Blood Flow Restriction Therapy After Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament reconstruction (ACLR) rehabilitation necessitates restoration of quadriceps strength to minimize reinjury and optimize return to sport (RTS). Patients recovering from ACLR are limited by pain and activity restrictions, resulting in quadriceps muscle atrophy. Blood flow restriction (BFR) therapy involves performing exercises while a specialized blood pressure cuff is applied to the proximal aspect of the operative extremity and inflated to 40% to 90% of the arterial occlusion pressure, as determined using Doppler ultrasonography. BFR is theorized to induce an anaerobic environment and metabolic stress during exercise, promoting muscle hypertrophy and strength gains. Although the physiological mechanism has not been fully elucidated, it is theorized that BFR combined with low-load resistance training could yield muscle adaptations comparable to those of high-load resistance training. For ACLR patients with pain and restrictions precluding high-intensity strength training, incorporation of BFR into postoperative rehabilitation protocols could help mitigate quadriceps weakness and promote RTS. Randomized controlled trials report a prolonged, dose-dependent relation between BFR use and quadriceps and hamstring strength gains, improved bone and muscle mass, and earlier RTS, whereas other studies report no significant difference in quadriceps size, strength, or patient satisfaction compared with controls. Furthermore, although generally considered safe, there are rare reports of associated adverse events such as rhabdomyolysis, and BFR should be avoided in patients with a history of thromboembolic disease or peripheral vasculopathy. The literature examining BFR after ACLR is heterogeneous; lacks standardization; and contains broad variation in reported cuff pressures, as well as timing and duration of BFR use, among protocols. Although the use of BFR after ACLR shows promise, further study is necessary to elucidate the efficacy, safety, and optimal protocols.

Patients' under 25 subjective readiness to return to sport after ACL reconstruction with bone-patellar-bone grafts: Autograft vs. allograft.

Purpose: To assess the difference in perceived readiness to return to sport (RTS) within the first year postoperative period between individuals undergoing anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) autografts or allografts. Methods: This was a prospective cohort study of patients undergoing primary ACL reconstruction done either with BTB autograft or allograft from 2010 to 2018. Skeletally mature patients aged 14 to 25 were eligible for inclusion. Patients completed the Marx Activity Rating Scale (MARS) questionnaire postoperatively evaluating perceived ability to perform various activities to compare subjective ability to RTS. Those patients who were outside outlined cohort age, failed to complete a single post-operative survey, underwent revision procedures, or underwent simultaneous or staged additional ligament surgery were excluded. Results: Fifty-nine patients (20.1 ± 3.19 years, 57.6 % Male) were included in the study. Sixteen patients underwent ACL reconstruction with allograft (19.8 ± 3.43 years) while 43 patients received autograft (20.2 ± 3.13). At 3 months autograft recipients reported higher perceived ability to cut (P = .003). At 6-months, allograft recipients reported higher perceived ability to run (P = .033), cut (P = .048), and decelerate (P = .008) as well as a higher overall perceived ability to RTS (P = .032). At all other times, there was no significant difference between cohorts' subjective readiness to perform activities. Conclusion: The results of this study indicate that at times within the first year of recovery following ACL reconstruction, patients who receive allografts and autografts may have significantly different perceived ability to perform activities or RTS. However, while present at various times throughout the first year of recovery, any difference in perceived ability to perform activities or in overall RTS is no longer present at 12 months. Level of evidence: Level II, Prospective cohort study.

Postoperative Opioid Usage and Disposal Strategies After Arthroscopic Procedures in a Young Cohort: A Prospective Observational Study.

