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To evaluate outcomes of hip arthroscopy in patients with global acetabular retroversion and to identify correlations between sex, radiographic measurements, athlete status, and return to play with patient-reported outcomes (PROs).Retrospective study of patients with global acetabular retroversion who underwent arthroscopic femoroacetabular impingement (FAI) surgery was performed. Global acetabular retroversion was defined by 3 criteria: the crossover sign, ischial spine sign, and posterior wall sign on an anteroposterior (AP) pelvic radiograph. Radiographs were used to measure lateral center edge angle, alpha angle, and anterior and posterior wall indices. Femoral version was measured with 3-dimensional computed tomography. Demographics included age, gender, athlete status, return to play, and reoperation. PROs included modified Harris Hip Score, Hip Outcome Score (HOS), Hip Disability and Osteoarthritis Outcome Score, visual analog scale (VAS), and Veterans RAND-12. Spearman correlation determined correlation with perioperative PROs. Generalized estimating equation determined independent predictors. Significance was set atFrom 2013 to 2019, 149 patients (65.0% female) with 160 hips with FAI and global acetabular retroversion underwent hip arthroscopy. Follow-up averaged 29.6 months. All PROs demonstrated significant improvement with the exception of the Veterans RAND-12 Mental. Female patients scored significantly lower on most postoperative PROs and had greater VAS scores (Patients with global acetabular retroversion and FAI undergoing hip arthroscopy report good outcomes at short-term follow-up. Male subjects and athletes had superior outcomes compared to female subjects and nonathletes. Radiographic measurements did not correlate with outcomes with exception of low femoral version. Athletes reported lower preoperative pain scores and greater postoperative PROs than nonathletes.Level IV, therapeutic case series.

Background Despite advances in shoulder arthroplasty, treatment options for advanced glenohumeral osteoarthritis (GHOA) remain limited. Surgical management includes total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), and hemiarthroplasty. The rates of TSA and RSA for the treatment of GHOA in the United States has increased in recent years. Trends in shoulder arthroplasty in recently trained surgeons have not been explored. The purpose of the study was to examine the trends in arthroplasty use (TSA, RSA, and hemiarthroplasty) for primary GHOA among American Board of Orthopedic Surgeons (ABOS) Part II examinees, and to identify patterns based on geographic region or fellowship training. Methods ABOS Part II examinees with at least 1 shoulder arthroplasty in the examination years 2008-2019 were collected. Hemiarthroplasty, TSA, and RSA performed from 2007-2018 for a diagnosis of primary GHOA were included. Arthroplasty for primary or secondary diagnoses of fracture, infection, tumor, rotator cuff arthropathy or tear, revision, and non-arthroplasty procedures were excluded. Proportion and volume of cases were evaluated, with sub-analyses of geographic region and fellowship training. Univariate logistic regression determined statistical significance (P Results A total of 946,946 cases from 8609 ABOS Part II examinees were submitted, with 8733 shoulder arthroplasties performed. Overall, 3923 arthroplasties for primary GHOA were included (44.9% of all shoulder arthroplasties). TSA was used in 50.9% of cases. The proportion of RSA performed for primary GHOA has increased over the past 11 years, with RSA surpassing TSA as the most common procedure for primary GHOA over the last 4 years (P Conclusion Utilization of RSA for treatment of primary GHOA by ABOS Part II examinees has increased significantly over the past twelve years. Among ABOS Part II examinees, RSA has recently surpassed TSA as the most common arthroplasty utilized for treatment of primary GHOA. Examination of early-career surgical practice allows for consideration of training influence in treatment of GHOA. As volume of shoulder arthroplasty continues to increase, trends and procedure volume have implications for clinical practice and patient outcomes. Level of evidence: Level III

