Blood Flow Restriction Therapy for 2 Weeks Prior to Anterior Cruciate Ligament Reconstruction Did Not Impact Quadriceps Strength Compared to Standard Therapy.

PURPOSE: To evaluate the efficacy of a 2-week home-based blood flow restriction (BFR) prehabiliation program on quadriceps strength and patient-reported outcomes prior to anterior cruciate ligament (ACL) reconstruction. METHODS: Patients presenting with an ACL tear were randomized into two groups, BFR and control, at their initial clinic visit. Quadriceps strength was measured using a handheld dynamometer in order to calculate peak force, average force, and time to peak force during seated leg extension at the initial clinic visit and repeated on the day of surgery. All patients were provided education on standardized exercises to be performed 5 days per week for 2 weeks between the initial clinic visit and date of surgery. The BFR group was instructed to perform these exercises with a pneumatic cuff set to 80% of limb occlusion pressure placed over the proximal thigh. Patient-Reported Outcome Measurement System Physical Function (PROMIS-PF), knee range of motion, and quadriceps circumference were gathered at the initial clinic visit and day of surgery, and patients were monitored for adverse effects. RESULTS: A total 45 patients met inclusion criteria and elected to participate. There were 23 patients randomized to the BFR group and 22 patients randomized into the control group. No significant differences were noted between the BFR and control groups in any demographic characteristics (48% vs 64% male [P = .271] and average age 26.5 ± 12.0 vs 27.0 ± 11.0 [P = .879] in BFR and control, respectively). During the initial clinic visit, there were no significant differences in quadriceps circumference, peak quadriceps force generation, time to peak force, average force, pain, and PROMIS scales (P > .05 for all). Following completion of a 2-week home prehabilitation protocol, all patients indeterminant of cohort demonstrated decreased strength loss in the operative leg compared to the nonoperative leg (P < .05 for both) However, there were no significant differences in any strength or outcome measures between the BFR and control groups (P > .05 for all). There were no complications experienced in either group, and both were compliant with the home-based prehabilitation program. CONCLUSIONS: A 2-week standardized prehabilitation protocol preceding ACL reconstruction resulted in a significant improvement in personal quadriceps peak force measurements, both with and without the use of BFR. No difference in quadriceps circumference, strength, or patient reported outcomes were found between the BFR and the control group. The home-based BFR prehabiliation protocol was found to be feasible, accessible, and well tolerated by patients. LEVEL OF EVIDENCE: Level II, randomized controlled trial with small effect size.

Machine Learning Model Identifies Preoperative Opioid Use, Male Sex, and Elevated Body Mass Index as Predictive Factors for Prolonged Opioid Consumption Following Arthroscopic Meniscal Surgery.

PURPOSE: To develop a predictive machine learning model to identify prognostic factors for continued opioid prescriptions after arthroscopic meniscus surgery. METHODS: Patients undergoing arthroscopic meniscal surgery, such as meniscus debridement, repair, or revision at a single institution from 2013 to 2017 were retrospectively followed up to 1 year postoperatively. Procedural details were recorded, including concomitant procedures, primary versus revision, and whether a partial debridement or a repair was performed. Intraoperative arthritis severity was measured using the Outerbridge Classification. The number of opioid prescriptions in each month was recorded. Primary analysis used was the multivariate Cox-Regression model. We then created a naïve Bayesian model, a machine learning classifier that uses Bayes' theorem with an assumption of independence between variables. RESULTS: A total of 581 patients were reviewed. Postoperative opioid refills occurred in 98 patients (16.9%). Multivariate logistic modeling was used; independent risk factors for opioid refills included male sex, larger body mass index, and chronic preoperative opioid use, while meniscus resection demonstrated decreased likelihood of refills. Concomitant procedures, revision procedures, and presence of arthritis graded by the Outerbridge classification were not significant predictors of postoperative opioid refills. The naïve Bayesian model for extended postoperative opioid use demonstrated good fit with our cohort with an area under the curve of 0.79, sensitivity of 94.5%, positive predictive value (PPV) of 83%, and a detection rate of 78.2%. The two most important features in the model were preoperative opioid use and male sex. CONCLUSION: After arthroscopic meniscus surgery, preoperative opioid consumption and male sex were the most significant predictors for sustained opioid use beyond 1 month postoperatively. Intraoperative arthritis was not an independent risk factor for continued refills. A machine learning algorithm performed with high accuracy, although with a high false positive rate, to function as a screening tool to identify patients filling additional narcotic prescriptions after surgery. LEVEL OF EVIDENCE: III, retrospective comparative study.

