Mass Participation and Tournament Event Management for the Team Physician: A Consensus Statement (2022 Update).

ABSTRACT: Mass participation events include endurance events (e.g., marathon, triathlon) and/or competitive tournaments (e.g., baseball, tennis, football (soccer) tournaments). Event management requires medical administrative and participant care planning. Medical management provides safety advice and care at the event that accounts for large numbers of participants, anticipated injury and illness, variable environment, repeated games or matches, and mixed age groups of varying athletic ability. This document does not pertain to the care of the spectator.

Utility of Stability and Tear Location in a Classification System for Discoid Meniscus Surgical Planning.

BACKGROUND: Despite the presence of multiple classification systems for discoid meniscus, no system has yet to demonstrate utility in predicting the need for meniscal repair. The purpose of this study was to correlate characteristics associated with meniscal repair and propose a model that can inform preoperative planning and initial counseling of surgical plans and expectations. METHODS: Medical and operative records of 434 knees with lateral discoid meniscus in children and adolescents treated between 1991 and 2016 were reviewed retrospectively to determine the surgical procedure performed (saucerization with or without meniscal repair), discoid meniscal morphology and stability, and location and type of any associated tear. Univariate associations between discoid meniscal characteristics and surgery type were calculated and a logistic regression model of surgery type was generated. RESULTS: In univariate models, unstable menisci (93%, or 179/204, P<0.001) and menisci with tears extending peripherally (75%, or 85/204, P<0.001) were more likely to receive surgery with repair. In isolation, instability demonstrated 89% sensitivity and 94% specificity in predicting surgery with repair. A logistic regression model including stability, tear, and their interaction (stability×tear) showed that that the odds of unstable lateral discoid menisci receiving surgery with repair was 114 times higher than stable menisci (P<0.001) while lateral discoid menisci with peripherally extending tears had 6.4 times higher odds of receiving repair than those that had an isolated central tear (P<0.001). CONCLUSION: Stability and tear location of lateral discoid menisci were associated with surgical treatment in univariate and logistic regression models. The proposed classification system, in which menisci are classified by stability [Stable (S0), Unstable (S1), morphology (Incomplete (M0), Complete (M1))], and tear [No tear (T0), Central tear, isolated (T1), or Central tear, peripheral extension (T2)], is easily remembered and predicts surgical repair for discoid menisci. This scheme can serve to inform preoperative planning and initial counseling of primary surgical management and postoperative expectations. Subsequent research should develop a system that predicts meniscal survival and patient outcomes following the index operation. LEVEL OF EVIDENCE: Level III.

Symptomatic Discoid Meniscus in Children and Adolescents: A Review of 470 Cases.

BACKGROUND: Discoid meniscus is a congenital variant, typically involving the lateral meniscus, that comprises a spectrum of meniscal shapes and degrees of instability in an estimated 1% to 15% of the population. The purpose of this study was to describe the clinical and operative course of a large cohort of children and adolescents patients with symptomatic lateral discoid meniscus. METHODS: Medical records of 470 knees with symptomatic lateral discoid meniscus in 401 patients ages 18 years or younger diagnosed at a single institution between 1991 and 2016 were reviewed retrospectively for patient characteristics, treatment course (nonoperative and/or operative), and complications. Surgical reports were reviewed in the operative group. RESULTS: The series included 401 patients of mean age 11.6 years (range: 1 mo-18.9 y), of which 222 (55%) were female, and 69 (17%) had bilateral involvement. Of 470 knees, 83 (18%) were initially managed nonoperatively. Of these, 32 knees (39%) failed nonoperative management and were converted to surgical treatment at a median of 7.9 months (interquartile range: 4.0-15.1). In total, 419 knees were managed surgically with saucerization (partial meniscectomy) with or without meniscal repair/stabilization; 84 knees (20%) required at least one concurrent nonmeniscal procedure. Discoid meniscus tears were reported in 264/419 knees (63%) intraoperatively; horizontal cleavage tears were most common. Reoperation was required for 66/379 cases (17%) with clinical follow-up, at a median of 19.6 months (range: 9.2-34.9) after index saucerization; 60/379 cases (16%) had ongoing pain and/or mechanical symptoms at final follow-up. CONCLUSION: With a failure rate of 39% (32/83 knees), nonoperative management for discoid lateral meniscus frequently convert to surgical treatment. During surgery, meniscus tearing and instability are common and should be anticipated. Postoperatively, 33% (126/379) of knees with clinical follow-up underwent either reoperation, or had ongoing symptoms of the knee at final follow-up. Discoid mensical retear is the most common complication (94%, 62/66) prompting repeat surgery, and should be discussed with families before the index operation. LEVEL OF EVIDENCE: Level IV-descriptive case series.

