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To systematically review the literature to evaluate the biomechanical properties of the interference screw (IS) versus suture anchor (SA) techniques for patellar and femoral fixation of medial patellofemoral ligament (MPFL) reconstruction.A systematic review was performed by searching PubMed, the Cochrane library, and Embase using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that analyzed the biomechanical properties of IS and SA techniques for MPFL reconstruction. The search phrase implemented was "medial patellofemoral ligament reconstruction biomechanics." Evaluated outcomes included ultimate load to failure (N), stiffness (N/mm), and mode of failure. Forest plots were created for statistical analysis and heterogeneity was assessed viaSix studies met inclusion criteria, including a total of 108 cadaveric specimens, for MPFL patellar fixation, and 3 studies met inclusion criteria, including a total of 50 cadaveric specimens, for MPFL femoral fixation. Pooled analysis from 5 studies reporting on stiffness for MPFL patellar fixation revealed a statistically significant difference in favor of IS compared with SA (The use of IS was associated with a greater stiffness compared with the use of SA in MPFL patellar fixation, but there was no difference in load to failure between IS and SA. The use of IS was associated with a greater load to failure compared with the use of SA in MPFL femoral fixation, but there was no difference in stiffness between IS and SA.There have been multiple individual biomechanical studies conducted comparing IS and SA fixation for MPFL patellar and femoral fixation; however, they have yielded conflicting results, with small sample sizes. Pooling the data from these studies in a meta-analysis may allow for more meaningful biomechanical data to coincide with the existing, albeit scarce, clinical data, this may help to inform clinical decision making for surgeons managing these injuries.

PURPOSE: The objective of this study was to examine the impact of progressive radial tears in the lateral meniscal root on the lateral compartment contact forces and joint surface area through a range of motion of knee and evaluate the role of the meniscofemoral ligament (MFL) in preventing adverse tibiofemoral joint forces. METHODS: Ten fresh frozen cadaveric knees were tested using 6 experimental conditions (0% lateral meniscal posterior root tear, 25% tear, 50% tear, 75% tear, 100% tear, 100% tear and resection of MFL) at five flexion angles (0°, 30°, 45°, 60°, and 90°) under 100-1,000-N axial load. Contact joint pressure and lateral compartment surface area were measured using Tekscan sensors. Statistical analysis, including descriptive, ANOVA, and post hoc Tukey analysis, was performed. RESULTS: Progressive radial tears of the lateral meniscal root were not associated with an increase in tibiofemoral contact pressure or decrease in lateral compartment surface area. Complete lateral root tear and resection of MFL were associated with increased joint contact pressure (P < .001) at knee flexion angles of 30, 45, 60, and 90° and decreased lateral compartment surface (P < .001) at all knee flexion angles area compared to complete lateral meniscectomy alone. CONCLUSION: Isolated complete tears of lateral meniscus root and progressive radial tears of the lateral meniscus posterior root were not associated with any change to tibiofemoral contact forces. However, additional resection of the MFL increased contact pressure and decreased lateral compartment surface area.

No previous study has investigated poly-L-lactic acid (PLLA) surgical mesh augmentation in the repair of inferior pole patellar tendon rupture. We compared the biomechanical properties of transosseous patellar tendon repair with PLLA surgical mesh augmentation to transosseous repair without augmentation. Ten matched pairs of cadaveric knees were used. Specimens in each pair were randomized to undergo the transosseous technique alone or the transosseous technique augmented with a PLLA surgical mesh. An inferior pole patellar tendon rupture was simulated and the repair procedure was performed. Specimens were cyclically loaded for 500 cycles. Gap formation was measured using two sensors placed medial and lateral to the repair site. After cyclic loading, load to failure was determined by pulling the tendon at a constant rate until a sudden decrease in load occurred. The primary outcome measure was cyclic gap formation at the medial and lateral sensors. Compared with controls, specimens that underwent PLLA mesh-augmented repair had significantly lower medial gap formation at all testing intervals up to 500 cycles (p

The optimal postoperative management of Achilles tendon (AT) rupture remains unknown. The past 2 decades have witnessed a trend toward less rigid immobilization, earlier weightbearing, and accelerated functional rehabilitation postoperatively. The objective of this study was to identify all high-quality studies pertaining to rehabilitation after AT repair and characterize the various rehabilitation protocols that have been described. A systematic review of the English-language literature was performed according to PRISMA guidelines. All included studies represented level 1, 2, or 3 evidence and examined postoperative rehabilitation protocols following the repair of an acute AT rupture. A total of 1187 subjects were included. Surgical technique, rehabilitation protocol, and outcome assessment varied widely between studies. Early postoperative weightbearing with less rigid immobilization appears to accelerate short-term functional recovery. An aggressive rehabilitation program may also be advantageous in the short term, but further studies are needed to determine the long-term effects of these accelerated physical therapy and return-to-play protocols.

