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Background: Both beach-chair and lateral decubitus patient positioning are often utilized for shoulder arthroscopy, with each offering its unique advantages and disadvantages. The surgical position is often selected according to each surgeon's preference, with no clear superiority of one position over the other. Purpose/Hypothesis: The purpose was to compare clinical and patient-reported outcomes between patients who underwent arthroscopic posterior labral repair in the beach-chair versus the lateral decubitus position. We hypothesized that patient positioning would not affect clinical and patient-reported outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A list of all patients diagnosed with the Current Procedural Terminology codes 29806 and 29807 between 2015 and 2019 was obtained from the medical records. Patients were only included if arthroscopic posterior labral repair with or without concomitant superior labral anterior to posterior repair was confirmed. Data collected for eligible patients included the number of anchors used, perioperative and postoperative complications, redislocations, subjective instability, reoperation, and revision. Patients were also contacted to complete several patient-reported outcome surveys. Preoperative data, perioperative data, and postoperative outcomes were compared between patients who underwent surgery in the beach-chair versus lateral decubitus position. Results: Overall, 126 patients were included—69 patients underwent surgery in the lateral decubitus position and 57 in the beach-chair position—with a mean follow-up of 2.6 ± 1.7 years. There were no significant pre- or perioperative differences between groups. Rates of postoperative dislocations, subjective instability, reoperations, revisions, all complications, and return to sports rates also did not differ between groups (all, P > .05). Finally, there was no difference between groups regarding postoperative pain, function, and subjective instability scores (all, P > .05). Results of the multivariate regression analysis showed that increased age was a weak independent risk factor for subjective recurrent posterior shoulder instability (odds ratio, 1.04; P = .036). Conclusion: Surgical positioning for arthroscopic posterior shoulder labral repair did not affect postoperative clinical and patient-reported outcomes. Both beach-chair and lateral decubitus position provided good outcomes for posterior shoulder labral repair, with an overall recurrence rate of 8.7%. Increased age was a weak independent risk factor for subjective recurrent instability.

Background: Biceps tendon pathology is common in patients with rotator cuff tears. Leaving biceps pathology untreated in rotator cuff repairs (RCRs) may lead to suboptimal outcomes. Purpose/Hypothesis: The purpose was to compare clinical outcomes between patients who underwent isolated RCR versus patients who underwent RCR with concomitant biceps treatment. It was hypothesized that there would be no difference in clinical outcomes between groups. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 244 patients who underwent RCR in 2016 were included. Patient characteristics, presence of concomitant biceps pathology, pre- and postoperative American Shoulder and Elbow Surgeons (ASES) scores, rotator cuff failure, revision surgery, and complications were recorded. Results: There were no significant differences between patients who underwent isolated RCR (n = 143) and those who underwent RCR with biceps treatment (n = 101) at 2 years postoperatively in ASES scores (RCR, 81.5; RCR+biceps treatment, 79.5; P = .532), cuff failure rate (5.6% vs 4.0%; P = .760), revision RCR rate (3.5% vs 2.0%; P = .703), or complication rate (11.9% vs 5.0%; P = .102). Furthermore, when comparing concomitant biceps tenotomy (n = 30) versus concomitant biceps tenodesis (n = 71), there were no differences in ASES scores ( P = .149), cuff failure rate ( P > .999), revision RCR rate ( P > .999), or complication rate ( P > .999) postoperatively. Finally, when comparing arthroscopic biceps tenodesis (n = 50) versus subpectoral biceps tenodesis (n = 21), there were no differences in ASES scores ( P > .592), cuff failure rate ( P > .999), revision RCR rate ( P = .507), or complication rate ( P > .999) 2 years postoperatively. Conclusion: Addressing biceps pathology when performing RCR resulted in similar rates of cuff failure, revision RCR, and complications, as well as a similar improvement in patient-reported outcomes when compared with isolated RCR at 2 years postoperatively. Furthermore, when comparing tenotomy versus tenodesis and arthroscopic versus subpectoral tenodesis, comparable outcomes with regard to rate of rotator cuff repair failure, revision RCR, complications, and patient-reported outcomes were found.

Purpose To retrospectively investigate the clinical and functional outcomes of patients who underwent knotted medial-row rotator cuff repair (KT-RCR) compared with patients who underwent knotless medial-row rotator cuff repair (KL-RCR). Methods A retrospective chart review of patients who underwent double-row transosseous-equivalent rotator cuff repair in 2016 was performed at a single institution with 2-year follow-up. Information regarding demographic characteristics, preoperative tear size (magnetic resonance imaging), surgical variables (including method of suture stabilization), preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) scores, and all complications (e.g., cuff failure, adhesive capsulitis, and persistent pain) was compiled. Results A total of 189 patients met the inclusion criteria: 72 in the KL-RCR group and 117 in the KT-RCR group. No significant difference in preoperative ASES scores was found between the KL-RCR and KT-RCR groups (48.3 vs 45.4, P = .327). Postoperative ASES scores did not differ between the groups (82.4 for KL-RCR vs 78.8 for KT-RCR, P = .579). We found no significant difference in cuff failure rates after 2 years, determined by magnetic resonance imaging (5.6% for KL-RCR vs 6.1% for KT-RCR, P > .999), or complication rates (11.1% for KL-RCR vs 8.6% for KT-RCR, P = .743). Conclusions The knotted approach and knotless approach to double-row rotator cuff repair showed similar outcome scores, cuff failure rates, and complication rates at minimum 2-year follow-up. Level of Evidence Level III, retrospective therapeutic comparative trial.

Pain management and opioid consumption following outpatient orthopedic surgery may be influenced by several variables, including knowledge of safe opioid use. A prospective randomized study was undertaken to understand the effect of preoperative opioid education on opioid consumption following outpatient orthopedic surgeries. A total of 237 patients undergoing outpatient orthopedic surgeries were prospectively randomized to receive preoperative opioid education or not. Postoperative data collected included the number of pills taken, daily visual analog scale (VAS) pain scores, adverse events, and attitude toward the pain experience. A total of 107 patients were randomized to receive preoperative education and 130 to not receive preoperative education. On average, 27 pills were prescribed to each patient. The preoperative opioid education group consumed significantly fewer opioids (6 pills) when compared with the group not receiving education (12 pills) ( P Orthopedics . 2021;44(2):123–127.]

Background: Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study. Purpose: To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures. Study Design: Meta-analysis. Methods: A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis. Results: Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, –95.51 to −27.46; P = .0004), lower hemarthrosis grade ( P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (−1.96 points; 95% CI, −2.19 to −1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced ( P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups. Conclusion: The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.

Background: Surgical positioning can affect both perioperative and postoperative complication rates. It is unclear whether beach-chair versus lateral decubitus positioning affects outcomes in patients undergoing arthroscopic anterior shoulder stabilization surgery. Purpose: The purpose of this study was to compare recurrent instability, complications, and patient-reported outcomes between patients who underwent arthroscopic anterior shoulder stabilization in the beach-chair versus the lateral decubitus positions. It was hypothesized that recurrent instability, complications, and patient-reported outcomes would not be affected by surgical positioning. Study Design: Cohort study; Level of evidence, 3. Methods: The authors reviewed the medical records of patients who underwent shoulder stabilization ( Current Procedural Terminology codes 29806 and 29807) from 2015 to 2019. Patients were included only if anterior instability was confirmed, arthroscopic surgery was performed in response to shoulder instability, and a minimum of 2 years of follow-up data were available. Data collected for eligible patients included perioperative and postoperative complications, recurrent instability, reoperation, and revision. Patients also completed surveys for the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Oxford Shoulder Instability (OSI) score, and a return to any level of sport (RTS) questionnaire. Results: Overall, 294 patients (162 lateral decubitus and 132 beach-chair positions) were included, with an average follow-up of 2.4 ± 1.6 years. There were no significant differences in demographics between groups, nor were there differences in the rates of postoperative dislocations, subjective instability, reoperations, revisions, or complications. There was a trend toward a higher revision rate in the beach-chair group (beach-chair, 6.1% vs lateral decubitus, 1.9%; P = .069). There was no significant difference between groups regarding RTS rates or postoperative ASES, SANE, and OSI scores at 3.3 ± 1.1 years postoperatively. Conclusion: Surgical positioning for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, and patient-reported outcomes. Both beach-chair and lateral decubitus positioning provided good outcomes for anterior shoulder stabilization, with an overall recurrent dislocation rate of 7.8% at a mean of 3.3 years after surgery.

