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Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome., Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up., Study Design: Cohort study; Level of evidence, 2., Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery., Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores ( P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized ( P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts ( P = .87) or between BTB autografts and soft tissue allografts ( P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft ( P = .010; OR, 0.56; 95% CI, 0.36-0.87)., Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Background: Arthroscopic shoulder capsulolabral repair using glenoid-based suture anchor fixation provides consistently favorable outcomes for patients with anterior glenohumeral instability. To optimize outcomes, inferior anchor position, especially at the 6-o'clock position, has been emphasized. Proponents of both the beach-chair (BC) and lateral decubitus (LD) positions advocate that this anchor location can be consistently achieved in both positions., Hypothesis: Patient positioning would be associated with the surgeon-reported labral tear length, total number of anchors used, number of anchors in the inferior glenoid, and placement of an anchor at the 6-o'clock position., Study Design: Cross-sectional study; Level of evidence, 3., Methods: This study was a cross-sectional analysis of a prospective multicenter cohort of patients undergoing primary arthroscopic anterior capsulolabral repair. Patient positioning in the BC versus LD position was determined by the operating surgeon and was not randomized. At the time of operative intervention, surgeon-reported labral tear length, total anchor number, anchor number in the inferior glenoid, and anchor placement at the 6-o'clock position were evaluated between BC and LD cohorts. Descriptive statistics and between-group differences (continuous: t test [normal distributions], Wilcoxon rank sum test [nonnormal distributions], and chi-square test [categorical]) were assessed., Results: In total, 714 patients underwent arthroscopic anterior capsulolabral repair (BC vs LD, 406 [56.9%] vs 308 [43.1%]). The surgeon-reported labral tear length was greater for patients having surgery in the LD position (BC vs LD [mean ± SD], 123.5°± 49° vs 132.3°± 44°; P = .012). The LD position was associated with more anchors placed in the inferior glenoid and more frequent placement of anchors at the 6-o'clock (BC vs LD, 22.4% vs 51.6%; P < .001). The LD position was more frequently associated with utilization of ≥4 total anchors (BC vs LD, 33.5% vs 46.1%; P < .001)., Conclusion: Surgeons utilizing the LD position for arthroscopic capsulolabral repair in patients with anterior shoulder instability more frequently placed anchors in the inferior glenoid and at the 6-o'clock position. Additionally, surgeon-reported labral tear length was longer when utilizing the LD position. These results suggest that patient positioning may influence the total number of anchors used, the number of anchors used in the inferior glenoid, and the frequency of anchor placement at the 6 o'clock position during arthroscopic capsulolabral repair for anterior shoulder instability. How these findings affect clinical outcomes warrants further study., Registration: NCT02075775 (ClinicalTrials.gov identifier).

Background: Posttraumatic osteoarthritis (PTOA) after injury to the anterior cruciate ligament (ACL) is common., Purpose: To perform a systematic review of basic science and animal studies to determine the effect of doxycycline treatment on the prevention of PTOA after ACL rupture/transection., Study Design: Systematic review., Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify basic science and animal studies evaluating the effect of doxycycline treatment on the prevention of PTOA of the knee joint after ACL/cranial cruciate ligament (CCL) injury. The search phrase used was "doxycycline cruciate ligament." Inclusion criteria were basic science and animal studies evaluating the effect of oral administration of doxycycline in ACL/CCL-deficient animals with or without a control group., Results: Seven studies met inclusion criteria and were included in this systematic review. Five studies were performed in dogs, 1 in rabbits, and 1 in mice. Overall, the effects of doxycycline treatment on the prevention of PTOA after ACL/CCL rupture/transection were mixed. In dogs, no significant effects of doxycycline treatment were found in terms of matrix metalloproteinase (MMP) activity, while a mouse study found significantly lower MMP-13 expression on the tibia in doxycycline-treated animals, suggesting that doxycycline may protect against proteoglycan loss and decrease osteoarthritis progression. Cartilage nitric oxide concentrations were lower in doxycycline-treated dogs compared with untreated dogs, suggesting decreased cartilage degradation among doxycycline-treated dogs, although there were no significant effects on cartilage stromelysin levels with no significant effects in terms of physiological remodeling or catabolism of cartilage. Bone formation or resorption was not found to be affected by doxycycline treatment. One study demonstrated a substantial beneficial effect of doxycycline on gross morphology of the medial femoral condyle. Doxycycline was found to conserve bone strain energy density and appeared to limit subchondral bone loss in 1 study., Conclusion: Based on the limited available animal studies, doxycycline appears to demonstrate some benefits in the prevention of PTOA after ACL/CCL rupture/transection. Additional studies are needed to further characterize the potential benefits, side effects, dosage, and duration of this treatment after ACL injury in human patients.

Background: Marrow stimulation (MST) surgery, which includes microfracture, subchondral drilling, and abrasion arthroplasty, and autologous chondrocyte implantation (ACI) are 2 surgical options to treat articular cartilage lesions in the knee joint. Recent studies have suggested worse outcomes when ACI is used after failed MST., Purpose: To investigate the failure rates and clinical outcomes of primary knee ACI versus ACI after failed MST surgery (secondary ACI)., Study Design: Systematic review., Methods: A systematic review was performed by searching the PubMed, Embase, and Cochrane Library databases to identify studies evaluating clinical outcomes of patients undergoing primary versus secondary ACI of the knee joint. The search terms used were as follows: "knee" AND ("autologous chondrocyte implantation" OR "osteochondral allograft") AND (microfracture OR "marrow stimulation"). Patients undergoing primary ACI (group A) were compared with those undergoing secondary ACI (group B) based on treatment failure rates and patient-reported outcomes (PROs)., Results: Seven studies (2 level 2 studies, 5 level 3 studies) were identified and met inclusion criteria, including a total of 1335 patients (group A: n = 838; group B: n = 497). The average patient age in all studies was 34.2 years, and the average lesion size was 5.43 cm 2 . Treatment failure occurred in 14.0% of patients in group A and 27.6% of patients in group B ( P < .00001). Four studies reported PROs. One study found significantly better Subjective International Knee Documentation Committee scores ( P = .011), visual analog scale (VAS) pain scores ( P = .028), and VAS function scores ( P = .005) in group A. Another study found significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) Pain scores ( P = .034), KOOS Activities of Daily Living scores ( P = .024), VAS pain scores ( P = .014), and VAS function scores ( P = .032) in group A. Two studies found no significant difference in PROs between groups A and B ( P < .05)., Conclusion: Patient-reported improvement can be expected in patients undergoing primary or secondary ACI of the knee joint. Patients undergoing secondary ACI have a significantly higher risk of treatment failure and may have worse subjective outcomes compared with patients undergoing primary ACI.

