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Purpose: A compression plate has recently been reported as a point of care processor for adapting the long head of the biceps into an autograft patch for rotator cuff augmentation. The purpose of this study was to evaluate the effects of this graft preparation technique on histological evidence of tenocyte mechanical damage., Methods: A consecutive series of patients undergoing biceps tenodesis for shoulder pathology were evaluated. After supra-pectoral tenodesis, 27 mm of the long head of the biceps was secured for compression into the patch. The remaining length of residual tendon was longitudinally split, resulting in two equal lengths of remnant tendon from the same zone. One sample was sent to pathology with no preparation, and the other was prepared as a compressed biceps autograft patch according to the manufacturer's recommendations. Both grafts were sent to pathology for evaluation of tenocyte morphology. Records were reviewed to determine if compression resulted in mechanical damage to the tenocytes at the time of biceps augmentation., Results: 55 shoulder procedures and 110 samples were sent for pathology analysis. 42 of the 55 (76%) specimens demonstrated morphologically normal tenocytes in both the compressed and non-compressed groups, and 7 (13%) cases showed evidence of tenocyte necrosis or mechanical damage in both groups. The difference abnormal tenocyte morphology between the compressed group and the native group was not statistically significant (p=0.625)., Conclusion: Autograft biceps compression into a point of care patch did not result in mechanical damage to tenocyte morphology at the time of insertion for augmentation of rotator cuff pathology., Clinical Relevance: Free proximal biceps tendon compression can result in a patch that does not mechanically damage the tenocyte. The patch can be used as a biologic autograft to enhance shoulder rotator cuff repair, as well as subscapularis repair in the setting of shoulder arthroplasty., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: To evaluate the superior to inferior glenoid height as a reliable reference in best-fit circle creation for glenoid anatomy., Methods: The morphology of the native glenoid was evaluated using magnetic resonance imaging (MRI) in patients without shoulder instability. Using T1 sagittal MRI images, 2 reviewers independently estimated glenoid size using the two-thirds technique and the "best-fit circle" technique at 2 different times. A Student t-test was used to determine significant difference between the two methodologies. Inter- and intra-rater reliability were calculated using interclass and intraclass coefficients., Results: This study included 112 patients. Using the results of glenoid height and "best-fit circle" diameter, the diameter of the "best-fit circle" was found to intersect the glenoid line at 67.8% of the glenoid height on average. We found no significant difference between the 2 measures of glenoid diameter (27.6 vs 27.9, P = .456). The interclass and intraclass coefficients for the two-third method were 0.85 and 0.88, respectively. The interclass and intraclass coefficients for the perfect circle methods were 0.84 and 0.73, respectively., Conclusions: We determined that the diameter of a circle placed on the inferior glenoid using the "best-fit circle" technique corresponds to 67.8% of the glenoid height. Additionally, we found that constructing a perfect circle using a diameter equal to two-thirds the height of the glenoid may improve intraclass reliability., Level of Evidence: Level IV, retrospective cohort study., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Biceps tenodesis has been proven to be an effective treatment for biceps tendon and superior labral pathology. Many techniques including both open and arthroscopic approaches have been reported. Open techniques afford management of the entire proximal biceps tendon but are limited by wound healing issues, increased bleeding, and increased surgical time. Arthroscopic tenodesis offers benefits in terms of surgical efficiency, cosmesis, and bleeding risk. However, standard arthroscopic tenodesis only addresses intra-articular biceps pathology. In this report we describe an all-arthroscopic biceps tenodesis technique at the suprapectoral region of the humerus using knotless suture anchor fixation., (© 2024 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.)

Background: The optimal alignment technique for total knee arthroplasty (TKA) remains controversial. We previously reported 6-month and 2-year results of a randomized controlled trial comparing kinematically versus mechanically aligned TKA. In the present study, we report the mean 13-year (range, 12.6-14.4) follow-up results from this trial., Methods: The original cohort included 88 TKAs (44 kinematically aligned using patient-specific guides and 44 mechanically aligned using conventional instrumentation), performed from 2008 to 2009. After institutional review board approval, the health records of the original 88 patients were queried. Revisions, reoperations, and complications were recorded. There were 26 patients who died, leaving 62 patients for follow-up. Of these, 48 patients (77%) were successfully contacted via phone. Reoperations and complications were documented. Furthermore, a battery of patient-reported outcome measures (PROMs) (including Western Ontario and McMaster University Index, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score Junior, Forgotten Joint Score, Modified-Single Assessment Numerical Evaluation, and patient satisfaction) were obtained., Results: Of the original 88 patients in the study, 15 patients had at least one reoperation (17%) and 5 patients had undergone complete revision surgery (6%). There was no difference between the 2 alignment methods for major and minor reoperations (P = .66). The kinematically aligned total knees self-reported a nonstatistically significant (P = .16) improved satisfaction (96% versus 82%), but no difference in other PROMs compared to mechanically aligned TKAs., Conclusion: Kinematically aligned TKA demonstrates excellent mean 13-year results, comparable to mechanically aligned TKA with similar reoperations, complications, and PROMs., (Published by Elsevier Inc.)

Background: The development of Achilles tendon treatment modalities has been rapid, and it is increasingly difficult for clinicians to stay up to date with the most influential studies in this field. In order to fully understand the current state of the literature regarding Achilles tendon injury, it is invaluable to be familiar with the foundational articles and studies upon which the field is built., Purpose: To objectively determine the 50 most frequently cited studies in Achilles tendon pathology and to conduct a bibliometric analysis., Study Design: Cross-sectional study., Methods: The Clarivate Analytics Web of Knowledge database was used to gather data and metrics of Achilles tendon research. The 50 most cited articles were selected for analysis from an initial 17,244 identified articles. The information extracted for each article included author name, publication year, country of origin, journal name, study type, and level of evidence., Results: For these 50 studies, the total number of citations was calculated to be 13,159, with a mean of 263.2 citations per paper. The most cited article collected 657 citations. The publication dates of the 50 studies included in this analysis spanned 41 years (1972-2013). The largest number of articles were published by Swedish authors (n = 14); however, many other countries were represented, including Canada and Finland (n = 6 articles each). The most prevalent study designs were cohort studies (n = 13) with level 4 evidence studies being the most common (n = 14)., Conclusion: Among the 50 most influential articles in Achilles tendon pathology, the study designs most commonly used were cohort studies and review articles. Sweden was the country of origin for the most studies included on this list, which reflects this country's interest and commitment to researching Achilles tendon injuries and treatments., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.A.P. has received education payments from Arthrex and ImpactOrtho. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Study Design: Retrospective comparative analysis of prospective cohort., Objective: To determine whether sacroiliac (SI) screw fixation ipsilateral to hand dominance compared to bilateral fixation impacts personal hygiene (wiping) after toileting., Methods: Inclusion criteria were adult spinal deformity (ASD) patients with long arthrodesis (≥T12-pelvis) who had undergone primary unilateral or bilateral SI fixation with a minimum of 2-years-follow-up., Results: 117 consecutive patients were included and separated into 2 groups: bilateral SI fixation (BL, n = 61) and unilateral SI fixation (UNI, n = 56), with no difference in age. Of UNI patients, 10.7% (6) performed personal hygiene with a different hand after surgery, compared to 6.6% (4) of patients who received BL fixation ( P = 0.422). All UNI patients who switched hands were right-hand dominant, and 5/6 received right-sided fixation. There was no statistical difference found between number of levels fused (<8, 9-11, or >11 levels) and changes in personal hygiene habits. Over a third of patients from both groups had difficulty performing personal hygiene after fusion (UNI = 39.3% BL = 36.1%, P = 0.719)., Conclusion: SI screws increase the difficulty of performing personal hygiene; yet, the side of unilateral screws does not significantly change personal hygiene habits when compared to bilateral screw placement. Moreover, the length of the construct does not have a significant impact on ability to perform personal hygiene, cause changes in habits, or require the assistance of another individual. However, among our sample of individuals, bilateral fixation did result in a higher rate of revision instrumentation.

