Revision Arthroscopic Bankart Repair Results in High Failure Rates and a Low Return to Duty Rate Without Recurrent Instability.

PURPOSE: The purpose of this study was to determine, in a military population without critical bone loss, the rate of recurrent instability after revision arthroscopic stabilization for failed primary arthroscopic Bankart repair. METHODS: Forty-one revision arthroscopic stabilizations were performed at a single military institution between 2005 to 2016 for recurrent anterior shoulder instability after primary arthroscopic Bankart repair. Minimum follow-up was 2 years, and shoulders with glenoid bone loss >20% were excluded. The primary outcome of interest was the incidence of failure, defined by recurrent instability. RESULTS: Age at revision surgery averaged 22.9 ± 4.3 years, and 88% were either service academy cadets or active duty combat arms soldiers. Mean follow-up was 7.8 years. Twenty-three patients (56%) returned to duty without recurrent instability after revision arthroscopic stabilization. Eighteen patients (44%) experienced recurrent instability after return to duty. Glenoid bone loss averaged 6.2% (95% confidence interval [CI], 3.2%-9.2%) in the successful group and 5.7% (95% CI, 3.1%-8.3%) in the failure group (P = .808). CONCLUSIONS: Revision arthroscopic stabilization of failed primary arthroscopic Bankart repair has a failure rate of 44% in a young military population. The similar amounts of bone loss between groups indicates that bone loss is not the primary determinant of failure in revision arthroscopic stabilization. LEVEL OF EVIDENCE: IV, Case Series.

Recurrent Instability and Surgery Are Common After Nonoperative Treatment of Posterior Glenohumeral Instability in NCAA Division I FBS Football Players.

BACKGROUND: In-season return to play after anterior glenohumeral instability is associated with high rates of recurrent instability and the need for surgical stabilization. We are not aware of previous studies that have investigated in-season return to play after posterior glenohumeral instability; furthermore, as posterior shoulder instability in collision athletes occurs frequently, understanding the expected outcome of in-season athletes may improve the ability of physicians to provide athletes with a better understanding of the expected outcome of their injury and their ability to return to sport. QUESTIONS/PURPOSES: (1) What proportion of athletes returned to play during the season after posterior instability in collegiate football players? (2) How much time did athletes lose to injury, what proportion of athletes opted to undergo surgery, and what proportion of athletes experienced recurrent instability after a posterior instability episode during a collegiate football season? METHODS: A multicenter, prospective, observational study of National Collegiate Athletic Association (NCAA) Division 1 Football Bowl Subdivision athletes was performed at three US Military Service Academies. Ten athletes who sustained a posterior instability event during the regular football season and who pursued a course of nonoperative treatment were identified and prospectively observed through the subsequent season. All athletes in the observed cohort attempted an initial course of nonoperative treatment during the season. All athletes sustained subluxation events initially identified through history and physical examination at the time of injury. None of the athletes sustained a dislocation event requiring a manual reduction. Intraarticular pathology consisting of posterior labral pathology was further subsequently identified in all subjects via MRI arthrogram. Return to play was the primary outcome of interest. Time lost to injury, surgical intervention, and subsequent instability were secondary outcomes. RESULTS: Of the 10 athletes who opted for a trial of initial nonoperative management, seven athletes were able to return to play during the same season. Although these seven athletes returned within 1 week of their injury (median of 1 day), 5 of 7 athletes sustained recurrent subluxation events with a median (range) of four subluxation events per athlete (0 to 8) during the remainder of the season. Seven athletes were treated surgically after the completion of their season, four of whom returned to football. CONCLUSION: This study suggests that although collegiate football players are able to return to in-season sport after a posterior glenohumeral instability event, they will likely sustain multiple recurrent instability events and undergo surgery after the season is completed. The results of this study can help guide in-season management of posterior shoulder instability by allowing more appropriate postinjury counseling and decision making through the identification of those athletes who may require additional attention from medical staff during the season and possible modifications to training regimens to minimize long-term disability. Further prospective studies involving a larger cohort over several seasons should be performed through collaborative studies across the NCAA that better assess function and injury risk factors before beginning collegiate athletics. This would better characterize the natural history and associated functional limitations that athletes may encounter during their collegiate careers. LEVEL OF EVIDENCE: Level IV, prognostic study.