Influence of Medial Meniscus Bucket-Handle Repair in Setting of Anterior Cruciate Ligament Reconstruction on Tibiofemoral Contact Mechanics: A Biomechanical Study.

PURPOSE: To compare the impact of an inside-out repair versus meniscectomy of a medial meniscus bucket-handle tear in restoring native contact areas and pressures across the tibial plateaus in the setting of an anterior cruciate ligament (ACL) reconstruction (ACLR). METHODS: Ten fresh-frozen cadaveric knees were tested in 6 knee conditions (1: intact; 2: ACL torn and bucket-handle tear of medial meniscus, flipped; 3: bucket-handle tear of medial meniscus, reduced; 4: bucket-handle tear of medial meniscus, repaired via inside-out vertical mattress suture technique; 5: ACLR with bone patella tendon bone autograft and bucket-handle repair; 6: ACLR and medial meniscus bucket-handle tear debridement) at 4 flexion angles (0°, 30°, 45°, and 60°), under a 1,000-N axial load. Contact area and pressure were measured with Tekscan sensors. RESULTS: ACLR with a concurrent medial meniscectomy for a medial meniscus bucket-handle tear resulted in significantly decreased contact area (P < .05) and increased mean and peak pressure in both the medial and lateral compartments across all tested flexion angles (P < .05). The ACLR with medial meniscectomy state also demonstrated significantly lower contact area than the bucket-handle repair state between 30° and 60° of flexion (all P < .05). CONCLUSIONS: Resection of a bucket-handle medial meniscus tear concurrent with an ACLR resulted in significant increases in mean and peak contact pressures in not only the medial but also the lateral compartment. Preservation of the medial meniscus in the face of a bucket-handle tear is essential to more closely restore native tibiofemoral biomechanics. CLINICAL RELEVANCE: The increased mean and peak tibiofemoral contact pressure seen with excision of a bucket-handle medial meniscus tear would over time result in increased cartilaginous degradation and resultant osteoarthritis. Decreasing both of these factors through concomitant ACLR and inside-out bucket-handle meniscal repairs should improve patient outcomes by restoring knee biomechanics and kinematics closer to that of the native state.

Posterolateral Corner Injuries of the Knee at the National Football League Combine: An Imaging and Outcomes Analysis.

