Successful Outcomes and Return to Sport After Arthroscopic Bankart Repair in National Collegiate Athletic Association and National Football League Football Players.

OBJECTIVE: To characterize recurrent instability, return to sport (RTS), and patient-reported outcomes (PROs) after arthroscopic Bankart repair for acute traumatic anterior shoulder instability in National Collegiate Athletic Association (NCAA) and National Football League (NFL) football players. DESIGN: Case series. SETTING: Orthopaedic and sports medicine clinic. PARTICIPANTS: National Collegiate Athletic Association and NFL football athletes with traumatic anterior shoulder instability who underwent arthroscopic shoulder stabilization at a single institution with at least 2-year follow-up. INTERVENTIONS OR ASSESSMENT OF RISK FACTORS OR INDEPENDENT VARIABLES: Arthroscopic Bankart repair. MAIN OUTCOME MEASURES: Recurrent instability, RTS, patient satisfaction, the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, and Rowe score. RESULTS: Thirty-three players were included with a mean age of 23.8 years (range, 18-33 years) and a mean follow-up of 6.3 years (range, 4.1-9.3 years). One shoulder (3.0%) had a postoperative subluxation event, and 1 shoulder (3.0%) required revision surgery for issues other than instability; 93.3% of players were able to RTS at the same level or higher for at least 1 season. Mean satisfaction was 8.9 ± 2.3. Mean VAS was 1.0 ± 1.7, and mean ASES and Rowe scores were 90.7 ± 18.5 and 89.7 ± 15.2, respectively. CONCLUSION: Arthroscopic Bankart repair is an effective surgical intervention for traumatic anterior shoulder instability in NCAA and NFL football players. At a mean 6-year follow-up, surgery restored stability in 97% of cases and 93.3% returned to their preinjury level of sport.

Biceps Tendon Changes and Pitching Mechanics in Youth Softball Pitchers.

With the lack of pitch count regulation, youth softball pitchers are experiencing unremitting high stresses on the anterior shoulder. The purpose of this study was to examine the association of acute changes in the long head of the biceps tendon with pitching kinematics and kinetics in youth softball pitchers following an acute bout of pitching. Twenty-three softball pitchers (12.17±1.50 yrs.; 160.32±9.41 cm; 60.40±15.97 kg) participated. To investigate the association between biceps tendon changes and kinematic and kinetic changes from pre- to post-simulated game, each biceps tendon measure was split into those whose biceps tendon thickness, width, and/or area increased pre- to post-simulated game, and those whose did not. There were significant differences in biceps tendon longitudinal thickness (Z=- 2.739, p=0.006) and pitch speed; as well as a difference between groups in biceps tendon transverse thickness and the amount of change in trunk rotation at the start of the pitching motion (p=0.017) and the amount of change in trunk flexion at ball release (p=0.030). This study illustrates the association of trunk and lower extremity kinematics and shoulder kinetics with morphologic changes in the biceps tendon with an acute bout of windmill softball pitching.

Clinical Outcome After Lateral Ulnar Collateral Ligament Reconstruction in an Adolescent Baseball Player: A Case Report.

Lateral ulnar collateral ligament (LUCL) reconstruction is a commonly used surgical procedure to treat posterolateral rotatory instability (PLRI) of the elbow. We report a 17-year-old right-handed pitcher with symptomatic PLRI after an injury to his LUCL during a baseball game. Having failed 8 months of conservative treatment, a LUCL reconstruction using the modified O'Driscoll technique was performed with the contralateral gracilis autograft. At 5-year follow-up, an excellent patient-reported outcome was achieved and the patient continued to play baseball at the recreational level. This type of injury is rarely reported in adolescent baseball players, and improving our knowledge of the long-term outcomes is crucial to assist clinicians in counseling patients about expectations after surgery.

Effects of a Simulated Game on Upper Extremity Pitching Mechanics and Muscle Activations Among Various Pitch Types in Youth Baseball Pitchers.