Background: Rates of opioid addiction and overdose continue to climb in the United States, increasing pressure on prescribers to identify solutions to decrease postoperative opioid consumption. Hand and upper extremity surgeries are high-volume surgeries with a predilection for inadvertent overprescribing. Recent investigations have shown that preoperative opioid counseling may decrease postoperative opioid consumption. In order to test this hypothesis, a prospective randomized trial was undertaken to determine the effect of preoperative opioid counseling on postoperative opioid consumption. Methods: Eligible patients undergoing outpatient upper extremity surgery were randomized to either receive preoperative opioid counseling or to receive no counseling. Surgeons were blinded to their patient’s counseling status. Preoperatively, patient demographics, surgical and prescription details were recorded. Postoperatively, patients’ pain experience including opioid consumption, pain levels, and satisfaction was recorded. Results: There were 131 total patients enrolled, with 62 in the counseling group and 69 in the control group. Patients receiving counseling consumed 11.8 pills compared to 17.4 pills in the control group ( P = .007), which translated to 93.7 Morphine Equivalent Units (MEU) in the counseling group compared to 143.2 MEU in the control group ( P = .01). There was no difference in pain scores at any time point between groups. Among all study patients a total of 3767 opioid pills were prescribed with approximately 50% left unused. Conclusion: Patients receiving preoperative counseling consumed significantly fewer opioids postoperatively. Inadvertant overprescribing remains high. Routine use of preoperative counseling should be implemented along with prescribing fewer opioids overall to prevent overprescribing.

To retrospectively compare return to sport rates and subjective outcomes of patients who underwent open or endoscopic compartment release for the surgical management of chronic exertional compartment syndrome.This was a retrospective review of patients who underwent lower-extremity fasciotomy for chronic exertional compartment syndrome from June 2012 to June 2020. Eligibility included patients 15 to 45 years of age who identified as an athlete and had at least 6 months of follow-up. Fasciotomies for trauma or infection were excluded. One surgeon exclusively performed each type of surgery. Postoperative outcome measures included the Lower Extremity Functional Scale, the Marx Activity Scale, and a return to play survey.In total, 24 patients (13 endoscopically assisted fasciotomies, 11 open fasciotomies) had a mean follow-up of 3.8 ± 2.1 years; 19 patients returned to their sporting activity. No significant difference existed between return to play rates (In this small sample of heterogenous groups of patients, we found no significant differences in return to sport rates or subjective results after surgery. Patients experienced a high subjective recurrence rate. The endoscopically assisted fasciotomy group reported greater subjective patient satisfaction compared with the open fasciotomy group.Level III, comparative study, retrospective.

Background: Several cadaveric imaging studies have demonstrated that the articular cartilage thickness on the tibial plateau varies depending on coverage by native meniscal tissue. These differences are thought to partially contribute to the rates of cartilage degeneration and development of osteoarthritis after meniscectomy. Because there is greater tibial plateau coverage with meniscal tissue in the setting of a discoid meniscus, these findings may also have implications for the long-term health of the knee after saucerization of a torn discoid meniscus. Purpose: To evaluate the relationship between lateral compartment articular cartilage thickness and the presence or absence of a discoid meniscus. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included in the study were 25 patients younger than 40 years of age who had undergone a 1.5-T or 3-T knee magnetic resonance imaging (MRI) between 2010 and 2016 at a single institution and had an intact, lateral discoid meniscus. Only patients with an otherwise asymptomatic lateral compartment were included. The authors then identified 35 age-matched controls with a nondiscoid, intact lateral meniscus who underwent knee MRI at the same institution and during the same period. The articular cartilage thicknesses in 6 zones of the lateral femoral condyle (LFC) and lateral tibial plateau (LTP) were measured for each patient by 2 musculoskeletal radiologists, and the mean thicknesses were compared between the study and control groups. Results: The average age at MRI was 22.63 years (range, 8.30-35.90 years) for the discoid group and 20.93 years (range, 8.43-34.99 years) for the nondiscoid group. The nondiscoid group had significantly greater mean articular cartilage thickness in all 6 zones of the LTP ( P < .05 for all). When comparing the zones of the LFC, there was no significant difference in the mean thickness in any zone between the 2 groups. Conclusion: Patients with discoid menisci had thinner baseline articular cartilage thickness in the LTP compared with those patients without discoid menisci.

Background: Questions remain regarding the traditional protocols used in rehabilitation and clearance for return to sports after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: To investigate the impact on injury rates after return to sports by developing and validating a Safer Return to Play Following ACL Reconstruction Checklist consisting of subjective and objective functional tests that can be quickly and easily implemented into a sports medicine practice. It was hypothesized that patients who successfully passed the checklist before returning to sports would experience lower rates of ipsilateral and contralateral knee injuries at a 2-year follow-up as compared with patients who returned to play before completing the checklist. Study Design: Cohort study; Level of evidence, 2. Methods: First, a systematic review was performed to generate a list of the most common outcome measures used to assess return to play after ACLR. To refine our checklist, we conducted a survey with an expert panel of 10 medical professionals utilizing the Delphi technique. After the creation of the checklist, validation was performed by prospectively evaluating patients who had undergone ACLR for injury of the ipsilateral or contralateral knee, with a minimum 2-year follow-up. Results: After our systematic review of 60 studies, 7 criteria were included in the final checklist. During the period studied, October 2014 to December 2017, a total of 222 patients met the inclusion criteria and were enrolled in the study. At a minimum 2 years of follow-up, there were 146 patients who successfully passed the checklist and 38 who did not. Overall, 24 (16.4%) patients who had passed the checklist sustained an injury to either knee, as compared with 10 (26.3%) from the group that did not pass the checklist ( P = .162). Of the group that passed the checklist, 8 (5.5%) patients sustained an injury to the ipsilateral knee, as compared with 7 (18.4%) in the group that did not pass ( P = .017). Conclusion: Prospective validation of our checklist demonstrated that patients who successfully passed the checklist before returning to play experienced a significantly lower incidence of ipsilateral anterior cruciate ligament injury as compared with patients who did not pass the checklist.

