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Background: The utilization of lateral extra-articular tenodesis (LET) augmentation for anterior cruciate ligament reconstruction has increased. Various fixation points have been recommended based on tactile and anatomic landmarks; however, there is limited reporting of the accuracy or precision of these techniques in clinical practice., Purpose/hypothesis: The purpose of this study was to evaluate whether LET fixation points identified using anatomic landmarks and tactile techniques would fall within a predefined radiographic zone. It was hypothesized that the majority of LET fixation points would be inside the radiographic zone., Study Design: Cross-sectional study; Level of evidence, 4., Methods: Postoperative lateral knee radiographs of patients who underwent anterior cruciate ligament reconstruction with LET using a landmark-based technique without fluoroscopy between January 2018 and September 2023 were reviewed. Fixation points were measured by 2 raters based on their distance from an extension of the posterior femoral cortex line (PFCL) distally and a line perpendicular to the PFCL at the posterior condylar flare (PCF). Patients were excluded if the tunnel position could not be identified or if postoperative radiographs were malrotated. The mean LET position and percentage of points within the radiographic isometric zone, defined as 4 ± 4 mm posterior and 4 ± 3 mm anterior to the PFCL and 6 ± 4 mm distal and 20 ± 5 mm proximal to the PCF were calculated., Results: Complete data sets were obtained for 47 cases. The mean LET position was 6.4 ± 7.1 mm (range, -9 to 27.3 mm) anterior to the PFCL and 1.8 ± 7.6 mm (range, -16.7 to 12.6 mm) proximal to the PCF. Overall, 53% of LET fixation points were within the predefined radiographic zone. Of the malpositioned tunnels (n = 22), their locations relative to the radiographic zone were anterior (n = 18), posterior (n = 2), proximal (n = 1), and anterior and distal (n = 1)., Conclusion: This study found large variation in the location of LET fixation points, and almost half of fixation points were outside the predefined radiographic zone. Accurate and precise tunnel placement is one of multiple factors that may be important to minimize the risk of lateral compartment overconstraint, anterior cruciate ligament graft failure, and anisometry leading to LET graft loosening., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Steadman Philippon Research Institute has received grant funding or in-kind donations from Arthrex, DJO, MLB, Ossur, Siemens, Smith & Nephew, and XTRE. T.R.H. has received consulting fees and research support from Arthrex Inc and owns stocks or stock options in NICE. J.A.G. has received consulting fees from Bioventus, Smith & Nephew, DePuy Synthes Products, and Mitek; owns stock or stock options in Nice Recovery Systems; has received support for education from Gemini Mountain Medical and Arthrex; and has received hospitality payments from Medical Device Business Services. A.F.V. has received research support and consulting fees from Arthrex Inc; IP royalties and consulting fees from Stryker; speaking fees from Vericel and Smith & Nephew; hospitality payments from Bodycad USA; and support for education from Gemini Mountain Medical. A.C.K. has received support for education from Suvon Surgical. M.E.C. has received support for education from Evolution Surgical 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.

Tibial-sided posterior cruciate ligament avulsion fractures are challenging injuries that often occur concomitantly in the setting of multiligament knee and other soft-tissue injuries. There is no consensus on the optimal surgical approach or timing of treatment for these injuries. This Technical Note describes the fixation of a displaced posterior cruciate ligament avulsion fracture with concomitant grade 3 medial collateral ligament injuries and bucket-handle lateral meniscus tears using open and arthroscopic techniques. This method allows the surgeon to address multiple pathologies in a single stage, although it requires strategic planning and rehabilitation considerations., (© 2023 The Authors.)

Purpose: The purpose of this systematic review was to evaluate outcomes and complications rates between inlay and onlay patellofemoral arthroplasty (PFA)., Methods: According to the PRISMA statement, 42 studies with 2552 patients were included. Data considered for quantitative analysis consisted of the Knee Society Score (KSS), the range of motion (ROM), the visual analogue score (VAS), and the Western Ontario and McMaster Universities questionnaire (WOMAC). Complications and revision surgery were considered., Results: Data on postoperative KSS showed no differences between the groups. The ROM was evaluated in 8 studies for 70 and 331 inlay and onlay PFA, respectively. Onlay group was favorable in terms of postoperative ROM. Postoperative VAS was available for 64 inlay and 110 onlay and no differences were found. Data on postoperative WOMAC were available for 49 inlay and 527 onlay PFA and inlay group showed better scores. A statistically significant higher rate of instability, persistent pain, malposition, stiffness, deep infection, disease progression, and wear of the patellar component were noted in the inlay group. A higher rate of lateral release was noted in the onlay group. A higher number of manipulations under anesthesia was noted in the inlay group. The revision to total knee arthroplasty was reported more frequently in the inlay group., Conclusion: A higher rate of conversion to total knee arthroplasty and complication rates after inlay technique was found. The potential of achieving better WOMAC scores with the inlay technique should be weighed against the higher complication and revision rates compared to the onlay technique., Level of Evidence: IV., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

As youth sports participation has increased in recent years, injuries to the anterior cruciate ligament (ACL) have become increasingly common in pediatric patients. Historically, ACL reconstruction was delayed in pediatric patients to avoid physeal damage with the potential for leg-length discrepancy or angular deformity. Current research shows that delaying reconstruction or choosing nonoperative management is associated with increased rates of meniscal and chondral injuries, persistent knee instability, and low rates of return to previous activity. Early ACL reconstruction using techniques to avoid physeal growth disturbance is now widely accepted among physicians. The purpose of this review was to describe the pediatric ACL in terms of the relevant anatomy and biomechanics, physical examination, and diagnostic imaging. In addition, the importance of skeletal age and possible physeal injury is discussed in the context of ACL reconstruction options by skeletal age and remaining growth potential., (© by the National Athletic Trainers' Association, Inc.)

Background: Hip dislocation is a rare occurrence during sports but carries serious implications for athletes., Purpose: To systematically review treatment strategies and outcomes for hip dislocation in athletes, with the ultimate goal of providing sports medicine physicians with the information necessary to appropriately treat and counsel patients sustaining this injury., Study Design: Systematic review; Level of evidence, 4., Methods: PubMed, MEDLINE, and Embase were searched for studies relating to hip instability and athletics from January 1, 1989 to October 1, 2019. Abstracts and articles were evaluated on the basis of predefined inclusion and exclusion criteria. Inclusion criteria were the following: (1) data from ≥1 patients, (2) native hip dislocation or subluxation occurring during sports, (3) patients aged at least 10 years, and (4) written in English. Exclusion criteria were (1) patients younger than 10 years; (2) nonnative or postoperative hip dislocation or subluxation; (3) a native hip injury without dislocation or subluxation; (4) patients with dislocation or subluxation secondary to neuromuscular, developmental, or syndromic causes; (5) dislocation or subluxation not occurring during sports; (6) patients with physeal fractures; or (7) review articles or meta-analyses. Data were recorded on patient demographics, injury mechanism, treatment strategies, and clinical and radiographic outcomes. Where possible, pooled analysis was performed. Studies were grouped based on reported outcomes. Meta-analysis was then performed on these pooled subsets., Results: A total of 602 articles were initially identified, and after screening by 2 reviewers, 27 articles reporting on 145 patients were included in the final review. There were 2 studies that identified morphological differences between patients with posterior dislocation and controls, including decreased acetabular anteversion ( P = .015 and .068, respectively), increased prevalence of a cam deformity ( P < .0035), higher alpha angles ( P ≤ .0213), and decreased posterior acetabular coverage ( P < .001). No differences were identified for the lateral center edge angle or Tonnis angle. Protected postreduction weightbearing was most commonly prescribed for 2 to 6 weeks, with 65% of reporting authors recommending touchdown, toe-touch, or crutch-assisted weightbearing. Recurrence was reported in 3% of cases. Overall, 4 studies reported on findings at hip arthroscopic surgery, including a 100% incidence of labral tears (n = 27; 4 studies), 92% incidence of chondral injuries, 20% incidence of capsular tears, and 84% incidence of ligamentum teres tears (n = 25; 2 studies). At final follow-up, 86% of patients reported no pain (n = 14; 12 studies), 87% reported a successful return to play (n = 39; 10 studies), and 11% had radiographic evidence of osteonecrosis (n = 38; 10 studies)., Conclusion: Various treatment strategies have been described in the literature, and multiple methods have yielded promising clinical and radiographic outcomes in patients with native hip dislocation sustained during sporting activity. Data support nonoperative treatment with protected weightbearing for hips with concentric reduction and without significant fractures and an operative intervention to obtain concentric reduction if unachievable by closed means alone. Imaging for osteonecrosis is recommended, with evidence suggesting 4- to 6-week magnetic resonance imaging and follow-up at 3 months for those with suspicious findings in the femoral head.

