High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review.

BACKGROUND: The Centers for Disease Control defines work-related musculoskeletal disorders as disorders of the nerves, muscles, tendons, joints, spinal discs, and cartilage that are caused or exacerbated by the environment or nature of work. Previous meta-analyses have characterized work-related musculoskeletal disorders among interventionists, general surgeons, and other surgical subspecialties, but prevalence estimates, prognosis, and ergonomic considerations vary by study and surgical specialty. QUESTIONS/PURPOSES: (1) What is the career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons? (2) What is the treatment prevalence associated with work-related musculoskeletal disorders in orthopaedic surgeons? (3) What is the disability burden of work-related musculoskeletal disorders in orthopaedic surgeons? (4) What is the scope of orthopaedic surgical ergonomic assessments and interventions? METHODS: A systematic review of English-language studies from PubMed, MEDLINE, Embase, and Scopus was performed in December 2022 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that presented prevalence estimates of work-related musculoskeletal disorders or assessed surgical ergonomics in orthopaedic surgery were included. Reviews, case reports, gray literature (conference abstracts and preprints), and studies with mixed-surgeon (nonorthopaedic) populations were excluded. The search yielded 5603 abstracts; 24 survey-based studies with 4876 orthopaedic surgeons (mean age 48 years; 79% of surgeons were men) were included for an analysis of work-related musculoskeletal disorders, and 18 articles were included for a descriptive synthesis of ergonomic assessment. Quality assessment using the Joanna Briggs Institute Tool revealed that studies had a low to moderate risk of bias, largely because of self-reporting survey-based methodology. Because of considerable heterogeneity and risk of bias, prevalence outcomes were not pooled and instead are presented as ranges (mean I 2 = 91.3%). RESULTS: The career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons ranged from 37% to 97%. By anatomic location, the prevalence of work-related musculoskeletal disorders in the head and neck ranged from 4% to 74%; back ranged from 9% to 77%; forearm, wrist, and hand ranged from 12% to 54%; elbow ranged from 3% to 28%; shoulder ranged from 3% to 34%; hip and thigh ranged from 1% to 10%; knee and lower leg ranged from 1% to 31%; and foot and ankle ranged from 4% to 25%. Of orthopaedic surgeons reporting work-related musculoskeletal disorders, 9% to 33% had a leave of absence, practice restriction or modification, or early retirement, and 27% to 83% received some form of treatment. Orthopaedic surgeons experienced biomechanical, cardiovascular, neuromuscular, and metabolic stress during procedures. Interventions to improve orthopaedic surgical ergonomics have been limited, but have included robotic assistance, proper visualization aids, appropriate use of power tools, and safely minimizing lead apron use. In hip and knee arthroplasty, robotic assistance was the most effective in improving posture and reducing caloric expenditure. In spine surgery, proper use of surgical loupes was the most effective in improving posture. CONCLUSION: Although the reported ranges of our main findings were wide, even on the low end of the reported ranges, work-related musculoskeletal disability among orthopaedic surgeons appears to be a substantial concern. We recommend that orthopaedic residency training programs incorporate surgical ergonomics or work injury lectures, workshops, and film review (alongside existing film review of surgical skills) into their curricula. We suggest hospitals engage in shared decision-making with surgeons through anonymous needs assessment surveys to implement wellness programs specific to surgeons' musculoskeletal needs. We urge institutions to assess surgeon ergonomics during routine quality assessment of novel surgical instruments and workflows. LEVEL OF EVIDENCE: Level III, prognostic study.

ChatGPT Responses to Common Questions About Anterior Cruciate Ligament Reconstruction Are Frequently Satisfactory.

PURPOSE: To evaluate ChatGPT responses to common questions patients have regarding anterior cruciate ligament (ACL) reconstruction. METHODS: Ten frequently asked questions regarding ACL tears and ACL reconstruction were chosen from the frequently asked questions found on the websites of major institutions. These were presented to ChatGPT and responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." RESULTS: Four responses were satisfactory, requiring minimal clarification, 3 were satisfactory, requiring moderate clarification, 2 were unsatisfactory, and 1 was excellent, requiring no clarification. CONCLUSIONS: As hypothesized, ChatGPT provided generally accurate information to common questions around ACL reconstruction. Although clarification often was needed, responses were satisfactory for providing generalized information about ACL tears and ACL reconstruction. CLINICAL RELEVANCE: ChatGPT is a promising avenue for patients to learn about general background information regarding ACL reconstruction, although questions specific to any planned operation need to be addressed directly with an orthopaedic provider.