Background Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from −9.2% to −13% for each procedure. Conclusion From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

Background: No study has provided a comprehensive systematic review of sports injuries on artificial turf versus natural grass. Purpose: To comprehensively examine the risk of overall injuries and multiple types of lower extremity injuries across all sports, all levels of competition, and on both old-generation and new-generation artificial turf. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review of the English-language literature was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All included articles compared overall injury rates or lower extremity (hip, knee, or foot and ankle) injury rates on artificial turf and natural grass. All sports, levels of competition, and turf types were included. Studies were excluded if they did not include overall injury rates or lower extremity injury rates. Because of the heterogeneity of the included studies, no attempt was made to aggregate risk ratios to conduct a quantitative meta-analysis. Results: A total of 53 articles published between 1972 and 2020 were identified for study inclusion. Most studies on new-generation turf (13/18 articles) found similar overall injury rates between playing surfaces. When individual anatomic injury locations were analyzed, the greatest proportion of articles reported a higher foot and ankle injury rate on artificial turf compared with natural grass, both with old-generation (3/4 articles) and new-generation (9/19 articles) turf. Similar knee and hip injury rates were reported between playing surfaces for soccer athletes on new-generation turf, but football players, particularly those at high levels of competition, were more likely to sustain a knee injury on artificial turf than on natural grass. Conclusion: The available body of literature suggests a higher rate of foot and ankle injuries on artificial turf, both old-generation and new-generation turf, compared with natural grass. High-quality studies also suggest that the rates of knee injuries and hip injuries are similar between playing surfaces, although elite-level football athletes may be more predisposed to knee injuries on artificial turf compared with natural grass. Only a few articles in the literature reported a higher overall injury rate on natural grass compared with artificial turf, and all of these studies received financial support from the artificial turf industry.

Previous studies have shown that intraoperative cerebral desaturation in patients undergoing shoulder surgery in the beach chair position varies widely, from 0% to 80%. To our knowledge, the risk of intraoperative cerebral desaturation is not known after all identified intraoperative modifiable physiologic parameters that influence cerebral blood flow have been controlled for.(1) What is the risk of intraoperative cerebral desaturation during shoulder surgery with the patient in the beach chair position when patients received combined general anesthesia and an interscalene block, and what other factors associated with intraoperative cerebral desaturation can be identified? (2) Is intraoperative cerebral desaturation associated with 24-hour cognitive decline? (3) What factors are associated with intraoperative hypotension?Between April and December 2020, 51 patients underwent elective shoulder surgery in the beach chair position at one center. Nine patients were excluded: four patients refused to participate, two patients were unable to receive an interscalene brachial plexus block, and three patients were operated on in less than 70° upright position. A total of 42 patients (aged 63 ± 10 years, of whom 52% [22 of 42] were female) were prospectively recruited into this study. Each patient was diagnosed with a rotator cuff tear and underwent arthroscopic repair in the beach chair position, which was performed in an upright position of 70° to 80°. Near-infrared spectroscopy was used to monitor regional cerebral oxygen saturation. The mean arterial pressure was monitored and controlled so that it was more than 70 mmHg in patients without hypertension and within 20% from the baseline mean arterial pressure in patients with hypertension. All patients received the standardized anesthesia protocol, which consisted of an interscalene brachial plexus block and general anesthesia. Intraoperative cerebral desaturation was defined as a decrease in the regional cerebral oxygen saturation level of more than 20% from the baseline value that lasted longer than 15 seconds after induction of anesthesia. Patients' clinical characteristics such as age, sex, BMI, preoperative hemoglobin level, preexisting medical conditions, and continuing antihypertensive medications on the morning of surgery were analyzed to identify the association with intraoperative cerebral desaturation. We used the Montreal Cognitive Assessment to assess cognitive function at preoperative and 24 hours postoperative. Episodes of hypotension and its treatment after maximum head elevation were recorded. The patients' clinical characteristics were analyzed to determine their association with hypotensive events.In this study, intraoperative cerebral desaturation occurred in 43% (18 of 42) of patients, and female sex was identified as an associated risk (odds ratio 4.3 [95% confidence interval 1.2 to 16.2]; p = 0.03). The median (interquartile range) duration of intraoperative cerebral desaturation was 19 minutes (5 to 38). There was no association between intraoperative cerebral desaturation and 24-hour postoperative cognitive decline (OR 0.6 [95% CI 0.1 to 2.4]; p = 0.44). Risk factors for intraoperative hypotension were a history of hypertension, regardless of whether or not the patient took antihypertensive drugs on the morning of surgery (OR 4.9 [95% CI 1.3 to 18.1]; p = 0.02), and dyslipidemia (OR 4.3 [95% CI 1.2 to 16.3]; p = 0.03).The intraoperative cerebral desaturation risk in the beach chair position was high. Female sex was an intraoperative cerebral desaturation risk factor. However, there was no association between intraoperative cerebral desaturation and postoperative cognitive decline. Patients with hypertension and dyslipidemia are at risk of intraoperative hypotension after positioning. Further large-scale studies are required to identify intraoperative cerebral desaturation-associated adverse neurologic outcome.Level II, therapeutic study.