Background Contemporary cementless reverse total shoulder arthroplasty (RSA) systems utilize a range of interference conditions based on the geometric relationships between the system instrumentation and the prosthesis design. The impact of prosthesis/bone interference, however, on the primary stability of the stemmed humeral component has not been characterized. The aim of this study was to evaluate the effect of over-reaming, standard reaming, and use of an upsized stem on stem stability in press fit reverse shoulder arthroplasty. Methods Three-dimensional humeral models were generated from CT data of 59 non-arthritic shoulders. Each model was prepared following the intended surgical technique, including resection of the humeral head and reaming of the humeral canal, assuming 1mm spacing in reamer diameters. The appropriate humeral stem (2mm increments in distal stem diameter) was then placed to represent instances of over-reaming (increased distal clearance between stem and reamed bone), standard reaming, and use of an upsized stem. Finite element analysis was performed to predict the primary stability of the humeral stem subjected to expected loads in RSA. Results Over-reaming was associated with both increased stem subsidence as well as stem-bone micromotion, as compared to standard bone preparation (P Conclusion Over-reaming of the humeral canal in cementless reverse shoulder arthroplasty results in increased micromotion and decreased primary stability of the humeral stem when subjected to loading representative of daily activities. Use of an upsized stem can recover the primary stability expected for standard reaming. Level of Evidence Biomechanical Study

The knee menisci are comprised of two orthogonal collagenous networks – circumferential and radial – that combine to enable efficient load bearing by the tissue in adults. Here, we assessed how the structural and functional characteristics of these networks developed over the course of skeletal maturation and determined the role of these fiber networks in defect tolerance with tissue injury. Imaging of the radial tie fiber (RTF) collagen structure in medial bovine menisci from fetal, juvenile, and adult specimens showed increasing heterogeneity, anisotropy, thickness, and density with skeletal development. Mechanical analysis showed that the tensile modulus in the radial direction did not change with skeletal development, though the resilience (in the radial direction) increased and the tolerance to defects in the circumferential direction decreased, in adult compared to fetal tissues. This loss of defect tolerance correlated with increased order in the RTF network in adult tissue. These data provide new insights into the role of the radial fiber network in meniscus function, will lead to improved clinical decision-making in the presence of a tear, and may improve engineering efforts to reproduce this critical load-bearing structure in the knee.

Background: Although a sex-based balance in US graduate medical education has been well-documented, a discrepancy remains in orthopaedic surgery. In orthopaedic sports medicine, the representation of women as team physicians has not previously been characterized. Purpose: To quantify the sex-related composition of team physicians of select National Collegiate Athletic Association (NCAA) Division I collegiate and professional teams. Additionally, the authors assess the sex-related composition of orthopaedic surgeon team physicians specifically and compare these proportions to the sex-related composition of orthopaedic surgeon membership of the American Orthopaedic Society for Sports Medicine (AOSSM). Study Design: Cross-sectional study. Methods: Publicly available sex-related data were collected for team physicians in select NCAA Division I collegiate conferences and professional sports organizations. Subspecialty characteristics and sex distribution were described by use of percentages. Chi-square tests were used to assess whether sex distributions of team physicians in collegiate and professional sports were (1) representative between the populations of female and male physicians compared with the general public and (2) representative of the sex-based composition of orthopaedic surgeons nationally. Results: Women represented 12.7% (112/879) of all team physicians and 6.8% (30/443) of all orthopaedic surgeons ( P < .0001). More than half (53.9%; 413/767) of male and 26.8% (30/112) of female team physicians were orthopaedic surgeons. In collegiate athletics, women comprised 18.1% of all team physicians and 7.7% of orthopaedic surgeon team physicians. In professional sports, women comprised 6.7% of all team physicians and 6.3% of orthopaedic surgeon team physicians, with the greatest proportion in the Women’s National Basketball Association (31.3%). Conclusion: Women comprise a minority of team physicians in select NCAA Division I collegiate and professional sports organizations. When compared with the composition of AOSSM orthopaedic surgeon membership, expected female orthopaedic surgeon representation varies between conferences and leagues with little statistical significance. Although efforts have been made to increase sex-based diversity in orthopaedic surgery, results of this study suggest that barriers affecting female orthopaedic surgeons as team physicians should be identified and addressed.

In adolescents and young adults, instability is a common shoulder pathology with a myriad of coexisting soft tissue and bony lesions. When evaluating a patient for the cause of instability, care must be given to assess for the infrequent lesions, including glenoid avulsion of the glenohumeral ligaments. This case example illustrates key points in the diagnosis, surgical, and postsurgical management of this less common cause of anterior shoulder instability.

