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Glenohumeral arthritis in the young patient presents a difficult problem with potentially devastating sequelae. Reports in the literature suggest a role for arthroscopic treatment in patients with symptomatic degenerative joint disease of the shoulder. However, no published study directly compares patients with unipolar versus bipolar cartilage lesions. We retrospectively reviewed 19 patients (20 shoulders) younger than 55 years with Outerbridge Grade 2-4 articular cartilage changes who underwent arthroscopic glenohumeral débridements. We obtained WOOS, SF-12, SANE and the American Shoulder and Elbow Society scores at last followup. The minimum follow up time was 12 months (average, 20 months; range, 12-33 months). Three patients progressed to shoulder arthroplasty. All but three patients reported their shoulder function at 60% or better based on the SANE score. The grade of the lesion did not influence outcome scores, but patients with unipolar lesions had higher outcome scores than patients with bipolar lesions. We believe arthroscopic glenohumeral débridement in young patients with shoulder arthritis can be an effective tool in managing symptoms and delaying the need for invasive resurfacing or prosthetic replacement. [ABSTRACT FROM AUTHOR]

BACKGROUND: The risk of tear of the intact anterior cruciate ligament in the contralateral knee after anterior cruciate ligament reconstruction of the opposite knee and the incidence of rupturing the anterior cruciate ligament graft during the first 2 years after surgery have not been extensively studied in a prospective manner. Clinicians have hypothesized that the opposite normal knee is at equal or increased risk compared with the risk of anterior cruciate ligament graft rupture in the operated knee. HYPOTHESIS: The risk of anterior cruciate ligament graft rupture and contralateral normal knee anterior cruciate ligament rupture at 2-year follow-up is equal. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The Multicenter Orthopaedic Outcome Network (MOON) database of a prospective longitudinal cohort of anterior cruciate ligament reconstructions was used to determine the number of anterior cruciate ligament graft ruptures and tears of the intact anterior cruciate ligament in the contralateral knee at 2-year follow-up. Two-year follow-up consisted of a phone interview and review of operative reports. RESULTS: Two-year data were obtained for 235 of 273 patients (86%). There were 14 ligament disruptions. Of these, 7 were tears of the intact anterior cruciate ligament in the contralateral knee (3.0%) and 7 were anterior cruciate ligament graft failures (3.0%). CONCLUSION: The contralateral normal knee anterior cruciate ligament is at a similar risk of anterior cruciate ligament tear (3.0%) as the anterior cruciate ligament graft after primary anterior cruciate ligament reconstruction (3.0%). [ABSTRACT FROM AUTHOR]

BACKGROUND: There have been reports of axillary nerve palsy after thermal capsular shrinkage with radiofrequency energy-generating devices. The exact cause of this is unknown. HYPOTHESIS: The temperature of the axillary nerve increases during shoulder capsular shrinkage at various degrees of shoulder abduction. STUDY DESIGN: Laboratory study. METHODS: Fifteen cadaveric shoulders had fiberoptic thermometer probes placed at various points along the axillary nerve and major branches under the capsule. The shoulders underwent thermal capsular shrinkage with a radiofrequency energy-inducing device at various positions of abduction. RESULTS: With the arm at the side, temperatures above 50 degrees C (56 degrees -61 degrees C) were evident along the teres minor branch of the axillary nerve in 4 of 6 specimens. The increase in temperature was noted in the middle to posterior aspect of the inferior capsule. At 45 degrees of abduction, 4 of 5 shoulders demonstrated increases in temperature greater or equal to 50 degrees. Three of 4 shoulders tested at 90 degrees of abduction revealed similar temperature increases. CONCLUSIONS: The arthroscopic technique of thermal capsular shrinkage causes an increase in the temperature of the axillary nerve and its branches in 11 of 15 cadaveric specimens tested at various arm positions-particularly affected is the teres minor branch. CLINICAL RELEVANCE: Orthopaedic surgeons using the radiofrequency device for thermal capsular shrinkage need to be aware of the possible increase in temperature along the axillary nerve and its branches during this procedure. The clinical effect of this type of increase on the nerve is unknown. [ABSTRACT FROM AUTHOR]

Background: There recently has been a resurgence in the utilization of ketamine, a unique anesthetic, for emergency-department procedures requiring sedation. The purpose of the present study was to examine the safety and efficacy of ketamine for sedation in the treatment of children's fractures in the emergency department.Methods: One hundred and fourteen children (average age, 5.3 years; range, twelve months to ten years and ten months) who underwent closed reduction of an isolated fracture or dislocation in the emergency department at a level-I trauma center were prospectively evaluated. Ketamine hydrochloride was administered intravenously (at a dose of two milligrams per kilogram of body weight) in ninety-nine of the patients and intramuscularly (at a dose of four milligrams per kilogram of body weight) in the other fifteen. A board-certified emergency physician skilled in airway management supervised administration of the anesthetic, and the patients were monitored by a registered nurse. Any pain during the reduction was rated by the orthopaedic surgeon treating the patient according to the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS).Results: The average time from intravenous administration of ketamine to manipulation of the fracture or dislocation was one minute and thirty-six seconds (range, twenty seconds to five minutes), and the average time from intramuscular administration to manipulation was four minutes and forty-two seconds (range, sixty seconds to fifteen minutes). The average score according to the Children's Hospital of Eastern Ontario Pain Scale was 6.4 points (range, 5 to 10 points), reflecting minimal or no pain during fracture reduction. Adequate fracture reduction was obtained in 111 of the children. Ninety-nine percent (sixty-eight) of the sixty-nine parents present during the reduction were pleased with the sedation and would allow it to be used again in a similar situation. Patency of the airway and independent respiration were maintained in all of the patients. Blood pressure and heart rate remained stable. Minor side effects included nausea (thirteen patients), emesis (eight of the thirteen patients with nausea), clumsiness (evident as ataxic movements in ten patients), and dysphoric reaction (one patient). No long-term sequelae were noted, and no patients had hallucinations or nightmares.Conclusions: Ketamine reliably, safely, and quickly provided adequate sedation to effectively facilitate the reduction of children's fractures in the emergency department at our institution. Ketamine should only be used in an environment such as the emergency department, where proper one-on-one monitoring is used and board-certified physicians skilled in airway management are directly involved in the care of the patient. [ABSTRACT FROM AUTHOR]

BACKGROUND: Intra-articular knee injections are routinely performed in clinical practice without documenting intra-articular placement. HYPOTHESIS: A small amount of air to an intra-articular knee injection produces an audible 'squishing' sound with range of motion. STUDY DESIGN: Prospective nonrandomized clinical trial. METHODS: The study group (20 knees from 20 patients) received an intra-articular injection with a mixture of local anesthetic, corticosteroid, contrast dye, and 1 to 2 cc of air. The control group (10 knees from 5 patients) received extra-articular injections of a mixture of local anesthetic, contrast dye, and 2 cc of air. All knees were examined immediately after injection for a squishing sound with range of motion. Postinjection arthrographic radiographs were taken to verify the actual placement. RESULT: All study group knees and no control group knees had intra-articular contrast by radiograph. Clearly audible squishing sounds were heard in 17 of 20 study knees (sensitivity of 85%). Squishing sounds were audible in none of the control knees (specificity of 100%). CONCLUSION: Adding 1 to 2 cc of air to knee injections provides a no-cost, reliable, sensitive, and specific method of confirming accurate placement. CLINICAL RELEVANCE: This simple method is easily reproduced, can confirm accurate placement, and can eliminate extra-articular injection as the reason for clinical response failure. [ABSTRACT FROM AUTHOR]

Background: As machine learning becomes increasingly utilized in orthopaedic clinical research, the application of machine learning methodology to cohort data from the Multicenter ACL Revision Study (MARS) presents a valuable opportunity to translate data into patient-specific insights., Purpose: To apply novel machine learning methodology to MARS cohort data to determine a predictive model of revision anterior cruciate ligament reconstruction (rACLR) graft failure and features most predictive of failure., Study Design: Cohort study; Level of evidence, 3., Methods: The authors prospectively recruited patients undergoing rACLR from the MARS cohort and obtained preoperative radiographs, surgeon-reported intraoperative findings, and 2- and 6-year follow-up data on patient-reported outcomes, additional surgeries, and graft failure. Machine learning models including logistic regression (LR), XGBoost, gradient boosting (GB), random forest (RF), and a validated ensemble algorithm (AutoPrognosis) were built to predict graft failure by 6 years postoperatively. Validated performance metrics and feature importance measures were used to evaluate model performance., Results: The cohort included 960 patients who completed 6-year follow-up, with 5.7% (n = 55) experiencing graft failure. AutoPrognosis demonstrated the highest discriminative power (model area under the receiver operating characteristic curve: AutoPrognosis, 0.703; RF, 0.618; GB, 0.660; XGBoost, 0.680; LR, 0.592), with well-calibrated scores (model Brier score: AutoPrognosis, 0.053; RF, 0.054; GB, 0.057; XGBoost, 0.058; LR, 0.111). The most important features for AutoPrognosis model performance were prior compromised femoral and tibial tunnels (placement and size) and allograft graft type used in current rACLR., Conclusion: The present study demonstrated the ability of the novel AutoPrognosis machine learning model to best predict the risk of graft failure in patients undergoing rACLR at 6 years postoperatively with moderate predictive ability. Femoral and tibial tunnel size and position in prior ACLR and allograft use in current rACLR were all risk factors for rACLR failure in the context of the AutoPrognosis model. This study describes a unique model that can be externally validated with larger data sets and contribute toward the creation of a robust rACLR bedside risk calculator in future studies., Registration: NCT00625885 (ClinicalTrials.gov identifier)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study was funded by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant 5R01-AR060846). See Supplemental Material for individual disclosures. 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) 2024.)

