How Canada's Black Hockey League Shaped the Sport and the Path to Our Arrival in the NHL Today.

Willie O'Ree, known as the "Jackie Robinson of hockey," was the first Black player in the National Hockey League (NHL), debuting with the Boston Bruins in 1958. From the moment the Canadian-born player stepped onto the ice, he changed the notion of hockey as a "White sport," and he has dedicated his career to making it more accessible, including working with the NHL Diversity Task Force initiative Hockey Is For Everyone (HIFE). HIFE supports nonprofit hockey programs around the country and gives kids from all backgrounds the opportunity to try out their skills on the ice. Since 1994, Willie O'Ree has introduced 50,000 children across North America to the sport. Nonetheless, in the NHL today, only approximately 5% of the players (43 of >700) are players of color. However, several aspects of hockey's history, and innovations in the game, can be traced back to communities of color. Established in 1895, the Black Hockey League (BHL) of the Maritimes in Canada grew out of local churches in small towns such as Africville, Nova Scotia. By the beginning of the 20th century, the BHL had grown from a 3-team league to include newly formed teams across the region. The league had its own championship at a time when Black players were not allowed to play for the Stanley Cup. The BHL was at its height between 1890 and 1930, with hundreds of players, 12 teams, and as many as 1,200 spectators. Unfortunately, the Canadian government did not provide equitable resources, and churches alone could not maintain these small Black communities. As the NHL developed, focus shifted away from regional leagues. In 2018, Willie O'Ree was inducted into the NHL Hall of Fame. Although he may have broken the color barrier in 1958, hockey is still a predominantly White sport, and society continues to grapple with systematic racism. NHL players have formed an independent group, the Hockey Diversity Alliance, to work to make the game more socioeconomically inclusive and to help eradicate racism and intolerance.

Comprehensive Case-Based Review of Knee Ligament Injuries.

The management of knee ligament injuries continues to evolve, and much debate persists over the timing of surgery, repair versus reconstruction, surgical technique, postoperative rehabilitation, graft selection, and fixation. Surgeons should be aware of updates on the best management strategies of knee ligament injuries in 2018 and understand the important history and physical examination findings of the knee with ligamentous injury; the anterior cruciate ligament; the role of the anterolateral ligament and lateral extra-articular tenodesis; combined anterior cruciate ligament and medial collateral ligament injuries; the posterior cruciate ligament; medial collateral ligament repair versus reconstruction; posterolateral corner repair versus reconstruction; the role of coronal plane osteotomies, including high tibial osteotomy and distal femoral osteotomy; the role of sagittal plane osteotomies, including anterior closing wedge osteotomy and anterior opening wedge osteotomy; the initial management of the multiligament-injured knee; and five keys to avoiding complications in the multiligament-injured knee. The best available evidence and sample case presentations help guide surgical decision making and improve patient outcomes.

Anterior Cruciate Ligament Injuries in Professional Hockey Players.

BACKGROUND: Performance outcomes and return-to-play data have been reported after anterior cruciate ligament (ACL) injuries in professional football and basketball, but they have rarely been reported in professional hockey. HYPOTHESIS: The hypothesis was that performance after ACL reconstruction would be comparable to prior levels of play in a series of National Hockey League (NHL) players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The NHL Injury Surveillance System (ISS) was utilized to identify all players with an ACL injury between 2006 and 2010. Medical staff members for all NHL teams were surveyed regarding these injuries. The medical staff completed a questionnaire for each injury, and statistics were analyzed using multiple analyses of variance to compare outcomes, performance, and the complication rate. A control group was identified and matched based on performance, career length before injury, age, height, and weight. RESULTS: There were 47 players identified by the NHL ISS. There were 3 goalies, 8 defensemen, and 36 wings or centers. The average age of these players was 27.69 years. The average length of time played after the injury was 2.8 years, which was less than that of the control group (4.4 years) (P = .004). The presence of a meniscal injury was associated with a decreased length of career compared with the control group (P = .012) and with patients with an isolated ACL injury (P = .002). For wings and centers, the number of games played decreased from 71.2 to 58.2 in the first full season after the injury (P = .05) and to 59.29 in the second season (P = .03). In the first season after the injury, for forwards and wings, assists and total points decreased from 20.3 and 35.2 to 13.8 (P = .005) and 25.9 (P = .018), respectively. In the second season after the injury, assists and goals decreased to 10.0 (P = .002) and 10.0 (P = .013), respectively. Compared with controls, the per-season averages of goals (P = .001), assists (P = .010), and total points (P = .004) decreased. Four players (8.5%) had subsequent failure of reconstruction, and there was a total reoperation rate of 20%. Five players (10.6%) did not return to play, and 4 (8.5%) were unable to return to play for a full season. CONCLUSION: Most players are able to return to play in the NHL after an ACL injury. However, career length and performance may be significantly decreased compared with controls. This may represent a more severe initial injury, and more focused return-to-play pathways may identify barriers to return to play.

