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

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

In Vivo Effect of Partial Ulnar Collateral Ligament Tear Location on Ulnohumeral Joint Gapping With Stress Ultrasound in Baseball Pitchers.

BACKGROUND: Stress ultrasonography (SUS) has provided clinicians with an alternative means of evaluating ulnar collateral ligament (UCL) injury by dynamically assessing ulnohumeral joint space gapping under applied valgus stress. However, 3 previous cadaveric studies have evaluated the biomechanical effect of partial UCL tears at different anatomic locations with conflicting results. PURPOSE/HYPOTHESIS: The purpose of this study was to use in vivo data from patients with magnetic resonance (MR)-confirmed partial UCL tears to determine if anatomic partial tear location influenced the resultant stability of the elbow in terms of ulnohumeral joint gapping on SUS. It was hypothesized that no difference would be seen in the amount of ulnohumeral joint gapping based on MR-identified anatomic partial UCL tear location. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All patients diagnosed with elbow injury from 2015 to 2020 were screened to identify competitive baseball pitchers with a partial UCL tear who received an SUS. Partial UCL tear was diagnosed via surgeon and radiologist interpretation of elbow MR imaging (MRI) as well as confirmation at the time of surgery as documented in the operative report. Demographic, injury, and treatment data were collected from the clinic notes, MRI reports, and stress ultrasound reports. Ulnohumeral joint gapping on SUS was calculated as the difference between ulnohumeral joint gapping without valgus stress versus ulnohumeral joint gapping with valgus stress (delta) as performed by a musculoskeletal radiologist. RESULTS: Overall, 60 male baseball pitchers (age, 19.2 ± 2.1 years), including 22 (37%) high school, 26 (43%) collegiate, and 12 (20%) professional pitchers, were evaluated. Regarding the location of partial UCL tears, 32 (53%) pitchers had proximal tears and 28 (47%) had distal tears. The mean delta value cohort was 2.1 ± 1.1 mm, and 34 pitchers (57%) had delta values >2.0 mm. Ulnohumeral joint gapping (high school [1.9 mm] vs collegiate [2.6 mm] vs professional [1.6 mm]; P = .004) and the percentage of pitchers with delta values >2.0 mm (45% vs 77% vs 33%; P = .017) differed based on level of competition. After controlling for age, body mass index, and level of competition in a multivariate linear regression, tear location was not related to ulnohumeral joint gapping (P = .499). CONCLUSION: No difference was observed in the amount of ulnohumeral joint gapping on SUS in symptomatic baseball pitchers with MR-identified partial UCL tears at differing anatomic locations. The findings of this study are contrary to previous cadaveric studies that have evaluated the effects of UCL tear characteristics on delta laxity.

Clinical Outcomes After Ulnar Collateral Ligament Reconstructions With Concomitant Ulnar Nerve Transposition in Overhead Athletes: A Matched Cohort Analysis.

BACKGROUND: Injury of the ulnar collateral ligament (UCL) has become increasingly common, particularly in overhead athletes. There is no consensus on management of the ulnar nerve in UCL reconstruction (UCLR) in patients with preoperative ulnar nerve symptoms, as literature supports both not decompressing the nerve as well as ulnar nerve transposition (UNT). HYPOTHESIS/PURPOSE: The purpose of this study was to compare subjective clinical outcomes and return-to-sports (RTS) metrics between patients who received UNT during UCLR and a matched cohort who underwent UCLR alone. We hypothesized that there would be no significant difference in patient outcomes or RTS metrics between the cohorts. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Using an institutional database, patients who underwent UCLR with UNT between 2007 and 2017 were retrospectively identified. These patients were matched based on sex, age at surgery (±3 years), and body mass index (±2 kg/m2) to a comparison group that underwent UCLR alone. Patients completed the Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow (KJOC) score, the Timmerman and Andrews elbow score, the Conway-Jobe scale, and custom patient satisfaction and RTS questionnaires. RESULTS: Thirty patients who underwent UCLR with concomitant UNT and 30 matched patients who underwent UCLR without UNT were available for follow-up at a mean of 6.9 (3.4-9.9) and 8.1 (3.4-13.9) years, respectively. The UNT group reported similar KJOC (78.4 in UNT vs 76.8; P = .780), Conway-Jobe (60% excellent in UNT vs 77% excellent; P = .504), Timmerman and Andrews (86.2 in UNT vs 88.8; P = .496), and satisfaction scores (85.3% in UNT vs 89.3%; P = .512) compared with UCLR group. In terms of RTS rate (84% in UNT vs 93% in UCLR; P = .289) and duration required to RTS (11.1 months in UNT vs 12.5 months in UCLR; P = .176), the 2 groups did not significantly differ. Finally, despite significant differences in preoperative ulnar nerve symptoms (100% in UNT vs 7% in UCLR; P < .001), the 2 groups did not statistically differ in the proportion of patients who experienced postoperative ulnar nerve symptoms (13% in UNT vs 0% in UCLR; P = .112). CONCLUSION: This matched cohort analysis showed no statistically significant differences in patient-reported outcomes and RTS between patients undergoing UCLR with and without UNT.