Purpose: To compare the 5-year clinical and functional outcomes of the soft-tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft., Methods: A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft-tissue QT or double-tendon HT autograft with at least 5 years of follow-up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications., Results: A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2-years' postoperatively. At 5 years' postoperatively, the QT group demonstrated significantly greater IKDC (P = .018) and Lysholm (P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years' postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications., Conclusions: Although the QT autograft demonstrated increased patient-reported outcome scores when compared with the HT at 5 years' postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years' postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid-term follow-up., Level of Evidence: III, retrospective comparison study., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The incidence of orthopedic disorders amongst patients with Prader-Willi Syndrome (PWS) is high when compared to the general pediatric population. The purpose of this retrospective study was to define the most commonly performed orthopedic procedures in pediatric patients with PWS and to characterize the peri-operative outcomes of these patients., Methods: The Kids Inpatient Database (KID) was queried to collect data and identify all pediatric patients with PWS who underwent orthopedic procedures from 2001 to 2012. A total of 3684 patients with PWS were identified, 334 of who underwent an orthopedic procedure. Population demographics, comorbidities, and specific procedures undergone were defined. The incidences of postoperative complications and length of associated hospital stay were additionally evaluated., Results: Mean age of patients in this sample was 10.33 years (SD 4.5). The most common comorbidities included obesity (18.1%), chronic pulmonary disease (14.1%), hypothyroidism (5.1%), hypertension (5.1%), and uncomplicated diabetes (4%). Common procedures were spinal fusion (165/334, 49%) and lower extremity procedures (50/334, 15%). Complications included acute blood loss anemia, device related complications, pneumonia, sepsis, and urinary tract infections. The overall complication rate was 35.6%. Average hospital lengths of stay for patients undergoing spinal fusion was 6.68 days (SD 4.13), lower extremity orthopedic procedure was 5.65 days (SD 7.4), and all other orthopedic procedures was 7.74 days (SD 16.3)., Conclusions: Orthopedic disorders are common in patients with PWS. Consequently, spinal fusions and lower extremity procedures are commonly performed in this patient population. Associated comorbid conditions may negatively impact surgical outcomes in these patients. This information should prove useful in the peri-operative management of patients with PWS undergoing orthopedic surgery and for shared decision making with families., Competing Interests: Declaration of competing interest All authors have Nothing to disclose., (Copyright © 2021 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Purpose: To investigate the characteristics of shoulder and elbow fellowship directors (FDs)., Methods: FDs for shoulder and elbow fellowship programs in the United States were identified. Demographic, educational, and professional background data were collected from available curricula vitarum, institutional biographies, and the Scopus database. Data collected included age, sex, race/ethnicity, training locations, graduation years, advanced degrees, current institutional information, and personal research H-index., Results: Thirty current orthopaedic shoulder and elbow FDs were identified. The mean Scopus H-index was 25.5. The mean age of FDs was 52.1 years. In total, 29 FDs (96.7%) were male and 1 (3.3%) was female. In addition, 25 of the 30 (83.3%) were White (83.3%), 4 were Asian, and 1 (3.3%) was Hispanic. Two (6.7%) had a military affiliation. Mean time from fellowship training graduation to FD appointment was 13.5 years. Mean number of years as FD was 6.1 years, whereas the number of years tenure with an FD-affiliated institution was 13.0 years. Mean calendar years for completion of orthopaedic residency training and fellowship training were 1998 and 2000, respectively. The residencies that produced the most future FDs were Hospital of the University of Pennsylvania (n = 2) and University of Nebraska Medical Center/Creighton University Health Foundation (n = 2). The fellowship that produced the most future FDs was Columbia University (n = 6). Moderate correlation was found between age and Scopus H-index (r = 0.48; P  = .04) and years as FD and Scopus H-index (r = 0.42; P  = .03)., Conclusions: Women and minorities are under-represented in leadership positions in shoulder and elbow surgery. Shoulder and elbow FDs have the highest H-index of any subspecialty reported in the orthopaedic literature. Research productivity is an important qualification when considering the characteristics of shoulder and elbow FDs., Clinical Relevance: Fellowship directors can have a profound influence on current and future orthopaedic surgeons. It is important to identify the traits that characterize current fellowship directors to have a better understanding of who we choose as leaders in our field., (© 2022 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.)

Background: The purpose of this analysis was to assess the public interest in total hip arthroplasty (THA) based on approach by analyzing Google Trends online search volume trends between 2007 and 2021., Methods: Data were obtained by querying the Google Trends online search tool for key terms and phrases relating to anterior, posterior, lateral, and minimally invasive approaches to THA. Data from January 2007 to December 2021 were utilized. Relative search volume (RSV) was generated for each THA approach group based on historical search volume trends in the United States., Results: Over the 15-year period, Google Trends Search Data demonstrated a statistically significant increase ( P < .001) in the RSV for all 4 major hip arthroplasty approaches. The growth in public interest for anterior hip arthroplasty was significantly greater than the growth for posterior ( P  = .02) and minimally invasive hip arthroplasty ( P  = .02). The difference in RSV growth between lateral and anterior approaches was not significant ( P  = .88). The average RSV for anterior hip arthroplasty was 59.0, which was significantly greater than the average RSV of all other groups., Conclusions: The anterior approach to hip arthroplasty has demonstrated a consistent and statistically significant increase in RSV over the past 15 years that has outpaced the increases observed in the posterior and minimally invasive approaches. Despite the increase in public awareness and interest for anterior approach hip arthroplasty, it is yet to demonstrate any long-term clinical benefits over other approaches., (© 2022 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.)

Background: Bibliometric citation analyses have been widely used in medicine to help researchers gain foundational knowledge about a topic and identify subtopics of popular interest for further investigations. There is a lack of similar research in collegiate athletics., Purpose: To identify the 100 most-cited research publications related to collegiate athletics., Study Design: Cross-sectional study., Methods: The Clarivate Analytics Web of Knowledge database was used to generate a list of articles relating to collegiate athletics on January 24, 2022. Articles were filtered by the total number of citations, and the 100 most-cited articles were selected. For each article, we identified and analyzed the following: author name, publication year, country of origin, journal name, article type, main research topic area, competitive level, sex of study population, and level of evidence., Results: Of the top 100 most-cited articles, 63 were related to medicine. In total, 96% of articles were published in the United States, and 80% were published in the year 2000 or later. Of the top 100 articles, 85 were observational; only 5 were experimental. The sport most represented was soccer, followed by football, baseball, and basketball. Of the top 100 articles, 21 were published in a single journal, the American Journal of Sports Medicine. Ten authors published ≥5 of the top 100 most-cited studies., Conclusion: The majority of top 100 articles were published in the United States after 1999 and primarily focused on medicine-related topics. Soccer was studied by more articles than football, baseball, and basketball. An author's prestige may have influenced the likelihood of citation. The top 100 most-cited studies provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions to the literature on collegiate athletics., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.C. has received consulting fees from Arthrex, Trice Medical, and Zimmer Biomet and speaking fees from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Introduction: The purpose of this study was to determine the objective characteristics of orthopaedic musculoskeletal oncology fellowship directors (FDs) by concentrating on the demographics, academic background, institutional history, research experience, and professional affiliations of these leaders., Methods: Data were collected for each FD through institutional biographies or publicly available curriculum vitae. The data collected for each FD included demographic, professional, and research information., Results: Of the 19 FDs, 15 (78.9%) were male, and 4 (21.1%) were female. The mean age for all FDs was 49.2 ± 9.1 years. Most FDs were White (n = 16; 84.2%). The mean Scopus H-index, total number of citations, and total number of publications among all 19 FDs were 21.6 ± 13.8, 2,290.6 ± 2,709.0, and 84.0 ± 54.7, respectively. The mean number of years serving in the FD role was 7.1 ± 9.1 years, and the mean number of years that the FD was employed at his/her current institution was 11.1 ± 8.1 years., Conclusion: This study shows that orthopaedic musculoskeletal oncology FDs were mainly White (84.2%), male (78.9%), and in their late 40s; have filled their role as FD for an average of 7.1 years; and are very productive in research., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Purpose: The purpose of this study is to examine the effects of scribe use on physicians, nurses, and patients in an orthopaedic sports medicine clinic., Methods: Surveys containing validated outcome measures relating to physician well-being and workplace satisfaction, among other variables, were used to assess the influence of medical scribes on clinic function. These surveys were collected for 8 months from all patients, nurses, and orthopaedic surgeons working in one orthopaedic sports medicine clinic. Time during a half-day clinic (i.e., 20 or more patients) was documented by surgeons after the last patient was seen., Results: The average time spent per half day of clinic was 104 minutes on nonscribe days and 25 minutes on scribe days. Additionally, the time spent documenting encounters per half day of clinic was 87 minutes on average without scribes and 26 minutes on average with scribes. The average surgeon single assessment numeric evaluation (SANE) score was 48.1 without scribes, and 89.3 with scribes. The overall assessment of the clinic by nurses was 73.4 out of 100 on average without scribes and 87.7 out of 100 on average with scribes. Patients did not report a significant change in rating of overall experience (4.7/5.0 with scribes and 4.8/5.0 without scribes, ( P  = .27) or wait time between scheduled appointment time and surgeon arrival (15.1 minutes with scribes and 18.1 minutes without scribes; P  = .12)., Conclusions: We found the use of scribes in a high-volume orthopaedic sports medicine clinic to have a favorable impact on physicians, nurses, and trainees. The use of a scribe also significantly reduced the time required by surgeons for documentation during clinic and at the end of each clinic day. Patients also reported no significant difference in patient clinic experience scores., Clinical Relevance: Orthopaedic surgeons spend a substantial amount of time on paperwork. The results of this study could provide information on whether the use of a scribe helps to reduce administrative burden on orthopedic surgeons., (© 2022 The Authors.)