Purpose To compare outcomes of hip arthroplasty in patients with and without a history of hip arthroscopy through a systematic review. Methods A comprehensive search of the PubMed (MEDLINE) and Cochrane Central databases was performed using combinations of the keywords “hip,” “arthroscopy,” “arthroscopic,” “arthroplasty,” “replacement,” and “conversion” in December 2017. Level I through III studies directly comparing outcomes of total or resurfacing hip arthroplasty between patients with and without a history of hip arthroscopy were included in this review if they reported at least 1 outcome measure. Results Seven retrospective case-control studies collectively evaluating arthroplasty outcomes of 235 patients (104 male and 131 female patients) with a history of hip arthroscopy and 374 matched controls met the inclusion criteria. The mean age in the arthroscopy and control groups was 47.2 years and 49.1 years, respectively. The mean follow-up period after arthroplasty was 3.2 years in the hip arthroscopy group and 3.3 years in the control group. The mean time between arthroscopy and arthroplasty was 1.8 years. A posterior approach was used in 83.6% of arthroplasties. No statistically significant differences were noted in intraoperative measures, postoperative complications, or revision rates, with the exception of 1 study that reported an increased operative time among controls. Most studies reported similar subjective outcomes between groups, with a single study noting worse postoperative findings for the Harris Hip Score, Forgotten Joint Score-12, visual analog scale pain score, and patient satisfaction in the prior hip arthroscopy group. Conclusions The current literature suggests that short-term and midterm outcomes of hip arthroplasty are comparable in patients with and without a history of hip arthroscopy. However, the available literature is limited given the small sample sizes and therefore greater potential for β error. Nevertheless, our findings may be useful for surgeons evaluating risks and prognoses in this patient population. Level of Evidence Level III, systematic review of Level III studies.

Objectives: Surgical positioning can affect intra- and post-operative complication rates for many reasons, including potential differences in anatomic approaches and proximity to nearby nerves. The beach chair and lateral decubitus positions are the two most common positions for shoulder arthroscopy, and each offers their own unique advantages and disadvantages for surgeons. Beach chair allows for an easier transition to open surgery if necessary, and also has a lower incidence rate of neuropathies, relative to lateral decubitus. However, the lateral decubitus positioning allows for better access to the glenohumeral joint, easier visualization of the labrum, and greater circumferential access to the joint. The surgical position is often selected according to each individual surgeon’s preference, with no clear superiority of one position over the other. This study was conducted to compare clinical and patient-reported outcomes between patients who underwent arthroscopic anterior shoulder stabilization in beach chair vs. lateral decubitus positions. Methods: A list of all patients diagnosed with the CPT codes 29806 and 29807 from 2015-2019 was obtained from the medical records. Patients were only included if anterior instability was confirmed, arthroscopic surgery was performed in response to shoulder instability, and a minimum of 2-year follow-up was available. Data collected for eligible patients includes: pathology present (Hill-Sachs lesion, bony Bankart lesion), number and location of anchors used, surgery duration, intra-operative and post-operative complications, recurrent instability, reoperation, and revision. Patients were also contacted to complete patient-reported outcome surveys including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score, Single Assessment Numeric Evaluation (SANE), and a return to sport (RTS) questionnaire. Demographic, intra-operative data, and post-operative outcomes were compared between patients who underwent surgery in beach chair vs lateral decubitus positioning. Results: 294 patients were included in this study, 162 patients who underwent surgery in the lateral decubitus position and 132 in beach chair position with an average follow-up of 3.3 years. There were no significant differences in demographics, concomitant surgeries, prevalence of Hill-Sachs and bony Bankart lesions, surgery duration, or intra-operative complications between groups (all p>0.05). Beach chair was associated with an increased number of anchors used (4.0 vs. 3.3, p=0.01) and a smaller proportion of inferior anchors being placed at the 6 o’clock position (8.3% vs. 25.0%, p=0.022) (Table 1). Rates of post-operative dislocations, recurrent instability, reoperations, all complications, and RTS also did not differ between groups (all p>0.05). Beach chair position had a trend for increase in revision rate but was not significant (beach chair 6.1% vs. lateral decubitus 1.9%, p=0.069). Finally, there was no difference between groups regarding post-operative ASES, SANE, and Oxford Shoulder Scores (all p>0.05). Conclusions: Surgical positioning for arthroscopic anterior shoulder stabilization did not affect post-operative clinical and patient-reported outcomes. Lateral decubitus patient positioning was associated with the use of fewer anchors and an increased proportion of inferior anchors placed at the 6 o’clock position of the labrum. [Table: see text]

Objectives: Tranexamic acid (TXA) is widely used in arthroplasty procedures and has recently gained popularity as an adjunct for improving perioperative outcomes after arthroscopic procedures. However, the safety, side-effect profile, and efficacy of various routes of administration (intravenous and intraarticular) of tranexamic acid in arthroscopic surgery have not been clearly delineated. The objectives of this study are to analyze the available literature on overall safety, efficacy, and complications such as deep vein thrombosis, pulmonary embolus, and infection following administration of intravenous (IV) or intraarticular (IA) tranexamic acid in arthroscopic procedures. Methods: A literature search in agreement with the Preferred Reporting Items from Systematic Reviews and Meta-Analyses (PRISMA) protocol was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of arthroscopic procedures. Inclusion criteria included randomized controlled trials (RCT), published at any time, which report adverse clinical outcomes, including deep vein thrombosis, pulmonary embolus, and adverse reactions following arthroscopic procedures, in which patients were randomized into an experimental group who received TXA (either intravenously or via intra-articular injection) preoperatively and a control group who did not receive TXA. The exclusion criteria were those studies that were non-RCT and did not assess outcomes following arthroscopic procedures. The studied outcomes included: thromboembolic events, adverse drug reactions, postoperative drain output, VAS pain scores, and joint aspiration requirements. Results: Thirteen prospective randomized controlled trials met inclusion criteria for analysis and were included in this review. These studies examined a total of 1,159 arthroscopic procedures, comprised of 174 hip arthroscopy procedures, 810 knee arthroscopy procedures for ACL reconstruction, 103 knee arthroscopy procedures for meniscectomy or repair, and 72 shoulder arthroscopy procedures for rotator cuff repair. Tranexamic acid use in arthroscopic procedures resulted in no increase in thromboembolic events or adverse drug reactions, with no thromboembolic events or adverse drug reactions reported across the 1,159 procedures. Tranexamic acid in IV and IA forms used in ACL reconstruction reduced 24-hour postoperative drain output (-48.47cc; P=0.001 in IV TXA and -39.11cc, P=0.004 in IA TXA group when compared to control) and improved VAS pain scores in the early postoperative period at 1 week (-1.4, PConclusions: The use of IV or IA TXA in arthroscopic surgery including rotator cuff repair, meniscus, femoroacetabular impingement surgery, and ACL reconstruction is safe and confers no increased risk of thromboembolic events. IV and IA TXA have proven to be effective in reducing postoperative drain output and even reducing pain in the early postoperative period following ACL reconstruction. Finally, IV TXA has been shown to reduce the need for postoperative aspiration following ACL reconstruction.