Adaptive management as a foundational framework for developing collaborative estuary management programs.

Collaborative nonregulatory programs can benefit the long-term sustainability of environmental resources. Such programs benefit from extensive planning and assessment relative to ecological systems as well as public participation. While many programs use adaptive management as a guiding programmatic framework, few programs successfully integrate social and human context into their adaptive management frameworks. While this adaptive governance framework can be successful, many potential challenges arise when incorporating public stakeholders into the adaptive management framework. To reduce those challenges, programs need participation from diverse stakeholder groups that represent multiple communities of interest, place, and identity. The participatory process benefits from a diverse group of stakeholders and can result in successful management of environmental resources. We highlight the participatory co-management process of three newly developing nonregulatory programs that are modeled after the United States EPA's National Estuary Program in the Perdido and Pensacola Bay systems, Choctawhatchee Bay, and the St. Andrew and St. Joseph Bay systems (Florida USA). This case study illustrates how collaborative nonregulatory programs can be implemented not only in the United States, but also in other regions of the world.

Likelihood of Return to Duty Is Low After Meniscal Allograft Transplantation in an Active-duty Military Population.

BACKGROUND: Meniscal allograft transplantation (MAT) is considered a viable surgical treatment option in the symptomatic, postmeniscectomy knee and as a concomitant procedure with ACL revision and articular cartilage repair. Although promising outcomes have recently been reported in active and athletic populations, MAT has not been well-studied in the high-demand military population. QUESTIONS/PURPOSES: (1) What proportion of active-duty military patients who underwent MAT returned to full, unrestricted duty? (2) What demographic and surgical variables, if any, correlated with return to full, unrestricted duty? METHODS: Between 2005 and 2015, three fellowship-trained sports surgeons (TMD, SJS, BDO) performed 110 MAT procedures in active-duty military patients, of which 95% (104 patients) were available for follow-up at a minimum 2 years (mean 2.8 ± SD 1.1 year). During the study period, indications for MAT generally included unicompartmental pain and swelling in a postmeniscectomized knee and as a concomitant procedure when a meniscal-deficient compartment was associated with either an ACL revision reconstruction or cartilage repair. Demographic and surgical variables were collected and analyzed. The primary endpoints were the decision for permanent profile activity restrictions and military duty termination by a medical board. The term "medical board" implies termination of military service because of medical reasons. We elected to set statistical significance at p < 0.001 to reduce the potential for spurious statistical findings in the setting of a relatively small sample size. RESULTS: Forty-six percent (48 of 104) of eligible patients had permanent profile activity restrictions and 50% (52 of 104) eventually had their military duty terminated by a military board. Only 20% (21 of 104) had neither permanent profile activity restrictions nor medical-board termination and were subsequently able to return to full duty, and only 13% (13 of 104) continued unrestricted military service beyond 2 years after surgery. Age, gender, tobacco use, and BMI did not correlate with return to full duty. Combat arms soldiers were less likely to have permanent profile activity restrictions (odds ratio 4.76 [95% confidence interval 1.93 to 11.8]; p = 0.001) and were more likely to return to full duty than soldiers in support roles (OR 0.24 [95% CI 0.09 to 0.65]; p = 0.005), although these findings did not reach statistical significance. Officers were more likely to return to full duty than enlisted soldiers at more than 2 years after surgery (OR 17.44 [95% CI 4.56 to 66.65]; p < 0.001). No surgical variables correlated with return-to-duty endpoints. CONCLUSIONS: Surgeons should be aware of the low likelihood of return to military duty at more than 2 years after MAT and counsel patients accordingly. Based on this study, MAT does not appear to be compatible with continued unrestricted military duty for most patients. LEVEL OF EVIDENCE: IV, therapeutic study.