Purpose: To use the National Collegiate Athletic Association Injury Surveillance Program (NCAA-ISP) from the 2009-2010 through the 2014-2015 seasons to report lumbar spine injury rates, characteristics, and time lost from sport in soccer players., Methods: Characteristics of lumbar spine injuries by season, competition/practice, and time lost from sport were determined using the NCAA-ISP database. Rates of injury were calculated as the number of injuries divided by the number of athlete exposures (AEs). AEs are any athlete participation in a competition or practice. Incidence rate ratios (IRRs) were calculated to compare rates between event types and time of season. Injury proportion ratios (IPRs) were used to evaluate differences in injury rates between men and women., Results: The NCAA-ISP estimated 4,464 LSIs over 5 years. The rate of LSI in men was 2.1/10,000 AEs and 3.0/10,000 AEs in women. Women were 1.43 times more likely to suffer an LSI compared to men. Women were 2.15 times as likely to suffer an LSI in competition compared to in practice while men were 1.10 times as likely. Women were 2.15 times as likely to be injured in the preseason compared to the regular season, while men were 3.76 times as likely. Non-contact injuries were the most common cause of lumbar spine injuries (LSIs) in men (35%); however, contact injuries were more common in women (33%). Most athletes both male (57%) and female (59%) returned to play within 24 hours., Conclusion: This study provides information on the characteristics of LSIs in NCAA soccer. The overall injury rate to the lumbar spine is relatively low. Injury rates are highest in the preseason and in competition. Women suffer from more recurrent LSI's than men, and men acquired more injuries through non-contact mechanisms. More than one-half of athletes returned to sport within 24 hours., (© 2022 The Authors.)

Purpose: To examine and analyze Medicare reimbursement rates from 2000 to 2020 for orthopaedic foot and ankle procedures., Methods: The 20 most used orthopaedic foot and ankle surgical procedures were gathered from the Centers for Medicare & Medicaid Services website using the Medicare Provider Utilization and Payment Data Public Use File 2017. The reimbursement data for each code were gathered from The Physician Fee Schedule Look-Up Tool from Centers for Medicare & Medicaid Services. The reimbursement values were adjusted for inflation to 2020 U.S. dollars using the consumer price index., Results: The average inflation-adjusted reimbursement for included procedures decreased by 30% from 2000 to 2020. The greatest mean decreases were observed for "correction of hallux valgus" (-47%) and "partial excision of foot bone" (-41%). The procedures with the smallest mean decreases were observed in "treatment of "Amputation of toe" (-19%) and "closed treatment of metatarsal fracture" (-7%)., Conclusions: From 2000 to 2020, Inflation-adjusted Medicare reimbursement for foot and ankle surgery decreased by 30%., Level of Evidence: IV; economic analysis., (© 2021 The Authors.)

Objective: Although both neurosurgeons and orthopedic surgeons specialize in spinal care, it is not clear how this increased demand for spine surgeons has affected these fields. In this study, we aim to characterize the total number, geographic distribution, and procedural rate of laminectomies of spine surgeons by their primary specialty from 2012 to 2017., Methods: Neurosurgical and orthopedic data from 2012 to 2017 were obtained from the Medicare Provider Utilization Database. The databases were filtered by the primary specialty to include "Neurosurgeons" and "Orthopedic surgery." To select specifically for spine surgeons, the 203 Healthcare Common Procedure Coding System codes relating to spinal procedures were chosen as additional filters., Results: Between 2012 and 2017, the total number of spine surgeons in the United States increased by 9.6% from 3,861 to 4,241 total surgeons. The South experienced the largest percentage increase in spine surgeons from 1,584 surgeons in 2012 to 1,769 in 2017 (11.7%). Over this 5-year span, neurosurgeons performed a greater share of both cervical and lumbar laminectomies, but orthopedic spine surgeons saw a greater increase in procedural growth (+87.2% cervical and +16.7% lumbar)., Conclusions: There is relatively slow growth in the workforce of spinal surgery, with orthopedic spine specialists outpacing the growth seen in neurosurgical spine. This growth is seen at different rates across different regions in the U.S., with the South experiencing the highest rate of growth. Finally, although neurologic surgery performs more laminectomies in both the lumbar and cervical region, orthopedic surgeons are quickly increasing their proportion of performed procedures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: In patients with femoroacetabular impingement, preoperative diagnostic injections are commonly used to establish a diagnosis of intra-articular pathology. In some cases, intra-articular steroid injections are also used for therapeutic purposes., Purpose/hypothesis: The purpose of this study was to determine if a positive response to intra-articular steroid injection was predictive of superior outcomes after hip arthroscopy to determine if the response to intra-articular steroid injection was predictive of outcomes after hip arthroscopy. It was hypothesized that a positive response to a preoperative hip injection would be predictive of improved short- to midterm outcomes after hip arthroscopy., Study Design: Cohort study; Level of evidence, 3., Methods: This was a retrospective study of 208 patients who elected to have ultrasound-guided intra-articular steroid injection before they underwent hip arthroscopy between January 2016 and December 2016. Patients were divided into 2 groups: those who showed improvement in pain after the injection (steroid responder group) and those who showed no response (nonresponder group). The authors compared the preoperative and 2-year postoperative patient-reported outcomes (modified Harris Hip Score [mHHS] and Hip Outcome Score-Activities of Daily Living [HOS-ADL]) and radiographic findings between groups. Clinical endpoints, including rates of revision and conversion to total hip arthroplasty, were also reviewed., Results: There were 88 patients in the nonresponder group and 120 patients in the responder group, with no significant between-group differences in preoperative descriptive variables. The responder group had significantly higher 2-year mHHS and HOS-ADL, pre- to postoperative change in mHHS and HOS-ADL, percentage of patients achieving the patient acceptable symptomatic state (PASS) on the mHHS, and percentage of patients reaching the minimum clinically important difference and the PASS on the HOS-ADL. There was no difference in Tönnis grade, acetabular labrum articular disruption grade, revision rate, or conversion to total hip arthroplasty between the 2 groups., Conclusion: The response to preoperative intra-articular injection did aid in predicting 2-year patient-reported outcomes of hip arthroscopy for femoroacetabular impingement. Overall, the result of a preoperative intra-articular injection can be a helpful clinical tool for surgical decision-making and counseling patients on expected outcomes after hip arthroscopy., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.D.H., J.L.M., and K.A.P. have received education payments from Arthrex. K.J.E. has received education payments from Arthrex and consulting fees from Arthrex, Desert Mountain Medical, Smith & Nephew, and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained from Mayo Clinic Arizona (study No. 1251075)., (© The Author(s) 2021.)

Background: Although lower back injuries (LBIs) are common among National Collegiate Athletic Association (NCAA) female volleyball athletes, their incidence and etiology has not been well-defined., Purpose: To describe the epidemiology of LBIs in collegiate female volleyball athletes over a 5-year period from the academic years 2009 to 2010 and 2013 to 2014., Study Design: Descriptive epidemiology study., Methods: The incidence and characteristics of spine injuries were identified utilizing the NCAA Injury Surveillance Program database. Rates of injury were calculated as the number of injuries by the total number of athlete-exposures (AEs). AEs were defined as any student participation in any single NCAA-sanctioned practice or competition. The injury rate was computed as the number of injuries per the total number of AEs and reported as a ration of injuries per 10,000 exposures. The ratio was then reported as overall number as well as stratified for event, time of season, and athletic NCAA division. Incidence rate ratios were then calculated to compare rates between event type. Results with 95% CIs that did not include 1.0 were considered statistically significant., Results: An estimated 3384 LBIs occurred in NCAA female volleyball players during this 5-year time frame. These LBIs occurred at a rate of 4.89 injuries per 10,000 AEs. LBIs were 2.76 times more likely in preseason when compared with regular season. More injuries occurred in practice (85%) when compared with competition (15%). The outside hitter and middle blocker were the most commonly position to sustain an LBI. Almost 70% of injuries were new injuries, and another 29% were recurrent injuries. The most common mechanism of injury was equally split between contact (50.4%) and overuse (45.5%) injuries, whereas the remaining mechanisms of injury were secondary for unknown reasons (4.14%). Most players returned to play within 24 hours (72.3%) followed by 1 to 6 days (16.4%), and finally 7 to 12 days (11.3%). No patient required surgical intervention., Conclusion: The rate of LBIs was high (4.89/10,000 AEs) and injuries commonly recurred (29.2%). Most injuries were new, with most athletes returning to play with 24 hours., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.L.M. has received education payments from Arthrex. A.C. has received consulting fees from Arthrex, Zimmer Biomet, and Trice Medical and speaking fees from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Background: While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty., Methods: A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia., Results: Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P < .008), increased rate of 30-day readmission (3.5% vs 1.1%, P = .036), increased 30-day reoperation (2.6% vs 0.4%, P = .007), extended length of stay (64% vs 49.9%, P = .004), wound complication (1.75% vs 0.11%, P = .002), and surgical site infection (2.6% vs 0.6%, P = .017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P = .023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P = .033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P = .066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P = .71)., Conclusion: This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia., Level of Evidence: Level III, retrospective comparative study.