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have inferior outcomes compared with primary ACL reconstruction. The reasons why remain unknown., Purpose: To determine whether surgical factors performed at the time of revision ACL reconstruction can influence a patient's outcome at 6-year follow-up., Study Design: Cohort study; Level of evidence, 2., Methods: Patients who underwent revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline patient characteristics, surgical technique and pathology, and a series of validated patient-reported outcome instruments: Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) subjective form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity rating score. Patients were followed up for 6 years and asked to complete the identical set of outcome instruments. Regression analysis was used to control for baseline patient characteristics and surgical variables to assess the surgical risk factors for clinical outcomes 6 years after surgery., Results: A total of 1234 patients were enrolled (716 men, 58%; median age, 26 years), and 6-year follow-up was obtained on 79% of patients (980/1234). Using an interference screw for femoral fixation compared with a cross-pin resulted in significantly better outcomes in 6-year IKDC scores (odds ratio [OR], 2.2; 95% CI, 1.2-3.9; P = .008) and KOOS sports/recreation and quality of life subscale scores (OR range, 2.2-2.7; 95% CI, 1.2-4.8; P < .01). Use of an interference screw compared with a cross-pin resulted in a 2.6 times less likely chance of having a subsequent surgery within 6 years. Use of an interference screw for tibial fixation compared with any combination of tibial fixation techniques resulted in significantly improved scores for IKDC (OR, 1.96; 95% CI, 1.3-2.9; P = .001); KOOS pain, activities of daily living, and sports/recreation subscales (OR range, 1.5-1.6; 95% CI, 1.0-2.4; P < .05); and WOMAC pain and activities of daily living subscales (OR range, 1.5-1.8; 95% CI, 1.0-2.7; P < .05). Use of a transtibial surgical approach compared with an anteromedial portal approach resulted in significantly improved KOOS pain and quality of life subscale scores at 6 years (OR, 1.5; 95% CI, 1.02-2.2; P ≤ .04)., Conclusion: There are surgical variables at the time of ACL revision that can modify clinical outcomes at 6 years. Opting for a transtibial surgical approach and choosing an interference screw for femoral and tibial fixation improved patients' odds of having a significantly better 6-year clinical outcome in this cohort., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This project was funded by grant No. 5R01-AR060846 from the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases. All author disclosures are listed in the Appendix (available in the online version of this article). 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.

Shoulder glenohumeral joint dislocations and subluxations are a relatively common injury among athletic populations. Evaluating the patient both on the field initially and through early recovery helps to determine the best treatment strategies and predict the natural history of each unique injury., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The Multicenter Orthopaedic Outcomes Network Shoulder Group conducted a prospective cohort study of 452 patients with symptomatic atraumatic rotator cuff tears treated with a physical therapy program to determine the predictors of failure of nonsurgical treatment, to provide insight into indications for surgery. After 10 years, we found the following: (1) Physical therapy was effective for over 70% of patients. (2) PROMs showed statistical and clinical improvement after 12 weeks of therapy and did not decline over 10 years. (3) Cuff tear severity did not correlate with pain, duration of symptoms, or activity level. (4) Of those who had surgery, 56.7% had surgery in the first 6 months while 43.3% had surgery between 6 months and 10 years. (5) Early surgery was primarily driven by low patient expectations regarding the effectiveness of therapy. (6) Later surgery predictors included workers' compensation status, activity level, and patient expectations. (7) Only 1 patient had a reverse arthroplasty (0.2% of the cohort). These data suggest that physical therapy is an effective and durable treatment of atraumatic symptomatic rotator cuff tears and most patients successfully treated with physical therapy do not exhibit a decline in patient-reported outcomes over time. Reverse arthroplasty after nonsurgical treatment is exceptionally rare., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: A prospective cohort study was conducted to assess the predictors of failure of nonoperative treatment, defined as the patient undergoing surgery for symptomatic, atraumatic full-thickness rotator cuff tears. We present the 10-year follow-up data of this population to determine if predictors for surgery change over time, and secondarily we report the outcomes of the cohort., Methods: At the time of enrollment, demographic, symptom, rotator cuff anatomy, and patient-reported outcome data were collected in patients with symptomatic, atraumatic full-thickness rotator cuff tears. Patients underwent a standard physical therapy protocol for 6 to 12 weeks. Patient data were then collected at 1, 2, 5, 7, and 10 years. Failure of nonoperative treatment was defined as the patient electing to undergo surgery., Results: Of the 452 patients in the original cohort, 20 patients (5%) withdrew from the study, 37 (9%) died before 10 years, and 40 (9%) were otherwise lost to follow-up. A total of 115 patients (27.0%) underwent a surgical procedure at some point during the 10-year follow-up period. Of these patients, 56.5% underwent surgery within 6 months of enrollment and 43.5%, between 6 months and 10 years. Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery. Workers' Compensation status and activity level were more important predictors of later surgery. Patient-reported outcome measures all improved following physical therapy. For patients who did not undergo a surgical procedure, patient-reported outcome measures did not decline over the 10-year follow-up period., Conclusions: Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery, whereas Workers' Compensation status and activity level were predictors of later surgery. Physical therapy was successful in >70% of patients with symptomatic, atraumatic full-thickness rotator cuff tears at 10 years. Outcome measures improved with physical therapy and did not decline over the 10-year follow-up period., Level of Evidence: Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This work was funded by the following agencies: Arthrex (unrestricted research gift), NFL Charities (medical research grant); National Institutes of Health (grant 5K23-AR05392-05 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases), American Orthopaedic Society for Sports Medicine (Career Development Award), and Pfizer (Scholars Grant in Clinical Epidemiology). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I98 )., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Management of the in-season athlete presenting with an anterior shoulder dislocation is a nuanced process that continues to be refined. Options and pathways between nonoperative and operative treatment have undergone many iterations over a century of orthopedic research and advancement. It requires an understanding of sport-specific demands and the individual athlete's goals. The orthopedic surgeon must have mastery of the natural history, treatment options, and outcomes of anterior shoulder dislocations. Balance of these factors is delicate and highly individualized for each athlete, and is why management of the in-season athlete with an anterior shoulder dislocation remains an art for the orthopedic surgeon., Materials and Methods: A narrative review of the literature regarding the in-season athlete with anterior shoulder dislocation was conducted of the PubMed, Embase, and Cochrane databases. The findings are summarized in this article., Results: Multiple studies have investigated management of the in-season athlete with anterior shoulder dislocation. Treatment is highly individualized for each athlete and their respective circumstances. Nonoperative treatment remains the only option for athletes that seek to return to play in the same season, however with a high risk of recurrence. Operative treatment has a track record of success in terms of returning to high level of play and lower recurrence, but would preclude a return to competition in the same season., Conclusions: Management of the in-season athlete with anterior shoulder dislocation remains a challenging issue without consensus recommendation among shoulder surgeons. Much has been done to understand the pathology and delineate indications for nonoperative treatment and surgical management. Although recurrence and return to play rates have improved with each iteration, recurrent instability and revision surgery continue to occur at high rates. Therefore, additional work remains to optimize return to play as well as long-term outcomes for athletes., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The effect of prior rotator cuff repair (RCR) on clinical outcomes after total shoulder arthroplasty (TSA) is unclear., Purpose: To systematically review the literature to compare the outcomes of TSA in patients with and without prior RCR., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching the PubMed, Cochrane Library, and Embase databases to identify studies comparing outcomes of TSA with and without prior RCR. The inclusion criteria were full-text studies that directly compared outcomes between patients undergoing anatomic or reverse TSA with and without prior RCR. A quality assessment was performed using the Modified Coleman Methodology Score (MCMS), and risk of bias assessment was performed using the Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) tool. A total of 1542 articles were identified for review based on initial database queries. Weighted means of quantifiable demographics and patient-reported outcomes were calculated for all included studies and compiled, in addition to the MCMS and ROBINS-I tool., Results: Twelve studies (10 level 3, 2 level 4) met inclusion criteria, including a total of 885 patients who underwent RCR before TSA (mean age, 68.2 years) and 2275 patients with no prior RCR (mean age, 70.0 years). Of all outcomes evaluated, patients with reverse TSA showed superior results in the no prior RCR group. Three reverse TSA studies found the no prior RCR group to have significantly higher postoperative American Shoulder and Elbow Surgeons scores when compared with the prior RCR group ( P < .05). Multiple reverse TSA studies found the no prior RCR group to have significantly higher postoperative Simple Shoulder Test scores ( P < .05) and significantly improved forward elevation ( P < .05) when compared with the prior RCR group. Of all outcomes in anatomic TSA studies, only complication rate was different between groups, with 1 study finding a significantly lower complication rate in the no prior RCR group ( P = .01)., Conclusion: Patients undergoing reverse TSA without prior RCR can be expected to experience statistically better outcomes when compared with patients with prior RCR, while patients undergoing anatomic TSA can be expected to have similar outcomes regardless of prior RCR status., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.K.M. has received hospitality payments from Stryker, Arthrosurface, and Medical Device Business Services and compensation for services other than consulting from Arthrosurface. R.M.F. has received consulting fees from Arthrex and compensation for services other than consulting from Arthrex; education payments from Arthrex, Gemini Mountain Medical LLC, and Pinnacle; and hospitality payments from Gemini Mountain Medical LLC, Joint Restoration Foundation, Smith+Nephew, Arthrex, and Stryker. A.J.S. has received consulting fees from Encore Medical and Medacta USA, honoraria from Encore Medical, and education payments from Arthrex. E.C.M. has received consulting fees from DePuy Synthes Products, Medical Device Business Services, Pacira Therapeutics, and Zimmer Biomet Holdings; royalty or license from Zimmer Biomet Holdings; education payments from Gemini Mountain Medical LLC; and compensation for services other than consulting from Arthrex. J.T.B. has received consulting fees from Encore Medical and Smith+Nephew, compensation for services other than consulting from Smith+Nephew, and education payments from Smith+Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval was not sought for the present study., (© The Author(s) 2024.)

