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OBJECTIVE: To compare the efficacy and tolerability of rofecoxib, hydrocodone/acetaminophen 7.5 mg/750 mg (H/A) and placebo in treating pain after arthroscopy of the knee. METHODS: A randomized, double-blind, placebo-controlled, single dose study enrolling patients experiencing moderate or severe pain after knee arthroscopy. Patients with moderate-to-severe postoperative pain received either rofecoxib 50 mg (n = 151), H/A (n = 145), or placebo (n = 147). Pain was measured over 24 h. The primary endpoint was total pain relief at 6 h for rofecoxib 50 mg compared with placebo. RESULTS: H/A (p = 0.003), but not rofecoxib (p = 0.256) was significantly more effective than placebo for total pain relief at 6 h (TOPAR6). Although analgesic onset and peak were significantly better for H/A than for both rofecoxib (p < 0.01, p < 0.05, respectively) and placebo (p < 0.05, p < 0.001, respectively), rofecoxib patients used significantly less rescue analgesia (p < 0.001) over 24 h. Rofecoxib also provided better Brief Pain Inventory Severity (p = 0.008) and Interference Domain (p = 0.045) scores at 24 h compared to placebo and had lower 24-h Pain Severity scores than H/A (p < 0.05). Treatments were generally well tolerated, with no significant difference in the frequency of patient-reported adverse events between groups. CONCLUSIONS: Rofecoxib 50 mg did not provide significantly different pain relief than placebo at 6 h, and the primary endpoint TOPAR was not attained, although it did show several efficacy benefits at 24 h, including a significant opioid-sparing effect. All treatments were well tolerated, with no significant differences observed. The limited efficacy of rofecoxib in this study contrasts to the results of previous surgical studies evaluating rofecoxib, and may be partially explained by the postoperative dosing in this arthroscopic surgical model. [ABSTRACT FROM AUTHOR]

BACKGROUND: Ruptures of the patellar tendon are rare injuries. Surgical treatment for this injury is mandatory. HYPOTHESIS: Gap formation does not differ between the three patellar tendon repair techniques. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve fresh-frozen cadaveric knees were used to compare three techniques of patellar tendon repairs. The standard suture repair used two Krackow sutures placed in the avulsed patellar tendon, passed through transpatellar drill holes, and secured with the knee in 30 degrees of flexion. In the second group, suture repair was augmented with a No. 5 Ethibond suture. In the third group, suture repair was augmented with a 2.0 Dall-Miles cable. Testing was performed with the specimens mounted to a custom knee jig with the tibia free, simulating the knee moment of a 70-kg person. Each knee was then cycled 250 times at 0.25 Hz. RESULTS: Gap formation across the standard suture repair averaged 7.3 mm; across the suture augmentation and cable augmentation groups it averaged 4.9 mm and 3.5 mm, respectively. CONCLUSIONS: Augmentation of patellar tendon avulsions can decrease gap formation at the repair site, allowing early mobilization. Clinical Relevance: Gap formation seen in repair without augmentation could lead to clinical failure with resultant patella alta and extensor mechanism lag. [ABSTRACT FROM AUTHOR]

Background: Osteochondritis dissecans (OCD) of the knee is a focal idiopathic alteration of subchondral bone and/or its precursor with risk for instability and disruption of adjacent cartilage. Treatment options focused on preventing premature osteoarthritis vary depending on multiple patient and lesion characteristics, including lesion mobility., Purpose: To differentiate lesion mobility before arthroscopy using a multivariable model that includes patient demographic characteristics and physical examination findings., Study Design: Cohort study (Diagnosis); Level of evidence, 2., Methods: Demographic, preoperative physical examination, and radiographic data were collected from a multicenter national prospective cohort of patients with OCD of the knee. Inclusion criteria included patients <19 years of age and patients with arthroscopically confirmed mobility status based on the Research on Osteochondritis Dissecans of the Knee arthroscopy classification. Multivariable logistic regression analysis using stepwise model selection was used to determine factors associated with the likelihood of a mobile versus an immobile lesion. A 75% partition of the data was used for model training, and 25% was used as a validation cohort. Quantitative model fit statistics were computed using the holdout data, including sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC), along with the corresponding 95% CI., Results: A total of 407 patients in the prospective cohort met inclusion criteria, and 62% were male. The mean ± SD age was 13.7 ± 2.2 years, height 161.8 ± 5.3 cm, and weight 59.2 ± 42.2 kg. Arthroscopic evaluation yielded 235 immobile and 172 mobile lesions. Multivariable analysis determined that the best model to predict lesion mobility included chronologic age ≥14 years ( P < .001), effusion on physical examination ( P < .001), and any loss of range of motion on physical examination ( P = .07), while controlling for male sex ( P = .38) and weight >54.4 kg ( P = .12). In the 25% holdout validation sample (n = 102), a sensitivity of 83%, a specificity of 82%, and an AUC of 0.89 (95% CI, 0.82-0.95) were achieved with these predictive factors., Conclusion: Age, effusion, and loss of motion can predict knee OCD lesion mobility at the time of arthroscopy. Education about lesion mobility can help with surgical planning and patient and family counseling., Competing Interests: One or more of the authors has declared potential conflict of interest or source of funding (see 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.

Background: Ulnar collateral ligament (UCL) injuries have been on the rise for the past 3 decades. Current epidemiological studies on the incidence of UCL injuries have been limited to state or regional data., Purpose: To utilize a large national claims database to determine the rates of UCL injuries and UCL surgical procedures over the past decade (2010-2019) and whether there has been a change in UCL surgical procedure patterns in the United States., Study Design: Descriptive epidemiology study., Methods: The PearlDiver patient claims database was used to identify UCL injuries occurring from 2010 and 2019 that were sustained by male patients between 10 and 34 years of age. The study cohort was divided into 5 age groups (10-14, 15-19, 20-24, 25-29, and 30-34 years). Primary outcomes included the number of patients in each age group who sustained a UCL injury, the number of patients in each age group who underwent surgery, and the mean time from injury to surgery., Results: A total of 19,348 UCL injuries occurred between 2010 and 2019, and 13% required a surgical intervention. Most of the injuries (54%) occurred in the 15- to 19-year group. Patients in the 20- to 24-year group were more likely to undergo surgery versus the 15- to 19-year group. Results demonstrated a trend toward delayed surgical interventions in patients in the 20- to 24-year group in the latter part of the decade., Conclusion: Data suggested that male patients <20 years account for the majority of UCL injuries, while male patients aged between 20 and 24 years are most likely to undergo surgery. Despite a number of targeted injury-prevention strategies and rule changes in sports, the UCL injury rate remained high. Therefore, there is a clear and present need to continue to develop UCL injury-prevention strategies for the younger population., Competing Interests: The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. 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: 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.