Purpose: To describe and compare the epidemiology of lumbar spine injuries (LSIs) in women's and men's ice hockey during the 2009-2010 to 2013-2014 academic years and to investigate sex-specific differences, using data from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) database., Methods: The incidence and characteristics of LSIs were identified utilizing the NCAA ISP. Rates of injury were calculated as number of injuries divided by total number of athlete exposures (AEs). AEs were defined as any student participation in one NCAA-sanctioned practice or competition. Incidence rate ratios (IRRs) were calculated to compare rates of injury between season, event type, mechanism, injury recurrence, and time lost from sport, and injury proportion ratios (IPRs) were calculated to examine the differences in injury rates between men and women., Results: There were a total of 165 LSIs from an average of 10 and 19 women's and men's teams, respectively, calculated to 1,254 LSIs nationally. Women were 2.48 times more likely to suffer a noncontact injury than men (95% CI: 1.33-4.61), whereas men were more likely than women to suffer contact LSIs (IPR: .51 [95% CI: .28-.92]). In Divisions II and III, women were 6.64 (95% CI: 4.14-10.64) and 1.28 (95% CI: 1.12-1.46) times more likely to suffer LSIs than men, respectively., Conclusions: Women and men were similarly likely to suffer an LSI, but sex-specific differences existed in a mechanism of injury and likelihood of injury within NCAA Divisions., (© 2021 The Authors.)

Purpose: To determine the objective characteristics of orthopaedic foot and ankle fellowship directors (FDs) by concentrating on the demographic characteristics, academic background, institutional history, research experience, and professional affiliations of these leaders., Methods: Data for each FD were collected by searching institutional biographies, personal websites, or publicly available curricula vitae. Data collection included the following variables: age, sex, race/ethnicity, previous training institutions, residency and fellowship graduation years, advanced degrees, military affiliation, institutional loyalty, year hired, FD career timeline, total number of publications, total number of citations, and h -index., Results: Of the 47 FDs, 44 (93.6%) were men and 3 (6.4%) were women. The mean age was 50.8 ± 9.4 years. Most orthopaedic foot and ankle FDs were white (n = 42, 89.4%), followed by Asian (n = 4, 8.5%) and black or African American (n = 1, 2.1%). The mean Scopus h -index, total number of publications, and total number of citations for all foot and ankle FDs were 13.3 ± 9.5, 47.5 ± 45.8, and 898.1 ± 1,040.3, respectively. Among all foot and ankle FDs, the mean tenure in the FD position was 5.8 ± 4.6 years., Conclusions: Orthopaedic foot and ankle FDs are primarily white men in their 50s, with minimal female and minority representations. These FDs are distinguished by their high level of research productivity. Additionally, orthopaedic foot and ankle training backgrounds seem to play an important role, given that most of the appointed FDs trained in only a few select programs., Clinical Relevance: This study outlines some of the most important characteristics among foot and ankle FDs and identifies important disparities within this population of leaders that may have detrimental effects on the field., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Background: Spine injuries are common in collegiate wrestlers and can lead to reinjury, persistent pain, and time lost from participation., Purpose: To describe the epidemiology of spine injuries in National Collegiate Athletic Association (NCAA) wrestlers between academic years 2009 to 2010 and 2013 to 2014., Study Design: Descriptive epidemiology study., Methods: The incidence and characteristics of spine injuries were identified utilizing the NCAA-Injury Surveillance Program database. Spine injuries were assessed for injury type, injury mechanism, time of season, event type, recurrence, participation restriction, and time lost from participation. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). Injury rate ratios (IRRs) were calculated for event type and time of season, and results with 95% confidence intervals that did not include 1.0 were considered statistically significant., Results: There were an estimated 2040 spine injuries reported in the database over the 4-year period, resulting in an injury rate of 0.71 per 1000 AEs.  Spine injuries were over twice as likely to occur in competitions as in practices (IRR, 2.02; 95% confidence interval, 1.10-3.69). More injuries occurred in both the preseason (0.94 per 1000 AEs) and the postseason (1.12 per 1000 AEs) compared with the regular season (0.55 per 1000 AEs). Contact injuries (42%) were the most common mechanism of injury, and brachial plexus injury (20%) was the most common diagnosis. Only 1.3% of injuries required surgery, and athletes most commonly returned to sport within 24 hours (33%) or within 6 days (25%)., Conclusion: This investigation found an overall injury rate of 0.71 per 1000 AEs in wrestling athletes between academic years 2009 to 2010 and 2013 to 2014. The majority of these injuries were new, and athletes most commonly returned to sport within 24 hours. The injury rate was highest in competition, and both the preseason and the postseason showed a higher injury rate than that in season. Efforts to improve injury prevention and management should be informed by these findings., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.S.M. has received grant support from Stryker and education payments from Goode Surgical. J.D.H. has received education payments from Arthrex. J.L.M. has received education payments from Arthrex. A.C. has received speaking fees from Arthrex and consulting fees from Arthrex, Zimmer-Biomet, and Trice Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Purpose: To determine the objective characteristics of fellowship directors (FDs) in orthopaedic sports medicine by focusing on the demographics, academic background, institutional history, research experience, and professional affiliations of FDs in this field., Methods: Data was collected for each FD via institutional biographies or publicly available curriculum vitae (CV). The data collected for each FD included age, gender, race/ethnicity, previous training institutions, residency and fellowship graduation years, additional advanced degrees, military affiliation, institutional loyalty, year hired by current institution, career timeline, Scopus H-index, number of publications, and total number of citations., Results: Of the 88 FDs, 87 (98.9%) were male and 1 (1.1%) was female. The mean age for all FDs was 54.7 years (± 9.1 standard deviation). The majority of FDs were White (n = 80; 90.9%). The mean Scopus H-index, total number of publications, and total number of citations were 22.5 ± 16.6, 90.0 ± 91.6, and 2773.9 ± 3962.9, respectively. On average, it took 9.5 ± 7.3 years from fellowship graduation until FD appointment. Additionally, the mean number of years of employment or affiliation with the current institution was 17.2 ± 9.4, and the mean number of years in an FD role was 10.9 ± 9.3., Conclusion: Orthopaedic sports medicine fellowship directors are largely distinguished by their high level of research productivity and accomplishment. Additionally, orthopaedic training pedigree seems to play a role in FD role attainment, with a handful of orthopaedic residency and sports medicine fellowship programs producing a large percentage of current FDs. Finally, FDs are overwhelmingly white males with little female or minority representation., Clinical Relevance: This study outlines some of the most important characteristics among orthopaedic sports medicine fellowship directors and identifies racial and gender disparities within this population of leaders that may have detrimental effects on the field as a whole., (© 2021 Published by Elsevier on behalf of the Arthroscopy Association of North America.)