The effect of subscapularis-specific rehabilitation following total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial.

BACKGROUND: Patients undergoing a total shoulder arthroplasty (TSA) through a deltopectoral approach will require repair of the subscapularis tendon. There are no universal postoperative guidelines for rehabilitation of the subscapularis specifically. We hypothesize that the addition of a subscapularis-specific regimen will result in improved subscapularis strength and function. METHODS: Adult patients undergoing anatomic TSA for the treatment of primary glenohumeral osteoarthritis were included. Patients were randomized into either the traditional rehabilitation (TR) control group or the subscapularis rehabilitation (SR) group, which consisted of the traditional therapy along with early and additional subscapularis exercises. Baseline demographics, patient-reported outcome measures (PROMs), range of motion (ROM), provocative tests, and subscapularis strength using a handheld dynamometer were measured preoperatively at the initial clinic visit (ICV) as well as 3 months, 6 months, and 1 year postoperatively. The primary outcome of interest was a comparison of subscapularis strength between cohorts relative to preoperative baseline, whereas secondary outcomes were functional, ROM, and PROMs. RESULTS: Sixty-six patients were included in the final analysis (32 TR vs. 34 SR). There were no statistically significant differences between cohorts at the ICV with regard to demographics, baseline subscapularis strength, functional testing, or PROMs. All postoperative time points demonstrated similar subscapularis strength testing between TR and SR groups (P > .05). Additionally, peak and average subscapularis strength testing at 3, 6, and 12 months postoperatively were similar to baseline ICV testing in both groups. Both groups demonstrated improvements across several provocative tests, ROM, and PROM outcome metrics at every postoperative time point as compared to baseline ICV values (P < .05). CONCLUSIONS: Patients undergoing anatomic TSA return to baseline internal rotation strength by 3 months postoperatively and demonstrate significant improvements in function, ROM, and several patient-reported outcome measures. The addition of early and focused subscapularis strengthening exercises does not appear to significantly impact any outcomes when compared to traditional rehabilitation programs.

Availability of Consumer Prices for Arthroscopic Meniscus Surgery.

The purpose is to examine the availability of consumer pricing information for arthroscopic meniscal surgery in the United States. Secondary objectives were comparing the price of meniscal repair to meniscectomy and regional pricing differences. Orthopaedic sports medicine clinics were sorted by state and randomly selected from American Orthopaedic Society for Sports Medicine's online directory. Following standardized script, each clinic was called a maximum of three times to obtain pricing information for meniscal surgery. A total of 1,008 distinct orthopaedic sport medicine practices were contacted. Six (6%) clinics were able to provide complete bundle pricing, and 183 (18.2%) clinics were able to provide physician-only fees for either meniscectomy or meniscal repair. Physician-only fees and bundle pricing were significantly less for meniscal repairs as compared to meniscectomies. There were no geographic regional differences in pricing for physician-only fees. There is a paucity of information regarding price transparency for arthroscopic meniscal surgery. (Journal of Surgical Orthopaedic Advances 32(2):083-087, 2023).

Multimodal Nonopioid Pain Protocol Provides Better or Equivalent Pain Control Compared to Opioid Analgesia Following Arthroscopic Rotator Cuff Surgery: A Prospective Randomized Controlled Trial.

PURPOSE: To evaluate the efficacy of a multimodal nonopioid analgesic protocol in controlling postoperative pain compared to opioids following a primary arthroscopic rotator cuff repair. METHODS: Seventy consecutive patients undergoing a primary rotator cuff repair were assessed for eligibility. An observer-blinded prospective randomized controlled trial was designed in accordance with the Consolidated Standards of Reporting Trials 2010 (CONSORT) statement. The two arms of the study included a multimodal nonopioid pain regimen for the experimental group, and a standard of care narcotics for the control group. The primary outcome was visual analog scale (VAS) pain scores for the first 10 postoperative days. Secondary outcomes included PROMIS-PI (Patient-Reported Outcomes Measurement Information System-Pain Interference) scale, patient satisfaction, and adverse drug events. RESULTS: Thirty patients declined to participate or were excluded, and 40 patients were included in the final analysis. A total of 23 patients were in the traditional group, and 17 patients were in the nonopioid group. Control patients on opioid pain management reported a significantly higher VAS pain score on postoperative day 1 (opioid: 5.7 ± 2, nonopioid: 3.7 ± 2.2; P = .011) and postoperative day 4 (opioid: 4.4 ± 2.7, nonopioid: 2.4 ± 2.2; P = .023). No significant difference was seen on any other postoperative day. When mixed measured models were used to control for confounding factors, the nonopioid group demonstrated significantly lower VAS and PROMIS-PI scores (P < .01) at every time point. Patients in the traditional analgesia group reported significantly more days with constipation (P = .003) and days with upset stomach (P = .020) than those in the nonopioid group. CONCUSSION: The present study found that a multimodal nonopioid pain protocol provided equivalent or better pain control compared to traditional opioid analgesics in patients undergoing primary arthroscopic rotator cuff repair. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort. All patients reported satisfaction with their pain management. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