Objectives: Disruption of the medial patellofemoral ligament (MPFL) may lead to recurrent lateral patellar dislocation and patellofemoral chondral injury. Optimal graft choice for MPFL reconstruction in the surgical treatment of patellar instability is unknown. While autograft remains readily available, easily harvested, and of lower cost, allograft is a viable alternative and portends several benefits over autograft. Autograft may provide superior strength or lower re-tear rate, but allograft has been shown to have similar outcomes with less donor site morbidity in some series. Overall, there is a paucity of research comparing autograft vs allograft in MPFL reconstruction. Prior studies have been limited by small sample sizes, incomplete data, or heterogeneous patient population. The objectives of this study were to compare outcomes scores, return to activity and revision rates between allograft and autograft in MPFL reconstruction. The authors hypothesized that there would be no significant difference in outcomes between those who received an allograft and those who received an autograft in MPFL reconstruction. Methods: Patients who underwent isolated MPFL reconstruction with allograft or autograft at a single institution between 2013-2020 were retrospectively reviewed. Patients with a follow-up of less than 2 years were excluded, along with those who underwent concomitant tibial tubercle osteotomy or trochleoplasty. Patients were contacted to complete functional assessments including the Single Assessment Numeric Evaluation (SANE), Visual Analog Scale for pain (VAS), and International Knee Documentation Committee (IKDC) scores. Patient demographics and complications were also reviewed. Outcomes were compared between those that underwent allograft and autograft MPFL reconstruction Results: Out of the fourty-six patients that were retrospectively reviewed, thirty-one (67.4%) patients underwent allograft reconstruction, while fifteen (32.6%) patients underwent autograft reconstruction. There were no differences between the two groups in age at surgery (25.2 years old in allograft vs 26.3 years old in autograft group, P=0.726), sex ratio (19F/12M in allograft and 9F/6M in autograft, P=1.000), or BMI (27.0 in allograft and 24.8 in autograft, P=0.179). There was a mean follow up duration of 4.57 years in the allograft group and 4.83 years in the autograft group (P=0.672), with an overall response rate of 70.2%. There were no differences between the two groups when assessing subjective pain using SANE (66.7 in allograft vs 74.5 in autograft, P=0.334) or VAS score (35.7 in allograft vs 22.9 in autograft, P=0.110). Further there were no differences in patient outcomes as assessed by IKDC score (68.3 in allograft vs 76.2 in autograft, P=0.247). Patients who received an allograft returned to activity at an average of 5.9 months, while patients who received an autograft returned to activity at an average of 5.2 months (P=0.416). One patient in the allograft group required revision surgery (P=0.246). Conclusions: Both allograft and autograft remain viable options in MPFL reconstruction. There were no significant differences in failure rates, PROs, pain, or time to return to play between allograft and autograft MPFL reconstruction in this series.

Background: The ability to return to school after orthopaedic surgery is an important consideration for young patients, as there is substantial literature indicating that school attendance is correlated strongly with academic performance. Purpose: To evaluate the time to return to school, the barriers that students encounter when returning to school, and the academic effect of anterior cruciate ligament reconstruction (ACLR) in high school (HS) and college students. Study Design: Cohort study; Level of evidence, 2. Methods: Full-time HS and college/graduate school (C/GS) students who underwent ACLR during the 2017 to 2018 and 2018 to 2019 academic periods were included in the study. Patients were contacted 2 weeks postoperatively to complete a questionnaire that assessed their time to return to school and barriers that interfered with their ability to return, and they completed a second questionnaire at 6 weeks postoperatively that assessed academic performance and challenges faced upon returning to school. Results: Included were 36 (52.2%) full-time HS students and 33 (47.8%) full-time C/GS students. HS students reported a longer time to return to school compared with C/GS students (8.51 vs 5.89 days; P = .008). In addition, HS students missed more scheduled school days than C/GS students (5.39 vs 2.90 days; P < .001). The majority of HS (73.5%) and C/GS (65.5%) students cited pain as a barrier to return, and more than half of HS (70.6%) and C/GS (55.2%) students also cited restricted mobility as a barrier to return. HS students were more likely to miss an examination in the early postoperative period compared with their C/GS counterparts (65.7% vs 39.3%; P = .037). Many students in both cohorts received a grade less than expected in the early postoperative period; this was not significantly different between the 2 groups (HS, 50.0%; C/GS, 42.9%; P = .489). Conclusion: ACLR can have a negative effect on school attendance and academic performance among HS and C/GS students. Orthopaedic surgeons should counsel all students and their families adequately about the potential academic effect of orthopaedic surgery in order to maximize clinical results, academic performance, and satisfaction in their patients.

Background:There is consensus that most complete ulnar collateral ligament (UCL) injuries in throwers would benefit from surgical intervention. Optimal treatment for partial UCL tears remains controversial. Stress ultrasonography has become a well-accepted diagnostic modality for assessing UCL injury.Hypothesis:Partial UCL tears will result in an intermediate increase in ulnohumeral joint space gapping as compared with that of an intact UCL and a complete UCL tear, but the degree of joint space gapping will vary by anatomic location of the partial tear.Study Design:Controlled laboratory study.Methods:Twenty-one cadaveric elbows were divided into 7 groups representing different anatomic locations of UCL partial tears. Partial tears were simulated by cutting 50% of the measured width of the UCL at 6 locations: distal anterior/posterior, midsubstance anterior/posterior, and proximal anterior/posterior. A seventh partial tear was created by partially elevating the undersurface of the distal UCL to simulate the radiographic “T-sign.” Valgus stress (15 daN) was applied to each cadaveric elbow at 30° of flexion using a standardized device. Each specimen was tested intact, partially torn, and completely torn. At each state, joint space was measured using stress ultrasonography, and the difference in joint space from unstressed to stressed (delta) was recorded.Results:There were 10 right and 11 left upper extremity specimens. The mean delta was 0.58 mm for the intact state and 1.5 mm (1.54-3.03 mm).Conclusion:These findings suggest that partial tears introduce a spectrum of instability from functionally intact to completely torn. As a result, some may be biomechanically amenable to nonoperative treatment, while others would be indicated for early reconstruction. Further research into the biological and biomechanical determinants of nonoperative treatment failure will assist with more precise treatment recommendations.Clinical Relevance:Describing the biomechanical consequences of different, clinically significant partial UCL tears potentially allows more precise recommendations for operative and nonoperative treatment.

Background:Although most anterior tibial stress fractures heal with nonoperative treatment, some may require surgical management. To our knowledge, no systematic review has been conducted regarding surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in high-performance athletes.Purpose:This systematic review was conducted to evaluate the surgical outcomes of anterior tibial stress fractures in high-performance athletes.Study Design:Systematic review; Level of evidence, 4.Methods:In February 2017, a systematic review of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases was performed to identify studies that reported surgical outcomes for anterior tibial stress fractures. Articles meeting the inclusion criteria were screened, and reported outcome measures were documented.Results:A total of 12 studies, published between 1984 and 2015, reporting outcomes for the surgical treatment of anterior tibial stress fractures were included in this review. All studies were retrospective case series. Collectively, surgical outcomes for 115 patients (74 males; 41 females) with 123 fractures were evaluated in this review. The overall mean follow-up was 23.3 months. The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Subsequent tibial fractures were reported in 8 patients (7.0%). Moreover, a total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. Following surgical treatment for anterior tibial stress fracture, 94.7% of patients were able to return to sports.Conclusion:The available literature indicates that surgical treatment of anterior tibial stress fractures is associated with a high rate of symptom resolution and return to play in athletes, although the high complication rate and potential need for subsequent procedures are important considerations for surgeons and patients.

Background:Fresh osteochondral allograft (OCA) is a treatment option that allows for the transfer of size-matched allograft cartilage and subchondral bone into articular defects of the knee. Although long-term studies show good functional improvement with OCA, there continues to be wide variability and a lack of consensus in terms of postoperative rehabilitation protocols and return to sport.Purpose:To systematically review the literature and evaluate the reported rehabilitation protocols after OCA of the knee, including weightbearing and range of motion (ROM) restrictions as well as return-to-play criteria.Study Design:Systematic review; Level of evidence, 4.Methods:PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature, SPORTDiscus, and Cochrane databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies on knee OCA. Studies were included if they reported return-to-play data or postsurgical rehabilitation protocols.Results:A total of 62 studies met the inclusion criteria, with a total of 3451 knees in 3355 patients. Concomitant procedures were included in 30 of these studies (48.4%). The most commonly cited rehabilitation protocols included weightbearing restrictions and ROM guidelines in 100% and 90% of studies, respectively. ROM was most commonly initiated within the first postoperative week, with approximately half of studies utilizing continuous passive motion. Progression to weightbearing as tolerated was reported in 60 studies, most commonly at 6 weeks (range, immediately postoperatively to up to 1 year). Of the 62 studies, 37 (59.7%) included an expected timeline for either return to play or return to full activity, most commonly at 6 months (range, 4 months to 1 year). Overall, 13 studies (21.0%) included either objective or subjective criteria to determine return to activity within their rehabilitation protocol.Conclusion:There is significant heterogeneity for postoperative rehabilitation guidelines and the return-to-play protocol after OCA of the knee in the literature, as nearly half of the included studies reported use of concomitant procedures. However, current protocols appear to be predominantly time-based without objective criteria or functional assessment. Therefore, the authors recommend the development of objective criteria for patient rehabilitation and return-to-play protocols after OCA of the knee.