Purpose: To identify factors predictive of a large labral tear at the time of shoulder instability surgery., Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects., Results: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007)., Conclusions: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf., Level of Evidence: I, prognostic study., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Biceps tenodesis and tenotomy are 2 surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior-to-posterior (SLAP) tears. The purpose of this systematic review was to compare the clinical outcomes and complications of biceps tenodesis and tenotomy for the treatment of LHBT or SLAP pathology during shoulder arthroscopy., Methods: We performed a systematic review by searching PubMed, the Cochrane Library, and Embase to identify level I randomized controlled trials that compared the clinical outcomes of biceps tenodesis vs. tenotomy. The search phrase used was as follows: biceps tenodesis tenotomy randomized. Patients were assessed based on the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Constant-Murley score, as well as postoperative range of motion, strength, and cosmetic deformity., Results: Five studies (all level I) met the inclusion criteria, including 236 patients undergoing biceps tenodesis (mean age, 60.3 years) and 232 patients undergoing biceps tenotomy (mean age, 59.7 years). The mean follow-up period was 23.0 months. Overall, 6.8% of tenodesis patients experienced cosmetic deformity at latest follow-up compared with 23.3% of tenotomy patients (P < .001). No differences in Constant-Murley, visual analog scale, or American Shoulder and Elbow Surgeons scores were found between groups in any study, and of all the studies evaluating strength and range of motion at latest follow-up, only 1 found a significant difference between groups, in which tenodesis patients demonstrated significantly increased forearm supination strength (P = .02). One study found tenodesis patients to experience significantly more biceps cramping at 6-month follow-up compared with tenotomy patients (P = .043), although no differences in complication rates at latest follow-up were found in any study., Conclusion: Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes. There is an increased rate of cosmetic deformity in patients undergoing biceps tenotomy compared with tenodesis., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To perform an updated systematic review of the anatomy, biomechanics, function of the anterolateral ligament (ALL), and the clinical outcomes of anterolateral ligament reconstruction (ALLR) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR)., Methods: A systematic search of the literature was performed by searching PubMed, the Cochrane Library, and Embase with the search phrase anterolateral ligament for articles published from February 2017 to May 2020. Inclusion criteria included studies that evaluated the anatomy, function, or biomechanics of the ALL; surgical technique articles on ALLR; clinical articles reporting outcomes of ALLR; studies published in English; and full-text articles. Exclusion criteria included studies published before February 2017. A subjective synthesis was performed, in which ranges were reported, and individual study data were presented in forest plots., Results: Overall, 40 articles were included in this systematic review, with 11 articles describing ALL anatomy, 14 articles analyzing ALL function and biomechanics, 7 articles discussing the surgical technique of combined ACLR and ALLR (ACLR/ALLR), and 8 articles describing the clinical outcomes of ACLR/ALLR. The addition of ALLR in combination with ACLR (ACLR+) results in lower graft failure rates for ACLR/ALLR (0.0%-15.7%) when compared with isolated ACLR (I-ACLR) patients (7.4%-21.7%). Three of 5 studies using the Subjective International Knee Documentation Committee score, 2 of 5 studies using the Lysholm score, and 1 of 2 studies using the Tegner score reported significantly better scores at latest follow-up among ACLR+ patients compared with I-ACLR (P < .05)., Conclusions: The ALL acts as a secondary stabilizer to the anterior cruciate ligament and helps resist internal knee rotation and anterior tibial translation. Based on the current literature, combined ACLR with ALLR may result in lower graft failure rates and improved patient-reported outcomes when compared with I-ACLR in patients with specific indications, although several studies have shown equivalent outcomes between these 2 cohorts., Clinical Relevance: The contents of this review provide great insight for orthopaedic surgeons who are performing ACLR and considering additional procedures to increase overall knee stability and decrease likeliness for re-rupture. The postoperative functional and clinical outcomes shown in patients undergoing ACLR+ compared with I-ACLR should be given proper consideration when evaluating available treatment courses., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The impact of preoperative opioid use on outcomes after shoulder surgery is unknown., Purpose/hypothesis: To examine the role of preoperative opioid use on outcomes in patients after shoulder surgery. We hypothesized that preoperative opioid use in shoulder surgery will result in increased postoperative pain and functional deficits when compared with nonuse., Study Design: Systematic review; Level of evidence, 3., Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were all English-language studies comparing clinical outcomes of shoulder surgery in patients who used opioids preoperatively (opioid group) as well as patients who did not (nonopioid group) with a minimum follow-up of 1 year. Outcomes included range of motion, American Shoulder and Elbow Surgeons score, Constant-Murley score, and visual analog scale for pain. Study quality was evaluated with the Modified Coleman Methodology Score and the MINORS score (Methodological Index for Non-randomized Studies)., Results: Included were 5 studies (level 2, n = 1; level 3, n = 4): Two studies were on total shoulder arthroplasty, 2 on reverse total shoulder arthroplasty, 1 on both, and 1 on arthroscopic rotator cuff repair. There were 827 patients overall: 290 in the opioid group (age, 63.2 ± 4.0 years [mean ± SD]; follow-up, 38.9 ± 7.5 months) and 537 in the nonopioid group (age, 66.0 ± 4.7 years; follow-up, 39.5 ± 8.1 months). The opioid group demonstrated significantly worse pre- and postoperative visual analog scale and Constant-Murley score pain scores as compared with the nonopioid group. Mean American Shoulder and Elbow Surgeons scores were significantly lower in the opioid group at pre- and postoperative time points as compared with the nonopioid group ( P < .05 for all). However, both groups experienced similar improvement in outcomes pre- to postoperatively. One study showed that the opioid group consumed significantly more opioids postoperatively than the nonopioid group and for a longer duration ( P < .05). The overall mean Modified Coleman Methodology Score and MINORS score were 64.2 ± 14 and 15.8 ± 1.0, respectively., Conclusion: Opioid use prior to various shoulder surgical procedures negatively affected postoperative pain and functionality. Although the opioid group showed significantly worse scores postoperatively, the groups experienced similar improvements., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.C.M. has received research support from Arthrex, Biomet, Breg, Mitek, Ossur, Smith & Nephew, and Stryker; consulting fees from Biomet, DePuy/Medical Device Business Services, and Zimmer Biomet; speaking fees from Arthrex; and royalties from Elsevier and Zimmer Biomet. A.J.S. has received education payments from Gemini Mountain Medical and consulting fees from Medacta. R.M.F. has received grant support from Arthrex; education payments from Arthrex, Medwest, and Smith & Nephew; and speaking fees from Arthrex. J.T.B. has received research support from Biomet; consulting fees from DJO, Smith & Nephew, and Encore Medical; and royalties from Shukla Medical. 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 systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder., Methods: A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed by searching PubMed, Cochrane Library, and Embase databases to locate randomized controlled trials comparing the clinical outcomes and postoperative complications of patients undergoing arthroscopy with and without TXA. Search terms used were "tranexamic acid," "arthroscopy," "knee," "hip," and "shoulder." Patients were evaluated based on early (<6 weeks) postoperative signs of hemarthrosis using the Coupens and Yates classification, postoperative complications (myocardial infarction, stroke, venous thromboembolism events), range of motion (ROM), and patient-reported outcome scores (Visual analog scale, Subjective International Knee Documentation Committee, Lysholm, and Tegner activity scores)., Results: Five studies (2 level I and 3 level II) met inclusion criteria, including a total of 299 patients undergoing arthroscopy with TXA and 299 patients without TXA. The average follow-up duration for all patients was 43.9 days. Procedures performed were partial meniscectomy, anterior cruciate ligament reconstruction, and rotator cuff repair. No studies evaluating TXA use in hip arthroscopy were identified. Coupens-Yates hemarthrosis grades significantly improved in the TXA groups across all studies. Three studies found TXA patients to experience significantly less postoperative pain at latest follow-up, 1 study found TXA patients to have significantly better postoperative Lysholm scores, and 1 study found TXA patients to have significantly more ROM at latest follow-up compared with non-TXA patients (P < .05)., Conclusion: Patients undergoing arthroscopy, particularly arthroscopic meniscectomy, arthroscopic-assisted anterior cruciate ligament reconstruction, and arthroscopic rotator cuff repair, with TXA can be expected to experience improved outcomes and less hemarthrosis-related complications in the early postoperative period compared with non-TXA patients., Level of Evidence: II, systematic review of level I and II studies., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The number of golfers aged ≥65 years has increased in recent years, and shoulder arthritis is prevalent in this age group. Guidelines for return to golf (RTG) after shoulder arthroplasty have not been fully established., Purpose: To review the data available in the current literature on RTG after shoulder arthroplasty., Study Design: Systematic review., Methods: A systematic review based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Two independent reviewers searched PubMed, Embase, and the Cochrane Library using the terms "shoulder,""arthroplasty,""replacement," and "golf." The authors sought to include all studies investigating RTG after total shoulder arthroplasty (TSA), shoulder hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA). Outcomes of interest included indications for shoulder arthroplasty, surgical technique, rehabilitation protocol, amount of time between surgery and resumption of golf activity, and patient-reported outcome measures., Results: A total of 10 studies were included, 2 of which reported on golf performance after shoulder arthroplasty. The other 8 studies described return to sports after shoulder arthroplasty with golf-specific data for our analysis. Three studies that included patients who underwent TSA reported RTG rates ranging from 89% to 100% after mean follow-up periods of 5.1 to 8.4 months. Two studies included patients who underwent TSA and HA and reported RTG rates of 77% and 100% after mean intervals of 5.8 and 4.5 months, respectively. Two studies included patients who underwent RSA, with RTG rates of 50% and 79% after mean postoperative intervals of 5.3 and 6 months, respectively. One study included only patients undergoing HA, with an RTG rate of 54% and a mean RTG time of 6.5 months. Varying surgical procedures and baseline patient characteristics precluded our ability to draw conclusions regarding surgical technique, rehabilitation protocol, or patient-reported outcome measures among studies reporting these data., Conclusion: Most patients who undergo a shoulder arthroplasty procedure can expect to resume playing golf approximately 6 months after the index procedure. The rate of return may be lower after RSA and HA as compared with anatomic TSA. The data presented in our review can help physicians counsel patients who wish to continue golf participation after a shoulder arthroplasty procedure.

Background: No study in the orthopaedic literature has analyzed the demographic characteristics or surgical training of sports medicine fellowship directors (FDs ) . Objective determinations as to what makes a physician qualified for this leadership position remain unclear; thus, it is important to identify these qualities as future physicians look to fill these roles., Purpose: To illustrate characteristics common among sports medicine FDs., Study Design: Cross-sectional study., Methods: The 2020 Accreditation Council for Graduate Medical Education Fellowship Directory was used to identify the FDs for all orthopaedic sports medicine fellowship programs in the United States. The characteristics and educational background data for FDs were gathered by 2 independent reviewers from up-to-date curricula vitarum, Web of Science, and institutional biographies and consolidated into 1 database. Data points gathered included age, sex, residency/fellowship training location and graduation year, name of current institution, length of time at current institution, time since training completion until being appointed FD, length of time in current FD role, and personal research H-index., Results: We identified 90 current orthopaedic sports medicine FDs. The mean Scopus H-index was 24.1 (median, 17). The mean age of FDs was 55.4 years; 87 of 90 (96.7%) were male and 3 (3.3%) were female; and 79/90 (87.8%) were White and 3/90 (3.3%) were African-American. The mean time to complete residency was 5.1 years (range, 5.0-6.0 years), and the most attended residency programs were the Hospital for Special Surgery (n = 9), the Harvard Combined Orthopaedic Residency Program (n = 5), and Duke University Medical Center (n = 4). The mean time required to complete a fellowship was 1.1 years (range, 1.0-2.0 years), and the fellowship programs that produced the most future FDs were the American Sports Medicine Institute (n = 11), the Steadman Hawkins Clinic (Vail) (n = 8), the Kerlan-Jobe Orthopaedic Clinic (n = 7), and the Hospital for Special Surgery (n = 7). The mean time from completion of fellowship to appointment as a FD was 12.8 years (range, 1-39 years)., Conclusion: Women and minority groups are largely underrepresented among leadership positions in the field of orthopaedic sports medicine., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.K.M. has received education payments from Arthrex, Alon Medical Technology, and Quest Medical; nonconsulting fees from Arthrex; and hospitality payments from Zimmer Biomet. T.F.S. has received education payments from Gemini Mountain Medical, royalties from Encore Medical, nonconsulting fees from Smith & Nephew, and hospitality payments from Arthrex and has stock/stock options in Avenu, CU Healthcare Innovation Fund, kaleo, NASH, and PrivIT. E.C.M. has received research support from Arthrex, Biomet, Breg, Mitek, Ossur, Smith & Nephew, and Stryker; education payments from Gemini Mountain Medical; consulting fees from Medical Device Business Services and Zimmer Biomet; speaking fees from Arthrex; and royalties from Zimmer Biomet and Elsevier. 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.)

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon-dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting postoperative infections. Allografts had a higher risk of infection than autografts (odds ratio, 6.8; 95% CI, 0.9-54.5; p = .045). Diabetes (odds ratio, 28.6; 95% CI, 5.5-149.9; p = .004) was a risk factor for infection. Patient age, sex, BMI, and smoking status were not associated with risk of infection after rACLR., (© 2020 Orthopaedic Research Society. Published by Wiley Periodicals LLC.)

Background: COVID-19 is a severe respiratory virus that spreads via person-to-person contact through respiratory droplets. Since being declared a pandemic in early March 2020, the World Health Organization had yet to release guidelines regarding the return of college or professional sports for the 2020-2021 season., Purpose: To survey the head orthopedic surgeons and primary care team physicians for the National Collegiate Athletic Association (NCAA) Football Bowl Subdivision (FBS) football teams so as to gauge the management of common COVID-19 issues for the fall 2020 college football season., Study Design: Cross-sectional study., Methods: The head team orthopaedic surgeons and primary care physicians for all 130 FBS football teams were surveyed regarding their opinions on the management of college football during the COVID-19 pandemic. A total of 30 questions regarding testing, return-to-play protocol, isolating athletes, and other management issues were posed via email survey sent on June 5, 2020., Results: Of the 210 team physicians surveyed, 103 (49%) completed the questionnaire. Overall, 36.9% of respondents felt that it was unsafe for college athletes to return to playing football during fall 2020. While the majority of football programs (96.1%) were testing athletes for COVID-19 as they returned to campus, only 78.6% of programs required athletes to undergo a mandatory quarantine period before resuming involvement in athletic department activities. Of the programs that were quarantining their players upon return to campus, 20% did so for 1 week, 20% for 2 weeks, and 32.9% quarantined their athletes until they had a negative COVID-19 test., Conclusion: While US Centers for Disease Control and Prevention guidelines evolve and geographic regions experience a range of COVID-19 infections, determining a universal strategy for return to socialization and participation in sports remains a challenge. The current study highlighted areas of consensus and strong agreement, but the results also demonstrated a need for clarity and consistency in operations, leadership, and guidance for medical professionals in multiple areas as they attempt to safely mitigate risk for college football players amid the COVID-19 pandemic., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.C.J. has received royalties from Wolters Kluwer Health–Lippincott Williams & Wilkins. R.J.J. has received education payments from Gemini Mountain Medical and hospitality payments from Zimmer Biomet. E.C.M. has received research support from Arthrex, Biomet, Breg, Mitek, Ossur, Smith & Nephew, and Stryker; education payments from Zimmer Biomet; consulting fees from Zimmer Biomet and Medical Device Business Services; nonconsulting fees from Arthrex; and royalties from Zimmer Biomet and Elsevier. L.E.L. has received education payments from Supreme Orthopedic Systems. M.A.S. has received education payments 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) 2021.)

