Imaging Modalities in the Preoperative Assessment of Femoroacetabular Impingement and Hip Dysplasia: Determining Best Practices.

¼ In the last decade, significant progress has been made in understanding hip pain, especially related to femoroacetabular impingement (FAI) and hip dysplasia (HD), which collectively affect over 20% of the population.¼ Preoperative imaging, including plain radiographs, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US), plays a pivotal role in diagnosing FAI and HD. Imaging precision, standardized techniques, and accurate interpretation are crucial for effective treatment planning.¼ The continual advancements in imaging techniques, especially seen in MRI (arthrograms, application of leg traction, and delayed gadolinium-enhanced MRI of cartilage), represent important strides in the precise assessment of pathology associated with FAI and HD.¼ By incorporating these advancements into routine imaging protocols, healthcare providers can ensure a comprehensive understanding of hip joint dynamics, enabling more accurate diagnosis and effective management strategies for patients with FAI and HD, ultimately leading to improved clinical outcomes.

Outcomes following open acetabular labrum reconstruction: Comparing fresh-frozen tendon with fresh meniscus allograft transplantation.

Background: Symptomatic acetabular labral insufficiency in young, active patients is often treated with labral repair or reconstruction using fresh-frozen allografts. However, fresh-frozen tendon allografts do not have tissue or material properties that closely mimic acetabular labral fibrocartilage. Recent studies suggest meniscal allografts may be a better biomechanical, geometric, and material alternative for acetabular labrum reconstruction (ALR). Hypothesis: Patients undergoing open ALR using fresh meniscus allograft transplants (MAT) will have better outcomes than those using fresh-frozen tendon allografts transplants (TAT) when comparing initial treatment success, diagnostic imaging assessments, and patient-reported pain and function scores. Study design: Cohort Study. Methods: With IRB approval, patients undergoing ALR with either TAT or MAT were included when initial (>1-year) outcomes data related to treatment success, pain, and function were available. In addition, a subcohort of patients underwent magnetic resonance imaging at least 6-months after surgery to evaluate allograft healing. Results: Initial success rate, defined as no need for ALR revision or conversion to total hip arthroplasty (THA), was 88.9% for the entire group (n = 27, TAT = 5, MAT = 22) with 1 (20%) patient in the TAT cohort and 2 patients (9.9%) in the MAT cohort undergoing THA. In the MAT cohort, significant improvements were documented for physical function and pain scores at 1 year and final follow-up (FFU)(mean 26.8 months). Improvements in pain and function were noted at 1-year, but not at FFU (mean 59.6 months) in the TAT group. MRIs completed at least 6 months after labrum reconstruction showed improved allograft integrity and integration in the MAT cohort over the TAT cohort. Conclusion: For acetabular labrum reconstructions, MAT was associated with a higher initial success rate, superior patient reported outcomes, and subjectively better MRI findings when compared to TAT.

Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist.

Purpose: To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery. Methods: A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. Results: Nine articles (level II-IV studies) were included in the final analysis. A total of 887 patients (54% male, average age 45 years) underwent arthroscopic surgery, including general knee (n = 3 studies), ACLR-only knee (n = 1 study), rotator cuff repair (n = 4 studies), and hip (n = 1 study). The Brief Resilience Scale was the most common instrument measuring resilience in 7 of 9 studies (78%). Five of 9 studies (56%) stratified patients based on high, normal, or low resilience cohorts, and these stratification threshold values differed between studies. Only 4 of 9 studies (44%) measured PROs both before and after surgery. Three of 9 studies (33%) reported rates of return to activity, with 2 studies (22%) noting high resilience to be associated with a higher likelihood of return to sport/duty, specifically after knee arthroscopy. However, significant associations between resilience and functional outcomes were not consistently observed, nor was resilience consistently observed to be predictive of subjects' capacity to return to a preinjury level of function. Conclusions: Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn. Level of Evidence: Level IV, systematic review of level II-IV studies.

Editorial Commentary: Pie-Crusting for Medial Meniscal Root Repair Shows Improved Outcomes Without Laxity.