Background: Ulnar collateral ligament (UCL) tears are prevalent in Major League Baseball (MLB) pitchers and can cause significant loss of time with varying reports of impact on performance. Revision UCL reconstruction (UCLR) is becoming increasingly common, with little known about the effects on fastball (FB) velocity and usage (FB%) in this setting., Hypothesis/purpose: The purpose was to evaluate the effect of revision UCLR on MLB pitchers with respect to postoperative FB velocity and FB% at 1 and 2 years after return to play. The hypothesis was postoperative FB velocity and FB% would significantly decrease vs. prerevision levels, and that revision UCLRs would result in significantly decreased FB velocity and FB% in comparison to a matched group of MLB pitchers after primary UCLR., Methods: Twenty-one pitchers who underwent revision UCLR and returned to MLB play were identified from public records from 2008-2021. The PITCHf(x) system collected FB velocity for 4-seam (4FB) and 2-seam (2FB) fastballs and total FB% for pitchers in the prerevision year as well as the 2 years after return. A matched control group of pitchers who underwent primary UCLR was used for comparison., Results: There were no significant differences in FB velocity between prerevision levels (4FB 92.9 mph, 2FB 91.4 mph) and years 1 (4FB 92.5 mph, 2FB 91.2 mph) and 2 (4FB 93.4 mph, 2FB 91.1 mph) after revision UCLR. FB% decreased from the prerevision season (60.1) and the first (56.2, P = .036) and second years (52.5, P = .002) after return. There were no significant differences between FB velocity and FB% or between the revision and primary UCLR groups., Conclusion: Pitchers returning to the MLB level after revision UCLR can expect similar FB velocity to their prerevision FB velocity and to pitchers undergoing primary UCLR; however, they do demonstrate a decrease in FB%, which may suggest less confidence in their FB after RTP., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Major league baseball (MLB) pitchers are at risk of numerous injuries during play, and there is an increasing focus on evaluating their performance in the context of injury. Historically, performance after return to play (RTP) from injury has focused on general descriptive statistics, such as innings or games played, or rate statistics with inherent variability (eg, earned run average, walks and hits per inning pitched, strikeouts per 9 innings, or walks per 9 innings). However, in recent years, MLB has incorporated advanced technology and tracking systems in every stadium, allowing for more in-depth analysis of pitcher-specific data that are captured with every pitch of every game. This technology allows for the ability to delve into the pitching performance on a basis that is more specific to each pitcher and allows for more in-depth analysis of different aspects of pitching performance. The purpose of this narrative review was to illustrate the current state of injury recording for professional baseball pitchers, highlight recent technological advances in MLB, and describe the advanced data available for analysis. We used advanced data in the literature to review the current state of performance analysis after RTP in MLB pitchers after injury. Finally, we strived to provide a framework for future studies to more meticulously assess RTP performance given the current available resources for analysis., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: C.M.L. has received education payments from Evolution Surgical. M.E.C. has received education payments from Evolution Surgical. M.R.S. has received consulting fees from Anika Therapeutics, Medacta, and Smith & Nephew; royalties and nonconsulting fees from Smith & Nephew; and honoraria from Medacta. M.T.F. has received grant support from Encore Medical, education payments from Evolution Surgical, consulting fees from Smith & Nephew and Stryker, speaking fees from Integra LifeSciences and Smith & Nephew, and hospitality payments from Wright Medical. C.A.W. has received hospitality payments from Arthrex and Smith & Nephew. R.F.L. has received consulting fees from Arthrex and Smith & Nephew, speaking fees from Smith & Nephew, and royalties from Arthrex and Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Ulnar collateral ligament reconstruction (UCLR) is commonly performed in Major League Baseball (MLB) pitchers, with variable reported effects on velocity and traditional rate statistics. Currently, no studies have evaluated spin rate in the context of return to play (RTP) after injury. Greater spin rate has become increasingly sought after in the baseball community, as it is believed to be a vital aspect of pitch effectiveness., Purpose/hypothesis: The purpose was to evaluate the effect of primary UCLR on fastballs (FB) and sliders (SL) of MLB pitchers in terms of spin rate, velocity, hard-hit rate, and whiff rate. It hypothesized that the post-UCLR FB and SL spin rates, velocity, and whiff rate would be significantly decreased versus their pre-UCLR levels, while the FB and SL hard-hit rates would be higher in comparison with pre-UCLR levels., Study Design: Case series; Level of evidence, 4., Methods: In total, 42 pitchers who underwent UCLR and returned to MLB play were identified from public records from 2016 to 2019. The Statcast system was used to collect spin rate, velocity, hard-hit rate, and whiff rate for 4-seam FB (4FB), 2-seam FB (2FB), and SL for pitchers in the preinjury year as well as the 2 years after return from UCLR. Data were analyzed using the appropriate statistical tests., Results: A total of 36 pitchers met the inclusion criteria, and 31 of the eligible 36 players (86.1%) were able to return to MLB pitching (RTP). There were no significant decreases for 4FB, 2FB, or SL in spin rate, measured in revolutions per minute (rpm), when comparing preinjury levels with the first and second seasons after return. There was a significant decrease in velocity for the 2FB in the first season (92.9 vs 93.7 miles per hour [mph]; P = .045) but not the second season (93 mph; P = .629) after RTP in comparison with pre-UCLR levels. For the 2FB, there was a significant increase in spin rate between preinjury and RTP season 2 (2173.5 vs 2253 rpm; P = .022). For the SL, there was a significant increase in spin rate between preinjury and RTP season 2 (2245.1 vs 2406 rpm; P = .016)., Conclusion: A cohort of MLB pitchers who underwent UCLR and returned to the MLB level demonstrated no significant decreases in the spin rate, velocity, whiff rate, or hard-hit rate of 4FB, 2FB, or SL at 2 years after UCLR.

Objectives: The purpose of the study was to compare treatment outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures., Data Sources: A systematic review of perioperative outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures was performed. The following databases were used: using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019). The queries were performed in June 2019., Study Selection: The following search term query was used: "Intramedullary Nail AND Intertrochanteric Fracture OR "Long OR Short Nail AND intertrochanteric Fracture." Studies were excluded if they were "single-arm" studies (i.e., reporting on either long or short CMN but not both), or did not report at least one of the outcomes being meta-analyzed. Furthermore, cadaveric studies, animal studies, basic science articles, editorial articles, surveys and studies were excluded., Data Extraction: Two investigators independently reviewed abstracts from all identified articles. Full-text articles were obtained for review if necessary, to allow further assessment of inclusion and exclusion criteria. Additionally, all references from the included studies were reviewed and reconciled to verify that no relevant articles were missing from the systematic review., Data Synthesis: Short nails were associated with statistically significantly less estimated blood loss and operative time compared to long nails. There were no significant differences in transfusion rates, implant failures or overall re-operation rates between implant lengths. Similarly, there was no significant difference in peri-implant fracture between implant lengths., Conclusions: Overall, the available clinical evidence supports the use of short cephalomedullary nails for the majority of intertrochanteric femur fractures., Study Design/level of Evidence: Meta-analysis; Level III, therapeutic., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Objective: To examine the current evidence regarding return-to-play (RTP) and performance after Achilles tendon rupture in elite athletes treated with operative intervention., Design: Scoping review., Data Sources: Published sources identified through a PubMed search of elite athletes, defined as professional or division one collegiate athletes in baseball, basketball, American football or soccer., Methods: Our search yielded a total of 2402 studies, with 13 studies fulfilling the study criteria of reporting elite athletes with objective measures of their athletic performance. A total of 709 elite athletes were included from the NBA, NFL, Major League Baseball (MLB), National Collegiate Athletic Association (NCAA) football and professional soccer., Results and Discussion: Overall, 61%-100% of elite male athletes RTP after Achilles tendon rupture and operative repair. NBA players had inferior performance compared with their preoperative status as well as controls of non-injured players. Studies did not show significantly different performance after Achilles injury for MLB players. Professional soccer, NFL and NCAA football studies reported varying performance after injury., Conclusions: Evidence suggests that sports with explosive plantarflexion demands, such as basketball, may be associated with a greater decrease in performance despite operative intervention after Achilles rupture., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Anteromedial (AM) femoral tunnel positioning in anterior cruciate ligament reconstruction (ACLR) has been reported by some authors to yield superior clinical and functional outcomes compared with the transtibial (TT) approach; however, differences in the subsequent rates of posttraumatic osteoarthritis (PTOA) are not clear., Purpose: To perform a systematic review and meta-analysis of the literature to evaluate the influence of femoral tunnel positioning during primary ACLR on the development of radiographic PTOA., Study Design: Systematic review and Meta-analysis., Methods: The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019) were queried for all studies describing the development of PTOA after TT or AM ACLR. Data pertaining to patient demographics, ACLR technique, and radiographic PTOA were extracted. A meta-analysis utilizing the DerSimonian-Laird method for random effects was used to compare the weighted proportion of PTOA after ACLR between the TT and AM approaches., Results: There were 16 studies identified for inclusion with a total of 1546 patients. The mean follow-up across all studies was 10.9 years (range, 5.4-17.8 years). The mean follow-up in the AM and TT groups was 10.8 years (range, 5.4-17 years) and 11.4 years (range, 6-17.8 years), respectively. A total of 783 (50.6%) patients underwent TT ACLR. Of these patients, 401 (weighted mean, 49.3%) developed radiographic PTOA. A total of 763 (49.4%) patients underwent AM ACLR. Of these patients, 166 (mean, 21.8%) went on to develop radiographic PTOA. The meta-analysis demonstrated a significantly greater rate of PTOA after ACLR using a TT technique compared with an AM technique overall (49.3% vs 25.4%, respectively; P < .001) and when studies were stratified by 5- to 10-year (53.7% vs 14.2%, respectively; P < .001) and greater than 10-year (45.6% vs 31.2%, respectively; P < .0001) follow-up., Conclusion: TT ACLR was associated with higher overall rates of radiographic PTOA compared with the AM ACLR approach. The rates of radiographic PTOA after ACLR with a TT approach were also significantly higher than using an AM approach when stratified by length of follow-up (5- to 10-year and >10-year follow-up).

Objective: To evaluate the effects of silicone ankle sleeves (SASs) and lace-up ankle braces (LABs) on neuromuscular control, net joint torques, and cutting agility in healthy, active individuals., Design: Markerless motion-capture technology tracked subjects fitted with SASs, LABs, or no brace while they performed the movements: Y-excursion, left cutting, right cutting, single-leg drop vertical jump (SLDVJ), 45-degree bound, and single-leg squat (SLS)., Setting: University Laboratory., Participants: Ten healthy, active individuals (5 males and 5 females, mean ± SD 23.60 ± 1.43 years of age)., Main Outcome Measures: Degrees of joint range of motion (ROM), Newton-meters of joint torque, time to perform a cutting maneuver., Results: SASs and LABs resulted in significantly different knee and ankle ROM and hip internal rotation in the SLDVJ, SLS, Y-excursion, cutting maneuver, and 45-degree bound when compared to control (p < .05). Both ankle and knee torque were significantly reduced in the 45-degree bound and cutting movements with both types of PABs (p < .05). There were minimal differences between the SASs and LABs for all conditions. There were no statistically significant differences in cutting times for any of the 3 conditions., Conclusion: Both SAS and LAB positively impacted neuromuscular control, reduced net joint torque, and neither impaired cutting agility when compared to control., Competing Interests: None of the authors report any relevant financial conflict of interest., (© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Purpose of Review: The importance of both the static and dynamic stabilizers of the medial elbow for the throwing athlete has been demonstrated in recent studies. Furthermore, recent anatomic studies have demonstrated the insertion of the anterior bundle (UCL) to be more distal and elongated, which has implications for surgical reconstruction of the UCL. The purpose of this review is to highlight recent anatomic and biomechanical studies evaluating the anatomy and reconstructions of the medial elbow., Recent Findings: Recent literature has highlighted the crucial role of the dynamic stabilizers in resisting valgus force, especially during the throwing motion. The dynamic stabilizers of the medial elbow include the flexor pronator mass, specifically the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS). The clinical importance of these findings cannot be under stated, as unrecognized dynamic stabilizer injury can lead to increased stress on a native or reconstructed UCL in the throwing athlete. The medial ulnar collateral ligament complex of the elbow has a crucial role in providing both static and dynamic elbow stability. Most notably, the anterior bundle (UCL) provides the primary resistance to valgus and rotational stresses, especially during throwing motion. An understanding of the humeral and ulnar footprints and their relationships with surrounding structures is necessary to restore the native isometry of the medial complex of the elbow during UCL reconstruction. The flexor pronator musculature plays an essential role in dynamic stability, and the intimate relationship of the FCU and FDS with the ulnar insertion of the UCL should be considered to optimize recovery and outcomes with repair or reconstruction.

