Search

Batter's shoulder is characterized by posterior shoulder instability in the lead (front) shoulder of a batting athlete. This most commonly occurs as a discrete event, particularly a swing and miss at an outside pitch, which leads to an episode of shoulder subluxation. A thorough history and physical examination is key to diagnosis, with patients feeling pain and instability of the lead shoulder when attempting the baseball swing or during pushing-type activities, as well as positive posterior labral signs in tests such as the Kim, jerk, and modified dynamic labral shear tests. Magnetic resonance imaging can confirm the diagnosis of posterior labral tear and may show concomitant pathologies such as a reverse Hill-Sachs lesion. Nonsurgical treatment is directed at rotator cuff and scapular strengthening; however, arthroscopic posterior labral repair is often required for definitive stabilization. Overall, this is a relatively rare diagnosis, but outcomes of surgical repair are favorable with high satisfaction and rates of return to competition., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Disability due to iliopsoas (IP) pain and dysfunction is underdiagnosed in the athletic population. The IP unit consists of the psoas major and iliacus muscles converging to form the IP tendon and is responsible primarily for hip flexion strength but has a number of secondary contributions such as femoral movement, trunk rotation, core stabilization, and dynamic anterior stability to the hip joint. As the IP passes in front of the anterior acetabulum and labrum, the diagnosis of IP pain may be confused with labral tearing seen on magnetic resonance imaging. This is in addition to the low sensitivity of magnetic resonance imaging to detect IP tendinitis and bursitis. Resisted seated hip flexion as well as direct palpation of the IP tendon and muscle belly are useful to assess function and help determine whether the IP may be the source of pain, which is common in athletes. Both biomechanical and clinical investigations have demonstrated the role of IP as an anterior hip stabilizer. Patients with signs of hip microinstability, developmental dysplasia of the hip, and increased femoral anteversion are at risk of IP pain and poor outcomes after IP lengthening, highlighting the importance of the IP in providing dynamic anterior hip stability., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: Quadriceps muscle atrophy remains a limiting factor in returning to activity after anterior cruciate ligament reconstruction (ACLR). Blood flow restriction (BFR) therapy may accelerate quadriceps strengthening in the perioperative period., Purpose: To evaluate postoperative isometric quadriceps strength in patients who underwent ACLR with a perioperative BFR program., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: Patients indicated for ACLR were randomized into 2 groups, BFR and control, at their initial clinic visit. All patients underwent 2 weeks of prehabilitation preoperatively, with the BFR group performing exercises with a pneumatic cuff set to 80% limb occlusion pressure placed over the proximal thigh. All patients also underwent a standardized postoperative 12-week physical therapy protocol, with the BFR group using pneumatic cuffs during exercise. Quadriceps strength was measured as peak and mean torque during seated leg extension and presented as quadriceps index (percentage vs healthy limb). Patient-reported outcomes (PROs), knee range of motion, and quadriceps circumference were also gathered at 6 weeks, 3 months, and 6 months postoperatively, and adverse effects were recorded., Results: Included were 46 patients, 22 in the BFR group (mean age, 25.4 ± 10.6 years) and 24 in the control group (mean age, 27.5 ± 12.0 years). At 6 weeks postoperatively, the BFR group demonstrated significantly greater strength compared with the controls (quadriceps index: 57% ± 24% vs 40% ± 18%; P = .029), and the BFR group had significantly better Patient-Reported Outcomes Measurement Information System-Physical Function (42.69 ± 5.64 vs 39.20 ± 5.51; P = .001) and International Knee Documentation Committee (58.22 ± 7.64 vs 47.05 ± 13.50; P = .011) scores. At 6 weeks postoperatively, controls demonstrated a significant drop in the peak torque generation of the operative versus nonoperative leg. There were no significant differences in strength or PROs at 3 or 6 months postoperatively. Three patients elected to drop out of the BFR group secondary to cuff intolerance during exercise; otherwise, no other severe adverse events were reported., Conclusion: Integrating BFR into perioperative physical therapy protocols led to improved strength and increased PROs at 6 weeks after ACLR. No differences in strength or PROs were found at 3 and 6 months between the 2 groups., Registration: NCT04374968 (ClinicalTrials.gov identifier)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: K.R.O. has received grant support from Arthrex; education payments from Arthrex, Endo Pharmaceuticals, and Smith & Nephew; nonconsulting fees from Arthrex and Smith & Nephew; consulting fees from Endo Pharmaceuticals and Smith & Nephew; honoraria from Wright Medical; and hospitality payments from Medical Device Business Services, Stryker, and Zimmer Biomet. J.S.T. has received education payments from Pinnacle. L.S.K. has received education payments from Pinnacle and Medwest Associates. T.R.J. has received consulting fees from Biogen; hospitality payments from Exactech and Zimmer Biomet; and education payments from DePuy Synthes, Pinnacle, and Smith & Nephew. V.M. has received consulting fees from Pacira Pharmaceuticals and education payments from Pinnacle. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained from Henry Ford Hospital (No. 13080)., (© The Author(s) 2023.)

Purpose: To leverage Google's search algorithms to summarize the most commonly asked questions regarding anterior cruciate ligament (ACL) injuries and surgery., Methods: Six terms related to ACL tear and/or surgery were searched on a clean-installed Google Chrome browser. The list of questions and their associated websites on the Google search page were extracted after multiple search iterations performed in January of 2022. Questions and websites were categorized according to Rothwell's criteria. The Journal of the American Medical Association (JAMA) Benchmark criteria were used to grade website quality and transparency. Descriptive statistics were provided. χ 2 and Student t -tests identified for categorical differences and differences in JAMA score, respectively (significance set at P < .05)., Results: A total of 273 unique questions associated with 204 websites were identified. The most frequently asked questions involved Indications/Management (20.2%), Specific Activities (15.8%), and Pain (10.3%). The most common websites were Medical Practice (27.9%), Academic (23.5%), and Commercial (19.5%). In Academic websites, questions regarding Specific Activities were seldom included (4.7%) whereas questions regarding Pain were frequently addressed (39.3%, P  = .027). Although average JAMA score was relatively high for Academic websites, the average combined score for medical and governmental websites was lower ( P < .001) than nonmedical websites., Conclusions: The most searched questions on Google regarding ACL tears or surgery related to indications for surgery, pain, and activities postoperatively. Health information resources stemmed from Medical Practice (27.9%) followed by Academic (23.5%) and Commercial (19.5%) websites. Medical websites had lower JAMA quality scores compared with nonmedical websites., Clinical Relevance: These findings presented may assist physicians in addressing the most frequently searched questions while also guiding their patients to greater-quality resources regarding ACL injuries and surgery., (© 2023 The Authors.)