Integrated polarizer based on 45° tilted gratings.

We report the first integrated implementation of a polarizer based on the use of 45° tilted gratings in planar waveguides. The waveguides and gratings are fabricated by direct UV writing in a hydrogenated germanium-doped silica-on-silicon chip. We experimentally demonstrate a polarization extinction ratio per unit length of 0.25 dB mm -1 with a modelled wavelength dependence smaller than 0.3 dB for a 20 mm device over the C band from 1530-1570 nm. We also present a novel numerical study and analytical description of the architecture that are in good agreement with each other and the experimental data.

High-birefringence direct UV-written waveguides for use as heralded single-photon sources at telecommunication wavelengths.

Direct UV-written waveguides are fabricated in silica-on-silicon with birefringence of (4.9 ± 0.2) × 10-4, much greater than previously reported in this platform. We show that these waveguides are suitable for the generation of heralded single photons at telecommunication wavelengths by spontaneous four-wave mixing. A pulsed pump field at 1060 nm generates pairs of photons in highly detuned, spectrally uncorrelated modes near 1550 nm and 800 nm. Waveguide-to-fiber coupling efficiencies of 78-91 % are achieved for all fields. Waveguide birefringence is controlled through dopant concentration of GeCl4 and BCl3 using the flame hydrolysis deposition process. The technology provides a route towards the scalability of silica-on-silicon integrated components for photonic quantum experiments.

Wideband and continuously-tunable fractional photonic Hilbert transformer based on a single high-birefringence planar Bragg grating.

We propose and experimentally demonstrate wideband and continuously tunable fractional-order photonic Hilbert transformers (FrHT). These are realized by a single apodized planar Bragg grating within a high-birefringence planar substrate. The fractional order of the FrHT is continuously tuned and precisely controlled by changing the polarization state of the input light. The experimental characterization demonstrates an operating bandwidth up to 120 GHz with amplitude ripples below 3 dB. The optical phase shift response is directly measured to verify the proposed tuning property, demonstrating transform orders of around 1, 0.7, and 0.5. This approach is simple, stable, and compact compared to other existing methods and has great potential in the fields of ultrafast all-optical signal processing.

Gait outcomes of patients with severe slipped capital femoral epiphysis after treatment by flexion-rotation osteotomy.

BACKGROUND: Flexion-rotational osteotomy of the proximal femur is an accepted intervention in the management of severe deformity and femoral acetabular impingement secondary to slipped capital femoral epiphysis (SCFE). The impact of this surgical intervention on gait kinematics and kinetics, validated functional questionnaires, and patient outcomes has not been well studied. The purpose of this study was to analyze the changes in standard gait parameters of patients with moderate to severe SCFE who were treated with a flexion-rotational osteotomy. METHODS: This study is a retrospective review of 8 patients treated for a unilateral moderate and severe SCFE with a flexion-rotational osteotomy. All patients had 3-D computerized gait analysis studies completed preoperatively and 1-year postoperatively. Additional data analyzed preoperatively and postoperatively included: anterior/posterior hip radiographs, standard physical examination measures, and Pediatric Outcomes Data Collection Instrument (PODCI), completed by parents. RESULTS: The Gait Deviation Index, a composite of gait kinematics, showed a significant improvement from 64.9 to 88.0 (P<0.001). Radiographically, significant improvement toward normal values were found in the epiphyseal-shaft angle on the AP view from 123 to 139 degrees (P=0.005) and on the frog lateral view from 61 to 16 degrees (P=0.00001). Hip abduction range of motion on physical examination increased from 15 to 27 degrees and hip external rotation decreased from 51 to 25 degrees after surgery (P<0.05). The PODCI significantly improved in the categories of basic mobility, sports function, and global function (P<0.05). CONCLUSIONS: Longstanding deformity as a result of a severe SCFE may lead to osteoarthritis of the hip, disabling pain, and functional deficits. Although radiographic evidence of degenerative disease may take years to develop, changes in gait parameters can be immediately evident in this population. A flexion-rotation osteotomy in the adolescent and young adult population can improve gait kinematics, radiographic measures, range of motion, and short-term functional outcome scores. It is felt that normalization of these parameters may reduce the risk of long-term hip deterioration and its related sequelae. LEVEL OF EVIDENCE: Level IV.

