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Biological and mechanical cues are both vital for biomaterial aided tendon repair and regeneration. Here, we fabricated mechanically tendon-like (0 s UV) QHM polyurethane scaffolds (Q: Quadrol, H: Hexamethylene diisocyanate; M: Methacrylic anhydride) and immobilized them with Growth and differentiation factor-7 (GDF-7) to produce mechanically strong and tenogenic scaffolds. In this study, we assessed QHM polymer cytocompatibility, amenability to fibrin-coating, immobilization and persistence of GDF-7, and capability to support GDF-7-mediated tendon differentiation in vitro as well as in vivo in mouse subcutaneous and acute rat rotator cuff tendon resection models. Cytocompatibility studies showed that QHM facilitated cell attachment, proliferation, and viability. Fibrin-coating and GDF-7 retention studies showed that mechanically tendon-like 0 s UV QHM polymer could be immobilized with GDF-7 and retained the growth factor (GF) for at least 1-week ex vivo. In vitro differentiation studies showed that GDF-7 mediated bone marrow-derived human mesenchymal stem cell (hMSC) tendon-like differentiation on 0 s UV QHM. Subcutaneous implantation of GDF-7-immobilized, fibrin-coated, QHM polymer in mice for 2 weeks demonstrated de novo formation of tendon-like tissue while implantation of GDF-7-immobilized, fibrin-coated, QHM polymer in a rat acute rotator cuff resection injury model indicated tendon-like tissue formation in situ and the absence of heterotopic ossification. Together, our work demonstrates a promising synthetic scaffold with human tendon-like biomechanical attributes as well as immobilized tenogenic GDF-7 for tendon repair and regeneration. STATEMENT OF SIGNIFICANCE: Biological activity and mechanical robustness are key features required for tendon-promoting biomaterials. While synthetic biomaterials can be mechanically robust, they often lack bioactivity. To biologically augment synthetic biomaterials, numerous drug and GF delivery strategies exist but the large tissue space within the shoulder is constantly flushed with saline during arthroscopic surgery, hindering efficacious controlled release of therapeutic molecules. Here, we coated QHM polymer (which exhibits human tendon-to-bone-like biomechanical attributes) with fibrin for GF binding. Unlike conventional drug delivery strategies, our approach utilizes immobilized GFs as opposed to released GFs for sustained, localized tissue regeneration. Our data demonstrated that GF immobilization can be broadly applied to synthetic biomaterials for enhancing bioactivity, and GDF-7-immobilized QHM exhibit high clinical translational potential for tendon repair.

The influence of health literacy on involvement in decision-making in orthopedic surgery has not been analyzed and could inform processes to engage patients. The goal of this study was to determine the relationship between health literacy and the patient's preferred involvement in decision-making. We conducted a cross-sectional observational study of patients presenting to a multispecialty orthopedic clinic. Patients completed the Literacy in Musculoskeletal Problems (LiMP) survey to evaluate their health literacy and the Control Preferences Scale (CPS) survey to evaluate their preferred level of involvement in decision-making. Statistical analysis was performed with Pearson's correlation and multivariable logistic regression. Thirty-seven percent of patients had limited health literacy (LiMP score r =0.130; P =.150). Among patients with orthopedic conditions, there is no significant relationship between health literacy and preferred involvement in decision-making. Results from studies in other specialties that suggest that limited health literacy is associated with a preference for less involvement in decision-making are not generalizable to orthopedic surgery. Efforts to engage patients to be informed and participatory in decision-making through the use of decision aids and preference elicitation tools should be directed toward variation in preference for involvement in decision-making, but not toward patient health literacy. [ Orthopedics . 2022;45(4):227–232.]