Purpose: To summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature., Methods: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across 3 databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active Major League Baseball (MLB) athletes and studies published in the English language. Exclusion criteria were non-MLB players, case series and case report studies with a cohort of ≤3 players, and/or review articles., Results: A total of 477 articles were identified from the initial search of 3 databases, with 105 studies meeting inclusion criteria. Among these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the greatest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament (UCL) tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40%-72.5%), rotator cuff tears (33.3%-87%), and UCL tears (51%-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated nonoperatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days), and anterior cruciate ligament (ACL) tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement requiring arthroscopy, athletes had a significantly lower workloads compared with before injury upon return to play., Conclusions: Most published investigations focus on elbow injuries of the UCL, with variable return to play and mixed performance following surgery. UCL tears, shoulder labral tears, and ACL tears result in the most missed time. Upper-extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest return to play rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for femoroacetabular impingement., Level of Evidence: Level IV, systematic review of level II-IV studies., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Blood flow restriction (BFR) therapy has demonstrated benefits across a spectrum of musculoskeletal injuries, including improved strength, endurance, function, and reduction in pain perception. There is, however, no standardized application of BFR therapy among orthopaedic surgeons within the United States (US)., Hypothesis: The indication and protocol for BFR therapy vary significantly across providers in the US., Methods: An online survey of 21 multiple-choice questions was sent to 3,281 surgeons listed on a large orthopaedic registry. A cross-sectional study was performed on all surgeons who successfully completed the questionnaire. Surgeons were queried on current or planned use of BFR, indications, contraindications, and peri-operative and non-operative management of sports-related injuries., Results: Overall, 250 physicians completed the survey, with 149 (59.8%) reporting current BFR use and 75.2% initiating use in the last 1-5 years. Most protocols (78.8%) utilize the modality 2-3 times per week while 15.9% use it only once weekly. Anterior cruciate ligament reconstruction (ACLR) rehabilitation was the most reported indication for initiating BFR therapy (95.7%) along with medial patellofemoral ligament reconstruction (70.2%), multiligamentous knee reconstruction (68.8%), meniscus repair (62.4%), collateral ligament reconstruction (50.4%), Achilles tendon repairs (30.5%), and meniscectomy (27%). Only 36.5% reported using BFR after upper extremity procedures, such as distal biceps repair (19.7%), ulnar collateral ligament elbow reconstruction (17%), rotator cuff (16.8%), and shoulder labrum repair (15.3%). For non-operative injuries, 65.8% of surgeons utilized BFR. Of those not currently using BFR therapy, 33.3% intended to implement its use in the future., Conclusion: BFR therapy has increased in popularity with most physicians implementing its use in the last 5 years. BFR was commonly utilized after ACLR., Clinical Relevance: BFR allows light-load resistance to simulate high-intensity resistance training. This study describes US orthopaedic surgeons' common practice patterns and patient populations that utilize BFR therapy., Competing Interests: There are no conflicts of interest to report., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Purpose: To evaluate the efficacy of a 2-week home-based blood flow restriction (BFR) prehabiliation program on quadriceps strength and patient-reported outcomes prior to anterior cruciate ligament (ACL) reconstruction., Methods: Patients presenting with an ACL tear were randomized into two groups, BFR and control, at their initial clinic visit. Quadriceps strength was measured using a handheld dynamometer in order to calculate peak force, average force, and time to peak force during seated leg extension at the initial clinic visit and repeated on the day of surgery. All patients were provided education on standardized exercises to be performed 5 days per week for 2 weeks between the initial clinic visit and date of surgery. The BFR group was instructed to perform these exercises with a pneumatic cuff set to 80% of limb occlusion pressure placed over the proximal thigh. Patient-Reported Outcome Measurement System Physical Function (PROMIS-PF), knee range of motion, and quadriceps circumference were gathered at the initial clinic visit and day of surgery, and patients were monitored for adverse effects., Results: A total 45 patients met inclusion criteria and elected to participate. There were 23 patients randomized to the BFR group and 22 patients randomized into the control group. No significant differences were noted between the BFR and control groups in any demographic characteristics (48% vs 64% male [P = .271] and average age 26.5 ± 12.0 vs 27.0 ± 11.0 [P = .879] in BFR and control, respectively). During the initial clinic visit, there were no significant differences in quadriceps circumference, peak quadriceps force generation, time to peak force, average force, pain, and PROMIS scales (P > .05 for all). Following completion of a 2-week home prehabilitation protocol, all patients indeterminant of cohort demonstrated decreased strength loss in the operative leg compared to the nonoperative leg (P < .05 for both) However, there were no significant differences in any strength or outcome measures between the BFR and control groups (P > .05 for all). There were no complications experienced in either group, and both were compliant with the home-based prehabilitation program., Conclusions: A 2-week standardized prehabilitation protocol preceding ACL reconstruction resulted in a significant improvement in personal quadriceps peak force measurements, both with and without the use of BFR. No difference in quadriceps circumference, strength, or patient reported outcomes were found between the BFR and the control group. The home-based BFR prehabiliation protocol was found to be feasible, accessible, and well tolerated by patients., Level of Evidence: Level II, randomized controlled trial with small effect size., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objectives: Hip and core injuries are common in National Football League (NFL) athletes; however, the impact following injury remains unclear. The goal of this manuscript was to determine the impact of nonoperative hip and core injuries on return to play and performance., Methods: NFL athletes who sustained a hip or core injury treated nonoperatively between 2010 and 2016 were identified. Offensive and defensive power ratings were calculated for each player's injury season and two seasons before and after to assess longitudinal impact. A matched control group without an identified hip and/or core injury was assembled for comparison., Results: A total of 41 offensive and 71 defensive players with nonoperative hip or core injury were analyzed. All athletes returned to play; offensive and defensive players missed 4.0 ± 5.2 and 3.1 ± 2.6 games after injury, respectively. Offensive players played fewer cumulative career games returning from core injury versus hip (23.5 ± 20.6 vs 41.0 ± 26.4). Defensive players played fewer games (58.1 ± 41.1 versus 37.4 ± 27.1, p < 0.05) with lower defensive power rating (133.9 ± 128.5 versus 219.8 ± 212.2, p < 0.05) cumulatively after hip or core injury. Additionally, 2 years following injury, defensive players played fewer games compared to controls (9.5 ± 7.0 versus 10.9 ± 6.8, p < 0.05). Following hip injury specifically, NFL defenders played fewer games (39.8 ± 27.9 vs 61.9 ± 38.8; p < 0.05) and had a lower defensive power rating (145.9 ± 131.7 vs 239.0 ± 205.9; p < 0.05) compared to before injury., Conclusion: Overall, NFL players return to play following nonoperative hip and core injuries. Defensive players played in fewer games following hip or core injury compared to controls; offensive players were unaffected. Hip injuries have a greater impact on performance compared to core injuries in defensive athletes; offensive players played fewer games upon return from core injury.

Rupture of the Achilles tendon is a common injury seen in patients of varying ages and activity levels. There are many considerations for treatment of these injuries, with both operative and nonoperative management providing satisfactory outcomes in the literature. The decision to proceed with surgical intervention should be individualized for each patient, including the patient's age, future athletic goals, and comorbidities. Recently, a minimally invasive percutaneous approach to repair the Achilles tendon has been proposed as an equivalent alternative to the traditional open repair, while avoiding wound complications associated with larger incisions. However, many surgeons have been hesitant to adopt these approaches due to poor visualization, concern that suture capture in the tendon is not as robust, and the potential for iatrogenic sural nerve injury. The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. This technique minimizes the drawbacks of poor visualization associated with percutaneous repair, while providing the benefit of a minimally invasive approach., (© 2022 The Authors.)