Objective: The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears., Methods: This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis., Results: A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m 2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear., Conclusions: Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients., Level of Evidence: III., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To systematically review the literature to assess the heterogeneity of platelet-rich plasma (PRP) preparation and composition reporting for the treatment of musculoskeletal/orthopaedic pathologies., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I and Level II studies from 2016 to 2022 that evaluated the use of PRP therapy for musculoskeletal pathologies. The search phrase used was "platelet-rich plasma clinical studies." Studies were assessed based on their reporting of the PRP preparation methods and reporting of PRP composition., Results: One hundred twenty-four studies (in 120 articles) met inclusion criteria for analysis. Of these studies, 15 (12.1%) provided comprehensive reporting, including a clear, well-described, and reproducible preparation protocol that future investigators can follow. Thirty-three studies (26.6%) quantitatively reported the final PRP product composition., Conclusions: Among the studies using PRP for the treatment of musculoskeletal/orthopaedic pathologies, less than 20% provided a clear, well-described, and reproducible PRP preparation protocol, and only one-fourth of studies reported on the final PRP product composition., Clinical Relevance: A diverse current reporting of PRP composition between studies provides a high heterogeneity of the term "PRP," which becomes a limitation for a comparison of studies using PRP., (Copyright © 2024 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Social media (SM) use by orthopaedic surgeons is becoming increasingly common; nonetheless, it needs to be clarified how patients perceive the content posted by physicians., Purpose: To characterize SM content posted by orthopaedic surgeons while investigating patient perceptions of this content and how it may influence their health care decisions., Study Design: Cross-sectional study., Methods: Posts on SM outlets by orthopaedic surgeons were reviewed and categorized. A survey to assess patient perception of these categories was administered between December 2021 and February 2022 in the clinics of 3 orthopaedic surgeons. Survey results were analyzed for differences in patient SM use and perception of SM content types., Results: There were 250 completed surveys. SM use was high among all age groups; however, the 18 to 24 years (87.1%) and 25 to 34 years (86.4%) age groups were more likely than older age groups to report daily use ( P = .002). Overall, 17% of patients reported using SM to see information about their health care at least once per month, 21% reported reviewing the SM account of a physician at least once per month, 19% reported that they were likely or very likely to view the SM account of their physician, and 23% reported that SM content was likely or very likely to influence which physician they see. Patients held the most consistently positive view of posts that educated patients, discussed sports team coverage, and provided patient testimonials. Patients had consistently neutral views of posts educating colleagues, discussing presentations at national meetings, displaying aspects of surgeons' personal lives, and supporting marginalized groups. Several post categories elicited highly polarized responses-including those discussing research publications and showing surgical techniques or pictures/videos taken during surgery. Respondents had a consistently negative response to posts making political statements., Conclusion: SM is likely a useful tool to help physicians interact with patients. Physicians who wish to interact with patients should consider posting content viewed most positively-including posts educating patients, discussing sports team coverage, and providing patient testimonials. Content that is viewed less favorably should be posted sparingly or with a sensitive tag., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.J.J. has received grants from Arthrex and DJO and education payments from Gemini Mountain Medical, Liberty Surgical, and Smith & Nephew. E.C.M. has received research support from Arthrex, Breg, DJ Orthopaedics, Elsevier, Mitek, Ossur, Smith & Nephew; education payments from Gemini Mountain Medical; consulting fees from DePuy Synthes Products, Medical Device Business Services, Pacira Therapeutics, Zimmer Biomet Holdings, and Flexion Therapeutics; nonconsulting fees from Arthrex; and royalties from Zimmer Biomet Holdings and Elsevier. J.T.B. has received research support from Zimmer Biomet Holdings, Mitek, Smith & Nephew, and Styker; education payments from Smith & Nephew; consulting fees from Encore Medical, DJ Orthopaedics, Smith & Nephew, and Shukla Medical; nonconsulting fees from Smith & Nephew; and royalties from Shukla Medical. R.M.F. has received research support from Arthrex, Elsevier, and Smith & Nephew; education payments from Arthrex, Gemini Mountain Medical, and Pinnacle; consulting fees from Arthrex, Allosource, and JRF Ortho; nonconsulting fees from Arthrex, Allosource, JRF Ortho, and Ossur; royalties from Elsevier; 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. Ethical approval was not sought for the present study., (© The Author(s) 2024.)