BACKGROUND: Throwing requires proper stability and orientation of the pelvis and scapula for efficient energy transfer during pitching. Fatigue of the pelvis and scapular musculature throughout the course of a game can impair pitching performance, and place excessive demands on the throwing arm leading to injury. The purpose of this study was to examine differences in pelvis, torso, and upper extremity pitching mechanics and muscle activations between the fastball, change-up, and curveball pitches in youth baseball pitchers following a simulated game. METHODS: Fourteen youth baseball pitchers with no history of injury participated. Pitching mechanics were collected using an electromagnetic tracking system. Surface electromyography data were collected on the bilateral gluteus medius and maximus; and throwing arm side latissimus dorsi, lower trapezius, upper trapezius, and serratus anterior. Participants were instructed to throw maximum effort pitches during a simulated game that provided random game situations similar to those that occur in competition. Participants were limited to 85 pitches based on age-restricted pitch counts. Data from 3 fastballs, curveballs, and change-ups thrown in the first and last innings were selected for analysis. RESULTS: Repeated measures multivariate analyses of variance revealed that neither pitch type nor the effect of a simulated game resulted in statistically significant changes in pitching mechanics (F(10,600)=0.55, P=0.85), or muscle activations (pelvic: F(4,195)=0.07, P=0.85; scapular: F(4,118)=0.09, P=0.52). CONCLUSIONS: The principle findings of this study revealed that pitching to the age-restricted pitch count limit did not result in altered pitching mechanics or muscle activations, and no differences occurred between the 3 pitches. These results support previous research that indicate the curveball pitch is no more dangerous for youth than the other pitches commonly thrown. This is supported by the pitcher's ability to maintain a proper arm slot during all 3 pitches and indicates that they are obtaining the spin on the ball from their grip and not by altering upper extremity mechanics. LEVEL OF EVIDENCE: Level 5.

Variability of Outcome Reporting Following Arthroscopic Bankart Repair in Adolescent Athletes: A Systematic Review.

PURPOSE: To conduct a systematic review of the literature to assess the variability of the reporting of outcome measures after arthroscopic Bankart repair for traumatic anterior shoulder instability in the adolescent population. METHODS: A systematic review was conducted investigating all studies reporting outcomes after arthroscopic Bankart repair in the adolescent population. Four databases (Medline, EMBASE, Ovid, and Google Scholar) were screened for clinical studies involving the arthroscopic management of anterior shoulder instability in adolescents. A full-text review of eligible studies was conducted. Inclusion and exclusion criteria were applied to the searched studies. A quality assessment was completed for each included study using the Methodological Index for Nonrandomized Studies instrument and the Center for Evidence-Based Medicine's Levels of Evidence Scale. RESULTS: We identified 8 eligible studies involving 274 patients (282 shoulders). There was considerable variation with regard to reported outcomes after arthroscopic Bankart repair for anterior shoulder instability in the adolescent population. The most common patient-reported outcomes included the Rowe Score (50%), Single Assessment Numeric Evaluation (37.5%), American Shoulder and Elbow Surgeons Shoulder Outcome Score (25%), and the Constant Score (25%). Clinical outcomes reported included recurrence (100%), return to sport (62.5%), patient satisfaction (37.5%), stability (37.5%), pain scores (37.5%), and range of motion (12.5%). CONCLUSIONS: There is considerable variation in reported clinical outcome measurements after arthroscopic Bankart repair for traumatic shoulder instability in the adolescent population. This study supports the need for standardized outcome reporting after arthroscopic anterior shoulder instability surgery in adolescents. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Minimizing Graft-Tunnel Mismatch in Allograft Anterior Cruciate Ligament Reconstruction Using Blumensaat's Line: A Cadaveric Study.

PURPOSE: To evaluate the accuracy of Blumensaat's line (BL) in predicting the tendinous graft length and tibial tunnel length (TTL) in an independent-tunnel anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BTB) allograft. METHODS: Eighteen ACLRs were performed on cadaveric specimens using an anteromedial portal technique. All knees had no previous surgeries or deformities. Lateral knee radiographs of each specimen were taken prior to the ACLR, and BL was measured. Length-specific allografts for the tendinous portion of the grafts were then ordered by adding 20 mm to the length of BL. The TTL was predicted by subtracting BL and femoral tunnel length (FTL) from the overall graft length. Graft-tunnel mismatch (GTM) was recorded for each specimen. Statistical analysis compared overall results with the gold standard (0 mm) of GTM. RESULTS: The average lateral femoral condyle width measured in line with the femoral tunnel was 33 ± 3.43 mm. The average FTL was 25 ± 0.54 mm. The average intra-articular distance (IAD) between femoral and tibial tunnel apertures was 31 ± 3.65 mm. The average TTL was 35 ± 2.21 mm. The difference between the predicted TTL and the actual TTL was not statistically significant (P = .3). The mean GTM was -0.9 ± 3.15 mm. There was no statistically significant difference between the BL method and the gold standard (P = .45). The mean percent difference between BL and the IAD was 5.2%. CONCLUSIONS: The BL method can accurately predict the desired length for the tendinous portion of a BTB allograft as well as the TTL, thereby potentially minimizing GTM during arthroscopic BTB allograft ACLR. Patient-specific allografts can be ordered preoperatively based on BL. CLINICAL RELEVANCE: This method provides the surgeon a way to avoid GTM preoperatively by ordering patient-specific grafts prior to performing an independent-tunnel BTB allograft ACLR.