Arthroscopic access to the posterior root of the medial meniscus is often difficult in a tight medial compartment. To facilitate ease of access, partial lengthening of the medial collateral ligament (MCL) "pie-crusting" has been advocated to increase the working space of the medial compartment during arthroscopy. Purported benefits of MCL include increased visualization and decreased misdiagnosis during diagnostic arthroscopy, decreased iatrogenic chondral injuries with instrumentation, and postoperative medial compartment off-loading. Several techniques of MCL lengthening have been described including percutaneous lengthening, transportal lengthening, and mini-open lengthening. The safety of MCL lengthening has been demonstrated. Patients receiving MCL lengthening have no difference in postoperative laxity, postoperative pain, nor damage to surrounding structures. MCL lengthening also shows improved patient outcome scores and decreased rates of retear of medial meniscal root tear repair.

The effect of pre-operative shoulder injections on post-operative opioid use, infection and revision following shoulder arthroplasty.

Background: Treatment of glenohumeral osteoarthritis (GHOA) may include conservative management with use of intraarticular injections, prior to considering total shoulder arthroplasty (TSA). The purpose of this study was to assess trends in the use of preoperative cortisone (CO) and hyaluronic acid (HA) injections, as well as investigate the relationship between injection use and infection or revision arthroplasty following TSA. Methods: Pearl Driver was used to identify all patients undergoing TSA for GHOA between 2010 and 2018. Patients were categorized based on the type and number of injections they received. Outcomes of interest included post-operative opioid use, post-operative infection, and risk of revision surgery within 1 year of the index procedure. Results: The incidence of patients receiving a CO or HA injections within 1 year of their TSA decreased by 83% and 54%, respectively. Patients who had received 1 or more steroid injections had higher odds of prolonged opiate use following surgery. Patients that received 1 or 2 CO injection prior to TSA had an increased risk of needing revision surgery. Discussion: Use of intraarticular injections for the management of GHOA has declined. Patients receiving preoperative injections had increased odds of prolonged opiate use and the need for revision surgery.

Anterior Cruciate Ligament Return to Play: Where Are We Now?

Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure, and it is crucial to assess an athlete's readiness to safely return to sports following ACLR to minimize the risk of reinjury. Despite this, determining optimal return to play (RTP) criteria following ACLR that is accurate, accessible, and reproducible remains challenging. This review aims to discuss commonly employed RTP criteria domains, including functional assessments, patient-reported outcomes, and psychological tests, as well as emerging technologies such as magnetic resonance imaging (MRI) that may play a role as a gold standard in RTP assessment. The findings of this review suggest RTP decision making after ACL surgery is nuanced and traditionally used objective measures do not perfectly predict RTS rates or clinical outcomes. In the future, a standardized MRI screening tool could help predict reinjury. The role of functional and psychological patient-reported outcome measures needs to defined, and objective criteria should be rigorously evaluated for whether they accurately screen an athlete's physical readiness and should be expanded to include more sport-specific movement analysis.

Effect of High School Showcase Exposures and Timing of Ulnar Collateral Ligament Tear on Professional Baseball Careers in Elite Pitchers.

BACKGROUND: Showcase participation has been considered a risk factor for elbow injuries. It remains unclear whether high school (HS) showcase volume negatively affects pitchers' career paths. Because pitchers are achieving 90 mph thresholds at younger ages, it is unknown whether shorter time intervals between achieving 90 mph thresholds and dates of ulnar collateral ligament reconstruction (UCL-R), known as time to tear (TTT), may affect career trajectory. HYPOTHESIS: Elite pitchers with higher HS showcase volumes would be less likely to reach Major League Baseball (MLB) level compared with elite pitchers with fewer HS showcase appearances. Elite pitchers with longer TTT intervals would be more likely to achieve MLB level. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Demographic, HS showcase and professional performance, and injury data from pitchers selected in the first 5 rounds of the MLB draft (2011-2017) were gathered from publicly available databases. Continuous and categorical variables were compared for the following subgroups: UCL-R group and pitcher group not undergoing UCL-R; "early" and "late" UCL-R groups; and pitchers achieving and pitchers not achieving MLB level. Multivariable analysis was performed using logistic regression. Standard deviations of ±1 SD were used to define early career versus late career UCL-R subgroups after normal distribution was confirmed (Shapiro-Wilk test; P = .227). The early UCL-R group was defined as those pitchers undergoing UCL-R ≤-1 SD from the mean age at first injury (group mean age, 19.43 years), whereas the late UCL-R group was defined as ≥+1 SD from that age (group mean age, 25.19 years). RESULTS: Of 611 pitchers, 455 (74.5%) had HS showcase performance data, and 608 (99.5%) had professional performance data. In total, 184 (30.1%) pitchers underwent UCL-R. Fewer pitchers who underwent early UCL-R achieved the MLB level compared with pitchers who underwent late UCL-R (48.1% vs 86.2%; P = .006). Elite pitchers who pitched in ≥10 showcases in HS had half the odds of achieving the MLB level compared with pitchers who participated in <10 HS showcases (adjusted odds ratio, 0.50; 95% CI, 0.29-0.86; P = .012). For every year longer that an elite pitcher did not tear his UCL after achieving the 90 mph threshold at an HS showcase (TTT after 90 mph [per year]), the likelihood of achieving the MLB level increased by 24% (adjusted odds ratio, 1.24; 95% CI, 1.02-1.52; P = .032). CONCLUSION: Higher HS showcase volume in elite pitchers was associated with a lower likelihood of achieving MLB level. A longer TTT after 90 mph (per year) was significantly associated with achieving MLB level in elite pitchers.