Hip microinstability has emerged as a contributor to young adult, non-arthritic hip pain. There is a paucity of objective clinical data to identify patients with hip microinstability and guide surgical treatment. The purpose of this study was to identify the degree of distractibility in patients with and without microinstability undergoing hip arthroscopy.A single-surgeon series of hip arthroscopies were retrospectively reviewed from 2014-2020. All procedures were performed with paralysis on a fracture table with a perineal post where 1 turn of fine traction equates to 4 mm of axial traction. Diagnosis was recorded as isolated instability, instability plus femoroacetabular impingement (FAI), and isolated FAI. Operative reports were reviewed to collect patient demographic data, number of turns of traction required for adequate distraction of the femoral head relative to the acetabulum (10 mm), and the presence of residual subluxation after initial traction was released.A total of 464 patients were identified, 26 (5.6%) with isolated microinstability, 183 (39.4%) with microinstability with FAI anatomy, and 255 (55.0%) with FAI. The concurrent diagnosis of microinstability was associated with decreased turns required to adequately distract the hip. Isolated microinstability patients required 6.9 turns (IQR 4.6-8.8) while those with instability plus FAI required 8.8 turns (IQR 6.5-11) and isolated FAI required 19.1 turns (IQR 15-22). Residual subluxation after removal of negative intra-articular pressure but before performing the hip arthroscopy was more commonly associated with instability, occurring in 84.6% of isolated instability and 86.9% of instability plus FAI as compared with 29.8% in the isolated FAI cohort.A diagnosis of hip microinstability, with or without features of FAI, is associated with decreased axial traction required to distract the hip. These data support the use of intra-operative ease of distraction as a method of identifying patients with hip microinstability.Level III.

Knee dislocations (KDs) are complex injuries defined as incongruity of the tibiofemoral joint, which leads to tears of two or more of the main stabilising knee ligaments, and they are often associated with damage to surrounding soft tissue or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system.A global panel of orthopaedic knee surgery specialists participated in a Delphi process. The first survey employed 91 orthopaedic surgeons to generate a list of patient- and system-specific factors that should be included in a KD classification system that may affect surgical planning and outcomes. This list was subsequently prioritised by 27 identified experts (mean 15.3 years of experience) from Brazil (n = 9), USA (n = 6), South Africa (n = 4), India (n = 4), China (n = 2), and the United Kingdom (n = 2). The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system.Of the 12 factors identified, four (33%) achieved at least 70% consensus for inclusion in a classification system. The factors deemed critical for inclusion in a classification system included vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%).Consensus for inclusion of various factors in a KD classification system was not easily achieved. The wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. To date, the Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injury classification. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier, although this is only a small step in updating the classification, and further studies should evaluate the inclusion of more advanced imaging modalities. Future research should focus on integrating these factors into useful existing classification systems that are predictive of surgical treatment and patient outcomes.

Objectives: Platelet-rich-plasma (PRP) is becoming an increasingly popular biologic treatment to enhance healing in quality of tissue and/or speed of recovery. While many use PRP to avoid surgery, some use PRP as an adjunct intraoperatively to accelerate healing and recovery. While there are few reports of "complications" associated with PRP injection, there are anecdotal reports of heterotopic ossification associated with PRP use, particularly in the treatment of core muscle injury. There is, however, little data regarding its safety profile in hip arthroscopy. Methods: We queried the IBM® MarketScan® Research databases (formerly Truven Health Analytics) to identify patients who underwent hip arthroscopy from 2007 to 2015. This database is a collection of commercial inpatient, outpatient, and pharmaceutical claims of more than 75 million employees, retirees, and dependents representing a substantial portion of the U.S. population covered by employer-sponsored insurance. Patients that underwent hip arthroscopy were stratified into groups based on whether or not they received platelet rich plasma during their surgery. Complications and reoperations for both groups were assessed for 90 days after surgery. Patients without laterality codes were excluded to assure any complications and/or reoperations were on the operated extremity. A multivariate logistic regression analysis was used to control for confounding factors. Results: 35,263 patients met the inclusion criteria of this study, of which 253 (0.7%) received PRP at the time of hip arthroscopy. Age and rates of diabetes, hypertension, hyperlipidemia, obesity, and tobacco use were similar between cohorts. However, there were significant differences in the concomitant procedure distribution. Unadjusted composite complications rates were significantly different between the two cohorts (arthroscopy only 7.9%, arthroscopy + PRP 14.2%, p = 0.0002). Heterotopic ossification was the main driver of this difference, occurring more commonly in the PRP cohort (10.7% vs 5.7%, p = 0.0006). When stratifying by procedure type, intraoperative PRP was associated with higher complications in patients undergoing femoroplasty (25.0% vs 10.4%, p < 0.0001), labral repair (18.8% vs 9.2%, p = 0.0002), and acetabuloplasty (20.3% vs 10.8%, p = 0.0009). In multivariate regression analysis, after controlling for all other variables, PRP did lead to higher rates of postoperative complications after hip arthroscopy (ref: no PRP, OR 1.9, 95% CI 1.3 – 2.7, p = 0.0003.). Unadjusted reoperation rate at 90 days was similar between cohorts (arthroscopy 3.5% vs PRP 4.0%, p = 0.6757) but through 2-years patients who received PRP had higher re-operation rates (13.0% vs 9.3%, p = 0.0381). Conclusions: Patients receiving intraoperative PRP during hip arthroscopy were at increased risk of developing a post-operative complication, particularly heterotopic ossification. Consideration should be made on which patients may benefit the most from PRP. Further reserach is needed to determine the pathophysiology of heterotopic ossification related to platelet rich plasma, and to elucidate whether or not a link exists between the biochemical process of heterotopic ossification and PRP.