Multimodal Nonopioid Pain Protocol Provides Equivalent Pain Versus Opioid Control Following Meniscus Surgery: A Prospective Randomized Controlled Trial.

PURPOSE: To assess the effectiveness of a nonopioid pain regimen in controlling postoperative pain as compared with a traditional opioid pain control following primary meniscectomy or meniscal repair. METHODS: Ninety-nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the Consolidated Standards of Reporting Trials 2010 statement. The 2 arms of the study included a multimodal nonopioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for the first 10 days postoperatively. Secondary outcomes included patient-reported outcomes, complications, and patient satisfaction. Randomization was achieved using a random-number generator. Patients were not blinded. Data collection was done by a blinded observer. RESULTS: Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen and 31 randomized to the nonopioid regimen. Patients receiving the nonopioid regimen demonstrated noninferior visual analog scale scores compared with patients who received opioid pain medication (P > .05). No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, P = .724) or postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, P = .064) Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form scores. No difference was found in recorded side effects between both groups at any given time point: constipation, nausea, diarrhea, upset stomach, and drowsiness (P > .05). CONCLUSIONS: This study found that a multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

Career Longevity and Performance After Shoulder Instability in National Football League Athletes.

PURPOSE: To investigate the career longevity, game utilization, and performance of National Football League (NFL) athletes after glenohumeral instability events treated operatively versus nonoperatively. METHODS: Using public resources, we identified NFL players who sustained a shoulder instability event from September 2000 to February 2019. Players with prior shoulder instability, without NFL experience before injury, or who did not return to play (RTP) after injury were excluded. Demographic information, utilization (games and seasons), and season approximate value (SAV) statistics were recorded 1 year prior to injury and 3 years after RTP. Statistical analysis compared utilization and the SAV after RTP for athletes managed operatively versus nonoperatively. RESULTS: We identified 97 NFL players who sustained their first instability event while playing in the NFL, 91 of whom returned to play (93.8%). Quarterbacks were significantly more likely to undergo immediate surgical management compared with players in other positions (P = .023). The final analysis included 58 players managed operatively and 33 managed nonoperatively by the end of the index season. Players treated operatively played in significantly more seasons after RTP during their remaining careers (4.1 ± 2.7 seasons vs 2.8 ± 2.5 seasons, P = .015). There were no differences in games played or started, offensive or defensive snap count percentage, or performance (SAV) before and after injury when compared between cohorts (P > .05). After surgical stabilization, time to RTP (36.62 ± 10.32 weeks vs 5.43 ± 12.33 weeks, P < .05) and time interval before recurrent instability (105.7 ± 100.1 weeks vs 24.7 ± 40.6 weeks, P < .001) were significantly longer than with nonoperative treatment. Additionally, the operative cohort experienced less recurrent instability (27% vs 50%, P = .035). CONCLUSIONS: Athletes who RTP in the NFL after a shoulder instability injury do so with a similar workload and performance irrespective of surgical or nonsurgical management. Whereas nonoperative treatment is associated with faster RTP, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Multimodal nonopioid pain protocol provides equivalent pain control versus opioids following arthroscopic shoulder labral surgery: a prospective randomized controlled trial.