Background: There is significant discrepancy in the reported vascularity within the meniscus, and a progressively diminishing blood supply may indicate a differential healing capacity of tears that is dependent on the affected meniscal zone., Purpose: To examine the outcomes after inside-out meniscal repair in all 3 meniscal vascularity zones., Study Design: Cohort study; Level of evidence, 3., Methods: Patients were included if they underwent inside-out meniscal repair by a single surgeon between 2010 and 2014 and had a minimum 2-year follow-up. Patients were divided into 3 groups based on the meniscal tear location (red-red, red-white, and white-white zones) as determined during an intraoperative assessment. Patient-reported outcome scores were obtained at final follow-up., Results: A total of 173 patients (mean age, 33.6 ± 14.3 years) were included, with a mean follow-up of 2.9 ± 0.9 years. All patients demonstrated significant improvements with inside-out meniscal repair from preoperatively to postoperatively, regardless of the meniscal tear location. Patients who underwent meniscal repair in the red-red and red-white zones had significantly increased postoperative Tegner, Lysholm, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores compared with patients who underwent meniscal repair in the white-white zone ( P < .05). Patients who underwent acute repair (≤6 weeks) demonstrated significantly higher improvements on the Tegner activity scale (acute: 5.8 ± 2.2; chronic: 4.6 ± 2.2; P = .001) and Lysholm score (acute: 85.6 ± 13.3; chronic: 80.8 ± 13.5; P = .025) compared with patients treated beyond 6 weeks from injury, regardless of the meniscal tear zone. Patients with grade IV femoral condyle chondral lesions at the time of surgery had significantly inferior outcomes compared with patients with grade I through III chondral lesions, regardless of the meniscal tear zone. Three patients (1.7%) subsequently underwent revision inside-out repair, and 3 (1.7%) underwent partial meniscectomy., Conclusion: Patients who underwent inside-out meniscal repair demonstrated significant improvements on subjective outcome measures at a minimum 2-year follow-up, regardless of the meniscal tear zone. Inside-out meniscal repair is recommended for potentially reparable meniscal tears in all 3 vascular zones; however, improved outcomes can be achieved when performed acutely, in the absence of full-thickness femoral condyle chondral injuries, and in the red-red and red-white zones., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.F.L. is a consultant for and receives royalties from Arthrex, Ossur, and Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Purpose: To perform a systematic review of the glenohumeral ligament anatomic attachments on the glenoid and humeral neck., Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase from 1980 to present. The inclusion criteria were as follows: cadaveric or clinical anatomic studies that qualitatively or quantitatively described the glenoid and humeral attachments of the glenohumeral ligaments in the English-language literature. Imaging and animal studies, editorial articles, and surveys were excluded from this study., Results: The 15 included studies analyzed a total of 983 shoulders. Only 5 studies reported quantitative measurements. The most common glenoid superior glenohumeral ligament attachment described was in the anterolateral region of the supraglenoid tubercle and was inserting on the humerus in close vicinity to the subscapularis tendon insertion. The superior labrum and lesser tuberosity were the most commonly reported middle glenohumeral ligament attachments. The inferior glenohumeral ligament was most commonly described to attach between the 2- and 4-o'clock positions of the glenoid and distally near the surgical neck of the humerus., Conclusions: There were limited quantitative data on the attachments of the glenohumeral ligaments. Although the literature was discordant, the most common descriptions of the attachments were as follows: The anterolateral region of the supraglenoid tubercle, the superior labrum, and the glenoid (between the 2- and 4-o'clock positions) were the medial attachments for the superior glenohumeral ligament, middle glenohumeral ligament, and inferior glenohumeral ligament, respectively. Laterally, they inserted on the humerus in close vicinity to the subscapularis tendon insertion, on the lesser tuberosity, and near the surgical neck of the humerus, respectively., Clinical Relevance: The glenohumeral ligaments are important anatomic structures contributing to the dynamic stability of the glenohumeral joint. Further detailed quantitative descriptions of their attachments are required for truly anatomically based repairs., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Cartilage lesions are a significant cause of morbidity and impaired knee function; however, cartilage repair procedures have failed to reproduce native cartilage to date. Thus, osteochondral allograft (OCA) transplantation represents a 1-step procedure to repair large chondral defects without the donor site morbidity of osteochondral autograft transplantation., Purpose: To perform a systematic review of clinical outcomes and failure rates after OCA transplantation in the knee at a minimum mean 2 years' follow-up., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review of the literature regarding the existing evidence for clinical outcomes and failure rates of OCA transplantation in the knee joint was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE from studies published between 1980 and 2017. Inclusion criteria were as follows: clinical outcomes and failure rates of OCAs for the treatment of chondral defects in the knee joint, English language, mean follow-up of 2 years and minimum follow-up of 18 months, minimum study size of 20 patients, and human studies. The methodological quality of each study was assessed using a modified version of the Coleman methodology score., Results: The systematic search identified 19 studies with a total of 1036 patients. The mean 5-year survival rate across the studies included in this review was 86.7% (range, 64.1%-100.0%), while the mean 10-year survival rate was 78.7% (range, 39.0%-93.0%). The mean survival rate was 72.8% at 15 years (range, 55.8%-84.0%) and 67.5% at 20 years (range, 66.0%-69.0%). The weighted mean patient age was 31.5 years (range, 10-82 years), and the weighted mean follow-up was 8.7 years (range, 2-32 years). The following outcome measures showed significant improvement from preoperatively to postoperatively: d'Aubigné-Postel, International Knee Documentation Committee, Knee Society function, and Lysholm scores. The weighted mean reoperation rate was 30.2% (range, 0%-63%). The weighted mean failure rate was 18.2% (range, 0%-31%). Of note, revision cases, patellar lesions, and bipolar lesions demonstrated worse survival rates., Conclusion: Improved patient-reported outcomes can be expected after OCA transplantation, with a survival rate of 78.7% at 10 years. Revision cases, patellar lesions, and bipolar lesions were associated with worse survival rates; therefore, utilization of the most appropriate index cartilage restoration procedure and proper patient selection are key to improving results.

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures studied in the orthopaedic literature. In this regard, graft preparation is a key factor for successful outcomes. Although current methods to reconstruct the ACL are generally perceived to be successful, recent studies indicate that normal structure and function of the knee are fully restored in less than half of the patients. Therefore, biologically augmenting these scaffolds could provide a potential solution for improving healing times and biomechanical properties of the graft. The purpose of this Technical Note is to describe our preferred technique for an ACL graft preparation (quadriceps tendon) augmented with platelet-rich plasma.

Introduction: Orthopaedic surgery residency training requires 5 clinical years; fellowship subspecialty training requires an additional year. Orthopaedic surgery fellowship training has financial implications regarding potential career earnings and opportunity cost. To evaluate the effect of fellowship training on employment, 30 years of orthopaedic job advertisements were analyzed to determine fellowship requirements for academic centers, private practices, urban areas, and rural areas. It was hypothesized that subspecialty training is an important prerequisite for orthopaedic employment., Methods: Job advertisements in the Journal of Bone and Joint Surgery ( JBJS Am ) and Orthopedics were analyzed to determine whether fellowship training versus "generalist" (no subspecialty fellowship) positions were advertised for the years 1984, 1989, 1994, 1999, 2004, 2009, and 2014. Jobs were categorized as academic (defined by the requirement to teach medical students, residents, or fellows); private practice; rural (defined as population under 200,000); and urban. "General" orthopaedic surgery job postings were defined as job advertisements that did not require fellowship training., Results: A total of 4,720 job advertisements were analyzed. From 1984 to 2014, the percentage of advertised jobs requiring fellowship training increased from 5% to 68% ( P < 0.05). Conversely, from 1984 to 2014, the percentage of advertised jobs targeting general orthopaedic surgeons decreased from 95% to 32% ( P < 0.05). Between 2009 and 2014, advertised jobs requiring fellowship surpassed general orthopaedic surgery jobs., Conclusions: Over the past 30 years, there was a trend toward fellowship being required as part of the advertised orthopaedic jobs available to graduates of orthopaedic training programs. The reasons for increased orthopaedic training are likely multifactorial, including limited clinical duty hours during orthopaedic residency, advertisement and marketing forces emphasizing super-sub-specialty care in multispecialty orthopaedic groups, and the greater complexity of orthopaedic procedures being performed.