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a valid and efficient means of collecting outcomes in patients with rotator cuff tears. The purpose of this study was to establish threshold score changes to determine minimal clinically important difference (MCID) and substantial clinical benefit (SCB) in PROMIS computer adaptive test (CAT) scores following rotator cuff repair (RCR). Additionally, we sought to identify potential risk factors for failing to achieve MCID and SCB., Methods: Patients undergoing arthroscopic RCR were identified over a 24-month period. Only patients who completed both preoperative and postoperative PROMIS CAT assessments were included in this cohort. PROMIS CAT forms for upper extremity physical function (PROMIS-UE), pain interference (PROMIS-PI), and depression (PROMIS-D) were used with a minimum of 1.5-year follow-up. Statistical analysis was performed to determine threshold score changes to determine anchor-based MCID and SCB, as well as risk factors for failure to achieve significant clinical improvement following surgery., Results: Of 198 eligible patients, 168 (84.8%) were included in analysis. ΔPROMIS-UE values of 5.8 and 9.7 (area under the curve [AUC] = 0.906 and 0.949, respectively) and ΔPROMIS-PI values of -11.4 and -12.9 (AUC = 0.875 and 0.938, respectively) were identified as threshold predictors of MCID and SCB achievement. On average, 81%, 65%, and 55% of patients achieved MCID for PROMIS-UE, PROMIS-PI, and PROMIS-D whereas 71%, 61%, and 38% of patients in the cohort, respectively, achieved SCB. MCID achievement in PROMIS-UE significantly differed according to risk factors, including smoking status (likelihood ratio [LR]: 9.8, P = .037), tear size (LR: 10.4, P < .001), distal clavicle excision (LR: 6.1, P = .005), and prior shoulder surgery (LR: 19.2, P < .001). Factors influencing SCB achievement for PROMIS-UE were smoking status (LR: 9.3, P = .022), tear size (LR: 8.0, P = .039), and prior shoulder surgery (11.9, P < .001). Significantly different rates of MCID and SCB achievement in PROMIS-PI for smoking status (LR: 7.0, P = .030, and LR: 5.2, P = .045) and prior shoulder surgery (LR: 9.1, P = .002, and LR: 7.4, P = .006) were also identified., Discussion and Conclusion: The majority of patients showed clinically significant improvements that exceeded the established MCID for PROMIS-UE and PROMIS-PI following RCR. Patients with larger tear sizes, a history of prior shoulder surgery, tobacco users, and those who received concomitant distal clavicle excision were at risk for failing to achieve MCID in PROMIS-UE. Additionally, smokers and patients who underwent prior shoulder surgery demonstrated significantly lower improvements in pain scores following surgery., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Anterior shoulder instability is a common orthopaedic condition that often involves damage to the bony architecture of the glenohumeral joint in addition to the capsulolabral complex. Patients with recurrent shoulder dislocations are at increased risk for glenohumeral bone loss, as each instability event leads to the accumulation of additional glenoid and/or humeral head bone defects. Depending on the degree of bone loss, successful treatment may need to address bony lesions in addition to injured soft-tissue structures. As such, a thorough understanding of methods for evaluating bone loss preoperatively, in terms of location, size, and significance, is essential. Although numerous imaging modalities can be used, three-dimensional imaging has proven particularly useful and is now an integral component of preoperative planning., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Background: Golf is a popular sport among patients undergoing total knee arthroplasty (TKA). The golf swing requires significant knee rotation, which may lead to changes in golfing ability postoperatively. The type of implant used may alter the swing mechanics or place different stresses on the knee. The purpose of this study was to evaluate golf performance and subjective stability after TKA and compare outcomes between cruciate-retaining (CR) and posterior-stabilized (PS) implants., Hypothesis: Patients with CR implants will experience better stability during the golf swing compared to patients with PS implants., Study Design: Retrospective cohort study., Level of Evidence: Level 3., Methods: Patients who underwent primary TKA were identified from the medical record and sent an electronic questionnaire focusing on return to play (RTP), performance, pain, and stability during the golf swing. Knee injury and Osteoarthritis Outcome Scores (KOOS) were collected before and at multiple time points after surgery. Patients were surveyed postoperatively and asked to evaluate overall performance, pain, and stability before and after surgery. Outcomes were compared based on implant type., Results: Most patients (81.5%) were able to return to golf at an average of 5.3 ± 3.1 months from surgery. The average postoperative KOOS was 74.6 ± 12.5 in patients able to RTP compared with 64.4 ± 9.5 in those who were not ( P < 0.05). Knee pain during golf significantly improved from 6.4 ± 2.1 to 1.8 ± 2.2 ( P < 0.01). There were no significant differences in pain, performance, or stability between the CR and PS patients., Conclusion: Most patients can successfully return to golfing after TKA. Knee replacement offers patients reliable pain relief during the golf swing and fewer physical limitations during golf, with no detriment to performance. There is no difference in performance or subjective knee stability based on component type., Clinical Relevance: Understanding associated outcomes of different TKA knee systems allows for unbiased and confident recommendations of either component to golfers receiving total knee replacement.

Purpose: To determine whether patient demographics have predictive influence on patient-reported outcomes measurement information system (PROMIS) domains of pain interference (PROMIS-PI), depression (PROMIS-D), and upper extremity (PROMIS-UE) for patients with shoulder pathology treated nonoperatively., Methods: Patients with partial rotator cuff tears, impingement, scapular dyskinesia, osteoarthritis, muscle strains, biceps tendonitis, instability, and acromioclavicular arthritis were retrospectively identified. Patients who underwent surgery were excluded. Demographic characteristics were documented, and PROMIS scores before and after nonoperative intervention were analyzed for correlations between each domain., Results: A total of 638 questionnaires (PROMIS-UE, PROMIS-PI, and PROMIS-D) were analyzed. PROMIS-UE had a strong negative correlation with PROMIS-PI (R = - 0.73, P < .001). PROMIS-PI and PROMIS-D demonstrated a positive correlation of moderate strength (R = 0.54, P < .001). Patients who never used tobacco, compared to current or former users, had significantly higher PROMIS-UE scores (34.5 vs. 30.6 and 31.9; P < .001), lower PROMIS-PI (59.7 vs. 63.1 and 60.9; P < .001), and lower PROMIS-D scores (47.3 vs. 52.1 and 49.3; P < .001). Patients with body mass index < 24.8 had significantly higher PROMIS-UE scores than those with > 24.8 (P < .05)., Conclusion: There is an inverse relationship between upper extremity physical function and pain and depression, as measured by PROMIS scores. Smoking and increased BMI are significant contributors to worse outcomes in patients with shoulder pathology, even in nonoperative populations. Counseling patients regarding prognosis and functional outcomes is important in managing their expectations in this patient population., (© 2020. Istituto Ortopedico Rizzoli.)

Background: Multimodal pain protocols have been effective for postsurgical pain control; however, no published protocol has been effective in eliminating opioid consumption., Purpose: To compare a multimodal nonopioid pain protocol versus traditional opioid medication for postoperative pain control in patients undergoing anterior cruciate ligament reconstruction (ACLR)., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: A total of 90 patients undergoing primary ACLR were assessed for participation. We performed a prospective, randomized controlled trial in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The study arms were a multimodal nonopioid analgesic protocol (acetaminophen, ketorolac, diazepam, gabapentin, and meloxicam) and a standard opioid regimen (hydrocodone-acetaminophen), and the primary outcome was postoperative visual analog scale (VAS) pain scores for 10 days. Secondary outcomes included patient-reported outcomes, complications, and satisfaction. The observers were blinded, and the patients were not blinded to the intervention., Results: A total of 9 patients did not meet inclusion criteria, and 19 patients declined participation. Thus, 62 patients were analyzed, with 28 patients randomized to the opioid group and 34 to the multimodal nonopioid group. Patients receiving the multimodal nonopioid pain regimen demonstrated significantly lower VAS scores compared with patients who received opioid pain medication ( P < .05). Patients were administered the Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form, and no significant difference was found in patients' preoperative scores (opioid group, 58.6 ± 7.9; multimodal nonopioid group, 57.5 ± 7.4; P = .385) and 1-week postoperative scores (opioid group, 66.3 ± 8.2; multimodal nonopioid group, 61.4 ± 8.8; P = .147). When we adjusted for possible confounders (age, sex, body mass index, graft type), no significant differences in pain control were found between the 2 groups. The most common adverse effects for both groups were drowsiness and constipation, with no difference between the groups. All patients in the multimodal nonopioid group reported satisfactory pain management., Conclusions: A multimodal nonopioid pain protocol provided at least equivalent pain control compared with traditional opioid analgesics in patients undergoing ACLR. Minimal side effects, which did not differ between groups, were noted, and all patients reported satisfaction with their pain management.