Differences in Segmental Speeds as a Function of Maturation in Youth Baseball Pitchers.

The purpose of this study was to determine how stride length, segmental sequencing of the pelvis, trunk, humerus, and forearm velocities and accelerations, and the timing of these values change as youth mature. Thirteen youth baseball pitchers participated at three consecutive time points: visit 1 (10.7±1.3 years; 151.8±10.7 cm; 45.0±9.65 kg), visit 2 (11.5±1.6 years; 155.5±11.1 cm; 50.4±10.0 kg), and visit 3 (12.4±1.7 years; 161.5±11.7 cm; 56.4±10.8 kg). Participants executed three pitches for a strike to a catcher. The maximum value of stride length and segmental speeds and accelerations was recorded. The point at which these maximum values occurred during the throw was calculated as a percentage from hand separation to maximum internal rotation of the shoulder. Repeated measures ANOVAs and Friedman Tests revealed no statistically significant differences between stride length, segmental speeds and accelerations, and their percentage of the pitch between the three visits. However, there was a significant increase in ball velocity across visits. No significant changes occurred in pitching mechanics between the ages of 10-12. The authors speculate the lack of differences can be accounted for because these ages are prior to any significant pubescent changes. Future research should consider pre- and post- pubescent age groups.

A Biomechanical Comparison of Modified Krackow and Locking Loop Suture Patterns for Soft-Tissue Graft Fixation.

PURPOSE: The purpose of this ex vivo biomechanical study was to evaluate the tensile mechanical properties of 2 modified suture-graft constructs regarding elongation after pre-tensioning and cyclic loading as well as load to failure. METHODS: Thirty fresh-frozen porcine Achilles tendons were randomly divided into 2 groups of 15 specimens to assess elongation of the suture-graft construct across 2 different tendon-grasping techniques: a modified locking SpeedWhip (MLS) stitch and a modified Krackow (MK) stitch. Each tendon was pre-tensioned to 89 N for 10 minutes and then cyclically loaded to 200 N for 200 cycles. Finally, each tendon was loaded to failure. RESULTS: After being pre-tensioned, the MK group elongated significantly more than the MLS group (7.12 ± 0.95 mm v 6.26 ± 0.94 mm, P = .02). Elongation after cyclic loading for the MK and MLS groups was not significantly different (3.39 ± 0.95 mm and 3.21 ± 0.93 mm, respectively; P > .05). The MK group showed a significantly larger load to failure compared with the MLS group (689 ± 61 N v 604 ± 46 N, P = .000024). The mean tendon cross-sectional area was larger in the MK group (399 ± 5 mm(2)v 393 ± 8 mm(2), P = .02), but this difference did not relate to the amount of elongation or load to failure. All but 1 specimen failed by suture breakage at the square knot. CONCLUSIONS: The MLS and MK stitches, pre-tensioned to 89 N for 10 minutes, both effectively minimized suture-graft construct elongation after cyclic loading. Consequently, both suture patterns are recommended for soft-tissue graft fixation. CLINICAL RELEVANCE: The MLS and MK suture configurations may provide sufficient biomechanical fixation of the tendon graft in the clinical setting of soft-tissue fixation without an interference screw.

The Relationship Between Tibial Tubercle-Trochlear Groove Distance and Noncontact Anterior Cruciate Ligament Injuries in Adolescents and Young Adults.