Arthroscopic Anatomic Knotless Coracoclavicular Ligament Repair Without Coracoid Drilling.

Acromioclavicular joint injuries are common in young active patients. A wide variety of surgical techniques exist to address specific complications associated with surgery. Complications after surgery include loss of reduction, fracture of the clavicle or coracoid, failure of fixation, and prominent and symptomatic hardware. This technique aims to reduce these complications with an arthroscopic anatomic coracoclavicular ligament repair using knotless adjustable loop buttons with fifth-generation suture tape and no drilling of the coracoid.

Subcortical Backup Tibial Fixation in Anterior Cruciate Ligament Reconstruction Has Similar Maximal Strength to Current Techniques.

Purpose: To evaluate the biomechanical profile of subcortical backup fixation (subcortical button [SB]) in anterior cruciate ligament (ACL) reconstruction as compared with a bicortical post and washer (BP) and suture anchor (SA) when used with interference screw (IS) primary fixation and to evaluate the utility of backup fixation for tibial fixation with extramedullary cortical button primary fixation. Methods: Fifty composite tibias with polyester webbing-simulated graft were used to test constructs across 10 methods. Specimens were separated into the following groups (n = 5): 9-mm IS only, BP (with and without graft and IS), SB (with and without graft and IS), SA (with and without graft and IS), extramedullary suture button (with and without graft and IS), and extramedullary suture button with BP as backup fixation. Specimens were tested under cyclic loading and then loaded to failure. Maximal load at failure, displacement, and stiffness were compared. Results: Without a graft, the SB and BP had similar maximal loads (802.46 ± 185.18 N vs 785.67 ± 100.96 N, P = .560), and both were stronger than the SA (368.13 ± 77.26 N, P < .001). With graft and an IS, there was no significant difference in maximal load between the BP (1,461.27 ± 173.75 N), SB (1,362.46 ± 80.47 N), and SA (1,334.52 ± 195.80 N). All backup fixation groups were stronger than the control group with IS fixation only (932.91 ± 99.86 N, P < .001). There was no significant difference in outcome measures between the extramedullary suture button groups with and without the BP (failure loads of 721.39 ± 103.32 N and 718.15 ± 108.61 N, respectively). Conclusions: Subcortical backup fixation in ACL reconstruction has similar biomechanical properties to current methods and is a viable backup fixation alternative. Backup fixation methods work synergistically with IS primary fixation to strengthen the construct. There is no advantage to adding backup fixation to extramedullary button (all-inside) primary fixation when all suture strands are secured to the extramedullary button. Clinical Relevance: This study provides evidence that subcortical backup fixation is a viable alternative for surgeons during ACL reconstruction.