Return to School After Anterior Cruciate Ligament Reconstruction: A Prospective Study of Adolescents and Young Adults.

Background: The ability to return to school after orthopaedic surgery is an important consideration for young patients, as there is substantial literature indicating that school attendance is correlated strongly with academic performance. Purpose: To evaluate the time to return to school, the barriers that students encounter when returning to school, and the academic effect of anterior cruciate ligament reconstruction (ACLR) in high school (HS) and college students. Study Design: Cohort study; Level of evidence, 2. Methods: Full-time HS and college/graduate school (C/GS) students who underwent ACLR during the 2017 to 2018 and 2018 to 2019 academic periods were included in the study. Patients were contacted 2 weeks postoperatively to complete a questionnaire that assessed their time to return to school and barriers that interfered with their ability to return, and they completed a second questionnaire at 6 weeks postoperatively that assessed academic performance and challenges faced upon returning to school. Results: Included were 36 (52.2%) full-time HS students and 33 (47.8%) full-time C/GS students. HS students reported a longer time to return to school compared with C/GS students (8.51 vs 5.89 days; P = .008). In addition, HS students missed more scheduled school days than C/GS students (5.39 vs 2.90 days; P < .001). The majority of HS (73.5%) and C/GS (65.5%) students cited pain as a barrier to return, and more than half of HS (70.6%) and C/GS (55.2%) students also cited restricted mobility as a barrier to return. HS students were more likely to miss an examination in the early postoperative period compared with their C/GS counterparts (65.7% vs 39.3%; P = .037). Many students in both cohorts received a grade less than expected in the early postoperative period; this was not significantly different between the 2 groups (HS, 50.0%; C/GS, 42.9%; P = .489). Conclusion: ACLR can have a negative effect on school attendance and academic performance among HS and C/GS students. Orthopaedic surgeons should counsel all students and their families adequately about the potential academic effect of orthopaedic surgery in order to maximize clinical results, academic performance, and satisfaction in their patients.

Ulnar collateral ligament reconstruction in javelin throwers: an analysis of return to play rates and patient outcomes.

BACKGROUND: Although results after ulnar collateral ligament reconstruction (UCLR) in baseball players have been well documented, the literature is replete regarding the outcomes after UCLR in javelin throwers. PURPOSE: To report outcomes after UCLR in javelin throwers. HYPOTHESIS: UCLR in javelin throwers will result in a high rate of return to play similar to that of previously published studies from athletes of other sports. METHODS: All patients who were identified preoperatively as javelin throwers and underwent UCLR between 2011 and 2017 with a minimum 2-year follow-up were eligible for inclusion. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score, Timmerman-Andrews Elbow score, Conway-Jobe score, patient satisfaction, return to sport rate questionnaire, and the occurrence of any postoperative complications. RESULTS: Eighteen patients met the inclusion criteria. Complete follow-up was available in 16 (88.9%) patients. The average age at surgery was 21.2 ± 2.0 (range, 18.6-24.9) years. At the final follow-up, the average Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score and Timmerman-Andrews Elbow score were 77.3 (range, 18.7-98.4) and 91.8 (range, 70.0-100.0), respectively. Outcomes on the Conway-Jobe scale were as follows: excellent (n = 6; 37.5%), good (n = 4; 25%), fair (n = 6; 37.5%). Ten (62.5%) patients returned to play at an average of 12.2 ± 3.6 (range, 6.0-18.0) months after surgery. Two (12.5%) patients sustained a shoulder injury postoperatively; however, neither required surgery. CONCLUSION: UCLR in javelin throwers results in good outcomes with a low rate of reinjury/reoperation. However, the return to play rate (62.5%) and good/excellent outcomes per the Conway-Jobe scale (68.8%) are lower than what has been previously reported in baseball players and javelin throwers. Further investigation regarding outcomes in javelin throwers after UCLR is warranted.

