Search

Purpose: To perform a systematic review about the varying definitions of “failure” of hip arthroscopy (HA) in the current literature and to provide a recommendation for the standardization of defining failure of HA. Methods: A systematic search of electronic databases was conducted to identity Level I-IV clinical studies on HA failure published between January 2016 and July 2021 according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inclusion criteria consisted of studies of patients who underwent an arthroscopic hip procedure and included a definition of failure. Studies with patients who underwent open hip procedures and non–full-text articles were excluded. Results: Of 1,290 titles, 85 (6.6%) met inclusion criteria and were analyzed in this review. The most common definition of HA failure used was the need for any subsequent ipsilateral hip surgery (80/85, 94.1%). Among studies that noted reoperation as a cause for failure, conversion to total hip arthroplasty was most frequently cited (66/85, 77.6%) followed by any other reoperation on the ipsilateral hip, including repeat HA, hip resurfacing, and hip periacetabular osteotomy (65/85, 76.5%). Multiple studies used subjective patient-reported outcomes, with use of the modified Harris Hip Score being the most common (17/85, 20%). Conclusions: There are numerous definitions of the term “failure” of HA used by authors in the peer-reviewed literature. A standardized definition of HA failure should be multifactorial. It may include any unplanned subsequent procedures; patient-reported outcomes with emphasis on minimal clinically important difference, substantial clinical benefit, and/or patient acceptable symptom state values; and the inability to return to normal function or sports. Level of Evidence: Level IV, systematic review of Level III and IV studies.

Purpose: To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations. Methods: A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: (“arthrofibrosis” OR “stiffness” OR “stiff” OR “complications”) AND (“arthroscopy” OR “arthroscop” OR “ACL” OR “anterior cruciate”) AND (“treat” OR “care” OR “management” AND “knee”). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients. Results: A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications. Conclusions: Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications. Level of Evidence: Level IV, systematic review of Level I-IV studies.

Purpose: To conduct a literature review to assess the definitions of anterior cruciate ligament reconstruction (ACLR) failure used throughout the orthopaedic literature. Methods: A systematic search of Embase, Ovid Medline, SPORTDiscus, and Web of Science was conducted by a university librarian to identity level I-IV clinical studies on ACLR failure. Inclusion criteria consisted of patients who underwent ACLR and included a definition of failure of ACLR. Patients who underwent anterior cruciate ligament (ACL) repairs, animal/cadaver studies, review studies, non-English language articles, and non-full text articles were excluded. Failure data were extracted from each study and categorized. Other data that were extracted included follow-up time after ACLR, failure reoperation rate, and failure reoperation procedure. Descriptive statistics was used to analyze the data. Results: Out of 2,775 studies, 104 (3.75%) met inclusion criteria and were analyzed in this review. The most common definition of ACLR failure included the use of a physical examination, specifically Lachman’s test (21/104 [20.2%]), anterior laxity assessment, or a Pivot-Shift test (24/104 [35.2%]) or undergoing or requiring revision ACLR (39/104 [37.5%]). Although some studies used quantitative tests or imaging to help define “failure,” others simply defined it as graft rerupture that was otherwise not defined (22/104 [22.5%]). Other common definitions included: the use of imaging (magnetic resonance imaging/radiographs) to confirm graft re-rupture (37/104 [35.6%]), patient-reported outcomes (recurrent instability)/patient reported outcomes measures (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner) (18/104 [17.3%]), and the use of an arthrometer (KT-1000/2000, Rollimeter, or Kneelax) (17/104 [16.3%]). The least common definitions included graft failure or rerupture confirmed by arthroscopy (13/104 [12.5%]) and nonrevision surgery (2/104 [1.0%]). The failure rate of this procedure ranged from 0% to 100% depending on the definition of “failure.” Conclusions: In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. The most common criteria for failure of ACLR were the results of physical examination tests (35%), the need for undergoing a revision ACLR (36%), and the use of imaging to diagnose the failure (34%). About 17% of studies included in this review used patient-reported outcomes, specifically recurrent instability, or PROMs (IKDC, KOOS, Tegner) in their assessment of failure of ACLR. The least used definitions of “failure” of ACLR included nonrevision ACLR surgery (2%). Although some studies used similar tests or categories in their definition of failure, there were a variety of score and grade cutoff points between them. Level of Evidence: Level IV, systematic review of Level II-IV studies.

Background: Anterior shoulder instability frequently occurs in young, physically active individuals and may be treated with surgical stabilization. Previous studies have shown that males more often require surgical management for anterior shoulder instability and may have a higher frequency of recurrent instability episodes after surgical management, but females have been found to have increased incidence of apprehension after surgical stabilization. The purpose of this study is to review the literature and assess anterior shoulder surgical stabilization postoperative outcomes between males and females to identify and describe sex-based differences. Methods: A systematic search of electronic databases was conducted to identify level I-IV clinical studies on anterior shoulder instability published between 1960 and August 2020. We included studies that evaluated sex-specific outcomes in patients who underwent anterior shoulder instability procedures. A meta-analysis of the data was performed to analyze sex-specific outcomes. Results: Thirty studies (2.1%) met inclusion criteria, representing 9829 patients. Of the studies that reported the number of male and female patients, 74% were male and 26% were female. Twenty-six studies used Bankart repair alone, two used open Latarjet procedure alone, and two had a Bankart repair group and Latarjet procedure group. Instability recurrence, return to sport, and apprehension were included in the meta-analysis. Our meta-analysis demonstrated a significantly higher rate of instability recurrence for males than for females who underwent arthroscopic Bankart repair (risk ratio [RR] = 1.25; 95% confidence interval [CI] = 1.03, 1.52; P = .0239). We did not identify a significant difference between males and females in rates of apprehension (RR = 0.68; 95% CI = 0.37, 1.27; P = .2300) or return to sport (RR = 0.98; 95% CI = 0.81, 1.18; I2 = 0%; P = .8110) for arthroscopic Bankart repair or open Latarjet procedure. Conclusion: For patients who underwent arthroscopic Bankart repair for anterior shoulder stabilization, recurrent rates of instability were significantly higher for males than for females. When open Bankart and Latarjet procedures were included, there was no difference. No difference was seen between males and females after arthroscopic Bankart repair or open Latarjet procedures with regard to return to sport or apprehension.