Patellar Instability.

➢: Certain anatomic factors, such as patella alta, increased tibial tubercle-trochlear groove distance, rotational deformity, and trochlear dysplasia, are associated with an increased risk of recurrent patellar instability. ➢: The presence of a preoperative J-sign is predictive of recurrent instability after operative management. ➢: Isolated medial patellofemoral ligament reconstruction may be considered on an individualized basis, considering whether the patient has anatomic abnormalities such as valgus malalignment, trochlear dysplasia, or patella alta in addition to the patient activity level. ➢: More complex operative management (bony or cartilaginous procedures) should be considered in patients with recurrent instability, malalignment, and certain anatomic factors.

Trends in operative duration of total shoulder arthroplasty from 2008 to 2018: a national database study.

Background: As total shoulder arthroplasty has emerged as the fastest growing joint replacement performed, optimizing surgical efficiency and patient outcomes is essential. The goals of the current study were to identify trends and factors affecting the operative time of total shoulder arthroplasty over a 10-year period. Methods: The National Surgical Quality Improvement Program database was analyzed to determine the operative time and 30-day complications of total shoulder arthroplasty from 2008 to 2018. Factors affecting total shoulder arthroplasty operative time were also assessed. Multivariable linear regression was used to analyze operative time over years studied while controlling for patient demographics and comorbidities. Results: A total of 20,587 total shoulder arthroplasty cases from 2008 to 2018 were included. Mean operative time in 2008 was 139.0 min, while in 2018, mean operative time decreased to 105.6 min (P < .001). Male sex, outpatient surgery, increased body mass index, and low preoperative hematocrit were associated with longer operative times, while elevated international normalized ratio, resident involvement, and elective surgeries were associated with decreased operative duration. Discussion: Operative time for total shoulder arthroplasty has decreased from 2008 to 2018. Patient factors and comorbidities are associated with operative time, and such factors are important to consider in operative planning to ensure appropriate patient and surgeon expectations.

Editorial Commentary: Meniscal Repair, When Possible, Is Better for Patients Than Meniscectomy.

Patients do not do as well after meniscectomy as after repair. Although saving the meniscus is not always easy and the success rate of repair is not 100%, repair-when possible-remains the best option for patients in the long run. Meniscal repair rates are on the rise, especially in younger patients, but are not high enough. Recent research has shown that more than 95% of meniscal procedures are partial meniscectomies. Improved surgical techniques and instrumentation, as well as a continued increase in understanding the importance of repair, are leading to an increase in meniscal repair rates. Preserve as much meniscus as possible and as often as possible.

Ulnar Collateral Ligament Tear in Elite Baseball Pitchers: Are High School Showcase Exposures Associated With Injury?