Background: Although several studies have noted that patients are routinely overprescribed opioids, few have reported usage after arthroscopic surgery. Purpose: To determine opioid consumption and allocation for unused opioids after common arthroscopic surgeries. Study Design: Case series; Level of evidence, 4. Methods: Patients between the ages of 15 and 40 years who were scheduled to undergo anterior cruciate ligament reconstruction (ACLR), labral repair of the hip or shoulder, meniscectomy, or meniscal repair were prospectively enrolled. Patients were prescribed either 5 mg hydrocodone-325 mg acetaminophen or 5 mg oxycodone-325 mg acetaminophen based on surgeon preference. Patients completed a daily opioid usage survey during the 2-week postoperative period. In addition, patients completed a survey on postoperative day 21 inquiring about continued opioid use and medication disposal, if applicable. Opioid medication consumption was converted to morphine milligram equivalents (MMEs). Results: Of the 200 patients who were enrolled in the study, 176 patients had sufficient follow-up after undergoing 85 (48%) ACLR, 26 (14.8%) hip labral repair, 34 (19.3%) shoulder labral repair, 18 (10.2%) meniscectomy, and 13 (7.4%) meniscal repair procedures. Mean age was 26.1 years (SD, 7.38); surgeons prescribed a mean of 26.6 pills whereas patients reported consuming a mean of 15.5 pills. The mean MME consumption in the 14 days after each procedure was calculated: ACLR (95.7; 44% of prescription), hip labral repair (84.8; 37%), shoulder labral repair (57.2; 35%), meniscectomy (18.4; 27%), and meniscal repair (32.1; 42%). This corresponded to approximately 39% of the total opioid prescription being utilized across all procedures. Mean MME consumption was greatest on postoperative day 1 in hip, shoulder, and meniscal procedures and on postoperative day 2 in ACLR. Only 7.04% of patients reported continued opioid use in the third postoperative week. Patients had a mean of 11 unused pills or 77.7 MMEs remaining. Of the patients with remaining medication, 24.7% intended to keep their medication for future use. Conclusion: The results of our study indicate that patients who undergo the aforementioned arthroscopic procedures consume <75 MMEs in the 2-week postoperative period, translating into a mean of 10 to 15 pills consumed. Approximately 60% of total opioids prescribed went unused, and one-fourth of patients intended to keep their remaining medication for future usage. We have provided general prescribing guidelines and recommend that surgeons carefully consider customizing their opioid prescriptions on the basis of procedure site to balance optimal postoperative analgesia with avoidance of dissemination of excess opioids.

The impact of preoperative benzodiazepine use on postoperative opioid use in total shoulder arthroplasty.

BACKGROUND: As the rate of total shoulder arthroplasty (TSA) and preoperative benzodiazepine use rise, there is an increased need to understand the impact of preoperative benzodiazepine use on postoperative opioid consumption following TSA, especially amid the current opioid epidemic. The relationship between preoperative benzodiazepine use and chronic opioid use postoperatively has been well described following other orthopedic procedures; however, the impact on patients undergoing TSA remains unclear. This study aims to identify the impact of preoperative benzodiazepine use on opioid use following TSA. METHODS: A retrospective chart review of 4488 patients undergoing primary TSA (Current Procedural Terminology code 23472) at a single institution from 2014 to 2022 was performed. Patient demographics, surgical variables, comorbidities, Distressed Communities Index (DCI), and clinical outcomes, including readmission and revision, were collected. The Charlson Comorbidity Index (CCI) was used to assess preoperative health status. Opioid use in morphine milligram equivalents (MMEs) and benzodiazepine use were also recorded using the Prescription Drug Monitoring Program Database. Opioid use was collected at 30-, 60-, and 90-day intervals both before and after each patient's date of surgery. Statistical analysis included stepwise logistic regression to identify variables independently affecting benzodiazepine use pre- and postoperatively. RESULTS: Overall, 16% of patients used benzodiazepines within 90 days before their date of surgery. Of those patients, 46.4% were also using preoperative opioids, compared with just 30.0% of patients who were benzodiazepine-naïve (P < .001). Preoperative benzodiazepine use was also associated with increased pre- and postoperative total opioid use in MMEs and the number of opioid prescriptions across all time points when compared to benzodiazepine-naïve patients (P < .001). Furthermore, 37.4% of preoperative benzodiazepine users went on to prolonged opioid use (filled prescriptions >30 days after surgery) compared to 19.0% of those who were benzodiazepine-naïve (P < .001). CONCLUSION: This study demonstrates a significant association between preoperative benzodiazepine use and increased and prolonged opioid use following TSA. Further exploration of risk factors contributing to preoperative benzodiazepine use may help to reduce overall opioid use in patients undergoing TSA.

Tibial Tubercle Trochlear Groove Distance Does Not Correlate With Patellar Tendon Length in Patients Who Underwent Anterior Cruciate Ligament Reconstruction.