Common characteristics of shoulder injury related to vaccine administration following COVID-19 vaccination: a comprehensive systematic review.

BACKGROUND: The pathogenesis of shoulder injury related to vaccine administration (SIRVA) is incompletely understood, but it is postulated to be an immune-mediated inflammatory response to a vaccine antigen, leading to shoulder pain and dysfunction. The purpose of this investigation is to systematically review the literature related to SIRVA specifically after the COVID-19 vaccination by describing the diagnostic and clinical characteristics, diagnoses associated with SIRVA, and incidence between vaccine types. METHODS: A systematic review was performed to identify level I to IV studies and case descriptions of shoulder pain occurring after COVID-19 vaccination. To confirm that no studies were missing from the systematic review, references of studies from the initial search were scanned for additional relevant studies. RESULTS: A total of 22 studies, comprised of 81 patients, were identified meeting the inclusion/exclusion criteria. Reports were most commonly published from countries in Asia (53.1%; n = 43/81). The most commonly described vaccines were Oxford-AstraZeneca at 37.0% (n = 30/81) and Pfizer-BioNTech at 33.3% (n = 27/81). Symptoms occurred most commonly after at least 72 hours of administration (30.9%, n = 25/81). One hundred percent of patients (n = 81/81) described pain as an associated symptom and 90.1% of patients (n = 73/81) described multiple symptoms. The diagnostic modalities utilized to identify a specific pathology consisted of magnetic resonance imaging (55.6%; n = 45/81), ultrasound (28.4; n = 23/81), radiograph (25.9%; n = 21/81), and computed tomography (4.9%; 4/81). Nearly a third of patients (32.1%; n = 26/81) were diagnosed with bursitis, while 22 (27.2%) were diagnosed with adhesive capsulitis, 17 (21.0%) with either rotator cuff tear or tendinopathy, and 14 (17.3%) with polymyalgia rheumatica or polymyalgia rheumatica-like syndrome. The 2 most common treatment options were physical therapy (34.6%; n = 28/81) and nonsteroidal anti-inflammatory medications (33.3%; 27/81). The majority of SIRVA cases (52.1%; n = 38/73) completely resolved within a few weeks to months. CONCLUSION: Despite the limited quality and lack of large-scale studies, it is important for providers to recognize SIRVA as a potential risk factor as the number of patients receiving COVID-19 vaccinations and boosters continues to rise.

Wearable Devices and Digital Biomarkers for Optimizing Training Tolerances and Athlete Performance: A Case Study of a National Collegiate Athletic Association Division III Soccer Team over a One-Year Period.

Wearable devices in sports have been used at the professional and higher collegiate levels, but not much research has been conducted at lower collegiate division levels. The objective of this retrospective study was to gather big data using the Catapult wearable technology, develop an algorithm for musculoskeletal modeling, and longitudinally determine the workloads of male college soccer (football) athletes at the Division III (DIII) level over the course of a 12-week season. The results showed that over the course of a season, (1) the average match workload (432 ± 47.7) was 1.5× greater than the average training workload (252.9 ± 23.3) for all positions, (2) the forward position showed the lowest workloads throughout the season, and (3) the highest mean workload was in week 8 (370.1 ± 177.2), while the lowest was in week 4 (219.1 ± 26.4). These results provide the impetus to enable the interoperability of data gathered from wearable devices into data management systems for optimizing performance and health.

Which Application Factors Are Associated With Outstanding Performance in Orthopaedic Surgery Residency?

BACKGROUND: Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice. QUESTIONS/PURPOSES: We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance. METHODS: Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program, were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p < 0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values < 0.05 were considered significant. RESULTS: The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ 2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ 2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ 2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study. CONCLUSION: Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought. LEVEL OF EVIDENCE: Level III, therapeutic study.