Background: Management of glenohumeral instability in the adolescent population can be both challenging and controversial. There are no current guidelines for optimal management of glenohumeral instability in this population (unidirectional or multidirectional), and the cutoff ages for transition to adult treatment are not known., Purpose: To develop consensus-based guidelines for the management of glenohumeral instability in adolescents., Study Design: Consensus statement., Methods: A 26-question, multiple-choice survey was developed after 2 rounds of iterations and was submitted to the orthopaedic surgeons of the Pediatric Research in Sports Medicine (PRiSM) Society. The survey comprised 3 sections-demographics, practice setting, and decision-making-and included cutoff ages and management in 5 specific case scenarios. Consensus-based guidelines were generated with 66% response agreement. An indication score was then applied to each response related to more aggressive management to determine if variables related to consensus (or lack thereof) could be identified., Results: A total of 54 responses were returned. Of the respondents, 59% were from academic practice, 84% were pediatric orthopaedic fellowship trained, and 46% performed >25 shoulder instability cases per year. In the setting of first-time anterior shoulder dislocation, nonoperative treatment was preferred for boys aged <14 years and girls aged <13 years. Besides age, proximal humerus physeal status, injury mechanism, sport, and presence of bony injury affected treatment selection. The presence of a Bankart lesion was an indication for stabilization in first-time dislocations for contact athletes with a closing or closed physis, but not in patients with an open physis or noncontact injury mechanisms. For recurrent anterior shoulder dislocation, stabilization was preferred irrespective of physis status. Initial nonoperative treatment was preferred for multidirectional instability., Conclusion: In the setting of first-time anterior shoulder dislocation in patients with open physes, nonoperative treatment was preferred for boys <14 years and girls <13 years. Future multicenter prospective studies focusing on outcomes would help to validate current practice patterns, especially in scenarios for which no consensus was reached., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.T.F. has received education payments from Evolution Surgical. E.W.E. has received education payments from Elevate Surgical and nonconsulting fees from Arthrex. A.C.E. has received education payments from Arthrex and Smith+Nephew. S.N.P. has received education payments from CDC Medical and consulting fees from Pfizer. 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.)

Hip flexibility is an important biomechanical factor for a baseball pitcher. However, there have been limited investigations into the association between upper-extremity joint stresses and ball velocity and hip flexibility, as assessed via motion patterns during the pitch. The purpose of this study was to provide a detailed kinematic description of the lead hip during the pitch and determine the association between lead hip motion and both ball velocity and the elbow varus moment. This study was a secondary analysis of the kinematic and kinetic data previously collected on 99 collegiate-level baseball pitchers using standard optoelectronic motion capture. Significant associations were noted between lead hip internal rotation and both peak ball velocity and the elbow varus moment. The data indicated that for every 10° increase in internal lead hip rotation, ball velocity increased by 0.6 m/s (P < .001, r2 = .26), and the elbow varus moment increased by 5 N·m (P < .001, r2 = .33). The results of this study suggested that internal hip rotation may be an important means of identifying pitchers that may be at risk for future injury.

Osteochondritis dissecans (OCD) describes a pathologic condition centered at the osteochondral junction that may result in an unstable subchondral fragment (progeny), disruption of the overlying cartilage, which may separate from the underlying parent bone. It is one of the causes of chronic knee pain in children and young adults. The current literature on OCD lesions focuses primarily on the medial femoral condyle (MFC), but inconsistent use of terminology, particularly in the distinction of OCD lesions between skeletally immature and mature patients has created uncertainty regarding imaging workup, treatment, and long-term prognosis. This article reviews the pathophysiology of MFC OCD lesions, highlighting the role of endochondral ossification at the secondary growth plate of the immature femoral condyles, the rationale behind the imaging work-up, and key imaging findings that can distinguish between stable lesions, unstable lesions, and physiologic variants. This overview also provides a case-based review to introduce imaging correlates with the ROCK (Research in Osteochondritis of the Knee) arthroscopic classification., (© 2024. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Background: Most healthcare providers utilize magnetic resonance imaging (MRI) to assist in diagnosing and treating osteochondritis dissecans (OCD) of the capitellum. However, consensus on imaging features that portend clinically relevant information in the care of these lesions has not been determined., Purpose: To conduct a survey on the MRI features of a capitellar OCD that are salient for clinical decision-making using a classic Delphi protocol., Study Design: A consensus statement., Methods: Invitations to participate were sent to 33 healthcare providers identified as capitellar OCD experts. A classic 3-round survey method was used to gather agreement and consensus on the level of importance for clinical decision-making on 33 MRI features. A concise list of features that guide decision-making on the stability of an OCD lesion and the ability of an OCD lesion to heal with nonoperative care was also identified. Agreement and consensus were determined a priori as ≥66%., Results: Of the 33 identified experts, 20 agreed to participate, and 17 (52%) completed all 3 rounds. Of the 33 MRI features evaluated, 17 reached agreement as important for clinical decision-making by the experts. Consensus was reached for a concise list of MRI features that were significant to decision-making (94%), suggestive of a stable lesion (100%), had the potential to heal with nonoperative treatment (94%), were suggestive of an unstable lesion (100%), and had low potential to heal with nonoperative treatment (88%)., Conclusion: This 3-round Delphi process produced consensus on clinically relevant MRI features that contribute to clinical decision-making for capitellar OCD. The results of this study will be used as the basis for an interrater reliability assessment of the identified salient features, creating the foundation for developing a reliable MRI assessment tool rooted in clinical experiences. The development of a standardized assessment of capitellar OCD is intended to improve clinical practice and patient outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.A. has received research funds from Smith+ Nephew. J.D.P. has received education payments from Rock Medical Orthopedics and Pylant Medical. D.B. has received royalties from Lippincott Williams & Wilkins. E.E. has received nonconsulting fees from Arthrex. T.G. has received research support from Vericel and AlloSource; education payments from Arthrex; and is a paid associate editor for The American Journal of Sports Medicine. J.L.P. has received consulting fees from Arthrex and JRF Ortho. D.P. has received education payments from Arthrex and has stock ownership in Zimmer Biomet, Medtronic, and Walgreens. P.S. has received speaking fees from Arthrex. M.S. has received grant support from DJO; education payments from Arthrex and Smith+Nephew; and nonconsulting fees from Arthrex. K.S. has received research grants from RCT and Vericel; education payments from Evolution Inc, Arthrex, and Stryker; and hospitality payments from BioMarin Pharmaceutical. E.W. has received education payments from Legacy Ortho. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained from Hartford HealthCare (ref No. HHC-2022-0182)., (© The Author(s) 2024.)