Category: Sports; Ankle; Other Introduction/Purpose: A uniform criterion has not been established for return to sport (RTS) testing which is complicated by the lack of a standardized definition of the term RTS. Most commonly, RTS is defined as playing in at least one game of the athletes' respective sport, or the first game played after treatment.1 However, the timeline from the injury and/or treatment date to RTS varies amongst each physician or institution. Regarding the ankle, there is an enormous paucity of functional testing research. Therefore, the purpose of this project is to review current literature for joint-specific and global lower extremity testing to determine the most valid functional test that can be utilized to prevent re-injury as athletes RTS. Methods: A systematic search of PubMed, PubMed Central, Cochrane Library, OVID, and Embase databases was conducted to identify clinical studies that included evaluation of a return to sport test or functional test (single test or test battery) for the lower extremities. Both operative and non-operative treatments included in this review. Only studies that had patients between the ages of 14 years old and 40 years old were included. Specfici rehab protocik or treatment plan, non-English publications, non- human or cadaver studies, and studies that did not evaluate return to sport test or function test were excluded. Results: Of 8,705 studies, 65 (0.7%) studies published through October of 2021 met inclusion criteria and were analyzed. 52 out of 65 (80%) articles discussed RTS for the knee. Furthermore, 50 out of the 52 (96%) specifically analzyed RTS following ACLR. With this said, we did not abandon ankle and hip RTS cases. Discussed herein, are numerous RTS tests including the most common, isokinetic dynamometry testing which is seen in 38 out of the 52 (73%) of the knee RTS cases. Unfortunately, only 4 out of 65 (6.2%) studies analyzed RTS for the hip and 1 out of the 65 (1.5%) barely touched on the ankle. The remaining studies analyzed healthy participants only. Conclusion: More research is clearly required to identify the most valid functional test batteries for joint-specific RTS lower extremity testing. Even with the enormous amount of literature that exists regarding ACL injuries and testing there is no standardized criterion for RTS clearance. As seen in this review, the research available for the hip and ankle is substantially scarcer in regards functional testing. We hope that the suggested test batteries from this review can serve as a framework for future research and validation for joint-specific RTS functional testing.

Category: Ankle; Sports; Trauma Introduction/Purpose: Tibiofibular syndesmotic injuries occur in association with fractures or in isolation, often referred to as 'high ankle sprains'. Dynamic instability of the syndesmosis in the high-level athlete is difficult to diagnose, requiring a high index of suspicion for the identification and surgical stabilization to prevent late adverse sequelae, such as recurrent ankle pain, anterolateral soft tissue impingement, local synovitis, and chronic instability of distal syndesmosis. Both CT and MRI have been helpful in identifying syndesmotic injuries, but are static, non-weight bearing imaging modalities that cannot demonstrate dynamic instability, which may miss the unstable nature of some injuries. We present a novel imaging technique utilizing weight-bearing CT with syndesmotic stress in which a case is presented to illustrate it's utility in the elite athlete. Methods: Cone beam weight bearing computed tomography (WBCT) is a well-described imaging modality for evaluation of foot and ankle injuries. We have found it highly beneficial to teach our CT technologists about syndesmosis injuries and the importance of augmented physiologic stress applied across the ankle joint (in addition to the standard WBCT) to better demonstrate instability or motion, particularly at the tibiofibular syndesmosis. To perform an augmented stress weight bearing CT, the patient is positioned in the WBCT scanner and initial images are acquired in the standing weight bearing position with feet directed forward and weight distributed equally. A second image acquisition is then performed (augmented stress), where the patient is coached to firmly plant both feet on the ground and internally rotate the shin and knee. This places an external rotational moment on the TFS due to the planted foot and ankle. Results: Our case is of a 21-year-old male collegiate football player, wide receiver, that sustained an eversion injury to his left ankle during game play. He subsequently was unable to bear weight, with pain anteriorly over the distal tibiofibular joint. Pain was reproduced with dorsiflexion and eversion stress; however, he had a negative 'squeeze test' on examination. Initial weight bearing radiographs were negative. An MRI was obtained which did not reveal evidence of syndesmotic injury. Subsequently, weight- bearing CT stress examination of the syndesmosis was obtained and found to have 8 mm widening of the tibiofibular syndesmosis, 4 mm increased when compared to his contralateral, uninjured, ankle. This was also compared with a neutral WBCT without stress that did not illustrate the unstable nature of the injury. The coronal images also demonstrate increased uncovering of the talus underneath the tibial plafond. Conclusion: Tibiofibular syndesmotic injuries have historically been detected with standard x-ray, stress plain films, standard CT, and MRI. In cases where injury and stability are not obvious by these diagnostic studies, more subtle injuries may be frequently missed leading to increased morbidity, chronic instability, and increased return to play times. The addition of a stress view on weight-bearing CT can allow further identification of instability of the syndesmosis. We propose this technique for diagnosing otherwise unrecognized, subtle dynamically unstable syndesmosis injuries where clinical suspicion persists despite negative imaging, particularly in the elite athlete.