Case A 36-year-old male competitive powerlifter sustained asynchronous bilateral Achilles tendon ruptures after using 2 types of selective androgen receptor modulators (SARMs). Both tendon ruptures occurred near the myotendinous junction and were treated with open surgical repair and an initial period of immobilization followed by progressive weightbearing and rehabilitation; no postoperative complications were observed. Conclusion Previous studies have reported that anabolic androgenic steroids have a deleterious impact on tendon structure and function. This case suggests that SARM compounds may also predispose users to Achilles tendon rupture.

Background:Adjustable cortical fixation devices have demonstrated utility in orthopaedic applications, such as ankle syndesmosis repair.Purpose:To assess the cyclic gap formation of a quadriceps tendon repair technique using an adjustable cortical fixation device compared with repair with knotless suture anchors and suture tape, a modification of conventional suture anchor repair.Study Design:Controlled laboratory study.Methods:Eight fresh-frozen matched pairs of cadaveric knees were used. Specimens in each pair were randomized to undergo either modified suture anchor repair (control) or adjustable cortical fixation repair. The control repair was performed as previously described. The experimental repair was performed using 2 No. 2 FiberWire sutures placed into the quadriceps tendon in a running locked Krackow configuration and 2 adjustable loop devices passed through transosseous tunnels. The lagging strands of the devices were tensioned to seat the cortical fixation buttons at the inferior patellar pole and then tied to the free Krackow strands at the superior pole to complete the repair. The mean plastic gap (permanent tendon displacement that did not recover with cyclic extension) and mean maximum gap (peak displacement that occurred with cyclic knee flexion and partially recovered with extension) were evaluated during cyclic loading for 500 cycles of full knee extension to 90° of flexion.Results:At all testing intervals, the mean plastic gap was significantly smaller for the cortical fixation group versus the suture anchor group ( P < .02). Similarly, the mean maximum gap was significantly smaller for the cortical fixation specimens at all testing intervals ( P < .01). After cyclic loading, the mean maximum gap was significantly smaller in the cortical fixation group (4.80 ± 1.56 mm) versus the suture anchor group (8.47 ± 1.47 mm; P = < .001). The mean plastic gap was also significantly smaller in the cortical fixation versus the suture anchor group (3.25 ± 1.10 mm vs 6.57 ± 1.62 mm, respectively; P = < .001).Conclusion:Quadriceps tendon repair using an adjustable cortical fixation device demonstrated superior biomechanical properties in cyclic displacement testing compared with repair using the suture anchor technique.Clinical Relevance:These results suggest that an adjustable cortical fixation device is a biomechanically viable alternative for quadriceps tendon repair.

BACKGROUND: Anterior instability has consistently been shown to be the most common type of glenohumeral instability. Recent studies have demonstrated a higher percentage of posterior and combined (anterior and posterior) instability than had previously been reported; however, this work has not been replicated recently in a particularly young military population, which may be representative of an especially athletic or high-demand group. QUESTION/PURPOSE: What proportion of arthroscopic shoulder stabilization procedures are performed to address isolated anterior instability, isolated posterior instability, and combined instability in a young, military population? METHODS: Between August 2009 and January 2020, two sports medicine fellowship–trained surgeons performed arthroscopic shoulder surgery on 543 patients at a single institution. During that time, the indication to be treated with arthroscopic stabilization surgery was symptomatic glenohumeral instability, as diagnosed by the operative surgeon, that restricted patients from carrying out their military duties. Of those, 82% (443 of 543) could be evaluated in this retrospective study, while 18% (100 of 543) were excluded due to either incomplete data or because the procedure performed was not to address instability. No patient underwent an open stabilization procedure during this period. Of the 443 patients investigated, the mean age was 22 ± 4 years, and 88% (392 of 443 patients) were men. Instability type was characterized as isolated anterior, isolated posterior, or combined (anterior and posterior) according to the physician’s diagnosis as listed in the patient’s clinical records and operative reports after the particular capsulolabral pathology was identified and addressed. RESULTS: Isolated anterior instability occurred in 47% of patients (210 of 443). Isolated posterior instability happened in 18% of patients (80 of 443), while combined anteroposterior instability occurred in 35% of patients (153 of 443). CONCLUSION: Shoulder instability is common in the military population. Although anterior instability occurred most frequently, these findings demonstrate higher proportions of posterior and combined instability than have been previously reported. Surgeons should have a heightened suspicion for posterior and combined anteroposterior labral pathology when performing arthroscopic stabilization procedures to ensure that these instability patterns are recognized and treated appropriately. The current investigation examines a unique cohort of young and active individuals who are at particularly high risk for instability and whose findings may represent a good surrogate for other active populations that a surgeon may encounter. Level of Evidence Level III; therapeutic study.