PURPOSE: (1) To determine the epidemiology, examination findings, imaging findings, and associated injuries of posterolateral corner (PLC) injuries in players participating in the National Football League (NFL) Combine and (2) to evaluate the impact of PLC injuries on performance compared with matched controls. METHODS: All PLC injuries identified at the NFL Combine between 2009 and 2015 were reviewed. The inclusion criteria were any player who had clinical findings or a previous surgical procedure consistent with a PLC injury and who participated in medical and performance testing at the NFL Combine. PLC injuries were identified by evaluating the side-to-side difference in lateral-compartment laxity with varus stress and reviewing magnetic resonance imaging studies. NFL performance outcomes (draft position and number of games played or started within the first 2 years) were compared with matched controls. RESULTS: Of the 2,285 players assessed at the NFL Combine, 16 (0.7%) were identified with a history of a grade II or III PLC tear and surgical management whereas 7 additional players (0.3%) had a PLC injury diagnosed on clinical examination, for 23 total PLC injuries (1%). On examination, 13 of 22 knees (59%) were shown to be stable; however, most of those managed surgically had significantly improved stability (13 of 15 stable) versus none of those managed nonsurgically (0 of 7 stable). Surgically managed PLC-injured athletes started significantly fewer games than controls (5.3 vs 10.5, P = .03); the mean draft position for players with surgically treated PLC injuries was 139.7 versus controls' mean draft position of 111.3. Of the 16 athletes treated operatively, 2 reported a PLC injury recurrence; both were managed nonoperatively. CONCLUSIONS: A small percentage of players at the NFL Combine had evidence of a previous PLC injury (1%), with 0.4% having residual varus asymmetry on clinical examination. A worse overall mean draft position for isolated PLC-injured athletes versus controls was found: 132.8 versus 111.3 (P = .02). It is recommended that the use of varus stress radiographs be considered for NFL Combine athletes to objectively determine their grade of injury. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Posterior Cruciate Ligament Injuries of the Knee at the National Football League Combine: An Imaging and Epidemiology Study.

PURPOSE: To determine the epidemiology by player position, examination, imaging findings, and associated injuries of posterior cruciate ligament (PCL) injuries in players participating in the National Football League (NFL) Combine. METHODS: All PCL injuries identified at the NFL Combine (2009-2015) were reviewed. Data were obtained from the database organized by the NFL medical personnel for the compilation of the medical and physical performance examination results of NFL Draftees participating in the NFL Combine from 2009 to 2015. Inclusion criteria were any player with clinical findings or a previous surgery consistent with a PCL injury who participated in the NFL Combine. RESULTS: Of the 2,285 players who participated in the NFL Combine between 2009 and 2015, 69 (3%) had evidence of a PCL injury, of which 11 players (15.9%) were managed surgically. On physical examination, 35 players (52%) had a grade II or III posterior drawer. Concomitant injuries were present frequently and included medial collateral ligament (MCL; 42%), anterior cruciate ligament (ACL; 11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. CONCLUSIONS: Three percent of the players at the NFL Combine presented with a PCL injury, with a significant amount being either running backs (14/69, 20.2%) or offensive linemen (14/69, 20.2%). Approximately half of the players with a PCL tear had a residual grade II or III posterior drawer after sustaining a PCL injury. Concomitant injuries were present frequently and included MCL (42%), ACL (11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. For those players with clinical concern for PCL ligamentous laxity, there should be a complete comprehensive workup that includes plain and PCL stress view radiographs, and magnetic resonance imaging. LEVEL OF EVIDENCE: Level IV, case series.

Sputum autoantibodies in patients with established rheumatoid arthritis and subjects at risk of future clinically apparent disease.

OBJECTIVE: To evaluate the generation of rheumatoid arthritis (RA)-related autoantibodies in the lung. METHODS: Simultaneous collection of serum and induced sputum was performed in 21 healthy controls, 49 at-risk subjects without inflammatory arthritis but at risk of RA due to family history or seropositivity for anti-citrullinated protein antibodies, and 14 subjects with early RA. Samples were tested for anti-cyclic citrullinated peptide 2 (anti-CCP2), anti-CCP3, anti-CCP3.1, rheumatoid factor isotypes IgM, IgG, and IgA, and total IgM, IgG, and IgA. RESULTS: One or more autoantibodies were present in sputum of 39% of at-risk seronegative subjects, 65% of at-risk seropositive subjects, and 86% of subjects with early RA. In at-risk seronegative subjects, the rate of anti-CCP3.1 positivity and the median number of autoantibodies were elevated in sputum versus serum. In subjects with early RA, the rate of positivity for several individual autoantibodies and the median number of autoantibodies were higher in serum than in sputum. Results in at-risk seropositive subjects were intermediate between these groups. In at-risk subjects with autoantibody positivity in sputum, the ratios of autoantibody to total Ig were higher in sputum than in serum, suggesting that these autoantibodies are generated or sequestered in the lung. CONCLUSION: RA-related autoantibodies are detectable in sputum in subjects at risk of RA and in subjects with early RA. In a subset of at-risk subjects, the presence of sputum autoantibodies in the absence of seropositivity, and the increased autoantibody-to-total Ig ratios in sputum, suggest that the lung may be a site of autoantibody generation in the early development of RA. These findings suggest an important role of the lung in the pathogenesis of RA.