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The Lisfranc joint is the interface between the midfoot and forefoot and forms a strong connection due to its bony architecture and ligamentous attachments in the foot. An unstable Lisfranc injury has traditionally been defined as displacement >2 mm between the 1st and 2nd metatarsal bases or between the medial cuneiform and the second metatarsal base, when compared to the contralateral side on imaging modalities. Classically, Lisfranc injuries have been detected with standard X- ray, stress plain films, standard CT, MRI and ultrasound. We describe an imaging technique that may be used to further assist in the diagnosis and management of subtle Lisfranc injuries, and include a case to demonstrate its use in athletes. Methods: Cone beam weight bearing computed tomography (WBCT) is a well-described imaging modality for evaluation of foot and ankle injuries. We have found it highly beneficial to teach our CT technologists about Lisfranc injuries and the importance of augmented physiologic stress applied across the midfoot (in addition to the standard WBCT) to better demonstrate instability or motion, particularly at the second TMT joint. To perform an augmented stress weight bearing CT, the patient is positioned in the WBCT scanner and initial images are acquired in the standing weight bearing position with feet directed forward and weight distributed equally. A second image acquisition is then performed (augmented stress), where the patient is coached to lift both heels from the scanner platform symmetrically, in a calf-raise type exercise. It is important that the patient distributes weight as evenly as possible between the feet so the affected side is stressed sufficiently. Results: We present here a 22-year-old male collegiate football player who is an offensive lineman. While blocking during a game, his foot was plantarflexed, and he 'felt a pop' in his midfoot. On exam, the player was tender to palpation over the medial midfoot, at the Lisfranc joint. He had pain with forced pronation and abduction as well as axial load through the first webspace. Initial weight bearing radiographs did not show evidence of widening between the medial cuneiform and second metatarsal base. Due to his concerning examination, an MRI was ordered, which revealed a small bony avulsion off the plantar aspect of the second metatarsal base with an otherwise intact Lisfranc ligament. He then underwent weightbearing CT stress views of the foot, which revealed greater than 2 mm of widening between the first and second metatarsals when compared to the contralateral side, indicating instability of the Lisfranc joint. Conclusion: We present the augmented stress weightbearing CT technique of the midfoot to evaluate for subtle Lisfranc injury. The need for this imaging modality has proven useful in the elite athlete with subtle injury to the midfoot, otherwise not found on conventional imaging techniques. Timely diagnosis and treatment is imperiative to these players due to the morbidity associated with missed Lisfranc injuries. We propose this technique for diagnosing otherwise unrecognized, subtle Lisfranc injuries in patients where clinical suspicion persists despite negative imaging because this technique stresses the joint and we believe makes the weightbearing CT more sensitive for this injury.

Category: Ankle; Other Introduction/Purpose: Treatment for lateral ankle instability (LAI) varies drastically from conservative to operative management depending on the individual's injury, symptoms, and lifestyle. Typically, surgical treatment is recommended when conservative treatments fail for LAI. The importance of determining the most effective treatment is necessary due to LAI costing $2 billion annually within the health care system [1]. Furthermore, residual physical disability following failed treatment for LAI occurs in up to 70% of patients [2]. Unfortunately, despite exceedingly high incidences and economic impact, a standard definition of failure for the surgical treatment of LAI alludes clinicians and researchers. Therefore, the purpose of this project is to identify LAI treatment 'failure' definitions that are currently in the literature and work towards standardization of the definition. Methods: A systematic search of Medline, SportDiscus, CINAHL, Embase, and Web of Science was conducted to identify clinical studies that included patients who underwent surgical treatment for lateral ankle instability and included information about surgical failures. Studies with level of evidence I to IV were included for this review. Animal studies, biomechanical studies, cadaveric studies, review articles, and expert opinion were excluded. These studies were then reviewed for definitions of failure of any surgical procedure used to correct lateral ankle instability. Results: Of the 1,200 studies, 3.5% (42/1,200) studies published between 1984 and 2020 met inclusion criteria and were analyzed. After reviewing the data, numerous definitions were found in the literature for LAI surgical failure. The most common was 'recurrent instability' (40%, 17/42) followed by 're-rupture' (24%, 10/42). For the original operation, the Modified Brostrom Gould technique was used most frequently (40%, 17/42) in cases treated operatively. The failure rate of this procedure ranged from 1.1% to 45.2% depending on the definition of 'failure.' Conclusion: There were multiple definitions of failure for surgical treatment of lateral ankle instability and is one of the reasons why the rate of failure can vary greatly. The literature would benefit greatly from a standardization of ankle instability treatment 'failure' definition. This definition should incorporate multiple facets, including history, physical examination findings, outcome scores, imaging, and surgical findings for an inclusive understanding of failure.

A nationally ranked Division One female collegiate tennis player presented with pain in the chest and right posterior rib region after feeling a popping sensation during a routine overhead movement. The patient was eventually diagnosed with 2 lower rib stress fractures. After unsuccessful conservative management, the player underwent an open reduction and internal fixation and autologous bone grafting of the sixth and seventh ribs with a muscle-sparing approach and was able to return to full competition. We present this case along with a systematic review of the literature regarding rib stress fractures, which included 6 separate online data sources (PubMed, EMBASE, Cochrane, CINAHL, SportDiscus, and Medline). The successful surgical intervention demonstrates a significant option for elite athletes who wish to return to competition but have been unable to with standard of care conservative management of rib stress fractures. [ABSTRACT FROM AUTHOR]