Purpose: To examine the relationship between tibial tubercle-trochlear groove (TT-TG) distance and patellar tendon length. Methods: All healthy athletes who underwent anterior cruciate ligament reconstruction who had a magnetic resonance imaging (MRI) study of the knee on file between July 2018 and June 2019 at a single institution were retrospectively reviewed. Exclusion criteria included patients without an MRI study of the knee on file or with an MRI of insufficient quality precluding reliable calculation of TT-TG and patellar tendon length. MRIs were reviewed to calculate TT-TG, patellar tendon length, and Caton-Deschamps Index (CDI). Patient charts were reviewed to obtain anthropometric characteristics including sex, concomitant injuries, and previous knee procedures as well as age at time of MRI. Spearman correlations were used to assess the relationship between TT-TG, patellar tendon length, and CDI, with regression analysis performed to assess for relationships between TT-TG, patellar tendon length, and patient-specific factors. Results: Overall, 235 patients (99 female [42.1%], 136 male [57.9%]; mean age: 30.0 years [23.0; 40.0]) were included. Inter-rater reliability between the 2 reviewers was 0.888 for TT-TG, 0.804 for patellar tendon length, and 0.748 for CDI, indicating strong agreement. The correlation between TT-TG and patellar tendon length was 0.021, indicating no true relationship. The correlation between TT-TG and CDI was -0.048 and that of patellar tendon length and CDI was 0.411, indicating a weak positive relationship. Regression analysis found that male sex is strongly correlated with a longer patellar tendon length (odds ratio 2.65, 95% confidence interval 1.33-3.97, P < .001). Conclusions: In this study, no correlation was found between TT-TG and patellar tendon length or CDI. Male sex was correlated with a longer patellar length. Level of Evidence: Level III.

ChatGPT Provides Unsatisfactory Responses to Frequently Asked Questions Regarding Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine whether the free online artificial intelligence platform ChatGPT could accurately, adequately, and appropriately answer questions regarding anterior cruciate ligament (ACL) reconstruction surgery. METHODS: A list of 10 questions about ACL surgery was created based on a review of frequently asked questions that appeared on websites of various orthopaedic institutions. Each question was separately entered into ChatGPT (version 3.5), and responses were recorded, scored, and graded independently by 3 authors. The reading level of the ChatGPT response was calculated using the WordCalc software package, and readability was assessed using the Flesch-Kincaid grade level, Simple Measure of Gobbledygook index, Coleman-Liau index, Gunning fog index, and automated readability index. RESULTS: Of the 10 frequently asked questions entered into ChatGPT, 6 were deemed as unsatisfactory and requiring substantial clarification; 1, as adequate and requiring moderate clarification; 1, as adequate and requiring minor clarification; and 2, as satisfactory and requiring minimal clarification. The mean DISCERN score was 41 (inter-rater reliability, 0.721), indicating the responses to the questions were average. According to the readability assessments, a full understanding of the ChatGPT responses required 13.4 years of education, which corresponds to the reading level of a college sophomore. CONCLUSIONS: Most of the ChatGPT-generated responses were outdated and failed to provide an adequate foundation for patients' understanding regarding their injury and treatment options. The reading level required to understand the responses was too advanced for some patients, leading to potential misunderstanding and misinterpretation of information. ChatGPT lacks the ability to differentiate and prioritize information that is presented to patients. CLINICAL RELEVANCE: Recognizing the shortcomings in artificial intelligence platforms may equip surgeons to better set expectations and provide support for patients considering and preparing for ACL reconstruction.

The Utilization of Minimally Invasive Surgery for Os Trigonum Syndrome: A Systematic Review.

BACKGROUND: A symptomatic os trigonum is a common cause of posterior ankle pain that has been traditionally managed with open excision. Minimally invasive surgery (MIS) has been proposed as an alternative to open excision for improved outcomes and decreased complication rates; however, no systematic review to date has examined the utilization of MIS for a symptomatic os trigonum. PURPOSE: To examine patient outcomes, return to sport, and complications associated with MIS for a symptomatic os trigonum. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed on February 22, 2023, using the PubMed, CINAHL, MEDLINE, and Web of Science databases from database inception until February 22, 2023, on the topic of MIS for a symptomatic os trigonum. RESULTS: Of 885 articles retrieved from an initial search, 17 articles (N = 435 patients) met full inclusion criteria. The mean age of the cohort was 26.01 ± 4.68 years, with a mean follow-up time of 34.63 ± 18.20 months. For patients treated with MIS, the mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 55.85 ± 12.75, the mean final postoperative AOFAS score was 94.88 ± 4.04, the mean preoperative visual analog scale pain score was 7.20 ± 0.43, and the mean final postoperative visual analog scale score was 0.71 ± 0.48. The mean time to return to sport for patients undergoing MIS was 7.76 ± 1.42 weeks. MIS had an overall complication rate of 5.0%, the majority of which consisted of transient neurapraxia of the sural or superficial peroneal nerve. CONCLUSION: Minimally invasive management of a symptomatic os trigonum appears to be a viable alternative to open surgery in terms of outcomes, return to sport, and complication rates. More high-quality evidence will be required to definitely recommend minimally invasive approaches as the standard of care over open surgery.