Background: Anterior cruciate ligament injury may accelerate knee osteoarthritis, and patients with a history of anterior cruciate ligament reconstruction (ACLR) tend to undergo total knee arthroplasty (TKA) at a greater rate than patients without a history of ACLR. Purpose: To compare clinical outcomes of TKA in patients with and without a history of ACLR through a systematic review. Study Design: Systematic review; Level of evidence, 3. Methods: A comprehensive search of the PubMed (MEDLINE), Cochrane Central, and SPORTDiscus databases from inception through November 2018 was performed to identify studies directly comparing outcomes of TKA between patients with and without a history of ipsilateral ACLR. Eligible studies were included in this review if they reported at least 1 outcome measure. Results: Included for review were 5 retrospective case-control studies collectively evaluating TKA outcomes in 318 patients (176 males, 142 females) with a history of ACLR and 455 matched controls. The mean age in the ACLR and control groups was 58.5 years and 60.9 years, respectively. The mean follow-up period after arthroplasty was 3.4 years in the ACLR group and 3.3 years in the control group. The mean time between ACLR and arthroplasty was 21.8 years. Three studies noted greater operative time in the ACLR group than in the control group. No differences in intraoperative blood loss were reported. Greater preoperative extension deficits were noted in the ACLR group in 2 studies. Two studies reported increased preoperative Knee Society Score function scores in the ACLR group, but no differences in postoperative subjective outcome scores were noted in any of the studies. One study reported increased incidence of periprosthetic joint infection and a higher total reoperation rate in the ACLR group, and another study reported an increased incidence of manipulation under anesthesia in the ACLR group. Conclusion: Short- and midterm subjective scores and functional outcomes of TKA appear to be comparable in patients with and without a history of ACLR, although the risk for reoperation after TKA may be greater in patients with prior ACLR. Surgeons should anticipate increased operative time in patients with a history of ACLR. However, the findings of this review must be interpreted within the context of its limitations.

Background:Effective postoperative pain management after shoulder arthroscopy is a critical component to recovery, rehabilitation, and patient satisfaction.Purpose:This systematic review provides a comprehensive overview of level 1 and level 2 evidence regarding postoperative pain management for outpatient arthroscopic shoulder surgery.Study Design:Systematic review.Methods:We performed a systematic review of the various modalities reported in the literature for postoperative pain control after outpatient shoulder arthroscopy and analyzed their outcomes. Analgesic regimens reviewed include regional nerve blocks/infusions, subacromial/intra-articular injections or infusions, cryotherapy, and oral medications. Only randomized control trials with level 1 or level 2 evidence that compared 2 or more pain management modalities or placebo were included. We excluded studies without objective measures to quantify postoperative pain within the first postoperative month, subjective pain scale measurements, or narcotic consumption as outcome measures.Results:A combined total of 40 randomized control trials met our inclusion criteria. Of the 40 included studies, 15 examined nerve blocks, 4 studied oral medication regimens, 12 studied subacromial infusion, 8 compared multiple modalities, and 1 evaluated cryotherapy. Interscalene nerve blocks (ISBs) were found to be the most effective method to control postoperative pain after shoulder arthroscopy. Increasing concentrations, continuous infusions, and patient-controlled methods can be effective for more aggressively controlling pain. Dexamethasone, clonidine, intrabursal oxycodone, and magnesium have all been shown to successfully improve the duration and adequacy of ISBs when used as adjuvants. Oral pregabalin and etoricoxib administered preoperatively have evidence supporting decreased postoperative pain and increased patient satisfaction.Conclusion:On the basis of the evidence in this review, we recommend the use of ISBs as the most effective analgesic for outpatient arthroscopic shoulder surgery.

The purpose of this study is to evaluate the clinical outcomes and revision rates of skeletally mature patients aged 25 years or younger who have undergone either BPTB autograft or deep-frozen, non-irradiated BPTB allograft ACL reconstruction by a single surgeon. Two hundred and twenty-four patients aged 25 or younger at the time of surgery were identified as having a transtibial ACL reconstruction with either a BPTB autograft or deep-frozen, non-irradiated BPTB allograft by one senior surgeon (101 autografts vs. 123 allografts) over the study time period. Primary outcome measure included the need for ACL revision. One hundred and nineteen patients with at least 2-year clinical follow-up agreed to participate in secondary outcome measurement arm of the study and were administered the Lysholm Knee Scoring Scale and IKDC Subjective Knee Evaluation Form. The median Lysholm scores were 95 (40–100) and 95 (68–100) and the median IKDC scores were 95.4 (54.0–100) and 95.4 (72.4–100) in the allograft and autograft groups, respectively. The differences in the Lysholm scores and the IKDC scores were not statistically significant (P = n.s.). There were 13 patients requiring ACL revision, 12 allograft versus one autograft (P = 0.005). Although there is no significant difference in patient-rated outcome between ACL reconstructions using BPTB autografts versus BPTB allografts, a significantly higher rate of ACL revision was found in allograft patients. The results of our study support a growing body of literature that BPTB autograft reconstruction leads to lower retear rates in younger individuals, an important factor in the graft selection process for these patients. III.

Background: An increasing number of youth baseball athletes are specializing in playing baseball at younger ages. Purpose: The purpose of our study was to describe the age and prevalence of single-sport specialization in a cohort of current professional baseball athletes. In addition, we sought to understand the trends surrounding single-sport specialization in professional baseball players raised within and outside the United States (US). Study Design: Cross-sectional study; Level of evidence, 3. Methods: A survey was distributed to male professional baseball athletes via individual team athletic trainers. Athletes were asked if and at what age they had chosen to specialize in playing baseball at the exclusion of other sports, and data were then collected pertaining to this decision. We analyzed the rate and age of specialization, the reasons for specialization, and the athlete’s perception of injuries related to specialization. Results: A total of 1673 professional baseball athletes completed the survey, representing 26 of the 30 Major League Baseball (MLB) organizations. Less than half (44.5%) of professional athletes specialized in playing a single sport during their childhood/adolescence. Those who reported specializing in their youth did so at a mean age of 14.09 ± 2.79 years. MLB players who grew up outside the US specialized at a significantly earlier age than MLB players native to the US (12.30 ± 3.07 vs 14.89 ± 2.24 years, respectively; P < .001). Additionally, MLB players raised in the US recalled a significantly higher incidence of sustaining an injury attributed to specializing in baseball than MLB athletes raised outside the US (27.7% vs 20.6%, respectively; P = .05). Conclusion: This study challenges the current trends toward early youth sport specialization, finding that the majority of professional baseball athletes studied did not specialize as youth and that those who did specialize did so at a mean age of 14 years. With the potential cumulative effects of pitching and overhead throwing on an athlete’s arm, the trend identified in this study toward earlier specialization within baseball is concerning.