Mass Participation and Tournament Event Management for the Team Physician: A Consensus Statement (2022 Update).

ABSTRACT: Mass participation events include endurance events (e.g., marathon, triathlon) and/or competitive tournaments (e.g., baseball, tennis, football (soccer) tournaments). Event management requires medical administrative and participant care planning. Medical management provides safety advice and care at the event that accounts for large numbers of participants, anticipated injury and illness, variable environment, repeated games or matches, and mixed age groups of varying athletic ability. This document does not pertain to the care of the spectator.

Strategies in the nutritional management of gestational diabetes.

Elucidating the optimal macronutrient composition for dietary management of gestational diabetes mellitus has enormous potential to improve perinatal outcomes. Diet therapy may result in significant cost savings if effective in deterring the need for expensive medical management within this growing population. In only 6 randomized controlled trials in 250 women, data suggest that a diet higher in complex carbohydrate and fiber, low in simple sugar, and lower in saturated fat may be effective in blunting postprandial hyperglycemia, preventing worsened insulin resistance and excess fetal growth. The use of diet in gestational diabetes mellitus remains an area in grave need for high-quality randomized controlled trials.

A modified Delphi consensus statement on patellar instability: part II.

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

A modified Delphi consensus statement on patellar instability: part I.

Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

The Beneficial Effect of an Intra-articular Injection of Losartan on Microfracture-Mediated Cartilage Repair Is Dose Dependent.

BACKGROUND: A previous publication demonstrated that the oral intake of losartan promoted microfracture-mediated hyaline-like cartilage repair in osteochondral defects of a rabbit knee model. However, an intra-articular (IA) injection of losartan may have direct beneficial effects on cartilage repair and has not been studied. PURPOSE: To determine the dosage and beneficial effects of an IA injection of losartan on microfracture-mediated cartilage repair and normal cartilage homeostasis. STUDY DESIGN: Controlled laboratory study. METHODS: Rabbits were divided into 5 groups (n = 6 each): a microfracture group (MFX group) and 4 different losartan treatment groups that received varying doses of IA losartan (0.1, 1, 10, and 100 mg per knee). An osteochondral defect (5 mm) was created in the trochlear groove cartilage of 1 limb in each rabbit, and 5 microfracture perforations were made in the osteochondral defect. Both the injured and the contralateral knee joints were injected with IA losartan immediately after microfracture and at 2 and 4 weeks after surgery. Rabbits were sacrificed at 6 weeks after surgery for analysis including gross observation, micro-computed tomography, histology, and reverse transcription quantitative polymerase chain reaction. RESULTS: Micro-computed tomography and gross observation demonstrated comparable subchondral bone healing and hyaline-like cartilage morphology in the 0.1-, 1-, and 10-mg losartan groups relative to the MFX group. Conversely, the 100-mg losartan group showed neither bony defect healing nor cartilage repair. Histology revealed higher O'Driscoll scores and hyaline-like cartilage regeneration in the 1-mg losartan group compared with the MFX group. In contrast, the 100-mg losartan group showed the lowest histology score and no cartilage repair. An IA injection of losartan at the doses of 0.1, 1, and 10 mg did not cause adverse effects on uninjured cartilage, while the 100-mg dose induced cartilage damage. Quantitative polymerase chain reaction results showed downregulation of the transforming growth factor ß (TGF-ß) signaling pathway after IA losartan injection. CONCLUSION: An IA injection of losartan at the dose of 1 mg was most effective for the enhancement of microfracture-mediated cartilage repair without adversely affecting uninjured cartilage. Conversely, a high dose (100 mg) IA injection of losartan inhibited cartilage repair in the osteochondral defect and was chondrotoxic to normal articular cartilage. CLINICAL RELEVANCE: An IA injection of losartan at an optimal dosage represents a novel microfracture enhancement therapy and warrants a clinical trial for future clinical applications.