Category: Sports Introduction/Purpose: Return to sport (RTS) commonly serves as a measure for assessment of clinical outcomes in orthopaedic sports medicine surgery. Unfortunately, while RTS is commonly utilized in research for this purpose, currently, there is no widely accepted or standardized definition for when an athlete has officially returned to his or her sport. The purpose of this study was to conduct a systematic review to evaluate and report the differences in specific definitions of return to sport (RTS) utilized in the orthopaedic surgery literature. Methods: A systematic review was performed using PubMed, Embase and Cochrane databases per PRISMA guidelines. Search terms consisted of variations of 'RTS' combined with variations of 'orthopedic surgery' and 'define' to capture as many relevant articles as possible. The definition of return to sport was recorded and analyzed. Results: 718 articles were identified in the initial search, 29 of which met eligibility criteria, providing a clear definition of RTS. Of the 29 studies included, 20 (69.0%) defined RTS as an athlete competing in a game or other competitive play, and these definitions are further broken down in Table 1. Three (10.3%) defined this as the athlete competing in a game or other competitive play, but with an explicitly stated competition-level modifier of the athlete returning to their pre-injury level of competition. Two articles (6.9%) included returning to training or practice and the remaining four articles (13.8%) used terminology other than the standard RTS. Conclusion: There is variability in the definition of RTS used in the literature. Most studies refer to the athlete competing in a game or other competitive play. Other variants include returning to practice/training and explicitly defined competition levels and objectives. Future studies should aim to standardize the definition of RTS to facilitate more precise assessment of outcome following sports medicine surgery. Using terminology that describes components of the recovery and rehabilitation process, such as 'return to participation' and 'return to performance' in addition to RTS will allow us to better understand the athlete's recovery and associated level of competition or performance.

Category: Trauma Introduction/Purpose: The common peroneal nerve (CPN) is the most commonly injured peripheral nerve of the lower extremity in trauma patients. Traumatic CPN injuries have historically been associated with relatively poor outcomes and patient satisfaction, though recent outcome data appear promising. Given the variety of underlying injury modalities, treatment options, and prognostic variables, this study sought to evaluate and summarize current literature on traumatic CPN injuries and provide recommendations for treatment and future research. Methods: A systematic review was performed using PubMed, Embase and Cochrane databases per PRISMA guidelines. Search terms consisted of variations of 'peroneal nerve' and 'fibular nerve' combined with 'injury,' or 'laceration,' or 'entrapment,' or 'repair,' or 'neurolysis.' Information regarding treatment modality, outcomes and patient demographics were recorded and analyzed. Results: 2,301 articles were identified in the initial search, 42 met eligibility criteria (Figure 1). Factors associated with better clinical outcomes included shorter pre-operative interval, shorter graft length when an interposed graft was used, nerve continuity and younger patient age. Sex or gender did not affect outcomes in any studies in this review. Motor grades of M3 or greater on the MRC scale are typically considered successful outcomes. In studies we analyzed, this was achieved in 81.2% of patients who underwent neurolysis, 78.8% of patients who underwent end to end suture, 49.8% of patients who underwent nerve grafting, 62.9% of patients who underwent nerve transfer, 86.0% of patients who underwent posterior tibial tendon transfer (PTTT) and 73.9% of patients who underwent surgery with concurrent PTTT. Conclusion: Included studies were heterogenous, complicating our ability to further analyze the data. It is not possible to uniformly advocate for the best treatment option given diverse injury modalities, presentations and prognostic factors. Many studies do not report outcomes with respect to specific injury modality. Future studies should clearly report outcomes based on injury modality and surgical treatment option. This would allow for greater analysis on the most appropriate treatment option for a given mechanism of injury. Newer surgical techniques, such as addition of growth factors to nerve repairs and concurrent tendon transfer are promising and should be further explored.

Category: Midfoot/Forefoot Introduction/Purpose: Lisfranc Ligamentous Complex injuries are commonly misdiagnosed due to their unreliable projection on plain films. Many studies have striven to establish baseline measurements of the frequently injured articulations. While cadaver, MRI, ultrasound, and non-weight bearing computer tomography (CT) have been utilized, weight bearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish reproducible and widely-referenced baseline anatomic positions. The hyoptheses of this study are: 1. Standing, weight bearing CT scan will allow for evaluation and measurement of the Lisfranc joint complex. 2. There will be no side to side variation or sex-based differences in the Lisfranc joint complex. Methods: A retrospective chart review was conducted using the electronic medical record. Inclusion criteria was applied as follows: patients who have undergone weight bearing CT of the bilateral lower extremities from 2018 to 2020. One hundred twelve foot CT scans were acquired for measurements. Measurements were collected by two independent reviewers twice in order to achieve inter- and intra-reliability. The measurements were then analyzed in order to establish a baseline for normal anatomy, compare injured to non-injured side, and observe any sex-based differences. Results: Measurements of uninjured legs were utilized to define normal parameters for Lisfranc ligamentous complex (LLC) injuries. Averages were found for measurements of base 1 to 2 MT 2.7mm (SD=0.7mm), medial cuneiform to 2nd MT [M2-C1] 3.7mm (SD=0.7mm), intercuneiform distance 1.2mm (SD=0.3mm), sagittal descent 12.2mm (SD=5.4mm).Patient's with injury to LLC had a larger base of M1-M2, distance from base of first metatarsal to base of second metatarsal (Δ=.5903, p

