-dosing for comet assay analysis. Overall, the TK data indicated that NNK was rapidly absorbed and metabolized extensively to NNAL after NNK administration via the three routes. The IP route had the greatest systemic exposure to NNK. NNK metabolism to NNAL appeared to be more efficient via INH than IP or PO. NNK induced significant increases in DNA damage in multiple tissues via the three routes. The results of this study provide new information and understanding of the TK and genotoxicity of NNK., (Published by Oxford University Press on behalf of the Society of Toxicology 2021. This work is written by US Government employees and is in the public domain in the US.)

Purpose: The purpose of this study is to further evaluate the construct validity and interobserver reliability of a hip arthroscopy virtual simulator using the Arthroscopic Surgery Skill Evaluation Tool (ASSET) global rating scale., Methods: Thirty participants (23 male/7 female) completed a diagnostic arthroscopy and a loose body retrieval simulation on the VirtaMed Arthros Hip Simulator (Zurich, Switzerland) twice at a minimum of 1 week apart. Subjects consisted of 12 novices (medical students, postgraduate year [PGY] 1-2), 5 intermediate trainees (PGY3-4), 9 senior trainees (PGY5 and fellows), and 4 attending faculty. Simulator metrics were recorded and then compiled to generate a total simulator score (TSS). The loose body retrieval was graded using the ASSET scoring tool. Inter-rater and intrarater reliability for the ASSET for 2 blinded raters and construct validity of the ASSET and the TSS were calculated. Correlation between the TSS, ASSET and individual simulator metrics was determined., Results: Prior simulation experience (P ≤ 0.01) correlated with higher TSS and higher ASSET, while video game experience correlated with higher TSS on the diagnostic module only (P = 0.004). There was a significant difference in ASSET score among all experience groups (P < 0.04). Novices had the lowest mean ASSET whereas experts had the highest mean ASSET with a difference of 17.4 points. Overall performance on the surgical module significantly correlated with the ASSET score (r = 0.444, P = 0.016). There was a significant positive correlation among higher ASSET and number of loose bodies retrieved, operation time, camera path and grasper path length, and percentage of cartilage injury. ASSET demonstrated excellent intrarater reliability and showed substantial or better inter-reliability in 8 of 9 domains., Conclusion: The VirtaMed hip arthroscopy simulator demonstrated good construct validity and excellent reliability for simulator-based metrics and ASSET score. Use of both simulator metrics and ASSET offers a more comprehensive performance assessment on hip arthroscopy simulation than either measure alone., Clinical Relevance: As virtual reality simulation for arthroscopy becomes more commonplace in orthopaedic training, evaluation of the most effective objective and subjective measures of performance is necessary to optimize simulation training., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Introduction: Orthopedic instrumentation is generally made as one-size-fits-all. The purpose of this study was to evaluate the effects of hand size and sex on ease of use and injury rates from orthopedic tools and surgical instruments., Methods: An anonymous 21-item online survey was distributed to orthopedic trainees and attendings. Questions regarding demographics, physical symptoms and treatment, perceptions, and instrument-specific concerns were included. The analysis included statistics comparing responses based on sex, height, and glove size, with significance as p<0.05., Results: There were 204 respondents: 119 female and 84 male. Male and female respondents differed significantly in height (mean difference 5.4 in, p<0.001) and glove size (median size 6.5 size for females, size 8 for males, p<0.001). While 69.8% of respondents reported physical discomfort or symptoms they attributed to their operating instruments, female surgeons were significantly more likely to endorse symptoms (87.3% female vs. 45.2% male, p<0.001). Of those reporting symptoms, 47.7% had undergone treatment, with no significant difference by surgeon sex (p=0.073). Female surgeons were significantly more likely than their male counterparts to have negative attitudes toward orthopedic surgical instruments and to report specific surgical instruments as difficult or uncomfortable to use., Conclusion: Female orthopedic surgeons are more likely than their male counterparts to report physical symptoms attributed to orthopedic surgical instruments, to have negative attitudes toward instruments, and to identify a larger number of common instruments as difficult or uncomfortable to use. Further emphasis on ergonomic instrument design is needed to allow all orthopedic surgeons to operate as safely and effectively as possible., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Fram et al.)