Purpose: To evaluate whether players with a history of an anterior cruciate ligament reconstruction (ACLR) before the National Football League (NFL) Combine played or started fewer games and/or participated in fewer eligible snaps compared with NFL Combine participants without a history of knee injury or surgery., Methods: We performed a retrospective review of all players who participated in the NFL Combine between 2009 and 2015 and who had a history of an ACLR. NFL Combine participants were included if they had a previous ACLR or combined anterior cruciate ligament (ACL) injury and nonoperatively managed medial collateral ligament injury. The number of games started, number of games played, draft number, overall draft pick, and snap percentage for each position were determined. The mean value of each outcome metric was compared between case and control players., Results: We identified 110 players who had an ACL injury (n = 76) or a combined ACL and medial collateral ligament injury (n = 34). Players in the ACLR group had a significantly worse mean draft pick number (difference of 30.2, P = .002) and mean draft round (difference of 0.8, P = .019) versus controls. Compared with control players, players in the ACLR group started and played significantly fewer games in both season 1 (difference of 2.7 games started, P < .001; difference of 2.7 games played, P < .001) and season 2 (difference of 7.4 games started, P < .001; difference of 3.0 games played, P = .003) and had a significantly lower snap percentage in both season 1 (difference of 23.1%, P < .001) and season 2 (difference of 24.0%, P < .001)., Conclusions: Athletes at the NFL Combine who previously underwent an ACLR had significantly lower early-career NFL player metrics, including fewer games started, fewer games played, and a lower snap percentage, than uninjured controls. Defensive linemen, defensive backs, and linebackers were the 3 most affected positions. Players with a prior ACLR and combined meniscal-chondral pathology had significantly lower numbers of games started and games played in seasons 1 and 2 and a significantly lower season 2 snap percentage., Level of Evidence: Level III, case-control study., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: While early weightbearing protocols have been advocated after anterior cruciate ligament (ACL) reconstruction, early weightbearing after fibular (lateral) collateral ligament reconstruction has not been well defined., Purpose: (1) To determine if early partial controlled weightbearing after fibular collateral ligament (FCL) reconstruction resulted in an objective difference in laxity on varus stress radiographs at postoperative 6 months as compared with nonweightbearing, and (2) to determine if there was a difference in pain, edema, range of motion, and subjective patient-reported outcomes between these groups at 3 time points., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: Patients were prospectively enrolled from January 2014 to April 2017. Patients who underwent isolated FCL reconstruction or combined ACL and FCL reconstructions were included in this study. Patients were randomly assigned to either a control group (nonweightbearing for 6 weeks) or a treatment group (partial controlled weightbearing at 40% body weight with crutches for 6 weeks). Patient-related data, including knee pain, edema, and range of motion, were collected for all patients at postoperative day 1, 6 weeks, and 6 months. Subjective outcomes were collected preoperatively and at 6 months postoperatively. The primary objective endpoint was varus stability, evaluated by bilateral varus stress radiographs obtained preoperatively and at 6 months postoperatively., Results: Thirty-nine patients were enrolled in the study, with 6-month follow-up obtained for 36 (92%). There was a significant improvement between the preoperative side-to-side difference (SSD) (2.4 ± 1.0) and postoperative SSD (0.2 ± 1.0) for lateral compartment laxity on varus stress radiographs among all patients ( P < .001). Clinical and statistical equivalence was found between groups in terms of SSD on varus stress radiographs ( P < .001). The SSD in knee edema was significantly lower in the partial early weightbearing group (beta = -0.6 cm, P = .001), but there were no significant group differences in knee pain, flexion, or extension. All patients demonstrated significant improvements in subjective outcome scores between the preoperative and 6-month postoperative conditions ( P < .001 for every score measured)., Conclusion: Clinical and statistical equivalence was found at postoperative 6 months between the early partial weightbearing and nonweightbearing groups among patients undergoing either an isolated FCL reconstruction or a combined ACL and FCL reconstruction. There were no significant differences observed between the groups regarding knee stability, pain, swelling, range of motion, or subjective outcomes. Given these findings, the authors recommend early partial weightbearing after isolated FCL reconstruction or combined ACL and FCL reconstruction.

Purpose: To evaluate the diagnostic accuracy of magnetic resonance imaging and varus stress radiographs for fibular collateral ligament (FCL) tears, and compare these modalities to intraoperative findings., Methods: All patients who underwent an isolated FCL or combined anterior cruciate ligament (ACL)/FCL reconstruction by a single surgeon between 2010 and 2017 with preoperative varus stress radiographs and magnetic resonance imaging (MRI) were included in this study. A control group was composed of patients with an MRI and intact ACL and FCL. Sensitivity and specificity of diagnosing FCL injuries on MRI were determined based on review by a fellowship-trained musculoskeletal radiologist, blinded to the pathology associated with each patient (FCL injury vs control), and compared with the gold standard of examination under anesthesia, followed by surgical confirmation of an FCL tear at the time of FCL reconstruction. The sensitivity of diagnosing an FCL injury based on varus stress radiographs was also determined. Furthermore, the ability of both imaging modalities to identify an FCL injury was stratified based on acute versus chronic etiology., Results: A total of 232 patients were included: 98 patients in the FCL tear group (mean age: 33.6 ± 12.2 years) and 134 patients in the control group (mean age: 44.0 ± 17.2 years). Varus stress radiographs were determined to be more sensitive in diagnosing FCL injuries compared with MRI, with an overall sensitivity of 70% compared with 66%, respectively. Based on MRI, overall specificity was 68%. Based on chronicity of the injuries, MRI was more accurate for detecting acute FCL injuries than chronic injuries (P = .002), and varus stress radiographs were more accurate for detecting chronic FCL injuries than acute injuries (P = .041)., Conclusions: The results support the use of both varus stress radiographs and MRI in diagnosing FCL injuries, because MRI is more sensitive in diagnosing an acute FCL tear, and varus stress radiographs are more sensitive in diagnosing a chronic FCL tear. Both imaging modalities are recommended to diagnose both acute and chronic FCL injuries., Level of Evidence: Level II, case-control study., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Historically, outcomes of posterior cruciate ligament (PCL) reconstructions have been less predictable and reported to yield inferior results when compared with those for anterior cruciate ligament (ACL) reconstructions., Purpose: To report on the outcomes of double-bundle PCL reconstructions (DB PCLRs) in isolated versus combined injuries and acute versus chronic PCL reconstructions. To compare the outcomes of isolated DB PCLR with isolated ACL reconstruction., Study Design: Cohort study; Level of evidence, 3., Methods: All patients who underwent a primary endoscopic DB PCLR for complete PCL tears (grade III) between May 2010 and March 2015 were reviewed. Patient-reported outcome scores (Tegner, Lysholm, WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index], SF-12 [12-item Short Form Health Survey]) and objective posterior stress radiographs were collected preoperatively and at a minimum 2 years postoperatively. A cohort subanalysis was additionally performed between isolated and combined PCL reconstruction and acute versus chronic PCL reconstruction. Patients who underwent isolated ACL reconstructions over the same inclusion period (2010-2015) were selected as a comparison group., Results: One hundred patients who underwent DB PCLR were included in this study. There were 31 isolated PCL injuries, and 69 patients had concurrent combined PCL injuries requiring surgery. The mean follow-up for the PCL cohort was 2.9 years (range, 2-6 years). The median Tegner activity score improved from 2 to 5, Lysholm from 48 to 86, WOMAC from 35.5 to 5, and SF-12 Physical Component Summary from 34 to 54.8 (all P values <.001). The mean side-to-side difference in posterior tibial translation on kneeling stress radiographs improved from 11.0 ± 3.5 mm preoperatively to 1.6 ± 2.0 mm postoperatively ( P < .001). There were no differences in postoperative functional scores between isolated PCL reconstructions and PCL-based multiligament reconstructions (all P values >.229). There was no significant difference in the reported outcome scores between acute and chronic reconstructions (all P values >.087) except for Tegner scores ( P < .001) and patient satisfaction ( P = .011) favoring acutely treated PCL injuries. There were no significant differences between patients who had an isolated DB PCLR and patients who underwent an isolated ACL reconstruction (n = 141) in postoperative outcome scores (all P values >.064)., Conclusion: Significantly improved functional and objective outcomes were observed after anatomic DB PCLR at a mean 3 years' follow-up, with low complication rates, regardless of concomitant ligamentous injury or timing to surgery. Additionally, contrary to previous reports, comparable subjective and functional clinical outcomes were achieved compared with an isolated ACL reconstruction control cohort.

Background: During multiple knee ligament reconstructions, the graft tensioning order may influence the final tibiofemoral orientation and corresponding knee kinematics. Nonanatomic tibiofemoral orientation may result in residual knee instability, altered joint loading, and an increased propensity for graft failure., Purpose: To biomechanically evaluate the effect of different graft tensioning sequences on knee tibiofemoral orientation after multiple knee ligament reconstructions in a bicruciate ligament (anterior cruciate ligament [ACL] and posterior cruciate ligament [PCL]) with a posterolateral corner (PLC)-injured knee., Study Design: Controlled laboratory study., Methods: Ten nonpaired, fresh-frozen human cadaveric knees were utilized for this study. After reconstruction of both cruciate ligaments and the PLC and proximal graft fixation, each knee was randomly assigned to each of 4 graft tensioning order groups: (1) PCL → ACL → PLC, (2) PCL → PLC → ACL, (3) PLC → ACL → PCL, and (4) ACL → PCL → PLC. Tibiofemoral orientation after graft tensioning was measured and compared with the intact state., Results: Tensioning the ACL first (tensioning order 4) resulted in posterior displacement of the tibia at 0° by 1.7 ± 1.3 mm compared with the intact state ( P = .002). All tensioning orders resulted in significantly increased tibial anterior translation compared with the intact state at higher flexion angles ranging from 2.7 mm to 3.2 mm at 60° and from 3.1 mm to 3.4 mm at 90° for tensioning orders 1 and 2, respectively (all P < .001). There was no significant difference in tibiofemoral orientation in the sagittal plane between the tensioning orders at higher flexion angles. All tensioning orders resulted in increased tibial internal rotation (all P < .001). Tensioning and fixing the PLC first (tensioning order 3) resulted in the most increases in internal rotation of the tibia: 2.4° ± 1.9°, 2.7° ± 1.8°, and 2.0° ± 2.0° at 0°, 30°, and 60°, respectively., Conclusion: None of the tensioning orders restored intact knee tibiofemoral orientation. Tensioning the PLC first should be avoided in bicruciate knee ligament reconstruction with concurrent PLC reconstruction because it significantly increased tibial internal rotation. We recommend that the PCL be tensioned first, followed by the ACL, to avoid posterior translation of the tibia in extension where the knee is primarily loaded during most activities. The PLC should be tensioned last., Clinical Relevance: This study will help guide surgeons in decision making for the graft tensioning order during multiple knee ligament reconstructions.

Competing Interests: Competing interests: None declared.