Category: Ankle; Sports Introduction/Purpose: Chronic ankle instability is a common condition that can be treated with lateral ankle ligament repair. These procedures have a reported success rate greater than 85% in the literature, but little has been reported about the differences in postoperative outcomes between males and females. The purpose of this study was to evaluate sex-specific outcomes following lateral ankle ligament repair. Methods: In this systematic review and meta-analysis, we utilized Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) criteria to search for articles on electronic databases. Inclusion criteria consisted of English-language, in-vivo clinical studies, mean follow-up of at least one year, sex-specific evaluation of outcomes, and study participants who underwent primary lateral ligament repair. Functional postoperative outcomes for males and females were recorded and statistically analyzed. Results: Out of 2,768 studies, eight (0.29%) met inclusion criteria and were analyzed in this review. These studies included 631 patients (409 males [65%] and 222 females [35%]) who underwent primary lateral ligament repair for ankle instability. There was no statistically significant difference between males and females in terms of Karlsson scores (93.5 +- 1.6 for males, 92.7+- 2.3 for females, P =.1582) or American Orthopaedic Foot & Ankle Society (AOFAS) scores (90.44 +- 4.82 for males, 90.19 +- 3.54 for females, P =.1586). Postoperative success was defined as a 'good' or 'excellent' Karlsson score (>81), and success rate analysis revealed no statistically significant difference between males and females (86% +- 7.1% for males, 87% +- 3.5% for females, P =.9374). Conclusion: There was no difference in postoperative mean Karlsson scores, AOFAS scores, or success rates between males and females who underwent primary lateral ankle ligament repair. This surgical procedure appears to have comparable outcomes in both sexes; however, more research is warranted to further assess the impact of patient sex on postoperative outcomes.

Category: Ankle; Sports Introduction/Purpose: Ankle sprains occur frequently within the general population, however, the extent to which this injury impacts the military population remains unknown. The purpose of this study was to systematically review the literature describing ankle sprains in the military population. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, articles were retrieved from PubMed, Embase, and Cochrane Library using the search terms 'military,' 'epidemiology,' 'incidence,' 'prevalence,' 'ankle sprain,' and 'ankle instability.' Inclusion criteria consisted of active military duty status, English language, and levels of evidence I-IV. Results: Nineteen articles were included, representing 1,671,763 study participants from six countries and four branches of the military. Among the ten studies that reported ankle sprain incidence in terms of overall injury incidence, seven studies reported ankle sprain as the most common injury, with an incidence ranging from 2.20% to nearly one third of all injuries in the paratrooper population. Ankle sprain was also reported as the most common injury among lower extremity injuries in two studies, with incidences of 35% and 38.7%, respectively. Ankle sprain incidence rate per 1,000 person-years was reported in four studies, with values ranging from 15.3 to 58.4. Incidence rate was also reported for males and females separately in three of these studies, ranging from 33.89 to 52.7 for males, and 41.17 to 96.4 for females. The number of days lost to ankle sprain ranged from one to eight days per servicemember. Conclusion: Ankle sprains are among the most prevalent injuries within the military population, with a reported incidence that is higher for females than males. This injury results in time away from active duty, which impacts overall readiness within the military system.

Category: Ankle Introduction/Purpose: Tibiofibular Syndesmosis injuries are commonly misdiagnosed due to their unreliable projection on plain films. Many studies have striven to establish baseline measurements of the distal tibial and fibular articulation. While cadaver, MRI, ultrasound, and non-weight bearing computer tomography (CT) have been utilized, weight bearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish reproducible and widely-referenced baseline anatomic positions. The hypotheses of this study are: 1. Standing, weight bearing CT scan will allow for evaluation and measurement of the tibio-fibular syndesmosis. 2. There will be no side to side variation or sex-based differences in syndesmosis measurements. Methods: A retrospective chart review was conducted using the electronic medical record. Inclusion criteria was applied as follows: Patients who have undergone weight bearing CT of the bilateral lower extremities from 2018 to 2020. One hundred twenty ankle CT scans were acquired for measurements. Measurements were collected by two independent reviewers twice in order to achieve inter- and intra-reliability. The measurements were then analyzed in order to establish a baseline for normal anatomy, compare injured to non-injured side, and observe any sex-based differences. Results: Measurements of uninjured legs were utilized to define normal parameters for tibiofibular syndesmosis on weight bearing CT. Averages were found for measurements of anterior incisura 3.2mm (SD=1.1mm), middle incisura 3.9mm (SD=1.1mm), posterior incisura 5.6mm (SD=1.7mm), alpha angle 16.3° (SD=6.3°), medial clear space 2.2mm (SD=0.6mm).Patients with syndesmotic injuries had significantly larger measurements for anterior (p

Purpose: To compare and contrast the various rehabilitation protocols for medial patellofemoral ligament (MPFL) reconstruction and MPFL reconstruction plus tibial tubercle osteotomy (TTO) published online by academic orthopaedic surgery residency programs and private practice institutions throughout the United States. Methods: We performed a systematic electronic search of MPFL reconstruction rehabilitation protocols in academic orthopaedic surgery residency programs in the United States using Google’s search engine (www.google.com) based on the Fellowship and Residency Electronic Interactive Database Access System (FREIDA). Private practice organizations publishing MPFL reconstruction or MPFL reconstruction–TTO rehabilitation protocols that were found on the first page of search results were also included, but no comprehensive search for private practice protocols was performed. Protocols specifying an MPFL reconstruction with TTO were included for separate review because of altered weight-bearing status postoperatively. A list of comparative criteria was created to assess the protocols for the presence and timing of the various rehabilitation components. Results: From the list of 189 U.S. academic residency programs, as well as additional private practice protocols found in the Google search, 38 protocols were included for review (31 protocols for isolated MPFL reconstruction and 7 protocols for MPFL reconstruction plus TTO). A return to full range of motion by week 6 was recommended by 15 (48.4%) of the isolated MPFL reconstruction protocols and 6 (85.7%) of the MPFL reconstruction–TTO protocols. Six weeks of knee brace wear was recommended by 13 isolated MPFL reconstruction protocols (43.3%) and 4 MPFL reconstruction–TTO protocols (57.1%). Moreover, 6 isolated MPFL reconstruction protocols (19.4%) and 3 MPFL reconstruction–TTO protocols (42.9%) recommended use of a patellar stabilizing brace postoperatively. Conclusions: There is substantial variability among rehabilitation protocols after MPFL reconstruction, as well as MPFL reconstruction plus TTO, including postoperative range of motion, weight-bearing status, and time until return to sport. Furthermore, many online protocols from academic orthopaedic surgery residency programs and private practices in the United States fail to mention several of these parameters, most notably functional testing to allow patients to return to sport. Clinical Relevance: Proper rehabilitation after MPFL reconstruction with or without TTO is an important factor to a patient’s postoperative outcome. This study outlines the variability in online rehabilitation protocols after MPFL reconstruction with or without TTO published online by academic residency programs and private practice institutions.