Isolated fibular collateral ligament injuries in athletes.

Isolated injuries to the fibular collateral ligament (FCL) are rare. Although recent data suggest that operative and nonoperative treatment can both result in good functional outcomes, limited data exist on return to play for nonoperative treatment of FCL injuries and the value of magnetic resonance imaging in predicting prognosis. In this article, we present a review of the current literature and present a focused review regarding the diagnosis, treatment, and prognosis of FCL injuries, as well as the senior authors experience and a cohort of National Football League players. Magnetic resonance imaging can be useful to predict the length of disability in isolated FCL injuries, and both operative and nonoperative management of isolated FCL injuries successfully resulted in return to play in all players in several series of elite athletes; however, nonoperative management may result in faster return to play. Evaluation of potential concomitant injury is imperative in treatment of FCL injuries.

Part I: An anatomic-based tunnel in the fibular head for posterolateral corner reconstruction using magnetic resonance imaging.

PURPOSE: Currently, there are no studies that clearly define a method for the placement of the fibular tunnel between the fibular collateral ligament (FCL) and popliteofibular ligament (PFL) insertions when performing an anatomic-based posterolateral corner reconstruction. The purpose of this study was to use magnetic resonance-based anatomic landmarks to describe the orientation of a fibular tunnel between the FCL and PFL insertions. METHODS: Magnetic resonance imaging (MRI) of 105 patients with normal posterolateral corner knee anatomy was identified by a musculoskeletal radiologist, and the FCL and popliteofibular insertions were labelled. Three experienced providers independently evaluated the images. In the axial plane, the Cobb angle of a fibular tunnel from the FCL to the popliteofibular insertion was measured using the tibial tubercle as a reference. In the sagittal plane, the same tunnel was measured in reference to the lateral tibial plateau. RESULTS: In the axial plane, the average Cobb angle for an anatomic-based fibular tunnel was 48.1° ± 10.7° (ICC(2,1) = 0.76, p < 0.01) externally rotated to the tibial tubercle. In the sagittal plane, the average Cobb angle for an anatomic-based fibular tunnel was 59.8° ± 11.9° (ICC(2,1) = 0.81, p < 0.01) cranial, referenced from the lateral tibial plateau. The average length of the fibular tunnel was 2.0 ± 0.4 cm (ICC(2,1) = 0.78, p < 0.01), at the point of the fibular insertion. The distance from the midpoint of the fibular tunnel to the posterolateral wall of the fibular head was 0.8 ± 0.2 cm (ICC(2,1) = 0.63, p < 0.01). CONCLUSIONS: The results of this study suggest that MRI can be used to identify the orientation between the FCL and PFL insertions to create an anatomic-based fibular tunnel, which is 50° externally rotated from the tibial tubercle in the axial plane and placed in a cranial direction of 60° relative to the lateral joint line. The clinical relevance of this study is that this information may aid surgeons in placing a fibular tunnel connecting the FCL and PFL insertions. LEVEL OF EVIDENCE: IV.

Accuracy and reliability of determining the isometric point of the knee for multiligament knee reconstruction.