Background: Multiple studies have compared outcomes among patients undergoing revision anterior cruciate ligament reconstruction (ACLR) with autograft versus allograft, but these data are inconsistently reported and long-term outcomes depending on graft type are yet to be determined., Purpose: To perform a systematic review of clinical outcomes after revision ACLR (rACLR) with autograft versus allograft., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review of the literature was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that compared the outcomes of patients undergoing rACLR with autograft versus allograft. The search phrase used was autograft allograft revision anterior cruciate ligament reconstruction . Graft rerupture rates, return-to-sports rates, anteroposterior laxity, and patient-reported outcome scores (subjective International Knee Documentation Committee, Tegner, Lysholm, and Knee injury and Osteoarthritis Outcome Score) were evaluated., Results: Eleven studies met inclusion criteria, including 3011 patients undergoing rACLR with autograft (mean age, 28.9 years) and 1238 patients undergoing rACLR with allograft (mean age, 28.0 years). Mean follow-up was 57.3 months. The most common autograft and allograft types were bone-patellar tendon-bone grafts. Overall, 6.2% of patients undergoing rACLR experienced graft retear, including 4.7% in the autograft group and 10.2% in the allograft group ( P < .0001). Among studies that reported return-to-sports rates, 66.2% of patients with an autograft returned to sports as opposed to 45.3% of patients with an allograft ( P = .01). Two studies found significantly greater postoperative knee laxity in the allograft group as compared with the autograft group ( P < .05). Among all patient-reported outcomes, 1 study found 1 significant difference between groups: patients with an autograft had a significantly higher postoperative Lysholm score when compared with patients with an allograft., Conclusion: Patients undergoing revision ACLR with an autograft can be expected to experience lower rates of graft retear, higher rates of return to sports, and less postoperative anteroposterior knee laxity when compared with patients undergoing revision ACLR with an allograft., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.C.M. has received research support from Arthrex and Smith+Nephew, consulting fees from Arthrex, honoraria from Vericel, and support for education from MedInc of Texas. E.C.M. has received consulting fees from Biomet, DePuy Synthes, Pacira Therapeutics, Flexion Therapeutics, and Medical Device Business Services; research support from Arthrex, Breg, DJ Orthopedics, Mitek, Ossur, and Smith+Nephew; support for education from Gemini Mountain Medical; and royalties from Biomet, Elsevier, and Zimmer. R.M.F. has received research support from Smith+Nephew and Arthrex; consulting fees from Allosource, Arthrex, and JRF; speaking fees from Ossur; support for education from Arthrex, Gemini Mountain Medical, and Pinnacle Inc; and publishing royalties from Elsevier. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Arthroscopic stabilization has been established as a superior treatment option for primary glenohumeral instability when compared with immobilization in internal rotation. However, immobilization in external rotation (ER) has recently gained interest as a viable nonoperative treatment option for patients with shoulder instability., Purpose: To compare the rates of recurrent instability and subsequent surgery in patients undergoing treatment for primary anterior shoulder dislocation with arthroscopic stabilization versus immobilization in ER., Study Design: Systematic review; Level of evidence, 2., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that'evaluated patients being treated for primary anterior glenohumeral dislocation with either arthroscopic stabilization or immobilization in ER. The search phrase used various combinations of the keywords/phrases "primary closed reduction,""anterior shoulder dislocation,""traumatic,""primary,""treatment,""management,""immobilization,""external rotation,""surgical,""operative,""nonoperative," and "conservative." Inclusion criteria included patients undergoing treatment for primary anterior glenohumeral joint dislocation with either immobilization in ER or arthroscopic stabilization. Rates of recurrent instability, subsequent stabilization surgery, return to sports, positive postintervention apprehension tests, and patient-reported outcomes were evaluated., Results: The 30 studies that met inclusion criteria included 760 patients undergoing arthroscopic stabilization (mean age, 23.1 years; mean follow-up time, 55.1 months) and 409 patients undergoing immobilization in ER (mean age, 29.8 years; mean follow-up time, 28.8 months). Overall, 8.8% of operative patients experienced recurrent instability at latest follow-up compared with 21.3% of patients who had undergone ER immobilization ( P < .0001). Similarly, 5.7% of operative patients had undergone a subsequent stabilization procedure at latest follow-up compared with 11.3% of patients who had undergone ER immobilization ( P = .0015). A higher rate of return to sports was found in the operative group ( P < .05), but no other differences were found between groups., Conclusion: Patients undergoing arthroscopic treatment for primary anterior glenohumeral dislocation with arthroscopic stabilization can be expected to experience significantly lower rates of recurrent instability and subsequent stabilization procedures compared with patients undergoing ER immobilization., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.T.B. has received research support from Biomet, Mitek, Smith & Nephew, and Stryker; consulting fees from DJ Orthopedics and Smith & Nephew; and royalties from Shukla Medical. A.J.S. has received consulting fees from DJ Orthopedics and Medacta USA, honoraria from Encore Medical, and support for education from Arthrex and Gemini Mountain Medical. R.M.F. has received consulting fees from Allosource, Arthrex, and JRF; research support from Arthrex and Smith & Nephew; speaking fees from JRF and Ossur; education support from Medwest, Smith & Nephew, Gemini Mountain Medical, and Pinnacle Inc; and publishing royalties from Elsevier. E.C.M. has received research support from Arthrex, Breg, DJ Orthopedics, Mitek, Ossur, and Smith & Nephew; consulting fees from Medical Device Business Services, Zimmer Biomet, Flexion Therapeutics, DePuy Synthes, and Pacira Therapeutics; IP royalties from Biomet and Zimmer; support for education from Gemini Mountain Medical; and publishing royalties from Elsevier. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) lesions are an uncommon cause of anterior glenohumeral instability and may occur in isolation or combination with other pathologies. As HAGL lesions are difficult to detect via magnetic resonance imaging (MRI) and arthroscopy, they can remain unrecognized and result in continued glenohumeral instability., Purpose: To compare patients with anterior shoulder instability from a large multicenter cohort with and without a diagnosis of a HAGL lesion and identify preoperative physical examination findings, patient-reported outcomes, imaging findings, and surgical management trends associated with HAGL lesions., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Patients with anterior glenohumeral instability who underwent surgical management between 2012 and 2020 at 11 orthopaedic centers were enrolled. Patients with HAGL lesions identified intraoperatively were compared with patients without HAGL lesions. Preoperative characteristics, physical examinations, imaging findings, intraoperative findings, and surgical procedures were collected. The Student t test, Kruskal-Wallis H test, Fisher exact test, and chi-square test were used to compare groups., Results: A total of 21 HAGL lesions were identified in 915 (2.3%) patients; approximately one-third (28.6%) of all lesions were visualized intraoperatively but not identified on preoperative MRI. Baseline characteristics did not differ between study cohorts. Compared with non-HAGL patients, HAGL patients were less likely to have a Hill-Sachs lesion (54.7% vs 28.6%; P = .03) or an anterior labral tear (87.2% vs 66.7%; P = .01) on preoperative MRI and demonstrated increased external rotation when their affected arm was positioned at 90° of abduction (85° vs 90°; P = .03). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization surgery (odds ratio, 74.6 [95% CI, 25.2-221.1]; P < .001)., Conclusion: Approximately one-third of HAGL lesions were missed on preoperative MRI. HAGL patients were less likely to exhibit preoperative imaging findings associated with anterior shoulder instability, such as Hill-Sachs lesions or anterior labral pathology. These patients underwent open procedures more frequently than patients without HAGL lesions., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This research was supported by the National Institutes of Health and Orthopaedic Research and Education Foundation. See the Supplemental Material for all author disclosures. 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.)

Anatomical total shoulder arthroplasty in its modern form where it reproduces the normal shoulder has been utilized clinically for more than half a century. As the technology and the designs have changed to recreate the humeral and glenoid sides of the joint, the sophistication of design has resulted in the growing number of cases annually worldwide. This increase is due in part to the increasing number of indications that the prosthesis can treat with successful results. On the humeral side, there have been design changes to better reflect the proximal humeral anatomy, and humeral stems are increasingly placed safely without cement. Platform systems which allow conversion of a failed arthroplasty to a reverse configuration without stem extraction is another design change. Similarly, there has been increasing utilization of short stem and stemless humeral components. Extensive experience with shorter stem and stemless devices, however, has yet to demonstrate the purported advantages of these devices, as recent studies have demonstrated equivalent blood loss, fracture rates, operative times, and outcome scores. Easier revision with these shorter stems remains to be definitively established, with only one study comparing the ease of revision between stem types. On the glenoid side, hybrid cementless glenoids, inlay glenoids, cementless all-polyethylene glenoids, and augmented glenoids have all been investigated; however, the indications for these devices remain unclear. Lastly, innovative surgical approaches to implanting shoulder arthroplasty and the use of patient specific guides and computerized planning, while interesting concepts, still await validation before they are utilized on a widespread basis. While reverse shoulder arthroplasty has been increasingly used to reconstruct the arthritic shoulder, anatomic glenohumeral replacement maintains a significant role in the armamentarium of the shoulder surgeon., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Patient-reported outcome measures (PROMs) have transitioned from primarily being used as research instruments to becoming increasingly used in the clinical setting to assess recovery and inform shared decision-making. However, there is a need to develop validated short-form PROM instruments to decrease patient burden and ease incorporation into clinical practice., Purpose: To assess the validity and responsiveness of a shortened version of the Western Ontario Shoulder Instability Index (Short-WOSI) when compared with the full WOSI and other shoulder-related PROM instruments., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: This study was a secondary analysis of data collected as part of an institutional review board-approved, multicenter cohort of 1160 patients undergoing surgical stabilization for shoulder instability. The following PROMs were captured preoperatively and 2 years after surgery: WOSI, American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and 36-Item Health Survey (RAND-36). The cohort was split into 2 data sets: a training set to be used in the development of the Short-WOSI (n = 580) and a test set to be used to assess the validity and responsiveness of the Short-WOSI relative to the full WOSI, ASES, SANE, and RAND-36., Results: The Short-WOSI demonstrated excellent internal consistency before surgery (Cronbach α = .83) and excellent internal consistency at the 2-year follow-up (Cronbach α = .93). The baseline, 2-year, and pre- to postoperative changes in Short-WOSI and WOSI were closely correlated ( r > 0.90), with both demonstrating large effect sizes (Short-WOSI = 1.92, WOSI = 1.81). Neither the Short-WOSI nor the WOSI correlated well with the other PROM instruments before ( r = 0.21-0.33) or after ( r = 0.25-0.38) surgery. The Short-WOSI, WOSI, and SANE scores were more responsive than ASES and RAND-36 scores., Conclusion: The 7-item Short-WOSI demonstrated excellent internal consistency and a lack of floor or ceiling effects. The Short-WOSI demonstrated excellent cross-sectional and longitudinal construct validity and was similarly responsive over time as the full WOSI. Neither the Short-WOSI nor WOSI correlated with more general shoulder PROMs, underscoring the advantage of using instability-specific instruments for this population.

Background: Predictors of return to activity after anterior cruciate ligament reconstruction (ACLR) among patients with relatively high preinjury activity levels remain poorly understood., Purpose/hypothesis: The purpose of this study was to identify predictors of return to preinjury levels of activity after ACLR, defined as achieving a Marx activity score within 2 points of the preinjury value, among patients with Marx activity scores of 12 to 16 who had been prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) cohort. We hypothesized that age, sex, preinjury activity level, meniscal injuries and/or procedures, and concurrent articular cartilage injuries would predict return to preinjury activity levels at 2 years after ACLR., Study Design: Cohort study; Level of evidence, 2., Methods: All unilateral ACLR procedures from 2002 to 2008 performed in patients enrolled in the MOON, with preinjury Marx activity scores ranging from 12 to 16, were evaluated with a specific focus on return to preinjury activity levels at 2 years postoperatively. Return to activity was defined as a Marx activity score within 2 points of the preinjury value. The proportion of patients able to return to preinjury activity levels was calculated, and multivariable modeling was performed to identify risk factors for patients' inability to return to preinjury activity levels., Results: A total of 1188 patients were included in the final analysis. The median preinjury Marx activity score was 16 (interquartile range, 12-16). Overall, 466 patients (39.2%) were able to return to preinjury levels of activity, and 722 patients (60.8%) were not able to return to preinjury levels of activity. Female sex, smoking at the time of ACLR, fewer years of education, lower 36-Item Short Form Health Survey Mental Component Summary scores, and higher preinjury Marx activity scores were predictive of patients' inability to return to preinjury activity levels. Graft type, revision ACLR, the presence of medial and/or lateral meniscal injuries, a history of meniscal surgery, the presence of articular cartilage injuries, a history of articular cartilage treatment, and the presence of high-grade knee laxity were not predictive of a patient's ability to return to preinjury activity level., Conclusion: At 2 years after ACLR, most patients with high preinjury Marx activity scores did not return to their preinjury level of activity. The higher the preinjury Marx activity score that a patient reported at the time of enrollment, the less likely he/she was able to return to preinjury activity level. Smoking and lower mental health at the time of ACLR were the only modifiable risk factors in this cohort that predicted an inability to return to preinjury activity levels. Continued effort and investigation are required to maximize functional recovery after ACLR in patients with high preinjury levels of activity.