Objective To identify the 50 most-cited articles in meniscal allograft transplantation (MAT) research and analyze their characteristics. Design In September 2017, the Scopus database was queried to identify the 50 most-cited articles in MAT research. Variables analyzed include number of citations, publication year, journal, institution, country of origin, article type, study design, and level of evidence. Citation density was calculated for each article. The correlation between citation density and publication year and the correlation between level of evidence and number of citations, citation density, and publication year were computed. Results The 50 most-cited articles were published in 12 journals between 1986 and 2011. The number of citations ranged from 59 to 290 (109.3 ± 48.6). Citation density ranged from 2.7 to 17.6 citations per year (7.0 ± 3.3). There was a positive correlation between citation density and publication year ( r = +0.489, P < 0.001). Overall, 56% of the articles were clinical and 44% were basic science. Of the 28 clinical articles, 61% were level IV or V evidence. Level of evidence was not significantly correlated with number of citations ( r = −0.059, P = 0.766), citation density ( r = +0.030, P = 0.880), or publication year ( r = −0.0009, P = 0.996). Conclusion This analysis provides the orthopedic community with a readily accessible list of the classic citations in MAT research and provides insight into the historical development of this procedure. Although there was a moderate positive correlation between citation density and publication year, articles with stronger levels of evidence were not more frequently cited despite the increasing trend toward evidence-based practice.

Background Injury to the ulnar collateral ligament (UCL) often results in valgus elbow instability requiring reconstruction. No standardized and validated outcome measure has compared outcomes between surgical techniques and institutions in the overhead throwing athlete. The aim of this study was to use the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score (KJOC score) to report functional outcomes in overhead throwing athletes undergoing UCL reconstruction. We predict that the KJOC score in our general throwing population will provide an accurate assessment of postoperative outcomes consistent with previously published reports. Methods A retrospective review of 33 patients undergoing UCL reconstruction was carried out during a 5-year period between 2004 and 2009. Minimum follow-up was 2.2 years with an average of 3.7 years. All surgeries were performed by fellowship-trained surgeons using either the docking (n = 12) or modified Jobe technique (n = 21). Age, sport, position, and return to play status were obtained. The KJOC score was administered to assess final functional outcome. Results A total of 33 athletes underwent UCL reconstruction—30 baseball players and 3 javelin throwers. Of these, 27 (82%) returned to their sport at their previous level in an average of 12.25 months. The overall average KJOC score was 76. Athletes who returned to their previous level of play had a mean KJOC score of 77. Those who were unable to return to play had a mean score of 69. Conclusion Our study demonstrates consistent outcomes for UCL reconstruction using the KJOC shoulder and elbow score compared with previously reported data.

Antibiotic prophylaxis is standard for patients undergoing surgical procedures, yet despite the wide use of antibiotics, breakthrough infections still occur. In the setting of total joint arthroplasty, such infections can be devastating. Recent findings have shown that synovial fluid causes marked staphylococcal aggregation, which can confer antibiotic insensitivity. We therefore asked in this study whether clinical samples of synovial fluid that contain preoperative prophylactic antibiotics can successfully eradicate a bacterial challenge by pertinent bacterial species. This study demonstrates that preoperative prophylaxis with cefazolin results in high antibiotic levels. Furthermore, we show that even with antibiotic concentrations that far exceed the expected bactericidal levels, Staphylococcus aureus bacteria added to the synovial fluid samples are not eradicated and are able to colonize model implant surfaces, i.e., titanium pins. Based on these studies, we suggest that current prophylactic antibiotic choices, despite high penetration into the synovial fluid, may need to be reexamined.

Background: Youth participation in organized sports in the United States is rising, with many athletes focusing on a single sport at an increasingly younger age. Purpose: To retrospectively compare single-sport specialization in current high school (HS), collegiate, and professional athletes with regard to the rate and age of specialization, the number of months per year of single-sport training, and the athlete’s perception of injury related to specialization. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A survey was distributed to HS, collegiate, and professional athletes prior to their yearly preparticipation physical examination. Athletes were asked whether they had chosen to specialize in only 1 sport, and data were then collected pertaining to this decision. Results: A total of 3090 athletes completed the survey (503 HS, 856 collegiate, and 1731 professional athletes). A significantly greater percentage of current collegiate athletes specialized to play a single sport during their childhood/adolescence (45.2% of HS athletes, 67.7% of collegiate athletes, and 46.0% of professional athletes; P < .001). The age of single-sport specialization differed between groups and occurred at a mean age of 12.7 ± 2.4 (HS), 14.8 ± 2.5 (collegiate), and 14.1 ± 2.8 years (professional) ( P < .001). Current HS (39.9%) and collegiate athletes (42.1%) recalled a statistically greater incidence of sport-related injury than current professional athletes (25.4%) ( P < .001). The majority (61.7%) of professional athletes indicated that they believed specialization helps the athlete play at a higher level, compared with 79.7% of HS and 80.6% of collegiate athletes ( P < .001). Notably, only 22.3% of professional athletes said they would want their own child to specialize to play only 1 sport during childhood/adolescence. Conclusion: This study provides a foundation for understanding current trends in single-sport specialization in all athletic levels. Current HS athletes specialized, on average, 2 years earlier than current collegiate and professional athletes surveyed. These data challenge the notion that success at an elite level requires athletes to specialize in 1 sport at a very young age.

Objectives: Youth participation in organized sports in the United States is rising, with many athletes focusing on a single sport at an increasingly younger age. There is considerable debate regarding the rationale, optimal timing, injury risk, and the psychosocial health of a young athlete specializing early in a single sport. The purpose of our study was to compare youth single sport specialization in high school (HS), collegiate, and professional athletes with respect to the age of specialization, the number of months per year of single sport training, and injury attributed by the athlete to specialization. Methods: A survey was distributed to HS, collegiate and professional athletes prior to their yearly pre-participation physical exam. Demographic information, details of current sport commitment, and future athletic plans were collected. Athletes were asked if they had chosen to specialize in only one sport during their childhood/adolescence, and data was then collected pertaining to when, how, and why this decision was made. Continuous data was analyzed using one-way ANOVA analysis and categorical variables were compared using chi-square analysis. Results: A total of 3,090 athletes d the survey (503 HS, 856 collegiate, and 1,731 professional athletes). 46.3% of HS athletes, 67.7% of collegiate athletes, and 45.9% of professional athletes specialized to play a single sport during their childhood/adolescence (p< 0.00001). Single sport specialization in these groups occurred at a younger age in the HS athletes (12.7 ± 2.4 years old), compared to the college (14.8 ± 2.5 years old) and professional athletes (14.06 ± 2.8 years old) (p

Background:An injury of the ulnar collateral ligament (UCL) is potentially career threatening for elite overhead-throwing athletes. Stress ultrasonography (SUS) allows for a rapid, cost-effective, and noninvasive evaluation of the UCL and elbow joint both at rest and with applied stress.Purpose/Hypothesis:To determine the amount of cadaveric elbow valgus gapping with sequential sectioning of medial elbow structures as measured by SUS. It was hypothesized that the greatest increase in ulnohumeral joint gapping would be noted with release of the anterior bundle of the UCL.Study Design:Descriptive laboratory study.Methods:Twelve cadaveric elbows were divided into 2 groups and dissected in reverse sequences under the direct supervision of an experienced orthopaedic surgeon. Baseline ultrasound and SUS with applied valgus loads were performed by an experienced radiologist. A valgus load was applied at each sectioning interval using a standardized device. Ulnohumeral joint gapping in millimeters was measured by SUS for each step as the width of the medial joint from the trochlea to the sublime tubercle. The mean increases in joint gapping (Δ) between each step were calculated to quantify the additional gapping achieved with release of each sequential stabilizer.Results:Release of the anterior band of the anterior bundle resulted in a mean Δ of 2.0 mm (95% CI, 1.1-2.8 mm). Release of the posterior band of the anterior bundle resulted in a mean Δ of 1.4 mm (95% CI, 0.6-2.2 mm). Release of the entire anterior bundle caused a mean increase in ulnohumeral valgus joint gapping of 3.4 mm (95% CI, 2.4-4.3 mm). Release of the remaining individual structures each resulted in a mean increase in valgus joint gapping of ≤0.8 mm.Conclusion:The results of the current cadaveric study suggest that different amounts of gapping are seen on SUS with sectioning of the medial elbow stabilizers. The hypothesis was confirmed with release of the anterior bundle of the UCL resulting in the greatest increase in joint gapping as measured by SUS.Clinical Relevance:This study illustrates that SUS can identify the contributions of each anatomic portion of the UCL and the flexor-pronator mass to ulnohumeral joint stability in a cadaveric model.