Background: As total joint arthroplasty (TJA) moves to the outpatient setting, it is becoming clear that postoperative urinary retention (POUR) is a potential impediment to same-day discharge. Although risk factors for POUR have been widely studied, the lack of their clinical utility warrants investigation of specific preoperative factors that can assist in surgical planning and patient optimization. The purpose of the current study was to determine whether preoperative symptom surveys and bladder scanning are useful tools in identifying POUR risk., Methods: We performed a prospective analysis of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) at a high-volume orthopaedic hospital between December 1, 2020, and September 30, 2021. A total of 507 patients (324 female and 183 male) undergoing TJA completed the American Urological Association (AUA) symptom index preoperatively and then again at 14 and 64 days postoperatively. Post-void bladder scans were obtained in the immediate preoperative setting. POUR was defined as a bladder volume of >500 mL that required catheterization. Chi-square and quintile analysis were used to compare bladder scanning volumes, and Student t tests were used to compare AUA scores., Results: The rate of POUR was 37% (66 female and 34 male) and 23% (37 female and 19 male) in the TKA and THA groups, respectively. Increasing post-void residual volume (PVRV) measured on preoperative bladder scanning was found to be predictive of POUR. Among the TKA cohort, younger age and lower body mass index were also associated with increased catheterization, although age was not statistically significant. The AUA symptom survey was not found to correlate with POUR in either population., Conclusions: There was a predictable and exponential increase in the rate of catheterization as preoperative PVRV increased from 50 to 200 mL. The AUA symptom score showed no utility in predicting POUR in our study population. We propose that preoperative bladder ultrasonography become standard practice in TJA, especially among patients scheduled for same-day discharge., Level of Evidence: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H881 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Researchers have postulated that the rise in the incidence of pitching injuries is partially due to poor pitching mechanics. A topic that is often debated revolves around the correct positioning of the elbow in relationship to the body. Therefore, this study attempts to understand the associations of vertical or horizontal elbow positon with upper extremity joint moments, and ball velocity, and how elbow position is influenced by trunk position. Motion analysis data from 99 collegiate pitchers were analysed for this study. A random intercept, mixed-effects regression model was used to determine if statistically significant associations existed between elbow position and upper extremity joint moments and ball velocity. Results indicated that visual impressions of the elbow position were highly correlated with trunk position, whereas kinematic definitions of elbow position were correlated to the glenohumeral angle. Visual vertical and horizontal elbow position was associated with increased elbow varus moments (p = 0.001) and ball velocity (p = 0.019), respectively. Whereas kinematic elbow position was not associated with either upper extremity joint moments or ball velocity. Therefore, what coaches visually interpret as an improperly positioned elbow may actually be a combination of lateral lean, anterior tilt, and over rotation of the trunk.

Background: When stable osteochondritis dissecans (OCD) lesions of the femoral condyle in a skeletally immature patient fail to heal with nonoperative methods, the standard of care treatment is condylar OCD drilling. Two primary OCD drilling techniques have been described, but no prospective studies have compared their relative effectiveness., Purpose/hypothesis: The purpose of this study was to compare the healing and function after transarticular drilling (TAD) with that after retroarticular drilling (RAD). It was hypothesized that there would be no difference in rate or time to healing, rate or time to return to sports, patient-reported outcomes (PROs), or secondary OCD-related surgery., Study Design: Randomized controlled clinical trial; Level of evidence, 1., Methods: Skeletally immature patients with magnetic resonance imaging-confirmed stable OCD lesions of the medial femoral condyle who did not demonstrate substantial healing after a minimum of 3 months of nonoperative treatment were prospectively enrolled by 1 of 17 surgeon-investigators at 1 of 14 centers. Patients were randomized to the TAD or RAD group. Tourniquet time, fluoroscopy time, and complications were compared between the treatment groups. Postoperatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months., Results: A total of 91 patients were included, consisting of 51 patients in the TAD and 40 patients in the RAD group, who were similar in age, sex distribution, and 2-year PRO response rate. Tourniquet time and fluoroscopy time were significantly shorter with TAD (mean, 38.1 minutes and 0.85 minutes, respectively) than RAD (mean, 48.2 minutes and 1.34 minutes respectively) ( P = .02; P = .004). In the RAD group, chondral injury from K-wire passage into the intra-articular space was reported in 9 of 40 (22%) patients, but no associated postoperative clinical sequelae were identified in these patients. No significant differences between groups were detected in follow-up Pediatric-International Knee Documentation Committee, Lysholm, Marx Activity Scale, or Knee injury and Osteoarthritis Outcome Score Quality of Life scores. Healing parameters were superior at 6 months and 12 months in the TAD group, compared with the RAD group, and secondary OCD surgery occurred in 4% of patients who underwent TAD and 10% of patients who underwent RAD ( P = .40). Patients in the TAD group returned to sports earlier than those in the RAD group ( P = .049)., Conclusion: TAD showed shorter operative time and fluoroscopy time and superior healing parameters at 6 and 12 months, but no differences were seen in 24-month healing parameters or PROs at all follow-up time points, when compared with RAD., Registration: NCT01754298 (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: 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.

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.

The instant of foot contact is an important transition point during the pitch cycle between the linear portion of the pitch, as a pitcher strides down the mound and the rotational portion of the pitch. Understanding the implications of lead foot angle at foot contact is an essential information needed to assist pitching coaches in their work with individual pitchers. Therefore, the purpose of this study was to determine the association between lead foot progression angle at foot contact and ball velocity, elbow varus moment, and pelvic rotation. Kinematic and kinetic data were collected from 99 collegiate pitchers and analyzed using a random intercept, mixed-effects regression model. Significant associations were found between lead foot progression angle at foot contact and elbow varus moment (P = .004), as well as pelvic rotation throughout the pitching motion (P < .001). The data indicate that increased lead foot internal rotation at foot contact is associated with increases in the elbow varus moment but is not associated with ball velocity. This study provides scientific evidence that the rotational positioning of the lead foot can affect both pelvic motion and upper-extremity joint moments.

An important aspect of the pitching motion is the lead leg knee angle, from initial lead foot contact to ball release, which can influence pitching performance and injury potential. Understanding the implication of this angle is essential to appropriately coach baseball pitchers. Therefore, the purpose of this study was to determine the lead leg knee flexion influence on both ball velocity and the elbow varus moment. Kinematic and kinetic data were collected using standard optoelectronic motion capture methods from 121 collegiate pitchers and analysed using a random intercept, mixed effects regression model to evaluate the association between the knee angle on peak ball velocity and peak elbow varus moment, independently. Statistically significant associations between the knee flexion angle and ball velocity as well as with the elbow varus moment were noted. The data indicated that a 10° increase in knee flexion at ball was associated with a 2.1 Nm reduction in the peak elbow varus moment (p = 0.021, r 2  = 0.12) and a 0.2 m/s reduction in peak ball velocity (p = 0.010, r 2  = 0.11). This study provides scientific evidence that the lead knee flexion angle influences both upper extremity stresses and ball velocity.