Purpose: To systematically review the literature to compare the efficacy and safety of platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and hyaluronic acid (HA) injections for the treatment of knee osteoarthritis (OA)., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I studies that compared the clinical efficacy of at least 2 of the following 3 injection therapies: PRP, BMAC, and HA for knee OA. The search phrase used was knee AND osteoarthritis AND randomized AND ("platelet rich plasma" OR "bone marrow aspirate" OR "hyaluronic acid"). Patients were primarily assessed based on patient-reported outcome scores (PROs) including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) score., Results: Twenty-seven studies (all Level I) met inclusion criteria, including 1,042 patients undergoing intra-articular injection(s) with PRP (mean age 57.7 years, mean follow-up 13.5 months), 226 patients with BMAC (mean age 57.0 years, mean follow-up 17.5 months), and 1,128 patients with HA (mean age 59.0 years, mean follow-up 14.4 months). Nonnetwork meta-analyses demonstrated significantly better postinjection WOMAC (P < .001), VAS (P < .01), and Subjective IKDC scores (P < .001) in patients who received PRP compared with patients who received HA. Similarly, network meta-analyses demonstrated significantly better postinjection WOMAC (P < .001), VAS (P = .03), and Subjective IKDC (P < .001) scores in patients who received BMAC compared with patients who received HA. There were no significant differences in postinjection outcome scores when comparing PRP with BMAC., Conclusions: Patients undergoing treatment for knee OA with PRP or BMAC can be expected to experience improved clinical outcomes when compared with patients who receive HA., Level of Evidence: Level I, meta-analysis of Level I studies., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Multiple studies have compared redislocation rates after stabilization and immobilization for patients experiencing a traumatic, first-time anterior shoulder dislocation (ASD)., Purpose: To systematically review the literature to compare rates of recurrent instability and subsequent instability surgery in patients undergoing treatment for a first-time ASD with surgical stabilization versus shoulder immobilization., Study Design: Systematic review and meta-analysis; Level of evidence, 1., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 randomized studies that compared outcomes of surgical stabilization versus immobilization for treatment of primary ASD. The following search phrase was used: (glenohumeral OR anterior shoulder) AND (conservative OR nonoperative OR nonsurgical OR physiotherapy) AND (Bankart OR repair OR stabilization OR surgical OR surgery OR arthroscopic OR arthroscopy) AND (instability OR dislocation). Patients with soft tissue disruption alone as well as those with additional minor bony lesions (Hill-Sachs, Bankart) were included. Recurrent instability and subsequent instability surgery rates, the Western Ontario Shoulder Instability Index (WOSI), and range of motion were evaluated., Results: A total of 5 studies met inclusion criteria, including 126 patients undergoing surgical stabilization (mean age, 23.6 years; range, 15.0-39.0 years) and 133 patients undergoing treatment with sling immobilization only (mean age, 23.1 years; range, 15.0-31.0 years). Mean follow-up was 59.7 months. Overall, 6.3% of operative patients experienced recurrent instability at latest follow-up compared with 46.6% of nonoperative patients ( P < .00001). Similarly, 4.0% of operative patients underwent a subsequent instability surgery compared with 30.8% of nonoperative patients ( P < .00001). These same trends were demonstrated when data were isolated to nonoperative patients immobilized in internal rotation. When comparing the operative and nonoperative groups at latest follow-up, 1 study found significantly improved WOSI scores among operative patients ( P = .035) and 1 study found significantly improved abducted external rotation in nonoperative patients ( P = .02)., Conclusion: Patients, particularly active men in their 20s and 30s, undergoing treatment for a first-time ASD with a surgical stabilization procedure can be expected to experience significantly lower rates of recurrent instability and a significantly decreased need for a future stabilization procedure when compared with patients treated nonoperatively.

Background: Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis., Hypothesis/purpose: The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects., Results: Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher., Conclusion: An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes., Registration: NCT02075775 (ClinicalTrials.gov identifier).

Background: Meniscal and chondral damage is common in the patient undergoing revision anterior cruciate ligament (ACL) reconstruction., Purpose: To determine if meniscal and/or articular cartilage pathology at the time of revision ACL surgery significantly influences a patient's outcome at 6-year follow-up., Study Design: Cohort study; Level of evidence, 3., Methods: Patients undergoing revision ACL reconstruction were prospectively enrolled between 2006 and 2011. Data collection included baseline demographics, surgical technique, pathology, treatment, and scores from 4 validated patient-reported outcome instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx Activity Rating Scale. Patients were followed up at 6 years and asked to complete the identical set of outcome instruments. Regression analysis assessed the meniscal and articular cartilage pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction., Results: An overall 1234 patients were enrolled (716 males, 58%; median age, 26 years). Surgeons reported the pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (43%), lateral femoral condyle (29%), medial tibial plateau (11%), lateral tibial plateau (17%), patella (30%), and trochlea (21%). Six-year follow-up was obtained on 79% of the sample (980/1234). Meniscal pathology and articular cartilage pathology (medial femoral condyle, lateral femoral condyle, lateral tibial plateau, trochlea, and patella) were significant drivers of poorer patient-reported outcomes at 6 years (IKDC, KOOS, WOMAC, and Marx). The most consistent factors driving outcomes were having a medial meniscal excision (either before or at the time of revision surgery) and patellofemoral articular cartilage pathology. Six-year Marx activity levels were negatively affected by having either a repair/excision of the medial meniscus (odds ratio range, 1.45-1.72; P ≤ .04) or grade 3-4 patellar chondrosis (odds ratio, 1.72; P = .04). Meniscal pathology occurring before the index revision surgery negatively affected scores on all KOOS subscales except for sports/recreation ( P < .05). Articular cartilage pathology significantly impaired all KOOS subscale scores ( P < .05). Lower baseline outcome scores, higher body mass index, being a smoker, and incurring subsequent surgery all significantly increased the odds of reporting poorer clinical outcomes at 6 years., Conclusion: Meniscal and chondral pathology at the time of revision ACL reconstruction has continued significant detrimental effects on patient-reported outcomes at 6 years after revision surgery.

Background: Some studies have suggested that running increases the risk of knee osteoarthritis (OA), while others believe it serves a protective function., Purpose: To perform an updated systematic review of the literature to determine the effects of running on the development of knee OA., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies evaluating the effect of cumulative running on the development of knee OA or chondral damage based on imaging and/or patient-reported outcomes (PROs). The search terms used were "knee AND osteoarthritis AND (run OR running OR runner)." Patients were evaluated based on plain radiographs, magnetic resonance imaging (MRI), and PROs (presence of knee pain, Health Assessment Questionnaire-Disability Index, and the Knee injury and Osteoarthritis Outcome Score)., Results: Seventeen studies (6 level 2 studies, 9 level 3 studies, and 2 level 4 studies), with 7194 runners and 6947 nonrunners, met the inclusion criteria. The mean follow-up time was 55.8 months in the runner group and 99.7 months in the nonrunner group. The mean age was 56.2 years in the runner group and 61.6 years in the nonrunner group. The overall percentage of men was 58.5%. There was a significantly higher prevalence of knee pain in the nonrunner group ( P < .0001). Although 1 study found a significantly higher prevalence of osteophytes in the tibiofemoral (TF) and patellofemoral (PF) joints within the runner group, multiple studies found no significant differences in the prevalence of radiographic knee OA (based on TF/PF joint-space narrowing or Kellgren-Lawrence grade) or cartilage thickness on MRI between runners and nonrunners ( P > .05). One study found a significantly higher risk of knee OA progressing to total knee replacement among nonrunners (4.6% vs 2.6%; P = .014)., Conclusion: In the short term, running is not associated with worsening PROs or radiological signs of knee OA and may be protective against generalized knee pain., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.J.S. has received consulting fees from DePuy/Medical Device Business Services; and hospitality payments from Globus Medical. E.C.M. has received education payments from Gemini Mountain Medical; consulting fees from Medical Device Business Services, Flexion Therapeutics, and Zimmer Biomet; and nonconsulting fees from Arthrex. P.C.M. has received education payments from MedInc and Smith & Nephew; consulting fees from Smith & Nephew; and speaking fees and honoraria from Vericel. 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.)