BACKGROUND: This study aimed to compare postoperative pain and patient satisfaction in patients undergoing primary arthroscopic labral surgery managed with either a nonopioid alternative pain regimen or a traditional opioid pain regimen. METHODS: Sixty consecutive patients undergoing primary arthroscopic shoulder labral surgery were assessed for participation. In accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement, a prospective randomized controlled trial was performed. The 2 arms of the study were a multimodal nonopioid analgesic protocol as the experimental group and a standard opioid regimen as the control group. The primary outcome was postoperative pain scores (on a visual analog scale [VAS]) for the first 10 days postoperatively. Secondary outcomes included patient satisfaction, patient-reported outcomes, and complications. Randomization was performed with a random number generator, and all data were collected by blinded observers. Patients were not blinded. RESULTS: Twelve patients did not meet the inclusion criteria or declined to participate. Thus, 48 patients were included in the final analysis: 24 in the nonopioid group and 24 in the opioid group. There was no significant difference in VAS or PROMIS (Patient-Reported Outcomes Measurement Information System) scores between patients in the 2 cohorts on any postoperative day (P > .05). When we controlled for confounding factors with repeated-measures mixed models, the nonopioid cohort reported significantly lower VAS and PROMIS (Patient-Reported Outcomes Measurement Information System) Pain Interference scores (P < .01) at all time points. No difference was found in reported adverse events (constipation, diarrhea, drowsiness, nausea, and upset stomach) between cohorts at any time point (P > .05). CONCLUSION: This study found that a multimodal nonopioid pain regimen provided, at the minimum, equivalent pain control, an equivalent adverse reaction profile, and equivalent patient satisfaction when compared with a standard opioid-based regimen following arthroscopic shoulder labral surgery.

High Return to Play Rate and Diminished Career Longevity are Seen Following Arthroscopic Shoulder Labral Repair in Major League Baseball Players.

Purpose: To evaluate the impact of arthroscopic shoulder labral repair, not related to instability, on return to play (RTP), return to prior performance (RTPP), game utilization, and performance in Major League Baseball (MLB) pitchers and positional players. Methods: A retrospective review of all MLB athletes who underwent arthroscopic shoulder labrum repair from 2002 to 2020 was performed. Players with a history of instability events were excluded. A 2:1 control cohort of healthy MLB players were matched to the operative cohort by age, years of experience, position, height, and body mass index (BMI). Player demographics, game utilization, and performance metrics were collected for all players. Results: Twenty-six of 39 MLB pitchers (66%) and 18 of 25 (72%) positional players, who underwent arthroscopic shoulder labral repair RTP, with 46.2% of pitchers and 72% of positional players successfully RTP. At one season postsurgery, pitchers and positional players experienced a significant reduction in games played compared to their one season preinjury (44.7 ± 29.3 vs 109.5 ± 73.2 games; P < .001 and 75.7 ± 47.1 vs 98.0 ± 50.7 games; P = .04). When compared with matched controls at one season postinjury, pitchers had significantly fewer runs allowed per 9 innings (5.8 ± 2.0 vs 4.3 ± 1.4; P = .0061) and walk and hits per inning pitched (WHIP) (1.5 ± 0.3 vs 1.3 ± 0.2; P = .0035), while positional players had worse on-base percentage (0.3 ± 0.1 vs 0.3 ± 0.1; P = .0116). Both pitchers and positional players experienced significantly shorter career lengths after surgery (P = .002) when compared to controls. Conclusions: Following arthroscopic shoulder labral surgery, most MLB pitchers and positional players were able to RTP successfully but experienced shorter careers thereafter. These players also experienced declines in game utilization and performance one season after surgery but were able to return to baseline at 3 seasons after surgery. Level of Evidence: Level III, retrospective case control.

Patient factors influencing the choice of opioid versus non-opioid postoperative analgesia following common sports procedures: a prospective survey study.

Purpose: Despite established opioid-free protocols for postoperative analgesia after common orthopaedic sports procedures, many patients continue to request opioids postoperatively. The purpose of this study was to elucidate patient factors influencing preferences for opioid versus nonopioid postoperative analgesia. Methods: Patients (age >/ = 15) without a history of a documented chronic pain disorder who were scheduled for one of ten sports procedure types from August 2020 to May 2021 were eligible for inclusion. Patients were excluded if undergoing revision surgery, had concomitant injuries, had opioids use >3 months preoperatively, or unable to read English. Recruitment ended after 100 patients enrolled. At the patients' preoperative visit, patients were administered a written survey assessing pain medication preferences. Participants completed the Opioid Risk Tool survey, as well as Visual Analog Scale and Patient-Reported Outcome Measurement Information System surveys. Results: One hundred patients participated in the study. Forty-two patients preferred opioids versus 58 patients preferring nonopioid postoperative analgesia. Patients preferring opiates were more likely to have had previous surgery (90.2% vs. 69.6%, p = 0.023) with post-operative pain managed with opiates (87.5% vs 55.4%, p = 0.003), higher preoperative Visual Analog Scale score (6±3.5 vs. 3±2, p < 0.001), reported post-operative pain as a reason for opioids preference (88.1% vs 20.0%, p < 0.001), and were less concerned about addiction (4.8% vs. 45.5%, p < 0.001) and side effects (11.9% vs. 52.7%, p < 0.001). For every unit increase in Visual Analog Scale score, the odds of preferring opioid pain control increased 1.41 times. Conclusions: Patients with a history of prior surgery utilizing opioid pain control, higher Visual Analog Scale scores preoperatively, and concern for inadequately managed postoperative pain were more likely to prefer opioid pain control following common orthopaedic sports procedures. Patients may benefit from increased preoperative education about opioid risks and the role of multimodal pain management regimens.