The Most Impactful Articles on the Shoulder Labrum From the United States or Europe, and Decreased Level of Evidence Is Associated With Increased Altmetric Attention Score.

Purpose: To use the top 100 articles pertaining to the shoulder labrum to understand the impact that social medial platforms have on the dissemination of shoulder research and to highlight bibliometric factors associated with Altmetric Attention Scores (AAS) to offer insight into the impact that social media platforms have on the dissemination, attention, and citation of shoulder research publications. Methods: This was a cross-sectional study. In January 2023, the Altmetric database was searched using the PubMed Medical Subject Headings terms "shoulder labrum." Articles with the greatest AAS were screened to exclude other topics unrelated to the labrum of the shoulder. The top 100 articles that met inclusion criteria were used in the final analysis. Bibliometric factors pertaining to each study were collected for further analysis of article characteristics in accordance with previous studies. Results: The Altmetric Database query yielded 619 studies. The top 100 articles with highest AAS were identified, mean Attestation Score was 24.85 ± 55.51, with a range of 7 to 460. The included articles represented 35 journals, with 57 articles attributed to 3 journals: American Journal of Sports Medicine (AJSM; 29%), Arthroscopy: The Journal of Arthroscopic & Related Surgery (Arthroscopy; 19%), and the Journal of Shoulder and Elbow Surgery (JSES; 9%). There was a significant increase in AAS for every decrease in the numerical Level of Evidence value for a study (P = .011) but no association between score and citation rate (P > 005). Conclusions: Top articles on the shoulder labrum, as defined by high AAS score, are most commonly original clinical research published in 1 of 3 sports medicine journals and performed in the United States or Europe. A decreased numerical Level of Evidence is associated with an increase in AAS score, but there is no association between AAS score and citation rate. Clinical Relevance: The increasing amount of science and health information shared freely through open-access journals, online servers, and numerous social media channels makes it difficult to measure the impact of research. Using measures such as the Altmetric Attention Score, in isolation or addition to measures of researcher or journal impact, has the potential to provide comprehensive information about the impact of research in the modern world.

ChatGPT Can Offer Satisfactory Responses to Common Patient Questions Regarding Elbow Ulnar Collateral Ligament Reconstruction.

Purpose: To determine whether ChatGPT effectively responds to 10 commonly asked questions concerning ulnar collateral ligament (UCL) reconstruction. Methods: A comprehensive list of 90 UCL reconstruction questions was initially created, with a final set of 10 "most commonly asked" questions ultimately selected. Questions were presented to ChatGPT and its response was documented. Responses were evaluated independently by 3 authors using an evidence-based methodology, resulting in a grading system categorized as follows: (1) excellent response not requiring clarification; (2) satisfactory requiring minimal clarification; (3) satisfactory requiring moderate clarification; and (4) unsatisfactory requiring substantial clarification. Results: Six of 10 ten responses were rated as "excellent" or "satisfactory." Of those 6 responses, 2 were determined to be "excellent response not requiring clarification," 3 were "satisfactory requiring minimal clarification," and 1 was "satisfactory requiring moderate clarification." Four questions encompassing inquiries about "What are the potential risks of UCL reconstruction surgery?" "Which type of graft should be used for my UCL reconstruction?" and "Should I have UCL reconstruction or repair?" were rated as "unsatisfactory requiring substantial clarification." Conclusions: ChatGPT exhibited the potential to improve a patient's basic understanding of UCL reconstruction and provided responses that were deemed satisfactory to excellent for 60% of the most commonly asked questions. For the other 40% of questions, ChatGPT gave unsatisfactory responses, primarily due to a lack of relevant details or the need for further explanation. Clinical Relevance: ChatGPT can assist in patient education regarding UCL reconstruction; however, its ability to appropriately answer more complex questions remains to be an area of skepticism and future improvement.