Purpose: To compare gap displacement at various intervals of cyclic testing and biomechanical load to failure of a Krackow patellar tendon repair augmented with high-strength suture tape versus the standard Krackow transosseous technique for inferior pole patellar tendon rupture. Methods: Twelve matched pairs of cadaveric knees were used (8 males and 4 females; mean age 79.6 years, range 57 to 96). An inferior pole patellar tendon rupture was simulated after random assignment of specimens in each pair to the standard or augmented Krackow technique. Each specimen was then repetitively cycled from 90° to 5° for 1,000 cycles. A differential variable reluctance transducer was used to measure gap displacement. After cyclic loading, load to failure was determined by pulling the tendon at a rate of 15 mm/s until a sudden decrease in load occurred. Results: Compared with the control repair, specimens with augmented repair demonstrated significantly less displacement at all testing intervals up to 1,000 cycles (P < .05). Two patellar tendons failed before the end of cyclic loading, and 4 specimens had inadequate tendon length for loading. Among the 18 remaining specimens, no significant difference in load to failure was observed between the experimental group (n = 11) and the control group (n = 7) (1,006.5 ± 332.1 versus 932.8 ± 229.1 N, respectively; P = .567). Conclusions: Significantly greater gap displacement was observed in the standard Krackow repair group compared with the augmented Krackow group at all cyclic loading intervals. This suggests that the Krackow transosseous procedure augmented with high-strength suture tape is biomechanically viable for inferior pole patellar tendon repair. Clinical Relevance: This biomechanical study supports the use of high-strength suture tape augmentation of Krackow transosseous repair for inferior pole patellar tendon rupture.

BACKGROUND: Foraminotomy has demonstrated clinical benefit in patients with lumbar foraminal stenosis (LFS), as evidenced by several small retrospective investigations. However, there is a subset of patients who have recurrent symptoms following the operation and therefore require revision surgery. Yet, despite this phenomenon, the relative efficacy of revision foraminotomy (RF) is not well elucidated due to limited literature on the quality of life (QOL) outcomes and cost associated with primary foraminotomy (PF) and RF. PURPOSE: To compare the effectiveness of PF and RF in terms of QOL outcomes and relative costs. STUDY DESIGN/SETTING: This is a retrospective cohort study conducted at a single tertiary-care institution. The patient sample consisted of patients undergoing foraminotomy for the treatment of LFS between 2008 and 2016. The primary outcome measure was improvement in postoperative QOL, as measured by EuroQol 5-Dimensions (EQ-5D), and secondary outcome measures included Pain Disability Questionnaire (PDQ) and Patient Health Questionnaire-9 (PHQ-9) perioperative cost as well as minimum clinically important difference (MCID). METHODS: A retrospective chart review was conducted to identify individuals who underwent PF or RF for LFS and to collect clinical, operative, and demographic data. QOL scores (EQ-5D, PDQ, and PHQ-9) were collected between 2008 and 2016, and perioperative financial data were extracted via the institution's cost utilization engine. Paired t tests were used to assess changes within treatment groups, and Fisher exact tests were used for intercohort comparisons. RESULTS: Five hundred seventy-nine procedures were eligible: 476 (82%) PF and 103 (18%) RF. A significantly higher proportion of males underwent RF than PF (71% versus 59%, P = .03), and PF was done on a significantly higher number of vertebral levels (2.2 versus 2.0, P = .04). There were no other significant differences in demographics. Preoperatively, mean PDQ-Functional scores (50 versus 54, P = .04) demonstrated significantly poorer QOL in the RF cohort. Postoperatively, EQ-5D index showed significant improvement in both the PF (0.547→0.648, P < .0001) and the RF (0.507→0.648, P < .0001) cohorts. Similarly, total PHQ-9 improved significantly in the PF cohort (7.84→5.91, P < .001) and in the RF cohort (8.55→5.53, P = .02), as did total PDQ (PF: 77→63, P < .0001; RF: 85→70, P = .04). QOL scores were also compared between groups preoperatively and postoperatively, and the only significant difference between PF and RF was observed in the preoperative PDQ-Functional score (49.7 versus 54.3, P = .04). The proportion of patients achieving MCID was not significantly associated with cohort. Finally, perioperative cost did not differ significantly between cohorts (PF: $13,383 versus RF: $13,595, P = .82). CONCLUSIONS: Both PF and RF produced significant improvement in nearly all measures in patients with LFS. There was no significant difference in cost between PF and RF, but both PF and RF showed postoperative QOL improvements as compared with preoperative scores, indicating that RF remains a reasonable treatment option for patients with recurrent symptoms of LFS.