Purpose: The purpose of this study was to assess the availability and variability of publicly accessible acromioclavicular (AC) joint reconstruction rehabilitation protocols. Methods: Protocols were identified by searching the websites of orthopedic surgery residency programs in the United States located from the Fellowship and Residency Electronic Interactive Database Access System. Private practice groups with publicly available protocols were also included. Results: Twenty-one protocols were included for review. Four of 14 (29%) protocols suggested starting passive range of motion (ROM) at postoperative week 2. Six of 20 (30%) protocols recommended initiation of full ROM at 6 weeks. Active ROM beginning at 6 weeks was recommended by 6 of 20 (30%) protocols. Six of 16 (38%) protocols recommended initiating active assisted ROM at 6 weeks. Sling immobilization for 6 weeks was recommended by 8 of 18 (44%) protocols. Shoulder isometric exercise initiated at 4 weeks was recommended by 4 of 13 (31%) protocols. Seven of 21 (33%) protocols recommended initiating shoulder strengthening at 12 weeks postoperatively. Return to sport time was included in 17 (81%) protocols with a range of 12 to 48 weeks (mean, 22 weeks). Conclusions: There was substantial variability in publicly accessible AC joint rehabilitation protocols, including a wide range in the recommendations for appropriate time to return to sport. Although strengthening exercises, active ROM, and active assisted ROM were recommended by most protocols, there were considerable differences in recommendations for when to initiate these rehabilitation components. Clinical Relevance: Rehabilitation is important for outcomes of AC joint reconstruction. This study shows the variability present in rehabilitation recommendations among online-accessible AC joint reconstruction rehabilitation protocols.

Abstract Purpose Despite increased utilization of unicompartmental knee arthroplasty (UKA) for unicompartmental knee osteoarthritis, outcomes in Medicare patients are not well‐reported. The purpose of this study is to analyze practice patterns and outcome differences between UKA and TKA in the Medicare population. It is hypothesized that UKA utilization will have increased over the course of the study period and that UKA will be associated with reduced opioid use and lower complication rates compared to TKA. Methods Using PearlDiver, the Humana Claims dataset and the Medicare Standard Analytic File (SAF) were analyzed. Patients who underwent UKA and TKA were identified by CPT codes. Postoperative complications were identified by ICD‐9/ICD‐10 codes. Opioid use was analyzed by the number of days patients were prescribed opioids postoperatively. Survivorship was defined as conversion to TKA. Results In the Humana dataset, 7,808 UKA and 150,680 TKA patients were identified. 8‐year survivorship was 87.7% (95% CI [0.861,0.894]). Postoperative opioid use was significantly higher after TKA (186.1 days) compared to UKA (144.7 days) (p 80 years old and lowest in patients

Abstract Purpose Controversy exists regarding the acute effect of non‐steroidal anti‐inflammatory drugs (NSAIDs) on early fracture healing. The purpose of this study was to analyze the rate of nonunion or delayed union in patients with fifth metatarsal (5th MT) fractures. We hypothesize that the use of NSAIDs would increase the rate of nonunion/delayed union in 5th MT fractures. Methods Using PearlDiver, a national insurance database was analyzed. ICD codes were used to identify patients diagnosed with 5th MT fracture from 2007‐2018. Patients were grouped by initial management (nonoperative vs. open reduction and internal fixation (ORIF) or non/malunion repair within 60 days) and sub‐grouped by whether they had been prescribed at least one pre‐defined NSAID. Subsequent ORIF or nonunion/malunion repair operative intervention was used as a surrogate for fracture nonunion/delayed union. Results Of the 10,991 subjects with a diagnosis of 5th MT, 10,626 (96.7%) underwent initial nonoperative treatment, 1,409 of which (13.3%) received prescription NSAIDS within 60 days of diagnosis. 16/1,409 (1.14%) subjects who received anti‐inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis while 46/9,217 (0.50%; P=0.003483) subjects who did not receive anti‐inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis. In the 365 subjects who underwent early repair/ORIF (within 60 days), there was no significant difference in the rate of nonunion/delayed union. Conclusion The rate of nonunion/delayed union of 5th MT fractures was significantly higher in subjects receiving NSAIDs within 60 days of initial diagnosis in patients managed non‐operatively. Level of evidence Level III

Category: Ankle; Sports Introduction/Purpose: Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study is to analyze the variability across rehabilitation for patients undergoing lateral ankle ligament repair, reconstruction, or suture tape augmentation. Methods: 26 protocols were found. Inclusion criteria was protocols for ankle ligament surgery. Protocols for nonoperative care were excluded. A rubric was created to analyze weightbearing, range of motion (ROM), immobilization, single leg exercises, return to running, and return to sport (RTS). Results: There was variability especially in recommendations for immobilizing brace, partial and full weigh bearing, specific ROM movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement. 100% (12/12) of repair and 86% (12/14) of reconstruction protocols recommended no ROM postoperatively, and 86% (6/7) repair and 78% (11/14) reconstruction recommended no weightbearing postoperatively, making postoperative ROM and weightbearing status the most consistent aspects across protocols. Suture tape augmentation protocols generally allowed rehabilitation on a quicker timeline with full weightbearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3). RTS was consistent in repair protocols (100% at week 12-16). Conclusion: ROM was variable across protocols and did not always match up with supporting literature. Return to sport was likely to correlate between protocols and the literature. Weightbearing was consistent between protocols. The variability between programs demonstrated the need for standardization of rehabilitation.