PURPOSE: To determine differences in tibial tubercle-trochlear groove (TT-TG) distance between patients with a history of noncontact anterior cruciate ligament (ACL) injury and an uninjured control group. METHODS: MRI studies of 60 patients (age range, 14 to 25 years) with ACL-deficient (ACLD) knees were compared with 60 intact-ACL controls. All patients underwent MRI after a noncontact sports injury. TT-TG distances were measured on proton density-weighted axial images. Independent t-tests were used to determine differences in TT-TG distance between the ACLD and control groups. RESULTS: The mean TT-TG distance in the ACLD group was 12.07 mm (95% confidence interval [CI], 11.11 to 13.02), compared with 10.44 mm (95% CI, 9.64 to 11.24) in the control group. The mean TT-TG distance in the male ACLD group was 12.95 mm (95% CI, 11.39 to 14.51), compared with 10.87 mm (95% CI, 9.52 to 12.21) in the male control group. The mean TT-TG distance in the female ACLD group was 11.48 mm (95% CI, 10.24 to 12.71), compared with 10.04 mm (95% CI, 9.06 to 11.02) in the female control group. There were statistically significant differences in TT-TG distance between the ACLD and control groups (P = .011) and between the male ACLD and control groups (P = .041). CONCLUSIONS: In adolescents and young adults, the TT-TG distance was statistically larger in knees with noncontact ACL tears than in intact-ACL control knees. When the groups were stratified on the basis of sex, only the male patients showed a statistical difference, with a 2.08 mm increase in TT-TG distance between the ACLD and intact-ACL patients. No difference in TT-TG distance was found between the ACLD and control groups for female patients. Despite the findings of this study, the clinical significance of an increased TT-TG distance as an isolated risk factor for noncontact ACL injury remains unanswered. LEVEL OF EVIDENCE: Level III, case-control study.

Arthroscopic irrigation and debridement in the treatment of septic arthritis after anterior cruciate ligament reconstruction.

PURPOSE: To systematically review the literature and characterize the success and failure rates of arthroscopic irrigation and debridement (I & D) in the treatment of septic arthritis after anterior cruciate ligament (ACL) reconstructions. We also aimed to identify which variables affected the failure rate. METHODS: Five databases (MEDLINE, Ovid, Medscape, Web of Science, and Google Scholar) were screened for clinical studies involving the treatment of septic arthritis after ACL reconstruction with arthroscopic I & D. A full-text review of eligible studies was conducted. Inclusion and exclusion criteria were applied to the searched studies. Failure of I & D was defined as the need for graft removal or revision ACL reconstructive surgery because of infection. Data from the selected studies were combined for statistical analyses to elucidate factors associated with the success or failure. RESULTS: We identified 11 eligible studies involving 90 patients. These studies described the results of 90 arthroscopic I & D procedures with an overall success rate of 85.6%. Repeated I & D was necessary in 34.5% of patients. Removal of the graft with or without subsequent revision ACL reconstruction was reported in 13 (14.4%) cases. Statistical analysis showed that cases involving Staphylococcus aureus (P = .053), 2 or more I & D procedures (P = .029), and allografts (P < .0001) were at greater risk of failure. CONCLUSIONS: Arthroscopic I & D with graft retention is an effective treatment for patients with septic arthritis after ACL reconstruction. Factors affecting the failure rate may include graft choice and organism virulence. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Comparison of physical therapy utilization, timing of return-to-sport test completion, and hop test performance by age and between sexes in youth athletes after anterior cruciate ligament reconstruction.

OBJECTIVE: To compare physical therapy (PT) utilization, timing of return-to-sport (RTS) test and hop test performance by age and between sexes in youth after anterior cruciate ligament reconstruction (ACLR). DESIGN: Multicenter retrospective cohort. METHODS: A retrospective review of adolescents after primary ACLR was conducted. Participants completed return-to-sport (RTS) tests including single-legged hop testing. PT frequency, average weekly visits, and timing of RTS test were calculated. T-tests assessed the effect of age and sex on average weekly PT visits and multivariable logistic regressions assessed odds of passing hop tests. RESULTS: 289 participants were included (15.7 ± 1.9 years). There was no difference in average weekly PT visits (p = 0.321) or time to RTS test (p = 0.162) by age. There were significant differences in average weekly PT visits (p = 0.047) and mean time from surgery to RTS test (p = 0.048) between sexes with small effect sizes (d = 0.24 and d = 0.21, respectively). Age and sex had no effect on odds of passing hop tests (OR, 1.29; 95% CI, 0.71-2.35 and OR, 0.79; 95%CI, 0.43-1.45, respectively). CONCLUSION: In a youth cohort, age and sex may have no clinically important effect on PT visit utilization, timing of RTS test or hop test performance.

