Pectoralis Major Tendon Rupture While Bouldering.

Pectoralis major tendon ruptures are rare injuries. We present a case of a pectoralis major tendon rupture incurred while bouldering that required surgical repair. The diagnosis of pectoralis major tendon rupture relies predominantly on clinical examination. Among athletes, outcomes after surgical repair are superior to those after nonoperative therapy in most cases of complete tendon rupture. Although infrequent, pectoralis major tendon ruptures can occur while climbing, and early recognition and expedited surgical treatment are paramount to maximize functional recovery.

Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review.

OBJECTIVE: To examine the current evidence regarding return-to-play (RTP) and performance after Achilles tendon rupture in elite athletes treated with operative intervention. DESIGN: Scoping review. DATA SOURCES: Published sources identified through a PubMed search of elite athletes, defined as professional or division one collegiate athletes in baseball, basketball, American football or soccer. METHODS: Our search yielded a total of 2402 studies, with 13 studies fulfilling the study criteria of reporting elite athletes with objective measures of their athletic performance. A total of 709 elite athletes were included from the NBA, NFL, Major League Baseball (MLB), National Collegiate Athletic Association (NCAA) football and professional soccer. RESULTS AND DISCUSSION: Overall, 61%-100% of elite male athletes RTP after Achilles tendon rupture and operative repair. NBA players had inferior performance compared with their preoperative status as well as controls of non-injured players. Studies did not show significantly different performance after Achilles injury for MLB players. Professional soccer, NFL and NCAA football studies reported varying performance after injury. CONCLUSIONS: Evidence suggests that sports with explosive plantarflexion demands, such as basketball, may be associated with a greater decrease in performance despite operative intervention after Achilles rupture.

Editorial Commentary: Operative Versus Nonoperative Management of Shoulder Instability in the National Football League Athlete: Do What Needs to Be Done-Treatment Choice Does Not Affect Future Performance or Games Played.

Shoulder instability is common in the National Football League athlete. Nonoperative versus operative treatment of shoulder labrum injury without bone loss depends on many factors, including type and direction of instability, presence or absence of pain and recurrent instability that limits function, and player and season situational issues. Prophylactic surgical treatment in an effort to enhance future player performance and increase the number of future games played should be discouraged. Management of shoulder instability should be based on clinical indication and surgical stabilization should not be done prophylactically in the hope of increasing the number of future games played or enhancing performance.

Ultrasound-guided musculoskeletal interventions in American football: 18 years of experience.

OBJECTIVE: Myotendinous strains, contusions, and hematomas are common injuries in American football. Along with ligament sprains and inflammatory disorders, musculoskeletal injuries often result in lost participation time. This article summarizes 18 years of experience with 128 ultrasound-guided drainages and injections in 69 football players with 88 injuries. CONCLUSION: When performed by an operator with sufficient expertise in diagnostic and procedural skills, ultrasound-guided musculoskeletal interventions are minimally invasive, are safe, and can play an integral role in injury management.

Prevalence of abnormal patellofemoral congruence in elite American football players and association with quadriceps isokinetic testing.

Abnormal patellofemoral joint alignment has been discussed as a potential risk factor for patellofemoral disorders and can impact the longevity of any elite athlete's career. The prevalence of abnormal patellofemoral congruence in elite American football athletes is similar to the general population and does not have a relationship with quadriceps isokinetic testing. A total of 125 athletes (220 knees) from the 2011 National Football League (NFL) Combine database who had radiographic and isokinetic studies were reviewed. Congruence angles (CA) and lateral patellofemoral angles (LPA) were calculated on a Merchant radiographic view. Isokinetic testing was used to determine quadriceps-to-hamstring strength (Q/H) ratio and side-to-side deficits. The relationships between abnormal CA and LPA with Q/H ratios, side-to-side deficits, and body mass index (BMI) were examined in separate logistic regression models. A Chi-square test was used to examine the association between CA and player position. Of all, 26.8% of the knees (95% CI: 21.1-33.2%) had an abnormal CA. Knees with normal CA (n = 161) did not significantly differ from those with an abnormal CA (n = 59) in Q/H ratios (mean: 0.699 vs. 0.728, p = 0.19) or side-to-side quadriceps deficits (mean: 4.0 vs. 1.24, p = 0.45). For each point increase in BMI, the odds ratio (OR) of abnormal congruence increased by 11.4% (p = 0.002). Of all the knees, 4.1% (95% CI: 1.9-7.6%) had an abnormal LPA, and this was not associated with Q/H ratios (p = 0.13). For each point increase in BMI, the odds of abnormal LPA increased by 16% (p = 0.036). CA abnormality had much higher odds of having an abnormal LPA (OR: 5.96, p = 0.014). We found that abnormal patellofemoral radiographic alignment in elite American football players is relatively common and there was no association with isokinetic testing.