Effects of a Perioperative Blood Flow Restriction Therapy Program on Early Quadriceps Strength and Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction.

Background: Quadriceps muscle atrophy remains a limiting factor in returning to activity after anterior cruciate ligament reconstruction (ACLR). Blood flow restriction (BFR) therapy may accelerate quadriceps strengthening in the perioperative period. Purpose: To evaluate postoperative isometric quadriceps strength in patients who underwent ACLR with a perioperative BFR program. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients indicated for ACLR were randomized into 2 groups, BFR and control, at their initial clinic visit. All patients underwent 2 weeks of prehabilitation preoperatively, with the BFR group performing exercises with a pneumatic cuff set to 80% limb occlusion pressure placed over the proximal thigh. All patients also underwent a standardized postoperative 12-week physical therapy protocol, with the BFR group using pneumatic cuffs during exercise. Quadriceps strength was measured as peak and mean torque during seated leg extension and presented as quadriceps index (percentage vs healthy limb). Patient-reported outcomes (PROs), knee range of motion, and quadriceps circumference were also gathered at 6 weeks, 3 months, and 6 months postoperatively, and adverse effects were recorded. Results: Included were 46 patients, 22 in the BFR group (mean age, 25.4 ± 10.6 years) and 24 in the control group (mean age, 27.5 ± 12.0 years). At 6 weeks postoperatively, the BFR group demonstrated significantly greater strength compared with the controls (quadriceps index: 57% ± 24% vs 40% ± 18%; P = .029), and the BFR group had significantly better Patient-Reported Outcomes Measurement Information System-Physical Function (42.69 ± 5.64 vs 39.20 ± 5.51; P = .001) and International Knee Documentation Committee (58.22 ± 7.64 vs 47.05 ± 13.50; P = .011) scores. At 6 weeks postoperatively, controls demonstrated a significant drop in the peak torque generation of the operative versus nonoperative leg. There were no significant differences in strength or PROs at 3 or 6 months postoperatively. Three patients elected to drop out of the BFR group secondary to cuff intolerance during exercise; otherwise, no other severe adverse events were reported. Conclusion: Integrating BFR into perioperative physical therapy protocols led to improved strength and increased PROs at 6 weeks after ACLR. No differences in strength or PROs were found at 3 and 6 months between the 2 groups. Registration: NCT04374968 (ClinicalTrials.gov identifier).

No Differences in Exercise Performance, Perceptual Response, or Safety Were Observed Among 3 Blood Flow Restriction Devices.

Purpose: To compare 3 separate blood flow restriction (BFR) systems in their capacity to reduce repetitions to failure, impact perceptual responses, and cause adverse events during a low-load free-flow exercise. Methods: The study included healthy subjects aged 18 years or older who presented to an ambulatory-care sports medicine clinic. On day 1, participants' demographic characteristics and anthropomorphic measurements were recorded. Each participant performed dumbbell biceps curl repetitions to failure using 20% of his or her 1-repetition maximum weight with each arm. Participants were exposed to 3 different tourniquet systems for familiarization. On day 2, each participant's arm was randomized to a cuff system, and the participant performed 2 sets of biceps curl repetitions to failure with the cuff inflated. Repetitions to failure, rating of perceived effort (RPE), rating of perceived discomfort, and pulse oxygenation levels were recorded after each set. On day 3, participants completed a survey of their perceived delayed-onset muscle soreness. Results: The final analysis was performed on 42 arms, with 14 limbs per system. The study population had a mean age of 28.7 ± 2.4 years and a mean body mass index of 24.9 ± 4.3. All 3 systems successfully reduced repetitions to failure compared with unrestricted low-load exercise from baseline to BFR set 1 and from baseline to BFR set 2. There were no significant between-group differences among BFR systems regarding the number of repetitions to failure performed at baseline versus BFR set 1 or BFR set 2. The Delfi Personalized Tourniquet System (PTS) cohort had the greatest reductions in repetitions to failure from BFR set 1 to BFR set 2 (P = .002) and reported the highest RPE after set 2 (P = .025). Conclusions: The Delfi PTS, SmartCuffs Pro, and BStrong BFR systems were each safe and were able to significantly reduce repetitions to failure compared with a low-load free-flow condition when used in a BFR exercise protocol. The Delfi PTS system may produce a higher RPE with prolonged use in comparison to the other systems. Level of Evidence: Level II, prospective cohort study.