Background: Patients undergoing elective procedures often utilize online educational materials to familiarize themselves with the surgical procedure and expected postoperative recovery. While the Internet is easily accessible and ubiquitous today, the ability of patients to read, understand, and act on these materials is unknown. Purpose: To evaluate online resources about anterior cruciate ligament (ACL) surgery utilizing measures of readability, understandability, and actionability. Study Design: Cross-sectional study; Level of evidence, 4. Methods: Using the term “ACL surgery,” 2 independent searches were performed utilizing a public search engine ( Google.com ). Patient education materials were identified from the top 50 results. Audiovisual materials, news articles, materials intended for advertising or medical professionals, and materials unrelated to ACL surgery were excluded. Readability was quantified using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, Coleman-Liau Index, Automated Readability Index, and Gunning Fog Index. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) was utilized to assess the actionability and understandability of materials. For each online source, the relationship between its Google search rank (from first to last) and its readability, understandability, and actionability was calculated utilizing the Spearman rank correlation coefficient (ρS). Results: Overall, we identified 68 unique websites, of which 39 met inclusion criteria. The mean Flesch-Kincaid Grade Level was 10.08 ± 2.34, with no website scoring at or below the 6th-grade level. Mean understandability and actionability scores were 59.18 ± 10.86 (range, 33.64-79.17) and 34.41 ± 22.31 (range, 0.00-81.67), respectively. Only 5 (12.82%) and 1 (2.56%) resource scored above the 70% adequate PEMAT-P threshold mark for understandability and actionability, respectively. Readability (lowest P value = .103), understandability (ρS = –0.13; P = .441), and actionability (ρS = 0.28; P = .096) scores were not associated with Google rank. Conclusion: Patient education materials on ACL surgery scored poorly with respect to readability, understandability, and actionability. No online resource scored at the recommended reading level of the American Medical Association or National Institutes of Health. Only 5 resources scored above the proven threshold for understandability, and only 1 resource scored above it for actionability.

Context: Upper extremity injuries are extremely common in contact sports such as football, soccer, and lacrosse. The culture of competitive athletics provides an environment where hand injuries are frequently downplayed in an effort to prevent loss of game time. However, studies have shown that many sport-induced hand injuries do not actually require immediate surgical attention and can be safely treated through immobilization so that the athlete may complete the athletic season. In these cases, appropriate casting and splinting measures should be taken to ensure protection of the injured player and the other competitors without causing loss of game time. Evidence Acquisition: Articles published between 1976 and 2015 were reviewed to capture historical and current views on the treatment of hand injuries in the in-season athlete. Study Design: Clinical review. Level of Evidence: Level 5. Results: Although traditionally many sports-induced traumatic injuries to the hand held the potential to be season-ending injuries, experience has shown that in-season athletes do not necessarily need to lose game time to receive appropriate treatment. A thorough knowledge of converting everyday splints and casts into game day, sport-approved protective immobilization devices is key to safely allowing athletes with select injuries to play while injured. Conclusion: Protective techniques allow for maximum functionality during gameplay while safely and effectively protecting the injury from further trauma while bony healing takes place.

Injury to the meniscus is common, but few viable strategies exist for its repair or regeneration. To address this, animal models have been developed to translate new treatment strategies toward the clinic. However, there is not yet a regulatory document guiding such studies. The purpose of this study was to carry out a systematic review of the literature on meniscus treatment methods and outcomes to define the state of the field. Public databases were queried by using search terms related to animal models and meniscus injury and/or repair over the years 1980-2015. Identified peer-reviewed manuscripts were screened by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. One of nine reviewers read each manuscript and scored them based on whether the publication described a series of predefined study descriptors and outcome measures. Additional data were extracted to identify common assays used. A total of 128 full-length peer-reviewed manuscripts were identified. The number of publications increased over the time frame analyzed, with 48% focused on augmented repair. Rabbit was, by far, the most prevalent species utilized (46%), with dog (21%) and sheep (20%) being the next most common. Analysis of study descriptors revealed that most studies appropriately documented details of the animal used, the surgical approach, and defect and implant characteristics (e.g., 63% of studies identified clearly the defect size). In terms of outcome parameters, most studies carried out macroscopic (85%), histologic (90%), and healing/integration (83%) analyses of the meniscus. However, many studies did not provide further analysis beyond these fundamental measures, and less than 40% reported on the adjacent cartilage and synovium, as well as joint function. There is intense interest in the field of meniscus repair. However, given the current lack of guidance documentation in this area, preclinical animal models are not performed in a standardized fashion. The development of a "Best Practices" document would increase reproducibility and external validity of experiments, while accelerating advancements in translational research. Advancement is of paramount importance given the high prevalence of meniscal injuries and the paucity of effective repair or regenerative strategies.