Lower Opioid Prescription Quantity Does Not Negatively Impact Pain Control or Patient Satisfaction After ACL Reconstruction: A Randomized, Prospective Trial.

BACKGROUND: The purpose of this study was to evaluate the effects of different quantities of prescribed opioid tablets on patient opioid utilization, postoperative pain and function, and satisfaction after anterior cruciate ligament reconstruction (ACLR). METHODS: This was a prospective, randomized trial enrolling patients undergoing primary ACLR. Patients were assigned to 1 of 3 prescription groups: 15, 25, or 35 tablets containing 5-mg oxycodone. Patients completed visual analog scale (VAS) pain and medication logs, opioid medication satisfaction surveys, and International Knee Documentation Committee (IKDC) questionnaires postoperatively. RESULTS: Among the 180 patients included in the analysis, there was no significant difference in VAS pain scores (p > 0.05), IKDC scores (p > 0.05), morphine milligram equivalents (MMEs) (p = 0.510) consumed, or patient satisfaction with regard to pain control (p = 0.376) between treatment groups. Seventy-two percent of opioids were consumed in the first 3 days postoperatively, and 83% of patients in the 15-tablet cohort felt that they received the "right amount" of or even "too many" opioids. CONCLUSIONS: The prescription of 15 opioid tablets resulted in equivalent pain control, patient satisfaction, and short-term functional outcomes as prescriptions of 25 or 35 opioid tablets after ACLR. Lower prescription quantities of opioid medication may provide equivalent postoperative pain and help to minimize the number of unused opioid doses at risk for possible diversion after ACLR. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Martial Arts: Orthopaedic Injuries and Related Biomechanics.

Martial arts are various systems of combat skills encompassing striking and grappling. Many styles have evolved into modern sports, and some have been included in the Olympics. The physicality of these can predispose practitioners to musculoskeletal injuries, such as anterior cruciate ligament ruptures; patellar, shoulder, or elbow instabilities; extremity fractures; and hand and spine injuries, which have been studied both clinically and biomechanically. The most common injury related to longer time loss from participation is an anterior cruciate ligament rupture. Higher injury incidence is associated with a higher level of experience and competition. Orthopaedic management of martial arts injuries should reflect the specific needs of each martial artist and the biomechanics of motions common to each style. Full-contact practitioners may benefit from broader surgical indications and special attention to the choice and positioning of implants; nonsurgical treatment may be appropriate for certain pediatric or noncontact practitioners. Approximately 60% of martial artists can return to the preinjury level of participation after a major injury. Injury prevention and rehabilitation programs should optimize neuromotor control and core engagement to ensure proper body mechanics. Gradual incorporation of martial arts movement into the postoperative physical therapy curriculum can benefit physical progress and help gain confidence toward full participation.

Towards two decades of Atlantic Ocean mass and heat transports at 26.5° N.

Continuous measurements of the Atlantic meridional overturning circulation (AMOC) and meridional ocean heat transport at 26.5° N began in April 2004 and are currently available through December 2020. Approximately 90% of the total meridional heat transport (MHT) at 26.5° N is carried by the zonally averaged overturning circulation, and an even larger fraction of the heat transport variability (approx. 95%) is explained by the variability of the zonally averaged overturning. A physically based separation of the heat transport into large-scale AMOC, gyre and shallow wind-driven overturning components remains challenging and requires new investigations and approaches. We review the major interannual changes in the AMOC and MHT that have occurred over the nearly two decades of available observations and their documented impacts on North Atlantic heat content. Changes in the flow-weighted temperature of the Florida Current (Gulf Stream) over the past two decades are now taken into account in the estimates of MHT, and have led to an increased heat transport relative to the AMOC strength in recent years. Estimates of the MHT at 26.5° N from coupled models and various surface flux datasets still tend to show low biases relative to the observations, but indirect estimates based on residual methods (top of atmosphere net radiative flux minus atmospheric energy divergence) have shown recent promise in reproducing the heat transport and its interannual variability. This article is part of a discussion meeting issue 'Atlantic overturning: new observations and challenges'.