Background: Repetitive lumbar hyperextension and rotation during athletic activity affect the structural integrity of the lumbar spine. While many sports have been associated with an increased risk of developing a pars defect, few previous studies have systematically investigated spondylolysis and spondylolisthesis in professional baseball players. Purpose: To characterize the epidemiology and treatment of symptomatic lumbar spondylolysis and isthmic spondylolisthesis in American professional baseball players. We also sought to report the return-to-play (RTP) and performance-based outcomes associated with the diagnosis of a pars defect in this elite athlete population. Study Design: Descriptive epidemiology study. Methods: A retrospective cohort study was conducted among all Major and Minor League Baseball (MLB and MiLB, respectively) players who had low back pain and underwent lumbar spine imaging between 2011 and 2016. Players with radiological evidence of a pars defect (with or without listhesis) were included. Analyses were conducted to assess the association between player-specific characteristics and RTP time. Baseball performance metrics were also compared before and after the injury episode to determine whether there was an association between the diagnosis of a pars defect and diminished player performance. Results: During the study period of 6 MLB seasons, 272 professional baseball players had low back pain and underwent lumbar spine imaging. Overall, 75 of these athletes (27.6%) received a diagnosis of pars defect. All affected athletes except one (98.7%) successfully returned to professional baseball, with a median RTP time of 51 days. Players with spondylolisthesis returned to play faster than those with spondylolysis, MLB athletes returned faster than MiLB athletes, and position players returned faster than pitchers. Athletes with a diagnosed pars defect did not show a significant decline in performance after returning to competition after their injury episode. Conclusion: Lumbar pars defects were a common cause of low back pain in American professional baseball players. The vast majority of affected athletes were able to return to competition without demonstrating a significant decline in baseball performance.

Background: Pelvic incidence (PI) is an important variable in assessing spinopelvic balance that is associated with hip pathology. A lateral radiograph of the pelvis can be used to measure PI, but this view is not routinely performed in the clinical setting during evaluation of hip pain. The false-profile (FP) radiographic view of the hip is commonly obtained to measure acetabular coverage. Purpose: To evaluate the tolerance of PI measurements to pelvic rotation and assess the feasibility of using an FP radiograph to obtain an accurate measurement of PI. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A mathematical model was developed to predict the change in PI with rotation. Fluoroscopic images were obtained of 6 reconstructed cadaveric adult pelvis and femur specimens at varying degrees of rotation, including a perfect lateral and FP image. PI was measured with the midpoint between the centers of the femoral heads as a reference point. The findings were confirmed clinically by retrospectively reviewing FP radiographs and computed tomography (CT) scans of 40 clinical patients. PI was measured on FP radiographs and CT scans by 2 independent reviewers. Results: With dry cadaveric pelvis specimens, the discrepancy in PI measured between fluoroscopic FP and lateral views was 1.6° (95% CI, 0.7°-2.4°). There was excellent agreement between CT and FP radiographs with regard to measurement of PI (intraclass correlation coefficient = 0.92; 95% CI, 0.78-0.98). Mean discrepancy in PI measured between the 40 clinical FP radiographs and CT scans was 2.8° (range, 0.1°-9.1°). Conclusion: Increased rotation from a lateral view results in greater error in measuring PI, although relatively nominally with a 2.8° error with the 25° of rotation in clinical true FP views. These data demonstrate that FP radiographs can be used to measure PI with reasonable accuracy.

Objectives: To identify the top 100 most impactful anterior cruciate ligament articles in online media as measured by the Altmetric Attention Score and compare their characteristics to the most-cited anterior cruciate ligament articles in the scientific literature. Methods: The Altmetric database was queried to identify all published articles pertaining to the anterior cruciate ligament. The search yielded 9445 articles, which were stratified by highest to lowest Altmetric Attention Score. The top 100 articles were included. Collected data included article type, article topic, journal name, and online mentions in news, blogs, Twitter, Facebook, Wikipedia, and other sources. The geographic origin of each article was also determined based on the institutional affiliation of the first author. Results: Altmetric Attention Score of the top 100 anterior cruciate ligament articles ranged from 109 to 2193 (median 172.0, interquartile range 137.5–271.5). Of the 100 articles, 65 were published in three journals: American Journal of Sports Medicine, British Journal of Sports Medicine, and Journal of Orthopaedic & Sports Physical Therapy. The most prevalent article type was original research (60%), followed by systematic review/meta-analysis (18%). The most prevalent article topic was rehabilitation and return to play after anterior cruciate ligament reconstruction (22%), followed by epidemiology/risk factors (16%), injury prevention (14%), and biomechanics of anterior cruciate ligament injuries (14%). Of the top 100 articles, 54% were American, 31% were European, and 15% were published in other countries outside of the United States and Europe. Conclusion: This study used Altmetric Attention Score to identify the 100 most engaged anterior cruciate ligament articles in online media. The characteristics of these articles differed substantially from the most-cited anterior cruciate ligament articles in the literature with regard to article type, article topic, geographic origin, and publication journal. These findings suggest that alternative metrics measure distinct components of anterior cruciate ligament article engagement and add an important dimension to understanding the overall impact of published research on the anterior cruciate ligament.