Purpose: To determine the change in Patient-Reported Outcomes Measurement Information System Computerized Adaptive Testing (PROMIS CAT) scores for physical function, pain interference, and depression that constitute minimum clinically important difference (MCID) using an anchor-based technique and to identify pre-operative clinical thresholds in anchor-based MCID that predict likelihood of achieving MCID following anterior cruciate ligament (ACL) reconstruction., Methods: Adult patients aged 18 years or older undergoing ACL reconstruction that completed both preoperative and postoperative PROMIS CAT assessments and an anchor-based questionnaire were identified over a 23-month period. Anchor-based MCID was determined for PROMIS CAT forms for physical function (PROMIS PF CAT), pain interference (PROMIS PI CAT), and depression (PROMIS D CAT)., Results: A total of 137 patients were included for statistical analysis, with pre-operative PROMIS CAT forms completed 27.9 ± 31.2 days before surgery and 492.5 ± 219.9 days postoperatively on average. Statistically significant improvements were observed for all PROMIS CAT domains. PROMIS PF CAT improved from 39.5 ± 8.2 to 55.0 ± 9.7 ( P < .0005), PROMIS PI CAT from 59.8 ± 7.2 to 48.2 ± 8.3 ( P < .0005), and PROMIS D CAT from 47.9 ± 8.8 to 41.5 ± 8.6 ( P < .0005). Anchor-based MCID for each PROMIS CAT form was calculated to be +4.5, -5.4, and -4.1 for PROMIS PF CAT, PROMIS PI CAT, and PROMIS D CAT, respectively. Mean difference between preoperative and postoperative PROMIS CAT scores exceeded MCID for all domains. The percentage of patients achieving MCID for PROMIS PF CAT, PROMIS PI CAT, and PROMIS D CAT was 85%, 72%, and 55%, respectively. After introduction of 95% specificity cutoffs, the percentage of patients achieving MCID for PROMIS PF CAT, PROMIS PI CAT, and PROMIS D CAT increased to 100% (<35.6 cutoff score), 92% (>65.7 cutoff score), and 83% (>57.5 cutoff score), respectively., Conclusions: According to anchor-based analysis of PROMIS CAT MCID, ACL reconstruction is effective in improving physical function, pain interference, and depression symptoms. In addition, preoperative PROMIS CAT scores can predict the likelihood of achieving MCID postoperatively., Level of Evidence: Level IV, prognostic case series., (© 2021 Published by Elsevier on behalf of the Arthroscopy Association of North America.)

Quadriceps tendon ruptures compromise the knee extensor mechanism and cause an inability to ambulate and significant functional limitations. Therefore, the vast majority of quadriceps tendon ruptures are indicated for operative intervention to restore patient mobility and function. Although these injuries were traditionally repaired using a transosseous repair technique, recent literature has shown that suture anchor repair may offer biomechanical advantages. Additionally, research in other areas of orthopaedics has found that a double-row suture anchor construct can offer additional biomechanical strength to tendinous repair. This technical note describes a safe and effective quadriceps tendon repair using a double-row suture anchor construct., (© 2021 Published by Elsevier on behalf of the Arthroscopy Association of North America.)

Case: A 38-year-old weight lifter presented with a complete distal biceps rupture with retraction and a near complete ipsilateral distal triceps tear sustained during the bench press exercise. The tendons were fixed operatively using a simultaneous posterior and anterolateral approach to the elbow., Conclusion: Simultaneous, ipsilateral distal biceps and distal triceps tendon injury is a rare occurrence that leads to significant functional loss. Repair of distal biceps rupture using a single-incision technique with a cortical button and distal triceps using a double-row suture anchor repair was successful in restoring functional anatomy to our patient., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B550)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Multimodal pain control can be beneficial in relieving postoperative pain and limiting narcotic use following orthopedic procedures. Additionally, with increasing interest in outpatient arthroplasty procedures, providers have interest in adequate early postoperative pain control and complications. The purpose of this study was to investigate the effect of dexamethasone on pain, postoperative nausea and vomiting, and length of stay following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA)., Methods: One hundred twelve patients undergoing TSA or RTSA by a single surgeon were assessed for inclusion in this investigation. We performed a prospective randomized controlled trial to investigate the effect of 10 mg of dexamethasone administered within 90 minutes of surgery. Primary outcome assessed was the average morphine equivalent use over the first 24 hours postsurgery. Secondary outcomes included postoperative visual analog scale (VAS) scores, antiemetic use, postoperative nausea and vomiting, and complications., Results: A total of 75 patients were included in the final analysis, with 32 patients (42.7%) randomized to the control group and 43 (57.3%) randomized to the dexamethasone group. Body mass index was significantly greater in the control group (33.8 vs. 30.3, P = .014); otherwise, there were no significant demographic differences between groups. Average ondansetron use was significantly lower in the dexamethasone group compared with controls for the 0- to 4-hour interval (0.1 vs. 0.9 mg, respectively, P = .006) and was lower overall for the first 24 hours (0.3 vs. 1.0 mg, P = .025). Differences in VAS scores were significantly lower in the dexamethasone group at all time points (P < .05 for all). The average VAS score over the 24-hour period for the dexamethasone group was also significantly lower than the controls (3 vs. 6, P < .001). Morphine equivalent use was significantly lower in the dexamethasone group compared with controls at 12-16 hours (1.7 vs. 4.0 mg, respectively, P = .004) and at 16-20 hours (1.7 vs. 3.4 mg, respectively, P = .006). When averaged over the first 24 hours, morphine equivalent was also significantly lower in the dexamethasone group (16.1 vs. 25.4 mg, P = .007). There was no significant difference in glucose control or complications between groups., Conclusion: Dexamethasone decreases opioid requirements in the first 24 hours following surgery, provides improved pain control, and decreases antiemetic use following shoulder arthroplasty. Dexamethasone is an important multimodal adjunct for controlling pain and postoperative nausea and vomiting following primary TSA., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The incidence of anterior cruciate ligament (ACL) injuries in women's basketball exceeds that of men. There is a paucity of data regarding career performance in Women's National Basketball Association (WNBA) athletes with a history of ACL reconstruction., Purpose: To determine whether WNBA athletes with a history of ACL injury prior to professional play have reduced career game utilization, defined as games played and started and minutes per game (MPG), as well as statistical performance, defined by player efficiency rating (PER)., Study Design: Cohort study; Level of evidence, 3., Methods: Included were 42 WNBA players from 1997 to 2018 who had a history of ACL reconstruction before entering professional leagues. Body mass index (BMI), age, and position were collected for each player. Career data and performance statistics were likewise collected for each player's entire WNBA career. A control group of WNBA players with no history of ACL injury were matched by position, BMI, and age at the time of WNBA debut. Statistics compared game utilization and performance to assess the impact of ACL reconstruction., Results: Athletes who sustained an ACL tear before entering the league played in fewer games per season in their first 3 professional seasons compared with healthy controls (24.2 ± 8.4 vs 28.2 ± 6.1; P = .02). Among athletes with a history of ACL reconstruction, 11 (26.2%) played only a single WNBA season, while no control athletes played in just 1 season. Additionally, athletes who had a previous ACL tear started significantly fewer games per season (9.0 ± 9.4 vs 14.0 ± 9.0; P < .01) and played fewer MPG (15.5 ± 7.2 vs 20.7 ± 5.5; P < .01) during their WNBA career. Athletes with a history of ACL tear had significantly shorter WNBA careers (4.8 ± 4.1 vs 8.1 ± 3.3 seasons; P < .001). Total professional play duration (WNBA + overseas) was significantly reduced in players with an ACL tear compared with controls ( P < .05). PER was not significantly different between cohorts at any time point., Conclusion: WNBA athletes with a history of an ACL tear before professional play had decreased career game utilization and workload throughout their career despite having similar PER compared with healthy controls., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: L.S.K. has received education payments from Pinnacle and hospitality payments from Exactech and Zimmer Biomet. P.A.K. has received education payments from Arthrex and Pinnacle and hospitality payments from DJO and Exactech. K.R.O. has received grant support from Arthrex; education payments from Arthrex, Pinnacle, and Smith & Nephew; and hospitality payments from Stryker, Medical Device Business Services, Wright Medical, and Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Background: The object of this study was to examine return to golf and changes in golf performance after shoulder arthroplasty. Additionally, we set out to determine if there were differences in return to play and performance between total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). We also examined pain during the golf swing to determine if there is a change in pain level after surgery., Methods: Patients were identified using a Current Procedural Terminology code 23472 search for TSA. A 19-question online survey was sent out to each patient with questions detailing golfing performance and pain during the swing before and after surgery. Comparisons were made to determine differences in pain, performance and enjoyment between TSA and RTSA groups before and after surgery., Results: A total of 586 patients who underwent shoulder arthroplasty were sent the online survey via email. Of those patients, 33 identified themselves as golfers and who responded to the survey, resulting in an overall response rate of 5.6%. Twenty-three of 31 (74%) patients were able to return to golf following their procedure. Overall, the respondents who reported pain associated with golfing activity had significantly decreased pain after undergoing either TSA or RTSA. The RTSA group had a significant drop in driving distance following the procedure and this was significantly lower than the postoperative driving distance in the TSA group, despite an insignificant preoperative difference., Conclusion: Overall, TSA offers a safe and effective means for reducing pain during the golf swing in patients suffering from advanced shoulder osteoarthritis. While there were no significant changes in performance following TSA, individuals undergoing RTSA can be counseled that they are at risk for lower driving distances due to altered mechanics. Overall, patients were satisfied with their procedure and their ability to return to the golf course.