Background: Posttraumatic osteoarthritis (PTOA) after anterior cruciate ligament (ACL) reconstruction ultimately translates into a large economic effect on the health care system owing to the young ages of this population. Purpose/Hypothesis: The purposes were to perform a meta-analysis to determine the prevalence of osteoarthritis after an ACL reconstruction, examining the effects of length of time after surgery, preoperative time interval from injury to surgery, and patient age at the time of surgery. It was hypothesized that the prevalence of PTOA increased with time from surgery and that increased time from injury to surgery and age were also risk factors for the development of PTOA., Study Design: Meta-analysis., Methods: A meta-analysis of the prevalence of radiographic PTOA after ACL reconstruction was performed of studies with a minimum of 5 years' follow-up, with a level of evidence of 1, 2, or 3. The presence of osteoarthritis was defined according to knee radiographs evaluated with classification based on Kellgren and Lawrence, Ahlbäck, International Knee Documentation Committee, or the Osteoarthritis Research Society International. Metaregression models quantified the relationship between radiographic PTOA prevalence and the mean time from injury to surgery, mean patient age at time of surgery, and mean postoperative follow-up time., Results: Thirty-eight studies (4108 patients) were included. Longer postsurgical follow-up time was significantly positively associated with a higher proportion of PTOA development. The model-estimated proportion of PTOA (95% CI) at 5, 10, and 20 years after surgery was 11.3% (6.4%-19.1%), 20.6% (14.9%-27.7%), and 51.6% (29.1%-73.5%), respectively. Increased chronicity of the ACL tear before surgery and increased patient age were also associated with a higher likelihood of PTOA development., Conclusion: The prevalence of osteoarthritis after an ACL reconstruction significantly increased with time. Longer chronicity of ACL tear and older age at the time of surgery were significantly positively correlated with the development of osteoarthritis. A timely referral and treatment of symptomatic patients are vital to diminish the occurrence of PTOA.

Purpose: To perform a systematic review of the available literature on clinical and radiographic outcomes after surgical treatment for acromioclavicular (AC) joint instability., Methods: A systematic review was performed according to PRISMA guidelines. Inclusion criteria were AC joint and coracoclavicular (CC) ligament reconstruction outcomes, English language, human studies, more than 10 patients in the study and a 2-year minimum follow-up. Exclusion criteria were animal studies, cadaveric studies, clinical studies without reported follow-up period or patient-reported outcomes, clinical studies of nonoperative treatment, AC reconstructions with concurrent lateral clavicle fracture, editorial articles, abstracts, presentations, reviews, case reports, and surveys., Results: The systematic review identified 34 studies (939 patients) after inclusion and exclusion criteria application. Postoperative American Shoulder and Elbow Surgeons (ASES) scores ranged from 93.8 to 96, 81.8 to 97.8, and 88.1 for free tendon graft, suspensory devices, and modified Weaver-Dunn techniques, respectively. Postoperative Constant scores were 76.4 to 96.0, 82.6 to 97.8, 85.9 to 97.0, 81 to 96 and 83.0 to 94.6 for free tendon graft, suspensory devices, synthetic ligament devices, modified Weaver-Dunn, and hook plate/K-wires techniques, respectively. All treatment modalities improved patient outcomes; however, hook plates and K-wires had the highest rate of complications (26.3%). Unplanned reoperation rates were 1.2%, 2.8%, 0.9%, 5.4%, and 2.6% in free tendon graft, suspensory devices, synthetic ligament devices, modified Weaver-Dunn, and hook plate/K-wires techniques, respectively., Conclusions: Comparable subjective outcomes after surgical treatment of AC joint instability was reported for all modalities, with relatively low unplanned reoperation rates. Treatment with hook plate/K-wires was associated with the highest complication rates, and modified Weaver-Dunn had the highest unplanned reoperation rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Fibular collateral ligament (FCL) tears are challenging to diagnose. Left untreated, FCL tears lead to residual ligament instability and increased joint loading on the medial compartment of the knee. Additionally, when a concomitant anterior cruciate ligament (ACL) reconstruction is performed, increased forces on reconstruction grafts occur, which may lead to premature graft failure. Stress radiographs constitute a reliable and validated technique for the objective assessment of a complete grade III FCL tear., Purpose: To evaluate side-to-side difference (SSD) values of lateral compartment gapping on varus stress radiographs in patients with a grade III injury to the FCL. Additionally, to evaluate the reliability and reproducibility of 3 different measurement techniques that used various radiographic reference points., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: Inclusion criteria were patients who sustained an FCL with or without a concomitant ACL injury and underwent a combined FCL + ACL reconstruction between 2010 and 2016. Patients were excluded if they had a complete posterolateral corner injury, open physes, intra-articular fracture, meniscal root tear, other ligament injury, or prior surgery on either knee. All FCL tears were diagnosed with a clinical varus stress examination at 0° and 20° of knee flexion and varus stress radiographs at 20° of knee flexion measured in 3 different locations. The SSD for lateral compartment gapping was obtained from the varus stress radiographs and then statistically compared for interrater and intrarater reliability., Results: A total of 98 consecutive patients (50 males, 48 females; 13 isolated FCL injuries, 85 combined ACL + FCL injuries) with mean age 33.6 years (range, 18-69 years) were included. Measurement techniques 1, 2, and 3 had mean ± SD lateral compartment SSDs of 2.4 ± 0.20 mm, 2.2 ± 0.20 mm, and 2.0 ± 0.03 mm, respectively (no significant differences). Interrater reliabilities for the 3 measuring techniques were 0.83, 0.86, and 0.91, respectively, while intrarater reliabilities were 0.99, 0.77, and 0.99, respectively., Conclusion: This study demonstrated a lower SSD value of 2.2 mm to be consistent with a grade III FCL tear on clinician-applied varus stress radiographs in the clinical setting. Although all SSD measurement locations had excellent reliability, the method using the midpoint of the lateral tibial plateau was found to be the most reproducible., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This research was sponsored by the Steadman Philippon Research Institute. P.W.K. has received educational support from Smith & Nephew and research support from DJO. M.T.P. is a consultant for Arthrex and the Joint Restoration Foundation (Allosource) and receives royalties from Arthrex and SLACK Inc. R.F.L. is a consultant for Arthrex, Ossur, and Smith & Nephew; receives royalties from Arthrex and Smith & Nephew; and receives research support from Arthrex, Smith & Nephew, Ossur, and Linvatec.

Provencher, MT, Chahla, J, Sanchez, G, Cinque, ME, Kennedy, NI, Whalen, J, Price, MD, Moatshe, G, and LaPrade, RF. Body mass index versus body fat percentage in prospective national football league athletes: overestimation of obesity rate in athletes at the national football league scouting combine. J Strength Cond Res 32(4): 1013-1019, 2018-Obesity has been previously noted as a major issue in the National Football League (NFL), where it has been shown that 97% of all players demonstrate a body mass index (BMI) of ≥25.0 with a reported obesity rate of 56% (BMI ≥ 30.0). However, BMI does not take into account body composition by mass, and may overestimate prevalence of obesity. The purposes of this study were (a) to determine the validity of BMI as a measure of body fat percentage and obesity in athletes at the NFL Combine, (b) to define the obesity rate based on body fat percentage compared with BMI, and (c) to determine the relationship between draft status and body composition. It was hypothesized that the rate of obesity, as measured by air displacement plethysmography (ADP), would be less than the rate of obesity as measured using BMI. Athletes who competed at the 2010 through 2016 NFL Combines were included in this study. Air displacement plethysmograph testing at the Combine was performed through BOD POD Body Composition Tracking System with collection of the following metrics: body fat percentage (%), and compared with BMI based on weight and height. In addition, the metrics were evaluated for differences over the 7-year study period to determine temporal changes and to determine draft status based on position relative to BOD POD calculations. A total of 1,958 NFL Combine participants completed ADP body composition testing. Based on BMI (≥30.0), the obesity rate was 53.4% versus an 8.9% obesity rate when using ADP. Drafted players demonstrated a significantly lower body fat percentage than undrafted players (p ≤ 0.05), with the exception of quarterbacks and running backs. All 8 positions of play, with the exception of defensive linemen, demonstrated a decrease in body fat percentage between 2010 and 2017. However, total body mass by position of play remained relatively constant with no significant change noted in any position. In conclusion, the obesity rate in prospective athletes at the NFL Combine was overestimated when calculated based on the BMI. Body fat percentage was more valid for determining an NFL player candidate's true body composition. Drafted players demonstrated a significantly lower body fat percentage in 6 of 8 positions compared with undrafted players. This is important to recognize for a strength and conditioning professional to use the correct metric when evaluating NFL players who could have been erroneously categorized in the obese population by their BMI. Furthermore, a higher percentage of fat translates to lower chances of becoming drafted.

Background: Interest in the therapeutic potential of bone marrow aspirate concentrate (BMAC) has grown exponentially. However, comparisons among studies and their processing methods are challenging because of inconsistent reporting of protocols, as well as poor characterization of the composition of the initial bone marrow aspirate and of the final products delivered. The purpose of this study was to perform a systematic review of the literature to evaluate the level of reporting related to the protocols used for BMAC preparation and the composition of BMAC utilized in the treatment of musculoskeletal diseases in published clinical studies., Methods: A systematic review of the literature was performed by searching PubMed, MEDLINE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials from 1980 to 2016. Inclusion criteria were human clinical trials, English language, and manuscripts that reported on the use of BMAC in musculoskeletal conditions., Results: After a comprehensive review of the 986 identified articles, 46 articles met the inclusion criteria for analysis. No study provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 14 (30%) of the studies provided quantitative metrics of the composition of the BMAC final product., Conclusions: The reporting of BMAC preparation protocols in clinical studies was highly inconsistent and studies did not provide sufficient information to allow the protocol to be reproduced. Moreover, comparison of the efficacy and yield of BMAC products is precluded by deficiencies in the reporting of preparation methods and composition. Future studies should contain standardized and stepwise descriptions of the BMAC preparation protocol, and the composition of the BMAC delivered, to permit validating and rationally optimizing the role of BMAC in musculoskeletal care.