The National Football League Scouting Combine is an annual event held to evaluate football players. The results of the combine are used to identify talent and player potential. Our study aims to examine the relationship between combine drill performance (e.g., speed, power, agility, explosiveness) and career longevity. We performed a retrospective review of The National Football League combine test results for all defensive players from 2005-2015 to determine the association of each player's combine test results with career longevity. The position that had the most significant associations for 1-year status was linebackers, with weight, 10-yard dash, 20-yard dash, 40-yard dash, broad jump, 3-cone drill, and shuttle being significantly associated with 1-year roster status. The position that had the most significant associations for 5-year status was cornerbacks, with weight, 10-yard dash, 20-yard dash, 40-yard dash, 3-cone drill, and shuttle being significantly associated with 1-year roster status. The least number of significant associations was found for safeties, with no drill being associated with 1-year roster status and only height and shuttle time significantly associated with 5-year career longevity. Our study demonstrates the utility of the combine results to help estimate the career longevity of NFL defensive players., Competing Interests: Conflict of Interest AC is a consultant and speaker's bureau member for Arthex. AC is a consultant for Zimmer Biomet. AC received an educational grant from Stryker. None of these present conflicts of interest for this work., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: The purpose of this study was to evaluate trends in annual arthroplasty volume among the Medicare population, as well as assess true Medicare reimbursement to physicians for all hip and knee arthroplasty procedures billed to Medicare since year 2000., Methods: The publicly available Medicare Part B National Summary Data File from years 2000 to 2019 was utilized. Collected data included true physician reimbursements for all primary total hip and knee, unicompartmental knee, and revision hip/knee arthroplasty procedures from 2000 to 2019. Monetary data was adjusted for inflation to year 2019 dollars. Change was assessed and compared by procedure type., Results: From 2000 to 2019, physicians billed Medicare Fee-for-service for 8,363,821 hip and knee arthroplasty procedures. During this time, the annual number of included arthroplasty procedures billed to Medicare increased by 100%. From 2000 to 2019 across all included procedures, the mean physician reimbursement after adjusting for inflation decreased by -$729.82 (-38.9%) per procedure. This varied by procedure type. Unicompartmental knee arthroplasty was the only procedure to experience an increased mean reimbursement when adjusting for inflation, increasing by $241.40 (+16.6%) per procedure from 2000 to 2019., Conclusion: This study demonstrates decreasing Medicare reimbursement to physicians within hip and knee arthroplasty from 2000 to 2019 when adjusting for inflation. This study is important for informing the potential development of more equitable payment models and maintaining access for arthroplasty care moving forward., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Rotator cuff tears (RCTs) remain a significant source of pain and disability in the shoulder. Although much work has been done in the study of the effects of rotator cuff tears on glenohumeral joint motion, much less has been done in understanding the effect of rotator cuff tearing on scapular motion or activation. It remains unknown whether scapular dyskinesis is causative or adaptive. The purpose of this study was to systematically review the literature to determine the relationship between rotator cuff tear presence and size on scapular motion, and if rotator cuff repair restored normal motion., Methods: A systematic review using PRISMA guidelines was accomplished to include all studies with biomechanical or clinical outcomes of scapular motion in the presence of RCTs. Studies were excluded if they involved shoulder arthroplasty, rotator cuff tendinopathy, or shoulder impingement without an RCT. From 530 initial references, 42 manuscripts were selected for full review and cross referenced. All studies were evaluated for inclusion and exclusion criteria., Results: Sixteen studies including 335 rotator cuff tears were included in the final review. There were several findings of interest in the literature. First, although all studies demonstrated scapular dyskinesis, they did not report a consistent pattern of motion in the presence of an RCT. In general, scapular posterior tilt was decreased, and scapular upward rotation was increased, especially in large tears, but the literature was unclear as to whether this was a result of the RCT or an adaptive attempt to maintain elevation. Larger RCTs resulted in more pronounced scapular dysfunction, but there was significant variability within studies. Further, dyskinesis was confounded by pain with more abnormal movement in symptomatic vs. asymptomatic RCTs, the latter of which were not different from normal healthy controls. Four studies addressed the effect of RCT on scapular mechanics and found that repair consistently improved it compared to the normal side, but the time to normalization varied between 5 months and 2 years., Conclusion: Scapular motion is abnormal in the presence of an RCT, but the literature is inconsistent regarding a universally affected variable or consistent degree of scapular dysfunction in this setting. Furthermore, it remains unknown which changes are adaptive vs. pathologic. Understanding the relationship between rotator cuff tearing and scapular dyskinesis will require better biomechanical models that consider scapular dyskinesis in their design., (Copyright © 2021. Published by Elsevier Inc.)

Background: Total joint arthroplasty (TJA) has been a recent target of reimbursement reform. As such, the purpose of this study was to evaluate trends in Medicare reimbursement to hospitals for TJA patients from 2011 to 2017., Methods: The Inpatient Utilization and Payment Public Use File was queried for all primary total hip and knee arthroplasty episodes. This file includes all services billed to Medicare via the Inpatient Prospective Payment System. Extracted data included hospital charges and amount paid by Medicare. All data were adjusted for inflation to 2017 US dollars. Multiple linear mixed-model regression analyses were conducted to assess change over time, and geo-modelling was used to represent reimbursement by location., Results: A total of 3,368,924 primary TJA procedures were billed to Medicare by hospitals from 2011 to 2017 and included in the study. The mean inflation-adjusted Medicare payment to hospitals for DRG 469 decreased from $22,783.66 to $19,604.62 per procedure (-$3179.04; -14.0%; P < .001) and decreased from $13,290.79 to $11,771.54 for DRG 470 (-$1519.25; -11.4%, P = .011) from 2011 to 2017. Meanwhile, the mean charge submitted by hospitals increased by $6483.39 and $5115.60 for DRGs 469 and 470, respectively (+7.4% for 469, +9.3% for 470; P < .001). Medicare reimbursement to hospitals varied by state., Conclusion: During the study period, the mean Medicare reimbursement to hospitals decreased for TJA from 2011 to 2017. Meanwhile, the average charge submitted by hospitals increased. As alternative payment models continue to undergo evaluation and development, these data are important for the advancement of more agreeable reimbursement models in arthroplasty care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: The aim of this study was to evaluate the safety of two-level cervical disc replacement (CDR) in the outpatient setting., Summary of Background Data: Despite growing interest in CDR, limited data exist evaluating the safety of two-level CDR in the outpatient setting., Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried for all two-level anterior cervical discectomy and fusion (ACDF) and CDR procedures between 2015 and 2018. Demographics, comorbidities, and 30-day postoperative complication rates of outpatient two-level CDR were compared to those of inpatient two-level CDR and outpatient two-level ACDF. Radiographic data are not available in the NSQIP., Results: A total of 403 outpatient CDRs were compared to 408 inpatient CDRs and 4134 outpatient ACDFs. Outpatient CDR patients were older and more likely to have pulmonary comorbidities compared to inpatient CDR (P < 0.03). Outpatient CDR patients were less likely to have an American Society of Anesthesiologists class ≥2 and have hypertension compared to outpatient ACDF patients (P < 0.0001). Outpatient CDR had a lower 30-day readmission rate (0.5% vs. 2.5%, P = 0.02) and lower 30-day reoperation rate (0% vs. 1%, P = 0.047) compared to inpatient CDR. Outpatient CDR had a lower readmission rate (0.5% vs. 2.1%, P = 0.03) compared to outpatient ACDF, but there was no difference in reoperation rates between the two procedures (0% vs. 0.8%, P = 0.07). Outpatient CDR had an overall complication rate of 0.2%, inpatient CDR had a complication rate of 0.9%, and outpatient ACDF had a complication rate of 1.3%. These differences were not significant., Conclusion: To our knowledge, this is the largest multicenter study examining the safety of two-level outpatient CDR procedures. Outpatient two-level CDR was associated with similarly safe outcomes when compared to inpatient two-level CDR and outpatient two-level ACDF. This suggests that two-level CDR can be performed safely in the outpatient setting.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To discuss the surgical outcomes of patients identified to have the wave sign without an accompanying labral tear treated with and without stabilization of the chondrolabral junction in conjunction with femoral osteoplasty., Methods: A retrospective study was performed in patients with cartilage delamination (wave sign) treated with femoral osteoplasty alone (FO group) or femoral osteoplasty with chondrolabral stabilization (CLS group). Patient-reported outcomes including the modified Harris Hip Score, Hip Outcome Score (HOS)-Activities of Daily Living, and HOS-Sports-Specific Subscale were obtained at a minimum of 2 years postoperatively. Other outcomes included rates of revision hip arthroscopy and conversion to hip arthroplasty., Results: The study consisted of 47 patients in the FO group and 38 in the CLS group. Both groups showed significant increases in all patient-reported outcomes over the study period compared with preoperative values. The final modified Harris Hip Score was 72.8 ± 9.2 in the FO group and 79.9 ± 9.3 in the CLS group (P < .001). The HOS-Activities of Daily Living in the FO and CLS groups was 81.4 ± 10.3 and 87.2 ± 7.5, respectively (P < .001). There was no difference in the HOS-Sports-Specific Subscale between the FO group (74.4 ± 10.3) and the CLS group (78.0 ± 14.6) at final follow-up (P = .198). Revision hip arthroscopy was required in 5 patients in the FO group (13%) and 3 in the CLS group (6.3%). No patient in either group required conversion to hip arthroplasty throughout the study period., Conclusions: Chondrolabral stabilization in conjunction with femoral osteoplasty is an effective treatment in patients with the wave sign without labral tears., Level of Evidence: Level III, retrospective cohort study., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Total shoulder arthroplasty (TSA) has increased in utilization over the past several decades. Anemia is a common preoperative condition among patients undergoing TSA and has been associated with poorer outcomes in other surgical procedures. To the best of our knowledge, no study has analyzed the association between anemia severity and TSA outcomes. Therefore, the purpose of this study is to determine the effects that increasing severity of anemia may have on the postoperative outcomes in patients receiving primary TSA., Methods: A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from the years 2015 to 2018. Current Procedure Terminology code 23472 was used to identify all primary TSA procedures recorded during this time frame. Patients with greater than 38% preoperative hematocrit (HCT) were classified as having normal HCT levels. Patients with HCT values between 33% and 38% were classified as having mild anemia. All patients with less than 33% HCT were classified as having moderate/severe anemia. Patient demographic information, preoperative risk factors, and postoperative outcomes were compared among the 3 cohorts. A multivariate logistic regression including demographic factors and comorbidities was performed to determine whether increasing severity of anemia is independently associated with poorer postoperative outcomes., Results: Of the 15,185 patients included in this study, 11,404 had normal HCT levels, 2962 patients were mildly anemic, and 819 patients had moderate to severe anemia. With increasing severity of anemia, there was an increased average hospital length of stay (1.6 vs. 2.1 vs. 3.0 days, P  < .001), rate of readmissions (2.3% vs. 4.8% vs. 7.0%, P  < .001), and rate of all reoperations (1.1% vs. 1.8% vs. 3.1%, P  < .001). There was a statistically significant increase in both minor (1.9% vs. 2.7% vs. 4.4%, P  < .001) and major (1.2% vs. 2.4% vs. 4.3%, P  < .001) postoperative complication rates as well. Multivariate analysis identified anemia as an independent predictor of readmissions, reoperations, minor complications, and major complications., Conclusion: We found increasing severity of anemia to be associated with progressively worse 30-day postoperative outcomes. This is consistent with the outcomes found for increasing severity of anemia in patients receiving other total joint procedures. Using preoperative HCT levels may be a useful tool for predicting the risk of postoperative complications in patients undergoing TSA. This information could be used to further optimize patient selection for primary TSA.