Category: Ankle Introduction/Purpose: Lateral ankle ligament sprains occur frequently in both general and athletic populations. Most patients recover from their injury without complication, however, some experience persistent pain and instability following lateral ankle injury, which requires treatment with surgical stabilization. The purpose of this study is to determine the utilization and associated costs of non-operative treatment modalities, such as physical therapy (PT), non-steroidal anti-inflammatory medication, and ankle bracing, as well the incidence of lateral ankle sprains that receive surgical treatment and the costs incurred by surgical treatment of chronic lateral ankle instability. Methods: Data was collected using the Pearl Diver Humana dataset using ICD-9, ICD-10, and CPT codes pertaining to ankle sprain, ankle ligament repair or reconstruction, physical therapy, ankle brace ordering, and non-steroidal anti-inflammatory medication (NSAID) ordering. Patients diagnosed with an ankle sprain were sub-divided into three categories: non-operative treatment, surgical ligament repair, and surgical ligament reconstruction. Incidence, cost, and PT usage was compared between patient groups. Cost analysis was performed per group using associated ICD/CPT cost and physical therapy cost. NSAID use and ankle bracing use was also examined. Results: Of patients who sustained lateral ankle injury, 64% were female and 36% were male. 306,180 (98.8%) patients successfully completed non-operative management. 2,774 (1.2%) patients underwent surgical intervention. 63,276 (20.7%) non- operative patients received physical therapy, whereas 1,536 (55.4%) surgically treated patients received PT after surgery. Only 725 (26.1%) surgical patients received pre-operative PT. Median time for total PT treatment of surgical patients was 21.8 weeks, while non-operative patients received treatment for a median time of 58.7 weeks. On average non-operative patients generated 11 billed days in PT while surgical patients received 8 days of PT before surgery and 11 days in PT after surgery. Average total cost per patient was $923.32 for non-operative patients, $3,384.63 for surgical ligament repair, and $3,659.98 for surgical ligament reconstruction. Conclusion: The vast majority of patients with lateral ankle ligament sprains do not progress to surgical treatment. Patients treated non-operatively used fewer physical therapy visits per patient and generated less cost compared to surgically treated patients. Only 20% of non-operative patients received physical therapy. Additionally, a higher proportion of surgically treated patients participated in PT compared to patients treated non-operatively.

Purpose: To compare publicly available rehabilitation protocols designated for rotator cuff (RTC) repairs published online by academic residency programs and private practice institutions. Methods: A systematic electronic search using the Fellowship and Residency Electronic Interactive Database Access System (FREIDA) was performed for RTC repair rehabilitation protocols. Private practice programs with published rehabilitation protocols that were discovered during the Google search were also included for review, but no comprehensive search for private practice protocols was performed. The main exclusion criteria consisted of non–English-language protocols and protocols without any of the time-based components in question. Included protocols were assessed independently based on the specified RTC tear size (small [≤1 cm], medium [1-4 cm], large or massive [≥5 cm], or no mention of size). Protocols were compared based on the inclusion, exclusion, and timing of certain rehabilitation components. Results: A total of 96 rehabilitation protocols were included for review, from 39 academic institutions and 28 private practice programs. Specific instructions for concomitant biceps tenodesis were included in 26 protocols (27.1%). Of the 96 protocols, 88 (91.7%) did not place restrictions on early postoperative passive range of motion (PROM) of the shoulder. Isolated PROM with restrictions on active range of motion was most commonly recommended for the first 4 or 6 weeks postoperatively (80.2%). Use of a sling or immobilizer was most frequently recommended for the first 4 or 6 weeks postoperatively (78.1%). Wide variation was noted in recommendations for returning to resistance strengthening, with the highest incidence being 27 protocols recommending returning at 12 weeks (28.1%); this further varied based on the size of the tear. A total of 21 protocols (21.9%) recommended the use of cryotherapy postoperatively. Conclusions: Although certain rehabilitation components were common, such as duration of PROM and sling or immobilizer use, a large degree of variation remains among published rehabilitation protocols after RTC repair, and this variability is still seen even when subdividing by the size or severity of the RTC tear. Clinical Relevance: Rehabilitation after RTC repair is crucial to patient outcomes. This study summarizes the variability among online rehabilitation protocols for RTC repair in the United States and emphasizes the importance of appropriate rehabilitation after RTC surgery.