The purpose of this study was to use the Altmetric Attention Score to determine the 50 most impactful medial ulnar collateral ligament articles in online media and compare their characteristics to the most-cited medial ulnar collateral ligament articles in the scientific literature. The Altmetric database was queried to identify all published articles about the medial ulnar collateral ligament, and this list was stratified by the Altmetric Attention Score to identify the 50 highest scoring articles. Several data elements were extracted, including article topic, article type, journal name, and the number of online mentions on Facebook, Twitter, news, and other platforms. Each article’s geographic origin was determined based on the institutional affiliation of the first author. Our index search yielded 1283 articles published between 1987 and 2020, from which the 50 articles with the highest Altmetric Attention Scores were included for analysis. Altmetric Attention Scores of the top 50 medial ulnar collateral ligament articles ranged from 20 to 482 (median: 32, interquartile range: 20–62). The most common article type was original research (72%), and the most common topic was epidemiology/risk factors (26%). A majority of studies were Level 3 (36%) or Level 4 evidence (36%). Of the top 50 medial ulnar collateral ligament articles, 94% originated from the United States. A few articles had a high Altmetric Attention Score, suggesting that medial ulnar collateral ligament research does not generate consistently high online attention. The lack of Level 1 studies suggests the need for high-level studies on the medial ulnar collateral ligament. Most studies originated in the United States and were published in the American Orthopaedic Society for Sports Medicine–affiliated journals. The medial ulnar collateral ligament articles included in this study differed substantially from a previous report of the most-cited medial ulnar collateral ligament articles in the literature, suggesting that alternative metrics add a unique dimension to understanding the overall impact of published research on the medial ulnar collateral ligament.

Background Context Multiple studies have determined minimum clinically important difference (MCID) thresholds for EuroQOL-5 Dimensions (EQ-5D) scores in lumbar fusion patients. However, a comprehensive understanding of predictors for a clinically significant improvement (CSI) postoperatively does not exist. Purpose To determine medical, radiographic, and surgical predictors for obtaining a CSI following lumbar fusion surgery. Study Design This is a retrospective review of patients who underwent instrumented lumbar fusion. Patient Sample We included patients who underwent lumbar fusion for any indication between 2008 and 2013. Outcome Measures Outcome measures included preoperative and postoperative EQ-5D Index scores. Materials and Methods The medical records of patients who received a lumbar fusion for any indication were retrospectively reviewed to identify patient medical and surgical characteristics. A blinded reviewer assessed radiographs for each patient to examine sagittal alignment following fusion. Multivariable logistic regression was used to model the achievement of a CSI based on two commonly cited MCID values. Results A total of 231 patients fit the inclusion criteria; 58% exceeded an MCID value for an EQ-5D score of 0.100, and 16% exceeded an MCID value of 0.390. Statistically significant independent predictors of not obtaining a CSI for an MCID threshold of 0.100 included a higher preoperative EQ-5D score (odds ratio [OR]=44.8) and L5-S1 fusion (OR=3.3). For an MCID value of 0.390, a higher preoperative EQ-5D score (OR=2,080.8) and a diagnosis of depression (OR=7.1) were predictive of not achieving a CSI, whereas spondylolisthesis (OR=4.1) was predictive of obtaining a CSI postoperatively. For both MCID values, patients who achieved a CSI had better postoperative quality of life (QOL) scores for all metrics measured, despite worse QOL scores preoperatively. Conclusions This study is the first to use a combination of medical, surgical, and postoperative sagittal balance variables as determinants for the achievement of a CSI after lumbar fusion. The awareness of these predictors may allow for better patient selection and surgical approach to decrease the probability of acquiring a poor outcome postoperatively.