Background: Women's National Basketball Association (WNBA) players have a greater incidence of lower extremity injury compared with male players, yet no data exist on functional outcomes after Achilles tendon rupture (ATR)., Purpose: To evaluate the effect of Achilles tendon repair on game utilization, player performance, and career longevity in WNBA athletes., Study Design: Cohort study; Level of evidence, 3., Methods: WNBA players from 1997 to 2019 with a history of ATR (n = 12) were matched 1:2 to a healthy control group. Player characteristics, game utilization, and in-game performance data were collected for each athlete, from which the player efficiency rating (PER) was calculated. Statistical analysis was performed comparing postinjury data to preinjury baseline as well as cumulative career data. Changes at each time point relative to the preinjury baseline were also compared between groups., Results: Of the 12 players with ATR, 10 (83.3%) returned to play at the WNBA level at a mean (±SD) of 12.5 ± 3.3 months. Four players participated in only 1 WNBA season after injury. There were no differences in characteristics between the 10 players who returned to play after injury and the control group. After return to play, the WNBA players demonstrated a significant decrease in game utilization compared with preinjury, playing in 6.0 ± 6.9 fewer games, starting in 12.7 ± 15.4 fewer games, and playing 10.2 ± 9.1 fewer minutes per game ( P < .05 for all). After the index date of injury, the players with Achilles repair played 2.1 ± 1.2 more years in the WNBA, while control players played 5.35 ± 3.2 years ( P < .01) Additionally, the players with Achilles repair had a significant decrease in PER in the year after injury compared with preinjury (7.1 ± 5.3 vs 11.0 ± 4.4; P = .02). The reduction in game utilization and decrease in PER in these players was maintained when compared with the matched controls ( P < .05 for both)., Conclusion: The majority of WNBA players who sustained ATR were able to return to sport after their injury; however, their career longevity was shorter than that of healthy controls. There was a significant decrease in game utilization and performance in the year after return to play compared with healthy controls., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.A.K. has received education payments from Pinnacle and hospitality payments from DJO and Exactech. K.R.O. has received educational support from Medwest (Arthrex) and Smith & Nephew and hospitality payments from Medical Device Business Services, Stryker, Wright Medical, and Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Purpose: To determine the relation between medial elbow torque, as measured by wearable sensor technology, and adaptations of the medial elbow structures on dynamic ultrasound imaging in asymptomatic collegiate pitchers., Methods: Thirty-four pitchers from National Collegiate Athletic Association Division II universities were eligible for preseason testing. The exclusion criteria included age younger than 18 years, history of surgery, non-pitcher, or current restrictions. Pitchers were fitted with a wearable sensor sleeve that recorded elbow torque, arm slot, arm speed, and arm rotation. Pitchers threw 5 fastballs in a standardized manner off the mound at game-speed effort. They also underwent dynamic ultrasound imaging of the elbow by a musculoskeletal sonographer, with standardized valgus loading. Images were deidentified, and measurements of the ulnar collateral ligament (UCL) and ulnohumeral joint space (UHJS), to assess elbow laxity, were performed by a musculoskeletal radiologist., Results: The final analysis included 28 pitchers with an average age of 20.1 years (standard deviation, 1.3 years; range, 18-23 years) and playing experience of 15.3 years (standard deviation, 1.8 years; range, 11-19 years). The dominant UCL thickness (P < .001), loaded UHJS (P = .039), and delta UHJS (P < .001) were significantly greater than the nondominant measurements. An inverse correlation was found between loaded UHJS and medial elbow torque (r = -0.4, P < .001). Additionally, every 1-mm increase in UHJS significantly reduced medial elbow torque by 2.27 Nm (P = .032) and arm slot by 8.8° (P = .019) and increased arm rotation by 5.3° (P = .043). Pitchers with a loaded UHJS of 4.4 mm or greater and delta UHJS of 1.25 mm or greater had significantly reduced medial elbow torque (P < .001). Pitchers with a UCL thickness of 1.65 mm or greater had significantly increased medial elbow torque (47.4 Nm vs 44.8 Nm, P = .006)., Conclusions: Pitchers with increased dynamic elbow laxity were found to experience reduced medial elbow torque while pitching. Additionally, pitchers with greater UCL thickness on ultrasound were found to experience increased medial elbow torque while pitching. This study's findings suggest a relation between anatomic adaptations found on ultrasound of the pitching elbow and medial elbow torque., Level of Evidence: Level II, prospective cohort study., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Humeral avulsion of the glenohumeral ligament (HAGL) lesions can lead to persistent shoulder instability. While rare, HAGL lesions may present as a concomitant injury following shoulder dislocation events. Traditionally, an open approach has been used to repair the inferior glenohumeral ligament and restore shoulder stability. Modern arthroscopic techniques and instrumentation have permitted a minimally invasive approach for treating HAGL lesions. While technically demanding, arthroscopic repair of HAGL lesions has demonstrated favorable outcomes with less soft-tissue disruption. The following Technical Note describes a safe and effective method for the arthroscopic repair of HAGL lesions. Our technique highlights the use of the lateral decubitus position, a 70° arthroscope, a curved anchor device, and a 90° SutureLasso device., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Background: National Basketball Association (NBA) players who return to sport (RTS) after Achilles tendon rupture have been reported to have poor outcomes., Purpose: To evaluate the effect of Achilles tendon ruptures on player performance and career longevity in NBA athletes., Study Design: Cohort study; Level of evidence, 3., Methods: NBA players who sustained Achilles tendon ruptures between 1970 and 2019 were identified using publicly available resources and were matched 1:1 to a healthy control group by age, position, height, and body mass index. Demographic characteristics, player utilization (games and minutes), and performance efficiency rating (PER) were documented for all athletes. The season of Achilles tendon rupture was set as the index year, and statistical analysis compared postindex versus preindex data both acutely and in the long term. Percentages relative to preoperative values were calculated to compare the injured and control groups in a standardized fashion., Results: Of 47 players, 34 (72.3%) with Achilles tendon ruptures returned to play at the NBA level after surgical intervention. A total of 7 players were excluded from the study. No differences were found in demographic characteristics or PER (2 years before injury) between the remaining 27 players and matched controls. The injured players had significantly shorter careers compared with control players (3.1 ± 2.3 vs 5.8 ± 3.5 seasons, respectively; P < .05). Injured players demonstrated significant declines in games per season (GPS), minutes per game (MPG), and PER at 1 year and 3 years after RTS compared with preindex baseline ( P < .05). Injured players, compared with control players, had reduced relative percentages of games started (GS) (50% vs 125%, respectively), MPG (83% vs 103%), and PER (80% vs 96%) at 1 year after return ( P < .05), but reductions at extended 3-year follow-up were seen only in GPS (71% vs 91%) and GS (39% vs 99%) ( P < .05)., Conclusion: Our study found that 72.3% of NBA players returned to play after Achilles tendon repair, but they had shorter careers compared with uninjured controls. Players returning from Achilles tendon repairs had decreased game utilization and performance at all time points relative to their individual preindex baseline. However, for the injured players when compared with controls, game utilization but not performance was found to be decreased at 3-year follow-up., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: T.R.J. has received educational support from DePuy Synthes and hospitality payments from Zimmer Biomet. N.M. has received educational support from Arthrex and Smith & Nephew and grant support from Arthrex and Linvatec. K.R.O. has received educational support from Arthrex and Smith & Nephew and hospitality payments from Medical Device Business Services, Stryker, Wright Medical, and Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Orthopaedic surgeons functioning as team physicians are in a unique position to recognize subtle changes in an athlete's behavior and may be the first responders to concussions at sporting events. The rate of sports-related concussions has increased over the past few decades, necessitating that orthopaedic team physicians gain a greater understanding of the diagnosis and management of this condition. During the sideline evaluation, life-threatening injuries must be ruled out before concussion evaluation may take place. In most cases, patients experience a resolution of symptoms within a week; however, a smaller subset of patients experience persistent symptoms. Physicians covering sporting events must remain current regarding recommendations for treating sports-related concussions and must document their management plan to minimize potential harm to an athlete.