Objectives: Tibial tubercle osteotomy is utilized to unload cartilage defects and/or to correct malalignment in the setting of patellofemoral instability and/or chondrosis. Controversy remains regarding the indications for TTO as an adjunct to soft tissue stabilization for patella instability. Our purpose was to evaluate safety and efficacy of MPFLR with or without concomitant tibial tubercle osteotomy (TTO). Our hypothesis was that adding TTO to MPFLR would lead to lower revision instability surgical rates but higher rates of overall re-operation, complication, and cost. Methods: We queried the MarketScan database in order to identify patients who underwent primary MPFLR from 2007-2015. Patients were stratified into cohorts based on concomitant TTO performed on the same day as index MPFLR. To minimize the effect of potential confounding on the direct comparison of patients undergoing the two procedures, a propensity-score match (PSM) was utilized. A greedy nearest-neighbor algorithm was employed to match patient cohorts with a 7:1 MPFLR to MPFLR + TTO ratio. Reoperations, complications, and costs were followed for two years post-index procedure. Patients without laterality codes were excluded. Results were analyzed statistically. Results: This study identified 968 patients who underwent primary MPFLR. Patients were stratified into two groups: 1) MPFLR only or 2) MPFLR + TTO. After matching the cohorts, mean age, sex distribution, and rates of baseline diabetes, hyperlipidemia, hypertension, tobacco use, and obesity were similar. Patients in the two cohorts experienced similar rates of postoperative complications (MPFLR + TTO: 9.9%, MPFLR: 8.7%, p= 0.6694). Rates of dislocation (MPFLR + TTO: 5.8%, MPFLR: 4.3%, p = 0.4434), stiffness (MPFLR + TTO: 0.8%, MPFLR: 2.5%, p = 0.2538), infection (MPFLR + TTO: 0.8%, MPFLR: 0.6%, p = 0.7559), and wound complication (MPFLR + TTO: 0.8% vs MPFLR: 0.8%, p = 1.000) were similarly low. Performing a concomitant TTO decreased revision surgery for instability (revision MPFLR) rates (6.6% vs 11.1%, p = 0.1327); however, this difference was not statistically significant. Hardware removal (MPFLR + TTO: 9.9%, MPFLR: 1.9%, p < 0.0001) was higher in the MPFLR + TTO cohort. Patients who underwent a concomitant TTO were associated with higher payments through 2 years of index surgery when compared to MPFLR only patients ($25,740 vs $17,727, p < 0.0001). Conclusions: Concomitant TTO at the time of MPFLR does not lead to increased post-operative complications. The addition of TTO to MPFLR reduced revision surgical rates for instability from 11.1 to 6.6% but this difference was not statistically significant. Combination TTO/MPFLR led to higher payments through 2 years. Further research is needed to refine the indications for TTO as a adjunct procedure to MPFLR and its impact on long-term stability and failure rates. [Table: see text][Table: see text][Table: see text][Table: see text][Table: see text][Table: see text]