Purpose: To determine the top orthopaedic surgery sports medicine fellowship programs in the United States and the most important aspects of fellowship programs as perceived by applicants., Methods: An anonymous survey was distributed via e-mail and text message to all current/former orthopaedic surgery residents who applied to one particular orthopaedic sports medicine fellowship program during the 2017-2018 through 2021-2022 application cycles. The survey asked applicants to rank what they considered to be the top-10 orthopaedic sports medicine fellowship programs in the United States before and after completion of their application cycle, based on operative and nonoperative experience, faculty, game coverage, research, and work-life balance. Final rank was calculated by awarding 10 points for a first-place vote, 9 points for a second-place vote, etc., with total number of points used to determine final ranking for each program. Secondary outcomes included rates of applying to perceived top-10 programs, relative importance of different fellowship program aspects, and preferred type of practice., Results: Seven-hundred sixty-one surveys were distributed with 107 applicants responding (14% response rate). Applicants voted the top orthopaedic sports medicine fellowships programs to be: (1) Steadman Philippon Research Institute, (2) Rush University Medical Center, and (3) Hospital for Special Surgery, both before and following the application cycle. When ranking fellowship program aspects, faculty members and fellowship reputation were most likely to be ranked highest in importance., Conclusions: This study demonstrates that most orthopaedic sports medicine fellowship applicants highly valued program reputation and faculty members when choosing a fellowship program and that the application/interview process did not have a substantial effect on how individuals perceived the top programs., Clinical Relevance: The findings of this study are important for residents applying to orthopaedic sports medicine fellowships and may have implications on fellowship programs and future application cycles., (© 2022 The Authors.)

Knee dislocations (KDs) are devastating injuries for patients and present complex challenges for orthopaedic surgeons. Although short-term outcomes have been studied, there are few long-term outcomes of these injuries available in the literature. The purpose of this study is to determine factors that influence mid- to long-term clinical outcomes following surgical treatment of KD. A review of the current literature was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies published from 2010 to 2019 with a minimum 2-year follow-up that reported outcomes following surgical treatment of KDs. Ten studies (6 level III, 4 level IV) were included. At mid- (2-10 y) to long-term (>10 y) follow-up, concomitant arterial, cartilage, and combined meniscus damage were predictive factors for inferior Lysholm and International Knee Documentation Committee (IKDC) scores when compared with patients without these associated injuries. Although concomitant neurological damage may influence short-term outcomes due to decreased mobility, at longer follow-up periods it does not appear to predict worse clinical outcomes when compared with patients without concomitant neurological injury. Frank and polytrauma KDs have been associated with worse mid- to long-term outcomes when compared with transient and isolated KDs. Patients who underwent surgery within 6 weeks of trauma experienced better long-term outcomes than those who underwent surgery longer than 6 weeks after the initial injury. However, the small sample size of this study makes it difficult to make valid recommendations. Lastly, female sex, patients older than 30 years at the time of injury and a body mass index (BMI) greater than 35 kg/m 2 are factors that have been associated with worse mid- to long-term Lysholm and IKDC scores. The results of this review suggest that female sex, age >30 years, BMI >35 kg/m 2 , concomitant cartilage damage, combined medial and lateral meniscal damage, KDs that do not spontaneously relocate, and KDs associated with polytrauma may predict worse results at mid- to long-term follow-up., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Bone marrow aspirate concentrate (BMAC) has emerged as a therapeutic option for symptomatic knee osteoarthritis (OA)., Purpose: To systematically review the literature to evaluate the efficacy of isolated BMAC injection in the treatment of OA of the knee joint., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review was performed by searching the PubMed, Embase, and Cochrane Library databases up to July 2020 to identify human studies that assessed the clinical outcomes of isolated BMAC injection for the treatment of knee OA. The electronic search strategy used was "bone marrow aspirate concentrate knee osteoarthritis.", Results: Eight studies met the inclusion criteria, including a total of 299 knees with a mean follow-up of 12.9 months (range, 6-30 months). Of all patient-reported outcomes assessed across studies, 34 of 36 (94.4%) demonstrated significant improvement from baseline to latest follow-up ( P < .05). Five studies evaluating numerical pain scores (visual analog scale and Numeric Rating Scale) reported significant improvements in pain level at final follow-up ( P < .01). However, 3 comparative studies evaluating BMAC in relation to other therapeutic injections failed to demonstrate the clinical superiority of BMAC., Conclusion: The BMAC injection is effective in improving pain and patient-reported outcomes in patients with knee OA at short- to midterm follow-up. Nevertheless, BMAC has not demonstrated clinical superiority in relation to other biologic therapies commonly used in the treatment of OA, including platelet-rich plasma and microfragmented adipose tissue, or in relation to placebo. The high cost of the BMAC injection in comparison with other biologic and nonoperative treatment modalities may limit its utility despite demonstrable clinical benefit.

Background: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described., Purpose: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics., Results: A total of 159 patients (13%) underwent tunnel grafting-64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group ( P ≤ .001). Patients who required 2-stage grafting had more previous ACLRs ( P < .001) and were less likely to have received a bone-patellar tendon-bone or a soft tissue autograft at primary ACLR procedure ( P ≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone-patellar tendon-bone allograft ( P ≤ .008) and less likely to receive a soft tissue autograft ( P ≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) ( P ≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group., Conclusion: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Purpose: To perform an updated systematic review comparing the clinical outcomes of autograft versus nonirradiated allograft for anterior cruciate ligament reconstruction (ACLR)., Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies directly comparing outcomes of primary ACLR with autograft versus nonirradiated allograft with a minimum 2-year follow-up. The search terms used were: "anterior cruciate ligament" AND autograft AND allograft AND (irradiation OR non-irradiated). Patients were evaluated based on graft failure rates, the Objective International Knee Documentation Committee (IKDC) score, anteroposterior laxity, and patient-reported outcomes (Subjective IKDC score, the visual analog scale [VAS], the Cincinnati Knee Rating System, Lysholm, and Tegner scores). Risk of bias was assessed using the ROBINS-I and Cochrane Collaboration's risk of bias tool for non-randomized and randomized studies, respectively., Results: Sixteen studies (3 Level I, 7 Level II, 6 Level III) met inclusion criteria, including a total of 15,502 patients undergoing ACLR with autograft and 1,577 with nonirradiated allograft. The average follow-up ranged from 24.0 to 132.0 months. Graft failure ranged from 0% to 9.4% of patients in the autograft group and 0% to 26.5% in the allograft group. Two studies showed greater failure rates among younger patients in the allograft group. There were no significant differences between the Objective IKDC score, anteroposterior laxity, or patient-reported outcomes between the groups within any of the included studies ( P > .05)., Conclusions: Autograft and nonirradiated allograft for primary ACLR demonstrate similar patient-reported outcomes and graft failure rates., Level of Evidence: III, systematic review of level I-III studies., (© 2022 The Authors.)

Background: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes)., Hypotheses: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA., Study Design: Cohort study; Level of evidence, 2., Methods: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level., Results: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels., Conclusion: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

Purpose: To systematically review the literature to compare the efficacy of platelet-rich plasma (PRP) and hyaluronic acid (HA) injections for the treatment of hip osteoarthritis (OA)., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that compared the clinical efficacy of PRP and HA injections for hip OA. The search phrase used was hip, osteoarthritis, platelet-rich plasma, hyaluronic acid, randomized. Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Visual Analog Scale (VAS) for pain, and the Harris Hip Score (HHS). Subanalyses were performed for any outcome score in which ≥3 studies reported results., Results: Six studies (5 level I, 1 level II) met inclusion criteria, including 211 patients undergoing intra-articular injection with PRP (mean age 60.0 years, mean follow-up 12.2 months) and 197 patients with HA (mean age 62.3 years, mean follow-up 11.9 months). No significant differences were found in the weighted improvement of any outcome score (WOMAC, VAS, or HHS) from preinjection to postinjection between groups. When excluding a study with the highest risk of bias to eliminate heterogeneity, pooled subanalysis demonstrated no significant differences in WOMAC subscores between PRP and HA groups. Similarly, in a pooled subanalysis that isolated patients treated with leukocyte-poor PRP, no significant differences in WOMAC subscores were found between PRP and HA groups., Conclusion: Patients undergoing treatment for hip OA with either PRP or HA injections can expect to experience similarly beneficial short-term clinical outcomes., Level of Evidence: II, systematic review of level I and II studies., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Patients undergoing shoulder stabilization surgery have been shown to have elevated activity levels. Factors associated with shoulder activity in this patient population at baseline and after surgery are unknown., Hypothesis: Patient-specific variables are associated with shoulder activity level at baseline and at 2-year follow-up in a cohort of patients undergoing shoulder stabilization surgery., Study Design: Cohort study; Level of evidence, 2., Methods: Patients undergoing shoulder stabilization surgery were prospectively enrolled. As part of the data collection process, patients completed a previously validated Shoulder Activity Scale. A regression analysis was performed to assess the association of patient characteristics with baseline and 2-year follow-up shoulder activity levels., Results: A total of 764 (n = 612 men, n = 152 women) out of 957 patients (80%) undergoing shoulder stabilization surgery with a median age of 25 years had baseline and 2-year follow-up data and were included in the current analysis. The baseline shoulder activity level was associated with race ( P < .0001) and preoperative duration of instability ( P < .0001). At 2 years, 52% of the cohort had returned to the same or higher activity level after surgery. Predictors of higher shoulder activity level at 2-year follow-up included higher baseline activity level ( P < .0001), male sex ( P < .0001), younger age ( P = .004), higher body mass index (BMI) ( P = .03), more dislocations ( P = .03), nonsmokers ( P = .04), and race ( P = .04)., Conclusion: A longer duration of preoperative symptoms was associated with a lower baseline activity in this cohort. High baseline preoperative shoulder activity, younger age, male sex, higher BMI, number of dislocations, and nonsmoking status predicted higher shoulder activity 2 years after shoulder stabilization surgery., Registration: NCT02075775 (ClinicalTrials.gov identifier).