Context: In active individuals with femoroacetabular impingement (FAI), the resultant reduction in functional range of motion leads to high impaction loads at terminal ranges. These increased forces result in compensatory effects on bony and soft tissue structures within the hip joint and hemipelvis. An algorithm is useful in evaluating athletes with pre-arthritic, mechanical hip pain and associated compensatory disorders. Evidence Acquisition: A literature search was performed by a review of PubMed articles published from 1976 to 2013. Level of Evidence: Level 4. Results: Increased stresses across the bony hemipelvis result when athletes with FAI attempt to achieve supraphysiologic, terminal ranges of motion (ROM) through the hip joint required for athletic competition. This can manifest as pain within the pubic joint (osteitis pubis), sacroiliac joint, and lumbosacral spine. Subclinical posterior hip instability may result when attempts to increase hip flexion and internal rotation are not compensated for by increased motion through the hemipelvis. Prominence of the anterior inferior iliac spine (AIIS) at the level of the acetabular rim can result in impingement of the anterior hip joint capsule or iliocapsularis muscle origin against the femoral head-neck junction, resulting in a distinct form of mechanical hip impingement (AIIS subspine impingement). Iliopsoas impingement (IPI) has also been described as an etiology for anterior hip pain. IPI results in a typical 3-o’clock labral tear as well as an inflamed capsule in close proximity to the overlying iliopsoas tendon. Injury in athletic pubalgia occurs during high-energy twisting activities in which abnormal hip ROM and resultant pelvic motion lead to shearing across the pubic symphysis. Conclusion: Failure to recognize and address concomitant compensatory injury patterns associated with intra-articular hip pathology can result in significant disability and persistent symptoms in athletes with pre-arthritic, mechanical hip pain. Strength-of-Recommendation Taxonomy (SORT): B

Elbow pain in pediatric throwing athletes can be very concerning and challenging to diagnose. Diagnosis involves determining whether the injury is chronic or acute in nature and the anatomical location of the pain. Physicians should be aware of the sport-specific forces that predispose athletes with immature skeletons to injury and should be familiar with the common presentations of these injuries. In order to narrow the diagnosis, physicians should gather a detailed history of how and when the pain occurred in addition to performing a thorough physical exam that includes tests, such as the modified milking maneuver and the moving valgus stress test. Appropriate imaging helps physicians to confirm the diagnosis and elucidates any associated pathology in patients. In most cases, the treatment given to patients is conservative and involves rest, ice, non-steroidal anti-inflammatory drugs for pain, and an appropriate physical therapy regimen with a progressive return to play when symptoms have resolved. When patients fail to respond to conservative treatment, surgical intervention may be needed. Knowing when to refer patients for orthopedic evaluation helps athletes return to play quickly and safely.

Intention to resume high-risk sports activity is a major motivating factor for patients who elect anterior cruciate ligament (ACL) reconstruction rather than nonoperative treatment. Some patients are able to cope with an ACL-deficient knee and resume preinjury activity levels, including level-1 sports (football, basketball, soccer, etc.), following nonoperative treatment; however, activity levels correlate with injury risk in ACL-deficient knees. Patients who have an ACL injury along with concomitant meniscal injury are at increased risk for osteoarthritis. It is unclear what effect reconstruction of an isolated ACL injury has on future osteoarthritis risk in ACL-deficient patients who are identified as "copers." There are distinct biomechanical differences between copers and noncopers, but no reliable screening tools are currently able to predict which patients will become copers following nonoperative treatment of an ACL injury. A trial of nonoperative treatment, including perturbation exercises, to determine whether reconstruction is needed does not increase the risk of additional knee injury.

Objectives: Knee arthroscopy results in significant improvements in functional outcomes, pain and quality of life for patients suffering from meniscal tears. Traditionally, patients have undergone formal physical therapy (PT) after knee arthroscopy to regain function. Prior studies have demonstrated that patients who undergo internet-based PT after total knee arthroplasty performed as well as patients receiving traditional PT, but this has not been studied in the knee arthroscopy population. The goal of this study is to compare traditional outpatient physical therapy to internet-based physical therapy in patients undergoing knee arthroscopy for partial meniscectomy. Methods: Patients undergoing knee arthroscopy from October 2017 to September 2018 for partial meniscectomy were enrolled. Patients were randomized to either an outpatient or internet-based physical therapy program. Participants in the outpatient physical therapy were prescribed PT for 2 sessions per week for 4-6 weeks while participants in the online physical therapy group were instructed to login daily to track progress and complete their exercises a minimum of 3 times per week. Additionally, participants completed 4 questionnaires: VR-12 mental and physical health, International Knee Documentation Committee (IKDC), Modified Cincinnati Rating System (MCRS) and Lysholm pre-operatively, 1 week, 6 weeks and 6 months after surgery. The primary outcome of knee function was measured via the IKDC. Results: Of the 97 patients who met the inclusion criteria, 51 (52.6%) were in the internet-based physical therapy group and 46 (47.4%) were in the outpatient PT group. There were 57 males (58.8%) and 40 females (41.2%). Participants in the online physical therapy group logged into the platform an average of 2.74 times pre-operatively and 14.99 times post-operatively. Additionally, patients viewed their PT exercise videos, on average, 5.58 times pre-operatively and 36.71 times post-operatively. At final follow-up, there was no significant difference in the primary outcome with an average IKDC score for the online physical therapy (71.83) compared to outpatient PT group (74.23) [p = 0.699]. Additionally, there was no significant difference noted in the three secondary outcome measures between the internet-based physical therapy group and the outpatient PT group at final follow-up (Table 1). Furthermore, no significant difference was noted between the two patient cohorts pre-operatively and 1 week and 6 weeks after surgery in all four outcome measures (Table 1). Conclusion: The results of our study indicate that patients using internet-based PT had similar functional outcomes as patients using traditional outpatient PT following knee arthroscopy for partial meniscectomy. [Table: see text]

Purpose The purpose of this study was to identify the incidence of symptoms consistent with athletic pubalgia (AP) in athletes requiring surgical treatment for femoroacetabular impingement (FAI) and the frequency of surgical treatment of both AP and FAI in this group of patients. Methods Thirty-eight consecutive professional athletes, with a mean age of 31 years, underwent arthroscopic surgery for symptomatic FAI that limited their ability to play competitively. In all cases a cam and/or focal rim osteoplasty with labral refixation or debridement was performed. In 1 case concomitant intramuscular lengthening of the psoas was performed. Retrospective data regarding prior AP surgery and return to play were collected. Results Thirty-two percent of patients had previously undergone AP surgery, and 1 patient underwent AP surgery concomitantly with surgical treatment of FAI. No patient returned to his previous level of competition after isolated AP surgery. Thirty-nine percent had AP symptoms that resolved with FAI surgery alone. Of the 38 patients, 36 returned to their previous level of play; all 12 patients with combined AP and FAI surgery returned to professional competition. The mean duration before return to play was 5.9 months (range, 3 to 9 months) after arthroscopic surgery. Conclusions There is a high incidence of symptoms of AP in professional athletes with FAI of the hip. This study draws attention to the overlap of these 2 diagnoses and highlights the importance of exercising caution in diagnosing AP in a patient with FAI. Level of Evidence Level IV, therapeutic, retrospective case series.