Objectives: The purpose of this study was to evaluate the demographics of female representation among team physicians in the National Collegiate Athletic Association (NCAA) and professional sports organizations. We hypothesized that female team physicians are underrepresented at the collegiate and professional level despite controlling for the percentage of women in orthopaedics overall. Methods: Team physicians responsible for providing medical care to athletes in the “Power Five” conferences (Southeastern Conference [SEC], Atlantic Coast Conference [ACC], BIG-10, BIG-12, PAC-12) and select professional organizations [Major League Baseball(MLB), National Football League (NFL), National Basketball Association (NBA), Women’s National Basketball Association (WNBA)] were surveyed using the most current publicly available online information for both collegiate and professional organizations (range, 2012-2018). Demographic data was used to sort physicians by gender. Team physicians were further stratified into orthopaedic and primary care sports medicine (PCSM) categories. The proportion of females in each field was analyzed using univariate analysis, with statistical significance defined as pResults: Analysis found that 100% of the teams in the NFL, NBA, and MLB as well as 82% of teams in the WNBA had male team physician representation, including either a male orthopaedic surgeon or male PCSM provider. Females (orthopaedic and PCSM) were represented among 13.3% of NBA teams, 55% of WNBA teams, 13.3% of MLB teams, and 6.3% of NFL teams. Specifically, female orthopaedic surgeons were represented in 3.33% of NBA, 45.45% of WNBA, 10% of MLB, and 3.13% of NFL teams. In the ”Power Five” conferences, female orthopaedic surgeons were represented in 7.14% of teams in the SEC, 8.33% in the ACC, 30.77% in the BIG-10, 0% in the BIG-12, and 50% in the PAC-12. The total number of male orthopaedic surgeons was significantly higher in the “Power Five” collegiate conferences, with team orthopaedic surgeons 1,483 times more likely to identify as male compared to female (pConclusion: There is a paucity of data describing representation of female team physicians among major athletic organizations. This analysis found that male orthopaedic surgeons represent a significantly higher proportion of team or orthopaedic physicians in several Division I collegiate conferences and professional sports compared to female physicians. Interestingly, the overall representation of female orthopaedic surgeons in the PAC12 and BIG 10 conferences was higher than their representation in the AAOS. However, female representation among team physicians has not kept pace with increasing numbers of female participation in collegiate and professional athletics. Overall, female team physicians are underrepresented in sports medicine in the United States at both the collegiate and professional levels. Further exploration of educational pathways and hiring processes for team physicians may be warranted. [Table: see text]

Proximal tibiofibular joint (PTFJ) instability is a rare cause of lateral-sided knee pain. The authors present a case of bilateral, symptomatic PTFJ instability with peroneal nerve dysfunction in an active 16-year-old female athlete. This was addressed with peroneal nerve decompression and PTFJ stabilization using a suspensory button fixation system. This provides an alternative treatment from historical methods such as PTFJ fusion or re-approximation of the joint with tendon through bone tunnels. The surgical technique, as well as potential treatment challenges, is described in detail. The purpose of this report is to highlight PTFJ instability as a cause of lateral-sided knee pain to avoid misdiagnosis and delay in appropriate treatment. This patient had significant improvement in pain and decreased neurologic symptoms after the stabilization and nerve decompression. She was able to return to high-level activity. [ Orthopedics. 2017; 40(6):e1107–e1111.]