Survey of blood flow restriction therapy for rehabilitation in Sports Medicine patients.

Background: Blood flow restriction (BFR) therapy has demonstrated benefits across a spectrum of musculoskeletal injuries, including improved strength, endurance, function, and reduction in pain perception. There is, however, no standardized application of BFR therapy among orthopaedic surgeons within the United States (US). Hypothesis: The indication and protocol for BFR therapy vary significantly across providers in the US. Methods: An online survey of 21 multiple-choice questions was sent to 3,281 surgeons listed on a large orthopaedic registry. A cross-sectional study was performed on all surgeons who successfully completed the questionnaire. Surgeons were queried on current or planned use of BFR, indications, contraindications, and peri-operative and non-operative management of sports-related injuries. Results: Overall, 250 physicians completed the survey, with 149 (59.8%) reporting current BFR use and 75.2% initiating use in the last 1-5 years. Most protocols (78.8%) utilize the modality 2-3 times per week while 15.9% use it only once weekly. Anterior cruciate ligament reconstruction (ACLR) rehabilitation was the most reported indication for initiating BFR therapy (95.7%) along with medial patellofemoral ligament reconstruction (70.2%), multiligamentous knee reconstruction (68.8%), meniscus repair (62.4%), collateral ligament reconstruction (50.4%), Achilles tendon repairs (30.5%), and meniscectomy (27%). Only 36.5% reported using BFR after upper extremity procedures, such as distal biceps repair (19.7%), ulnar collateral ligament elbow reconstruction (17%), rotator cuff (16.8%), and shoulder labrum repair (15.3%). For non-operative injuries, 65.8% of surgeons utilized BFR. Of those not currently using BFR therapy, 33.3% intended to implement its use in the future. Conclusion: BFR therapy has increased in popularity with most physicians implementing its use in the last 5 years. BFR was commonly utilized after ACLR. Clinical relevance: BFR allows light-load resistance to simulate high-intensity resistance training. This study describes US orthopaedic surgeons' common practice patterns and patient populations that utilize BFR therapy.

Concussions in the National Hockey League: Analysis of Incidence, Return to Play, and Performance.

BACKGROUND: Concussion injuries are common in professional hockey; however, their effect on player performance remains unclear. PURPOSE: To quantify the effect of concussions on the performance of position players in the National Hockey League (NHL). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Concussion data from the NHL were collected using publicly available databases for the seasons between 2009-2010 and 2015-2016, coinciding with new NHL concussion rules. Age, body mass index, position, number of concussions during a player's NHL career, games played, and time on ice were recorded. Basic and advanced performance metrics were collected for 1 season pre- and postconcussion (short-term period) and 3 seasons before and after concussion (long-term period) to assess short- and long-term changes in performance. A control group of players without an identified concussion who competed during the study period was assembled for comparison. Wilcoxon signed rank tests were used to evaluate pre- to postconcussion data in the short- and long-term settings as well as to compare the cohorts at each time point. RESULTS: Overall, 48 players were identified as having a concussion during the study period. Players missed 17.2 ± 15.1 days (mean ± standard deviation) and 7.5 ± 6.9 games postconcussion. There were no significant differences in any metric when pre- and postconcussion intraseason performance was assessed. Athletes who were concussed demonstrated significantly deceased performance metrics (assists per 60 minutes, points per 60 minutes, Corsi percentage, and Fenwick percentage) in the 3 years after the concussion as compared with the year before injury (P < .05). However, no difference was found between the concussed group and matched control group in the short- or long-term period. Players with concussion played fewer career games (856.4 ± 287.4 vs 725.7 ± 215.0; P < .05) than did controls. CONCLUSION: A high rate of NHL players were able to return to play after a concussion injury. Players with concussion did not experience a reduction in performance metrics in the short- or long-term setting when compared with matched controls. The concussed cohort maintained a similar workload up to 3 seasons postconcussion but played in fewer career games when compared with matched controls.

Reduced Career Longevity but Return to Baseline Performance After Arthroscopic Shoulder Labral Repair in National Hockey League Players.