Influence of Graft Type on Lower Extremity Functional Test Performance and Failure Rate After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Both autografts and allografts are used to reconstruct the anterior cruciate ligament (ACL) after injury; however, it is unclear whether graft source affects lower extremity functional test performance or failure rate in an active military population. OBJECTIVE: To compare lower extremity functional test performance and graft failure rates between ACL grafts [allograft, hamstring, bone-patellar tendon-bone (BTB)]. STUDY DESIGN: Cross-sectional. LEVEL OF EVIDENCE: Level 2. METHODS: Ninety-eight cadets entering a US Service Academy with a history of unilateral ACL reconstruction (ACLR) agreed to participate. Before basic training, participants completed 4 lower extremity functional tests. Active injury surveillance was conducted within the study cohort to identify all subsequent graft failures. RESULTS: Cadets with hamstring autografts outperformed the BTB and allograft groups on the Lower Quarter Y-Balance Test-Posteromedial direction and single-leg hop test, respectively. No differences were detected by graft type for the other functional tests. The incidence of subsequent ipsilateral graft failures in patients with autograft was 8.11%. No failures were observed in the allograft group during the follow-up period. After controlling for sex, joint hypermobility, and time since injury and surgery, the risk of graft failure was 9.8 times higher for patients with a hamstring autograft than with a BTB (P = 0.045). CONCLUSION: After ACLR, graft type appears to influence some single-limb measures of lower extremity function and the risk of subsequent failure. Hamstring autografts demonstrated better functional performance but increased risk of graft failure. CLINICAL RELEVANCE: Surgeons need to weigh the pros and cons of all graft options in relation to the patient's lifestyle. Regardless of graft type, individuals with an ACLR may require additional rehabilitation to regain neuromuscular control during dynamic single-limb tasks and mitigate graft failure.

Risk of Upper Extremity Musculoskeletal Injury Within the First Year After a Concussion.

Background: Emerging evidence suggests that athletes and military personnel are at increased risk for lower extremity musculoskeletal injury after a concussion; however, the association between concussion and subsequent upper extremity (UE) musculoskeletal injury is unknown. Purpose: To prospectively examine the association between concussion and UE musculoskeletal injury risk within the first year after returning to unrestricted activity. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 316 cases of concussion 42% (132/316 women) were observed among 5660 Concussion Assessment, Research and Education Consortium participants at the United States Military Academy from May 2015 to June 2018. Active injury surveillance within the cohort was conducted for 12 months after unrestricted return to activity to identify any incident cases of acute UE musculoskeletal injury. Injury surveillance during the follow-up period was also conducted for nonconcussed controls who were matched by sex and competitive sport level. Univariate and multivariable Cox proportional hazards regression models were used to estimate hazard ratios between concussed cases and nonconcussed controls for time to UE musculoskeletal injury. Results: During the surveillance period, 19.3% of concussed cases and 9.2% of nonconcussed controls sustained a UE injury. In the univariate model, concussed cases were 2.25 times (95% CI, 1.45-3.51) more likely to sustain a UE injury during the 12-month follow-up period when compared with the nonconcussed controls. In the multivariable model, adjusted for history of concussion, sport level, somatization, and history of UE injury, concussed cases were 1.84 times (95% CI, 1.10-3.07) more likely to sustain a UE injury during the surveillance period compared with nonconcussed controls. Sport level remained an independent risk factor for UE musculoskeletal injury; however, concussion history, somatization, and history of UE injury were not independent risk factors. Conclusion: Concussed cases were more than twice as likely to sustain an acute UE musculoskeletal injury within the first 12 months after unrestricted return to activity when compared with nonconcussed controls. The higher hazard of injury remained in the concussed group after adjusting for other potential risk factors.

Beach-Chair Versus Lateral Decubitus Positioning for Primary Arthroscopic Anterior Shoulder Stabilization: A Consecutive Series of 641 Shoulders.