Arthroscopy in the posterior knee continues to improve as new techniques arise. Traditionally, posterior techniques included posteromedial and posterolateral portals. Although frequently used, these techniques do have some limitations. We propose the use of dual posteromedial portals for complex arthroscopy cases to improve access and instrumentation in the posterior knee. Applications include, but are not limited to, resection of tumors or masses in the posterior knee, meniscal posterior horn repair, ramp lesion repair, repair of posterior cruciate ligament avulsions, and use as accessory portals for arthroscopic posterior cruciate ligament reconstruction. We describe a technique for establishing dual posteromedial portals for complex arthroscopy in the posterior knee, specifically in relation to a case of a posterior knee mass biopsy and resection., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Study Design: Retrospective review., Objectives: (1) Identify the 90-day rate of readmission following revision lumbar fusion, (2) identify independent risk factors associated with increased rates of readmission within 90 days, (3) and identify the hospital costs associated with revision lumbar fusion and subsequent readmission within 90 days., Methods: Utilizing 2014 data from the Nationwide Readmissions Database, patients undergoing elective revision lumbar fusion were identified. With this sample, multivariate logistic regression was utilized to identify independent predictors of readmission within 90 days. An analysis of total hospital costs was also conducted., Results: In 2014, an estimated 14 378 patients underwent elective revision lumbar fusion. The readmission rate at 90 days was 3.1% (n = 446). Diabetes with chronic complications was the only comorbidity found to carry significantly increased odds of readmission. Surgical complications such as deep venous thrombosis, surgical wound disruption, hematoma, and pneumonia (experienced during the index admission) were also independent predictors of readmission. Anterior approaches were associated with increased odds of readmission. The most common related diagnoses on readmission were hardware issues, postoperative infection, and disc herniation. Readmissions were associated with an average of $96 152 in increased hospital costs per patient compared with those not readmitted., Conclusion: Relevant patient comorbidities and surgical complications were associated with increased readmission within 90 days. Readmission within 90 days was associated with significant increases in hospital costs.

Background: Hand and wrist injuries (HWIs) are common in National Collegiate Athletic Association (NCAA) basketball players and can negatively affect performance. There is limited literature available on this topic., Purpose: To open a discussion on prevention strategies and encourage future research on HWIs in basketball athletes., Study Design: Descriptive epidemiology study., Methods: HWIs sustained by male and female NCAA basketball players during the 2009-2010 through 2013-2014 academic years and reported to the NCAA Injury Surveillance Program (NCAA-ISP) database were utilized to characterize the epidemiology thereof. Rates and distributions of HWIs were identified within the context of mechanism of injury, injury recurrence, and time lost from sport., Results: Over the 5-year period, 81 HWIs in women and 171 HWIs in men were identified through the NCAA-ISP database. These were used to estimate 3515 HWIs nationally in women's basketball athletes and 7574 HWIs nationally in men's basketball athletes. The rate of HWIs in women was 4.20 per 10,000 athlete-exposures (AEs) and in men was 7.76 per 10,000 AEs, making men 1.85 times more likely to sustain HWIs compared with women. In men, HWIs were 3.31 times more likely to occur in competition compared with practice, while in women, HWIs were 2.40 times more likely to occur in competition than in practice. Based on position, guards, both men and women, were the most likely to suffer HWIs., Conclusion: HWIs were common in collegiate basketball players. Most injuries were new, and the majority of players were restricted from participation for less than 24 hours. Men were more likely to be injured compared with women, and injuries were most common in the setting of competition for both sexes. The majority of injuries was considered minor and did not extensively limit participation; however, prevention and detection remain important for optimal performance., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.L.S. has received educational support from Arthrex. A.C. has received educational support from Arthrex and Stryker and consulting fees from Arthrex, Cayenne Medical, Trice Medical, and Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

An understanding of knee ligament anatomy and biomechanics is foundational for physicians treating knee injuries, especially the more rare and morbid multiligamentous knee injuries. This chapter examines the roles that the cruciate and collateral anatomy and morphology play in their kinematics. Additionally, the biomechanics of the ACL, PCL, MCL, and LCL are discussed as they have surgical and reconstructive implications.

Background: Hip arthroscopy has been shown to be effective in athletes who have femoral acetabular impingement and labral tearing. The effect of complete capsular closure versus nonclosure on return to play is unknown., Hypothesis: Complete capsular closure after hip arthroscopy would lead to a higher rate and faster return to sports in high-level athletes., Study Design: Cohort study; Level of evidence, 3., Methods: A nonrandomized retrospective review was performed of high school, collegiate, and professional athletes undergoing hip arthroscopy by a single high-volume hip arthroscopic surgeon. Athletes were divided into those undergoing complete capsular closure (CC group) and non-capsular closure (NC group) after hip arthroscopy. Rate and time to return to play were determined between the 2 groups. Patient-reported outcomes including modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL), and Hip Outcome Score Sport-Specific Subscale (HOS-SSS) were obtained at a minimum of 2 years., Results: A total of 111 athletes with a minimum 2-year follow-up were included in the study. There were 62 in the CC group and 49 in the NC group. A higher percentage of athletes in the CC group returned to play compared with that in the NC group (90.3% vs 75.5%, respectively; P = .03). The CC group returned to play at a mean ± SD of 4.7 ± 1.9 months compared with 5.8 ± 2.6 months in the NC group ( P < .001). Patients in the CC group met the minimal clinically important difference for the mHHS, HOS-ADL, and HOS-SSS patient-reported outcomes at higher percentages: mHHS, 98.3% vs 87.7% for CC vs NC, respectively ( P = .02); HOS-ADL, 98.3% vs 87.7% ( P = .02); and HOS-SSS, 96.7% vs 89.7% ( P = .13). The difference between groups was statistically significant for mHHS and HOS-ADL., Conclusion: Complete capsular closure after hip arthroscopy was associated with faster return to play and a higher rate of return compared with that of nonclosure of the capsule in this sample population of high-level athletes. At a minimum 2-year follow-up, complete capsular closure was associated with significantly higher patient-reported outcomes compared with those of nonclosure in athletes who underwent hip arthroscopy.