Biologics, Stem Cells, Growth Factors, Platelet-Rich Plasma, Hemarthrosis, and Scaffolds May Enhance Anterior Cruciate Ligament Surgical Treatment.

Biologics including mesenchymal stem cells (MSCs), growth factors, and platelet-rich plasma may enhance anterior cruciate ligament (ACL) reconstruction and even ACL primary repair. In addition, hemarthrosis after acute ACL injury represents a source of biologic factors. MSCs can differentiate into both fibroblasts and osteoblasts, potentially providing a transition between the ligament or graft and bone. MSCs also produce cytokines and growth factors necessary for cartilage, bone, ligament, and tendon regeneration. MSC sources including bone marrow, synovium, adipose tissue, ACL-remnant, patellar tendon, and umbilical cord. Also, scaffolds may represent a tool for ACL tissue engineering. A scaffold should be porous, which allows cell growth and flow of nutrients and waste, should be biocompatible, and might have mechanical properties that match the native ACL. Scaffolds have the potential to deliver bioactive molecules or stem cells. Synthetic and biologically derived scaffolds are widely available. ACL reconstruction with improved outcome, ACL repair, and ACL tissue engineering are promising goals. LEVEL OF EVIDENCE: Level V, expert opinion.

Asymptomatic Bone Marrow Edema in Weight-bearing Bones in Athletes and Military Trainees: A Systematic Literature Review.

Asymptomatic bone marrow edema (aBME) is a non-specific radiographic finding often found in athletes. Although aBME may represent the body's physiological response to training load, the etiology, MRI characteristics, and natural history of aBME remain unknown. To better characterize aBME in the lower extremities of military trainees and athletes. A systematic literature review in accordance with PRISMA guidelines was performed to identify primary research articles reporting on aBME in the lower extremities of athletes and military trainees. We identified 347 unique articles and after applying inclusion and exclusion criteria, 10 articles were included for qualitative synthesis. There were a total of 444 patients with an average age of 28.4±9.6 included. The most commonly used MRI sequences were proton-density with fat-saturation and T1-weighted imaging. The pattern of BME was inconsistently described, with various classification schemas used. The changes in aBME during longitudinal follow-up were dynamic and demonstrated both radiographic progression and regression. aBME is a highly prevalent and radiographically dynamic entity observed in high-level athletes and military trainees. Although follow-up was limited in the included studies, aBME may represent a natural, non-pathologic, reaction in response to specific biomechanical stressors.

Smaller diameter femoral tunnel biocomposite interference screws provide adequate fixation strength in anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to evaluate the effect of bioabsorbable interference screw diameter on the pullout strength and failure mode for femoral tunnel fixation in primary anterior cruciate ligament reconstruction (ACLR) at time zero fixation using bone-patellar tendon-bone (BTB) autograft in a cadaveric model. METHODS: Twenty-four fresh-frozen cadaveric knees were obtained from 17 different donors. Specimens were allocated to three different treatment groups (n = 8 per group) based on interference screw diameter: 6 mm, 7 mm, or 8 mm biocomposite interference screw. All specimens underwent dual energy X-ray absorptiometry (DEXA) scanning prior to allocation to ensure no difference in bone mineral density among groups (n.s.). All specimens underwent femoral-sided ACLR with BTB autograft. Specimens subsequently underwent mechanical testing under monotonic loading conditions to failure. The load to failure and failure mechanism were recorded. RESULTS: The mean pullout force (N) at time zero for each group was 309 ± 213 N, 518 ± 313 N, and 541 ± 267 N for 6 mm, 7 mm, and 8 mm biocomposite interference screw diameter, respectively (n.s.). One specimen in the 6 mm group, two specimens in the 7 mm group, and one specimen in the 8 mm group failed by screw pullout. The remainder in each group failed by graft failure (n.s.). CONCLUSION: Biocomposite interference screw diameter did not have a significant influence on fixation pullout strength or failure mode following femoral tunnel fixation using BTB autograft at time zero. A 6 mm interference screw can improve preservation of native bone stock, increase potential for biologic healing, and decrease the risk of damage to the graft during insertion without significantly compromising fixation strength. This study supports the use of smaller 6 mm interference screw diameter options for femoral tunnel fixation in ACLR.