Background: Guidelines for return to driving after anterior cruciate ligament reconstruction (ACLR) have not been established., Purpose: To review the literature pertaining to driving after ACLR and provide evidence-based guidelines to aid clinicians in counseling patients about driving after ACLR., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two independent reviewers searched PubMed, EMBASE, and the Cochrane Library using the terms anterior cruciate ligament , ACL , drive , and driving . Studies reporting on functional recovery after ACLR were included when data regarding return to driving were reported., Results: Five studies were included. Two studies included patients who underwent right-sided ACLR. Of these, 1 study evaluated bone-patellar tendon-bone autograft and reported that brake response time (BRT) returned to normal approximately 4 to 6 weeks postoperatively. The other study found that BRT returned to normal 3 weeks after allograft ACLR, but 6 weeks elapsed after autograft ACLR before values were not significantly different than controls. One study reported that patients who underwent left-sided hamstring tendon autograft ACLR demonstrated BRTs similar to controls within 2 weeks, while those with right-sided ACLR had significantly slower BRTs until 6 weeks postoperatively. Another study including patients who underwent either right- or left-sided ACLR and employed a manual transmission simulator found that 4 to 6 weeks should elapse after ACLR with hamstring tendon autograft. Survey data from 1 study demonstrated that the mean time for patients to resume driving was 13 and 10 days after right- and left-sided ACLR, respectively., Conclusion: BRT returned to normal values approximately 4 to 6 weeks after right-sided ACLR and approximately 2 to 3 weeks after left-sided ACLR. According to 1 study in this review, ACLR laterality should be disregarded for patients who drive manual transmission automobiles, as a 4- to 6-week time period was required for driving ability to reach the level of healthy controls. Future studies should aim to elucidate the influence of graft choice and transmission type on return to driving after ACLR., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.T.B. has received consulting fees from DJO, Encore Medical, and Smith & Nephew; nonconsulting fees from Mitek, Smith & Nephew, and Stryker; and royalties from Shukla Medical. E.C.M. has received educational support from Mitek, Smith & Nephew, Stryker, and Zimmer Biomet; consulting fees from Zimmer Biomet; speaking fees from Arthrex and Stryker; and royalties from Zimmer Biomet. R.M.F. has received grant support from Arthrex, educational support from Arthrex/Medwest and Smith & Nephew, speaking fees from Arthrex, and royalties from Elsevier. 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.)

Background: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are 2 nonoperative treatment options for knee osteoarthritis (OA) that are supposed to provide symptomatic relief and help delay surgical intervention., Purpose: To systematically review the literature to compare the efficacy and safety of PRP and HA injections for the treatment of knee OA., Study Design: Meta-analysis of level 1 studies., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 studies that compared the clinical efficacy of PRP and HA injections for knee OA. The search phrase used was platelet-rich plasma hyaluronic acid knee osteoarthritis randomized . Patients were assessed via the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) scale. A subanalysis was also performed to isolate results from patients who received leukocyte-poor and leukocyte-rich PRP., Results: A total of 18 studies (all level 1) met inclusion criteria, including 811 patients undergoing intra-articular injection with PRP (mean age, 57.6 years) and 797 patients with HA (mean age, 59.3 years). The mean follow-up was 11.1 months for both groups. Mean improvement was significantly higher in the PRP group (44.7%) than the HA group (12.6%) for WOMAC total scores ( P < .01). Of 11 studies based on the VAS, 6 reported PRP patients to have significantly less pain at latest follow-up when compared with HA patients ( P < .05). Of 6 studies based on the Subjective IKDC outcome score, 3 reported PRP patients to have significantly better scores at latest follow-up when compared with HA patients ( P < .05). Finally, leukocyte-poor PRP was associated with significantly better Subjective IKDC scores versus leukocyte-rich PRP ( P < .05)., Conclusion: Patients undergoing treatment for knee OA with PRP can be expected to experience improved clinical outcomes when compared with HA. Additionally, leukocyte-poor PRP may be a superior line of treatment for knee OA over leukocyte-rich PRP, although further studies are needed that directly compare leukocyte content in PRP injections for treatment of knee OA.

Anterior glenohumeral instability remains a common clinical problem in the athletic and working patient populations, and further, recurrence rates following stabilization surgery continue to be problematic. Over the past 5 years, there have been substantial improvements in the understanding of anterior shoulder instability. To better counsel and treat patients, it is imperative for surgeons to have a comprehensive understanding of the epidemiology of shoulder instability, the anatomy of the glenohumeral joint particularly as it relates to glenoid and humeral head bone loss, surgical indications, and surgical techniques. These critical topics are summarized in an effort to provide a complete guide to managing anterior shoulder instability in 2020.

Purpose: To determine whether range of motion (ROM) varies with the location and extent of labral tear seen in patients undergoing arthroscopic anterior shoulder stabilization., Methods: Consecutive patients undergoing arthroscopic anterior shoulder stabilization who were enrolled in the Multicenter Orthopaedic Outcomes Network Shoulder Instability database underwent a preoperative physical examination and intraoperative examination under anesthesia in which ROM was recorded. Intraoperatively, the location and extent of the labral tear was recorded using conventional clock-face coordinates. Patients were grouped by combinations of quadrants involved in the labral tear (G1-G7): G1 = anterior only, G2 = anterior + inferior, G3 = anterior + inferior + posterior, G4 = all quadrants, G5 = superior + anterior, G6 = superior + anterior + inferior, and G7 = posterior + superior + anterior. Statistical analyses were performed with the Kruskal-Wallis rank-sum test. When P < .05, a post-hoc Dunn's test was performed. For categorical variables, the χ 2 test was performed. We performed a series of bivariate negative binomial regression models testing pairwise combinations of ROM parameters predicting the count of labral tear locations (possible: 0-5) within each quadrant., Results: A total of 467 patients were included, with 13 (2.8%) in G1, 221 (47.3%) in G2, 40 (8.6%) in G3, 51 (10.9%) in G4, 18 (3.9%) in G5, 121 (25.9%) in G6, and 3 (0.6%) in G7. Multiple statistically significant differences were noted in ROM, specifically active internal rotation at side (IRS) ( P  = .005), active abduction ( P  = .02), passive IRS ( P  = .02), and passive external rotation in abduction ( P  = .0007). Regression modeling revealed a positive correlation between passive abduction and predicted count of labral tear locations in the superior quadrant and between passive IRS and predicted count of labral tear location in the inferior quadrant., Conclusions: In patients undergoing arthroscopic shoulder stabilization for anterior instability, ROM varies with location and extent of labral tear. However, the clinical relevance of such small ROM differences remains undetermined., Level of Evidence: II, prospective comparative study., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Anterior shoulder (glenohumeral joint [GHJ]) dislocations are relatively common injuries in sports. Previous studies have evaluated clinical outcomes of operative and nonoperative management for primary traumatic anterior GHJ dislocations. The purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing closed reduction of a traumatic anterior GHJ dislocation, particularly among the athletic population. Two independent reviewers performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. Unfortunately, the quantity and quality of published articles on this subject is very limited. In many studies, younger age (between 21 and 30 years) was associated with greater risk for recurrence of GHJ dislocations. Twelve studies (total N = 753) directly compared outcomes of operative versus nonoperative management. It seems that operative management significantly reduces recurrence rates with patients treated operatively among the young and active population. Operative management should be considered as a treatment option for young and athletic patients presenting with a first-time anterior GHJ dislocation.

Purpose: The purpose of this systematic review was to examine the effect that sex has on recurrence of anterior shoulder instability following primary arthroscopic anterior shoulder stabilization., Methods: A systematic review using PRISMA guidelines was performed by searching PubMed, Embase and Cochrane Library databases to identify studies reporting recurrence rates following arthroscopic anterior shoulder stabilization with a minimum follow-up period of 2 years. Patient demographics as well as preoperative, intraoperative and postoperative findings, including patient-reported outcomes and recurrence rates, were analyzed by 2 independent reviewers. Recurrence was defined as an episode of dislocation, subluxation or instability following primary arthroscopic anterior shoulder stabilization. Study methodological quality was evaluated with the Modified Coleman Methodology Score (MCMS). Risk bias was evaluated using the Methodological Index for Non-randomized Studies (MINORS score). Descriptive statistics are presented., Results: Ten studies (1 Level I, 1 Level II, 5 Level III, and 3 Level IV), including a total of 7,102 patients with primary traumatic and/or recurrent traumatic shoulder instability without previous procedures who underwent primary arthroscopic anterior shoulder stabilization, were included (mean follow-up, 34.6 months; mean age, 25.4 years). There was a total of 5,097 males (71.8%) and 2,005 females (28.2%). There was a higher recurrence rate in males (6%-37%) compared to females (0-32%). Clinical outcomes were inconsistently reported, so no quantitative analysis of clinical outcomes or return-to-sport between sexes was possible. The average MCMS of all 10 studies was 76.8 ± 8.0, indicating good methodology., Conclusions: Males may have higher recurrence rates than females following primary arthroscopic anterior shoulder stabilization; however, the heterogeneity of the included studies precludes any definitive conclusions., Level of Evidence: IV, Systematic Review of Level I-IV., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented., Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting., Study Design: Case-control study; Level of evidence, 3., Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment., Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction., Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both <10% and consistent with success rates of primary ACL reconstruction meniscal repair. Medial tears underwent reoperation for failure at a significantly higher rate than lateral tears.