Background: Postoperative urinary retention (POUR) is a significant problem in total joint arthroplasty (TJA). Although risk factors for POUR have been well documented, they are ubiquitous in an aging total joint population, which makes risk stratification difficult. The purpose of this study was to determine if a high preoperative post-void bladder scan identifies patients at risk for POUR., Methods: A retrospective analysis was conducted on all TJAs performed at a high-volume orthopedic center between December 2019 and February 2020. A total of 585 elective TJA patients received post-void bladder scans before surgery. Bladder scan volumes were correlated with catheterization via Chi-squared tests., Results: A high post-void residual volume (PVRV > 50 ml) was associated with an increased risk of catheterization (23% vs 34%, chi-squared statistic = 6.2638, P value = .013), as was intravenous fluid volume (>1000 ml in knee, >2000 ml in hip). Catheterization rates were higher among total knee arthroplasty patients younger than 60 years (37% vs 24%, chi-squared statistic = 4.284, P value = .0385) and total hip arthroplasty (THA) patients older than 65 years (30% vs 18%, chi-squared statistic = 3.292, P value = .0695). Multiple risk factors were additive., Conclusions: Higher PVRV and intravenous fluids were independently associated with catheterization after TJA. Younger age was associated with greater risk in total knee arthroplasty, while older age increased risk in THA. We propose that a preoperative bladder scan to detect a high PVRV may provide clinical utility to identify patients likely to develop POUR., (© 2021 The Authors.)

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease., Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest., Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases., Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome., Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up., Study Design: Cohort study; Level of evidence, 2., Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery., Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores ( P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized ( P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts ( P = .87) or between BTB autografts and soft tissue allografts ( P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft ( P = .010; OR, 0.56; 95% CI, 0.36-0.87)., Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

The incidence of elbow injury experienced by baseball pitchers is on the rise. Biomechanical investigations focusing on the acceleration phase of the pitch have yet to elucidate a singular cause for these injuries. Leading to the question is there an additional significant stress on the elbow during other phases of the pitch? This study sought to determine the magnitude of the elbow varus moment during the deceleration phase of the pitching cycle for the fastball, curveball, slider and change-up. Eighty-seven collegiate-level pitchers were evaluated using motion analysis techniques to determine the magnitude of the elbow varus moment occurring during the deceleration phase. The results indicated that the elbow varus moment during the deceleration phase of the pitch was typically between 40% and 50% of the peak acceleration phase moment and was greatest when throwing a slider. Results also indicated that more pitchers experienced deceleration phase moments in excess of 50% of the acceleration moment when throwing breaking pitches. These moments which are the result of the pitchers' need to rapidly decelerate their arm produce an additional significant elbow varus moment that results in additional stress to the elbow.

Objective: The purpose of this study was to examine whether readiness to return to sport (RTS) differed between adolescent male and female athletes after anterior cruciate ligament reconstruction (ACLR)., Design: Longitudinal, prospective cohort., Setting: Outpatient office associated with tertiary-care hospital., Patients: A total of 93 adolescent athletes, 17 years of age and younger, who underwent ACLR surgery with a hamstring autograft were included., Independent Variables: Male and female athletes., Main Outcome Measures: Anterior cruciate ligament-return to sport after injury (ACL-RSI) completed at 3 time points: (1) preoperatively (Pre-op), (2) approximately 3 months into rehabilitation (Post-op 1), and (3) during RTS phases of recovery (Post-op 2)., Results: There was a significant main effect for both sex (P < 0.010) and time (P < 0.0001) with male athletes having higher ACL-RSI scores than female athletes at all 3 time points; however, there was no significant time by sex interaction. All ACL-RSI scores increased significantly across time, regardless of sex. There were no statistically significant differences between ACL-RSI scores at all 3 time points between individuals who did and did not receive physician clearance., Conclusions: This study provides a longitudinal depiction of adolescent athletes' readiness to RTS after ACL injury throughout recovery. Both male and female athletes demonstrated diminished ACL-RSI scores before undergoing surgery, with increasing scores at both postoperative time points for both sexes. Overall, female athletes reported lower readiness to RTS at all 3 time points compared with male athletes., Competing Interests: C. W. Nissen, M. D. Milewski: as members of ROCK, Inc. we receive educational grants from Allosource and Vericel. The remaining authors report no conflicts of interest. M. D. Milewski receives royalties from Elsevier, Inc. for editorial work., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

The association between breaking pitches and elbow injury remains nebulous. Biomechanical studies have shown that throwing a fastball rather than a curveball results in greater elbow moments, despite some epidemiological studies and pitcher self-report indicating the opposite. This leads to the following question: Are biomechanical studies missing something that could explain this discrepancy? This study evaluated the association between elbow kinematics of baseball pitchers during the deceleration phase of the pitch and the elbow varus moment. Eighty-seven uninjured collegiate pitchers were analysed using 3-dimensional motion capture techniques. Results indicated that pitchers who remained in greater elbow flexion had greater post ball release elbow varus moments (EVMPBR) ( p = 0.001). Regression analysis indicated that for every 10° of increased elbow flexion during follow-through the EVMPBR increased by 5.4 Nm for the fastball and 8.2 Nm for the curveball ( p < 0.001). This suggests a concerning second stress on the elbow joint occurring during the deceleration phase of the pitch. The results showed that maintaining greater elbow flexion during the deceleration phase of the pitch can substantially increase the elbow varus moment after ball release (BR), especially when pitching the curveball. The results reinforce the need to emphasise appropriate pitching mechanics.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon-dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting postoperative infections. Allografts had a higher risk of infection than autografts (odds ratio, 6.8; 95% CI, 0.9-54.5; p = .045). Diabetes (odds ratio, 28.6; 95% CI, 5.5-149.9; p = .004) was a risk factor for infection. Patient age, sex, BMI, and smoking status were not associated with risk of infection after rACLR., (© 2020 Orthopaedic Research Society. Published by Wiley Periodicals LLC.)

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented., Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting., Study Design: Case-control study; Level of evidence, 3., Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment., Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction., Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both <10% and consistent with success rates of primary ACL reconstruction meniscal repair. Medial tears underwent reoperation for failure at a significantly higher rate than lateral tears.