Anterior Cruciate Ligament Tears in the Adolescent Population: Injury Demographics and Risk of Reinjury Among High School Athletes.

BACKGROUND: The incidence of anterior cruciate ligament (ACL) injuries is increasing among the adolescent population with a peak occurring in the high school age range. PURPOSE: To characterize recent epidemiologic trends of ACL injuries, ACL reconstruction (ACLR), and retear rates in high school adolescents based on age, participating sport, and mechanism of injury. STUDY DESIGN: Retrospective case series. METHODS: A prospectively maintained institutional database was retrospectively reviewed for all patients 18 or younger who underwent primary ACLR between 2015 and 2020. Odds ratios were calculated for baseline patient characteristics and their association with risk of retear. Multivariate regression analysis was also performed to identify the relationship between retear and specific categorical variables. RESULTS: A total of 482 patients were included, with a mean follow-up time of 13.0 ± 11.8 months. Patients were an average age of 16.1 ± 1.3 years old (range: 13 to 18 y). Initial presentation of ACL injuries in high school athletes often occurred at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. One hundred three patients (21.6%) completed at least 2 or more years of follow-up after ACLR. Of these patients, 38.8% received a bone-tendon-bone (BTB) autograft, 36.9% hamstring autograft, 14.6% quadriceps tendon autograft, and 3.9% received hamstring allograft or other graft (eg, tibialis anterior and BTB allograft), respectively. There were 25 ipsilateral ACL retears that occurred in the patient cohort (5.2%). Thirteen (52%) of retears were females. Football and soccer were the most common sports played by patients with a retear of the ipsilateral knee (31.8% and 27.3%, respectively). Patients who were 13 to 14 or 18 years old ( P = 0.009 and 0.035, respectively) or who received a tibialis anterior/BTB allograft ( P = 0.002) were found to have increased risk of ACL retear compared with other age groups. When evaluating by sex, female soccer players had a greater risk of retear compared with male soccer players ( P = 0.007). When adjusting for multiple variables, (including age, sex, body mass index, primary reconstruction graft choice, sport, and length of follow-up), the odds of ipsilateral retear in patients who received hamstring autograft ( P = 0.02), sustained a contralateral ACL tear ( P = 0 .04), or a contact injury ( P = 0.01) were increased. CONCLUSION: Initial presentation of ACL injuries in high school athletes often occurs at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. However, the overall rate of ACL retear in high school athletes of all ages is low. Patients who underwent ACLR with hamstring tendon autograft had a greater risk of retear compared with other graft types. Female soccer players also had a greater risk of ACL retear. High school athletes must take caution when in the early high school years (underclassman) and more senior years (upperclassman), as susceptibility for ACL retears is elevated. LEVEL OF EVIDENCE: Level IV.

Effects of opioid-limiting legislation on postoperative opioid use in shoulder arthroplasty in an epidemic epicenter.