The Use of Biologics in NFL Athletes: An Expert Consensus of NFL Team Physicians.

Background: There is a lack of published information outlining the use of biologics in National Football League (NFL) athletes and limited data to guide biologic treatment strategies. Purpose: To develop a consensus on the use of biologics among NFL team physicians. Study Design: Consensus statement. Methods: A working group of 6 experts convened a consensus process involving NFL team physicians using validated Delphi methodology. Physicians from 32 NFL teams as well as NFL London were invited to take part. This iterative process was used to define statements on the use of biologics in NFL athletes. A recent scoping review exploring biologics in professional athletes was used to inform the first of 3 rounds of surveys, with statements considered under 7 headings: biologics in general, challenges of treating NFL athletes, terminology/nomenclature, autologous blood products, cell-based therapies, guidance for NFL team physicians, and biologic research in the NFL. In addition to rating agreement, experts were encouraged to propose further items or modifications. Predefined criteria were used to refine item lists after each survey. For a consensus within the final round, defined a priori, items were included in the final information set if a minimum of 75% of respondents agreed and fewer than 10% disagreed. Results: Physicians from 26 NFL teams and NFL London responded to the initial invitation to participate in the Delphi process; 88.9% of participating team physicians completed the round 1 survey, with response rates of 87.5% in round 2 and 95.2% in round 3. After 3 rounds, 47 statements reached a consensus. A consensus was achieved that platelet-rich plasma has a positive impact on patellar tendinopathy and on symptoms in early osteoarthritis but not for other indications. NFL team physicians agreed that while cell therapies have the potential to improve symptoms, the misrepresentation of uncharacterized preparations as "stem cells" has contributed to the widespread use of unproven therapies. Conclusion: This study established an expert consensus on 47 statements relating to the use of biologics in NFL athletes. In addition to providing clinical guidance for the use of biologics in NFL athletes, this study identified key areas for future focus including the development of athlete education materials.

An anatomic study of the coracoid process as it relates to bone transfer procedures.

INTRODUCTION: The Latarjet and Bristow procedures address recurrent anterior shoulder instability in the context of a significant bony defect. However, the bony and soft tissue anatomy of the coracoid as they relate to coracoid transfer procedures has not yet been defined. The purpose of this study was to describe the soft tissue attachments of the coracoid as they relate to the bony anatomy and to define the average amount of bone available for use in coracoid transfer. METHODS: Ten paired fresh frozen shoulders from deceased donors were dissected, exposing the coracoid, lateral clavicle, and acromion, along with the coracoid soft tissue attachments. The bony dimensions of the coracoid and the locations and sizes of the soft tissue footprints of the coracoid were measured. RESULTS: The mean maximum length of the coracoid available for transfer (ie, distance from the coracoid tip to the anterior border of the coracoclavicular ligament) was 28.5 mm. The mean distance from the coracoid tip to the anterior pectoralis minor was 4.6 mm, to the posterior pectoralis minor was 17.7 mm, to the anterior coracoacromial ligament was 7.8 mm, and to the posterior coracoacromial ligament was 25.7 mm. CONCLUSION: Average dimensions of the bony coracoid and average locations and sizes of coracoid soft tissue footprints are provided. This anatomic description of the coracoid bony anatomy and its soft tissue insertions allows surgeons to correlate the location of their coracoid osteotomy with the soft tissue implications of the coracoid transfer as the native anatomy is manipulated in these nonanatomic procedures.