BACKGROUND: There are limited data comparing the beach-chair (BC) versus lateral decubitus (LD) position for arthroscopic anterior shoulder stabilization. PURPOSE: To identify predictors of instability recurrence and revision after anterior shoulder stabilization and evaluate surgical position and glenoid bone loss as independent predictors of recurrence and revision at short- and midterm follow-ups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A consecutive series of 641 arthroscopic anterior stabilization procedures were performed from 2005 to 2019. All shoulders were evaluated for glenohumeral bone loss on magnetic resonance imaging. The primary outcomes of interest were recurrence and revision. Multivariable logistic regression models were used to assess the relationships of outcomes with age, position, glenoid bone loss group, and track. RESULTS: A total of 641 shoulders with a mean age of 22.3 years (SD, 4.45 years) underwent stabilization and were followed for a mean of 6 years. The overall 1-year recurrent instability rate was 3.3% (21/641) and the revision rate was 2.8% (18/641). At 1 year, recurrence was observed in 2.3% (11/487) and 6.5% (10/154) of BC and LD shoulders, respectively. The 5-year recurrence and revision rates were 15.7% (60/383) and 12.8% (49/383), respectively. At 5 years, recurrence was observed in 16.4% (48/293) and 13.3% (12/90) of BC and LD shoulders, respectively. Multivariable modeling demonstrated that surgical position was not associated with a risk of recurrence after 1 year (odds ratio [OR] for LD vs BC, 1.39; P = .56) and 5 years (OR for LD vs BC, 1.32; P = .43), although younger age at index surgery was associated with a higher risk of instability recurrence (OR, 1.73 per SD [4.1 years] decrease in age; P < .03). After 1 and 5 years, surgical position results were similar in a separate multivariable logistic regression model of revision surgery as the dependent variable, when adjusted for age, surgical position, bone loss group, and track. At 5 years, younger age was an independent risk factor for revision: OR 1.68 per SD (4.1 years) decrease in age (P < .05). CONCLUSION: Among fellowship-trained orthopaedic surgeons, there was no difference in rates of recurrence and revision surgery after performing arthroscopic anterior stabilization in either the BC or the LD position at 1- and 5-year follow-ups. In multivariable analysis, younger age, but not surgical position, was an independent risk factor for recurrence.

All-Inside Tibial Tunnel Drilling: How to Calculate a Safe Drilling Length to Avoid Anterior Cortex Violation.

The all-inside technique for bone tunnel drilling during ligament reconstruction procedures (ACL, PCL etc.) is gaining popularity as a bone preserving, less invasive technique with the potential for more rapid recovery. To preserve the advantages of closed-socket tunnels, it is essential not to violate the cortex during retro-drilling. The risk of cortical breach is higher with the tibial tunnel compared to the femoral one due to the obliquity of the tunnel relative to the cortex. Our purpose is to introduce a trigonometric formula, which allows the surgeon to calculate the safe tibial tunnel drilling length during all-inside ligament reconstruction and explain its proof.

Subcortical Backup Fixation in ACL Reconstruction.

Anterior cruciate ligament (ACL) injuries result in knee instability in a majority of patients. Repair and reconstruction techniques have continually evolved over the past several decades. ACL reconstruction outcomes are directly impacted by physical therapy with early range of motion, weightbearing, and progressive strengthening. Therefore, the fixation must be sufficient to withstand the tensile and shear stresses across the graft construct during the biological healing phase. Occasionally, the primary fixation device is not strong enough to withstand these stresses. In turn, supplementary fixation devices, which are important especially in cases of revision ACL reconstruction, are imperfect. They occasionally become symptomatic, requiring hardware removal. Posts and washers require bicortical fixation, with moderate-sized holes in the tibia. Biocomposite screws rely on friction in the bone-screw interface, making them susceptible to failure. Tensioning can be problematic with the use of a post-and-washer construct. Subcortical fixation, which has not previously been described as a backup fixation method, provides several advantages. It requires a smaller, unicortical hole and provides fixation with a much lower profile than post-and-washer and interference-screw constructs. This is the first description of subcortical backup fixation in ACL reconstruction.

Concomitant Glenohumeral Instability and Rotator Cuff Injury: An Epidemiologic and Case-Control Analysis in Military Cadets.