Young, active, skeletally mature patients have higher failure rates after various surgical procedures, including stabilization for shoulder instability and primary ACL reconstruction. It is unclear whether young, active, skeletally mature patients share similarly high failure rates after revision ACL reconstruction.We therefore determined whether revision ACL reconstruction restores knee stability and allows young (younger than 18 years), active, skeletally mature patients to return to preinjury activity levels.We retrospectively identified 36 patients who had an initial ACL reconstruction between the ages of 12 and 17 years (mean, 15.4 years) and subsequent revision between the ages of 13 and 18 years (mean, 16.9 years); of these, 2-year followup was available for 21 (75%). Mechanisms of primary graft failure included traumatic rerupture (23 noncontact, seven contact), persistent instability (five), and infection (one). One patient had open physes at the time of revision. All revisions were single-stage transosseous reconstructions. The minimum followup was 24 months (mean, 36 months; range, 24-63 months).At last followup, 19 of 21 patients had a negative or IA Lachman and 20 of 21 had a negative pivot shift. Mean International Knee Documentation Committee subjective score was 89 (range, 64-99). Eleven of the 21 patients returned to the same or higher activity/sport level as before their original injury. Two patients reported subjective knee instability, with two having repeat revision reconstruction for failure.Single-stage transosseous revision ACL reconstruction in young, active, skeletally mature patients restores knee stability but returns only 52% of patients to their prior level of activity or sport.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background:Effective pain management after anterior cruciate ligament (ACL) reconstruction improves patient satisfaction and function.Purpose:To collect and evaluate the available evidence from randomized controlled trials (RCTs) on pain control after ACL reconstruction.Study Design:Systematic review.Methods:A systematic literature review was performed using PubMed, Medline, Google Scholar, UpToDate, Cochrane Reviews, CINAHL, and Scopus following PRISMA guidelines (July 2014). Only RCTs comparing a method of postoperative pain control to another method or placebo were included.Results:A total of 77 RCTs met inclusion criteria: 14 on regional nerve blocks, 21 on intra-articular injections, 4 on intramuscular/intravenous injections, 12 on multimodal regimens, 6 on oral medications, 10 on cryotherapy/compression, 6 on mobilization, and 5 on intraoperative techniques. Single-injection femoral nerve blocks provided superior analgesia to placebo for up to 24 hours postoperatively; however, this also resulted in a quadriceps motor deficit. Indwelling femoral catheters utilized for 2 days postoperatively provided superior analgesia to a single-injection femoral nerve block. Local anesthetic injections at the surgical wound site or intra-articularly provided equivalent analgesia to regional nerve blocks. Continuous-infusion catheters of a local anesthetic provided adequate pain relief but have been shown to cause chondrolysis. Cryotherapy improved analgesia compared to no cryotherapy in 4 trials, while in 4 trials, ice water and water at room temperature provided equivalent analgesic effects. Early weightbearing decreased pain compared to delayed weightbearing. Oral gabapentin given preoperatively and oral zolpidem given for the first week postoperatively each decreased opioid consumption as compared to placebo. Ibuprofen reduced pain compared to acetaminophen. Oral ketorolac reduced pain compared to hydrocodone-acetaminophen.Conclusion:Regional nerve blocks and intra-articular injections are both effective forms of analgesia. Cryotherapy-compression appears to be beneficial, provided that intra-articular temperatures are sufficiently decreased. Early mobilization reduces pain symptoms. Gabapentin, zolpidem, ketorolac, and ibuprofen decrease opioid consumption. Despite the vast amount of high-quality evidence on this topic, further research is needed to determine the optimal multimodal approach that can maximize recovery while minimizing pain and opioid consumption.Clinical Relevance:These results provide the best available evidence from RCTs on pain control regimens after ACL reconstruction.

The American Academy of Orthopaedic Surgeons (AAOS) and other orthopedic societies require authors to disclose conflicts of interest (COIs). We conducted a study to evaluate how a hypothetical research team's reported COI would influence the perceived value of its data. Using a hypothetical prospective study, we asked orthopedic surgeons and nonoperative sports medicine specialists to rate the value of the data, given different study designs, statistical significance, and research institutions (academic vs private). The fictional research team disclosed the project was funded by a pharmaceutical company and all team members received consulting compensation. Eighty percent of 522 respondents thought COI disclosure is important in the interpretation of study results, 41% reported always using this information when interpreting data, and 24% reported that a case series with significant positive results at an academic center was likely trustworthy (this percentage decreased to 5% when the study was set in a community hospital). When no significant difference was found in results, 42% thought the study was trustworthy. When the study design yielded level I evidence (randomized controlled trial) at an academic center, 57% thought the study was trustworthy (when the study was set in a community hospital, this percentage decreased to 39%). When the results of the design showed no difference among groups, the majority of respondents (62%) thought the study was trustworthy. Although the majority of respondents thought disclosure is important, fewer than half reportedly used this information when interpreting study results. Randomized controlled trial status improved the perceived reliability of the data over a case series but was not as important as reporting "negative" results.

Background: The elbow is the second most commonly dislocated major joint in the general population. Previous studies that focused on emergency department populations indicate that such injuries occur most frequently among adolescent athletes. Purpose: To describe the epidemiological rates and patterns of sports-related elbow dislocations in high school athletes. Study Design: Descriptive epidemiology study. Methods: Sports-related injury data for the 2005-2006 through 2013-2014 academic years from a national convenience sample of high schools participating in the National High School Sports-Related Injury Surveillance Study (High School Reporting Information Online [RIO]) were analyzed. Results: Certified athletic trainers participating in High School RIO reported 115 of 1246 (9.2%) elbow injuries as elbow dislocations. A total of 30,415,179 athlete exposures (AEs) were reported during the study period, resulting in a dislocation rate of 0.38 per 100,000 AEs. The majority of the dislocations resulted from boys’ wrestling (46.1%) and football (37.4%). Elbow dislocation rates were higher in competition than in practice. Also, 91.3% of dislocations occurred in boys’ sports. Among both boys (60.4%) and girls (88.9%), the majority of injuries occurred during varsity sports activities. Contact with another person was the most common injury mechanism (46.9%), followed by contact with the playing surface (46.0%). Dislocations more commonly resulted in removal from play for more than 3 weeks (23.4% vs 6.9%, respectively) or medical disqualification (36.9% vs 7.0%, respectively) compared with other elbow injuries. Dislocations were also more likely to result in surgical treatment than other elbow injuries (13.6% vs 4.7%, respectively). Conclusion: In high school athletes, elbow dislocations result in longer removal from play and are more likely to require surgical treatment than nondislocation-associated elbow injuries. Rates and patterns of elbow dislocations vary by sport. In high-risk sports, focused sport-specific prevention strategies may help to decrease the rates and severity of elbow dislocation injuries.

Management of glenohumeral arthrosis with a total shoulder prosthesis is becoming increasingly common. However, failure of the glenoid component remains one of the most common causes for failure. Our understanding of this problem has evolved greatly since the first implants were placed in the 1970’s. However glenoid failure remains a challenging problem to address and manage. This article reviews the current knowledge regarding the glenoid in total shoulder arthroplasty touching on anatomy, component design, implant fixation, causes of implant failure, management of glenoid failure and alternatives to glenoid replacement.