BACKGROUND: Ulnar collateral ligament reconstruction (UCLR) surgeries have increased significantly in amateur and professional baseball pitchers. Although showcase participation has been considered an injury risk factor, limited data are available to corroborate this association. HYPOTHESIS: Elite pitchers achieving fastball velocities ≥90, ≥92, and ≥95 mph at younger ages would be more likely to undergo UCLR earlier in their careers compared with pitchers not achieving these velocity thresholds at younger ages. Elite pitchers participating in high showcase volumes would be more likely to undergo UCLR compared with elite pitchers participating in fewer showcases. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Descriptive, showcase performance, and injury data from pitchers selected in the first 5 rounds of the Major League Baseball draft (2011-2020) were gathered from publicly available databases. Continuous and categorical variables for pitchers undergoing UCLR and those not undergoing UCLR were compared, and multivariable analysis was performed using logistic regression. We used standard deviations (SDs) of ±1 SD of mean age at first UCLR to define early-career versus late-career UCLR subgroups after normal distribution was confirmed (Shapiro-Wilk test; P = .183). The "early" UCLR group was defined as ≤-1 SD (19.09 years), whereas the "late" UCLR group was defined as ≥+1 SD (24.79 years). Trends in time were evaluated using linear regression. RESULTS: Of the 845 pitchers selected, 659 pitchers (78.0%) had retrievable showcase performance data. Of the 845 pitchers, 229 (27.1%) underwent UCLR. Peak fastball velocity recorded at showcases was the strongest predictor of UCLR (adjusted odds ratio, 1.19; 95% CI, 1.02 to 1.39; P = .03). Peak fastball velocity in high school (HS) was significantly higher among pitchers who underwent UCLR compared with pitchers in the no-UCLR group (91.57 vs 90.71 mph, respectively; 95% CI, -1.43 to -0.29; P < .01). Age at which pitchers participated in their first HS showcase was significantly younger for the early versus the late UCLR group (15.53 vs 16.51 years, respectively; 95% CI, -1.53 to -0.41; P < .01). Elite pitchers with early UCLR participated in nearly twice as many showcases compared with the late UCLR group (5.38 vs 2.89, respectively; 95% CI, 0.43 to 4.54; P = .02). The mean number of HS showcases that elite pitchers attended more than doubled during the 2011-2020 study period (from 2.88 to 6.00 total showcases; P < .001). Mean age at which pitchers attended their first HS showcase steadily declined as well over the 10-year period (from 16.52 to 15.63 years; P < .001). CONCLUSION: Peak fastball velocity was the strongest predictor of UCLR in elite pitchers before initiating professional careers. Elite amateur pitchers attended more showcases at younger ages in a decade-long trend. Overall, the variables included in this multivariable analysis were weak predictors, explaining only 3.8% of the variance in UCLR rates.

Descriptive Characteristics and Outcomes of Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction With and Without Tunnel Bone Grafting.

BACKGROUND: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described. PURPOSE: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics. RESULTS: A total of 159 patients (13%) underwent tunnel grafting-64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group (P≤ .001). Patients who required 2-stage grafting had more previous ACLRs (P < .001) and were less likely to have received a bone-patellar tendon-bone or a soft tissue autograft at primary ACLR procedure (P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone-patellar tendon-bone allograft (P≤ .008) and less likely to receive a soft tissue autograft (P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) (P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group. CONCLUSION: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Moderate Return to Play and Previous Performance After SLAP Repairs in Competitive Overhead Athletes: A Systematic Review.

PURPOSE: To perform a systematic review of return to play (RTP) and return to previous level of performance (RPP) in competitive overhead athletes after SLAP repair to identify factors associated with failure to RTP. METHODS: Systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Review was registered with PROSPERO International prospective register of systematic reviews (CRD42020215488). Inclusion criteria were literature reporting RTP or RPP following SLAP repair in overhead athletes were run in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Categories for data collection for each full article included (1) article information; (2) patient demographics; (3) surgical techniques; (4) level of competition; (5) rotator cuff treatment; (6) player position; (7) patient-reported outcome measures; and (8) RTP and RPP rates. The Methodological Index for Non-randomized Studies checklist was used to evaluate quality of all included studies. RESULTS: Eight studies with 333 subjects were identified. Overall RTP and RPP rates were 50% to 83.6% and 35.3% to 64%, respectively. Patients with surgically treated rotator cuff pathology had lower RTP (12.5%-64.7%) rates compared with those without (80.0%-83.6%). Professional athletes had similar RTP rates (62.5%-81.5%) compared with high-school (75.0%-90.0%) and college athletes (12.5%-83.3%). However, professional athletes demonstrated the lowest relative range of reported RPP rates (27.7%-55.6%). Pitchers had lower RTP (62.5%-80.0%) and RPP (52.0%-58.9%) compared with position players (91.3% RTP, 76.3%-78.2% RPP). CONCLUSIONS: Studies reviewed reported moderate RTP and RPP rates following SLAP repairs in competitive overhead athletes. Those with associated rotator cuff tear requiring treatment, and baseball pitchers were less likely to RTP and RPP. Professional athletes had similar RTP to an amateur; however, they were less likely to RPP. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Does native glenoid anatomy predispose to shoulder instability? An MRI analysis.