Background: Imaging characteristics of osteochondritis dissecans (OCD) lesions quantified by magnetic resonance imaging (MRI) are often used to inform treatment and prognosis. However, the interrater reliability of clinician-driven MRI-based assessment of OCD lesions is not well documented., Purpose: To determine the interrater reliability of several historical and novel MRI-derived characteristics of OCD of the knee in children., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: A total of 42 OCD lesions were evaluated by 10 fellowship-trained orthopaedic surgeons using 31 different MRI characteristics, characterizing lesion size and location, condylar size, cartilage status, the interface between parent and progeny bone, and features of both the parent and the progeny bone. Interrater reliability was determined via intraclass correlation coefficients (ICCs) with 2-way random modeling, Fleiss kappa, or Krippendorff alpha as appropriate for each variable., Results: Raters were reliable when the lesion was measured in the coronal plane (ICC, 0.77). Almost perfect agreement was achieved for condylar size (ICC, 0.93), substantial agreement for physeal patency (ICC, 0.79), and moderate agreement for joint effusion (ICC, 0.56) and cartilage status (ICC, 0.50). Overall, raters showed significant variability regarding interface characteristics (ICC, 0.25), progeny (ICC range, 0.03 to 0.62), and parent bone measurements and qualities (ICC range, -0.02 to 0.65), with reliability being moderate at best for these measurements., Conclusion: This multicenter study determined the interrater reliability of MRI characteristics of OCD lesions in children. Although several measurements provided acceptable reliability, many MRI features of OCD that inform treatment decisions were unreliable. Further work will be needed to refine the unreliable characteristics and to assess the ability of those reliable characteristics to predict clinical lesion instability and prognosis.

Background: Patient-reported outcomes (PROs) are a valid measure of results after revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes when compared with primary ACL reconstruction. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for patients., Purpose/hypothesis: The purpose was to describe PROs after revision ACL reconstruction and test the hypothesis that patient- and technique-specific variables are associated with these outcomes., Study Design: Cohort study; Level of evidence, 2., Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons over 52 sites. Data included baseline demographics, surgical technique and pathology, and a series of validated PRO 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. Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors to determine the positive and negative predictors of PRO scores at 2 years after revision surgery., Results: A total of 1205 patients met the inclusion criteria and were successfully enrolled: 697 (58%) were male, with a median cohort age of 26 years. The median time since their most recent previous ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained from 989 patients (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male sex, and having a longer time since the most recent previous ACL reconstruction, while negative predictors included having a lateral meniscectomy before the revision ACL reconstruction or having grade 3/4 chondrosis in either the trochlear groove or the medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between the most recent previous ACL reconstruction and revision surgery were significant positive predictors for having a better (ie, higher) 2-year KOOS, while having a lateral meniscectomy before the revision ACL reconstruction was a consistent predictor for having a significantly worse (ie, lower) 2-year KOOS. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male sex, and being a nonsmoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery., Conclusion: PROs after revision ACL reconstruction are associated with a variety of patient- and surgeon-related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectations as well as potentially improve outcomes.

Background: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery., Hypotheses: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates., Results: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC ( P < .0001), KOOS-Symptoms ( P = .01), KOOS-Sports and Recreation ( P = .04), and KOOS-Quality of Life ( P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates., Conclusion: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Background: Osteochondritis dissecans (OCD) of the capitellum is an increasingly recognized disease affecting young athletes. Because lesion progression is common, early identification is potentially beneficial for an athlete's treatment and recovery. However, there is currently no analysis available that evaluates the impact of symptom duration on preoperative and postoperative outcomes., Purpose/hypothesis: The purpose of this study was to perform a systematic review of surgically treated OCD lesions to examine the effect of symptom duration before the initial presentation on preoperative and postoperative outcomes. We hypothesized that a longer symptom duration would correlate with more severe preoperative signs and symptoms and poorer postoperative outcomes., Study Design: Systematic review; Level of evidence, 4., Methods: Ovid MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects were queried for studies evaluating symptom duration before the clinical presentation of capitellar OCD and surgical outcomes. A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines., Results: A total of 23 studies reporting outcomes in 258 patients (mean patient age, 14.4 ± 1.5 years) were analyzed. Locking as a chief complaint predominated in a greater proportion of patients who presented with a longer history of OCD symptoms ( P = .007). A longer symptom duration also correlated with a longer time to return to sport ( P = .008) and older age ( P < .001). Range of motion limitations as both a chief complaint and a physical examination finding correlated with a longer symptom duration ( P = .014 and .001, respectively). Symptom duration did not show a relationship with most postoperative outcomes, including the return-to-sport rate ( P = .172), which ranged from 70.7% to 91.1% depending on the surgical procedure performed. No significant difference was observed between symptom duration and the surgical procedure performed ( P = .376)., Conclusion: Advanced OCD lesions were observed in patients with a longer symptom duration. However, treatment specifics rather than symptom duration correlated best with return to sport for patients with advanced OCD lesions requiring surgery. The earlier detection of capitellar OCD may be valuable in reducing the severity of lesions, the time to return to sport, and potential need for surgery in young athletes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: C.C. and H.S.R. have received an unrestricted grant from the Research in Osteochondritis Dissecans of the Knee (ROCK) Group. M.D.M. and C.W.N. have received unrestricted research grants from AlloSource and Vericel as members of the ROCK Group and receive royalties from Elsevier. J.J.N. is a consultant for Smith & Nephew, Responsive, and Ceterix Orthopaedics and has received research funding from Smith & Nephew and Zimmer. 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: The trunk is a major contributor to the kinetic chain during baseball pitching by helping to transfer energy from the lower limbs to produce the desired ball speed. However, most of the research detailing the trunk's contribution to the pitch is focused on rotational timing and coronal plane lean, with little attention focused on sagittal plane positioning of the trunk., Purpose: To determine the association between sagittal plane trunk motion and elbow varus moment and ball velocity in collegiate baseball pitchers., Study Design: Descriptive laboratory study., Methods: A total of 99 collegiate pitchers were recruited for this study and underwent a comprehensive biomechanical assessment of their pitching motion using 3-dimensional motion techniques. A random-intercepts, mixed-effects regression model was used to determine whether statistically significant associations were noted between sagittal plane trunk motion and the ball velocity and elbow varus moment., Results: There were a number of significant associations between sagittal plane trunk tilt and the elbow varus moment and ball velocity. Increased forward trunk tilt at the time of ball release was associated with an increase in elbow varus moment and a small increase in ball velocity; for every 10° of increased forward trunk tilt greater than 28° at ball release, the elbow varus moment increased by 2.9 N·m ( P = .007), and the ball velocity increased by 0.7 m/s ( P = .002)., Conclusion: Sagittal plane positioning of the trunk plays a role in pitching mechanics, as it can affect both pitching performance and elbow moments. The results also indicated that there is a potential optimal trunk position and range of motion during the acceleration of the pitch that could limit the stress placed on the elbow joint. Implementing proper trunk mechanics from an early age could lead to a reduction in joint moments., Clinical Relevance: The results provide evidence for coaches and trainers to emphasize the importance of proper trunk positioning through the inclusion of core strengthening and motor control in their practice and coaching sessions in an effort to reduce the moments placed on the elbow during the pitch., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. 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: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture., Study Design: Cohort study; Level of evidence, 2., Methods: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR., Results: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as "younger" and those above as "older" (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03)., Conclusion: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