Coordinated clinical and financial analysis as a powerful tool to influence vendor pricing.

BACKGROUND: As costs continue to outpace reimbursements, hospital administrators and clinicians face increasing pressure to justify new capital purchases. Massachusetts Health Care Reform has added further economic challenges for Disproportionate Share Hospitals (DSH), as resources formerly available to treat the uninsured have been redirected. In this challenging climate, many hospitals still lack a standardized process for technology planning and/or vendor negotiation. PURPOSE: : The purpose of this study was to determine whether a simple, coordinated clinical and financial analysis of a technology, Endoscopic Carpal Tunnel Release (ECTR), is sufficient to impact vendor pricing at Cambridge Health Alliance (CHA), a disproportionate share hospital (DSH) in Cambridge, Massachusetts. METHODOLOGY: This case study addressed the topic of technology adoption, a complex decision-making process every hospital administration faces. Taking note of other hospitals approaches to instill a strategic management culture, CHA combined a literature review on clinical outcomes and financial analysis on profitability. Clinical effectiveness was evaluated through a literature review. The financial analysis was based on a retrospective inquiry of fixed and variable costs, reimbursement rates, actual payer mix, and profitability of adopting ECTR over open carpal tunnel release at CHA. This clinical and financial analysis was then shared with the vendor. FINDINGS: A literature review revealed that although there are short-term benefits to ECTR, there is little to no difference in long-term outcomes to justify a calculated incremental loss of $91.49 in revenue per case. Sharing this analysis with the vendor resulted in a 30% price reduction. A revised cost analysis demonstrated a $53.51 incremental gain in revenue per case. CHA has since elected to offer ECTR to its patients. PRACTICE IMPLICATIONS: Smaller hospital systems often have modest leverage in vendor negotiations. Our results suggest that the development of adoption criteria and an evidence-based managerial approach can create dialogue with vendors and directly impact pricing. Coordinated clinical and financial analysis is a powerful tool, enabling administrators, clinicians, and medical device suppliers to work constructively to provide patients access to innovative technology, even in the face of a challenging payer mix. Ongoing assessment of clinical outcomes and financial data must be performed to reflect the most up-to-date scientific and economic climate.

Return to Sport After Arthroscopic Rotator Cuff Repair: Is There a Difference Between the Recreational and the Competitive Athlete?

BACKGROUND: Return to sport (RTS) remains an important challenge and measure of success for athletes undergoing arthroscopic rotator cuff repair (RCR). PURPOSE: To determine the rate of RTS after RCR and to analyze predictive factors associated with a lower rate of return. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed, MEDLINE, Cochrane, and Google Scholar were used for the literature search. Study quality was evaluated according to the Coleman Methodology Score. Studies in English evaluating RTS after arthroscopic repair of partial- or full-thickness rotator cuff tears among athletes of all levels, ages, and sports were included. Random effects meta-analysis and metaregression were performed to investigate RTS activity rate after arthroscopic RCR and to explore study heterogeneity, respectively. RESULTS: Fifteen studies were reviewed, including 486 patients (499 shoulders) who were treated with arthroscopic RCR and who had a mean follow-up of 40.1 months (range, 18-74.4 months). Eighteen patients were lost to follow-up, leaving 468 patients with outcome data; 347 identified themselves as athletes (81 competitive, 266 recreational). The most commonly included sports were baseball (n = 45), golf (n = 38), football (n = 23), and tennis (n = 18). RTS specific to the type of athlete was reported for 299 of 347 athletes. According to the meta-analysis, the overall rate of RTS at a similar level of play or higher was 70.2%, with 73.3% of recreational athletes and 61.5% of competitive athletes able to return. A subset of 43 baseball and softball players across 4 studies yielded a 79% rate of RTS; however, only 38% returned to the same level of play or higher. Subgroup meta-analysis revealed no significant difference in the rate of RTS between competitive and recreational athletes. Metaregression analysis revealed that the mean follow-up time and mean age at surgery were not significantly associated with RTS rate. CONCLUSION: Most athletes (70.2%) were able to return to a preinjury level of play after arthroscopic RCR. While recreational sports participation (73.3%) was associated with higher return, competitive sports (61.5%) and overhead sports (38%) were associated with lower return. Exactly why all athletes do not return remains uncertain and likely multifactorial.