PURPOSE: To compare the accuracy and reliability of the anatomic and radiographic techniques for identifying the isometric point of the knee. METHODS: Only four specimens were used; however, eight experienced multiligament knee injury surgeons were recruited to address this limitation. Surgeons estimated the isometric point (EIP) on the medial and lateral sides using an anatomic and radiographic method. The x and y coordinates of the EIP were compared to the true isometric point (TIP). T-tests and interclass correlation coefficients (ICC) were performed to determine the accuracy and reliability between the methods. RESULTS: There was no difference in placement of the EIP on the medial side of the knee in the anterior/posterior (x; p = n.s.) and superior/inferior direction (y; p = n.s). The EIP was anterior (p = 0.001) to the TIP with the radiographic method on the lateral side and approached significance (p = 0.05) in the superior/inferior direction. The ICC (95% CI) for identifying the EIP on the medial side in the anterior/posterior direction using the anatomic method was 0.64 (0.28-0.96) and 0.11 (-0.06 to 0.77) in the superior/inferior direction. Using the radiographic method, the ICC in the anterior/posterior and superior/inferior direction was 0.49 (0.14-0.94) and 0.15 (-0.47 to 0.81), respectively. On the lateral side, the ICC for the anatomic method was 0.84 (0.56-0.99) in the anterior/posterior direction and 0.36 (0.05-0.90) in the superior/inferior direction. Using the radiographic method, the ICC in the anterior/posterior and superior/inferior direction was 0.61 (0.26-0.96) and 0.89 (0.67-0.99), respectively. CONCLUSIONS: There was no difference in accuracy on the medial side of the knee. On the lateral side, the anatomic method was more accurate in the anterior/posterior direction. Reliability was greater in the anterior/posterior direction on both sides of the knee. Surgeons were most likely to place the isometric point anterior and superior to the TIP on both the medial and lateral sides of the knee with either method which has the potential to cause graft lengthening. This should be taken into consideration during reconstruction/repair of the MCL/PMC and LCL/PLC.

Patient-specific instrumentation and return to activities after unicondylar knee arthroplasty.

In the past decade, there has been a major increase in the use of unicompartmental knee arthroplasty (UKA) as surgical techniques have been refined and patient selection has improved. UKAs now account for 8% to 10% of knee arthoplasty procedures. Recent studies have suggested excellent medium- and long-term results of UKA. Overall, results have shown 85% to 90% survivorship at 10 years, with 90% of patients reporting good to excellent subjective and objective outcomes. Recent studies suggest that unicompartmental arthroplasty allows a high percentage of patients to return to presurgical sport and activity participation.

Correlating MRI findings with disability in syndesmotic sprains of NFL players.

BACKGROUND: Syndesmotic sprains may be a significant source of missed playing time, especially in football players. Advanced imaging is frequently used to confirm the clinical diagnosis. Our purpose was to evaluate the prognostic ability of MRI in predicting time of disability. METHODS: Training room records from 1993 to 2007 for three National Football League teams were reviewed. Forty-three players were diagnosed with syndesmotic ankle injuries and underwent radiographs and magnetic resonance imaging. A blinded musculoskeletal radiologist interpreted all images. Players with fractures were excluded. RESULTS: Thirty-six professional football players were included in the final analysis. Twenty-three players had a positive squeeze test which was correlated with increased missed practices (p = 0.012) and increased missed games (p ≤ 0.01). The average number of games missed was 3.3 (range, 0 to 20) and the average number of practices missed was 16.7 (range, 0 to 114). Four players had isolated injury to the anterior tibio-fibular ligament (AITFL) (MRI Grade I). Five players had injury to the AITFL and interosseous ligament (MRI Grade II). Twenty-four players sustained injury to the AITFL, interosseous ligament, and posterior inferior tibio-fibular ligament (MRI Grade III). Three players had Grade III injuries with additional injury to the deltoid ligament (MRI Grade IV). Increasing grade of injury was positively correlated with increased number of missed games (p = 0.033) and missed practices (p = 0.002). CONCLUSION: MRI can be useful to help delineate the injury pattern and associated injuries, and may be useful in predicting time of disability using a grading system. Positive squeeze test can also be useful to determine prognosis.