Background: Microfracture (MFx) is one of the most common techniques used for the treatment of articular cartilage defects, although recently there has been a trend toward the use of drilling rather than MFx for the treatment of these defects., Purpose: To perform a systematic review of basic science studies to determine the effect of microfracture versus drilling for articular cartilage repair., Study Design: Systematic review., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and EMBASE to identify basic science studies comparing outcomes of MFx versus drilling. The search phrase used was microfracture AND (drilling OR microdrilling) . Inclusion criteria were basic science studies that directly compared the effect of MFx versus drilling on subchondral bone, bone marrow stimulation, and cartilage regeneration., Results: A total of 7 studies met the inclusion criteria and were included in this systematic review. Of these, 4 studies were performed in rabbits, 1 study in sheep, and 2 studies in humans. All of the included studies investigated cartilage repair in the knee. In the animal studies, microfracture produced fractured and compacted bone and led to increased osteocyte necrosis compared with drilling. Deep drilling (6 mm) was superior to both shallow drilling (2 mm) and MFx in terms of increased subchondral hematoma with greater access to marrow stroma, improved cartilage repair, and increased mineralized bone. However, the overall quality of cartilage repair tissue was poor regardless of marrow stimulation technique. In 2 studies that investigated repair tissue after MFx and/or drilling in human patients with osteoarthritis and cartilage defects, the investigators found that cartilage repair tissue did not achieve the quality of normal hyaline articular cartilage., Conclusion: In the limited basic science studies that are available, deep drilling of cartilage defects in the knee resulted in improved biological features compared with MFx, including less damage to the subchondral bone and greater access to marrow stroma. Regardless of marrow stimulation technique, the overall quality of cartilage regeneration was poor and did not achieve the characteristics of native hyaline cartilage. Overall, there is a general lack of basic science literature comparing microfracture versus drilling for focal chondral defects., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.J.S. has received research support from Isto Biologics, consulting fees from DePuy/Medical Device Business Services and Mitek, nonconsulting fees from Flexion Therapeutics, and hospitality payments from Smith & Nephew. E.C.M. has received research support from Arthrex, Breg, Mitek, Ossur, Smith & Nephew, Stryker, and Zimmer Biomet; consulting fees from Zimmer Biomet; and royalties from Elsevier and Zimmer Biomet. M.K.M. has received educational support from Alon Medical Technology, Arthrex, and Quest Medical; nonconsulting fees from Arthrex; and hospitality payments from Zimmer Biomet. 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: The cause of subsequent surgery after anterior cruciate ligament (ACL) reconstruction varies, but if risk factors for specific subsequent surgical procedures can be identified, we can better understand which patients are at greatest risk., Purpose: To report the incidence and types of subsequent surgery that occurred in a cohort of patients 6 years after their index ACL reconstruction and to identify which variables were associated with the incidence of patients undergoing subsequent surgery after their index ACL reconstruction., Study Design: Cohort study; Level of evidence, 2., Methods: Patients completed a questionnaire before their index ACL surgery and were followed up at 2 and 6 years. Patients were contacted to determine whether any underwent additional surgery since baseline. Operative reports were obtained, and all surgical procedures were categorized and recorded. Logistic regression models were constructed to predict which patient demographic and surgical variables were associated with the incidence of undergoing subsequent surgery after their index ACL reconstruction., Results: The cohort consisted of 3276 patients (56.3% male) with a median age of 23 years. A 6-year follow-up was obtained on 91.5% (2999/3276) with regard to information on the incidence and frequency of subsequent surgery. Overall, 20.4% (612/2999) of the cohort was documented to have undergone at least 1 subsequent surgery on the ipsilateral knee 6 years after their index ACL reconstruction. The most common subsequent surgical procedures were related to the meniscus (11.9%), revision ACL reconstruction (7.5%), loss of motion (7.8%), and articular cartilage (6.7%). Significant risk factors for incurring subsequent meniscus-related surgery were having a medial meniscal repair at the time of index surgery, reconstruction with a hamstring autograft or allograft, higher baseline Marx activity level, younger age, and cessation of smoking. Significant predictors of undergoing subsequent surgery involving articular cartilage were higher body mass index, higher Marx activity level, reconstruction with a hamstring autograft or allograft, meniscal repair at the time of index surgery, or a grade 3/4 articular cartilage abnormality classified at the time of index ACL reconstruction. Risk factors for incurring subsequent surgery for loss of motion were younger age, female sex, low baseline Knee injury and Osteoarthritis Outcome Score symptom subscore, and reconstruction with a soft tissue allograft., Conclusion: These findings can be used to identify patients who are at the greatest risk of incurring subsequent surgery after ACL reconstruction.