Background: Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited., Methods: We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates., Results: A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m 2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men., Conclusions: Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the biomechanical properties of the knotted versus knotless transosseous-equivalent (TOE) techniques for rotator cuff repair (RCR)., Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and the Cochrane Library to identify studies that compared the biomechanical properties of knotted and knotless TOE RCR techniques. The search phrase used was as follows: (Double Row) AND (rotator cuff) AND (repair) AND (biomechanical). Evaluated properties included ultimate load to failure, cyclic displacement, stiffness, footprint characteristics, and failure mode., Results: Eight studies met the inclusion criteria, including a total of 67 specimens in each group. Of 6 studies reporting on ultimate load to failure, 4 found tendons repaired with the knotted TOE technique to experience significantly higher ultimate load to failure compared with knotless TOE repairs (knotted range, 323.5-549.0 N; knotless range, 166.0-416.8 N; P < .05). Of 6 studies reporting on failure stiffness, 2 found knotted TOE repairs to have significantly higher failure stiffness compared with knotless TOE repairs (knotted range, 30.0-241.8 N/mm; knotless range, 28.0-182.5 N/mm; P < .05), whereas 1 study found significantly higher failure stiffness in knotless TOE repairs compared with knotted TOE repairs (P = .039). Cyclic gap formation favored the knotted TOE group in 2 of 3 studies (knotted range, 0.6-5.2 mm; knotless range, 0.4-9.1 mm; P < .05). The most common mode of failure in both groups was suture tendon tear., Conclusions: On the basis of the included cadaveric studies, rotator cuff tendons repaired via the knotted TOE technique display superior time-zero biomechanical properties, including greater ultimate load to failure, compared with rotator cuffs repaired via the knotless TOE technique. Suture tearing through the tendon remains a common failure method for both techniques., Clinical Relevance: The results of this systematic review provide helpful insight into the biomechanical differences between 2 popular techniques for RCR. Although these results should be carefully considered by surgeons who are using either of these techniques in the operating room, they should not be mistaken for direct clinical applicability because cadaveric studies may not directly correlate to clinical outcomes., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this systematic review is to evaluate the current literature in an effort to investigate sleep quality and disturbances and the association with clinical outcomes of patients undergoing shoulder surgery., Methods: A systematic review of the PubMed, Embase, and Cochrane Library databases was performed according to PRISMA guidelines. All English-language literature reporting clinical outcomes and sleep quality and disturbance after shoulder surgery was reviewed by 2 independent reviewers. Outcomes assessed included patient-reported outcomes (PROs) and sleep quality. Specific PROs included the Pittsburgh Sleep Quality Index (PSQI), Visual Analog Scale (VAS) for pain, Simple Shoulder Test (SST), University of California Los Angeles (UCLA) Shoulder Rating Scale, and American Shoulder and Elbow Surgeons Score (ASES). Study methodology was assessed using the Modified Coleman Methodology Score. Descriptive statistics are presented., Results: Sixteen studies (11 level IV, 2 level III, 3 level II) with a total of 2748 shoulders were included (age, 12-91 years; follow-up, 0.25-132 months). In total, 2198 shoulders underwent arthroscopic rotator cuff repair (RCR), 131 shoulders underwent arthroscopic capsular release, 372 shoulders underwent total shoulder arthroplasty (TSA), 18 shoulders underwent comprehensive arthroscopic management, and 29 shoulders underwent sternoclavicular joint procedures. All shoulder surgeries improved self-reported sleep and PROs from before to after surgery. In RCR patients, PSQI scores were significantly associated with VAS scores, SST scores (r = 0.453, r = -0.490, P < .05, respectively), but not significantly associated with UCLA Shoulder rating scale or the ASES scores (r = 0.04, r = 0.001, P > .05, respectively). In TSA patients, PSQI scores were significantly associated with ASES scores (r = -0.08, P < .05). All 4 RCR studies and 1 TSA study using PSQI found significant improvements in mean PSQI scores within 6 to 24 months (P < .05)., Conclusions: Surgical intervention for rotator cuff tear and glenohumeral osteoarthritis significantly improves self-reported sleep in patients with shoulder pain. However, there remains a dearth of available studies assessing the effects of surgical intervention for adhesive capsulitis, sternoclavicular joint instability, and sternoclavicular osteoarthritis on sleep. Future studies should use sleep-specific PROs and quantitative measures of sleep to further elucidate the relationship between sleep and the effect of shoulder surgery., Level of Evidence: Level IV, systematic review of Level II-IV studies., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To understand the perceptions of program directors (PDs) and fellowship applicants regarding the virtual interview process for orthopaedic surgery sports medicine fellowship programs., Methods: An anonymous online survey was distributed through the American Orthopaedic Society for Sports Medicine (AOSSM) to applicants and PDs of orthopaedic surgery sports medicine fellowship programs following the 2020-2021 fellowship application cycle., Results: A total of 40 responses were received from PDs for a response rate of 47% (40 of 85) and 72 responses were received from applicants for a response rate of 27% (72 of 271). All of the surveyed PDs (40/40, 100%) agreed/strongly agreed that the applicant's interview carries significant weight in determining where an applicant is ranked on the match list. Fifty-eight percent (23 of 40) of PDs agreed/strongly agreed that virtual interviews negatively affected their personal connection with the fellowship interviewee. The presence of virtual interviews allowed 80% (57 of 71) of applicants to go on more interviews. Seventy-three percent (51 of 70) of applicants were able to save greater than $5,000 on travel expenses and 63% (25 of 40) of fellowship programs were able to save greater than $2,500 by conducting virtual interviews., Conclusions: Virtual interviews allowed fellowship programs and applicants to complete more interviews, but both PDs and applicants stated that interviewing in-person was important for applicants to meet faculty and tour the institution where they may be spending a year. In contrast, significant financial savings resulted due to the transition to virtual interviews. Finally, both PDs and applicants were in favor of having the option of interviewing virtually, suggesting that virtual interviews may continue to play a role in future application cycles., Clinical Relevance: This study may be valuable to fellowship programs that will continue to implement virtual interviews into future application cycles., (© 2021 The Authors.)

Background: Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy., Purpose: To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption., Study Design: Systematic review., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was "hip arthroscopy fascia iliaca randomized." Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption., Results: Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; P = .054), IAR (7.7 vs 7.9; P = .72), control group (no FIB: 4.1 vs 3.8; P = .76); or saline placebo (difference, -0.2 [95% CI, -1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; P = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; P = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities., Conclusion: In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.