Autograft versus allograft: an economic cost comparison of anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to compare the costs associated with anterior cruciate ligament (ACL) reconstruction with either bone-patellar tendon-bone (BPTB) autograft or BPTB allograft. METHODS: Surgical costs are reported, including supply costs, based on invoice costs per item used per procedure, and personnel costs calculated as cost per minute. All operations were performed at an ambulatory surgery center between March 2005 and March 2006. A total of 160 patients underwent primary ACL reconstruction with either BPTB autograft (n = 106) or BPTB allograft (n = 54). Procedure cost data were retrieved from a financial management database and divided into various categories for comparison of the 2 groups. Payment data were provided by the surgery center's billing office. RESULTS: The total mean cost per case was $4,147 ± $943 in the allograft group compared with $3,154 ± $704 in the autograft group; this was statistically significant (P < .001). The mean operating room time was 12 minutes greater in autograft cases (P = .006). Supply costs comprised a mean of 58.7% of total expenses in the autograft group and 72.2% in the allograft group. CONCLUSIONS: Allograft reconstruction of the ACL was significantly more expensive than autograft reconstruction. LEVEL OF EVIDENCE: Level II, economic analysis.

Management of complex knee ligament injuries.

The ideal management of the dislocated knee remains controversial. These injuries often can be elusive; a significant number of dislocated knees spontaneously reduce and appear relatively benign on routine radiographs. A high index of suspicion, based on the mechanism of injury, soft-tissue assessment of the limb, and the level of knee instability should alert the physician to the possibility of a dislocated knee. Early recognition and appropriate neurovascular assessment is paramount to the successful treatment of these complex injuries. Controversies exist regarding surgical versus nonsurgical management, early versus delayed surgery, the use of allograft versus autograft tissue, the decision to repair versus reconstruct torn ligamentous structures, and the type of reconstruction technique and postoperative rehabilitation program. To achieve optimal patient care, it is important to be aware of the current evaluation and treatment strategies for complex knee ligament injuries, including modern anatomic reconstruction techniques. Current recommendations include measurement of the ankle-brachial indices in each patient, early surgical management, the use of autograft or allograft tissue, reconstruction as opposed to repair alone of the fibular collateral ligament/posterolateral corner structures, reconstruction of the anterior and posterior cruciate ligaments, and repair and/or reconstruction of the medial collateral ligament/posteromedial corner depending on the injury pattern and the quality of tissue.

Surgical treatment of acute and chronic anterior and posterior cruciate ligament and lateral side injuries of the knee.

Combined anterior cruciate ligament, posterior cruciate ligament, and lateral-sided injuries of the knee most often occurs secondary to a forced varus moment or after knee dislocation. Management controversies include the optimal timing of surgery, operative techniques, and postoperative rehabilitation. Recent systematic literature reviews have demonstrated higher rates of failure with repair of the lateral and posterolateral corner structures, as opposed to reconstruction. However, the ideal ligament reconstruction techniques remain unclear. This chapter will review the combined anterior cruciate ligament/posterior cruciate ligament/lateral-sided injury pattern, including the physical examination findings, imaging, timing of surgery, graft selection, operative techniques, and postoperative rehabilitation protocols.

Diagnosis and management of knee dislocations.

An acute knee dislocation is an uncommon injury, with a high rate of associated vascular and neurologic injuries as well as potentially limb-threatening complications. High-energy trauma is the most common cause of an acute knee dislocation, although lower-energy injuries, such as those sustained during athletic competition, are increasing in incidence. Injuries to the popliteal artery and common peroneal nerve are relatively common, requiring a high index of suspicion and complete neurovascular examination in a timely fashion. All cases of suspected knee dislocation should have an ankle-brachial index performed, reserving arteriography for those with an abnormal finding. Initial management consists of closed reduction, if possible, and application of a hinged brace or external fixator. Definitive management remains an area of controversy, although anatomic surgical repair or reconstruction is favored by most surgeons to help optimize knee function. Most patients treated for a knee dislocation can expect to return to their daily activities, but with less predictable returns to sporting activities.