Purpose: To systematically review the literature to compare the adductor canal block (ACB) with the femoral nerve block (FNB) following primary anterior cruciate ligament reconstruction (ACLR) in terms of early postoperative analgesic requirements and postoperative quadriceps strength., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to August 2019 to identify randomized controlled trials that compared postoperative pain and functional outcomes in patients following primary ACLR with ACB versus FNB. The search phrase used was: adductor canal femoral nerve anterior cruciate ligament. Patients were evaluated based on analgesic consumption and quadriceps muscle strength. Study quality and risk of bias were evaluated with the Modified Coleman Methodology Score and Cochrane risk-of-bias tool respectively., Results: Five studies (all Level I evidence) were identified that met inclusion criteria, including 221 patients undergoing primary ACLR with ACB (mean age 26.8 years, 68.3% male) and 221 with FNB (mean age 28.2 years, 67.0% male). Statistical assessment for heterogeneity found for opioid consumption of ACB versus FNB groups was I 2  = 97% (P < .0001). There were no significant differences in analgesic consumption within the first 24 hours following surgery between groups except in 1 study, in which patients receiving ACB required significantly greater analgesics (P < .001). Three studies using 3 different techniques to measure strength found patients receiving ACB to have significantly greater quadriceps muscle function within 24 hours of surgery when compared with patients receiving FNB (P < .05)., Conclusions: In patients undergoing ACLR, the ACB may provide similar analgesic requirements, and the included studies suggest a potential advantage in preserving muscle strength at short-term (24-48 hours) follow-up when compared with FNB. However, the differences in muscle strength assessments between studies do not allow for strong conclusions., Level of Evidence: I, systematic review and meta-analysis of Level I studies., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The effect of platelet-rich plasma (PRP) augmentation for meniscal repair (MR) is unclear, as current evidence is limited to small, mostly nonrandomized studies., Purpose: To systematically review the literature to evaluate the efficacy and safety of MR with PRP augmentation., Study Design: Systematic review; Level of evidence, 3., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies (level of evidence 1-3) that compared the clinical efficacy of MR performed with versus without PRP. The search phrase used was platelet-rich plasma meniscus. Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the visual analog scale (VAS) for pain, the Lysholm score, the Knee injury and Osteoarthritis Outcome Score (KOOS), the subjective International Knee Documentation Committee (IKDC) score, and treatment failure., Results: We identified 6 studies (2 studies with level 1 evidence; 4 studies with level 3 evidence) that met inclusion criteria, for a total of 309 patients undergoing MR with PRP (mean age, 31.9 years) and 445 patients without PRP augmentation (mean age, 29.6 years). The mean follow-up was 32.8 months (range, 12-72 months). Overall, 17.0% of PRP patients experienced MR failure compared with 22.1% of non-PRP patients. No differences in VAS, Lysholm, or subjective IKDC scores were found between groups except in 1 study, in which postoperative subjective IKDC scores were significantly better in the PRP group ( P < .01). Another study found significantly better postoperative WOMAC scores among PRP patients, and 2 studies found significantly better KOOS subscores among PRP patients., Conclusion: There are a limited number of high-quality studies comparing outcomes and healing rates between patients undergoing MR with versus without PRP augmentation. Based on the available evidence, patients undergoing MR with PRP augmentation experience similar clinical outcomes at midterm follow-up when compared with conventional MR, and additional studies are needed to determine the efficacy of MR augmented with PRP., Competing Interests: One or more of the authors has declared the following potential conflicts of interest or source of funding: S.G.T. has received educational support from Quest Medical. E.C.M. has received research support from Arthrex, Biomet, Breg, Mitek, Ossur, Smith & Nephew, and Stryker; consulting fees from Zimmer Biomet; and royalties from Elsevier and Zimmer Biomet. 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: There remains a paucity of literature comparing clinical outcomes after anterior cruciate ligament reconstruction (ACLR) between skiers and non-skiers, particularly in older patient populations., Purpose: To compare clinical outcomes after ACLR between skiers and non-skiers, with a subanalysis based on age., Study Design: Cohort study; Level of evidence, 3., Methods: A nested cohort of 128 patients from the Multicenter Orthopaedic Outcomes Network cohort who underwent primary ACLR completed a series of patient-reported outcomes pre- and postoperatively at 2 and 6 years including the Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, and subjective International Knee Documentation Committee (IKDC) score. Data including patient sex, age at surgery, graft type, and sport participation were analyzed. Patients were stratified by participation in skiing (skiers vs non-skiers) and by age subgroup (≤29, 30-39, and ≥40 years). Student t tests and analysis of variance were used to compare mean improvement between pre- and postoperative outcomes., Results: A total of 44 skiers (female, 59.1%; age, 35.3 ± 11.6 years) and 84 non-skiers (female, 34.5%; age, 27.7 ± 11.3 years) were included. ACLR was performed using allograft in 36.7% (22 skiers, 25 non-skiers), autograft in 58.6% (19 skiers, 56 non-skiers), or hybrid autograft-allograft in 4.7% (3 skiers, 3 non-skiers). Although both non-skiers and skiers demonstrated improvements in outcomes from baseline to 2 and 6 years, non-skiers demonstrated significantly less overall improvement from 2 to 6 years postoperatively in KOOS Symptoms ( P = .01), KOOS Pain ( P = .002), and KOOS Activities of Daily Living ( P = .03) subscales compared with skiers. There were 15 skiers who were 29 years or younger (34.1%), 14 skiers between 30 and 39 years (31.8%), and 15 skiers 40 years or older (34.1%). Skiers 40 years and older demonstrated significantly greater mean improvement in KOOS Symptoms ( P = .02) and KOOS Quality of Life (QoL) ( P = .01) subscales at 2 years and KOOS QoL ( P = .01) at 6 years postoperatively compared with skiers 29 years or younger., Conclusion: Compared with non-skiers, skiers demonstrated significantly greater mean improvements in KOOS scores between 2 and 6 years after ACLR. In addition, skiers 40 years or older showed greater improvement in KOOS QoL compared with younger skiers. This information can be used to counsel skiers, especially those older than 40 years, as to their expected outcomes after ACLR., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Research reported in this publication was partially supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award No. R01AR053684. A.F.V. has received educational support from Arthrex, consulting fees from Stryker, and speaking fees from Arthrex and Smith & Nephew. M.L.W. has received educational support from Gemini Mountain. E.C.M. has received research support from Arthrex, Biomet, Breg, Mitek, Ossur, Smith & Nephew, and Stryker; consulting fees from DePuy and Zimmer Biomet; speaking fees from Arthrex; and royalties from Elsevier and Zimmer Biomet. J.T.B. has received research support from Biomet and Stryker; consulting fees from DJO, Encore Medical, and Smith & Nephew; and royalties from Shukla Medical. R.M.F. has received grant support from Arthrex; educational support from Arthrex, Medwest, and Smith & Nephew; speaking fees from Arthrex; and royalties from Elsevier. 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: Few studies have investigated the relationship between the Patient-Reported Outcomes Measurement Information System (PROMIS) and legacy patient-reported outcome (PRO) measurements., Purpose: To compare patient-reported outcomes from the PROMIS physical function (PF) and upper extremity (UE) platforms against one another and against legacy PRO measurements to assess the potential strengths and weaknesses of the National Institutes of Health PROMIS initiative and expand on the use of PRO measurements in clinical orthopaedic practice., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic search of the PubMed, Embase, and Cochrane Library databases was conducted following PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. All English-language studies published between 2017 and 2019 using PROMIS to evaluate patients for shoulder surgery were analyzed. PROs were compared based on survey administered and the shoulder condition being investigated. Study quality was evaluated using the Modified Coleman Methodology Score and the Methodological Index for Non-Randomized Studies score., Results: We included 9 studies (5 studies were level 2; 3 studies were level 3; 1 study was level 4) encompassing a total of 1130 patients (60.2% male; mean age, 52.6 ± 16.5 years; mean BMI, 29.8 ± 2.8 kg/m 2 ). Of these, 6 studies administered the PROMIS PF, and 6 studies administered the PROMIS UE. The strongest correlation was between PROMIS PF computer adaptive test and the 36-Item Short Form Health Survey Global Health (SF-36 GH) ( r = 0.75). The highest overall correlation with the PROMIS UE was found with the American Shoulder and Elbow Surgeons (ASES) Shoulder Score ( r = 0.70). The lowest correlations were found between PROMIS PF and the Marx Shoulder Activity Scale ( r = 0.08) and the PROMIS UE and the Marx Shoulder Activity Scale ( r = 0.18)., Conclusion: From available data, the PROMIS PF and PROMIS UE were most closely correlated with outcomes measured by the SF-36 GH. The PROMIS UE alone was most correlated with ASES Shoulder Score. Thus, either PROMIS PF or UE may provide a possible alternative to legacy PRO measurements but with a lower overall number of questions and higher generalizability. Future research should compare the time and question burden of the various PROMIS platforms with a more consistent evaluation of standard PRO measurements., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.M.F. has received grant support from Arthrex; educational support from Arthrex, Medwest, and Smith & Nephew; speaking fees from Arthrex; and royalties from Elsevier. J.T.B. has received research support from Biomet and Stryker; consulting fees from DJO, Encore Medical, and Smith & Nephew; and royalties from Shukla Medical. E.C.M. has received research support from Arthrex, Biomet, Breg, Mitek, Ossur, Smith & Nephew, and Stryker; consulting fees from DePuy and Zimmer Biomet; speaking fees from Arthrex; and royalties from Elsevier and Zimmer Biomet. 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: Cutibacterium acnes is a gram-positive anaerobe that can lead to postoperative shoulder infections. The purpose of this study was to determine the incidence of C acnes infections following shoulder arthroscopy and evaluate the efficacy of perioperative antibiotic prophylaxis in the prevention of these infections., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that evaluated the prevalence and clinical indications of C acnes infections after various arthroscopic shoulder surgical procedures. Patients were assessed based on positive culture rates, the contraction of infection, and antibiotic regimens used to prevent infection., Results: A total of 9 studies (1 level I, 5 level II, 1 level III, and 2 level IV) met the inclusion criteria, including a total of 3758 patients with a mean age of 59.9 years (range, 17-87 years) at the time of surgery. The mean follow-up time was 1.6 months (range, 1.0-12.0 months). Overall, 37.3% of patients (173 of 464) had positive C acnes skin and/or joint culture results, and in 0.22% of patients (8 of 3586), a C acnes infection was diagnosed postoperatively. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery significantly reduced the positive culture rate from 41.6% to 9.6% (P < .001)., Conclusions: C acnes infections occur at a very low rate (0.22%) following shoulder arthroscopy. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery in combination with preoperative antibiotic prophylaxis significantly reduces the prevalence of C acnes in shoulder arthroscopy patients., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Knot tying is a crucial component of successful arthroscopic shoulder surgery. It is currently unknown whether sliding or nonsliding techniques result in superior clinical outcomes., Purpose: To assess the clinical outcomes of arthroscopic sliding knot (SK)- versus nonsliding knot (NSK)-tying techniques during arthroscopic shoulder surgery, including rotator cuff repair, Bankart repair, and superior labral anterior-posterior (SLAP) repair., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic search of the PubMed, Embase, and Cochrane Library databases was performed using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. All English-language literature published between 2000 and 2018 reporting clinical outcomes utilizing SK- or NSK-tying techniques during rotator cuff repair, Bankart repair, and SLAP repair with a minimum 24-month follow-up was reviewed by 2 independent reviewers. Information on type of surgery, knot used, failure rate, patient satisfaction, and patient-reported outcomes was collected. Patient-reported outcome measures included the Constant-Murley score, Rowe score, and visual analog scale for pain. Study quality was evaluated using the modified Coleman Methodology Score., Results: Overall, 9 studies (6 level 3 and 3 level 4) with a total of 671 patients (mean age, 52.8 years [range, 16-86 years]; 65.7% male; 206 SK and 465 NSK) were included. There were 4 studies that reported on Bankart repair in 148 patients (63 SK and 85 NSK), 3 on SLAP repair in 59 patients (59 SK), and 2 on rotator cuff repair in 464 patients (84 SK and 380 NSK). Also, 6 studies compared knot-tying with knotless techniques (3 Bankart repair studies and 3 SLAP repair studies), while the studies reporting the outcomes of SLAP repair evaluated SK-tying techniques only. The failure rate for Bankart repair was 3.2% (2/63) for SKs and 4.7% (4/85) for NSKs. The failure rate for rotator cuff repair was 2.4% (2/84) for SKs and 6.3% (24/380) for NSKs. The failure rate for SLAP repair was 11.9% (7/59). Because of inconsistencies in outcomes and procedures, no quantitative analysis was possible. The mean modified Coleman Methodology Score for all studies was 65.1 ± 8.77, indicating adequate methodology., Conclusion: The literature on clinical outcomes using SKs or NSKs for shoulder procedures is limited to level 4 evidence. Future studies should be prospective and focus on comparing the use of SKs and NSKs for shoulder procedures to elucidate which arthroscopic knot results in superior clinical outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.C.M. has received research support from Arthrex, Biomet, Breg, Mitek, Ossur, Smith & Nephew, and Stryker; consulting fees from DePuy and Zimmer Biomet; speaking fees from Arthrex; and royalties from Elsevier and Zimmer Biomet. A.J.S. has received educational support from Gemini Mountain Medical and Arthrex, honoraria from Encore Medical, and consulting fees from Medacta. M.L.W. has received educational support from Gemini Mountain Medical. A.F.V. has received educational support from Arthrex, consulting fees from Stryker and Smith & Nephew, and speaking fees from Arthrex and Smith & Nephew. R.M.F. has received grant support from Arthrex; educational support from Arthrex, Medwest, and Smith & Nephew; speaking fees from Arthrex; and royalties from Elsevier. 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: Patients with posterior shoulder instability may have bone and cartilage lesions (BCLs) in addition to capsulolabral injuries, although the risk factors for these intra-articular lesions are unclear., Hypothesis: We hypothesized that patients with posterior instability who had a greater number of instability events would have a higher rate of BCLs compared with patients who had fewer instability episodes., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group instability patient cohort were analyzed. Patients aged 12 to 99 years undergoing primary surgical treatment for shoulder instability were included. The glenohumeral joint was evaluated by the treating surgeon at the time of surgery, and patients were classified as having a BCL if they had any grade 3 or 4 glenoid or humeral cartilage lesion, reverse Hill-Sachs lesion, bony Bankart lesion, or glenoid bone loss. The effects of the number of instability events on the presence of BCLs was investigated by use of Fisher exact tests. Logistic regression modeling was performed to investigate the independent contributions of demographic variables and injury-specific variables to the likelihood of having a BCL. Significance was defined as P < .05., Results: We identified 271 patients (223 male) for analysis. Bone and cartilage lesions were identified in 54 patients (19.9%) at the time of surgical treatment. A glenoid cartilage injury was most common and was identified in 28 patients (10.3%). A significant difference was noted between the number of instability events and the presence of BCLs ( P = .025), with the highest rate observed in patients with 2 to 5 instability events (32.3%). Multivariate logistic regression modeling indicated that increasing age ( P = .019) and 2 to 5 reported instability events ( P = .001) were significant independent predictors of the presence of BCLs. For bone lesions alone, the number of instability events was the only significant independent predictor; increased risk of bone lesion was present for patients with 1 instability event (OR, 6.1; P = .012), patients with 2 to 5 instability events (OR, 4.2; P = .033), and patients with more than 5 instability events (OR, 6.0; P = .011)., Conclusion: Bone and cartilage lesions are seen significantly more frequently with increasing patient age and in patients with 2 to 5 instability events. Early surgical stabilization for posterior instability may be considered to potentially limit the extent of associated intra-articular injury. The group of patients with more than 5 instability events may represent a different pathological condition, as this group showed a decrease in the likelihood of cartilage injury, although not bony injury.

Purpose: To systematically review the literature in an effort to compare the demographics and clinical outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with a hamstring tendon autograft (HT) versus an irradiated or nonirradiated hybrid autograft-allograft., Methods: A systematic review of the PubMed, Cochrane Library, and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All English-language literature that reported general demographics and compared the clinical outcomes of patients undergoing primary ACLR with autograft versus hybrid graft (HG) with a minimum 2-year follow-up was reviewed by 2 independent reviewers. Search terms used were "anterior cruciate ligament" and "hybrid graft." Patients were assessed based on graft failure, anteroposterior laxity, and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, visual analog scale, Subjective International Knee Documentation Committee score, Lysholm, and Tegner scores). Study quality was evaluated with the Modified Coleman Methodology Score and ROBINS-I risk of bias tool., Results: Twelve studies (1 level II, 11 level III) met inclusion criteria (follow-up, 2.0-8.9 years), including 471 patients undergoing ACLR with an irradiated hybrid graft (IH), 89 patients with a nonirradiated hybrid graft, and 829 patients with HT. Graft diameter ranged from 7.5 to 10.0 mm and from 6.5 to 10.0 mm in HG and HT patients, respectively. Overall, graft failure ranged from 0% to 30.0% and from 0% to 28.3% in HG and HT patients, respectively (I 2  = 35.9%; 95% confidence interval 0%-74.8%). Among HG patients, graft failure ranged from 0%-30.0% and from 2.4%-4.2% in IH and nonirradiated hybrid graft groups, respectively (I 2  = 33.6%; 95% confidence interval, 0%-71.8%). Results for postoperative anteroposterior laxity and patient-reported outcomes were also inconsistent., Conclusions: Patients undergoing ACLR with HT demonstrate inconsistent differences in clinical outcomes at midterm follow-up compared with IH patients., Level of Evidence: III, systematic review of level II and III studies., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss., Purpose: (1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months., Study Design: Case-control study; Level of evidence, 3., Methods: A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports., Results: Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) ( P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02)., Conclusion: A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.

Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery., Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction., Study Design: Systematic review., Methods: A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. PubMed, EMBASE, and the Cochrane Library were queried through use of the terms anterior cruciate ligament and revision to identify all studies reporting outcomes of bone tunnel grafting in 2-stage revision ACL reconstruction. Data extracted included indications for 2-stage surgery, surgical technique, graft material, time between surgeries, rehabilitation protocols, physical examination findings, patient-reported outcomes, and radiographic and histologic findings., Results: The analysis included 7 studies with a total of 234 patients. The primary outcome in 2 studies was graft incorporation (mean follow-up, 8.8 months), whereas the other 5 studies reported clinical outcomes with follow-up mean ± SD of 4.2 ± 2.1 years. The indication for bone grafting and between-stage protocol varied among studies. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). Finally, 1 study compared ICBG to a synthetic bone substitute. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. In 4 studies, the authors reported the time interval between first and second surgeries, with an average of 6.1 months for ICBG compared with 8.7 months for allogenic and synthetic grafts. Revision ACL graft failure rates were reported by 5 studies, including 1 study with ABM (6.1%), 1 study with AC (8.3%), 1 study with TBA (0%), and 2 studies with ICBG (0% and 2%)., Conclusion: The indications for staged ACL reconstruction and the rehabilitation protocol between stages need to be clearly established. The available data indicate that autograft for bone tunnel grafting in 2-stage ACL revision may be associated with a lower risk of revision ACL reconstruction graft failure compared with allograft bone.

Background: Patients who have undergone shoulder instability surgery are often allowed to return to sports, work, and high-level activity based largely on a time-based criterion of 6 months postoperatively. However, some believe that advancing activity after surgery should be dependent on the return of strength and range of motion (ROM)., Hypothesis: There will be a significant loss of strength or ROM at 6 months after arthroscopic Bankart repair with remplissage compared with Bankart repair alone., Study Design: Cohort study; Level of evidence, 2., Methods: A total of 38 patients in a prospective multicenter study underwent arthroscopic Bankart repair with remplissage (33 males, 5 females; mean age, 27.0 ± 10.2 years; 82% with ≥2 dislocation events in the past year). Strength and ROM were assessed preoperatively and at 6 months after surgery. Results were compared with 104 matched patients who had undergone Bankart repair without remplissage, although all had radiographic evidence of a Hill-Sachs defect., Results: At 6 months, there were no patients in the remplissage group with anterior apprehension on physical examination. However, 26% had a ≥20° external rotation (ER) deficit with the elbow at the side, 42% had a ≥20° ER deficit with the elbow at 90° of abduction, and 5% had persistent weakness. Compared with matched patients who underwent only arthroscopic Bankart repair, the remplissage group had greater humeral bone loss and had a greater likelihood of a ≥20° ER deficit with the elbow at 90° of abduction ( P = .004). Risk factors for a ≥20° ER deficit with the elbow at 90° of abduction were preoperative stiffness in the same plane ( P = .02), while risk factors for a ≥20° ER deficit with the elbow at the side were increased number of inferior quadrant glenoid anchors ( P = .003), increased patient age ( P = .02), and preoperative side-to-side deficits in ER ( P = .04). The only risk factor for postoperative ER weakness was preoperative ER weakness ( P = .04), with no association with remplissage ( P = .26)., Conclusion: Arthroscopic Bankart repair with remplissage did not result in significant strength deficits but increased the risk of ER stiffness in abduction compared with Bankart repair without remplissage at short-term follow-up., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: G.L.C. has received hospitality payments from Smith & Nephew, Zimmer Biomet, Arthrex, and CDC Medical. A.N. has received hospitality payments from DePuy Synthes and Encore Medical. G.L.J. has received hospitality payments from DJO, Encore Medical, the Musculoskeletal Transplant Foundation, and Smith & Nephew and honoraria from the Musculoskeletal Transplant Foundation. C.M.H. has received hospitality payments from Heraeus Medical, Zimmer Biomet, Smith & Nephew, and Wright Medical Technology. B.R.W. has received hospitality payments from Arthrex, DJO, Vericel, and Wright Medical Technology and consulting fees from Linvatec. 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: Understanding predictors of pain is critical, as recent literature shows that comorbid back pain is an independent risk factor for worse functional and patient-reported outcomes (PROs) as well as increased opioid dependence after total joint arthroplasty., Purpose/hypothesis: The purpose of this study was to evaluate whether comorbid back pain would be predictive of pain or self-reported instability symptoms at the time of stabilization surgery. We hypothesized that comorbid back pain will correlate with increased pain at the time of surgery as well as with worse scores on shoulder-related PRO measures., Study Design: Cross-sectional study; Level of evidence, 3., Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients consented to participate in pre- and intraoperative data collection. Demographic characteristics, injury history, preoperative PRO scores, and radiologic and intraoperative findings were recorded for patients undergoing surgical shoulder stabilization. Patients were also asked, whether they had any back pain., Results: The study cohort consisted of 1001 patients (81% male; mean age, 24.1 years). Patients with comorbid back pain (158 patients; 15.8%) were significantly older (28.1 vs 23.4 years; P < .001) and were more likely to be female (25.3% vs 17.4%; P = .02) but did not differ in terms of either preoperative imaging or intraoperative findings. Patients with self-reported back pain had significantly worse preoperative pain and shoulder-related PRO scores (American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index) ( P < .001), more frequent depression (22.2% vs 8.3%; P < .001), poorer mental health status (worse scores for the RAND 36-Item Health Survey Mental Component Score, Iowa Quick Screen, and Personality Assessment Screener) ( P < .01), and worse preoperative expectations ( P < .01)., Conclusion: Despite having similar physical findings, patients with comorbid back pain had more severe preoperative pain and self-reported symptoms of instability as well as more frequent depression and lower mental health scores. The combination of disproportionate shoulder pain, comorbid back pain and mental health conditions, and inferior preoperative expectations may affect not only the patient's preoperative state but also postoperative pain control and/or postoperative outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported, in part, by research grants from the Orthopaedic Research & Education Fund. B.R.W. is a paid board member of United HealthCare and a paid consultant for ConMed Linvatec and SportsMed Innovate. B.R.W.’s institution has received educational support from ConMed, Smith & Nephew, Arthrex, and Wardlow Enterprises. K.M.B. has received consulting fees from Wright Medical, speaking fees from Wright Medical and Arthrex, and royalties from Lippincott Williams & Wilkins. J.T.B. has received consulting fees from Encore Medical, Smith & Nephew, and DJO Global; speaking fees from Smith & Nephew; and royalties from Shukla Medical. R.H.B. has received educational support from Arthrex and Elite Orthopedics, speaking fees from Arthrex and Smith & Nephew, and consulting fees from ISTO Technologies and Sanofi-Aventis. B.T.F. has received hospitality payments from Zimmer Biomet. J.A.G. has received educational support from Pinnacle, hospitality payments from Aesculap Biologics and Smith & Nephew, and consulting fees from Ossur and JRF Ortho. G.L.J. is a board member for the Musculoskeletal Transplant Foundation and has received educational support from CDC Medical. J.E.K. is a paid editor for the Journal of Shoulder and Elbow Surgery. C.B.M. has received speaking fees from Zimmer Biomet and consulting fees from Zimmer Biomet, Medacta, Stryker, Tornier, Wright Medical, and Linvatec. R.G.M. is a paid editor for the Journal of Bone and Joint Surgery and receives royalties from Springer and Demos Health. E.C.M. has received consulting fees from Zimmer Biomet; research support from Smith & Nephew, Arthrex, and DePuy; and royalties from Zimmer Biomet and Elsevier. B.S.M. has received consulting fees from Arthrex. A.J.S. has received educational support from Gemini Medical and Arthrex, honoraria from Encore Medical, and consulting fees from Medacta. M.V.S. has received educational support from Elite Orthopedics and consulting fees from Arthrex and Flexion Therapeutics. R.W.W. has received royalties from Wolters Kluwer–Lippincott Williams & Wilkins and is a team physician for the St. Louis Blues Hockey Club. A.L.Z. has received consulting fees from Stryker. C.M.H. has received research support from Zimmer Biomet, speaking fees from Pacira Pharmaceuticals, and hospitality payments from Arthrex and Tornier., (© The Author(s) 2020.)

Background: Physicians' and patients' decision-making process between bone-patellar tendon-bone (BTB) and hamstring tendon autografts for anterior cruciate ligament (ACL) reconstruction (ACLR) may be influenced by a variety of factors in the young, active athlete., Purpose: To determine the incidence of both ACL graft revisions and contralateral ACL tears resulting in subsequent ACLR in a cohort of high school- and college-aged athletes who initially underwent primary ACLR with either a BTB or a hamstring autograft., Study Design: Cohort study; Level of evidence, 2., Methods: Study inclusion criteria were patients aged 14 to 22 years who were injured in sports, had a contralateral normal knee, and were scheduled to undergo unilateral primary ACLR with either a BTB or a hamstring autograft. All patients were prospectively followed for 6 years to determine whether any subsequent ACLR was performed in either knee after their initial ACLR. Multivariable regression modeling controlled for age, sex, ethnicity/race, body mass index, sport and competition level, baseline activity level, knee laxity, and graft type. The 6-year outcomes were the incidence of subsequent ACLR in either knee., Results: A total of 839 patients were eligible, of which 770 (92%) had 6-year follow-up for the primary outcome measure of the incidence of subsequent ACLR. The median age was 17 years, with 48% female, and the distribution of BTB and hamstring grafts was 492 (64%) and 278 (36%), respectively. The incidence of subsequent ACLR at 6 years was 9.2% in the ipsilateral knee, 11.2% in the contralateral normal knee, and 19.7% for either knee. High-grade preoperative knee laxity (odds ratio [OR], 2.4 [95% confidence interval [CI], 1.4-3.9]; P = .001), autograft type (OR, 2.1 [95% CI, 1.3-3.5]; P = .004), and age (OR, 0.8 [95% CI, 0.7-1.0]; P = .009) were the 3 most influential predictors of ACL graft revision in the ipsilateral knee. The odds of ACL graft revision were 2.1 times higher for patients receiving a hamstring autograft than patients receiving a BTB autograft (95% CI, 1.3-3.5; P = .004). No significant differences were found between autograft choices when looking at the incidence of subsequent ACLR in the contralateral knee., Conclusion: There was a high incidence of both ACL graft revisions and contralateral normal ACL tears resulting in subsequent ACLR in this young athletic cohort. The incidence of ACL graft revision at 6 years after index surgery was 2.1 times higher with a hamstring autograft compared with a BTB autograft.

Purpose of Review: Reverse total shoulder arthroplasty (RTSA) is a procedure that has been increasingly utilized since its inception over 20 years ago. The purpose of this review is to present the most up to date practice and advances to the RTSA literature from the last 5 years., Recent Findings: Recent literature on RTSA has focused on identifying complications, maximizing outcomes, and determining its cost-effectiveness. RTSA has become a valuable tool in the treatment of various shoulder pathologies from fractures to massive-irreparable rotator cuff tears. Maximizing outcomes, proper patient counseling, and limiting complications are vital to a successful procedure. RTSA can be a difficult procedure; however, when utilized appropriately, it can be an invaluable tool in the orthopedic surgeon's armament. Recent evidence suggests, more and more, that RTSA not only provides value to the patient, but it is also cost-effective.