Atlantic meridional overturning circulation increases flood risk along the United States southeast coast.

The system of oceanic flows constituting the Atlantic Meridional Overturning Circulation (AMOC) moves heat and other properties to the subpolar North Atlantic, controlling regional climate, weather, sea levels, and ecosystems. Climate models suggest a potential AMOC slowdown towards the end of this century due to anthropogenic forcing, accelerating coastal sea level rise along the western boundary and dramatically increasing flood risk. While direct observations of the AMOC are still too short to infer long-term trends, we show here that the AMOC-induced changes in gyre-scale heat content, superimposed on the global mean sea level rise, are already influencing the frequency of floods along the United States southeastern seaboard. We find that ocean heat convergence, being the primary driver for interannual sea level changes in the subtropical North Atlantic, has led to an exceptional gyre-scale warming and associated dynamic sea level rise since 2010, accounting for 30-50% of flood days in 2015-2020.

Seasonality of the Meridional Overturning Circulation in the subpolar North Atlantic.

Understanding the variability of the Atlantic Meridional Overturning Circulation is essential for better predictions of our changing climate. Here we present an updated time series (August 2014 to June 2020) from the Overturning in the Subpolar North Atlantic Program. The 6-year time series allows us to observe the seasonality of the subpolar overturning and meridional heat and freshwater transports. The overturning peaks in late spring and reaches a minimum in early winter, with a peak-to-trough range of 9.0 Sv. The overturning seasonal timing can be explained by winter transformation and the export of dense water, modulated by a seasonally varying Ekman transport. Furthermore, over 55% of the total meridional freshwater transport variability can be explained by its seasonality, largely owing to overturning dynamics. Our results provide the first observational analysis of seasonality in the subpolar North Atlantic overturning and highlight its important contribution to the total overturning variability observed to date.

Red, orange, and dual wavelength vortex emission from Pr:WPFGF fiber laser using a microscope slide output coupler.

Visible vortex beams have a large array of applications; however, the sources are often large or complex. Here, we present a compact vortex source with red, orange, and dual wavelength emission. This Pr:Waterproof Fluoro-Aluminate Glass fiber laser uses a standard microscope slide as an interferometric output coupler, yielding high quality first order vortex modes in a compact setup. We further demonstrate the broad (∼5 nm) emission bands in the orange (610 nm), red (637 nm) and near-infrared regions (698 nm), with the potential for green (530 nm) and cyan (485 nm) emission. This is a low-cost, compact and accessible device giving high quality modes for visible vortex applications.

Outcomes and Patient Satisfaction of Delayed Distal Biceps Repairs without Graft Augmentation: A Systematic Review.

BACKGROUND: Distal biceps tendon tears are responsible for 3% to 10% of all biceps ruptures. Treated nonoperatively, these injuries result in poor endurance, loss of supination strength, and loss of flexion strength compared with those treated operatively with repair or reconstruction. When presenting in a chronic fashion, operative management can involve graft reconstruction or primary repair. When there is adequate tendon excursion and quality, primary repair is preferred. The purpose of this systematic review was to investigate the literature regarding outcomes of direct surgical repair of chronic distal biceps tendon ruptures. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to perform this systematic review and for the presentation of results. A search of the literature was performed on the electronic database Medline, Scopus, and the Cochrane Library. Included studies evaluated subjective and objective outcomes after delayed treatment (≥4 weeks postinjury) for chronic distal biceps tendon ruptures, without use of graft augmentation. Subjective and objective outcome metrics such as functional scores, range of motion, strength, pain level, and return to employment were collected. RESULTS: Eight studies were reviewed. The studies included 124 patients with chronic distal biceps tendon tears, treated surgically after a mean delay to surgery of 121.8 days. Four studies included comparison of patients with acute and chronic tears, whereas the other 4 studies assessed chronic tears only. The findings of these 4 studies suggest that direct repair of chronic tears is correlated with a mildly higher rate of lateral antebrachial cutaneous nerve (LABCN) injury palsy (10/82 [12.1%] chronic vs. 3/38 [7.9%] acute, p = 0.753); however, this complication was overwhelmingly transient. There were only 3 reported reruptures (3.19%) across 5 studies reporting this complication. Overall, patients who had undergone direct repair of chronic distal biceps tears had good patient satisfaction, outcomes, and range of motion. CONCLUSION: Direct repair of chronic distal biceps tendon tears without the use of graft reconstruction is associated with acceptable patient satisfaction, range of motion, and functional outcome scores, although transient LABCN palsy rates may be slightly higher. When sufficient residual tendon is present in the setting of chronic distal biceps rupture, direct repair is a viable treatment option. However, the existing literature regarding direct repair of chronic distal biceps repair is limited, and further prospective assessment directly comparing primary repair vs. reconstruction of chronic distal biceps ruptures is warranted. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Minimally Invasive Surgery Using a Shannon Burr for the Treatment of Hallux Valgus Deformity: A Systematic Review.