Purpose:The purpose of this study was to assess the accuracy and precision of pelvic rotation in existing false-profile (FP) radiographs and to devise a method to improve accuracy and precision of FP radiographs.Methods:An imaging protocol was developed to obtain FP radiographs. Pelvic rotation was calculated using the described method for FP images obtained in the 3 months prior to and after implementation of this protocol. Student’s t-test and variance ratio tests were used to determine differences in mean and variance of pelvic rotation between the 2 cohorts. Pelvic rotation calculation methodology was validated by using fluoroscopic C-arm to obtain AP and rotated images of 10 osteologic pelvises. The ratio of the distance between hip centres of each rotated image and AP image ( WP/ W) was determined. Intraclass coefficient correlation (ICC) was used to verify the relationship between WP/ W and pelvic rotation.Results:Mean WP/ W was 0.47 (95% CI, 0.45–0.49). There were significant differences in mean pelvic rotation of the pre-protocol group (47.6°; 95% CI, 45.6–49.5°) and the post-protocol group (60.0°; 95% CI, 58.7–61.3°, p Conclusions:The quality of FP radiographs obtained in the clinical setting may be inconsistent. Standardising FP imaging produces more accurate images. Appropriate FP radiographs should have a distance between hip centres that is approximately 0.5 times the same distance found on an anteroposterior (AP) radiograph.

Background:Femoral-sided graft fixation in medial patellofemoral ligament (MPFL) reconstruction is commonly performed using an interference screw (IS). However, the IS method is associated with several clinical disadvantages that may be ameliorated by the use of suture anchors (SAs) for femoral fixation.Purpose:To compare the load to failure and stiffness of SAs versus an IS for the femoral fixation of a semitendinosus autograft in MPFL reconstruction.Study Design:Controlled laboratory study.Methods:Based on a priori power analysis, a total of 6 matched pairs of cadaveric knees were included. Specimens in each pair were randomly assigned to receive either SA or IS fixation. After an appropriate reconstruction procedure, the looped end of the MPFL graft was pulled laterally at a rate of 6 mm/s until construct failure. The best-fit slope of the load-displacement curve was then used to calculate the stiffness (N/mm) in a post hoc fashion. A paired t test was used to compare the mean load to failure and the mean stiffness between groups.Results:No significant difference in load to failure was observed between the IS and the SA fixation groups (294.0 ± 61.1 vs 250.0 ± 55.9; P = .352), although the mean stiffness was significantly higher in IS specimens (34.5 ± 9.6 vs 14.7 ± 1.2; P = .004). All IS reconstructions failed by graft pullout from the femoral tunnel, whereas 5 of the 6 SA reconstructions failed by anchor pullout.Conclusion:In this biomechanical study using a cadaveric model of MPFL reconstruction, SA femoral fixation was not significantly different from IS fixation in terms of load to failure. The mean load-to-failure values for both reconstruction techniques were greater than the literature-reported values for the native MPFL.Clinical Relevance:These results suggest that SAs are a biomechanically viable alternative for femoral-sided graft fixation in MPFL reconstruction.

Purpose To investigate whether the location of distal radius osteotomy/shortening relative to the radial insertion of the distal interosseous membrane (DIOM) is correlated with distal radioulnar joint (DRUJ) instability. We hypothesized that distal radius osteotomy and shortening proximal to the DIOM insertion would result in increased DRUJ instability because of induced laxity in the DIOM. Methods Osteotomies of the distal radius were performed proximal and distal to the DIOM insertion in 14 fresh-frozen cadaveric specimens. Using a volar plate, 5 conditions were tested: anatomical radius alignment; 2- and 4-mm shortening at the proximal osteotomy site; and 2- and 4-mm shortening at the distal osteotomy site. Basilar ulnar styloid osteotomy was performed to simulate triangular fibrocartilage complex (TFCC) detachment—specimens were tested with the ulnar styloid detached and the ulnar styloid fixed (to restore normal anatomy). The DRUJ stability was quantified using dorsal-volar displacement of the radius in response to 20 N of force using a force-displacement probe in neutral, pronation, and supination. Posttesting specimen dissections assessed DIOM and distal oblique bundle (DOB) anatomy. The DRUJ stability in each experimental condition was compared with a multifactor repeated measures analysis of variance with the specimen treated as the repeated factor. Results There were no significant differences in dorsal-volar translation of the radius (ie, DRUJ stability) between radial osteotomy/shortening proximal and distal to the DIOM insertion, regardless of forearm rotational position or magnitude of shortening. Five (36%) of the 14 specimens had a DOB present. There was a significant increase in DRUJ instability in the setting of TFCC detachment (via basilar ulnar styloid osteotomy). Conclusions No difference in DRUJ stability was observed between distal radius osteotomy/shortening proximal and distal to the DIOM radial insertion, regardless of forearm rotation, magnitude of shortening, and/or TFCC detachment. Clinical relevance Distal radius osteotomy and shortening did not affect DRUJ stability regardless of location relative to the DIOM insertion.