BACKGROUND: The current opioid epidemic in the United States has become a public health crisis with an estimated 150 daily deaths and nearly 47,000 opioid-related deaths in the United States in 2017 alone. Sensible prescriber practice changes have been a focus of policymakers to decrease the total number of narcotic pain medications in circulation. In the state of Ohio, opioid prescription limits for acute pain were enacted in August 2017. However, given the association of acute opioid exposure with long-term use and lack of assessment of these policies, there is an unmet need to evaluate the effects of similar legislation in Ohio on postoperative opioid dosing after shoulder arthroplasty. This study evaluates the effects of opioid prescription-limiting legislation in Ohio on postoperative opioid dosing in shoulder arthroplasty and assesses risk factors related to long-term opioid use. METHODS: All patients undergoing primary and revision shoulder arthroplasty over a 5-year period performed by a single surgeon were included. The pre-legislation (PRE) and post-legislation (POST) groups were defined as patients undergoing shoulder arthroplasty before August 31, 2017 and on or after August 31, 2017, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively. Patients were designated as opioid tolerant if they had filled an opioid prescription within 30 days of surgery. A binary logistic regression analysis was applied to assess factors related to long-term opioid use. RESULTS: A total of 334 patients were categorized into 2 cohorts: PRE (n = 99) and POST (n = 235). Accounting for legislative effects, we observed significant reductions in cumulative morphine milligram equivalent (MME) dosing in the opioid-naive patients in the 7-day and 30-day postoperative periods (450.0 MMEs in PRE group vs. 210.0 MMEs in POST group, P < .001) and in the opioid-tolerant patients in the 7-day postoperative period (450.0 MMEs in PRE group vs. 250.0 MMEs in POST group, P = .001). Among the opioid-naive patients, the POST group had a significant MME reduction in the 90-day postoperative period relative to the PRE cohort (P < .001). Preoperative opioid tolerance and benzodiazepine tolerance were independent risk factors for increased MME dosing at 90 days postoperatively (P < .001 and P = .02, respectively). CONCLUSION: Opioid prescription-limiting legislation for acute pain in the state of Ohio is associated with a notable reduction in opioid MME dosing in the 90-day postoperative period after shoulder arthroplasty, particularly in opioid-naive patients in the first 30 days postoperatively. Preoperative opioid tolerance is correlated with significantly higher MME dosing postoperatively after shoulder arthroplasty.

Wearable Sensor Technology to Predict Core Body Temperature: A Systematic Review.

Heat-related illnesses, which range from heat exhaustion to heatstroke, affect thousands of individuals worldwide every year and are characterized by extreme hyperthermia with the core body temperature (CBT) usually > 40 °C, decline in physical and athletic performance, CNS dysfunction, and, eventually, multiorgan failure. The measurement of CBT has been shown to predict heat-related illness and its severity, but the current measurement methods are not practical for use in high acuity and high motion settings due to their invasive and obstructive nature or excessive costs. Noninvasive predictions of CBT using wearable technology and predictive algorithms offer the potential for continuous CBT monitoring and early intervention to prevent HRI in athletic, military, and intense work environments. Thus far, there has been a lack of peer-reviewed literature assessing the efficacy of wearable devices and predictive analytics to predict CBT to mitigate heat-related illness. This systematic review identified 20 studies representing a total of 25 distinct algorithms to predict the core body temperature using wearable technology. While a high accuracy in prediction was noted, with 17 out of 18 algorithms meeting the clinical validity standards. few algorithms incorporated individual and environmental data into their core body temperature prediction algorithms, despite the known impact of individual health and situational and environmental factors on CBT. Robust machine learning methods offer the ability to develop more accurate, reliable, and personalized CBT prediction algorithms using wearable devices by including additional data on user characteristics, workout intensity, and the surrounding environment. The integration and interoperability of CBT prediction algorithms with existing heat-related illness prevention and treatment tools, including heat indices such as the WBGT, athlete management systems, and electronic medical records, will further prevent HRI and increase the availability and speed of data access during critical heat events, improving the clinical decision-making process for athletic trainers and physicians, sports scientists, employers, and military officers.

Opioid-prescribing patterns among shoulder and elbow surgeons: considerations for future prescription guidelines.

BACKGROUND: Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers. METHODS: In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents' prescribing practices, and methods of patient counseling regarding opioid use and disposal. RESULTS: A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient's symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines. DISCUSSION: To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.

Emergency Department Utilization After Elective Hip Arthroscopy.