Introduction: The optimal tuberosity repair method in reverse total shoulder arthroplasty for fracture is unknown., Methods: Eight matched pairs of cadaver shoulders were randomly assigned to a stem-based tuberosity repair technique or a nonstem-based repair (Boileau technique) and mechanically tested with a 10 kN load cell. Cyclic loading was performed between 10 and 100 N for 500 cycles at 1 Hz, followed by static pull to failure at 33 mm/s. Ultimate load was determined from the maximum load reached during the pull to failure. A paired Student t-test was used to compare the means of the ultimate load and average cyclic displacement of the two sample groups., Results: The ultimate load to failure for the stem-based tuberosity repair technique was significantly higher than the nonstem-based technique (668 ± 164 N versus 483 ± 67 N; P = 0.032). The average cyclic displacement for the stem-based tuberosity repair technique was significantly less than the nonstem-based technique 0 (0.83 ± 0.67 mm versus 3.36 ± 2.36 mm; P = 0.017)., Conclusion: The stem-based tuberosity repair technique afforded higher ultimate load to failure with less average cyclic displacement than the nonstem-based technique. Consideration to the stem-based technique should be given when performing a tuberosity repair in the setting of reverse total shoulder arthroplasty for fracture., Level of Evidence: Level III., (Copyright © 2020 by the American Academy of Orthopaedic Surgeons.)

The goal of training in orthopedic residency is to produce surgeons who are proficient in all aspects of the practice of orthopedic surgery; however, most residents receive either inadequate or no training in medical coding. The purpose of this study was to determine how well orthopedic residents code when compared with practicing surgeons and to identify whether coding education improves accuracy in medical coding. A mock coding survey was developed using commonly encountered orthopedic clinical scenarios. The survey was distributed to orthopedic trainees post-graduate years (PGY) 1 to 6 at 2 training programs and to attending surgeons. Results were analyzed in 3 groups: junior residents (PGY 1-3), senior residents (PGY 4-6), and attending surgeons. Overall and subcategory scores of (1) type of visit, (2) modifiers, (3) Evaluation and Management (E/M), and (4) Current Procedural Terminology code identification were recorded. Participants were also asked if they had ever received various forms of coding education. Sixty-seven total participants were enrolled, including 28 junior residents, 24 senior residents, and 15 attendings. Practicing surgeons performed significantly better than both senior (P<.027) and junior (P<.001) residents in all categories, with a mean overall correct response rate of 72.8%, 51.0%, and 47.4%, respectively. Any form of coding education was associated with a significantly improved overall score for residents (P=.013) and a nonsignificant increase for attending surgeons (P=.390). This study demonstrates that residents performed poorly when identifying proper billing codes for common procedures and encounters in orthopedic surgery. Further, those participants who received coding education did better than those who did not. [Orthopedics. 2020;43(6):380-383.]., (Copyright 2020, SLACK Incorporated.)

Background: Total shoulder arthroplasty (TSA) is an effective treatment option for glenohumeral arthritis. Historically, this surgical procedure was performed on an inpatient basis. There has been a recent trend in performing TSA on an outpatient basis in the proper candidates., Methods: All patients who underwent outpatient TSA performed by a single surgeon between 2015 and 2017 were included. Demographic information and clinical outcome scores, as well as data on complications, readmissions, and revision surgical procedures, were recorded. This group of patients was then compared with a matched cohort of patients who underwent inpatient TSA over the same period., Results: Overall, 94 patients (average age, 60.4 years; 67.0% male patients) underwent outpatient TSA and were included. Patients who underwent outpatient TSA showed significant improvement in all clinical outcome scores at both 1 and 2 years postoperatively. The control group consisted of 77 patients who underwent inpatient TSA (average age, 62.6 years; 53.2% male patients). No significant differences in complications or improvements in clinical outcome scores were found between the inpatient and outpatient groups., Conclusion: TSA performed in an outpatient setting is a safe and reliable procedure that provides significant improvement in clinical outcome scores and no difference in complication rates compared with inpatient TSA., (© 2020 The Authors.)