BACKGROUND: It is unclear if native glenohumeral anatomic features predispose young patients to instability and if such anatomic risk factors differ between males and females. The purpose of this study was to compare glenoid and humeral head dimensions between patients with a documented instability event without bone loss to matched controls and to evaluate for sex-based differences across measurements. The authors hypothesized that a smaller glenoid width and glenoid surface area would be significant risk factors for instability, whereas humeral head width would not. METHODS: A prospectively maintained database was queried for patients aged <21 years who underwent magnetic resonance imaging (MRI) for shoulder instability. Patients with prior shoulder surgery, bony Bankart, or glenoid or humeral bone loss were excluded. Patients were matched by sex and age to control patients who had no history of shoulder instability. Two blinded independent raters measured glenoid height, glenoid width, and humeral head width on sagittal MRI. Glenoid surface area, glenoid index (ratio of glenoid height to width), and glenohumeral mismatch ratio (ratio of humeral head width to glenoid width) were calculated. RESULTS: A total of 107 instability patients and 107 controls were included (150 males and 64 females). Among the entire cohort, there were no differences in glenoid height, glenoid width, glenoid surface area, humeral head width, or glenoid index between patients with instability and controls. Overall, those with instability had a greater glenohumeral mismatch ratio (P = .029) compared with controls. When stratified by sex, female controls and instability patients showed no differences in any of the glenoid or humerus dimensions. However, males with instability had a smaller glenoid width by 3.5% (P = .017), smaller glenoid surface area by 5.2% (P = .015), and a greater glenohumeral mismatch ratio (P = .027) compared with controls. CONCLUSION: Compared with controls, males with instability were found to have smaller glenoid width and surface area, and a glenoid width that was proportionally smaller relative to humeral width. In contrast, bony glenohumeral morphology did not appear to be a significant risk factor for instability among females. These sex-based differences suggest that anatomic factors may influence risk of instability for male and female patients differently.

Reverse total shoulder arthroplasty in patients 80 years and older: a national database analysis of complications and mortality.

BACKGROUND: Although reverse total shoulder arthroplasty (RSA) is considered a safe surgical option in elderly patients, large-scale analyses of complications and mortality after RSA in patients 80 years and older are scarce. The goals of the current study were to identify revision, complication, and early mortality rates after RSA in patients 80 years and older and compare these to younger patients. METHODS: The PearlDiver Database, which contains services rendered to Medicare, Medicaid, and commercial insurance patients, was queried for patients undergoing RSA using International Classification of Diseases, Ninth/Tenth Revision (ICD-9/ICD-10) procedure codes. Patients were separated into 2 groups based on their age: 80 years and older and <80 years of age. The incidence of revision arthroplasty, medical, and surgical complications after RSA were extracted. Multivariate regression was used to compare revision arthroplasty and complication rates between groups. Statistical significance was set at P <.05. RESULTS: A total of 29,430 cases of RSA were included, with 486 cases in patients 80 years and older (median age, 80 years; age range, 2 years). Patients 80 years and older had 1- and 2-year revision rates of 3.9% and 5.1%, compared with the younger cohort at 3.0% and 3.1%, respectively. In patients 80 years and older, there were higher rates of deep venous thrombosis (DVT) (odds ratio [OR] 2.87, 95% CI 1.5-4.97), urinary tract infection (OR 1.42, 95% CI 1.01-1.94), acute renal failure (OR 2.18, 95% CI 1.44-3.17), and pneumonia (OR 1.75, 95% CI 1.09-2.68) within 90 days postoperatively. Ninety-day surgical complications were similar between the cohorts; however, younger patients experienced higher rates of dislocation, stiffness, periprosthetic fracture, and implant complications 1 year postoperatively. Patients 80 years and older had a significantly higher 90-day mortality rate at 2.7% compared with 1.5% in younger patients (P = .002). CONCLUSIONS: RSA is a generally safe procedure even in patients 80 years and older, with low complication and revision rates. Patients 80 years and older had higher early mortality and medical complication rates, including DVT, renal failure, and pneumonia than patients <80 years of age. However, patients 80 years and older had lower rates of dislocation, periprosthetic fracture, and implant-related complication at 1 year postoperatively.