Biologics in professional and Olympic sport: a scoping review.

AIMS: The aim of this study was to prepare a scoping review to investigate the use of biologic therapies in the treatment of musculoskeletal injuries in professional and Olympic athletes. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published primary and secondary studies, as well as grey literature. The identified studies were screened with criteria for inclusion comprising clinical studies evaluating the use of biologic therapies in professional and Olympic athletes, systematic reviews, consensus statements, and conference proceedings. Data were extracted using a standardized tool to form a descriptive analysis and a thematic summary. RESULTS: A total of 202 studies were initially identified, and 35 met criteria for the scoping review; 33 (94.3%) were published within the last eight years, and 18 (51.4%) originated from the USA. Platelet rich plasma was the most studied biologic therapy, being evaluated in 33 (94.3%) studies. Ulnar collateral ligament and hamstring injuries were the conditions most studied (nine (25.7%) studies and seven (20.0%) studies, respectively). Athletes most frequently participated in baseball, soccer, and American football. Only two (5.7%) studies were level 1 evidence, with interpretation and comparison between studies limited by the variations in the injury profile, biologic preparations, and rehabilitation protocols. CONCLUSION: There is diverse use of biologic therapies in the management of musculoskeletal injuries in professional and Olympic athletes. There is currently insufficient high-level evidence to support the widespread use of biologic therapies in athletes. Further research priorities include the development of condition/pathology-specific preparations of biologic therapies, and of outcome measures and imaging modalities sufficiently sensitive to detect differences in outcomes, should they exist. Cite this article: Bone Joint J 2021;103-B(7):1189-1196.

The use of biologics in professional and Olympic sport: a scoping review protocol.

AIMS: The use of biologics in the treatment of musculoskeletal injuries in Olympic and professional athletes appears to be increasing. There are no studies which currently map the extent, range, and nature of existing literature concerning the use and efficacy of such therapies in this arena. The objective of this scoping review is to map the available evidence regarding the use of biologics in the treatment of musculoskeletal injuries in Olympic and professional sport. METHODS: Best-practice methodological frameworks suggested by Arksey and O'Malley, Levac et al, and the Joanna Briggs Institute will be used. This scoping review will aim to firstly map the current extent, range, and nature of evidence for biologic strategies to treat injuries in professional and Olympic sport; secondly, to summarize and disseminate existing research findings; and thirdly, to identify gaps in existing literature. A three-step search strategy will identify peer reviewed and non-peer reviewed literature, including reviews, original research, and both published and unpublished ('grey') literature. An initial limited search will identify suitable search terms, followed by a search of five electronic databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Web of Science, and Google Scholar) using keyword and index terms. Studies will be screened independently by two reviewers for final inclusion. DISSEMINATION: We will chart key concepts and evidence, and disseminate existing research findings to practitioners and clinicians, through both peer reviewed and non-peer reviewed literature, online platforms (including social media), conference, and in-person communications. We will identify gaps in current literature and priorities for further study.

Delayed Union of a Diaphyseal Forearm Fracture Associated With Impaired Osteogenic Differentiation of Prospectively Isolated Human Skeletal Stem Cells.

Delayed union or nonunion are relatively rare complications after fracture surgery, but when they do occur, they can result in substantial morbidity for the patient. In many cases, the etiology of impaired fracture healing is uncertain and attempts to determine the molecular basis for delayed union and nonunion formation have been limited. Prospectively isolating skeletal stem cells (SSCs) from fracture tissue samples at the time of surgical intervention represent a feasible methodology to determine a patient's biologic risk for compromised fracture healing. This report details a case in which functional in vitro readouts of SSCs derived from human fracture tissue at time of injury predicted a poor fracture healing outcome. This case suggests that it may be feasible to stratify a patient's fracture healing capacity and predict compromised fracture healing by prospectively isolating and analyzing SSCs during the index fracture surgery. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

An analysis of four ulnar collateral ligament reconstruction procedures with cyclic valgus loading.