Long-Term Sports Participation and Satisfaction After UCL Reconstruction in Amateur Baseball Players.

BACKGROUND: While the incidence of ulnar collateral ligament reconstruction (UCLR) has increased across all levels of play, few studies have investigated the long-term outcomes in nonprofessional athletes. PURPOSE: To determine the rate of progression to higher levels of play, long-term patient-reported outcomes (PROs), and long-term patient satisfaction in nonprofessional baseball players after UCLR. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We evaluated UCLR patients who were nonprofessional baseball athletes aged <25 years at a minimum of 5 years postoperatively. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC), the Timmerman-Andrews (T-A) Elbow score, the Mayo Elbow Performance Score (MEPS), and a custom return-to-play questionnaire. RESULTS: A total of 91 baseball players met the inclusion criteria, and 67 (74%) patients were available to complete the follow-up surveys at a mean follow-up of 8.9 years (range, 5.5-13.9 years). At the time of the surgery, the mean age was 18.9 ± 1.9 years (range, 15-24 years). Return to play at any level was achieved in 57 (85%) players at a mean time of 12.6 months. Twenty-two (32.8%) of the initial cohort returned to play at the professional level. Also, 43 (79.1%) patients who initially returned to play after surgery reported not playing baseball at the final follow-up; of those patients, 12 reported their elbow as the main reason for eventual retirement. The overall KJOC, MEPS, and T-A scores were 82.8 ± 18.5 (range, 36-100), 96.7 ± 6.7 (range, 75-100), and 91.9 ± 11.4 (range, 50-100), respectively . There was an overall satisfaction score of 90.6 ± 21.5 out of 100, and 64 (95.5%) patients reported that they would undergo UCLR again. CONCLUSION: In nonprofessional baseball players after UCLR, there was a high rate of progression to higher levels of play. Long-term PRO scores and patient satisfaction were high. The large majority of patients who underwent UCLR would undergo surgery again at long-term follow-up, regardless of career advancement.

Trends in leadership at orthopaedic surgery sports medicine fellowships.