Background: Pitching velocity is one of the most important metrics used to evaluate a baseball pitcher's effectiveness. The relationship between age and pitching velocity after a lighter ball baseball training program has not been determined., Purpose/hypothesis: The purpose of this study was to examine the relationship between age and pitching velocity after a lighter ball baseball training program. We hypothesized that pitching velocity would significantly increase in all adolescent age groups after a lighter baseball training program, without a significant difference in magnitude of increase based on age., Study Design: Cohort study; Level of evidence, 2., Methods: Baseball pitchers aged 10 to 17 years who completed a 15-week training program focused on pitching mechanics and velocity improvement were included in this study. Pitchers were split into 3 groups based on age (group 1, 10-12 years; group 2, 13-14 years; group 3, 15-17 years), and each group trained independently. Pitch velocity was assessed at 4 time points (sessions 3, 10, 17, and 25). Mean, maximum, and mean change in pitch velocity between sessions were compared by age group., Results: A total of 32 male baseball pitchers were included in the analysis. Mean/maximum velocity increased in all 3 age groups: 3.4/4.8 mph in group 1, 5.3/5.5 mph in group 2, and 5.3/5.2 mph in group 3. While mean percentage change in pitch velocity increased in all 3 age groups (group 1, 6.5%; group 2, 8.3%; group 3, 7.6%), the magnitude of change was not significantly different among age groups. Program session number had a significant effect on mean and maximum velocity, with higher mean and maximum velocity seen at later sessions in the training program ( P = .018). There was no interaction between age and program session within either mean or maximum velocity ( P = .316 and .572, respectively)., Conclusion: Age had no significant effect on the magnitude of increase in maximum or mean baseball pitch velocity during a velocity and mechanics training program in adolescent males., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.N.C. has received educational support from Tornier and Active Medical, consulting fees from Arthrex and DePuy, and royalties from DePuy. M.E.B. has received educational support from Arthrex and Smith & Nephew, grant support from Arthrex, and hospitality payments from Stryker. A.A.R. has received research support from Aesculap/B. Braun, Arthrex, Histogenics, Medipost, Major League Baseball, NuTech, OrthoSpace, Smith & Nephew, and Zimmer; has received consulting fees and speaking fees from Arthrex; has received royalties from Arthrex, Saunders/Mosby-Elsevier, and SLACK; and is a board or committee member for Atreon Orthopaedics. B.J.E. has received educational support from Arthrex, DePuy, and Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Background: Treatment of the subscapularis in reverse total shoulder arthroplasty (RTSA) is a controversial topic, with conflicting evidence regarding outcomes after repair., Purpose/hypothesis: The purpose of this study was to report clinical and sonographic outcomes of a through-implant double-row suture technique for subscapularis repair in RTSA and to compare clinical outcomes and range of motion (ROM) between patients with an intact subscapularis tendon repair versus those whose tendon repair was not intact. The authors hypothesized that the novel repair technique would find more than 80% of tendons intact on ultrasound, with significant improvement in clinical outcome scores and ROM. The authors also hypothesized that patients with an intact subscapularis tendon repair would have better clinical outcomes compared with those with a nonintact tendon repair., Study Design: Case series; Level of evidence, 4., Methods: The study included all patients who underwent RTSA by 1 of 2 surgeons between August 2016 and March 2017 with the through-implant double-row suture technique for subscapularis repair. Subscapularis tendon integrity was assessed postoperatively via ultrasound at minimum 1-year follow-up. American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain visual analog scale (VAS) scores were recorded at the final follow-up visit in addition to ROM measures., Results: A total of 48 patients (31 males, 17 females; mean age, 68.9 ± 7.4 years; mean follow-up, 13.8 ± 2.1 months) were included. On ultrasound, the subscapularis was intact