Arthroscopic shoulder stabilization offers a safe and effective means for restoring glenohumeral mechanics in the setting of shoulder instability. Modern arthroscopic techniques have allowed improved access and efficiency when treating patients with shoulder instability. However, access to certain areas of the labrum and the creation of safe accessory portals can still prove difficult for the arthroscopic surgeon. Currently, there is debate as to the ideal patient position, portal location, equipment, and technique for addressing anterior-inferior labral pathology. The following article presents a safe and effective approach to accessing the labrum for treatment of shoulder instability in the lateral decubitus position. In addition, this paper highlights the use of accessory portals, including a percutaneous "7-o'clock" portal for suture anchor placement, along with multiple types of suture anchor and suture shuttling techniques., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Background: The incidence of anterior cruciate ligament (ACL) injuries in Women's National Basketball Association (WNBA) athletes continues to increase. There is a paucity of data regarding return-to-play (RTP) rates and performance after ACL reconstruction in these athletes., Purpose: To quantify RTP rates and performance after ACL reconstruction in WNBA athletes., Study Design: Cohort study; Level of evidence, 3., Methods: All ACL tears sustained in the WNBA from 1997 through 2018 were identified. Body mass index (BMI), age, and position at the time of injury were collected for each player. RTP rates were calculated, and performance data were collected for each player before and after injury to determine changes in playing time and statistical performance. Players who successfully returned to play after ACL reconstruction were compared with a group of healthy controls who were matched by age, years of experience, position, height, and BMI. Statistics at 1 and 3 years after injury were compared to assess acute and longitudinal changes in performance relative to preinjury baseline., Results: A total of 59 WNBA players sustained ACL tears during the study period, and 41 (69.5%) were able to successfully RTP. Players played a mean of 7.5 ± 12.8 fewer games, played 5.0 ± 9.2 fewer minutes per game, and scored 3.7 ± 5.0 fewer points per game in their first year after RTP compared with the year before injury. Athletes with ACL reconstruction demonstrated significantly decreased performance measures regarding games played, games started, minutes, rebounds, assists, and blocks per game in their first season after RTP compared with control athletes in the same indexed year; however, these differences resolved by year 3 after surgery., Conclusion: WNBA athletes have a high RTP rate after ACL reconstruction. Players may experience an initial decrease in playing time and performance when returning to play; however, these variables were found to return to baseline over time., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: N.M. has received grant support from Arthrex and Linvatec and educational support from Arthrex and Smith & Nephew. K.R.O. has received educational support from Medwest Associates (Arthrex) and Smith & Nephew and hospitality payments from Medical Device Business Systems, Stryker, Wright Medical, and Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Purpose: To determine the correlation between preoperative and postoperative opioid use in patients undergoing arthroscopic shoulder labral repair, as well as patient risk factors associated with increased postoperative opioid use after the procedure., Methods: A retrospective review of all patients undergoing arthroscopic shoulder labral surgery at a single institution between August 2013 and November 2017 was performed. Patients were stratified as opioid nonusers, acute users, or chronic users based on preoperative consumption. Patient demographic characteristics, injury characteristics, surgical interventions, and postoperative opioid use for the first 12 months after surgery were then analyzed., Results: A total of 340 patients were included in this study. The average age was 26.3 years (range, 13-68 years), and the average body mass index was 27.5 (range, 18.4-45.0). Preoperative opioid users (acute and chronic) were found to continue to receive opioid medications at extended time points beyond 2 months postoperatively compared with nonusers (P < .001). Patients with intraoperatively identified SLAP tears experienced more preoperative pain and required more postoperative opioid prescriptions (P = .018). On stratification for other common shoulder instability injury patterns, no differences were found between the number of postoperative opioid prescriptions filled and the presence of Bankart lesion, Hill-Sachs lesion, reverse Hill-Sachs lesion, anterior labroligamentous periosteal sleeve avulsion, glenolabral articular disruption, or humeral avulsion of the glenohumeral ligament (P > .05)., Conclusions: In patients undergoing arthroscopic labral surgery, the chronicity of preoperative opioid use, number of concomitant procedures at the time of initial surgery, and presence of biceps tenodesis were found to significantly increase postoperative opioid demand. Orthopaedic surgeons should recognize risk factors for increased opioid use postoperatively and adapt treatment strategies and patient counseling accordingly., Level of Evidence: Level III, retrospective cohort study., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: This cohort study was designed to determine the discrepancy between the quantity of opioid prescribed vs that which was consumed after total knee arthroplasty (TKA) and total hip arthroplasty (THA) in opioid-naive patients., Methods: Seven hundred twenty-three opioid-naive patients (426 TKAs and 297 THAs) from 7 hospitals in Michigan were contacted within 3 months of their surgery. Opioid prescribing and self-reported consumption was calculated in oral morphine equivalents (OMEs). Secondary outcomes included opioid refill in the first 90 days, pain in the first 7 days post-operatively, and satisfaction with pain care., Results: For TKA, the mean prescribing was 632 mg OME (±229), and the mean consumption was 416 mg (±279). For THA, the mean prescribing was 584 mg OME (±335), and the mean consumption was 285 mg (±301). There were no associations between the amount of opioid prescribed and the likelihood of refill, post-operative pain, or satisfaction with pain control. The amount of opioid prescribed was associated with increased consumption, such that each increase of 1 pill was associated with approximately an additional half pill consumed after adjusting for other covariates. Moreover, 48.2% felt that they received "More" or "Much more" opioid than they needed., Conclusion: We recommend no more than 50 tablets of 5 mg oxycodone or its equivalent after TKA and 30 tablets after THA. Although dose reductions in other surgeries have not resulted in harm, continued assessment is needed to ensure that there are no unintended effects of opioid reduction, including worsened pain, decreased satisfaction, emergency department visits, or hospital readmissions., Level of Evidence: Level III; Retrospective, cohort study., (Copyright © 2019. Published by Elsevier Inc.)