Reporting the Influence of Sex in Research: Trends at AAOS Annual Meetings.

BACKGROUND: Several initiatives have urged the inclusion of sex in data analysis, but few studies have examined the prevalence of sex-specific reporting in musculoskeletal research. This study aims at determining the presence of sex-specific analyses reported in research at American Academy of Orthopaedic Surgeons Annual Meetings. METHODS: Abstracts listed in the American Academy of Orthopaedic Surgeons Annual Meeting programs from 2006 to 2013 were retrospectively reviewed for the presence of research reporting the results of a sex-specific analysis. RESULTS: The number of abstracts reporting a sex-specific analysis increased from 48 (2006) to 117 (2013) but accounts for 5.4% of research presented from 2006 to 2013. Hip and knee arthroplasty literature accounted for 37% of included abstracts. CONCLUSIONS: The reporting of sex-specific analyses has improved over time but accounts for 5.4% of research presented at annual meetings from 2006 to 2013. The inclusion of sex-specific analyses should be required for future research publications to better understand the influence of sex in musculoskeletal medicine.

REHABILITATION FOLLOWING DISTAL BICEPS REPAIR.

BACKGROUND AND PURPOSE: Distal biceps rupture is less common than injury to the proximal biceps; however, injury distally has profound functional implications on activities which rely on power during elbow flexion and forearm supination. The majority of distal biceps ruptures can be treated with surgical repair of the distal biceps utilizing either a single or two-incision technique; both of which achieve comparable improved outcomes and reported minimal pain and disability at two years. Safe and effective rehabilitation following distal biceps repair is accomplished through a phased progression, with avoidance of premature stress to the healing soft tissue repair.The purpose of this clinical commentary is to provide a concise review of distal biceps tendon injury, including relevant anatomy, etiology, diagnosis, and operative intervention as well as post-operative factors influencing the pursuit of a criterion based, progressive rehabilitation program after distal biceps tendon repair. This commentary seeks to provide an update on current treatment strategies used in distal biceps rehabilitation with accompanying scientific rationale. LEVEL OF EVIDENCE: 5.

REHABILITATION FOLLOWING SUBSCAPULARIS TENDON REPAIR.

Subscapularis (SSC) tendon tears are less common than tears of the remaining rotator cuff tendons, but one with serious consequences given its function as one of the main internal rotators and anterior stabilizers. Mild fraying involving the upper third of the tendon can be treated non-operatively; however, more substantive tears usually require repair in cases of pain or functional impairment. Given the importance of the subscapularis tendon in maintaining stability of the glenohumeral joint and performing internal rotation of the arm, surgical intervention with emphasis on repair may be recommended to eliminate pain and restore strength. Postoperative rehabilitation through phased progression is utilized to avoid premature stress on the healing tissue while enabling early return to daily activities. The purpose of this clinical commentary is to provide an evidence-based description of postoperative rehabilitation following SSC tendon repair with guidance for safe and effective return to activity and sports. LEVEL OF EVIDENCE: 5.