Importance: Arthroscopic suprapectoral biceps tenodesis (ABT) and open subpectoral biceps tenodesis (OBT) are two surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior to posterior (SLAP) tears. There is insufficient knowledge regarding the clinical superiority of one technique over the other., Objective: To systematically review the literature in order to compare the clinical outcomes and safety of ABT and OBT for treatment of LHBT or SLAP pathology., Evidence Review: A systematic review was performed by searching PubMed, the Cochrane Library and Embase to identify studies that compared the clinical efficacy of ABT versus OBT. The search phrase used was: ( bicep OR biceps OR biceps brachii OR long head of biceps brachii OR biceps tendinopathy) AND (tenodesis ). Patients were assessed based on the American Shoulder and Elbow Surgeons Score, the visual analogue scale, the Single Assessment Numeric Evaluation, Constant-Murley Score, clinical failure, range of motion, bicipital groove pain and strength. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and both the Cochrane Collaboration's and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) risk of bias tools were used to evaluate risk of bias., Findings: Eight studies (one level I, seven level III) met inclusion criteria, including 326 patients undergoing ABT and 381 patients undergoing OBT. No differences were found in treatment failure rates or patient-reported outcome scores between groups in any study. One study found OBT patients to experience significantly increased range of shoulder forward flexion when compared with ABT patients (p=0.049). Two studies found ABT patients to experience significantly more postoperative stiffness when compared with OBT patients (p<0.05)., Conclusions: Patients undergoing ABT and OBT can be expected to experience similar improvements in clinical outcomes at latest follow-up without differences treatment failure or functional performance. ABT patients may experience an increased incidence of stiffness in the early postoperative period., Level of Evidence: III., Competing Interests: Competing interests: None declared., (© International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To systematically review the literature to evaluate the biomechanical properties of the suture anchor (SA) versus transosseous tunnel (TO) techniques for quadriceps tendon (QT) repair., Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase using PRISMA guidelines to identify studies that evaluated the biomechanical properties of SA and TO techniques for repair of a ruptured QT. The search phrase used was "quadriceps tendon repair biomechanics". Evaluated properties included ultimate load to failure (N), displacement (mm), stiffness (N/mm), and mode of failure., Results: Five studies met inclusion criteria, including a total of 72 specimens undergoing QT repair via the SA technique and 42 via the TO technique. Three of 4 studies found QTs repaired with SA to have significantly less elongation upon initial cyclic loading when compared to QTs repaired with the TO technique ( P  < .05). Three of 5 studies found QTs repaired with SA to have significantly less elongation upon final cyclic loading when compared to QTs repaired with the TO technique ( P < .05). The pooled analysis from 4 studies reporting on initial displacement showed a statistically significant difference in favor of the SA group compared to the TO group ( P  = .03). The pooled analysis from studies reporting on secondary displacement and ultimate load to failure showed no significant difference between the SA and TO groups ( P > .05). The most common mode of failure in both groups was suture slippage., Conclusion: On the basis of the included cadaveric studies, QTs repaired via the SA technique have less initial displacement upon cyclic testing when compared to QTs repaired via the TO technique. However, final displacement and ultimate load to failure outcomes did not reveal differences between the two fixation strategies. Knot slippage remains a common failure method for both strategies., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Background: When meniscal repair is performed during anterior cruciate ligament (ACL) reconstruction (ACLR), the effect of ACL graft type on meniscal repair outcomes is unclear., Hypothesis: The authors hypothesized that meniscal repairs would fail at the lowest rate when concomitant ACLR was performed with bone--patellar tendon--bone (BTB) autograft., Study Design: Cohort study; Level of evidence, 3., Methods: Patients who underwent meniscal repair at primary ACLR were identified from a longitudinal, prospective cohort. Meniscal repair failures, defined as any subsequent surgical procedure addressing the meniscus, were identified. A logistic regression model was built to assess the association of graft type, patient-specific factors, baseline Marx activity rating score, and meniscal repair location (medial or lateral) with repair failure at 6-year follow-up., Results: A total of 646 patients were included. Grafts used included BTB autograft (55.7%), soft tissue autograft (33.9%), and various allografts (10.4%). We identified 101 patients (15.6%) with a documented meniscal repair failure. Failure occurred in 74 of 420 (17.6%) isolated medial meniscal repairs, 15 of 187 (8%) isolated lateral meniscal repairs, and 12 of 39 (30.7%) of combined medial and lateral meniscal repairs. Meniscal repair failure occurred in 13.9% of patients with BTB autografts, 17.4% of patients with soft tissue autografts, and 19.4% of patients with allografts. The odds of failure within 6 years of index surgery were increased more than 2-fold with allograft versus BTB autograft (odds ratio = 2.34 [95% confidence interval, 1.12-4.92]; P = .02). There was a trend toward increased meniscal repair failures with soft tissue versus BTB autografts (odds ratio = 1.41 [95% confidence interval, 0.87-2.30]; P = .17). The odds of failure were 68% higher with medial versus lateral repairs ( P < .001). There was a significant relationship between baseline Marx activity level and the risk of subsequent meniscal repair failure; patients with either very low (0-1 points) or very high (15-16 points) baseline activity levels were at the highest risk ( P = .004)., Conclusion: Meniscal repair location (medial vs lateral) and baseline activity level were the main drivers of meniscal repair outcomes. Graft type was ranked third, demonstrating that meniscal repairs performed with allograft were 2.3 times more likely to fail compared with BTB autograft. There was no significant difference in failure rates between BTB versus soft tissue autografts., Registration: NCT00463099 (ClinicalTrials.gov identifier)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Research reported in this publication was partially supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award No. R01AR053684 (to K.P.S.) and under award No. K23AR066133, which supported a portion of M.H.J.’s professional effort. Contents of this article are solely the responsibility of the authors and do not necessarily represent official views of the National Institutes of Health. 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: Articular cartilage and meniscal damage are commonly encountered and often treated at the time of anterior cruciate ligament reconstruction (ACLR). Our understanding of how these injuries and their treatment relate to outcomes of ACLR is still evolving., Hypothesis/purpose: The purpose of this study was to assess whether articular cartilage and meniscal variables are predictive of 10-year outcomes after ACLR. We hypothesized that articular cartilage lesions and meniscal tears and treatment would be predictors of the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level outcomes at 10-year follow-up after ACLR., Study Design: Cohort study (prognosis); Level of evidence, 1., Methods: Between 2002 and 2008, individuals with ACLR were prospectively enrolled and followed longitudinally using the IKDC, KOOS, and Marx activity score completed at entry, 2, 6, and 10 years. A proportional odds logistic regression model was built incorporating variables from patient characteristics, surgical technique, articular cartilage injuries, and meniscal tears and treatment to determine the predictors (risk factors) of IKDC, KOOS, and Marx outcomes at 10 years., Results: A total of 3273 patients were enrolled (56% male; median age, 23 years at time of enrollment). Ten-year follow-up was obtained on 79% (2575/3273) of the cohort. Incidence of concomitant pathology at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 22%; lateral femoral condyle [LFC], 15%; medial tibial plateau [MTP], 4%; lateral tibial plateau [LTP], 11%; patella, 18%; trochlea, 8%) and meniscal pathology (medial, 37%; lateral, 46%). Variables that were predictive of poorer 10-year outcomes included articular cartilage damage in the patellofemoral ( P < .01) and medial ( P < .05) compartments and previous medial meniscal surgery (7% of knees; P < .04). Compared with no meniscal tear, a meniscal injury was not associated with 10-year outcomes. Medial meniscal repair at the time of ACLR was associated with worse 10-year outcomes for 2 of 5 KOOS subscales, while a medial meniscal repair in knees with grade 2 MFC chondrosis was associated with better outcomes on 2 KOOS subscales., Conclusion: Articular cartilage injury in the patellofemoral and medial compartments at the time of ACLR and a history of medial meniscal surgery before ACLR were associated with poorer 10-year ACLR patient-reported outcomes, but meniscal injury present at the time of ACLR was not. There was limited and conflicting association of medial meniscal repair with these outcomes.

Background: Recent evidence suggests that there may be an increased risk of infection for patients undergoing a corticosteroid injection before, during, or after knee arthroscopy., Purpose: To systematically review the literature to evaluate the risk of postoperative infection in patients undergoing intra-articular corticosteroid injections (CSI) before, during, or after knee arthroscopy., Study Design: Systematic review; Level of evidence, 3., Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies that evaluated the rate of postoperative infection in patients undergoing knee arthroscopy who received an intra-articular CSI during the perioperative period. The search phrase used was "knee AND arthroscopy AND injection AND (infection OR revision)." A subanalysis was also performed to analyze infection rates based on the timing of the corticosteroid injection in relation to arthroscopy., Results: Four studies met the inclusion criteria, representing 11,925 patients undergoing knee arthroscopy with an intra-articular CSI administered during the perioperative period (mean follow-up, 5.3 months) and 247,329 patients without a corticosteroid injection during the perioperative period (mean follow-up, 5.9 months). Patients who received an injection experienced a statistically significantly higher rate of postoperative infection (2.2%) when compared with patients who did not receive an injection (1.1%; P < .001). When analyzed by the timing of the injection, patients receiving an injection preoperatively or intraoperatively experienced a statistically significantly higher rate of postoperative infection (3% and 2.6%, respectively) when compared with patients receiving an injection postoperatively (1.4%; P = .001 for both)., Conclusion: Patients undergoing knee arthroscopy who receive an intra-articular CSI during the perioperative period can be expected to experience significantly higher postoperative infection rates when compared with patients not receiving an injection. Furthermore, patients receiving a corticosteroid injection pre- or intraoperatively may experience significantly higher rates of postoperative infection when compared with patients receiving an injection postoperatively., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: O.M.-D. has received research support, consulting fees, and royalties from Stryker and nonconsulting fees from Smith & Nephew; and has stock/stock options in MITA. A.J.S. has received research support from ISO-Biologics and consulting fees from DePuy. E.C.M. has received research support from Arthrex, Biomet, Breg, Mitek, Ossur, Smith & Nephew, and Stryker; education payments from Gemini Mountain; consulting fees from Zimmer and Medical Device Business Services; speaking fees from Arthrex; and royalties from Elsevier and Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Background: The purpose of this study was to describe the clinical outcomes following bilateral total shoulder arthroplasty (TSA)., Methods: A systematic search of the PubMed, Embase, and Cochrane Library databases following PRISMA guidelines was performed. English-language literature published from 2010 to 2018 analyzing bilateral TSA (anatomic and/or reverse) with a minimum one-year follow-up was reviewed by two independent reviewers. Study quality was evaluated with the Modified Coleman Methodology Score and the methodological index for non-randomized studies score., Results: Eleven studies (1 Level II, 3 Level III, 7 Level IV) with 292 patients were included. Two studies reported on bilateral anatomic TSA ( n  = 54), six reported on bilateral reverse TSA (RTSA; n  = 168), two reported on anatomic TSA with contralateral RTSA (TSA/RTSA; n  = 31), and one compared bilateral anatomic TSA ( n  = 26) and bilateral RTSA ( n  = 13). Among studies, mean revision rate ranged from 0% to 10.53% and mean complication rate ranged from 4.9% to 31.3%. At final follow-up, patients experienced significant overall improvements in range of motion and patient-reported outcome score measurements. However, bilateral anatomic TSA resulted in greater improvements in external rotation compared to bilateral RTSA. Overall patient satisfaction was 91.0%., Conclusion: The available data indicate that bilateral TSA allows for functional and pain improvements and result in high patient satisfaction., Level of Evidence: IV., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2020 The British Elbow & Shoulder Society.)