Objectives: Ulnar collateral ligament (UCL) tears are prevalent in Major League Baseball (MLB) pitchers and cause significant loss of time with varying reports of impact on performance. Revision UCL reconstruction (UCLR) is increasingly common, with little known about the effects on both fastball (FB) velocity and usage (%) in this setting. The purpose of this study was to evaluate the effect of revision UCLR on MLB pitchers with respect to post-operative FB % and velocity at one and two years after return-to-play. The hypothesis was that post-operative FB usage (FB%) and velocity would significantly decrease versus pre-injury levels in the revision UCLR group, and that revision UCLRs would result in significantly decreased FB % and velocity in comparison to a matched group of MLB pitchers after primary UCLRs. Methods: Public records were used to identify MLB pitchers from 2008 to 2020 who underwent a revision UCLR. The PITCHf/x system, which was installed in 2007 and is a standardized recording of all pitches thrown in MLB stadiums, collected FB velocity for four-seam (4FB) and two-seam (2FB) fastballs and total FB % for pitchers in the pre-injury year as well as the first two years after return. A matched control group of pitchers who underwent primary UCLR was used for comparison. Results: Nineteen pitchers fit the study criteria. There were no significant differences in the revision UCLR group in FB velocity between pre-injury levels (4FB 92.87 mph, 2FB 91.43 mph) and years one (4FB 92.55 mph, p=.375) (2FB 91.2 mph, p=0.448) and two (4FB 93.38 mph, p=.695) (2FB 91.59 mph, p=0.806) after return (Table 1). There were also no significant differences in FB % usage between the pre-injury season (60.4) and first (56.5, p=.095) or second years (52.5, p=.053) after return (Table 1). In terms of walks and hits per innings pitched (WHIP), strikeouts per 9 innings (K/9), and walks per 9 innings (BB/9), the only significant difference between pre-injury and post-injury outcomes was a significant higher K/9 in the first season after return (p=0.031) (Table 1). There were no significant differences between FB velocity or % usage between the revision and primary UCLR groups at any time point (Tables 2-4). There were also no significant differences in the revision and primary UCLR groups between WHIP, K/9, or BB/9 with the exception of lower WHIP (p=0.015) and K/9 (p=0.001) in the pre-injury season (Tables 2-4). Conclusions: In pitchers that return to the MLB level, there were no significant differences in FB velocity versus their pre-injury levels or in comparison to pitchers after primary UCLR. While not statistically significant, a trend was demonstrated that there was a clinically relevant decrease in FB % usage, potentially suggesting less confidence in their FB. [Table: see text][Table: see text][Table: see text][Table: see text]

Objectives: Both natural grass (NG) and artificial turf (AT) are popular playing surfaces for soccer. Biomechanical studies have found increased frictional forces on artificial turf that may lead to anterior cruciate ligament (ACL) injury. Few studies have examined the differences between ACL injury risk in male and female soccer athletes playing on AT versus NG. Given the higher risk for female ACL injury in sports, and soccer in particular, it is important to define whether AT may compound this injury risk. The purpose of this investigation was to systematically review the literature for studies comparing ACL injury risk on AT versus NG in soccer, and to specifically determine if there were differences in injury risk in males versus females when considering the playing surface. Methods: A systematic review was pre-registered on PROSPERO and performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-III studies that compared the incidence of ACL injuries on AT versus NG in soccer players. Data recorded included study demographics, sex, competition level, exposure setting (games or practices), turf type, and ACL injury information. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) score. Incidence rate ratios (IRRs) were calculated by dividing the incidence of ACL injury on AT over NG, where IRRs < 1 indicate a lower incidence of ACL injuries on AT compared to NG, and IRRs > 1 signify a higher incidence of ACL injuries on AT compared to NG. A Mantel-Haenszel random effects model was used for meta-analyses of IRRs, and forest plots were generated for the pooled IRR for ACL injuries in game and training settings. Additionally, sub-analyses based on athlete sex were conducted for IRRs of ACL injuries in games. A p-value of less than 0.05 was set as significant. Results: Seven articles (four male, two female, one male and female cohort; mean MINORS score 20 + 0.8) were included and analyzed (Figure 1). There were two studies that investigated ACL injuries in a female only cohort, four studies that used a male only cohort, and one study that included both males and females (Table 1). Levels of play included professional (n = 3 studies), college (n = 3 studies), and youth (n = 1 studies). Pooled ACL injury IRRs demonstrated no significant differences in overall ACL injury risk when playing soccer on AT compared to NG (IRR = 0.61 [0.23-1.60], p = 0.31; Figure 2). A significantly increased risk of ACL injury in games played on AT compared to NG was detected for females (IRR = 1.18 [1.05-1.31], p = 0.004) but not for males (IRR = 1.18 [0.97- 1.42], p = 0.09; Figure 3). Subgroup analyses showed no significant differences in injury risk for games (IRR = 1.07 [0.97- 1.18], p = 0.20) or practices (IRR = 0.21 [0.04-1.23], p = 0.09; Figure 2). A total of 3,023 ACL injuries occurred on NG and 526 ACL injuries happened on AT, and the majority of soccer exposures in each study was on NG (range: 50.33% - 85.74%). Conclusions: .This investigation found that females had a significantly higher risk of ACL injury when playing games on AT versus NG, whereas no significant difference was seen in males. No differences were found for the combined male/female population nor soccer games or training sessions played on AT compared to NG. [Figure: see text][Figure: see text][Figure: see text][Table: see text]