Background: Arthroscopic capsular release (ACR) for the treatment of adhesive capsulitis of the shoulder can be performed in either the beach-chair (BC) or lateral decubitus (LD) position., Purpose: To determine the clinical outcomes and recurrence rates after ACR in the BC versus LD position., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed by searching PubMed, Embase, and the Cochrane Library databases for studies reporting clinical outcomes of patients undergoing ACR in either the BC or LD position. All English-language literature from 1990 through 2017 reporting on clinical outcomes after ACR with a minimum 3-month follow-up were reviewed by 2 independent reviewers. Recurrence rates, range of motion (ROM) results, and patient-reported outcome (PRO) scores were collected. Study methodological quality was evaluated using the modified Coleman Methodology Score (MCMS)., Results: A total of 30 studies (3 level 1 evidence, 2 level 2 evidence, 4 level 3 evidence, 21 level 4 evidence) including 665 shoulders undergoing ACR in the BC position (38.1% male; mean age, 52.0 ± 3.9 years; mean follow-up, 35.4 ± 18.4 months) and 603 shoulders in the LD position (41.8% male; mean age, 53.0 ± 2.3 years; mean follow-up, 37.2 ± 16.8 months) were included. There were no significant differences in overall mean recurrence rates between groups (BC, 2.5%; LD, 2.4%; P = .81) or in any PRO scores between groups ( P > .05). There were no significant differences in improvement in ROM between groups, including external rotation at the side (BC, 36.4°; LD, 42.8°; P = .91), forward flexion (BC, 64.4°; LD, 79.3°; P = .73), abduction (BC, 77.8°; LD, 81.5°; P = .82), or internal rotation in 90° of abduction (BC, 40.8°; LD, 45.5°; P = .70). Significantly more patients in the BC group (91.6%) underwent concomitant manipulation than in the LD group (63%) ( P < .0001). There were significantly more patients with diabetes in the LD group (22.4%) versus the BC group (9.6%) ( P < .0001)., Conclusion: Low rates of recurrent shoulder stiffness and excellent improvements in ROM can be achieved after ACR in either the LD or BC position. Concomitant manipulation under anesthesia is performed more frequently in the BC position compared with the LD position., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.F.V. has received consulting fees from ArthroCare and Stryker, speaking fees from Arthrex and Ceterix, educational support from Smith & Nephew, and hospitality payments from Steris. E.C.M. has received research support from Biomet, Mitek, Smith & Nephew, and Stryker; consulting fees from Zimmer Biomet and DePuy; and royalties from Zimmer Biomet and Elsevier. J.T.B. has received research support from Stryker; educational support from Mitek; royalties from Shukla Medical; and consulting fees from DJO, Encore Medical, Smith & Nephew, and Stryker. A.J.S. has received educational support from Gemini Mountain Medical, honoraria from Encore Medical, consulting fees from Medacta, and hospitality payments from Stryker. R.M.F. has received grant support from Arthrex; educational support from Arthrex, Medwest, 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) 2019.)

The purpose of this study was to report the demographics and clinical outcomes of patients at our institution following anterior cruciate ligament reconstruction (ACLR) with a planned or unplanned hybrid autograft-allograft. At a minimum 2-year follow-up, patients at our institution who had undergone primary ACLR with a planned (P) or unplanned (U) hybrid graft using fresh-frozen allografts were contacted to complete a survey containing the Knee Injury and Osteoarthritis Outcome Score, Subjective International Knee Documentation Committee score, Single Assessment Numeric Evaluation, 12-Item Short Form Health Survey, and visual analog scale for activity level. Demographics were compared between groups. Patient-reported outcomes (PROs) and a revision rate were reported for each group. Mean follow-up among all patients was 3.3 years. Revision rate at follow-up was 0.8 and 6.3% in the P and U groups, respectively ( p  = 0.03). Among patients reached for follow-up (90 P, 30 U), a lower proportion of males was found in the unplanned hybrid graft group (P: 52%, U: 23%, p  < 0.01). Unplanned hybrid graft patients were significantly younger at the time of surgery (P: 41.0 years, U: 31.0 years, p  < 0.0001). Graft size did not differ between groups (P: 9.1 mm, U: 8.9 mm, p  = 0.11). Patients in both groups achieved moderate to high PROs. Demographics differ between patients undergoing ACLR with a planned or unplanned hybrid graft. Patients with a planned hybrid graft are at a significantly reduced risk of postoperative graft failure, likely due to the older age of this group., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Understanding the risk factors for loss to follow-up in prospective clinical studies may allow for a targeted approach to minimizing follow-up bias and improving the generalizability of conclusions in anterior cruciate ligament reconstruction (ACLR) and other sports-related interventions., Purpose: To identify independent risk factors associated with failure to complete (ie, loss to follow-up) patient-reported outcome measures (PROMs) at 2 years after ACLR within a well-funded prospective longitudinal cohort., Study Design: Cohort study (prognosis); Level of evidence, 2., Methods: All patients undergoing primary or revision ACLR enrolled in the prospectively collected database of the multicenter consortium between 2002 and 2008 were included. Multivariate regression analyses were conducted to determine which baseline risk factors were significantly associated with loss to follow-up at a minimum of 2 years after surgery. Predictors assessed for loss to follow-up were as follows: consortium site, sex, race, marital status, smoking status, phone number provided (home or cell), email address provided (primary or secondary), years of school completed, average hours worked per week, working status (full-time, part-time, homemaker, retired, student, or disabled), number of people living at home, and preoperative PROMs (Knee injury and Osteoarthritis Outcome Score, Marx Activity Rating Scale, and International Knee Documentation Committee)., Results: A total of 3202 patients who underwent ACLR were enrolled. The 2-year PROM follow-up rate for this cohort was 88% (2821 of 3202). Multivariate analyses showed that patient sex (male: odds ratio [OR], 1.80) and race (black: OR, 3.64; other nonwhite: OR, 1.81) were independent predictors of 2-year loss to follow-up of PROMs. Education level was a nonconfounder., Conclusion: While education level did not predict loss to follow-up, patients who are male and nonwhite are at increased risk of loss to follow-up of PROM at 2 years. Capturing patient outcomes with minimal loss depends on equitable, not equal, opportunity to maximize generalizability and mitigate potential population-level health disparities., Registration: NCT00478894 (ClinicalTrials.gov identifier).

Sports-related injuries to the shoulder are common causes of disability. Injuries to the sternoclavicular joint (SCJ) in sports are more rare, though have been reported in a small number of cases. SCJ injury classification is determined by the degree of joint displacement and direction of clavicular displacement. Direction of displacement is particularly important due to risk of injury to intrathoracic structures, which has the potential to result in fatal outcomes. These injuries are important to identify in athletes and can be difficult to assess on the field. Specific radiographic views and use of ultrasound can improve accuracy of diagnosis. Reduction of acute traumatic SCJ dislocations is recommended and may require open reduction in the case of posteriorly displaced dislocations. Surgical treatment is indicated in cases of persistent pain or significant compression to intrathoracic soft tissue structures. Long-term outcomes are generally favorable, and athletes are able to return to sport without functional limitations.

Background: Patient-reported outcomes (PROs) are a valid measure of results after revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes when compared with primary ACL reconstruction. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for patients., Purpose/hypothesis: The purpose was to describe PROs after revision ACL reconstruction and test the hypothesis that patient- and technique-specific variables are associated with these outcomes., Study Design: Cohort study; Level of evidence, 2., Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons over 52 sites. Data included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale. Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors to determine the positive and negative predictors of PRO scores at 2 years after revision surgery., Results: A total of 1205 patients met the inclusion criteria and were successfully enrolled: 697 (58%) were male, with a median cohort age of 26 years. The median time since their most recent previous ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained from 989 patients (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male sex, and having a longer time since the most recent previous ACL reconstruction, while negative predictors included having a lateral meniscectomy before the revision ACL reconstruction or having grade 3/4 chondrosis in either the trochlear groove or the medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between the most recent previous ACL reconstruction and revision surgery were significant positive predictors for having a better (ie, higher) 2-year KOOS, while having a lateral meniscectomy before the revision ACL reconstruction was a consistent predictor for having a significantly worse (ie, lower) 2-year KOOS. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male sex, and being a nonsmoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery., Conclusion: PROs after revision ACL reconstruction are associated with a variety of patient- and surgeon-related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectations as well as potentially improve outcomes.