in 83.3% of patients. Regarding preoperative versus postoperative outcome scores, the ASES score (mean ± SD) significantly improved from 38.3 ± 14.7 to 81.9 ± 13.6, the SANE score significantly improved from 29.8 ± 24.2 to 75.5 ± 21.0, and the VAS pain score significantly improved from 5.9 ± 2.1 to 1.2 ± 1.6 ( P < .001 for all). Forward flexion and external rotation significantly improved. No significant difference existed in clinical outcome scores or ROM between patients with intact versus torn subscapularis tendons based on ultrasound., Conclusion: Subscapularis repair using a stem-based double-row repair technique during RTSA demonstrated an overall healing rate of 83.3%, as evidenced by ultrasound examination at short-term follow-up. Integrity of subscapularis repair did not affect clinical outcome or ROM., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.J.E. has received educational support from Arthrex, Smith & Nephew, and DePuy and hospitality payments from Linvatec and Stryker. M.E.B. has received educational support from Arthrex and Smith & Nephew, grant support from Arthrex, and hospitality payments from Stryker. A.A.R. has received research support from Aesculap/B.Braun, Arthrex, Histogenics, Medipost, NuTech, OrthoSpace, Smith & Nephew, and Zimmer; consulting fees and speaking fees from Arthrex; and royalties from Arthrex, Saunders/Mosby-Elsevier, and SLACK and is a board or committee member for Atreon Orthopaedics. E.S.L. has received research support, consulting fees, speaking fees, and royalties from Arthrex. R.G. has received research support, consulting fees, speaking fees, and royalties from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Sex and gender are not the same. Sex is defined by the human genotype and pertains to biologic differences between males and females. Gender is a fluid concept molded by self-perception, social constructs, and culturally laden attitudes and expectations of men and women. In general, males have longer limb levers, stronger bones, greater muscle mass and strength, and greater aerobic capacity. Females exhibit less muscle fatigability and faster recovery during endurance exercise. Physiologic sex-based differences have led to an average performance gap of 10% that has remained stable since the 1980s. The performance disparity is lowest for swimming and highest for track and field events. The International Olympic Committee currently mandates that female athletes with differences of sex development, or intersex traits, and transgender female athletes must limit their blood testosterone to <10 nmol/L for 12 months to be eligible for competition in the female classification.

Quantifying mutant or variable allele frequencies (VAFs) of ≤10-3 using next-generation sequencing (NGS) has utility in both clinical and nonclinical settings. Two common approaches for quantifying VAFs using NGS are tagged single-strand sequencing and duplex sequencing. While duplex sequencing is reported to have sensitivity up to 10-8 VAF, it is not a quick, easy, or inexpensive method. We report a method for quantifying VAFs that are ≥10-4 that is as easy and quick for processing samples as standard sequencing kits, yet less expensive than the kits. The method was developed using PCR fragment-based VAFs of Kras codon 12 in log10 increments from 10-5 to 10-1, then applied and tested on native genomic DNA. For both sources of DNA, there is a proportional increase in the observed VAF to input VAF from 10-4 to 100% mutant samples. Variability of quantitation was evaluated within experimental replicates and shown to be consistent across sample preparations. The error at each successive base read was evaluated to determine if there is a limit of read length for quantitation of ≥10-4, and it was determined that read lengths up to 70 bases are reliable for quantitation. The method described here is adaptable to various oncogene or tumor suppressor gene targets, with the potential to implement multiplexing at the initial tagging step. While easy to perform manually, it is also suited for robotic handling and batch processing of samples, facilitating detection and quantitation of genetic carcinogenic biomarkers before tumor formation or in normal-appearing tissue., (Published by Oxford University Press on behalf of the Society of Toxicology 2019. This work is written by US Government employees and is in the public domain in the US.)