Ecological momentary assessment of sleep, pain, and opioid use among adolescents following surgery.

Background: Opioids are effective for acute pain management following surgery among adolescents, yet are associated with significant negative consequences, including respiratory depression and opioid misuse. Sleep deficiency is common following surgery and extant research indicates strong cross-sectional associations between sleep deficiency and increased problematic opioid use. Objective: This study examined longitudinal associations between postsurgical sleep deficiency and opioid use among adolescents undergoing outpatient surgery. We also examined daily pain and mood as mechanisms linking previous night's sleep deficiency and next day prescription opioid use. Methods: This prospective, observational study enrolled 106 adolescents (11-19 years) who underwent orthopedic outpatient surgery and collected pre-surgery and longitudinal measurements. Participants were 52% female, African-American (7%), American Indian/Alaska Native (7%), Hispanic (9%), Native Hawaiian or Other Pacific Islander (4%), or white, non-Hispanic (66%). Using ecological momentary assessment methods, participants reported sleep, pain, and mood in real time over the first 14 days following surgery. Postsurgical opioid use was measured using an electronic medication cap monitoring device, eCAPTM. Associations between variables were measured using multilevel structural equation modeling. Results: Using multi-level mediation models, pain, but not mood-mediated associations between postsurgical sleep deficiency (sleep quality, total sleep time, sleep onset latency, and wake after sleep onset) and opioid use, at both the within-person and between-person levels. Results highlight that greater previous night's sleep deficiency (both generally and greater than a person's mean level) was associated with higher next day pain (both generally and greater than a person's mean level), which, in turn, was associated with higher opioid use. Furthermore, between-person total effect models provide support for sleep deficiency predicting higher opioid use. Conclusions: Our findings should be considered preliminary yet underscore the need for a comprehensive and personalized approach to postsurgical pain management and opioid use, potentially implementing interventions targeting sleep quality and quantity to reduce pain and opioid use.

Effect of Age and Body Mass Index on Time to Advanced Imaging and Surgery in Young Athletes With Anterior Cruciate Ligament Injury.

Background: In young athletes with anterior cruciate ligament (ACL) injury, increased times from injury to magnetic resonance imaging (MRI) and injury to surgery can lead to the accrual of new injuries over time. Purpose: To determine the patient characteristics associated with differences in timing between injury, MRI, and surgery in young athletes with ACL tears. Study Design: Case-control study; Level of evidence, 3. Methods: We reviewed the electronic medical records of patients aged 13 to 25 years who underwent isolated primary ACL reconstruction between January 2017 and June 2020 at a single orthopaedic surgery department. The times from injury to MRI, MRI to surgery, and injury to surgery were documented. Patient demographic data (age, sex, body mass index [BMI], race and ethnicity, and insurance type) were recorded. Multivariable analysis was used to determine if any patient characteristic had a significant association with increased time to MRI or surgery. Results: A total of 369 patients (mean age, 18.0 years; 56% female) were included. Both age and BMI were found to be significantly associated with timing of care while holding all other predictors constant. For every 1-year increase in patient age, time from injury to MRI increased by 9.6 days (95% CI, 1.8-17.4 days; P = .02), time from MRI to surgery increased by 7.4 days (95% CI, 4.4-10.5 days; P < .001), and time from injury to surgery increased by 17.0 days (95% CI, 8.4-25.6 days; P < .001). Compared with patients with normal BMI, overweight patients (BMI range, 25-29.9 kg/m2) had an MRI-to-surgery time that was on average 37.2 days (95% CI, 11.7-62.7 days; P < .004) longer and an injury to surgery time that was on average 71.8 days (95% CI, 0.5-143.0 days; P = .048) longer. Obese patients (BMI ≥30 kg/m2) did not demonstrate a significant relationship with the studied time intervals. Conclusion: Increasing age and elevated BMI were found to be associated with increased time to MRI and surgical care in young athletes with ACL injuries.

MRI Features That Contribute to Decision-Making for Treatment of Capitellar OCD Lesions: An Expert Consensus Using the Delphi Method.