Category: Ankle, Arthroscopy Introduction/Purpose: Lateral ankle ligament stabilization may be performed with concomitant arthroscopy. Arthroscopy has been shown to aid in the diagnosis of intra-articular defects that often accompany lateral ankle ligament injuries. This study compares the differences in cost, complications, newly diagnosed intra-articular defects, and reoperations among patients with ankle sprain/chronic instability who underwent lateral ankle ligament repair/reconstruction with or without concomitant arthroscopic procedures. Methods: Data was collected from the PearlDiver Technologies Humana dataset using CPT and ICD9/10 codes. Patients included in this study (n=2,428) had records of ankle sprain or ankle instability prior to or on the same day as one of two procedures: lateral ankle ligament repair (n=1,236) or lateral ankle ligament reconstruction (n=1,211). This population was subdivided by whether patients had records of arthroscopic procedure(s) on the same day as the ligament surgery. This yielded four groups: repair with arthroscopy (n=314), repair without arthroscopy (n=922), reconstruction with arthroscopy (n=473), reconstruction without arthroscopy (n=738). Cost, complications, newly diagnosed intra-articular defects, and reoperations were assessed. Results: Cost was higher for arthroscopy groups: repair with arthroscopy ($5,991.32) versus repair without arthroscopy ($3,677.11; p

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Controversy exists regarding the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on fracture healing. Our retrospective study uses a private payer database to isolate patients diagnosed with 5th metatarsal (MT) fractures and compare the rate of delayed open reduction and internal fixation (ORIF) or non/malunion repair as a surrogate for nonunion or delayed union, in those prescribed anti-inflammatories and those not prescribed anti-inflammatories. Methods: Data was collected from the PearlDiver Technologies Humana dataset using CPT and ICD-10 codes. All patients included had a diagnosis of 5th MT fracture and did not receive ORIF or repair of non/malunion within 60 days of diagnosis. Two groups were then created based on the presence or absence of insurance claim records for anti-inflammatory medications within 60 days of diagnosis. The number of patients in each group who underwent ORIF or non/malunion repair after 60 days post- diagnosis was determined, and the rates were compared using a chi-square analysis. Results: 10,626 patients had a diagnosis of 5th MT fracture and did not undergo early repair/ORIF (within 60 days). 1,615 had records of insurance claims for anti-inflammatories within 60 days of diagnosis, leaving 9,011 who did not receive these medications. 18 (1.11%) patients who received an anti-inflammatory medication underwent ORIF or repair of non/malunion after 60 days post-diagnosis. 44 (0.49%; p=0.0055) subjects who did not receive an anti-inflammatory prescription underwent ORIF or repair of non/malunion after 60 days post-diagnosis. Conclusion: The rate of delayed ORIF or non/malunion repair of 5th MT fractures, a surrogate for delayed union or nonunion in an insurance database study, was significantly higher in subjects receiving anti-inflammatories within 60 days of diagnosis. This study isolates a specific fracture and finds a negative correlation between NSAIDs and fracture healing. Further, this provides valuable information to help guide future higher level studies.

Category: Ankle, Sports, Post-op protocol Introduction/Purpose: Lateral ankle instability represents a common orthopaedic diagnosis. Nonoperative treatment through focused physical therapy provides satisfactory results in most patients. Some patients, however, experience persistent chronic lateral ankle instability despite appropriate nonoperative treatment. These patients may require stabilization which can include primary lateral ligament repair to restore ankle stability. Optimal post-operative rehabilitation of lateral ankle ligament repairs remains unknown, as surgeon vary in how they balance protection of surgical repair with immobilization with the need for ankle joint mobilization to restore range of motion. The aim of this review is to provide insight into early and delayed mobilization post- operative protocols in patients undergoing primary lateral ankle ligament repairs to determine if an optimal evidence-based post- operative rehabilitation protocol exists in the literature. Methods: Following PRIMSA criteria, a meta-analysis using the PubMed/Ovid Medline database was performed (10/11/1947- 10/16/2017). Manuscripts that were duplicates, non-lateral ligament repair, biomechanical and non-English language were excluded. Protocols were reviewed and divided into two categories; early mobilization (within 3 weeks of surgery) and delayed mobilization (after 4 weeks of surgery). Return to sport, outcome scores (AOFAS, Karlsson scores) and complications of both populations were recorded and statistically analyzed. Results: 31 out of 1,844 studies met the criteria for the final analysis, representing 1,608 patients undergoing primary lateral ligament repair. There was no statistical difference in pre-operative AOFAS scores with delayed mobilization having a score of 67.3 and early mobilization having a score of 67.6 (p

Category: Sports Introduction/Purpose: The prevalence of turf toe injuries has increased in recent years due to heightened awareness and the large number of athletes participating in sports today. Uncertainty remains, however, as to how to properly treat turf toe and the prognosis for these injured athletes. The purpose of this study was to systematically review the literature to provide recommendations on treatment of turf toe and expectations for outcomes and return to play. Methods: Following PRISMA criteria, a systematic review and meta-analysis using the PubMed/Ovid Medline/PMC databases was performed (May 1964 – August 2018). Studies evaluating non-turf toe injuries, biomechanical studies, and those written in non- English language were excluded. Return to sport, treatment, severity of injury, athletic position, and sport were recorded and statistically analyzed. Results: 12/944 studies met criteria, which included 112 athletes and 120 turf toe injuries. The athletes played a variety of sports: football (111), basketball (2), soccer (1), and track (3). 58 of these injuries were treated non-operatively, while 62 required surgery. There was one grade 1 injury, ten grade 2 injuries, and fifty-four grade 3 injuries. Fifty-five injuries were unclassifiable and excluded. Return to sport for patients treated non-operatively was 5.9 weeks versus 19.2 weeks in patients treated operatively (p=0.007). Patients with a grade 2 injury returned to sport quicker (11.7 weeks) than patients with grade 3 injuries (19.9 weeks) (p=0.016). Return to play was different according to the athlete’s level of play (13.9 weeks high school, 16.8 weeks college, 14.4 weeks professional) (p=0.018). Conclusion: Return to sport in patients suffering from a turf toe injury can be affected by either the severity of injury and/or level of competition of the athlete. However, this study also acknowledges the limited number of high level studies evaluating turf toe in the athletic population. Further research is necessary to clearly define appropriate treatment and return to play protocols based on sport, position, and level of play.