The "Not" Good, the Bad and the Ugly: Prevention and Management of Common Intraoperative and Delayed Complications in Orthopedic Sports Medicine Surgical Procedures.

Despite advances in techniques designed to make arthroscopic sports medicine procedures simple, complications still arise in the operating room; even in the most trained hands. However, what marks a skilled surgeon is not just the ability to steer the ship amidst smooth seas, but a knack for getting out of trouble once things deviate from the set course. Each surgical case presents a unique challenge, and no 2 are the same. For this reason, a true expert surgeon must know how to deal with "complications" ranging from a mild swell to a raging storm. In this review we present strategies to prevent and navigate some of the most common, and fearsome complications a sports medicine surgeon may face during surgery. A great surgeon is one that acknowledges that throughout their career it is not a question of "if" these situations will arise, but "when"; and preparation is the key to success.

Assessment of Femoral Torsion on Magnetic Resonance Imaging is More Reliable Using Axial-Oblique Sequences Compared With Standard Axial Slices in Patients With Femoroacetabular Impingement Syndrome.

PURPOSE: To determine the agreeability of femoral torsion measurements on axial and oblique axial magnetic resonance imaging (MRI) sequences in patients with femoroacetabular impingement syndrome (FAIS). METHODS: Patients who underwent primary hip arthroscopy for FAIS between January 2012 to January 2019 were identified. Inclusion criteria were all patients with an MRI scan containing the pelvis and knee imaging. MRI-based measurements of femoral torsion were performed on axial and oblique-axial slices by 2 raters, and inter-rater and intrarater reliability was assessed. Bland Altman plots were constructed to evaluate the agreeability between femoral torsion measurements performed using axial and oblique-axial slices. Bivariate correlation analyses were performed to assess the relationship between measurement methods on each respective scan. A linear regression was performed between measurements performed using axial and oblique-axial sequences. RESULTS: A total of 164 patients were included. The mean true-axial and oblique axial femoral torsion were 12.2° ± 9.9° and 11.1° ± 9.2°, respectively. The intrarater reliability for axial and oblique-axial measurements were 0.993 and 0.997, respectively. The inter-rater reliability for axial and oblique-axial measurements were 0.925 and 0.965, respectively. The number of differences within the limits of agreement for axial and oblique-axial femoral torsion measurements was 58.54%. On Pearson correlation analysis, strong positive correlations were found between oblique-axial measurements at multiple time points (r = 0.994, P < .001), as well as axial measurements at multiple time points (r = 0.986, P < .001). A strong positive correlation was found between axial and oblique-axial measurements (r = 0.894, P < .001). A significant regression equation indicated that for each additional increase in axial femoral torsion, the oblique-axial femoral torsion increased 0.837 (95% confidence interval 0.772-0.901). CONCLUSIONS: Femoral torsion values measured on oblique-axial sequences are smaller than on true-axial sequences. Femoral torsion measurements on axial and oblique-axial MRI sequences exhibit poor agreement. Oblique-axial sequences demonstrated greater measurement consistency at multiple timepoints. When evaluating torsional measurements, it is important to delineate which axial sequence was used, especially in patients with suspected severe femoral antetorsion. Standardization of MRI femoral version protocols within one's practice can ensure more consistent decision-making, especially in patients with suspected femoral antetorsion. LEVEL OF EVIDENCE: Retrospective cohort, level III.

Defining the contemporary epidemiology and return to play for high ankle sprains in the National Football League.