PURPOSE: (1) To identify the most common reasons for presentation to the emergency department (ED) after hip arthroscopy and (2) to determine preoperative risk factors for these ED visits. METHODS: Patients undergoing elective hip arthroscopy between the start of 2014 and the third quarter of 2015 were retrospectively evaluated using discharge records from New York and Florida. The primary outcome was all-cause 7-, 30-, and 90-day ED utilization. Reasons for presentation to the ED were recorded and manually stratified. Bivariate and multivariate analyses were performed to identify independent predictors of ED utilization. RESULTS: The overall rate of postoperative ED visits after hip arthroscopy was 1.8% at 7 days, 3.5% at 30 days, and 6.6% at 90 days. Postoperative pain was the most common reason for visiting the ED at all time points (25.4%, 23.7%, and 20.3%, respectively), followed by gastrointestinal complaints (19.5%, 15.0%, and 15.3%, respectively) and neurologic complaints (8.7%, 9.8%, and 10.5%, respectively). Female sex (relative risk [RR], 1.86; 95% confidence interval [CI], 1.35-2.54; P < .001), Medicare insurance (RR, 2.39; 95% CI, 1.41-4.04; P < .001), and Medicaid insurance (RR, 3.45; 95% CI, 2.37-5.04; P < .001) were identified as independent risk factors for ED utilization at 90 days postoperatively. Of all patients who presented to the ED, only 3.9% were admitted to the hospital. CONCLUSIONS: ED visits after elective hip arthroscopy are uncommon. The most common reason for a visit is postoperative pain, followed by gastrointestinal and neurologic complaints. After accounting for confounding, we found that female sex, Medicare and Medicaid insurance status, and hypertension were risk factors for all-cause ED visits at up to 90 days postoperatively. Only 4% of patients who present to the ED require inpatient hospital admission. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Anterior Cruciate Ligament Injuries in Skeletally Immature Patients: A Meta-analysis Comparing Repair Versus Reconstruction Techniques.

BACKGROUND: Anterior cruciate ligament (ACL) surgery remains challenging in the skeletally immature patient. Despite the widespread use of physeal-sparing reconstruction techniques, there has been renewed interest in the ACL repair. The purpose of this study was to systematically review the literature to better understand outcomes following all-epiphyseal (AE) reconstruction to extraphyseal reconstruction, while also evaluating ACL repair outcomes in skeletally immature patients. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, all studies in the literature from January 1970 to August 2019 reporting on skeletally immature patients undergoing ACL surgery were identified. Inclusion criteria were pediatric patients with open physes indicative of skeletal immaturity sustaining complete ACL ruptures treated with AE reconstruction, extraphyseal reconstruction or ACL repair. Chronologic age, bone age, postoperative outcomes scores, return to sport rate, and the incidence of complications, namely reruptures, were analyzed. RESULTS: A total of 14 studies comprising 443 patients were identified. No significant difference in chronologic age or postoperative outcome scores at final follow-up were appreciated between patients undergoing AE versus extraphyseal reconstruction. Return to activity rate was significant greater following extraphyseal reconstruction when compared with AE reconstruction. The incidence of any limb-length discrepancies and limb discrepancies measuring ≥10 mm were significant higher following AE reconstruction, while rerupture rates were more common following AE reconstruction. CONCLUSIONS: Patients undergoing AE reconstruction possessed significantly lower return to activity rates, higher incidences of limb-length discrepancies and more commonly experienced ACL reruptures when compared with patients undergoing extraphyseal reconstruction. Further investigations analyzing results following ACL repair in skeletally immature patients are warranted to allow for the comparison of outcomes with current physeal-sparing reconstruction techniques. LEVEL OF EVIDENCE: Level IV-systematic review-therapeutic study.

Recurrent Labral Tearing on Magnetic Resonance Imaging Is Not Predictive of Diminished Participation Among National Football League Athletes.