Purpose: (1) To determine the epidemiology, examination findings, imaging findings, and associated injuries of posterolateral corner (PLC) injuries in players participating in the National Football League (NFL) Combine and (2) to evaluate the impact of PLC injuries on performance compared with matched controls., Methods: All PLC injuries identified at the NFL Combine between 2009 and 2015 were reviewed. The inclusion criteria were any player who had clinical findings or a previous surgical procedure consistent with a PLC injury and who participated in medical and performance testing at the NFL Combine. PLC injuries were identified by evaluating the side-to-side difference in lateral-compartment laxity with varus stress and reviewing magnetic resonance imaging studies. NFL performance outcomes (draft position and number of games played or started within the first 2 years) were compared with matched controls., Results: Of the 2,285 players assessed at the NFL Combine, 16 (0.7%) were identified with a history of a grade II or III PLC tear and surgical management whereas 7 additional players (0.3%) had a PLC injury diagnosed on clinical examination, for 23 total PLC injuries (1%). On examination, 13 of 22 knees (59%) were shown to be stable; however, most of those managed surgically had significantly improved stability (13 of 15 stable) versus none of those managed nonsurgically (0 of 7 stable). Surgically managed PLC-injured athletes started significantly fewer games than controls (5.3 vs 10.5, P = .03); the mean draft position for players with surgically treated PLC injuries was 139.7 versus controls' mean draft position of 111.3. Of the 16 athletes treated operatively, 2 reported a PLC injury recurrence; both were managed nonoperatively., Conclusions: A small percentage of players at the NFL Combine had evidence of a previous PLC injury (1%), with 0.4% having residual varus asymmetry on clinical examination. A worse overall mean draft position for isolated PLC-injured athletes versus controls was found: 132.8 versus 111.3 (P = .02). It is recommended that the use of varus stress radiographs be considered for NFL Combine athletes to objectively determine their grade of injury. LEVEL OF EVIDENCE: Level IV, retrospective case series., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the epidemiology by player position, examination, imaging findings, and associated injuries of posterior cruciate ligament (PCL) injuries in players participating in the National Football League (NFL) Combine., Methods: All PCL injuries identified at the NFL Combine (2009-2015) were reviewed. Data were obtained from the database organized by the NFL medical personnel for the compilation of the medical and physical performance examination results of NFL Draftees participating in the NFL Combine from 2009 to 2015. Inclusion criteria were any player with clinical findings or a previous surgery consistent with a PCL injury who participated in the NFL Combine., Results: Of the 2,285 players who participated in the NFL Combine between 2009 and 2015, 69 (3%) had evidence of a PCL injury, of which 11 players (15.9%) were managed surgically. On physical examination, 35 players (52%) had a grade II or III posterior drawer. Concomitant injuries were present frequently and included medial collateral ligament (MCL; 42%), anterior cruciate ligament (ACL; 11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment., Conclusions: Three percent of the players at the NFL Combine presented with a PCL injury, with a significant amount being either running backs (14/69, 20.2%) or offensive linemen (14/69, 20.2%). Approximately half of the players with a PCL tear had a residual grade II or III posterior drawer after sustaining a PCL injury. Concomitant injuries were present frequently and included MCL (42%), ACL (11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. For those players with clinical concern for PCL ligamentous laxity, there should be a complete comprehensive workup that includes plain and PCL stress view radiographs, and magnetic resonance imaging., Level of Evidence: Level IV, case series., (Copyright © 2017. Published by Elsevier Inc.)

Purpose: The purpose of this study was to evaluate the differences in intra-articular pathology, demographic characteristics, and radiographic characteristics of the knee associated with primary anterior cruciate ligament reconstruction (ACLR) versus revision ACLR at the time of initial presentation with either a native anterior cruciate ligament tear or an anterior cruciate ligament graft tear. Secondarily, we aimed to investigate risk factors for concomitant medial and lateral meniscal tears and cartilage injuries at the time of ACLR., Methods: This was a retrospective review of patients who underwent primary or revision ACLR by a single surgeon. The exclusion criteria were as follows: skeletally immature patients; patients with an intra-articular fracture; patients with an ipsilateral knee infection; or patients who underwent an osteotomy, cartilage restoration procedure, or meniscal transplantation either previously or concomitantly with the ACLR. Detailed patient demographic data, radiographic long-standing alignment, tibial slope, and intraoperative findings including articular cartilage injury grade and meniscus integrity were documented at surgery., Results: There were 487 patients included in this study (363 with primary ACLR and 124 with revision ACLR). There were no significant differences in age (P = .119), sex (P = .917), body mass index (P = .468), allograft versus autograft reconstruction (P = .916), or prevalence of meniscal tears (P = .142) between the primary and revision groups. Patients who underwent revision ACLR had a significantly increased medial tibial slope (P = .048) and a higher prevalence of chondral defects on both the medial (P < .001) and lateral (P = .003) femoral condyles when compared with primary ACLR patients. Logistic regression showed that a decreased tibial slope was correlated with femoral medial-sided chondral injuries and that varus or valgus coronal-plane malalignment was correlated with lateral meniscal tears in both groups., Conclusions: The findings of this study show that patients undergoing a revision ACLR have significantly more chondral lesions, as well as higher-grade chondral lesions, at the time of presentation. Furthermore, coronal malalignment and a decreased tibial slope may contribute to injury patterns of the lateral meniscus and medial compartment cartilage, respectively. LEVEL OF EVIDENCE: Level III, retrospective case-control study., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to document subjective outcomes following anatomic-based reconstruction of the popliteus tendon when the popliteus tendon was the only injured posterolateral knee structure. It was hypothesized that popliteus tendon reconstruction would result in improved patient outcomes after surgery regardless of the concurrent ligamentous or intra articular pathology., Methods: A consecutive series of 5 patients with a median age of 23 years (range, 22-36 years) who underwent anatomic popliteus tendon reconstruction along with concomitant ligament reconstruction or meniscus repair (if needed) were included in this study. All patients completed pre-operative and post-operative subjective questionnaires, which included the Lysholm score to document function, the Tegner activity scale to document activity level, and a patient satisfaction with outcome question., Results: All patients were available for a final follow-up at a median time of 2.8 years (range, 2-3.9 years) following the index surgery. Three patients had a combined popliteus tendon and posterior cruciate ligament reconstruction. Two of the three PCL reconstructions were revision procedures. The Lysholm score improved to from 53 (range, 34-90) to 91 (range, 44-100) at post-operative follow-up. The median pre-operative Tegner activity scale improved from 3 (range, 0-9) to a median score of 4.8 (range, 2-7) at post-operative follow-up. The median patient satisfaction with outcome was 9 (range, 7-10). The dial test at 30° and 90° improved in all patients following surgery., Conclusions: Anatomic-based popliteus tendon reconstructions resulted in improved outcomes and a high patient satisfaction in patients with a complete tear of the popliteus tendon and symptomatic knee instability., Level of Evidence: IV, case series.

Purpose: To (1) describe the magnetic resonance imaging (MRI) characteristics of knee chondral injuries identified at the National Football League (NFL) Combine and (2) assess in-game performance of prospective NFL players with previously untreated knee chondral injuries and compare it with matched controls., Methods: All players with knee chondral injuries identified at the NFL Combine (2009-2015) were retrospectively reviewed. Players with prior knee surgery were excluded. A knee MRI for each player was reviewed; location, modified International Cartilage Repair Society (ICRS) grade (I-IV), and associated compartment subchondral edema were documented. Position, respective NFL Draft pick selection number, games started, played, snap percentage, and position-specific performance metrics during the first 2 NFL seasons were recorded for the injury and injury-free control group composed of players with (1) no prior knee injury, (2) no significant missed time prior to the NFL (≤2 total missed games in college), (3) no history of knee surgery, and (4) drafted in the respective NFL Draft following the NFL Combine., Results: Of the 2,285 players reviewed, 101 (4.4%) had an injury without prior knee surgery. The patella (63.4%) and trochlea (34%) were most commonly affected. Defensive linemen were at highest risk for unrecognized injuries (odds ratio 1.8, P = .015). Players with previously untreated injuries, compared with controls, were picked later (mean pick: 125.8) and played (mean: 23) and started (mean: 10.4) fewer games during the initial 2 NFL seasons (P < .001 for all). Particularly, subchondral bone edema and full-thickness cartilage injuries were associated with fewer games played (P = .003)., Conclusions: The patellofemoral joint was most commonly affected in NFL Combine participants. Previously untreated knee articular injuries in players at the NFL Combine are associated with poorer early NFL performance in comparison to uninjured players. Subchondral bone edema and full-thickness cartilage injury on MRI were associated with fewer games played during the initial NFL career., Level of Evidence: Level III, case-control study., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The anterior bundle of the medial ulnar collateral ligament (UCL) and the forearm flexors provide primary static and dynamic stability to valgus stress of the elbow in overhead-throwing athletes. Quantitative anatomic relationships between the dynamic and static stabilizers have not been described., Purpose: To perform qualitative and quantitative anatomic evaluations of the medial elbow-UCL complex with specific attention to pertinent osseous and soft tissue landmarks., Study Design: Descriptive laboratory study., Methods: Ten nonpaired, fresh-frozen human cadaveric elbows (mean age, 54.1 years [range, 42-64 years]; all male) were utilized for this study. Quantitative analysis was performed with a 3-dimensional coordinate measuring device to quantify the location of pertinent bony landmarks and tendon and ligament footprints on the humerus, ulna, and radius., Results: The anterior bundle of the UCL attached 8.5 mm (95% CI, 6.9-10.0) distal and 7.8 mm (95% CI, 6.6-9.1) lateral to the medial epicondyle, 1.5 mm (95% CI, 0.5-2.5) distal to the sublime tubercle, and 7.3 mm (95% CI, 6.1-8.5) distal to the joint line on the ulna along the ulnar ridge. The flexor digitorum superficialis (FDS) ulnar tendinous insertion was closely related and interposed within the anterior bundle of the UCL, overlapping with 45.6% (95% CI, 38.1-53.6) of the length of the anterior bundle of the UCL. The flexor carpi ulnaris (FCU) attached 1.9 mm (95% CI, 0.8-2.9) posterior and 1.3 mm (95% CI, 0.6-3.2) proximal to the sublime tubercle and overlapped with 20.9% (95% CI, 7.2-34.5) of the area of the distal footprint of the anterior bundle of the UCL., Conclusion: The anterior bundle of the UCL had consistent attachment points relative to the medial epicondyle and sublime tubercle. The ulnar limb of the FDS and FCU tendons demonstrated consistent insertions onto the ulnar attachment of the anterior bundle of the UCL. These anatomic relationships are important to consider when evaluating distal UCL tears both operatively and nonoperatively. Excessive stripping of the sublime tubercle should be avoided during UCL reconstruction to prevent violation of these tendinous attachments., Clinical Relevance: The findings of this study enhance the understanding of valgus restraint in throwing athletes and provide insight into the difference in nonoperative outcomes between proximal and distal tears of the UCL.