Background: Anterior cruciate ligament (ACL) ruptures have become increasingly common in pediatric and adolescent athletes. While multiple methods exist, all-epiphyseal ACL reconstruction is a popular technique in the skeletally immature patient. Given the high rate of reruptures in this population and the increasing number of commercially available fixation devices, biomechanical testing is crucial to understand the performance of these devices in pediatric epiphyseal bone. To our knowledge, there has not been a biomechanical analysis of ACL fixation devices in skeletally immature bone., Purpose: To compare cortically based button fixation with interference screw and sheath fixation in skeletally immature femoral epiphyseal cadaveric bone. Our hypothesis was that there would be no difference in peak load to failure, stiffness, or cyclic displacement between these 2 fixation constructs., Study Design: Controlled laboratory study., Methods: Fresh-frozen matched-pair knees from 3 pediatric cadaveric specimens were obtained. A synthetic graft was fixed in an all-epiphyseal femoral tunnel. Both the lateral and medial condyles were utilized to increase the sample size. Specimens were randomized and assigned to receive either an interference screw and sheath construct designed for pediatric patients or an adjustable loop cortical button. Biomechanical testing was performed to obtain ultimate load to failure, stiffness, total displacement after 500 cycles, and the failure mode for each condyle., Results: Each medial and lateral condyle in 3 pairs of skeletally immature cadaveric knees (ages 7, 9, and 11 years) was utilized for testing. One specimen was excluded after it failed by having a transphyseal fracture. The median peak load to failure was 769.80 N (interquartile range [IQR], 628.50-930.41 N) for the screw and sheath group and 862.80 N (IQR, 692.34-872.65 N) for the button group ( P = .893). The median displacement after 500 cycles for the screw and sheath group was 0.65 mm (IQR, 0.47-1.03 mm) and 1.13 mm (IQR, 0.96-1.25 mm) for the button group ( P = .08). The median stiffness of the screw and sheath group was significantly higher than that of the button group (31.47 N/mm [IQR, 26.40-43.00 N/mm] vs 25.22 N/mm [IQR, 21.18-27.07 N/mm], respectively) ( P = .043)., Conclusion: When comparing femoral fixation with a screw and sheath construct developed for pediatric patients to an adjustable loop cortical button in skeletally immature bone, our results showed that fixation did not significantly differ with respect to cyclic displacement or peak load to failure. While the screw and sheath construct was significantly stiffer, its effect on clinical outcomes is not yet known., Clinical Relevance: With regard to femoral fixation, there is no significant biomechanical difference between the use of cortically based button fixation or interference screw and sheath fixation in pediatric epiphyseal cadaveric bone., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.G.S. has received educational support from DePuy and Sanofi-Aventis. P.D.F. has received educational support from Smith & Nephew. M.D.M. receives royalties from Elsevier. K.G.S., C.W.N., P.D.F., and M.D.M. are members of the Research in Osteochondritis Dissecans of the Knee (ROCK) study group, which receives research funding from AlloSource and Vericel.

The treatment of sports injuries in the skeletally immature has a unique set of complications. Growth deformity may occur after anterior cruciate ligament reconstruction; therefore, skeletal age is used to help guide the choice between physeal sparing and transphyseal techniques. Arthrofibrosis after tibial spine fracture fixation can be reduced by initiating immediate range of motion, and should be treated early and cautiously to avoid iatrogenic fracture. Nonunions of medial epicondyle elbow fractures are more common with nonoperative treatment, but seldom lead to clinical problems outside of certain athletes. Risks of OCD fixation are specific to the material of screw used., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage., Hypothesis: Larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction., Study Design: Case-control study; Level of evidence, 3., Methods: Subjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery., Results: A total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus ( P < .001). For the medial compartment, patients who had <33% of the medial meniscus excised at the time of the primary reconstruction had 4.8-times greater odds of progression of articular cartilage injury than those with an intact medial meniscus ( P = .02). Odds of significant chondral surface change increased by 5% in the lateral compartment and 6% in the medial compartment for each increased year of age ( P ≤ .02). For the patellofemoral compartment, the use of allograft in primary reconstruction was associated with a 15-fold increased odds of progression of articular cartilage damage relative to a patellar tendon autograft ( P < .001). Each 1-unit increase in BMI at the time of revision surgery was associated with a 10% increase in the odds of progression of articular cartilage damage ( P = .046) in the patellofemoral compartment., Conclusion: Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment.

Background: Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood., Purpose: To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique., Study Design: Case series; Level of evidence, 4., Methods: Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed., Results: Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb., Conclusion: The femoral physeal-sparing with transphyseal tibial drilling "hybrid" technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.D.M. has received grant funding from the Pediatric Orthopaedic Society of North America, has received publishing royalties from Elsevier Inc, and receives research support from Vericel Corp and AlloSource Inc as a member of the Research in OsteoChondritis of the Knee (ROCK) group. C.W.N. has received unrestricted educational grants as a member of the ROCK group from Vericel Corp and AlloSource Inc.

Background: The incidence of upper extremity injury in baseball pitchers has increased over the past decade. This has resulted in a large body of research mainly focused on the kinematic and kinetic patterns of the elbow and shoulder to elucidate the cause of these injuries, with little attention on studying the associations of forearm rotation and upper arm joint moments., Hypothesis: There will be significant differences in forearm kinematics and kinetics when comparing the fastball pitch with the curveball pitch. There will be a positive association between forearm kinetics, specifically supination and pronation moments, and the elbow varus moment., Study Design: Descriptive laboratory study., Methods: A total of 78 pitchers were recruited for this study, and they underwent a pitching analysis using motion analysis techniques. A random-intercept, mixed-effects regression model was used to determine differences in forearm kinematics and kinetics when pitching a fastball compared with a curveball, as well as to determine if associations existed between forearm supination and pronation moments and the elbow varus moment., Results: There were a number of significant differences in forearm position when pitching a fastball compared with a curveball, with the curveball producing a more supinated forearm position. Significant associations were found between increasing forearm supination moments and an increase in elbow varus moment for both the fastball and the curveball ( P = .002 and P < .001, respectively). For every 1-N·m increase in the supination moment, there was a 1-N·m and 1.1-N·m increase in the elbow varus moment for the fastball and curveball, respectively., Conclusion: The results demonstrated that the forearm position was not associated with the elbow varus moment. However, the supination moment was associated with the elbow varus moment., Clinical Relevance: On the basis of these findings, pitching coaches and trainers can understand the implications of proper lower arm pitching mechanics in the later portion of the pitch cycle as a potential risk of injury and, therefore, can develop coaching strategies to reduce incorrect positioning, especially when players are pitching the curveball.