Objectives: Previous studies in the evidence-based literature suggest that lumbar spine injuries can lead to a significant decrease in athletic performance. This phenomenon is particularly evident in sports that require repetitive truncal rotation, such as baseball. Although we have previously characterized the natural history of symptomatic spondylolysis and spondylolisthesis in professional baseball players, no prior study has investigated the impact of pars injuries on player performance in this patient population. The purpose of this study was to report performance-based outcomes following symptomatic pars injuries in elite-level baseball athletes. Methods: A retrospective cohort study was conducted among all professional baseball players who presented with a symptomatic pars defect between 2011 and 2016. Both Major League and Minor League players were enrolled using a de-identified injury surveillance database maintained by the MLB. Lumbar spine imaging reports were reviewed to confirm the radiologic diagnosis of spondylolysis or spondylolisthesis. Players were stratified according to baseball position (pitcher vs. position player). Primary outcome measures for pitchers were earned run average (ERA) and walks plus hits per inning pitched (WHIP), while primary outcomes for position players were batting average (AVG) and on-base plus slugging (OPS). Paired t tests were used to compare pre-injury statistical performance to post-injury performance, with p < 0.05 treated as statistically significant. Results: During the defined study period, 75 players presented with low-back pain in the setting of a pars defect. 47 players were diagnosed with spondylolysis (62.7%), while 28 were diagnosed with spondylolisthesis (37.3%). Of those individuals, 19 players were excluded due to incomplete statistical data in the MLB injury surveillance system. Pre-injury vs. post-injury statistical comparisons are presented in Table 1. Pitching performance after the pars injury did not significantly differ with regard to the primary outcome measures, ERA (3.45 vs. 4.73; p = 0.25) and WHIP (1.28 vs. 1.47; p = 0.26). There was also no significant difference in any of the secondary outcomes - runs per 9 innings (R/9), hits per 9 innings (H/9), walks per 9 innings (BB/9), strikeouts per 9 innings (K/9), home runs per 9 innings (HR/9), and strikeout-to-walk ratio (K/BB). Similarly, batting performance among position players did not significantly differ from pre-injury to post-injury with regard to the primary outcomes, AVG (.261 vs. .256; p = 0.59) and OPS (.672 vs. .667; p = 0.87), or any of the secondary outcomes - on-base percentage (OBP), slugging percentage (SLG), runs per plate appearance (R/PA), hits per plate appearance (H/PA), runs batted in per plate appearance (RBI/PA), extra-base hits per plate appearance (XBH/PA), home runs per plate appearance (HR/PA), and walk-to-strikeout ratio (BB/K). Conclusion: This study represents the most comprehensive analysis of the impact of symptomatic pars injuries on MLB player performance. While previous studies suggest that lumbar injuries lead to shorter careers in both pitchers and position players, our current data demonstrate that pars defects do not cause a significant decrease in performance when MLB athletes return to play following these injury episodes. Given the limitations of our study design, larger prospective investigations are needed to validate these conclusions. [Table: see text]

Purpose The purpose of this study was to determine the radiologic tolerance of the lateral center edge angle (LCEA) and anterior center edge angle (ACEA) to pelvic rotation. Methods Eleven dry cadaveric pelvises from an osteological collection were reconstructed and placed in anatomic position with corresponding bilateral proximal femurs. Conventional anteroposterior (AP) and false-profile (FP) pelvic radiographs were taken at 5° increments with fluoroscopy from 0° to 25° of rotation. LCEA and ACEA were measured for conventional and rotated AP and FP fluoroscopic views, respectively. Statistical analysis was conducted to determine the error in ACEA and LCEA with pelvic rotation. Results The mean LCEA was 29.1° (95% confidence interval [CI], 25.5°-32.7°). Mean ACEA was 38.9° (95% CI, 34.1°-43.8°). There was significant change in the LCEA past 10° of rotation (P = .041). There was significant change in the ACEA with 5o or more of rotation (P Conclusions Rotation of AP and FP radiographs significantly affects the measured values of the LCEA and ACEA, respectively. The ACEA experiences more dramatic changes with rotation of the FP view compared with the LCEA with the same amount of rotation of an AP view. This study illustrates the importance of verifying the quality of the FP radiograph when using ACEA to guide therapy for hip pathology. Clinical Relevance This study emphasizes the importance of evaluating pelvic rotation when using the center edge angle to assess femoral head coverage.

Purpose: Pelvic incidence (PI) is an important spinopelvic parameter that is a major determinant in spine and hip pathology. PI is ideally measured using a lateral radiograph, and the midpoint of the two femoral heads is commonly used as an approximation when the view is slightly rotated. The accuracy of using this approximation has not been rigorously studied and is important to better understand as the understanding of PI continues to grow. Methods: This was a descriptive laboratory study utilizing the Haman-Todd cadaveric research collection. Fluoroscopic …