Background: Most healthcare providers utilize magnetic resonance imaging (MRI) to assist in diagnosing and treating osteochondritis dissecans (OCD) of the capitellum. However, consensus on imaging features that portend clinically relevant information in the care of these lesions has not been determined. Purpose: To conduct a survey on the MRI features of a capitellar OCD that are salient for clinical decision-making using a classic Delphi protocol. Study Design: A consensus statement. Methods: Invitations to participate were sent to 33 healthcare providers identified as capitellar OCD experts. A classic 3-round survey method was used to gather agreement and consensus on the level of importance for clinical decision-making on 33 MRI features. A concise list of features that guide decision-making on the stability of an OCD lesion and the ability of an OCD lesion to heal with nonoperative care was also identified. Agreement and consensus were determined a priori as ≥66%. Results: Of the 33 identified experts, 20 agreed to participate, and 17 (52%) completed all 3 rounds. Of the 33 MRI features evaluated, 17 reached agreement as important for clinical decision-making by the experts. Consensus was reached for a concise list of MRI features that were significant to decision-making (94%), suggestive of a stable lesion (100%), had the potential to heal with nonoperative treatment (94%), were suggestive of an unstable lesion (100%), and had low potential to heal with nonoperative treatment (88%). Conclusion: This 3-round Delphi process produced consensus on clinically relevant MRI features that contribute to clinical decision-making for capitellar OCD. The results of this study will be used as the basis for an interrater reliability assessment of the identified salient features, creating the foundation for developing a reliable MRI assessment tool rooted in clinical experiences. The development of a standardized assessment of capitellar OCD is intended to improve clinical practice and patient outcomes.

Minimal differences in acute postoperative pain after anterior cruciate ligament reconstruction with quadriceps versus hamstring autograft.

Studies are lacking that evaluate early postoperative pain after all-soft-tissue quadriceps tendon anterior cruciate ligament reconstruction (ACLR), particularly in young patients. The purpose of this study was to investigate differences in early postoperative pain between adolescent patients undergoing ACLR with quadriceps tendon versus hamstring autograft. A retrospective review was performed of 60 patients (mean age, 15.6 ± 1.3 years) who underwent ACLR using either quadriceps tendon (n = 31) or hamstring (n = 29) autografts between January 2017 and February 2020. Intraoperative and postoperative milligram morphine equivalents (MMEs), postanesthesia care unit (PACU) length of stay and PACU pain scores were recorded. Pain scores and supplemental oxycodone use were recorded on postoperative days (POD) 1-3. Differences were compared between the two groups. There were no statistically significant differences in age, sex, body mass index or concomitant meniscus repairs between the two groups (P > 0.05). There were no statistically significant differences in intraoperative MMEs, PACU MMEs or PACU length of stay between groups (P > 0.05). There were no statistically significant differences in maximum PACU pain scores (3.7 ± 3.0 vs. 3.8 ± 3.2; P = 0.89). Maximum pain scores on POD 1-3 were similar between groups (P > 0.05). There were no statistically significant differences in supplemental oxycodone doses between groups on POD 1-3 (P > 0.05). Adolescent patients undergoing ACLR with quadriceps tendon and hamstring autografts have similar pain levels and opioid use in the early postoperative period.

Effect of Increased Time to Surgery on the Ability of MRI to Rule Out Medial Meniscal Tears in Young Athletes With ACL Injury.

Background: The prevalence of meniscal tears in patients with anterior cruciate ligament (ACL) injury increases with extended time between injury and ACL reconstruction. Purpose/Hypothesis: The purpose of this study was to determine if there is a relationship between time from magnetic resonance imaging (MRI) to ACL reconstruction and the predictive value of MRI to diagnose meniscal tears in the young active population. It was hypothesized that increased time between MRI and ACL reconstruction would lead to a decrease in the negative predictive value of MRI in diagnosing meniscal tears, as more injuries may accrue over time in the ACL-deficient knee. Study Design: Case series; Level of evidence, 4. Methods: Included were patients aged 13 to 25 years at the authors' institution who underwent primary ACL reconstruction from January 2017 to June 2020. Time from MRI to surgery as well as descriptions of medial and lateral meniscal tears on both MRI and operative reports were documented. Time from MRI to surgery was divided into 4 intervals: 0 to 6 weeks, >6 weeks to 3 months, >3 to 6 months, and beyond 6 months. Multivariable analysis was used to determine the positive and negative predictive values of MRI in diagnosing a meniscal tear as compared with arthroscopic findings. Results: A total of 432 patients were included with a mean age of 17.9 ± 3.4 years. The mean time from MRI to surgery was 70.5 ± 98 days. There was a significant decrease in the negative predictive value of MRI to identify a medial meniscal tear in patients who underwent ACL reconstruction >6 months after imaging (odds ratio, 0.16 [95% CI, 0.05-0.53]; P = .003). This same relationship was not shown for lateral meniscal tears, nor was any other predictor significant. Conclusion: The utility of MRI to rule out a medial meniscal tear significantly diminished in the young athletic population when >6 months passed between MRI and ACL reconstruction. These data suggest these tears occur between the time of the MRI and surgery and that the medial meniscus is more susceptible than the lateral meniscus to new injury once the ACL has torn.