Background: Meniscal and chondral lesions are commonly associated with anterior cruciate ligament (ACL) tears, and these lesions may play a role in patient outcomes after ACL reconstruction., Purpose: To determine the effects of the presence and location of meniscal and chondral lesions at the time of ACL reconstruction on patient-reported outcomes at a minimum 2-year follow-up., Study Design: Cohort study; Level of evidence, 3., Methods: Patients with no prior knee surgery who underwent primary ACL reconstruction by a single surgeon between 2010 and 2014 were included in this study. Those meeting inclusion criteria were divided into the following groups based on the arthroscopic diagnosis: patients without concomitant meniscal or chondral lesions, patients with isolated meniscal lesions, patients with isolated chondral lesions, and patients with both chondral and meniscal lesions. Patient-reported outcomes (Short Form-12 [SF-12] physical component summary [PCS] and mental component summary [MCS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Lysholm scale) were assessed at a minimum of 2 years from the index surgery., Results: A total of 151 patients met the inclusion criteria and were included in the study. The mean age at the time of surgery was 36.2 years (range, 14-73 years), and the mean follow-up was 3.2 years (range, 2.0-5.6 years). At the time of surgery, 33 (22%) patients had no concomitant lesions and served as the control group, 63 (42%) patients had isolated meniscal lesions, 21 (14%) patients had isolated chondral lesions, and 34 (22%) patients had both chondral and meniscal lesions. There was significant improvement in all outcome scores postoperatively for the 3 groups ( P < .05 for all outcome scores). The presence of a meniscal tear and laterality of the meniscal lesion did not have a negative effect on any postoperative outcome scores. Patients with isolated chondral lesions had significantly lower postoperative WOMAC scores compared with patients without chondral lesions ( P < .05). No significant differences were found for all other scores. Patients with patellofemoral chondral lesions had significantly lower postoperative SF-12 PCS and Lysholm scores than patients with tibiofemoral chondral lesions ( P < .05)., Conclusion: Patients with ACL tears achieved improved functional scores at a mean 3.2 years after ACL reconstruction. While meniscal lesions did not affect postoperative outcomes in the short term, chondral lesions were identified as a predictor for worse outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.F.L. receives royalties from Arthrex, Ossur, and Smith & Nephew; is a paid consultant for Arthrex, Ossur, and Smith & Nephew; and receives research support from Arthrex, Linvatec, Ossur, and Smith & Nephew.

Background: Magnetic resonance imaging (MRI) of the knee is a highly sensitive and specific method for diagnosing acute posterior cruciate ligament (PCL) tears, with a reported accuracy of 96% to 100%. In chronic and revision settings, these injuries may be missed on MRI because of the apparent continuity of nonfunctional PCL fibers. Posterior tibial translation (PTT) of the medial compartment has been identified as a potential secondary finding of PCL tear on routine MRI. Purpose/Hypothesis: The purpose of this study was to evaluate the sensitivity of PTT on MRI associated with PCL injuries and compare it with the sensitivity of a radiologist's MRI interpretation with preoperative posterior knee stress radiographs as the gold standard. Our hypothesis was that the MRI measurement of PTT of the medial compartment would improve diagnostic sensitivity as compared with the diagnosis made by the interpreting radiologist's evaluation of the continuity of the PCL fibers for chronic and postrecostruction graft injuries., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: Cases of patients who underwent a primary or revision PCL reconstruction, without anterior cruciate ligament injury, by a single surgeon between 2010 and 2016 were retrospectively analyzed. Measurements of medial and lateral compartment PTT were performed with the MRI of PCL-injured cases and controls without clinical or MRI evidence of ligamentous injury. The sensitivity of this technique was compared with the preoperative MRI diagnosis determined by review of the musculoskeletal radiologist's report and confirmed by the gold standard of posterior knee stress radiographs. The sensitivity of medial compartment PTT was determined by receiver operator characteristic (ROC) analysis and compared with the MRI sensitivity for chronic PCL and PCL graft tears., Results: One hundred patients (80 males and 20 females) with a mean age of 31.1 years (range, 15-66 years) met the inclusion criteria: 57 acute primary tears, 32 chronic primary, and 11 PCL graft tears. MRI sensitivity was 100% for acute primary PCL tears, 62.5% for chronic primary PCL tears, and 18.1% for PCL graft tears. There were significant differences in medial compartment PTT on MRI for acute versus chronic injuries ( P = .025) and acute versus graft injuries ( P = .007). ROC curve analysis indicated that the most accurate cutoff point for the detection of chronic PCL tears was 2.0 mm of medial compartment PTT on MRI, with a sensitivity and specificity of 0.80 and 0.89, respectively. For PCL graft injuries, the ROC curve indicated that the most accurate medial compartment PTT cutoff for the detection of PCL graft failure was 3.6 mm (sensitivity, 0.92; specificity, 0.72)., Conclusion: MRI evaluation of the PCL fibers had poor sensitivity for chronic PCL tears and PCL reconstruction graft tears. The sensitivity for diagnosing chronic PCL tears and PCL reconstruction graft failures was improved by measuring posteromedial tibial translation.

Background and Purpose: Early sport specialization (ESS) refers to intense training year round in a specific sport starting at a young age with no or limited participation in other sports. This approach to training is highly controversial; recent literature suggests that this type of specialized training could be a contributing source to overuse injuries in youth athletes. The purpose of this case report was to describe a patellofemoral articular cartilage defect of the knee in a preadolescent skier due to overuse and repetitive microtrauma as a result of ESS., Study Design: Case Report., Case Description: A healthy 11-year-old male competitive alpine skier presented with recurrent swelling of his right knee and persistent anterior knee pain while skiing without evidence of any specific history of injury or traumatic event. The patient failed a conservative treatment regimen including rest and formal physical therapy focused on generalized knee strengthening. Magnetic resonance imaging was ordered and revealed an articular cartilage defect of the medial patellar facet. The patient was treated with an arthroscopic debridement of his articular cartilage defect., Outcome: At 12 weeks postoperatively, the patient presented with a normalized gait pattern, no evidence of knee effusion, full knee range of motion and patellar mobility symmetric to his contralateral limb, and no patellar crepitation or painful palpation on physical exam. The patient was released to begin return to sport progression at 12 weeks, and was cleared for full activities/returned to competitive skiing at 15 weeks postoperatively. At 16 weeks postoperatively, he won an international alpine ski race in Europe for his age group., Discussion: Cartilage injuries and osteochondral defects are very common in adolescent athletes and often go undiagnosed. Allied healthcare professionals must be educated on the known causes of recurrent knee effusions and how early sport specialization may result in overuse injuries to knee joint cartilage., Level of Evidence: 4.

Background: The effect of prior meniscectomy and the resulting reduction in meniscal tissue on a potential National Football League (NFL) player's articular cartilage status and performance remain poorly elucidated. Purpose/Hypothesis: (1) To determine the epidemiology, imaging characteristics, and associated articular cartilage pathology of the knee among players with a previous meniscectomy who were participating in the NFL Combine and (2) to evaluate the effect of these injuries on performance as compared with matched controls. The hypothesis was that players with less meniscal tissue would have worse cartilage status and inferior performance metrics in their first 2 NFL seasons., Study Design: Cohort study; Level of evidence, 3., Methods: All athletes with a history of a meniscectomy and magnetic resonance imaging scan of the knee who participated in the NFL Combine (2009-2015) were identified. Medical records and imaging were analyzed, and surgical history, games missed in college, position played, and draft position were documented. The conditions of the meniscus and cartilage were graded with modified ISAKOS scores (International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine) and ICRS scores (International Cartilage Repair Society), respectively. Players with a previous meniscectomy of at least 10% of total medial or lateral meniscal volume excised (ISAKOS meniscus grade ≤8) and matched controls without a significant pre-Combine injury were similarly evaluated and compared by position of play through analysis of draft position, number of games played and started, and how many eligible plays they participated in (snap percentage) within the first 2 NFL seasons., Results: Of the 2285 players who participated in the NFL Combine (2009-2015), 287 players (322 knees) had a prior meniscectomy (206 lateral, 81 medial). Among these players, 247 (85%) had a total of 249 chondral lesions, most commonly on the lateral femoral condyle (111 lesions, 45%). There was a significant inverse correlation found between the ISAKOS medial and lateral meniscus grade and the corresponding compartment chondral lesion grade ( P = .001). A poorer meniscus score was also associated with worse chondral pathology, especially in the lateral compartment. After controlling for position of play, the injury-free control group had a significantly greater number of total games played and games started and higher snap percentage versus those with a prior meniscectomy of at least 10% volume (ISAKOS meniscus grade ≤8). Players with severe chondral lesions (ICRS grade 4) in the medial and lateral compartments had significantly worse performance metrics when compared with matched controls., Conclusion: Previous meniscectomy of at least 10% of total medial or lateral meniscus volume in prospective NFL players was significantly correlated with larger and more severe chondral lesions. Chondral and meniscal defects of the knee were found to result in a significant decrease in objective performance measures during a player's initial NFL career versus matched controls. Given these findings, players with a prior meniscectomy with evidence of chondral damage should be evaluated carefully for their overall functional levels; however, additional work is needed to fully clarify the effect of prior knee meniscal surgery on overall NFL performance.