INTRODUCTION: Concomitant rotator cuff tear and glenohumeral instability in a large cohort of young and active patients has not been examined. The purpose of this study was to investigate the incidence, associated variables, and outcomes in military cadets undergoing shoulder stabilization procedures with these concomitant pathologies. METHODS: A retrospective cohort study of a consecutive series of collegiate patients who underwent shoulder stabilization from 2014 to 2018 at a single service academy was conducted. Exclusion criteria were noncadets, revision instability cases, multidirectional instability, and prior rotator cuff repair. A nested case-control analysis was done in a matched series of patients with and without MRI evidence of rotator cuff tear. Baseline demographics, VAS pain scale, physical therapy duration, and time to surgery were analyzed. Postoperative metrics included rate of recurrent instability, subjective outcomes, VAS pain scale, and military-specific criteria. RESULTS: Three hundred twenty-four cadets met the inclusion criteria, including 272 men and 52 women averaging 20.53 ± 1.80 years of age. MRI demonstrated concomitant rotator cuff tears in 5.56% of cases. A matched case-control comparison between patients with (rotator cuff tear group) and without (no rotator cuff tear group) rotator cuff tear showed no differences in preoperative data, recurrent instability rate, or postoperative VAS pain scores (0.24 versus 0.88, P = 0.207) at mean 44-month follow-up. Fifteen of 17 patients (88.2%) in each group returned to full activity (P > 0.999). No patients failed to graduate due to shoulder concerns. No patients in the rotator cuff tear group underwent a medical board for separation from the military compared with 2 (11.8%) in the no rotator cuff tear group (P = 0.163). CONCLUSIONS: The incidence of concomitant rotator cuff tears in this study of military cadets undergoing shoulder stabilization was 5.56%. In a matched cohort comparison, the presence of a rotator cuff tear on preoperative MRI was not associated with inferior clinical outcomes.

Heterotopic Ossification After Arthroscopic Procedures: A Scoping Review of the Literature.

BACKGROUND: Heterotopic ossification (HO) is the formation of bone in soft tissue resultant from inflammatory processes. Lesion formation after arthroscopic procedures is an uncommon but challenging complication. Optimal prophylaxis and management strategies have not been clearly defined. PURPOSE: To present a scoping review of the pathophysiology, risk factors, diagnostic modalities, prophylaxis recommendations, and current treatment practices concerning HO after arthroscopic management of orthopaedic injuries. STUDY DESIGN: Scoping review; Level of evidence, 4. METHODS: A scoping review via a PubMed search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The search strategy was based on the terms "heterotopic ossification" AND "arthroscopy." The clinical outcomes review included studies on the arthroscopic management of orthopaedic injuries in which the primary subject matter or a secondary outcome was the development of HO. An analysis of the pathophysiology, diagnostic modalities, and management options was reported. RESULTS: A total of 43 studies (33,065 patients) reported on HO after hip arthroscopy, while 21 (83 patients) collectively reported on HO after arthroscopic procedures to the shoulder, elbow, knee, or ankle; however, management techniques were not standardized. Identified risk factors for HO included male sex and mixed impingement pathology, while intraoperative capsular management was not suggested as a contributing factor. Diagnosis of ossification foci was performed using radiography and computed tomography. The rate of HO after hip arthroscopy procedures approached 46% without prophylaxis, and administration of nonsteroidal anti-inflammatory drugs (NSAIDs) decreased occurrence rates to 4% but carries associated risks. External beam radiation has not been exclusively studied for use after arthroscopic procedures. CONCLUSION: HO is a known complication after arthroscopic management of orthopaedic injuries. NSAID prophylaxis has been demonstrated to be effective after hip arthroscopy procedures. Patients with persistent symptoms and mature lesions may be indicated for surgical excision, although variability is present in patient-reported outcome scores postoperatively.

Automated Landing Error Scoring System Performance and the Risk of Bone Stress Injury in Military Trainees.