Effect of Delayed Anterior Cruciate Ligament Reconstruction on Repair of Concomitant Medial Meniscus Tears in Young Athletes.

BACKGROUND: Delayed anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with an increased risk of meniscal injury. Limited data are available regarding the relationship between surgical delay and meniscal repairability in the setting of ACLR in young patients. PURPOSE: To determine whether time from ACL injury to primary ACLR was associated with the incidence of medial and/or lateral meniscal repair in young athletes who underwent meniscal treatment at the time of ACLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Records were retrospectively reviewed for patients aged 13 to 25 years who underwent primary ACLR between January 2017 and June 2020 by surgeons from a single academic orthopaedic surgery department. Demographic data were collected, and operative reports were reviewed to document all concomitant pathologies and procedures. Univariable and multivariable logistic regression analyses were used to determine factors associated with meniscal repair, including time elapsed from ACL injury to surgery. RESULTS: Concomitant meniscal tears were identified and treated in 243 of 427 patients; their mean age was 17.9 ± 3.3 years, and approximately half (47.7%) of patients were female. There were 144 (59.3%) medial tears treated and 164 (67.5%) lateral tears treated; 65 (26.7%) patients had both medial and lateral tears treated. Median time from ACL injury to ACLR was 2.4 months (interquartile range, 1.4-4.7 months). Adjusted univariate analysis showed a statistically significant correlation between medial meniscal repair and time to surgery, with a 7% decreased incidence of medial meniscal repair per month elapsed between injury and surgery (odds ratio, 0.93 per month; 95% CI, 0.89-0.98; P = .006). No similar relationship was found between lateral meniscal repair and time to surgery (odds ratio, 1.02; 95% CI, 0.99-1.06; P = .24). CONCLUSION: In the setting of concomitant ACL and meniscal injuries, surgical delay decreased the incidence of medial meniscal repair in young athletes by 7% per month from time of injury.

Relationship Between Age and Pathology With Treatment of Pediatric and Adolescent Discoid Lateral Meniscus: A Report From the SCORE Multicenter Database.

BACKGROUND: Surgical treatment options of discoid lateral meniscus in pediatric patients consist of saucerization with or without meniscal repair, meniscocapular stabilization, and, less often, subtotal meniscectomy. PURPOSE: To describe a large, prospectively collected multicenter cohort of discoid menisci undergoing surgical intervention, and further investigate corresponding treatment of discoid menisci. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter quality improvement registry (16 institutions, 26 surgeons), Sports Cohort Outcomes Registry, was queried. Patient characteristics, discoid type, presence and type of intrasubstance meniscal tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Discoid meniscus characteristics were compared between age groups (<14 and >14 years old), based on receiver operating characteristic curve, and discoid morphology (complete and incomplete). RESULTS: In total, 274 patients were identified (mean age, 12.4 years; range, 3-18 years), of whom 55.6% had complete discoid. Meniscal repairs were performed in 55.1% of patients. Overall, 48.5% of patients had rim instability and 36.8% had >1 location of peripheral rim instability. Of the patients, 21.5% underwent meniscal debridement beyond saucerization, with 8.4% undergoing a subtotal meniscectomy. Patients <14 years of age were more likely to have a complete discoid meniscus (P < .001), peripheral rim instability (P = .005), and longitudinal tears (P = .015) and require a meniscal repair (P < .001). Patients ≥14 years of age were more likely to have a radial/oblique tear (P = .015) and require additional debridement beyond the physiologic rim (P = .003). Overall, 70% of patients <14 years of age were found to have a complete discoid meniscus necessitating saucerization, and >50% in this young age group required peripheral stabilization/repair. CONCLUSION: To preserve physiological "normal" meniscus, a repair may be indicated in >50% of patients <14 years of age but occurred in <50% of those >14 years. Additional resection beyond the physiological rim may be needed in 15% of younger patients and 30% of those aged >14 years.