We describe a new transolecranon fossa ulnar (TOFU) collateral ligament reconstruction technique and compare its response to cyclic valgus loading with the Jobe, Docking, and DANE procedures. TOFU is an arthroscopically assisted, modified all-interference screw technique. A cyclic valgus moment was applied to 32 intact and reconstructed, unembalmed elbows. Valgus angles were measured at 1, 10, 100, and 1000 cycles. At all cycles, there was no difference between intact and TOFU-treated elbows. TOFU resulted in significantly smaller angles than DANE at cycles 10, 100, and 1000; Docking at cycle 1000; and Jobe at cycles 10, 100, and 1000. The TOFU procedure shows superior resistance to valgus loading than DANE and Jobe by cycle 10, and Docking by cycle 1000. Further study is needed to evaluate the clinical value of the TOFU procedure as an arthroscopically assisted technique.

Tendon Excision Following Distal Semitendinosus Injury in the Elite Athlete: A Surgical Technique.

BACKGROUND: Hamstring injuries can present in numerous forms, some of which can lead to persistent pain, loss of function, and delay in return to sport. Although most are treated conservatively, proximal and distal tendon avulsion injuries have become more commonly treated with surgery. Distal semitendinosus avulsion injuries have been largely reported in the elite athlete population. While conservative management has been utilized, failure in this group can significantly impact a future career. PURPOSE: The purpose of the manuscript is to describe our approach of surgical tendon excision for distal semitendinosus injury in an elite athlete. METHODS: We highlight a two-incision technique to isolate the avulsed tendon, followed by exteriorization and tendon excision. In addition, we provide insight on clinical and imaging findings to help guide management. RESULTS: This technique provides a reliable and effective surgical option for managing these rare injuries of the distal semitendinosus, along with outlining rehabilitation goals in the postoperative period. CONCLUSION: In this setting, we present a detailed surgical technique to excise the injured distal semitendinosus tendon to promote recovery and potentially allow for earlier return to play.

Cartilage Subsurface Changes to Magnetic Resonance Imaging UTE-T2* 2 Years After Anterior Cruciate Ligament Reconstruction Correlate With Walking Mechanics Associated With Knee Osteoarthritis.

BACKGROUND: Anterior cruciate ligament (ACL) injury increases risk for posttraumatic knee osteoarthritis (OA). Quantitative ultrashort echo time enhanced T2* (UTE-T2*) mapping shows promise for early detection of potentially reversible subsurface cartilage abnormalities after ACL reconstruction (ACLR) but needs further validation against established clinical metrics of OA risk such as knee adduction moment (KAM) and mechanical alignment. HYPOTHESIS: Elevated UTE-T2* values in medial knee cartilage 2 years after ACLR correlate with varus alignment and higher KAM during walking. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Twenty patients (mean age, 33.1 ± 10.5 years; 11 female) 2 years after ACLR underwent 3.0-T knee magnetic resonance imaging (MRI), radiography, and gait analysis, after which mechanical alignment was measured, KAM during walking was calculated, and UTE-T2* maps were generated. The mechanical axis and the first and second peaks of KAM (KAM1 and KAM2, respectively) were tested using linear regressions for correlations with deep UTE-T2* values in the central and posterior medial femoral condyle (cMFC and pMFC, respectively) and central medial tibial plateau (cMTP). UTE-T2* values from ACL-reconstructed patients were additionally compared with those of 14 uninjured participants (mean age, 30.9 ± 8.9 years; 6 female) using Mann-Whitney U and standard t tests. RESULTS: Central weightbearing medial compartment cartilage of ACL-reconstructed knees was intact on morphological MRI. Mean UTE-T2* values were elevated in both the cMFC and pMFC of ACL-reconstructed knees compared with those of uninjured knees ( P = .003 and P = .012, respectively). In ACL-reconstructed knees, UTE-T2* values of cMFC cartilage positively correlated with increasing varus alignment ( R = 0.568). Higher UTE-T2* values in cMFC and cMTP cartilage of ACL-reconstructed knees also correlated with greater KAM1 ( R = 0.452 and R = 0.463, respectively) and KAM2 ( R = 0.465 and R = 0.764, respectively) and with KAM2 in pMFC cartilage ( R = 0.602). CONCLUSION: Elevated deep UTE-T2* values of medial knee cartilage 2 years after ACLR correlate with 2 clinical markers of increased risk of medial knee OA. These results support the clinical utility of MRI UTE-T2* for early diagnosis of subsurface cartilage abnormalities. Longitudinal follow-up of larger cohorts is needed to determine the predictive and staging potential of UTE-T2* for posttraumatic OA.