Decision making in the multiligament-injured knee: an evidence-based systematic review.

PURPOSE: The purpose of this systematic review was to address the treatment of multiligament knee injuries, specifically (1) surgical versus nonoperative treatment, (2) repair versus reconstruction of injured ligamentous structures, and (3) early versus late surgery of damaged ligaments. METHODS: Two independent reviewers performed a search on PubMed from 1966 to August 2007 using the terms "knee dislocation," "multiple ligament-injured knee," and "multiligament knee reconstruction." Study inclusion criteria were (1) levels I to IV evidence, (2) "multiligament" defined as disruption of at least 2 of the 4 major knee ligaments, (3) measures of functional and clinical outcome, and (4) minimum of 12 months' follow-up, with a mean of at least 24 months. RESULTS: Four studies compared surgical treatment with nonoperative treatment. There was a higher percentage of excellent/good International Knee Documentation Committee (IKDC) scores (58% v 20%) in surgically treated patients, as well as higher rates for return to work (72% v 52%) and return to full sport (29% v 10%). Two studies compared repair with reconstruction of damaged structures, with similar mean Lysholm scores (88 v 87) and excellent/good IKDC scores (51% v 48%). However, repair of the posterolateral corner had a higher failure rate (37% v 9%). Similarly, repair of the cruciates yielded decreased stability and range of motion and a lower return to preinjury activity levels (0% v 33%). There were 5 studies comparing early surgery (

Controversies in the treatment of knee dislocations and multiligament reconstruction.

A systematic approach to evaluation and treatment is needed for the patient with knee dislocation. There is a paucity of high-level evidence on which to base treatment decisions. Reported controversies related to the treatment of the multiligament-injured knee include the selective use of arteriography for vascular assessment, serial physical examination with the ankle-brachial index, acute surgical treatment of all damaged structures, the selective application of preoperative and postoperative joint-spanning external fixation, arthroscopic reconstruction of the anterior cruciate ligament and posterior cruciate ligament, simultaneous open reconstruction with repair of the posterolateral corner, reconstruction and/or repair of the posteromedial corner, and the use of allograft tissue.

Understanding the politics of being a team physician.

The team physician landscape is littered with political land mines. In the high-stakes world of professional sports, the politics of each encounter and medical decision--from figuring out how to get hired, to setting up a communication chain of command, to treating visiting players, to fending off the media--must be identified, assessed, and resolved. Key information must be communicated according to the expectations and unique personalities of each owner, general manager, coach, trainer, and athlete. The best team physicians manage relationships, competing agendas, and politically charged circumstances as adeptly as they wield a scalpel.

Bilateral anterior cruciate ligament reconstruction as a single procedure: evaluation of cost and early functional results.

BACKGROUND: The ideal treatment for patients presenting with bilateral anterior cruciate ligament (ACL) deficiency remains controversial. PURPOSE: To evaluate cost and early functional results after bilateral ACL reconstruction at a single setting. STUDY DESIGN: Retrospective review. METHODS: Eleven patients (22 knees) who underwent bilateral ACL reconstruction at a single setting were compared with 33 patients (35 knees) who underwent unilateral ACL reconstruction during the same time period. RESULTS: The mean time to full unrestricted activity between groups was 6.5 months for both groups (P = 0.92). There were no significant differences between groups at latest follow-up for complication rates or laxity as judged by Lachman test, pivot shift test, and KT 1000 arthrometry. The mean International Knee Documentation Committee subjective score at a mean 3.1-year follow-up was 91.9 for the bilateral ACL group compared to 92.0 for the unilateral ACL group (P = 0.95). There was a total cost savings per knee (based on 2001 dollars) of $3751.59 when performing bilateral ACL reconstruction at a single setting (P = 0.0001). CONCLUSIONS: For patients presenting with bilateral ACL deficient knees, reconstruction of both knees at a single setting is safe, cost effective, and does not appear to compromise early functional results.