Purpose: To investigate the impact of arthroscopic shoulder labral repair without shoulder instability on career longevity, game use, and performance in National Hockey League (NHL) athletes. Methods: A retrospective review of all NHL players who underwent arthroscopic shoulder labral repair from 2004 to 2020 was performed. A 2:1 matched control group was used for comparison. Controls were matched by age, body mass index, position, and experience prior to the index year. Demographic characteristics, game use, and performance metrics were collected for all athletes. Statistical analysis examined game use and performance both at 1-year and 3-year follow-up compared with one season before injury. Results: Twenty-nine players who underwent arthroscopic shoulder labral surgery returned to play (100%) and were matched with 55 control players. The operative cohort experienced shorter careers compared with controls (4.4 ± 3.1 vs 6.0 ± 3.6 seasons, P < .05). After one season, injured players experienced significant reductions in goals per 60 (0.6 ± 0.4 vs 0.8 ± 0.5, P = .013), points per 60 (1.5 ± 0.9 vs 2.0 ± 0.9, P = .001), and shooting percentage, (8.5 ± 5.8 vs 10.5 ± 5.2, P = .02) compared with the year prior. The reduction in goals (0.6 ± 0.4 vs 0.8 ± 0.5, P = .01) and shooting % (8.5 ± 4.7 vs 10.5 ± 5.2, P = .04) persisted at 3 years. Compared with controls, the surgical group experienced significant reductions at one season postindex in percentage of goals, assists, points per 60, and shooting percentage. Only the reduction in goals per 60 persisted at 3 seasons postindex. Conclusions: Following return to play after arthroscopic shoulder labral repair, NHL players demonstrated reduced career longevity compared with healthy controls. Players exhibited significant reductions in game use and performance at one season after injury but returned closer to baseline after 3 seasons. Level of Evidence: Level III; retrospective case control.

Maximum subjective outcome improvement is reported by 3 Months following arthroscopic partial meniscectomy: A systematic review.

Purpose: To review patient outcomes in the literature following arthroscopic partial meniscectomy (APM) in order to identify when patients report reaching subjective maximal improvement postoperatively. Methods: A systematic review of the literature from January 2004 to August 2019 was conducted using PRISMA guidelines to identify articles evaluating patient-reported outcome measures (PROMs) up to a minimum of 6 months after APM in patients >18 years old. Studies were excluded if additional interventions were performed such as repairs, ligamentous reconstruction or repair, cartilaginous manipulation, or revision surgery. PROMs were pooled between studies at preoperative, 3 months, 6 months, 1 year, and 2 year time points. Weighted averages were used within a mixed model method in order to account for the differences in sample size and variance among studies. Significant improvements in PROMs at various time intervals were statistically analyzed using minimal clinically important difference. Results: A total of 12 studies including 1663 patients who underwent APM were selected for the review. The pooled cohort consisted of 1033 (62%) males and 630 (38%) females. Significant improvements were demonstrated from preoperative scores to 3 months postoperatively in Knee Injury and Osteoarthritis Outcome Score subcategories, Lysholm, and visual analog scale scores while no differences were found for Tegner and International Knee Documentation Committee scores. Although statistically significant improvement in PROMs remained at all postoperative time points compared to preoperative scores, no significant differences were observed after 3 months postoperatively. Conclusions: Patients undergoing APM had significant mean changes in legacy PROMs by 3 months postoperatively that exceeded given minimal clinically important difference values, without further clinically important improvement reported up to 2 years postoperatively. Study design: Level III, systematic review.

Patellar Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments.

¼: Patellar tendinopathy is an attritional injury of the patellar tendon that is frequently identified in jumping athletes. Through repetitive or explosive movements, considerable loads and high peak strains are generated across the patellar tendon. ¼: This leads to microinjury of tendon fibers, local mucoid degeneration, and loss of the fibrocartilaginous tissue that attaches tendon to bone. ¼: Management of patellar tendinopathy often begins with nonoperative modalities: progressive tendon loading and eccentric rehabilitative exercise programs are the most effective. While a variety of additional treatment modalities are available, the comparative efficacy of these supportive treatments is not well differentiated at this time. ¼: In this article, we analyze the existing literature regarding nonoperative treatment of patellar tendinopathy and provide additional insight on the effectiveness of current modalities.

Lower Extremity Injury After Return to Sports From Concussion: A Systematic Review.