Two ulnar collateral ligament reconstruction methods: the docking technique versus bioabsorbable interference screw fixation--a biomechanical evaluation with cyclic loading.

We compared the effects of cyclic valgus loading on 2 techniques for reconstruction of the elbow ulnar collateral ligament (UCL): the docking procedure and the bioabsorbable interference screw procedure. A cyclic valgus load was applied to the 16 unembalmed elbows, and the valgus angle was measured at 1, 10, 100, and 1000 cycles. Testing was repeated after UCL palmaris tendon reconstruction via either the docking technique or bioabsorbable interference screw fixation. At cycle 1, the valgus angle was not different between treated and intact cases. At cycles 10 and 100, the valgus angle for the docking technique was significantly greater than that for both the intact cases and the interference screw technique. By the 1000th cycle, no difference was measured between the 2 techniques. In this study, bioabsorbable interference screw fixation resulted in less valgus angle widening in response to early cyclic valgus load as compared with the docking technique.

Ligament and tendon injury to the elbow: clinical, surgical, and imaging features.

Significant advances in the understanding of elbow anatomy, biomechanics, imaging, and surgical technique have been made over the last decade. Tendon injuries are often seen in athletes and physical laborers from repetitive eccentric overload. Ligament injuries are commonly seen in throwing athletes or after elbow dislocation. Magnetic resonance imaging has proven valuable for diagnosing and monitoring most of these soft tissue injuries, and effective surgical techniques have evolved to address them. This article describes typical clinical findings associated with ligament and tendon injuries in the elbow as well as common surgical therapies. The use of magnetic resonance imaging is highlighted throughout because this modality has revolutionized noninvasive evaluation of the elbow.

Chondral Rib Fractures in Professional American Football: Two Cases and Current Practice Patterns Among NFL Team Physicians.

BACKGROUND: Although a recognized and discussed injury, chondral rib fractures in professional American football have not been previously reported in the literature. There currently exists no consensus on how to identify and treat these injuries or the expected return to play for the athlete. PURPOSE: To present 2 cases of chondral rib injuries in the National Football League (NFL) and discuss the current practice patterns for management of these injuries among the NFL team physicians. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Two cases of NFL players with chondral rib injuries are presented. A survey regarding work-up and treatment of these injuries was completed by team physicians at the 2014 NFL Combine. Our experience in identifying and treating these injuries is presented in conjunction with a survey of NFL team physicians' experiences. RESULTS: Two cases of rib chondral injuries were diagnosed by computed tomography (CT) and treated with rest and protective splinting. Return to play was 2 to 4 weeks. NFL Combine survey results show that NFL team physicians see a mean of 4 costal cartilage injuries per 5-year period, or approximately 1 case per year per team. Seventy percent of team physicians use CT scanning and 43% use magnetic resonance imaging for diagnosis of these injuries. An anesthetic block is used acutely in 57% and only electively in subsequent games by 39%. CONCLUSION: A high index of suspicion is necessary to diagnose chondral rib injuries in American football. CT scan is most commonly used to confirm diagnosis. Return to play can take up to 2 to 4 weeks with a protective device, although anesthetic blocks can be used to potentially expedite return. CLINICAL RELEVANCE: Chondral rib injuries are common among NFL football players, while there is no literature to support proper diagnosis and treatment of these injuries or expected duration of recovery. These injuries are likely common in other contact sports and levels of competition as well. Our series combined with NFL team physician survey results can aid team physicians in identifying these injuries, obtaining useful imaging, and counseling players and coaches and the expected time of recovery.