Age, Sex, and BMI Differences Related to Repairable Meniscal Tears in Pediatric and Adolescent Patients.

BACKGROUND: The incidence of meniscus tears and ACL tears in pediatric patients continues to rise, bringing to question the risk factors associated with these injuries. As meniscus tears are commonly repaired in pediatric populations, the epidemiology of repairable meniscus tears is an important for consideration for surgeons evaluating treatment options. PURPOSE: To describe meniscal tear patterns in pediatric and adolescent patients who underwent meniscal repair across multiple institutions and surgeons, as well as to evaluate the relationship between age, sex, and body mass index (BMI) and their effect on the prevalence, type, and displacement of repaired pediatric meniscal tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data within a prospective multicenter cohort registry for quality improvement, Sport Cohort Outcome Registry (SCORE), were reviewed to describe repaired meniscal tear patterns. All consecutive arthroscopic meniscal repairs from participating surgeons in patients aged <19 years were analyzed. Tear pattern, location, and displacement were evaluated by patient age, sex, and BMI. A subanalysis was also performed to investigate whether meniscal tear patterns differed between those occurring in isolation or those occurring with a concomitant anterior cruciate ligament (ACL) injury. Analysis of variance was used to generate a multivariate analysis of specified variables. Sex, age, and BMI results were compared across the cohort. RESULTS: There were 1185 total meniscal repairs evaluated in as many patients, which included 656 (55.4%) male and 529 (44.6%) female patients. Patients underwent surgery at a mean age of 15.3 years (range, 5-19 years), with a mean BMI of 24.9 (range, 12.3-46.42). Of the 1185 patients, 816 (68.9%) had ACL + meniscal repair and 369 (31.1%) had isolated meniscal repair. The male patients underwent more lateral tear repairs than the female patients (54.3% to 40.9%; P < .001) and had a lower incidence of medial tear repair (32.1% vs 41.4%; P < .001). Patients with repaired lateral tears had a mean age of 15.0 years, compared with a mean age of 15.4 years for patients with repaired medial or bilateral tears (P = .001). Higher BMI was associated with "complex" and "radial" tear repairs of the lateral meniscus (P < .001) but was variable with regard to medial tear repairs. CONCLUSION: In pediatric and adolescent populations, the data suggest that the surgical team treating knees with potential meniscal injury should be prepared to encounter more complex meniscal tears, commonly indicated in those with higher BMI, while higher rates of lateral meniscal tears were seen in male and younger patients. Future studies should analyze correlates for meniscal repair survival and outcomes in this pediatric cohort undergoing knee surgery.

Biomechanics Related to Increased Softball Pitcher Shoulder Stress: Implications for Injury Prevention.

BACKGROUND: Softball pitchers exhibit high throwing shoulder distraction force, which is a theorized mechanism of throwing shoulder overuse injury. Windmill pitching involves a variety of highly individualistic pitching styles, and certain kinematics preceding ball release likely influence the amount of shoulder stress that a pitcher accrues. PURPOSE: To examine the association of trunk and throwing arm kinematics, kinetics, and timing variables with peak throwing shoulder distraction force in high school softball pitchers. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 37 high school pitchers (mean ± SD; height, 1.71 ± 0.06 m; weight, 75.53 ± 16.12 kg; age, 16 ± 2 years) threw 10 fastball pitches at regulation distance (43 ft [13.1 m]) and with maximum effort. Kinematic data were collected at 240 Hz using an electromagnetic motion capture system synced with motion analysis software. The 3 fastest pitches were averaged and analyzed. Kinematic, kinetic, and timing variables were entered into a stepwise linear regression analysis. RESULTS: Four variables were included in the significant model (F4,39 = 147.51; P < .001) and explained peak shoulder distraction force (R2 = 0.944; adjusted R2 = 0.938; SE = 0.036): increased peak elbow distraction force (t = 19.90; P < .001) and extension moment (t = 3.63; P = .001), as well as decreased elbow flexion velocity (t = -2.37; P = .023) and trunk flexion at foot contact of the pitch (t = -3.00; P = .005). CONCLUSION: Elbow kinetics and angular velocity, as well as trunk positioning at foot contact, are associated with peak throwing shoulder distraction force in high school softball pitchers. CLINICAL RELEVANCE: Variables associated with peak throwing shoulder distraction force provide information regarding injury mechanism and coachable cues that might reduce shoulder injury risk among pitchers.