Background: The optimal treatment for chronic patella instability remains controversial. Medial patellofemoral ligament reconstruction (MPFLR) has emerged as the “gold standard” for soft tissue stabilization. However, isolated lateral release (ILR) is still commonly performed to treat chronic patella instability despite growing evidence against this approach. Hypothesis/Purpose: Our purpose is to evaluate long-term revision rates and short-term post-operative complications in pediatric patients undergoing either MPFLR or ILR for recurrent patellar instability. The hypothesis is that MPFLR is a superior treatment option with reduced long term revision rates and comparable short-term complications. Methods: The MarketScan database was queried from 2007-2015 to identify patients who underwent MPFLR or ILR as their primary surgical treatment of their chronic patellar instability. Patients were excluded if they had incomplete records up to 5 years or if they underwent concomitant osteotomy or cartilage restoration during their index stabilization procedure. Baseline demographic data and patient co-morbidities were documented. Two and five year revision surgical stabilization rate and post-operative complications were reported. Results were analyzed statistically. Results: This study identified 471 patients (mean age 15.6 years, female 56.9%) who underwent MPFLR and 528 patients (mean age 15.5 years, female 70.5%) who underwent ILR for chronic patellar instability. Patients were stratified into two mutually exclusive groups: 1) MPFLR only or 2) ILR only. Patients who underwent MPFLR experienced higher rates of overall complications within 90 days of surgery (8.7% vs 4.9%, p = 0.0171). MPFLR had a higher rate of early wound complications (0.8% vs. 0%, p Conclusions: Isolated lateral release is an inferior treatment option for surgical stabilization of chronic patella instability as compared to medial patellofemoral ligament reconstruction in pediatric patients. Despite slightly higher rate of short term complications in the MPFLR group and similar revision rates at 2 years, MPFLR has significantly decreased risk of revision stabilization at 5 year follow-up. [Table: see text][Table: see text]

Femoroacetabular impingement (FAI) has been recognized as a significant clinical problem. While hip reshaping surgery for treating FAI has had positive clinical outcomes, there remains a need for objective functional outcomes of FAI treatment. We tested the hypothesis that during walking and stair climbing significant changes in hip kinematics would occur following hip reshaping surgery that indicate restoration of normal function post-operatively. Hip and pelvic kinematics were collected for 17 FAI patients pre- and 1 year post-operatively and compared to 17 healthy matched controls. Prior to surgery, FAI patients had significantly reduced hip internal rotation and hip sagittal plane range of motion during walking (p = 0.01, p0.001, respectively) and stair climbing (p = 0.01, p0.001, respectively) as compared with controls. Post-operatively, these motions were restored to normal during walking (p = 0.70, p = 0.46, respectively), but remained significantly reduced in the FAI patients during stair climbing (p = 0.03, p0.001, respectively). These results have important implications for understanding the functional pathomechanics of FAI and providing an objective basis for evaluating treatment outcome. The stair climbing results indicate that problems still exist in the hip joint for activities requiring higher ranges of hip motion and suggest a basis for exploring future improvements for the treatment of FAI.

The purpose of this chapter is to critically review the existing studies on the epidemiology of tennis injuries in pediatric athletes, present suggestions for the prevention of injury based on these studies, and present suggestions for future research.Data sources included published articles on pediatric tennis injuries, a previously published review by the authors, and unpublished data from one of the authors (MS).Most studies of tennis injuries show that they are of microtrauma origin, develop over time, and result in short times of absence from play. They involve all joints of the body, but have a higher incidence in the shoulder, back, and knee. Intrinsic and extrinsic risk factors may be related to the incidence of injury. These factors may be evaluated by a comprehensive pre-participation exam, and preventive strategies may be implemented.Most injury studies in pediatric tennis players vary in the population studied, methods of injury evaluation, and risk factors studied. Consequently, few specific conclusions can be derived about the causative factors. Further longitudinal prospective studies need to be done to completely discover all the factors involved in producing tennis injuries.

‘Highlights’ presents summaries of sports medicine-related articles culled from more than 30 medical journals. Experts comment on what the new findings add to current medical thinking and on the implications for practice.