OSTEOCHONDRAL ALLOGRAFT TRANSPLANTATION for the KNEE: POST-OPERATIVE REHABILITATION.

Articular cartilage injuries of the knee are common among young, active patients presenting with knee pain, swelling, and/or mechanical symptoms. These injuries have limited healing potential due to the avascular nature of hyaline cartilage. While several treatment options exist, osteochondral allograft (OCA) transplantation for the knee has been used successfully in primary management of large chondral or osteochondral defects and salvage of previously failed cartilage repair. OCA transplantation potentially yields a natural, matching contour of the native recipient surface anatomy and transplants mature, viable hyaline cartilage to the affected defect. Following OCA transplantation, strict compliance with a rehabilitation protocol is essential to enable optimal recovery. The outlined rehabilitation protocol is informed by the existing literature and incorporates current rehabilitation principles, the science of osteochondral incorporation, and adaptations based on an individual's readiness to progress through subsequent phases. The purpose of this clinical commentary is to discuss the diagnosis, surgical management, and post-operative rehabilitation following OCA transplantation and to assist the physical therapist in returning athletes to full sports participation.

Fibular Collateral Ligament Reconstruction in Adolescent Patients.

Fibular collateral ligament (FCL) injuries can present as lateral-sided knee pain with feelings of side-to-side instability during activity. Patients with FCL injuries can have accompanying symptoms related to irritation of the common peroneal nerve. Preoperative diagnosis is imperative and should include a thorough physical examination complemented with varus stress radiographs before surgical reconstruction is indicated. In the adolescent cohort, surgical planning can be complicated by the presence of open physes, and caution must be taken to avoid drilling through or placing screw fixation across the physes. Potential complications include growth arrest and limb length discrepancy. Therefore, the purpose of this Technical Note is to describe an anatomic FCL reconstruction technique in the skeletally immature adolescent patient.

Comparison of ductal lavage and random periareolar fine needle aspiration as tissue acquisition methods in early breast cancer prevention trials.

PURPOSE: Short-term phase I and phase II breast cancer prevention trials require tissue acquisition at baseline and after intervention to evaluate modulation of potential biomarkers. Currently used tissue acquisition methods include ductal lavage (DL), random periareolar fine needle aspiration (RPFNA), and core needle biopsy. The optimum method to retrieve adequate samples and the most accepted method by study participants is not known. EXPERIMENTAL DESIGN: We compared RPFNA and DL as breast tissue acquisition methods for short-term breast cancer prevention trials by evaluating sample adequacy and tolerability in subjects who participated in two prospective phase II breast cancer prevention trials. Eighty-six women at increased risk for breast cancer were included in this study and underwent baseline DL and RPFNA. High risk was defined as having a 5-year Gail score of >1.67% or a history of atypical hyperplasia (AH), lobular carcinoma, or breast cancer. RESULTS: Median age was 54.5 years (range, 39-75 years); 75% of the women were postmenopausal. About 51% of the women yielded nipple aspiration fluid, and breast fluid samples via DL were retrieved in 73% of these subjects. Of these samples, 71% were adequate samples (greater than 10 epithelial cells). However, when the entire cohort was considered, only 31% of the subjects had adequate samples. RPFNA was also attempted in all subjects, and sample retrieval rate was 100%. Out of these, 96% of the subjects had adequate samples. In DL samples, AH rate was 3.7% was and hyperplasia (H) rate was 11.1%. In RPFNA samples, AH rate was 12.9%, and H rate was 24.7%. Cytology findings in RPFNA samples correlated with age, menopausal status, and breast cancer risk category (previous history of lobular carcinoma in situ). Both procedures were well tolerated, and no complications occurred among participants. CONCLUSIONS: Considering that the main end point for short-term prevention trials is the modulation of biomarkers, it is important to optimize adequate sample acquisition; therefore, RPFNA is a more practical option for future phase I and II breast cancer prevention trials compared with DL.