CONTEXT: Lower extremity bone stress injuries (BSIs) place a significant burden on the health and readiness of the US Armed Forces. OBJECTIVE: To determine if preinjury baseline performance on an expanded and automated 22-item version of the Landing Error Scoring System (LESS-22) was associated with the incidence of BSIs in a military training population. DESIGN: Prospective cohort study. SETTING: US Military Academy at West Point, NY. PATIENTS OR OTHER PARTICIPANTS: A total of 2235 incoming cadets (510 females [22.8%]). MAIN OUTCOME MEASURE(S): Multivariable Poisson regression models were used to produce adjusted incidence rate ratios (IRRs) to quantify the association between preinjury LESS scores and BSI incidence rate during follow-up and were adjusted for pertinent risk factors. Risk factors were included as covariates in the final model if the 95% CI for the crude IRR did not contain 1.00. RESULTS: A total of 54 BSIs occurred during the study period, resulting in an overall incidence rate of 0.07 BSI per 1000 person-days (95% CI = 0.05, 0.09). The mean number of exposure days was 345.4 ± 61.12 (range = 3-368 days). The final model was adjusted for sex and body mass index and yielded an adjusted IRR for a LESS-22 score of 1.06 (95% CI = 1.002, 1.13; P = .04), indicating that each additional LESS error documented at baseline was associated with a 6.0% increase in the incidence rate of BSI during the follow-up period. In addition, 6 individual LESS-22 items, including 2 newly added items, were significantly associated with the BSI incidence. CONCLUSIONS: We provided evidence that performance on the expanded and automated version of the LESS was associated with the BSI incidence in a military training population. The automated LESS-22 may be a scalable solution for screening military training populations for BSI risk.

Prospective Evaluation of Posterior Glenoid Bone Loss After First-time and Recurrent Posterior Glenohumeral Instability Events.

BACKGROUND: Although posterior glenohumeral instability is becoming an increasingly recognized cause of shoulder pain, the role of posterior glenoid bone loss on outcomes remains incompletely understood. PURPOSES: To prospectively determine the amount of bone loss associated with posterior instability events and to determine predisposing factors based on preinstability imaging. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 1428 shoulders were evaluated prospectively for ≥4 years. At baseline, a subjective history of shoulder instability was ascertained for each patient, and bilateral noncontrast magnetic resonance imaging (MRI) scans of the shoulders were obtained regardless of any reported history of shoulder instability. The cohort was prospectively followed during the study period, and those who were diagnosed with posterior glenohumeral instability were identified. Postinjury MRI scans were obtained and compared with the screening MRI scans. Glenoid version, perfect-circle-based bone loss was measured for each patient's pre- and postinjury MRI scans using previously described methods. RESULTS: Of the 1428 shoulders that were prospectively followed, 10 shoulders sustained a first-time posterior instability event and 3 shoulders sustained a recurrent posterior instability event. At baseline, 11 of 13 shoulders had some amount of glenoid dysplasia and/or bone loss. The change in glenoid bone loss was 5.4% along the axis of greatest loss (95% CI, 3.8%-7.0%; P = .009), 4.4% at the glenoid equator (95% CI, 2.7%-6.2%; P = .016), and 4.2% of total glenoid area (95% CI, 2.9%-5.3%; P = .002). Recurrent glenoid instability was associated with a greater amount of absolute bone loss along the axis of greatest loss compared with first-time instability (recurrent: 16.8% ± 1.1%; 95% CI, 14.6%-18.9%; first-time: 10.0% ± 1.5%; 95% CI, 7.0%-13.0%; P = .005). Baseline glenoid retroversion ≥10° was associated with a significantly greater percentage of bone loss along the axis of greatest loss (≥10° of retroversion: 13.5% ± 2.0%; 95% CI, 9.6%-17.4%; <10° of retroversion: 8.5% ± 0.8%; 95% CI, 7.0%-10.0%; P = .045). CONCLUSIONS: Posterior glenohumeral instability events were associated with glenoid bone loss of 5%. The amount of glenoid bone loss after a recurrent posterior glenohumeral instability event was greater than that after first-time instability. Glenoid retroversion ≥10° was associated with a greater amount of posterior glenoid bone loss after a posterior instability event.

The Military Orthopedics Tracking Injuries and Outcomes Network: A Solution for Improving Musculoskeletal Care in the Military Health System.

INTRODUCTION: Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense's Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care. MATERIALS AND METHODS: MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management. RESULTS: This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report. CONCLUSIONS: MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency's Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.