With the recent "description" of the anterolateral ligament (ALL) of the knee, its role in controlling rotational stability has reemerged. An improved understanding of the anatomy of the anterolateral complex of the knee has led to an expansion of the literature on the biomechanics of many structures, including the contribution of the iliotibial band and its deep (Kaplan) fibers, the capsulo-osseous layer, the ALL, and the lateral meniscal posterior root to knee stability. This article describes the primary and secondary roles of key anatomic structures at the anterolateral aspect of the knee., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The qualitative and quantitative anatomy of the medial patellar stabilizers has been reported; however, a quantitative analysis of the anatomic and radiographic attachments of all 4 ligaments relative to anatomic and osseous landmarks, as well as to one another, has yet to be performed., Purpose: To perform a qualitative and quantitative anatomic and radiographic evaluation of the medial patellofemoral ligament (MPFL), medial patellotibial ligament (MPTL), medial patellomeniscal ligament (MPML), and medial quadriceps tendon femoral ligament (MQTFL) attachment sites, with attention to their relationship to pertinent osseous and soft tissue landmarks., Study Design: Descriptive laboratory study., Methods: Ten nonpaired fresh-frozen human cadaveric knees were dissected, and the MPFL, MPTL, MPML, and MQTFL were identified. A coordinate measuring device quantified the attachment areas of each structure and its relationship to pertinent bony landmarks. Radiographic analysis was performed through ligament attachment sites and relevant anatomic structures to assess their locations relative to pertinent bony landmarks., Results: Four separate medial patellar ligaments were identified in all specimens. The center of the MPFL attachments was 14.3 mm proximal and 2.1 mm posterior to the medial epicondyle and 8.3 mm distal and 2.7 mm anterior to the adductor tubercle on the femur and 8.9 mm distal and 19.9 mm medial to the superior pole on the patella. The MQTFL had a mean insertion length of 29.3 mm on the medial aspect of the distal quadriceps tendon. The MPTL and MPML shared a common patellar insertion and were 9.1 mm proximal and 15.4 mm medial to the inferior pole. The MPTL attachment inserted on a newly identified bony ridge, which was located 5.0 mm distal to the joint line. The orientation angles of the MPTL and MPML with respect to the patellar tendon were 8.3° and 22.7°, respectively., Conclusion: The most important findings of this study were the correlative anatomy of 4 distinct medial patellar ligaments (MPFL, MPTL, MPML, MQTFL), as well as the identification of a bony ridge on the medial proximal tibia that consistently served as the attachment site for the MPTL. The quantitative and radiographic measurements, while comparable with current literature, detailed the meniscal insertion of the MPML and defined a patellar insertion of the MPTL and the MPML as a single attachment. The data allow for reproducible landmarks to be established from previously known bony and soft tissue structures., Clinical Relevance: The findings of this study provide the anatomic foundation needed for an improved understanding of the role of medial-sided patellar restraints. This will help to further refine injury patterns and/or soft tissue deficiencies that result in lateral patellar instability, which can then be addressed with an anatomic-based reconstruction or repair technique and potentially lead to improved outcomes.

- Knee pathologies including focal cartilage injuries, osteoarthritis (OA), and ligament injuries are common. The poor regeneration and healing potential of cartilage has led to the search for other treatment modalities with improved healing capacity. Furthermore, with an increasing elderly population that desires to remain active, the burden of knee pathologies is expected to increase. Increased sports participation and the desire to return to activities faster is also demanding more effective and minimally invasive treatment options. Thus, the use of biologic agents in the treatment of knee pathologies has emerged as a potential option. Despite the increasing use of biologic agents for knee pathology, there are conflicting results on the efficacy of these products. Furthermore, strong data supporting the optimal preparation methods and composition for widely used biologic agents, such as platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), largely remain absent from the literature. This review presents the literature on the most commonly employed biologic agents for the different knee pathologies.

Purpose: To determine the exact value of side-to-side difference (SSD) in heel height that was associated with combined anterior cruciate ligament (ACL) and fibular collateral ligament (FCL) tears (compared with an isolated ACL tear) and determine the clinical utility of heel height SSD in the assessment of this injury pattern., Methods: Two patient groups were identified: (1) patients with isolated ACL tears and (2) patients with combined ACL-FCL tears but without additional collateral or cruciate ligament injuries. Determination of the amount of the heel height SSD was determined during the outpatient clinic visit. Receiver operator characteristic curves were used to evaluate the accuracy of diagnostic tests by plotting the true-positive (sensitivity) rate against the false-positive (1-specificity) rate at various thresholds. In addition, magnetic resonance imaging (MRI) reports were reviewed to calculate the sensitivity of MRI for the detection of FCL injury. MRI sensitivity was then compared with the sensitivity of the heel height examination., Results: One hundred and fifty-eight patients (71 men, 87 women) in the isolated ACL tear patient group and 117 patients (60 men, 57 women) in the combined ACL-FCL tear patient group were reviewed. A 3-cm or greater SSD was found in 13 of the 158 (8.2%) isolated ACL tear patients and 84 of the 117 (72%) ACL-FCL tear patients. The sensitivity, specificity, positive predictive value, and negative predictive value of the heel height test were 72%, 92%, 86%, and 86%, respectively. The area under the receiver operator characteristic curve was found to be 0.876. After review of all preoperative MRI musculoskeletal radiology reports for patients in the ACL-FCL patient group, a sensitivity of 48% was found., Conclusions: The clinical heel height test resulted in high sensitivity and excellent specificity for the diagnosis of combined ACL-FCL tears compared with the sensitivity and specificity of the MRI detection of FCL injury. The information presented in the current study will improve diagnostic ability through a simple physical examination and avoid missed injuries that are known to compromise surgical outcomes., Level of Evidence: Level III, cross-sectional., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To report on the clinical and radiologic outcomes and complications after surgical treatment in National Football League (NFL) Combine athletes with a history of a scaphoid fracture., Methods: The medical records of 2,285 athletes participating in the NFL Combine from 2009 to 2015 were evaluated for a history of scaphoid, hand, or wrist injury. Clinical outcomes, including grip strength, pinch test, range of motion, and presence of pain and stiffness, were recorded. Imaging studies were evaluated for the percentage of healing, fixation treatment type, hardware complications, radiographic deformity, and presence of osteoarthritis., Results: Of the 2,285 athletes evaluated, 56 presented with a history of a scaphoid fracture. Most fractures were in the middle and proximal aspects of the scaphoid. Of the scaphoid fractures, 76% (43 players) were treated with screw fixation. Of the athletes, 36 (72%) had normal range of motion of the affected wrist, 52 (93%) reported no pain, and 44 (83%) reported no stiffness in the affected wrist. The grip strength and pinch strength were 91% and 96%, respectively, of the uninjured side. The fracture was healed in 75% of the cases; however, 34% had degenerative changes. Hardware complications were found in 15% of the athletes., Conclusions: Good clinical outcomes can be achieved after scaphoid fractures in prospective NFL athletes. However, the rates of nonunion (25%), degenerative changes (34%), and hardware complications (15%) in this study suggest the need for close postoperative radiographic follow-up in this population of patients because their athletic demands may lead to higher rates of the aforementioned complications., Level of Evidence: Level IV, retrospective study., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Common upper extremity injuries in resistance training athletes include muscle strains, ligament sprains, pectoralis major tendon ruptures, distal biceps tendon ruptures, and chronic shoulder pain and capsulolabral injuries. While each injury is unique in its specific anatomic location and mechanism, each is preventable with proper exercise technique, safety and maintenance of muscle balance. Conservative treatment is the therapeutic modality of choice and these injuries generally resolve with workout modification, appropriate recovery, anti-inflammatory medication, and physical therapy. If conservative treatment fails, surgical intervention is often successful and can return the weightlifter to a level of performance near their pre-injury level.

Meniscal injuries and meniscal loss are associated with changes in knee kinematics and loading, ultimately leading to poor functional outcomes and increased risk of progression to osteoarthritis. Biomechanical studies have shown restored knee function, and clinical studies have reported improved outcomes and decreased risk of osteoarthritis after meniscal repair. This has led orthopaedic surgeons to try and save the meniscus by repair whenever possible, as shown by increasing incidence of meniscal repair surgeries. Historically, meniscal lesions, particularly those greater in size and located in the white-white region of the meniscus, have been shown to have poor healing. In recent years, there has been an increasing interest in the use of biologic agents to help stimulate and expedite healing in traditionally more avascular tissue. Preliminary results for biologic therapeutic agents, such as platelet rich plasma and bone marrow aspirate concentrate, have been encouraging. However, these options are more demanding in regard to time, financial burden, resources, and regulations than some more classic agents such as fibrin clots. Fibrin clot is readily available, easy to use, affordable, and minimally invasive. This Technical Note describes a step-by-step and reproducible technique for harvesting, preparation, and using a fibrin clot to augment healing of meniscal repairs.

Quadriceps tendinopathy in an increasingly recognized diagnosis can lead to quadriceps tendon rupture, especially in the older population. It can be caused by repeated micro trauma or also predisposed by systemic diseases such as diabetes mellitus and connective tissue disorders that can in turn lead to extensor mechanism deficits. Although a trial of conservative treatment is advocated, operative treatment should be performed in cases of persistent pain, extension deficit, or complete rupture of the tendon. The purpose of this Technical Note is to describe in detail a procedure for open repair of a quadriceps tendon, with significant degeneration due to quadriceps tendinopathy, using suture anchors and semitendinosus tendon allograft augmentation.

Anterior cruciate ligament reconstruction is one of the most commonly performed procedures in orthopaedics, with more than 125,000 performed in the United States per year. There are several reconstruction graft choices that can be used to reconstruct the native anterior cruciate ligament, with autograft hamstring tendons being one of the most commonly used. Preparation of a hamstring autograft varies depending on patient characteristics and physician preference. The purpose of this Technical Note is to describe in detail different variants of hamstring graft preparation techniques that are commonly used in practice.

Purpose: To perform a systematic review on the techniques and a meta-analysis on the functional and objective outcomes after single-bundle (SB) versus double-bundle (DB) posterior cruciate ligament (PCL) reconstructions., Methods: A systematic review of the techniques, as well as functional and objective outcomes of clinical studies comparing SB versus DB PCL reconstruction with a mean follow-up of at least 24 months and minimum level of evidence of III were performed. After review of the literature, a quality analysis of the studies (Detsky score) and a meta-analysis comparing raw mean differences in data between SB and DB PCL groups were performed. Clinical outcome measures included in the meta-analysis were functional outcomes (Lysholm, Tegner, and objective International Knee Documentation Committee [IKDC] scores) and objective measurements (arthrometer and stress radiographs)., Results: The systematic search identified 11 studies (441 patients). Three studies were prospective randomized controlled trials and the other 8 studies were case-control studies. Two hundred thirty-two patients were treated with SB PCL reconstruction, whereas 209 were treated with DB PCL reconstruction. Only 4 studies satisfied the threshold for a satisfactory level of methodologic quality (>75%). There were no significant differences between SB and DB PCL reconstructions in postoperative Lysholm (P = .6, 95% confidence interval [CI], -0.98, 2.18) or Tegner scores (P = .37, 95% CI, -0.19, 0.92). DB PCL reconstruction provided significantly better objective posterior tibial translation stability than the SB technique using the Telos technique at 90° (P = -.58, 95% CI, -1.06, -0.10)., Conclusions: Improved patient-reported outcomes and knee stability were achieved with both SB and DB PCL reconstruction surgery. DB PCL reconstruction provided significantly improved objective posterior tibial stability and objective IKDC scores when compared with SB PCL reconstruction in randomized clinical trials. No significant difference was found for the other patient-reported outcomes., Level of Evidence: Level III, systematic review and meta-analysis of Level II and III studies., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)