PURPOSE: To investigate the prevalence of shoulder labral repair and utility of magnetic resonance imaging (MRI) in determining the risks of recurrent labral tearing and impact on future participation in the National Football League (NFL). METHODS: Athletes invited to the NFL Combine between 2012 and 2015 were retrospectively reviewed. Athletes with a history of labral repair and MRI of the operative shoulder at the Combine were included in the study for further analysis, excluding athletes without a history of labral repair, labral repair without MRI at the Combine, additional procedure to the operative shoulder, or athletes still undergoing rehabilitation at the time of the Combine after labral repair. All MRIs were reviewed to determine initial labral repair location, the presence of recurrent tearing, and any concomitant shoulder pathology. Prospective information on future NFL participation in regard to draft status, games played, and games started in the athlete's first NFL season after the Combine was compared between athletes with a history of labral repair with and without recurrent tearing versus all other athletes participating in the Combine. RESULTS: A total of 132 (10.1%) athletes underwent 146 shoulder labral repair procedures before the NFL Combine, of whom 32% (n = 39 athletes, n = 46 shoulders) had recurrent labral tears on MRI. Athletes with recurrent tears were more likely to have undergone bilateral labral repairs (P = .048) and possess concomitant shoulder pathology (P < .001). Recurrent labral tearing was significantly more common in the posterior labrum in athletes with a history of posterior labral repairs (P = .032). Prospective participation in the NFL in terms of games played (P = .38) or started (P = .98) was not significantly reduced in athletes with a history of labral repair compared with those without repair. Participation was not diminished in athletes with recurrent labral tears compared with those with intact repairs or those with evidence of degenerative joint disease. CONCLUSIONS: Athletes invited to the NFL Scouting Combine with a history of bilateral repair, posterior labral repair, and concomitant shoulder pathology are at high risk of recurrent labral tearing on MRI. No significant reduction in NFL participation the year after the Combine was seen in athletes with a history of labral repair, recurrent labral tearing, or degenerative joint disease who were successfully drafted into the NFL. In athletes with a history of labral repair, assessment of labral integrity on MRI alone is not predictive of future short-term participation. LEVEL OF EVIDENCE: Level IV, prognostic study-case series.

Prevalence of Surgical Repair for Athletic Pubalgia and Impact on Performance in Football Athletes Participating in the National Football League Combine.

PURPOSE: To examine the prevalence and impact of athletic pubalgia (AP) surgery in elite American football athletes participating in the National Football League (NFL) Combine. METHODS: Results from 1,311 athletes participating in the Combine from 2012 to 2015 were evaluated. Athletes with a history of AP repair were identified using the NFL Combine Database. Athlete history and available imaging was reviewed. NFL performance based on draft status, games played, games started, and current status in the NFL was gathered using publicly available databases. Statistical analysis was performed to detect for significant associations between athlete history and NFL performance in the presence of AP repair and pelvic pathology on postsurgical magnetic resonance imaging (MRI). RESULTS: AP repair was identified in 4.2% (n = 55) of athletes. MRI was performed in 35% (n = 19 of 55) with AP repair, of which 53% (n = 10 of 19) had positive pathology. Athletes with repair were not at risk of playing (P = .87) or starting (P = .45) fewer regular season games, going undrafted (P = .27), or not being on an active NFL roster (P = .51). Compared with athletes with negative imaging findings, positive pathology on MRI did not have a significant impact on games played (P = .74), games started (P = .48), draft status (P = .26), or being on an active roster (P = .74). Offensive linemen (P = .005) and athletes with a history of repair within 1 year of the Combine (P = .03) had a significantly higher risk of possessing positive pathology on MRI. CONCLUSIONS: Athletes with a history of successful AP surgery invited to the NFL Combine and those with persistent pathology on MRI are not at increased risk for diminished performance in the NFL. Offensive linemen and athletes less than 1 year out from surgery have a higher risk for positive MRI findings at the pubic symphysis. LEVEL OF EVIDENCE: Level IV, prognostic study-case series.

Risk Factors of Emergency Department Utilization After Outpatient Surgery for Sports-Related Injuries.

INTRODUCTION: The purpose of this study was to identify the most common reasons for and risk factors associated with postoperative emergency department (ED) utilization after orthopaedic procedures for sports-related injuries. METHODS: Using the 2014 to 2016 New York and Florida State Databases from the Healthcare Cost and Utilization Project, outpatient procedures for sports-related injuries were identified. Patient records were tracked across care settings within each state to determine the rate and reasons of postoperative ED utilization within 90 days after the index surgery. Multiple logistic regression models were used to identify risk factors associated with ED visits at 0 to 7 days, 8 to 30 days, 31 to 90 days postoperatively. RESULTS: A total of 28,192 surgery visits for sports-related injuries were identified, with knee arthroscopy with partial meniscectomy (18.48%) and arthroscopic anterior cruciate ligament reconstruction (17.04%) as the two most common procedures treating sports injuries. The overall postoperative ED utilization rates were 1.6% (0 to 7 days postoperative), 1.3% (8 to 30 days) and 2.1% (31 to 90 days). The main cause of ED visits was markedly different during each postoperative period: mainly musculoskeletal pain (36.3%) during 0 to 7 days, either musculoskeletal pain (17%) or injury (16.6%) during 8 to 30 days, and injury (24.2%) during 31 to 90 days. Sports with the highest ED utilization in descending order were basketball, football, ice/snow sports, walking/running, cycling, and soccer. Relative to open procedures, arthroscopic procedures were 0.71 times as likely to result in a postoperative ED visit. Independent predictors of ED utilization up to 90 days postoperatively included renal failure, chronic pulmonary disease, psychosis, diabetes, and alcohol abuse. DISCUSSION: Rate of ED utilization after outpatient surgery for sports-related injuries is low (<2.2%), with postoperative musculoskeletal pain and reinjury as the two most common causes, highlighting the importance of postoperative pain management and injury prevention. Arthroscopic procedures showed markedly lower ED utilization compared with open surgery, although not indicative of overall superiority. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction.