Purpose: To assess whether labral size is predictive of labral repair failure or shows an association with patient outcomes after hip arthroscopy., Methods: We performed a retrospective chart review of patients who underwent arthroscopic hip labral repair. Labral size was measured in 4 quadrants with an arthroscopic probe. The average size across torn labral segments was assessed for failure as determined by the change in patient-reported outcomes, the rate at which subjects achieved the minimal clinically important difference and patient acceptable symptomatic state, and the need for additional surgery. Outcomes were evaluated for any continuous correlation as well as significant differences between the middle 50% of labral sizes and classes of labral sizes derived from upper and lower quartile and decile ranges. Included hips were those from patients aged between 18 and 55 years with 2-year postoperative follow-up and lateral center-edge angles between 25° and 40°., Results: The study included 571 hips. Labral width did not show a significant difference between hips requiring revision and those not requiring revision (P = .4054). No significant correlation was found between labral width and the change in the International Hip Outcome Tool 12 score (R 2  = 0.05780), modified Harris Hip Score (R 2  = 0.19826), or Nonarthritic Hip Score (R 2  = 0.23543) from preoperatively to 2 years postoperatively. Hips with labral sizes in the upper decile of our cohort showed significantly decreased improvement in the International Hip Outcome Tool 12 score (P = .0287) and Nonarthritic Hip Score (P = .0490) compared with the middle 50% of labral sizes. No statistically significant difference was found in the rate at which the groups achieved the minimal clinically important difference or patient acceptable symptomatic state., Conclusions: Hypertrophic labra in the largest 10th percentile showed lower postoperative outcome scores. However, no detectable clinical benefit was found in terms of patient-perceived clinical difference or acceptable symptomatic state. For most patients, labral size does not appear to significantly alter patient outcomes or the need for arthroplasty., Level of Evidence: Level IV, retrospective case series., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

The ideal solution for the irreparable rotator cuff tear remains in question. A recent innovative technique, superior capsular reconstruction (SCR), has demonstrated promising results with some early clinical outcomes demonstrating statistically notable improvements in active forward flexion and American Shoulder and Elbow Surgeons scores. Multiple biomechanical studies have also demonstrated its ability to reduce superior translation of the humerus after massive rotator cuff tear. Even so, these results are still early and durability of the reconstruction over time needs to be determined. Although more than 15,000 SCRs have been done worldwide, there remains a paucity of outcome data and one must be vigilant to not allow enthusiasm to overtake critical evaluation. The potential mechanisms of action, including tenodesis effect, force coupler, or subacromial spacer, need further elucidation and the ideal indications for this procedure, as well as its technical optimization, and limitations have yet to be fully determined. The purpose of this review is to critically evaluate the biomechanical and clinical literature that has assessed SCR, along with the controversies and considerations encountered with this procedure.

Background: The frequency of incidental findings with computer-assisted total joint arthroplasty (CA TJA) preoperative imaging and their clinical significance are currently unknown., Methods: We reviewed 573 patients who underwent primary CA TJA requiring planning imaging. Incidental findings were defined as reported findings excluding those related to the planned arthroplasty. Secondary outcomes were additional tests or a delay in surgery. Associated charges were obtained from our institution's website. Charge and incidence data were combined with TJA volumes obtained from the 2016 National Inpatient Sample to model costs to the healthcare system., Results: Overall, 262 patients (45.7%) had at least 1 incidental finding, 144 patients (25.1%) had 2, and 65 (11.3%) had 3. The most common finding types were musculoskeletal (MSK, 67.7%), digestive (19.5%), cardiovascular (4.9%), and reproductive (4.7%). Also, 9.3% of patients had at least 1 non-MSK incidental finding. Both MSK and non-MSK incidental findings were more common with total hip arthroplasty compared to total knee arthroplasty (67.9% vs 42.2%, P < .0001, and 15.4% vs 8.3%, P < .05, respectively). Further testing was required in 6 cases (1.0%); 1 case required delay in surgery (0.2%). Using the 2016 volume of TJA procedures and assuming a 10%, 15%, and 25%, utilization rate of image-based CA TJA, the annual cost of additional testing was $2.7 million (95% confidence interval, $1.1-$6.3 million), $4.1 million ($1.6-$9.5 million), and $6.9 million (95% confidence interval, $2.7-$15.8 million), respectively., Conclusion: Incidental findings are relatively common on planning images. Stakeholders should be aware of the hidden costs of incidental findings given the increasing popularity of image-based CA TJA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Isolated patellofemoral arthritis is a common debilitating condition in adults older than 40 years of age. Surgical options such as patellofemoral arthroplasty exist for those who failed to respond to nonoperative treatment. However, early patellofemoral arthroplasty techniques often resulted in poor outcomes due to mal-tracking and malalignment of components. Robotic-assisted surgery recently has been introduced as an alternative to classic patellofemoral arthroplasty, with the potential to improve the anatomical fit and reproducibility of implant positioning. We present the technique for minimally invasive robotic-assisted patellofemoral arthroplasty system., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Background: Hip arthroscopy is a safe and effective mechanism for treating femoroacetabular impingement symptoms in high level athletes. Bilateral symptoms occur in a subset of this population., Purpose: To discuss outcomes of bilateral hip arthroscopy in high-level athletes and compare a standard staged timeline for bilateral hip arthroscopic surgery versus an accelerated timeline., Study Design: Cohort study; Level of evidence, 3., Methods: A retrospective review of all staged bilateral hip arthroscopies was performed on high-level athletes over a 3-year period. Patients were categorized into cohorts based upon when the second procedure was performed (4-6 weeks after the index procedure or >6 weeks after the index procedure). Exclusion criteria included any prior hip surgery, advanced arthritis, previous pelvic or femoral fracture, or inflammatory arthropathy. Demographics, radiographic measurements, operative reports of procedures performed, and patient-reported outcomes (Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport Specific Subscale, modified Harris Hip Score, return to sports, return to same level of play) were compared between groups at 6-month, 1-year, and 2-year intervals, with the Student t test used for continuous data and a chi-square test used for categorical data., Results: 50 patients were identified: 22 in the accelerated surgery (AS) group and 28 in the standard surgery (SS) group. Age and number of collegiate participants were greater in the AS group, whereas the number of high school participants and the time away from sports were higher in the SS group. Preoperative alpha angles were significantly larger among the AS group, but no differences were found in postoperative alpha angles, center edge angles, or Tönnis grades. No significant difference was seen in patient-reported outcomes between the 2 groups at 6-month, 1-year, and 2-year follow-up., Conclusion: Bilateral hip arthroscopy performed 4 to 6 weeks apart is a safe and effective treatment option for athletes with bilateral femoroacetabular impingement and labral tears; the procedures entail a high rate of return to sports, return to the same level of sports, and decreased time lost from sports. This information could be useful for an athlete deciding on whether to proceed with bilateral hip arthroscopy and deciding on the timing for the procedures.

Knowledge and understanding of the complex anatomy and biomechanical function of the native posterior cruciate ligament (PCL) is vitally important when evaluating PCL injury and possible reconstruction. The PCL has important relationships with the anterior cruciate ligament, menisci, tibial spines, ligament of Humphrey, ligament of Wrisberg, and the posterior neurovascular structures. Through various experimental designs, the biomechanical role of the PCL has been elucidated. The PCL has its most well-defined role as a primary restraint/stabilizer to posterior stress and it seems this role is greatest at higher degrees of knee flexion. The natural history of high-grade deficiency leads to increased contact pressures and degeneration of both the medial and patellofemoral compartments. There is still considerable debate regarding whether high-level athletes can return to sport at the same level with conservative treatment of a high-grade PCL tear, and whether greater laxity in the knee correlates with decreased subjective and objective outcomes. Poor surgical outcomes after PCL reconstruction have been attributed to many factors, the most common of which include: additional intra-articular pathology, poor fixation methods, insufficient knowledge of PCL anatomy, improper tunnel placement, and poor surgical candidates.