BACKGROUND: High ankle sprains and syndesmotic injuries are commonly sustained by National Football League players, yet there is apaucity of literature reporting the incidence, risk factors and return to play (RTP) rates for these injuries. The purpose of this study is to examine the epidemiology and trends in incidence of high ankle sprains across 11 NFL seasons. METHODS: Publicly available data from the 2009-2010 through 2019-20 seasons were reviewed to identify injuries and collect player characteristics and return to play. Incidence of high ankle injuries was calculated per 10,000 athlete-exposures. Linear regression was performed for incidence of injuries. Risk factors for failure to RTP were identified through multivariate logistic regression, controlling foryear of injury, player position, body mass index (BMI), age at injury, and years of experience before injury. RESULTS: A total of 533 high ankle sprains were identified in 498 players at an average age of 25.8 ± 3.1 and average BMI of 31.8 ± 4.6. The annual incidence of high ankle sprains in the NFL increased at alinear rate of 0.067per 10,000 player exposures (R2 = 0.3357) in 2009, to 1.75per 10,000 player exposures to 2.49 in 2019-20. Most injuries were in offensive players (304/533 injuries, 57.0%). Overall, 89.7% (478/533) of players returned to play; average RTP time was 80.5 ± 132.9 days. Defensive players had afaster RTP (68.1 ± 114.6 days) compared to offensive players (90.1 ± 144.8 days) (p = 0.084). Higher age at injury was found to increase the risk of failure to RTP (p = 0.0088). CONCLUSION: RTP rate was high following high ankle sprain aamongNFL players at 90%, with an average recovery period of 11 weeks. Defensive players experience RTP faster than offensive players. Future studies are needed to determine performance outcomes following RTP, along with which patients might benefit from surgery.

Quantifying the magnitude of local tendon injury from electrosurgical transection.

BACKGROUND: Electrocautery is a common surgical technique and is often used during shoulder arthroplasty to elevate or transect the subscapularis tendon. The relative amount of tissue damage caused by cautery as opposed to sharp transection is not currently known. The purpose of this study was to examine local tissue damage resulting from electrocautery vs. sharp transection with a scalpel. We hypothesized that the electrosurgical unit would cause higher collateral tissue damage and cell death compared with sharp transection. METHODS: Twelve cadaveric ovine shoulders were randomized to either the electrosurgical or sharp transection group. The infraspinatus tendon was isolated, and a partial-thickness transection was made using either a monopolar electrosurgical device (Bovie) or No. 10 scalpel blade. Tendon explants were then visualized with confocal microscopy to evaluate tissue architecture. A live/dead assay was performed using microscopy imaging analysis software. Comparisons between Bovie and scalpel transection were made using the Mann-Whitney U test, and the cell death percentage at standardized distances from the transection site was compared between groups using a mixed-model analysis. Significance was defined at P < .05. RESULTS: The cellular and tendon fibril architecture was well maintained beyond the scalpel transection site, whereas Bovie transection disrupted the architecture beyond its transection path. The percentage of dead cells in the Bovie group (74.9% ± 31.2%) was significantly higher than that in the scalpel group (27.6% ± 29.9%, P = .0004). Compared with the transection site, the cell death percentage after Bovie transection significantly declined at 2.5 mm whereas that after scalpel transection significantly declined at 1 mm from the transection site. CONCLUSION: There was a significantly higher dead cell percentage in the Bovie transection group, indicating extensive damage beyond the local incision site, compared with sharp transection. Electrosurgical transection of the ovine infraspinatus tendon ex vivo caused higher cell death and greater tissue architecture disruption compared with sharp scalpel transection.

Alternatives to Knee Braces.

Knee braces continue to be a widely utilized piece of medical equipment, ranging from simple over the counter sleeves to more complex functional braces, with the ability to provide electrical stimulation to muscle groups. Despite their popularity, alternatives to knee braces exist for patients who find braces to be ineffective, uncomfortable, cumbersome, or overly expensive. While high-quality studies are lacking for modalities such as neoprene sleeves, compression stockings, and kinesiotaping, there is promising evidence that these interventions can confer an element of stability and pain relief for a variety of knee pathologies both with regard to acute and chronic injuries as well as in the postoperative rehabilitation period. While no "holy grail" exists for the ideal brace, or bracing alternative, it is important for providers to be aware of the options available to patients as well as the current evidence for these various modalities, so that the provider can best guide musculoskeletal care.