Background: As the incidence of overuse injuries to the medial elbow in overhead athletes continues to rise, recent evidence suggests a link between these injuries and alterations in biomechanics produced by athlete fatigue. Previous studies have evaluated the effect of fatigue on elbow injuries using a wide array of fatigue protocols/athletic tasks, and, as a consequence, the results have been heterogeneous., Purpose: To determine whether there is a uniform alteration in neuromuscular function or biomechanics as the overhead athlete fatigues. Furthermore, this study sought to determine whether player fatigue should be accounted for in ulnar collateral ligament (UCL) injury prevention programs., Study Design: Systematic review., Methods: A systematic review of the literature using PubMed and MEDLINE databases was performed. Keywords included fatigue , upper extremity , baseball , pitcher , throwing , and muscle activity . Inclusion criteria consisted of original research articles in the English language involving healthy athletes, use of fatigue protocols, and the evaluation of at least 1 upper limb biomechanical variable., Results: A total of 35 studies involving 644 athletes (90 females, 554 males; mean age, 20.2 years) met the inclusion criteria. General fatigue protocols were used in 2 investigations, peripheral protocols were used in all 35 studies, and 5 different athletic tasks were studied (simulated baseball game, overhead throwing, high-effort swimming, simulated tennis game, and overhead serving). There was a uniform decrease in muscle force production and proprioception in athletes after completing a fatigue protocol. However, there was no consistency among studies when evaluating other important upper limb biomechanical factors. The fatigue protocols did not consistently produce statistically significant changes in elbow torque, pitching biomechanics, or ball velocity., Conclusion: A uniform decrease in muscle force production and proprioception was found after fatigue protocols; however, a majority of fatigue protocols published in the current literature are inconsistently measured and produce heterogeneous results. Therefore, currently, no recommendations can be made for changes in UCL injury prevention training programs to account for potential effects of fatigue. The effect of muscle force production and proprioception on upper extremity injuries should be evaluated in future studies., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: T.R.J. has received educational support from DePuy/Medical Device Business Services and hospitality payments from Zimmer Biomet. K.R.O. has received educational support from Smith & Nephew and Medwest and hospitality payments from Stryker and Wright Medical. J.C. has received educational support from Smith & Nephew and Arthrex. V.M. has received educational support from Arthrex and Pinnacle and hospitality payments from Stryker and Smith & Nephew. N.V. has received consulting fees from Smith & Nephew, Medacta, and Arthrex; nonconsulting fees from Pacira and Arthrex; educational support from Medwest; and royalties from Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2019.)

Background: Recent studies of patients with rotator cuff tears have demonstrated improved efficiency with Patient-Reported Outcomes Measurement Information System (PROMIS) when compared with traditional patient-reported outcome measures (PROM). However, these studies have been cross-sectional in nature and the responsiveness of PROMIS computer adaptive test (CAT) forms has not been evaluated. The purpose of this study was to determine the responsiveness of PROMIS CAT assessments in patients undergoing arthroscopic rotator cuff repair., Methods: All patients undergoing arthroscopic rotator cuff repair by one of 3 fellowship-trained surgeons were included in the study. PROMIS CAT upper extremity physical function ("PROMIS-UE"), pain interference ("PROMIS-PI"), and depression ("PROMIS-D") scores from preoperative and 6-month postoperative visits were collected and analyzed. Patient-centric demographic factors, tear size, and biceps involvement were also correlated to preoperative and postoperative PROMIS scores., Results: A total of 101 patients were enrolled in the study. The average age was 59.8 ± 8.9 years with 51 males (50.5%). Preoperative PROMIS-UE, PROMIS-PI, and PROMIS-D CAT scores improved significantly from 29.8 ± 6.0, 62.6 ± 5.1, and 48.4 ± 8.7, respectively, to 40.9 ± 9.8, 51.2 ± 9.3, and 42.9 ± 9.0, respectively, at 6-month follow-up (P < .001). Preoperative correlations were found between PROMIS-UE and PROMIS-PI scores (P < .001) and between PROMIS-PI and PROMIS-D scores (P = .001). No significant correlation was found between PROMIS-UE and PROMIS-D scores (P = .08), preoperatively. Preoperative PROMIS-UE, PROMIS-PI, or PROMIS-D scores were not correlated with rotator cuff tear size (P = .4)., Conclusion: PROMIS CAT forms demonstrate responsiveness in patients undergoing arthroscopic rotator cuff repair across numerous domains., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To examine the relation between the Patient-Reported Outcomes Measurement Information System (PROMIS) domains of Pain Interference (PROMIS-PI), Depression (PROMIS-D), and Physical Function (PROMIS-PF) for nonoperative patients presenting to our ambulatory sports orthopaedic clinic with knee complaints and to determine whether patient demographic characteristics influence PROMIS scores, particularly tobacco use., Methods: All patients treated nonoperatively for a primary complaint of knee pain were recruited for participation. Patients were included if they completed all 3 PROMIS questionnaires prior to their clinical evaluation. Patients were excluded if their treatment plan determined that surgical intervention was warranted. Survey results were compiled, and statistical correlations were run between PROMIS domains and patient demographic characteristics., Results: A total of 527 PROMIS questionnaire sets were included. PROMIS-PF had a strong negative correlation with PROMIS-PI (R = -0.75, P < .001) and a nearly moderate negative correlation with PROMIS-D (R = -0.47, P < .001). When evaluating patient demographic characteristics, we found a significant decrease in physical function scores and increases in pain and depression scores in both current and former tobacco users compared with nonsmokers. Differences in all PROMIS domains between smokers and nonsmokers exceeded minimal clinically important differences., Conclusions: Our study showed an inverse correlation between PROMIS-PI and PROMIS-PF, as well as between PROMIS-D and PROMIS-PI, in patients seen in the ambulatory setting for knee complaints treated nonoperatively. A positive correlation was found between PROMIS-PI and PROMIS-D. Tobacco use was a patient demographic factor found to significantly impact PROMIS scores leading to minimal clinically important differences across all 3 PROMIS domains. The findings of this study may be used to identify patients at high risk of poor outcomes., Level of Evidence: Level III, observational study., (Copyright © 2019. Published by Elsevier Inc.)