Background: Injuries to the posterolateral corner (PLC) may occur concurrently with anterior cruciate ligament (ACL) injury., Purpose/hypothesis: This study evaluated the outcomes of patients who underwent operative management of PLC injuries concurrently with ACL reconstruction in a prospective multicenter cohort. We hypothesized that there would be no differences in outcomes between patients who were treated with PLC repair and PLC reconstruction., Study Design: Cohort study; Level of evidence, 3., Methods: Patients undergoing ACL reconstruction were enrolled into a prospective longitudinal multicenter cohort between 2002 and 2008. Those with complete 6-year follow-up data (patient-reported outcomes and subsequent surgery information) were identified. Excluded from the study were patients with posterior cruciate ligament injuries. Patients who underwent PLC repair were compared with those who underwent PLC reconstruction with regard to interval from injury to surgery, need for revision surgery, and long-term outcomes at 6 years., Results: During the identified time frame, 3026 identified patients underwent primary ACL reconstruction; 34 (1.1%) also underwent concurrent PLC surgery (15 repairs, 19 reconstructions [18 allografts, 1 autograft]). With the numbers available, we did not detect significant differences between groups regarding the rate of meniscal or chondral injuries. Median time to PLC reconstruction was 121 days as compared with 19 days for concurrent ACL reconstruction and PLC repair ( P = .01). There were no between-group differences in Marx activity scores prior to surgery ( P = .4). At 6-year follow-up, there were no between-group differences in Knee injury and Osteoarthritis Outcome Score ( P = .36-.83) or International Knee Documentation Committee score ( P = .84); however, patients treated with PLC reconstructions had lower Marx activity scores (4.1 vs 9.4; P = .02). There was 1 ACL revision in the PLC reconstruction group, and 1 of the PLC repairs was revised to a reconstruction during the follow-up period., Conclusion: Good outcomes were achieved at 6-year follow-up with both repair and reconstruction of PLC injuries treated concurrently with ACL reconstruction. The PLC reconstruction group had lower activity levels 6 years after surgery. The present data suggest that, for appropriately selected patients undergoing acute surgical treatment of combined ACL and PLC injuries, PCL repair can achieve good long-term outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Research reported in this publication was partially supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award R01AR053684 (K.P.S.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. R.W.W. has received educational support from Arthrex and Smith & Nephew and hospitality payments from Medical Device Business Systems. R.G.M. has received educational support from Arthrex. K.P.S. has received research support from DonJoy and Smith & Nephew; has received consulting fees from Cytori, Mitek, and the National Football League Flexion Therapeutics, and Samumed; has received hospitality payments from Biosense Webster and DePuy; and receives royalties from commercial product nPhase. 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: Little is known about the epidemiology of clavicle fractures in United States (US) high school athletes. Sports participation among high school students has increased steadily, placing increased numbers at risk of sports-related injury., Purpose: To describe the epidemiology of clavicle fractures among high school athletes, including injury rates by sex, sport, and type of play and trends in operative versus nonoperative treatment., Study Design: Descriptive epidemiology study., Methods: The study data set included all athlete-exposure (AE) and clavicle fracture data collected from 2008-2009 through 2016-2017 from a large sample of US high schools as part of the National High School Sports-Related Injury Surveillance Study for students participating in boys' football, boys'/girls' soccer, boys'/girls' basketball, boys'/girls' volleyball, boys' wrestling, boys' baseball, girls' softball, girls' field hockey, boys' ice hockey, boys'/girls' lacrosse, boys'/girls' swimming and diving, boys'/girls' track and field, girls' gymnastics, girls' cheerleading, boys'/girls' tennis, and boys'/girls' cross-country., Results: Overall, 567 clavicle fractures were reported during 31,520,765 AEs, an injury rate of 1.80 per 100,000 AEs. Injury rates varied by sport, with the highest rates in the boys' full-contact sports of ice hockey (5.27), lacrosse (5.26), football (4.98), and wrestling (2.21). Among girls' sports, the highest rates were in soccer (0.92), lacrosse (0.26), and basketball (0.25). In sex-comparable sports, injury rates were still significantly higher among boys (1.03) than girls (0.35) (rate ratio, 2.91; 95% CI, 1.97-4.30). Injury rates were significantly higher in competition (4.58) as compared with practice (0.87) (rate ratio, 5.27; 95% CI, 4.44-6.26). Most injuries were treated conservatively (82.7%) rather than operatively (17.3%). Time to return to sports varied, with a greater proportion of medical disqualifications among those treated operatively (40.0%) as compared with those treated conservatively (22.6%) (injury proportion ratio, 1.77; 95% CI, 1.31-2.39)., Conclusion: Although clavicle fracture rates are relatively low, they vary by sport, sex, and activity. Understanding such differences should drive more effective, targeted injury prevention efforts. Increased time loss from sports with surgical versus conservative treatment may have been influenced by factors including injury severity and its timing relative to the season's progress., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The High School Reporting Information Online surveillance study was funded in part by the Centers for Disease Control and Prevention (grants R49/CE000674-01, R49/CE001172-01, and R49/CE002106-01) as well as research funding contributions of the National Federation of State High School Associations, National Operating Committee on Standards for Athletic Equipment , DonJoy Orthotics, and EyeBlack. E.C.M. has received educational support from Zimmer Biomet, Mitek, Smith & Nephew, and Stryker; consulting fees from Zimmer Biomet; and royalties from Zimmer Biomet. R.M.F. has received educational support from Arthrex, Smith & Nephew, and Medwest and research support from Arthrex. M.M.M. has received educational support 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.

Background: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery., Hypotheses: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates., Results: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC ( P < .0001), KOOS-Symptoms ( P = .01), KOOS-Sports and Recreation ( P = .04), and KOOS-Quality of Life ( P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates., Conclusion: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Background: Prior studies have analyzed the quality of information available on the Internet regarding common orthopaedic surgical procedures. The purpose of the present study was to evaluate the quality of information available for reverse total shoulder arthroplasty (rTSA)., Methods: Websites were identified using the search term 'reverse total shoulder arthroplasty' and the first 50 websites from three separate search engines (Google, Yahoo, and Bing) were selected for evaluation of authorship and quality of information using the DISCERN instrument (www.discern.org.uk). After disregarding duplicated or overlapping websites within and among search engines, 90 of the total 150 websites were evaluated. A one-way analysis of variance test was used to compare differences in DISCERN scores between three categories of authorship (academic, private, other)., Results: The majority of the websites evaluated were authored by academic (43%) and private institutions (36%). These were the most credible sources, providing overall better quality and reliability than other sources. DISCERN reliable ( p  = 0.017) and overall scores ( p  = 0.020) were significantly higher for academic institutions compared to other websites., Conclusions: The information available on the Internet pertaining to reverse total shoulder arthroplasty is highly variable and provides moderate quality information about treatment choices with some limitations based on the DISCERN instrument.

Background: Previous studies have evaluated functional outcomes and return-to-sport rates after proximal hamstring tendon (HT) repair., Purpose: To systematically review the literature in an effort to evaluate return-to-sport rates after proximal HT repair., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that evaluated postoperative lower extremity function and return-to-sport rates in patients after proximal HT repair. Search terms used were "hamstring," "repair," "return to sport," and "return to play." Patients were assessed based on return to sport, return to preinjury activity level, type of HT tear (complete or partial), and interval from injury to surgery. Patients were also divided into subgroups depending on timing of the surgical intervention: early, <1 month; delayed, 1 to 6 months; and late, >6 months from the time of injury., Results: Sixteen studies (one level 2, five level 3, ten level 4) met the inclusion criteria, including 374 patients with a complete proximal HT tear (CT group) and 93 patients with a partial proximal HT tear (PT group), with a mean follow-up of 2.9 years. Overall, 93.8% of patients (438/467) returned to sport, including 93.0% (348/374) in the CT group and 96.8% (90/93) in the PT group ( P = .18). The mean time to return to sport was 5.7 months, and 83.5% of patients (330/395) returned to their preinjury activity level. The early group demonstrated the greatest rate of return to sport at 94.4% (186/197) as well as the quickest time to return at a mean of 4.8 months, although this was not found to be statistically significant., Conclusion: Over 90% of patients undergoing repair of a complete or partial proximal HT tear can be expected to return to sport regardless of the tear type. Early surgical interventions of these injuries may be associated with a quicker return to sport, although the rate of return to sport does not differ based on timing of the surgical intervention., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: O.M.-D. has received nonconsulting fees from Arthrex, has received educational support from Arthrex, is a consultant for Stryker and Smith & Nephew, and receives royalties from Stryker. E.C.M. has received nonconsulting fees from Biomet, receives royalties from Zimmer Biomet, and is a consultant for DePuy and Zimmer Biomet. M.K.M. has received educational support from Arthrex and Quest Medical and has received hospitality payments from Biomet and Zimmer. 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.

Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.C.M. receives royalties from Biomet and Elsevier, is a consultant for Biomet and DePuy, and receives research support from Biomet, Mitek, Smith & Nephew, and Stryker. J.T.B. is a consultant for DJ Orthopaedics, Shukla Medical, Encore Medical, and Smith & Nephew; receives royalties from Shukla Medical; receives research support from Stryker; has received hospitality payments from Encore Medical and Smith & Nephew; and has received fellowship funding from Smith & Nephew, Mitek, and 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.

Background: Traumatic anterior shoulder instability is a common condition affecting sports participation among young athletes. Clinical outcomes after surgical management may vary according to patient activity level and sport involvement. Overhead athletes may experience a higher rate of recurrent instability and difficulty returning to sport postoperatively with limited previous literature to guide treatment., Purpose: To report the clinical outcomes of patients undergoing primary arthroscopic anterior shoulder stabilization within the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Consortium and to identify prognostic factors associated with successful return to sport at 2 years postoperatively., Study Design: Case series; Level of evidence, 4., Methods: Overhead athletes undergoing primary arthroscopic anterior shoulder stabilization as part of the MOON Shoulder Instability Consortium were identified for analysis. Primary outcomes included the rate of recurrent instability, defined as any patient reporting recurrent dislocation or reoperation attributed to persistent instability, and return to sport at 2 years postoperatively. Secondary outcomes included the Western Ontario Shoulder Instability Index and Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow questionnaire score. Univariate regression analysis was performed to identify patient and surgical factors predictive of return to sport at short-term follow-up., Results: A total of 49 athletes were identified for inclusion. At 2-year follow-up, 31 (63%) athletes reported returning to sport. Of those returning to sport, 22 athletes (45% of the study population) were able to return to their previous levels of competition (nonrefereed, refereed, or professional) in at least 1 overhead sport. Two patients (4.1%) underwent revision stabilization, although 14 (28.6%) reported subjective apprehension or looseness. Age ( P = .87), sex ( P = .82), and baseline level of competition ( P = .37) were not predictive of return to sport. No difference in range of motion in all planes ( P > .05) and Western Ontario Shoulder Instability Index scores (78.0 vs 80.1, P = .73) was noted between those who reported returning to sport and those who did not., Conclusion: Primary arthroscopic anterior shoulder stabilization in overhead athletes is associated with a low rate of recurrent stabilization surgery. Return to overhead athletics at short-term follow-up is lower than that previously reported for the general athletic population.

Background: Previous meta-analyses have been conducted to compare outcomes of various treatment injections for lateral epicondylitis (LE), including corticosteroid injection (CSI) and autologous blood products such as autologous blood (AB) and platelet-rich plasma (PRP)., Purpose: To conduct a systematic review of overlapping meta-analyses comparing different injection treatments (CSI, AB, PRP) for LE to determine which meta-analyses provide the best available evidence., Study Design: Systematic review; Level of evidence, 2., Methods: A systematic review was performed by searching PubMed, Embase, and the Cochrane Library to locate meta-analyses that compared clinical outcomes of CSI, AB, and PRP for the treatment of LE. Search terms included "injection," "corticosteroid," "platelet-rich plasma," "autologous blood," "tennis elbow," "lateral epicondylitis," and "meta-analysis." Results were reviewed to determine study eligibility. Patient outcomes were extracted from these meta-analyses. Meta-analysis quality was assessed with the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad decision algorithm was then used to determine which meta-analyses provided the best level of evidence., Results: Nine meta-analyses (two level 1 studies, seven level 2 studies) containing 8656 patients met the eligibility criteria. Seven meta-analyses found that autologous blood products such as AB and PRP significantly improved pain and elbow function in the intermediate term (12-26 weeks), while 4 studies found that CSI effectively relieved pain and improved elbow function in the short term (<12 weeks). The study by Arirachakaran et al in 2016 received the highest QUOROM and Oxman-Guyatt scores; therefore, this meta-analysis appears to have the highest level of evidence. In addition, this study was rated the highest-quality study in this systematic review according to the Jadad decision algorithm. Lower-quality meta-analyses indicated that dosage, number of injections, and differences in therapeutic duration between CSI and autologous blood products may be essential factors in determining the appropriate treatment injection protocol for LE., Conclusion: The current best available evidence suggests that CSI improves functional outcomes and pain relief in the short term, while AB and PRP are the most effective treatments in the intermediate term., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.C.M. has received research support from Mitek, Smith & Nephew, Stryker, and Zimmer Biomet; is a paid consultant for DePuy and Zimmer Biomet; and receives royalties from Elsevier and Zimmer Biomet. J.T.B. has received research support from Stryker; is a paid consultant for DJ Orthopaedics, Encore Medical, Smith & Nephew, and Stryker; has received educational fellowship funding from Mitek; and receives royalties from Shukla Medical. 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.