Background: Superior capsular reconstruction (SCR) has recently been proposed as a surgical solution to the irreparable rotator cuff tear and has gained popularity because of promising early results. Therefore, the purpose of this study is to review the biomechanical and clinical outcomes in shoulders with this condition treated with SCR., Methods: A systematic review was conducted following PRISMA guidelines using PubMed, EMBASE, and Cochrane databases. Studies were included if they reported biomechanical, radiographic, or clinical outcomes data after undergoing SCR in shoulders with irreparable rotator cuff tears. Studies were broken down into 3 categories: cadaveric biomechanical studies, autograft clinical outcome studies, and allograft clinical outcome studies. Biomechanical, radiographic, patient-reported, and functional outcomes data were recorded for each study., Results: Eight cadaveric biomechanical studies, 5 autograft clinical studies, and 4 allograft clinical studies met inclusion criteria. In biomechanical studies, subacromial contact pressure and superior humeral translation were decreased in most tested scenarios. An increase in American Shoulder and Elbow Surgeons (ASES) scores, forward elevation and external rotation values, and acromiohumeral distance (AHD) were found in all autograft clinical studies reporting. Allograft clinical studies reported increases in ASES scores, forward elevation values, and AHD but decreases in visual analog scale scores in all studies reporting., Conclusions: SCR is emerging as a viable surgical option to address the irreparable rotator cuff tear. Biomechanical studies suggest that the humeral head-stabilizing effect of SCR appears to translate into improved clinical outcomes. Future research should focus on further defining the indications, limitations, and optimal technique., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Hip and groin injuries are common in competitive soccer players and have been shown to be significant sources of time loss. There are few studies describing the epidemiology of hip and groin injuries in female National Collegiate Athletic Association (NCAA) soccer players., Purpose: To describe the epidemiology of hip and groin injuries in women's collegiate soccer players., Study Design: Descriptive epidemiology study., Methods: The NCAA Injury Surveillance System/Program (ISS/ISP) was analyzed from 2004 through 2014 for data related to hip and groin injuries in female collegiate soccer players. Injuries and athlete-exposures (AEs) were reported by athletic trainers. Data were stratified by time of season, event type, injury type, treatment outcome, time loss, and player field position., Results: Between 2004 and 2014, there were 439 recorded hip or groin injuries in female soccer players and an overall rate of injury of 0.57 per 1000 AEs. Injuries were 12.0 times more likely to occur during the preseason (4.41/1000 AEs) as opposed to during the regular season (0.37/1000 AEs) (injury rate ratio [IRR], 12.01; 95% confidence interval [CI], 9.92-14.55) or postseason (0.38/1000 AEs) (IRR, 11.55; 95% CI, 7.06-18.91). Rates of injury were similar during the regular season and postseason (IRR, 0.96; 95% CI, 0.59-1.58). Rates of injury were higher during competition (0.69/1000 AEs) than during practice (0.52/1000 AEs) (IRR, 1.33; 95% CI, 1.08-1.63). Most injuries were new (87.5%; n = 384) and unlikely to recur (12.5%; n = 55)., Conclusion: Hip and groin injuries in female NCAA soccer players are uncommon, and fortunately, most players return to play quickly without recurrence. Future prospective studies should evaluate the effectiveness of strength and conditioning programs in preventing these injuries., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.A. has received educational support from Goode Surgical, grant support from Stryker, and hospitality payments from Stryker. J.L.M. has received educational support from Arthrex and Goode Surgical. J.H. has received educational support from Arthrex. K.P. has received educational support from Arthrex. A.C. has received consulting fees from Arthrex, Trice Medical, and Zimmer Biomet; educational support from Arthrex and Stryker; and hospitality payments from Arthrex. D.H. has received consulting fees from Arthrex; grant support from Arthrex; educational support from Arthrex, Goode Surgical, and Smith & Nephew; and hospitality payments from Smith & Nephew and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Study Design: Descriptive epidemiology study., Objective: The purpose of this study was to describe the epidemiology of neck and cervical spine injuries in collegiate athletes over a 5-year period., Summary of Background Data: The incidence and etiology of neck and cervical spine injuries in National Collegiate Athletic Association (NCAA) athletes has not been well defined in recent years., Methods: The incidence and characteristics of neck and cervical spine injuries were identified utilizing the NCAA Injury Surveillance Program database. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in one NCAA-sanctioned practice or competition., Results: Nationally, there were an estimated 11,510 neck and cervical spine injuries over the 5-year period. These occurred at a rate of 7.05 per 100,000 athlete-exposures (AEs). The rate of neck and cervical spine injuries in men was 2.66 per 100,000 AEs, while women suffered injuries at a rate of 1.95 per 100,000 AEs. In sex-comparable sports, men were 1.36 times more likely to suffer a neck or cervical spine injury compared with women. Men's football (29.09 per 100,000 AEs) and women's field hockey (11.51 per 100,000 AEs) were the sports with the highest rates of injuries. These injuries were 3.94 times more likely to occur during competition compared with practice. In-season injury rates were the highest, at 8.18 per 100,000 AEs., Conclusion: The vast majority of neck and cervical spine injuries in NCAA athletes are minor and uncommon. Across all sports in both sexes, the majority of injuries were new, and occurred during in-season competitions. Most athletes returned to play within 24 hours of injury. These data can inform players, parents, coaches, athletic trainers, and physicians regarding the prevalence and rates of these injuries and potentially inform decision-making regarding injury prevention, treatment, and rehabilitation., Level of Evidence: 4.

Background: Anterior cervical discectomy and fusion (ACDF) is well-tolerated by most patients and commonly necessitates only a short hospital admission. Surgical delay after hospital admission, however, may result in longer hospital stays, consequently increasing hospital resource utilization. The current study evaluates risk factors for surgical delay in patients undergoing elective ACDF., Methods: A retrospective analysis of ACS-NSQIP data from 2006-2015 was performed. Patients undergoing elective ACDF were selected using current procedural terminology (CPT) codes (22251, 22252, 22554). A surgical delay was defined as surgery that occurred one day or later after initial hospital admission. Differences in outcomes between the non-delayed and delayed cohorts were evaluated with univariate analysis. Multivariate logistic regression was performed to identify risk factors for surgical delay., Results: There were a total of 771 (2.0%) surgical delays out of 39,371 patients undergoing elective ACDF from 2006-2015. Multivariate analysis found partially dependent functional status (OR 5.88; 95% CI: 4.48-7.71; P<0.001), totally dependent functional status (OR 18.22; 95% CI: 9.60-34.59; P<0.001), ASA class 4 (OR 2.73; 95% CI: 1.70-4.38; P<0.001), bleeding disorders (OR 1.75; 95% CI: 1.08-2.85; P=0.024), male sex (OR 1.19; 95% CI: 1.03-1.38; P=0.019), and chronic steroid use (OR 1.76; 95% CI: 1.30-2.37; P<0.001) as independent predictors of delay. Univariate analysis found surgical delay was associated with a higher rate of post-operative major adverse events (4.8% vs. 1.1%; P<0.001), mortality (1.0% vs. 0.2%; P<0.001) and greater than five-fold increase in total length of stay (9.52 vs. 1.65 days; P<0.001)., Conclusions: Impaired pre-operative functional status, a higher comorbidity burden, and chronic steroid use are risk factors for surgical delay, increased complications, and length of stay in patients undergoing elective ACDF. This is helpful information to consider given a rising incidence of cervical fusions in the Medicare population, a wide variation in costs, and increasing popularity of bundled-payment models., Level of Evidence: 3., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2019 Journal of Spine Surgery. All rights reserved.)

Background: Lumbar spine injuries (LSIs) are common in both men's and women's National Collegiate Athletic Association (NCAA) basketball players and can frequently lead to reinjuries and persistent pain., Purpose: To describe the epidemiology of an LSI in collegiate men's and women's basketball during the 2009-2010 through 2013-2014 academic years., Study Design: Descriptive epidemiology study., Methods: The incidence and characteristics of LSIs were identified utilizing the NCAA Injury Surveillance Program (ISP). Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in 1 NCAA-sanctioned practice or competition. Incidence rate ratios (IRRs) were then calculated to compare the rates of injury between season, event type, mechanism, injury recurrence, and time lost from sport., Results: The NCAA ISP reported 124 LSIs from an average of 28 and 29 men's and women's teams, respectively. These were used via validated weighting methodology to estimate a total of 5197 LSIs nationally. The rate of LSIs in women was 2.16 per 10,000 AEs, while men suffered LSIs at a rate of 3.47 per 10,000 AEs. Men were 1.61 times more likely to suffer an LSI compared with women. In men, an LSI was 3.48 times more likely to occur in competition when compared with practice, while in women, an LSI was 1.36 times more likely to occur in competition than in practice. Women suffered the highest LSI rate during the postseason, while the highest rate in men was during the regular season. The majority of both female (58.9%; n = 1004) and male (73.1%; n = 2353) athletes returned to play within 24 hours of injury., Conclusion: To date, this is the largest study to characterize LSIs in NCAA basketball and provides needed information on the prevalence and timing of these injuries. The majority of injuries in both sexes were new, and most athletes returned to play in less than 24 hours. Injury rates were highest during competition in both sexes., Competing Interests: One or more of the authors declared the following potential conflict of interest or source of funding: A.C. has received consulting fees from Trice Medical, Zimmer Biomet, and Arthrex and educational support from Arthrex and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2019.)