BACKGROUND: Recent studies have suggested increased rates of lower extremity (LE) musculoskeletal injury after a diagnosed concussion, although significant heterogeneity exists. PURPOSE: To examine the current body of research and determine whether there is an increased risk for LE musculoskeletal injury after a concussion and to identify populations at an increased risk. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A systematic review of current literature using MEDLINE and PubMed databases was performed. Keywords included concussion, athlete, lower extremity injury, and return to sport. Inclusion criteria required original research articles written in the English language examining the rate of LE injuries after a diagnosed concussion. RESULTS: A total of 13 studies involving 4349 athletes (88.1% male and 11.9% female; mean age, 19.8 years) met inclusion criteria. Athletes were classified as high school (46.1%), collegiate (17.0%), or professional (36.9%). Of the 13 studies, 4 demonstrated an increased risk of LE injury within 90 days of a diagnosed concussion (odds ratio [OR], 3.44; 95% CI, 2.99-4.42), and 6 revealed an elevated risk of injury within 1 year of concussion (OR, 1.85; 95% CI, 1.73-2.84). Increased risk was seen in professional (OR, 2.49; 95% CI, 2.40-2.72) and collegiate (OR, 2.00; 95% CI, 1.96-2.16) athletes compared with high school athletes (OR, 0.97; 95% CI, 0.89-1.05). A stepwise increase in risk of sustaining an LE injury was observed with multiple concussions, with increasing risk observed from ≥2 (OR, 2.29; 95% CI, 1.85-2.83) to ≥3 (OR, 2.86; 95% CI, 2.36-3.48) career concussions. CONCLUSION: An increased incidence of LE injuries was observed at 90 days and 1 year after the diagnosis of a concussion. Higher levels of competition, such as at the collegiate and professional levels, resulted in an increased risk of sustaining a subsequent LE injury after a diagnosed concussion. These results suggest an at-risk population who may benefit from injury prevention methods after a concussion. Future studies should focus on identifying which injuries are most common, during what time period athletes are most vulnerable, and methods to prevent injury after return to sports.

An Automated Technique for the Measurement of Limb Occlusion Pressure During Blood Flow Restriction Therapy Is Equivalent to Previous Gold Standard.

Purpose: To evaluate the efficacy of an automated pneumatic torniquet pump and its ability to automatically calculate the limb occlusion pressure (LOP), as compared with the manual Doppler ultrasound technique. Methods: Participants presenting to a Sports Medicine clinic were evaluated for study enrollment. Participants were fitted with a pneumatic tourniquet for the upper and lower extremity. LOP measurements were taken with a Doppler ultrasound or automated SmartCuffs PRO device in a randomized order. Results: Final analysis was performed on 96 limbs (48 upper extremities and 48 lower extremities). The study population had a mean age 37.1 ± 14.7 years old and a mean body mass index of 25.47 ± 3.80. The mean measured LOP pressure on the upper extremity with Doppler ultrasound was 174.0 ± 48.7 mm Hg with a range from 120 to 282 mm Hg, whereas the mean measured LOP by the automated pump was 184.0 ± 44.9 mm Hg with a range from 135 to 266 mm Hg. There was no statistically significant difference found between the Doppler LOP and the Smart Cuff upper extremity LOP (P = .29). When evaluating LOP pressure on the lower extremity the mean LOP found with the Doppler ultrasound was 195.0 ± 31.9 mm Hg with a range from 160 to 272 mm Hg, whereas the automated pump the mean LOP was 205.0 ± 27.1 mm Hg with a range from 168 to 278 mm Hg. There was no statistically significant difference found between the Doppler LOP and the automated pump lower extremity LOP (P = .09). Conclusions: No difference in the personalized LOP measurement was found when comparing an automated pump with the current gold standard of manual Doppler ultrasound. No patients companied of pain or discomfort during the LOP measurement. Level of Evidence: Level II, diagnostic: prospective cohort study.

The Use of Biologics for Hip Preservation.

PURPOSE OF REVIEW: A wide array of nonoperative modalities to treat hip pain are aimed at restoring and maintaining the structural and physiologic characteristics of the joint. The purpose of this review is to describe the current understanding of biologics in hip pathology by providing an evidence-based overview of treatment modalities available for orthopedic surgeons. RECENT FINDINGS: The use of biologics as a primary treatment or adjunct to traditional management has shown encouraging results for the treatment of hip pain. Studies have demonstrated safety with minimal complications when using platelet rich plasma, hyaluronic acid, or stem cells to treat hip pain caused by osteoarthritis, femoroacetabular impingement syndrome, tendinopathy, or osteonecrosis of the femoral head. Several studies have been able to demonstrate meaningful clinical results that can improve treatment standards for hip pain; however, more work must be performed to better delineate the appropriate protocols, indications, and limitations of each modality. Recent advances have inspired renewed interest in biologics for patients with hip pain. We present a concise review of platelet rich plasma, hyaluronic acid, stem cells, and matrix metalloprotease inhibitors and their applicability to hip preservation surgery.