Acute compartment syndrome of the thigh in a football athlete: a case report and the role of the vacuum-assisted wound closure dressing.

We present a case of compartment syndrome of the thigh due to blunt injury in a Division I American football player managed with fasciotomy and vacuum-assisted wound closure. This case report discusses the vacuum-assisted wound closure dressing as an alternative to more traditional closure techniques such as suture retention devices and split-thickness skin grafting. We feel that any surgeon involved in performing fasciotomies should be familiar with this increasingly used closure device and its potential complications.

Improving resident work environment: evaluation of a novel cooperative program.

BACKGROUND: Improving the resident work environment is a major concern for surgery faculty. This study evaluated the ability of a cooperative program with nurses and interns to decrease the number of nonurgent pages and consistently generate a 4-hour block of time at night without nonurgent pages. METHODS: Multiple discussions with interns and with nurses on 2 nursing floors identified ways to improve nurse/resident communication. These included use of a notebook by nurses to record nonurgent issues and having on-call interns check with the night nurses after night shift report. For the week before and after institution of the program, interns logged each page received. Pretest and posttest data were compared by use of t testing. RESULTS: Interns logged fewer pages after intervention compared with preintervention (P <.01). In addition, the interns had a 4-hour block of time on call nights without pages more frequently during the posttest period (100% vs 25%, P <.01). The percent of necessary calls increased from 50% to 70% during day shifts (P <.01). CONCLUSIONS: A cooperative program that focused on decreasing nonurgent pages and maximizing efficient communication led to a decrease in the number of nonurgent pages received by interns and increased the number of call nights in which a 4-hour block of sleep or study time was generated, thereby improving residents' work environment.

The role of plain films and computed tomography in the evaluation of scapular neck fractures.

OBJECTIVE: To assess the ability of plain films and computed tomography scans to show the pattern, displacement, and angulation of scapular neck fractures. To assess the ability of computed tomography to identify concomitant occult shoulder injuries. DESIGN: Masked retrospective radiographic review. SETTING: Level I trauma center. PARTICIPANTS: Three orthopaedic surgeons (two attending physicians and one senior resident) and one musculoskeletal radiology attending physician reviewed the imaging studies of scapula neck fractures in twenty patients treated at our institution. MAIN OUTCOME MEASURES: Kappa analysis of agreement of fracture characteristics and benefits of computed tomography for scapular neck fractures. RESULTS: The mean weighted kappa coefficient for interobserver reliability of fracture displacement was 0.49 when the fractures were assessed by plain films alone, 0.15 when they were assessed by computed tomography scans alone, and 0.35 when they were assessed by plain films and computed tomography scans. The mean weighted kappa coefficients for fracture angulation were 0.30, 0.23, and 0.16, respectively. The mean simple kappa coefficients for fracture classification were 0.81, 0.20, and 0.33, respectively. Concomitant injury to the superior shoulder suspensory complex was seen in 57 percent of cases, including nine clavicle fractures, one coracoid fracture, and three acromion process fractures. The coracoid fracture and two of the acromion process fractures were minimally displaced and seen on computed tomography scans only. CONCLUSION: Scapular neck fracture displacement, angulation, and anatomic classification showed moderate interobserver reliability by plain films but were not enhanced by computed tomography. Computed tomography confused, rather than clarified, the assessment of these characteristics. Computed tomography may be useful to identify associated injuries to the superior shoulder suspensory complex, which can be missed by plain films alone. Routine computed tomography in patients with scapular neck fractures cannot be recommended based on this study. Computed tomography of scapular neck fractures may be useful in selected cases in which intraarticular extension is noted on plain films.