Purpose: Examine demographic factors of all patients treated for adhesive capsulitis by a single surgeon, report the treatments and outcomes of these patients, and determine the effectiveness of various treatments, including corticosteroid injections and operative intervention in relation to risk factors for adhesive capsulitis., Methods: All patients treated for adhesive capsulitis by a single surgeon between 2008 to 2014 with minimum 2 years' follow-up were identified via charts and operative reports and were eligible for inclusion. Demographic information including sex and medical comorbidities was documented. Preintervention and postintervention shoulder range of motion was recorded. Specific treatment information (number of corticosteroid injections, etc) was collected. Treatment outcomes were then compared as an aggregate and among varying comorbidities., Results: Overall, 1377 patients were treated for adhesive capsulitis (946 women vs 431 men [ P  = .001]). For patients with adhesive capsulitis: a higher percentage of men than women had diabetes (24.8% vs 17.3% [ P  = .001]); nondiabetic patients had better forward flexion at initial presentation than patients with diabetes (114° vs 108° [ P  = .015]); more patients with diabetes required capsular release than nondiabetic patients (13% vs 7.3% [ P  = .003]); more nondiabetic patients resolved adhesive capsulitis without corticosteroid or surgical intervention than patients with diabetes (83.6% vs 61.7% [ P  = .001]); more nondiabetic patients resolved adhesive capsulitis after single corticosteroid injection than did patients with diabetes (95.9% vs 86.7% [ P  = .001]). Multiple intraarticular corticosteroid injections provided no added benefit over a single injection in resolving adhesive capsulitis in patients with diabetes and nondiabetic patients., Conclusion: In shoulder adhesive capsulitis, women and patients with diabetes are more commonly affected, patients with diabetes respond less favorably to physical therapy in isolation and physical therapy plus corticosteroid injections than nondiabetic patients. No benefit from multiple intraarticular corticosteroid injections was seen compared with a single intraarticular corticosteroid injection in patients with diabetes and nondiabetic patients. Patients with diabetes and nondiabetic patients have functional improvement after capsular release and manipulation if conservative treatment for adhesive capsulitis fails., Level of Evidence: III, case control., (© 2019 Published by Elsevier on behalf of the Arthroscopy Association of North America.)

Background: Medial patellofemoral ligament (MPFL) reconstruction is the treatment of choice for recurrent patellar instability in the skeletally immature patient. Avoiding the open physes during anatomic MPFL reconstruction is a challenge in this population., Purpose: To describe a novel method using magnetic resonance imaging (MRI) to determine the distance from the Schöttle point to the medial distal femoral physis among skeletally immature individuals with patellar instability., Study Design: Descriptive laboratory study., Methods: Preoperative MRI scans were analyzed from 34 patients with open distal femoral physes and lateral patellar instability. With the multiplanar reconstruction mode on a picture archiving and communication system (PACS), the location of the Schöttle point was determined according to previously reported distances from the posterior femoral cortical line and the posterior origin of the medial femoral condyle. This location was then extrapolated to the most medial sagittal slice on MRI showing the medial distal femoral physis. The distance was measured from this point to the most distal aspect of the physis., Results: The mean age of the study cohort was 13.6 years (range, 10.6-15.7 years); there were 13 males and 21 females. The mean distance from the medial distal femoral physis to the Schöttle point was 7.27 ± 1.78 mm. The Schöttle point was distal to the medial distal femoral physis in all cases. There was no significant correlation between age and mean distance in either the overall study population ( r = 0.046, P = .798) or when stratified by sex (females, P = .629; males, P = .089). The distance between the Schöttle point and the medial distal femoral physis was shorter for females than for males (6.51 vs 7.71 mm, P = .043). After adjustment for age, females on average were 1.31 mm closer to the Schöttle point than were males ( B = -1.31, P = .041)., Conclusion: This technique can be used to determine the distance between the medial distal femoral physis and the Schöttle point. The Schöttle point was distal to the physis in all patients, and it was closer to the physis in skeletally immature females compared with age-matched males., Clinical Relevance: The long-term repercussions of improperly placed MPFL reconstruction include recurrent patellar instability, increased patellofemoral contact pressures and overtensioning of the ligament, and possibly patellofemoral arthritis. The current technique can be used preoperatively to determine the appropriate safe distance for drilling a socket distal to the physis., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.E.B. has received educational support from Smith & Nephew; S.R.B. has received educational support from Arthrex; and B.S.S. has received speaking fees and educational support from Arthrex and hospitality payments from DePuy. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Although most anterior tibial stress fractures heal with nonoperative treatment, some may require surgical management. To our knowledge, no systematic review has been conducted regarding surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in high-performance athletes., Purpose: This systematic review was conducted to evaluate the surgical outcomes of anterior tibial stress fractures in high-performance athletes., Study Design: Systematic review; Level of evidence, 4., Methods: In February 2017, a systematic review of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases was performed to identify studies that reported surgical outcomes for anterior tibial stress fractures. Articles meeting the inclusion criteria were screened, and reported outcome measures were documented., Results: A total of 12 studies, published between 1984 and 2015, reporting outcomes for the surgical treatment of anterior tibial stress fractures were included in this review. All studies were retrospective case series. Collectively, surgical outcomes for 115 patients (74 males; 41 females) with 123 fractures were evaluated in this review. The overall mean follow-up was 23.3 months. The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Subsequent tibial fractures were reported in 8 patients (7.0%). Moreover, a total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. Following surgical treatment for anterior tibial stress fracture, 94.7% of patients were able to return to sports., Conclusion: The available literature indicates that surgical treatment of anterior tibial stress fractures is associated with a high rate of symptom resolution and return to play in athletes, although the high complication rate and potential need for subsequent procedures are important considerations for surgeons and patients.

Somatic mutations accumulate in the human genome and are correlated with increased cancer incidence as humans age. The standard model for studying the carcinogenic effects of exposures for human risk assessment is the rodent 2-year carcinogenicity assay. However, there is little information regarding the effect of age on cancer-driver gene mutations in these models. The mutant fraction (MF) of Kras codon 12 GGT to GAT and GGT to GTT mutations, oncogenic mutations orthologous between humans and rodents, was quantified over the lifespan of B6C3F1 mice. MFs were measured in lung and liver tissue, organs that frequently develop tumors following carcinogenic exposures. The MFs were evaluated at 4, 6, 8, 12, 21, and 85 weeks, with the 12-week and 21-week time points being coincident with the conclusion of 28-day and 90-day exposure durations used in short-term toxicity testing. The highly sensitive and quantitative Allele-specific Competitive Blocker PCR (ACB-PCR) assay was used to quantify the number of mutant Kras codon 12 alleles. The mouse lung showed a slight, but significant trend increase in the Kras codon 12 GAT mutation over the 85-week period. The trend with age can be equally well-fit by several non-linear functions, but not by a linear function. In contrast, the liver GAT mutation did not increase, and the GTT mutation did not increase for either organ. Even with the slight increase in the lung GAT MFs, our results indicate that the future use of Kras mutation as a biomarker of carcinogenic effect will not be confounded by animal age. Environ. Mol. Mutagen. 59:715-721, 2018. Published 2018. This article is a U.S. Government work and is in the public domain in the USA., (Published 2018. This article is a U.S. Government work and is in the public domain in the USA.)

Case: This report describes 2 cases of failed decellularized "off-the-shelf" Chondrofix (Zimmer Biomet) osteochondral allografts within a year after implantation in a 44-year-old man and a 50-year-old woman., Conclusion: Although it is a successful technique for cartilage repair, the use of osteochondral allograft transplantation has been limited by the availability of fresh grafts; therefore, decellularized osteochondral allografts recently have been developed. Physicians should be cautious when considering the use of these implants for the repair of articular cartilage lesions.