Background: Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) is being used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR). However, the knee flexion angle at which fixation of ALLR or LET is performed during the procedure is quite variable based on existing technique descriptions. Purpose/Hypothesis: The purpose of this study was to identify whether flexion angle at the time of ALLR/LET fixation affected postoperative outcomes in a clinical population. It was hypothesized that ALLR/LET fixation at low versus high flexion angles would lead to no statistically significant differences in patient-reported outcome measures and graft failure rates. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify published clinical studies of ACLR with ALLR/LET in which the knee flexion angle at the time of ALLR/LET was reported. A priori, low flexion was defined as 0° to 30°, and high flexion was defined as 60° to 90°. Studies were excluded if the flexion angle was between 31° and 59° because these angles constituted neither low nor high flexion angles and including them in an analysis of high versus low flexion angle at fixation would have biased the study results toward the null. The overall risk of bias was assessed using the Newcastle-Ottawa Scale. The pooled results of the studies were analyzed using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores, along with reported graft failure rates. Results: A total of 32 clinical studies (5230 patients) met inclusion criteria: 22 studies (1999 patients) in the low-flexion group and 10 studies (3231 patients) in the high-flexion group. The median Newcastle-Ottawa Scale score was 6. Comparisons of patients with a low flexion angle versus a high flexion angle demonstrated no differences in the IKDC (P = .84), Lysholm (P = .67), or Tegner (P = .44) scores or in graft failure (3.4% vs 4.1%, respectively; P = .69). Conclusion: The results of this review indicated that ACLR performed in conjunction with ALLR/LET provides good to excellent patient-reported outcomes and low graft failure rates when ALLR/LET fixation is performed in either low or high knee flexion.

The arthroscopic "subdeltoid approach" to the anterior shoulder.

Surgical management of shoulder pathologies has evolved tremendously during the past 3 decades, such that many lesions previously treated with open techniques are now addressed arthroscopically. Despite this movement, many surgeons and outcome studies continue to prefer open repairs as the gold standard, criticizing--with good reason--the reliability, reproducibility, and extended operative time of arthroscopic repairs, particularly with respect to anterior stabilizations and subscapularis repairs. With this in mind, we present the arthroscopic "subdeltoid approach," a novel standardized exposure technique for extracompartmental anterior shoulder arthroscopy. We define the subdeltoid space as the fascial plane bound superiorly by the acromion and coracoacromial ligament, medially by the coracoid and the conjoint tendon, inferiorly by the musculotendinous insertion of the pectoralis major to the humerus, and laterally by the lateral border of the humerus. When coupled with existing arthroscopic tools, this space dramatically enhances our ability to apply open techniques to some of the more challenging anterior shoulder pathoanatomy and expand the indications and efficacy of arthroscopy. This exposure technique has been used in more than 300 cases during the past decade to treat a myriad of shoulder pathologies, without any longstanding postoperative complications.

Common Sports Infectious Disease.

There is growing concern about the impact of infectious diseases in athletes, especially as they relate to exposures in athletic training facilities. This article reviews common pathogens encountered in athletic training facilities, while offering an evidence-based overview of practical preventative measures that can be implemented to reduce the incidence of infectious diseases in close-contact sports such as American football and wrestling.