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction., Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes., Study Design: Case-control study; Level of evidence, 3., Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction., Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort., Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

Background: Access to health care services is a critical component of health care reform and may differ among patients with different types of insurance. Hypothesis/Purpose: The purpose was to compare adolescents with private and public insurance undergoing surgery for anterior cruciate ligament (ACL) and/or meniscal tears. We hypothesized that patients with public insurance would have a delayed presentation from the time of injury and therefore would have a higher incidence of chondral injuries and irreparable meniscal tears and lower preoperative International Knee Documentation Committee (IKDC) scores than patients with private insurance., Study Design: Cross-sectional study; Level of evidence, 3., Methods: This was a retrospective study of patients under 21 years of age undergoing ACL reconstruction and/or meniscal repair or debridement from January 2013 to March 2016 at a single pediatric sports medicine center. Patients were identified by a search of Current Procedural Terminology (CPT) codes. A chart review was performed for insurance type; preoperative diagnosis; date of injury, initial office visit, and surgery; preoperative IKDC score; intraoperative findings; and procedures., Results: The study group consisted of 119 patients (mean age, 15.0 ± 1.7 years). Forty-one percent of patients had private insurance, while 59% had public insurance. There were 27 patients with isolated meniscal tears, 59 with combined meniscal and ACL tears, and 33 with isolated ACL tears. The mean time from injury to presentation was 56 days (range, 0-457 days) in patients with private insurance and 136 days (range, 0-1120 days) in patients with public insurance ( P = .02). Surgery occurred, on average, 35 days after the initial office visit in both groups. The mean preoperative IKDC score was 53 in both groups. Patients with meniscal tears with public insurance were more likely to require meniscal debridement than patients with private insurance (risk ratio [RR], 2.3; 95% CI, 1.7-3.1; P = .02). Patients with public insurance were more likely to have chondral injuries of grade 2 or higher (RR, 4.4; 95% CI, 3.9-5.0; P = .02)., Conclusion: In adolescent patients with ACL or meniscal tears, patients with public insurance had a more delayed presentation than those with private insurance. They also tended to have more moderate-to-severe chondral injuries and meniscal tears, if present, that required debridement rather than repair. More rapid access to care might improve the prognosis of young patients with ACL and meniscal injuries with public insurance.

Background: While revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR., Purpose: To report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR., Study Design: Case-control study; Level of evidence, 3., Methods: A total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation., Results: Of the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged <20 years had twice the odds of patients aged 20 to 29 years to undergo a reoperation. The use of an allograft at the time of revision ACLR (odds ratio [OR], 1.79; P = .007) was a significant predictor for reoperations at 2 years, while staged revision (bone grafting of tunnels before revision ACLR) (OR, 1.93; P = .052) did not reach significance. Patients with grade 4 cartilage damage seen during revision ACLR were 78% less likely to undergo subsequent operations within 2 years. Sex, body mass index, smoking history, Marx activity score, technique for femoral tunnel placement, and meniscal tearing or meniscal treatment at the time of revision ACLR showed no significant effect on the reoperation rate., Conclusion: There was a significant reoperation rate after revision ACLR at 2 years (11%), with meniscal procedures most commonly involved. Independent risk factors for subsequent surgery on the ipsilateral knee included age <20 years and the use of allograft tissue at the time of revision ACLR.

Left-handed baseball pitchers are thought to have a number of theoretical advantages compared to right-handed pitchers; however, there is limited scientific research detailing differences in the pitching mechanics of right- and left-handed pitchers. Therefore, this study sought to understand whether any kinematic and kinetic differences existed between right- and left-handed baseball pitchers. A total of 52 collegiate pitchers were included in this study; 26 left-handed pitchers were compared to 26 age-, height-, weight- and ball velocity-matched right-handed pitchers. Demographic information, passive shoulder range of motion and kinematic and kinetic data were obtained for each pitcher participating in the study. Results indicated that left-handed pitchers did not have a glenohumeral internal rotation deficit as compared to right-handed pitchers. Kinematic analysis indicated that elbow flexion, horizontal glenohumeral abduction and wrist coronal plane motion were significantly different between the two study cohorts. It was also noted that left-handed pitchers had increased elbow varus moments. The findings of this study suggest that pitching coaches should be aware that there are biomechanical differences between left- and right-handed pitchers.

Background: The reliability of assessing healing on plain radiographs has not been well-established for knee osteochondritis dissecans (OCD)., Purpose: To determine the inter- and intrarater reliability of specific radiographic criteria in judging healing of femoral condyle OCD., Study Design: Cohort study (Diagnosis); Level of evidence, 3., Methods: Ten orthopedic sports surgeons rated the radiographic healing of 30 knee OCD lesions at 2 time points, a minimum of 1 month apart. First, raters compared pretreatment and 2-year follow-up radiographs on "overall healing" and on 5 subfeatures of healing, including OCD boundary, sclerosis, size, shape, and ossification using a continuous slider scale. "Overall healing" was also rated using a 7-tier ordinal scale. Raters then compared the same 30 pretreatment knee radiographs in a stepwise progression to the 2-, 4-, 7-, 12-, and 24-month follow-up radiographs on "overall healing" using a continuous slider scale. Interrater and intrarater reliability were assessed using intraclass correlations (ICC) derived from a 2-way mixed effects analysis of variance for absolute agreement., Results: Overall healing of the OCD lesions from pretreatment to 2-year follow-up radiographs was rated with excellent interrater reliability (ICC = 0.94) and intrarater reliability (ICC = 0.84) when using a continuous scale. The reliability of the 5 subfeatures of healing was also excellent (interrater ICCs of 0.87-0.89; intrarater ICCs of 0.74-0.84). The 7-tier ordinal scale rating of overall healing had lower interrater (ICC = 0.61) and intrarater (ICC = 0.68) reliability. The overall healing of OCD lesions at the 5 time points up to 24 months had interrater ICCs of 0.81-0.88 and intrarater ICCs of 0.65-0.70., Conclusion: Interrater reliability was excellent when judging the overall healing of OCD femoral condyle lesions on radiographs as well as on 5 specific features of healing on 2-year follow-up radiographs. Continuous scale rating of OCD radiographic healing yielded higher reliability than the ordinal scale rating. Raters showed substantial to excellent agreement of OCD overall radiographic healing measured on a continuous scale at 2, 4, 7, 12, and 24 months after starting treatment.