Hypothesis: Our hypothesis was that seasonal adaptive changes in the ulnar collateral ligament (UCL), ulnohumeral joint space (UHJS), and glenohumeral internal rotation deficit (GIRD) of the pitching extremity would subsequently resolve with off-season rest., Methods: Eleven collegiate pitchers underwent preseason, postseason, and off-season evaluations including physical examination; dynamic ultrasound imaging of the UCL and UHJS; and the short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Ultrasound images were evaluated by 2 fellowship-trained musculoskeletal radiologists., Results: All 11 pitchers were included in the final analysis, with an average age of 20.1 years and with 14.1 years of playing experience. After a season of pitching, we found significant increases in GIRD ( P  = .004) and UCL thickness ( P  = .033) and nonsignificant increases in both unloaded ( P  = .069) and loaded ( P  = .122) UHJS. Preseason GIRD correlated with this increase in loaded UHJS ( r  = 0.80, P  = .003). The increase in UCL thickness was significantly greater in pitchers with GIRD greater than 10° ( P < .05). After the off-season, UCL thickness returned to baseline and significant decreases were noted in both unloaded ( P  = .004) and loaded ( P  = .041) UHJS, but a progression in GIRD was found ( P  = .021). Pitchers with GIRD of 10° or less showed greater improvement in UHJS after the off-season ( P < .05)., Conclusions: The pitching season produced adaptive changes in the throwing elbow that subsequently resolved after off-season rest. However, shoulder range-of-motion deficits were progressive and did not resolve. Ultrasound adaptations of the pitching elbow were significantly related to GIRD.

Ultrasonography (US) is an inexpensive, convenient, and effective tool that can be used to evaluate the shoulder. It does not expose the patient to harmful radiation and can be used to evaluate the musculoskeletal system dynamically. Additionally, US is not subject to metal artifacts when evaluating patients with previously placed hardware. Over the years, US has been found to be reliable and accurate for diagnosing rotator cuff tears (RCTs), despite its operatordependence. The usage of US for diagnosing RCTs in orthopedic practice varies depending on practitioners' familiarity with the exam and the availability of experienced technicians. The purpose of this article is to review the diagnostic accuracy of US for identifying RCTs.

Purpose: To determine whether the length of time between primary anterior cruciate ligament reconstruction (ACLR) and return to sport (RTS) predicted the need for revision ACLR in National Football League (NFL) athletes., Methods: All NFL players who underwent ACLR from 2009 to 2015 were identified. The date of index ACLR and date of return to NFL regular-season game play after surgery were recorded. The length of time between ACLR and RTS was compared between players who required revision ACLR and those who did not. Correlation coefficients were used to assess whether players who RTS sooner sustained recurrent anterior cruciate ligament injury at an earlier date., Results: A total of 130 NFL players (average age, 25.3 ± 3.2 years) who underwent ACLR and returned to sport were identified. The average time to RTS after ACLR was 49.7 weeks after surgery. Of the players, 23 (18%) required revision ACLR. There was no significant difference in the length of time between ACLR and RTS in players who did not require revision ACLR (50.2 ± 10.1 weeks) and those who did (48.3 ± 11.0 weeks, P = .40). Time to RTS was not found to correlate with time to reinjury in athletes requiring revision ACLR (R = 0.21; 95% confidence interval, -0.18 to 0.54). A large proportion of players (56%) sustained a reinjury within the first 10 weeks of returning to NFL game play., Conclusions: Our study found that timing of RTS after ACLR was not a significant risk factor for revision surgery in NFL athletes. Time to RTS was also not shown to correlate with time to reinjury., Level of Evidence: Level III, case-control study., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: A proposed mechanism for recurrent instability following anterior cruciate ligament (ACL) reconstruction is failure of the anterolateral ligament (ALL). Presently, there are a number of approaches to treating ALL pathology., Purpose: To determine practice patterns among orthopaedic surgeons regarding ALL during ACL reconstruction., Study Design: Cross-sectional study., Methods: An online 7-question survey was sent to all physicians registered with the American Orthopaedic Society for Sports Medicine between June and July 2017. Results were analyzed with the survey website., Results: Overall, 225 of 3467 surgeons responded to the survey, 86 of whom performed ALL reconstruction and completed each question in the survey. Eighty-six (38.2%) surgeons who responded to the questionnaire stated that they perform ALL reconstruction/lateral extra-articular tenodesis in conjunction with ACL reconstruction. The most common indications for ALL reconstruction were grade III pivot-shift test (46.0%) on physical examination and revision ACL reconstruction (46.0%). The most common technique used to perform ALL reconstruction was hamstring autograft (48.2%). The majority of participating surgeons (87.5%) stated that they do not make any alterations to their postoperative rehabilitation protocol after they perform ALL reconstruction. In addition, most surgeons responding to the survey (91.3%) anticipated either an increase in or the same number of ALL procedures performed in the coming year., Conclusion: The majority of surgeons who responded to the survey did not routinely reconstruct the ALL. Revision procedures and grade III pivot shift were the most cited indications for performing lateral augmentation. Anatomic reconstruction with hamstring was the most commonly used procedure, although there was no consensus among surgeons responding to the survey. Understanding the ALL and its contribution to knee stability is essential. For a community of physicians, it is useful to discover how fellow sports orthopaedic surgeons address ALL pathology to integrate effective and efficient treatment strategies into practice., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: T.R.J. has received educational support and hospitality payments from DePuy. E.C.M. has received educational support from Smith & Nephew and Pinnacle and hospitality payments from Stryker. T.L. has received educational support from Arthrex and Pinnacle. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Femoroacetabular impingement (FAI) is a major cause of performance inhibition in elite-level athletes. The condition is characterized by pain, osseous abnormalities such as an increased alpha angle, and decreased range of motion at the affected hip joint. Arthroscopic surgical decompression is useful in reshaping the joint to alleviate symptoms. Functional kinematic outcomes of sport-specific movements after surgery, however, are presently unknown., Hypothesis: The ability of an ice hockey goaltender to execute sport-specific movements would improve after arthroscopic surgery., Study Design: Clinical research., Level of Evidence: Level 5., Methods: An ice hockey goaltender was evaluated after arthroscopic correction of FAI on the symptomatic hip. Passive range of motion and radiographic parameters were assessed from a computed tomography-derived 3-dimensional model. An on-ice motion capture system was also used to determine peak femoral shock and concurrent hip joint postures during the butterfly and braking movements., Results: Maximum alpha angles were 47° in the surgical and 61° in the nonsurgical hip. Internal rotation range of motion was, on average, 23° greater in the surgically corrected hip compared with contralateral. Peak shock was lower in the surgical hip by 1.39 g and 0.86 g during butterfly and braking, respectively. At peak shock, the surgical hip demonstrated increased flexion, adduction, and internal rotation for both tasks (butterfly, 6.1°, 12.3°, and 30.8°; braking, 14.8°, 19.2°, and 41.4°)., Conclusion: On-ice motion capture revealed performance differences between hips after arthroscopic surgery in a hockey goaltender. Range of motion and the patient's subjective assessment of hip function were improved in the surgical hip. While presenting as asymptomatic, it was discovered that the contralateral hip displayed measurements consistent with FAI. Therefore, consideration of preemptive treatment in a presently painless hip may be deemed beneficial for young athletes seeking a long career in sport, and future work is needed to determine the costs and benefits of such an approach., Clinical Relevance: Surgical treatment of symptomatic FAI can achieve pain relief and improved kinematics of the hip joint with athletic activities. Additional studies are necessary to determine whether improved kinematics enhance the longevity of the native hip and alter the progression of osteoarthritic changes in those with asymptomatic FAI deformity., (© 2015 The Author(s).)