Background: Recently there has been an increase in minimally invasive surgery (MIS) for the correction of hallux valgus deformity. This systematic review aims to evaluate and present the current literature on MIS hallux valgus correction in studies reporting the use of the Shannon burr with distal metatarsal osteotomies to help establish evidence-based guidelines for surgeons using this technique. Methods: Two independent authors performed a systematic literature search using the following databases: PubMed, Embase, and the Cochrane library. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2008 to 2022 and included the use of the Shannon burr during distal metatarsal osteotomies MIS for hallux valgus and at least 12-month follow-up. The MINORS score criteria was used to evaluate the strength and quality of 17 studies by 3 authors. Statistical analysis and meta-analysis were not performed because of the heterogeneity of the included studies and the data being descriptive. Results: A total of 17 studies were reviewed. A total of 911 subjects were included, and 1088 MIS procedures were performed. The average follow-up was 23.8 (12-59.1) months. American Orthopaedic Foot & Ankle Society scale and visual analog scale scores improved from 52.1 (41-62.5) to 90.3 (83.3-97.1) and 4.9 (3-8.2) to 0.8 (0-1.9). Satisfaction rates were very high among the studies that reported it. The hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle improved from 31.4 (23.5-44.1) to 11.1 (7-17.2), 13.4 (8.1-18.6) to 7.3 (4.2-10.3), and 12.3 (9-16.3) to 4.1 (1-6.7), respectively. The complication rate was 16.6%, and recurrence was 2.2%. Nonunion comprised 0.4%, infections 1.1%, nerve injury 2.2%, avascular necrosis 0%, hallux varus 0.09%, transfer metatarsalgia 0.1%, and hardware removal 6.2%. Conclusion: MIS for the treatment of hallux valgus using the Shannon burr appears to be a safe and effective therapy, with appropriate correction of the hallux valgus deformity, improvement in functional outcomes, high patient satisfaction, low recurrence, and acceptable complication rates. Level of Evidence: Level II, systematic review.

Unidirectional ring vortex laser using a wedge-plate shearing interferometer.

In response to growing demand from optical vortex (OV) beam applications, numerous generation techniques have been developed competing in power scalability, purity, and wavelength flexibility. Direct vortex emission from lasers typically grants access to efficient, high power, and pure mode generation. In this work we demonstrate a compact, unidirectional Nd:YVO4 ring laser with an intracavity wedge-plate shearing interferometer (WPSI) as an output coupler, which converted the internal Gaussian mode to LG01 (Laguerre-Gaussian OV) output. It directly generated a watt-level LG01 OV with high mode purity (98%) in a single longitudinal mode. The monolithic WPSI has advantages in stability and simplicity compared to other designs. The system is compact and cheap, using off-the-shelf components, and can be readily adapted to any gain media, widening the scope for OV generation at wavelengths currently unobtainable using competing methods.

Distal Hamstring Muscle Injuries.

¼: Distal hamstring muscle injuries, although relatively uncommon, can potentially lead to substantial morbidity in athletes; prolonged rehabilitation times and high rates of reoccurrence have been documented. ¼: Overall, magnetic resonance imaging is considered the "gold standard" for evaluation of hamstring injuries because it allows assessment for concomitant pathology and can clarify return-to-sport timelines. ¼: Complete tears of the distal biceps femoris and semimembranosus muscles respond well to surgical repair, whereas complete tears of the distal semitendinosus can be successfully treated nonoperatively or with surgical resection. ¼: Future research may be necessary to further optimize treatment of these injuries and to determine the efficacy of biologic adjuvant therapy.

Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis.

Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.