Background: Several systems have been proposed for classifying osteochondritis dissecans (OCD) of the knee during surgical evaluation. No single classification includes mutually exclusive categories that capture all of the salient features of stability, chondral fissuring, and fragment detachment. Furthermore, no study has assessed the reliability of these classification systems., Purpose: To determine the intra- and interobserver reliability of a novel, comprehensive arthroscopic classification system with mutually exclusive OCD lesion types., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: The Research in OsteoChondritis of the Knee (ROCK) study group developed a classification system for arthroscopic evaluation of OCD of the knee that includes 6 arthroscopic categories-3 immobile types and 3 mobile types. To optimize comprehensibility and applicability, each was developed with a memorable name, a brief description, a line diagram corresponding to the archetypal arthroscopic appearance, and an arthroscopic photograph depicting this archetype. Thirty representative arthroscopic videos were evaluated by 10 orthopaedic surgeon raters, who classified each lesion. After 4 weeks, the raters again classified the OCD lesions depicted in the 30 videos in a new, randomly selected order. Reliability was assessed via the intraclass correlation coefficient (ICC)., Results: The interobserver reliability of this novel arthroscopy classification was estimated by an ICC of 0.94 (95% CI, 0.91-0.97) for the first round and 0.95 (95% CI, 0.93-0.98) for the second round. According to the standards for the magnitude of the reliability coefficient of Altman, these ICCs indicate that interobserver reliability was very good. The intraobserver reliability was estimated by an ICC of 0.96 (95% CI, 0.95-0.97), which indicates that the intraobserver reliability was similarly very good., Conclusion: The ROCK OCD knee arthroscopy classification system demonstrated excellent intra- and interobserver reliability. In light of this reliability, this classification system may be used clinically and to facilitate future research, including multicenter studies for OCD., (© 2016 The Author(s).)

Background: The results of open and arthroscopic instability repairs have been shown to be equivalent in recent literature., Purpose: To compare the time to recurrence (TTR) of instability and disease-specific outcome measures in patients undergoing open and arthroscopic Bankart repair., Study Design: Cohort study; Level of evidence, 3., Methods: Patients with recurrent traumatic anterior shoulder instability and a Bankart lesion on diagnostic arthroscopy underwent either open Bankart repair (OB) or arthroscopic Bankart and suture capsulorrhaphy (ABSC) using suture anchors. There was a minimum follow-up of 24 months. The primary outcome measures included Western Ontario Shoulder Instability Index (WOSI) score and time to recurrence of instability (dislocation or subluxation). Rowe score, Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons (ASES) score, and Short Form-12 (SF-12) score were also compared., Results: A total of 82 shoulders in 80 patients (ABSC, n = 58; OB, n = 24) were evaluated at a mean of 39 months postoperatively. There were 4 clinical failures in the OB group (4 dislocations) and 7 clinical failures in the ABSC group (2 dislocations and 5 subluxations; P = .72 vs OB). The mean time to recurrence of postoperative instability was significantly shorter in the ABSC group (12.6 ± 2.7 months) compared with the OB group (34.2 ± 12 months; P = .04). The WOSI score in the OB group (265 ± 48.1) was better but not statistically significantly compared with the ABSC group (449.8 ± 63.8; P = .06)., Conclusion: The time to recurrence of instability after open Bankart repair is significantly longer compared with arthroscopic Bankart repair., Clinical Relevance: Delayed time to recurrence after open Bankart repair suggests that the open technique may be more suited to withstand the high stress and demands of a heavy-duty profession (contact athletes and heavy manual labor)., Competing Interests: One or more of the authors has declared the following potential conflicts of interest or source of funding: A.D.M. is a consultant for and receives research support from Arthrex. R.A.A. is a consultant for and receives research support from Arthrex, Depuy-Mitek, Soft Tissue Regeneration, and Biomet.

Background: Early sport specialization is not a requirement for success at the highest levels of competition and is believed to be unhealthy physically and mentally for young athletes. It also discourages unstructured free play, which has many benefits., Purpose: To review the available evidence on early sports specialization and identify areas where scientific data are lacking., Study Design: Think tank, roundtable discussion., Results: The primary outcome of this think tank was that there is no evidence that young children will benefit from early sport specialization in the majority of sports. They are subject to overuse injury and burnout from concentrated activity. Early multisport participation will not deter young athletes from long-term competitive athletic success., Conclusion: Youth advocates, parents, clinicians, and coaches need to work together with the sport governing bodies to ensure healthy environments for play and competition that do not create long-term health issues yet support athletic competition at the highest level desired.

Background: The incidence of upper extremity injuries in baseball pitchers is increasing. Over the past decade there has been a great deal of research attempting to elucidate the cause of these injuries, focusing mainly on the mechanics of the pitching arm with no examination of other key segments, such as the trunk. This is surprising, as coaches will often comment on trunk position in an effort to improve pitching outcomes., Purpose: To determine the association between contralateral trunk lean and ball velocity and the moments about the elbow and glenohumeral joint., Study Design: Descriptive laboratory study., Methods: A total of 99 pitchers were recruited for this study and underwent a pitching analysis using 3-dimensional motion analysis techniques. A random intercept mixed-effects regression model was used to determine if statistically significant associations existed between contralateral trunk lean (away from the pitching arm side) and ball velocity, as well as the elbow varus moment and glenohumeral internal rotation moment., Results: The results demonstrated that the greatest contralateral trunk lean occurs around the time of the peak elbow varus moment. Statistically significant associations were found between contralateral trunk lean and increased ball velocity (P=.003) indicating that for every 10° increase in contralateral lean, ball velocity increased 0.5 m/s. Results also indicated that for every 10° increase in contralateral lean, elbow varus moments increased by 3.7 N·m and glenohumeral internal rotation moments increased by 2.5 N·m (P<.001 for both)., Conclusion: Study findings indicate that the positioning of the trunk plays a substantial role in pitching performance and pitcher injury potential. This work helps to demonstrate the importance of proper trunk mechanics in pitching and highlights the need for future research to understand the contribution of the trunk to pitching mechanics., Clinical Relevance: Pitching coaches and trainers can use the results of this study to stress the importance of proper trunk mechanics in pitching. Specifically, improving core strength and trunk control in an effort to maintain a more upright posture through the pitching cycle can reduce upper extremity joint stresses., (© 2015 The Author(s).)

Background: Anterior cruciate ligament (ACL) reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel placement., Hypothesis: Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (MARS) database. Each case included the patient's history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-part questionnaire dealing with each surgeon's training and practice, as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon's opinion as to the causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK)., Results: The 10 reviewers have been in practice an average of 14 years and have performed at least 25 ACL reconstructions per year, and 9 were fellowship trained in sports medicine. There was wide variability in agreement among knee experts as to the specific causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, interobserver agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK = 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17)., Conclusion: This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction., (© 2014 The Author(s).)