BACKGROUND: Fellowship directors (FDs) in sports medicine influence the future of trainees in the field of orthopaedics. Understanding the characteristics these leaders share must be brought into focus. For all current sports medicine FDs, our group analyzed their demographic background, institutional training, and academic experience. AIM: To serve as a framework for those aspiring to achieve this position in orthopaedics and also identify opportunities to improve the position. METHODS: Fellowship programs were identified using both the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America Sports Medicine Fellowship Directories. The demographic and educational background data for each FD was gathered via author review of current curriculum vitae (CVs). Any information that was unavailable on CV review was gathered from institutional biographies, Scopus Web of Science, and emailed questionnaires. To ensure the collection of as many data points as possible, fellowship program coordinators, orthopaedic department offices and FDs were directly contacted via phone if there was no response via email. Demographic information of interest included: Age, gender, ethnicity, residency/fellowship training, residency/fellowship graduation year, year hired by current institution, time since training completion until FD appointment, length in FD role, status as a team physician and H-index. RESULTS: Information was gathered for 82 FDs. Of these, 97.5% (n = 80) of the leadership were male; 84.15% (n = 69) were Caucasian, 7.32% (n = 6) were Asian-American, 2.44% (n = 2) were Hispanic and 2.44% (n = 2) were African American, and 3.66% (n = 3) were of another race or ethnicity. The mean age of current FDs was 56 years old (± 9.00 years), and the mean Scopus H-index was 23.49 (± 16.57). The mean calendar years for completion of residency and fellowship training were 1996 (± 15 years) and 1997 (± 9.51 years), respectively. The time since fellowship training completion until FD appointment was 9.77 years. 17.07% (n = 14) of FDs currently work at the same institution where they completed residency training; 21.95% (n = 18) of FDs work at the same institution where they completed fellowship training; and 6.10% (n = 5) work at the same institution where they completed both residency and fellowship training. Additionally, 69.5% (n = 57) are also team physicians at the professional and/or collegiate level. Of those that were found to currently serve as team physicians, 56.14% (n = 32) of them worked with professional sports teams, 29.82% (n = 17) with collegiate sports teams, and 14.04% (n = 8) with both professional and collegiate sports teams. Seven residency programs produced the greatest number of future FDs, included programs produced at least three future FDs. Seven fellowship programs produced the greatest number of future FDs, included programs produced at least four future FDs. Eight FDs (9.75%) completed two fellowships and three FDs (3.66%) finished three fellowships. Three FDs (3.66%) did not graduate from any fellowship training program. The Scopus H-indices for FDs are displayed as ranges that include 1 to 15 (31.71%, n = 26), 15 to 30 (34.15%, n = 28), 30 to 45 (20.73%, n = 17), 45 to 60 (6.10%, n = 5) and 60 to 80 (3.66%, n = 3). Specifically, the most impactful FD in research currently has a Scopus H-index value of 79. By comparison, the tenth most impactful FD in research had a Scopus H-index value of 43 (accessed December 1, 2019). CONCLUSION: This study provides an overview of current sports medicine FDs within the United States and functions as a guide to direct initiatives to achieve diversity equality.

Return to play rates after ulnar nerve transposition and decompression surgery: a retrospective analysis.

BACKGROUND: Medial elbow pain is a common complaint in overhead throwing athletes. The throwing motion places repetitive tensile and compressive forces on the elbow resulting in significant stress across the ulnohumeral joint. This stress can result in soft-tissue, ligamentous, and ulnar nerve injury. The purpose of this study was to retrospectively investigate the clinical findings and outcomes, including return to play rates, of patients who underwent ulnar nerve transposition surgery for isolated ulnar neuritis. METHODS: Throwing athletes who underwent isolated, primary ulnar nerve transposition surgery over an eight-year period, 2009 to 2017, were identified and included in our analysis. Nonthrowing athletes, those who underwent revision ulnar nerve transposition surgery, and those who underwent concomitant ulnar collateral ligament reconstruction or repair were excluded. Patients were contacted to complete the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score as well as a return to play rate questionnaire. The minimum follow-up was 2 years. RESULTS: Fifteen patients met the inclusion criteria: 13 (86.7%) men and 2 (13.3%) women. The average age at the time of surgery was 19.2 years old (range, 15.6-28.0). Preoperatively, 13 (86.7%) patients played baseball and 2 (13.3%) patients played softball. Two patients (13.3%) underwent a previous ulnar collateral ligament reconstruction. There were no complications. The average final follow-up was 65.26 (range, 24.44-113.29) months with an average Kerlan-Jobe Orthopaedic Clinic Score of 64.51 (range, 28.60-100.00). Thirteen (86.7%) patients were able to return to their preinjury sport, 2 to a higher level of competition, 8 to the same level, and 3 to a lower level. Seven of the 13 (53.8%) patients sustained a postoperative ipsilateral shoulder or elbow injury at an average of 19.57 (range, 7.00-36.00) months postoperatively. All patients reported sustaining the injury as a result of throwing. CONCLUSION: The results of our study indicate that ulnar nerve transposition surgery in throwing athletes allows athletes to return to throwing with low reoperation rates. However, more than half of the athletes in our analysis sustained a subsequent ipsilateral shoulder or elbow injury. Further investigation regarding outcomes in throwing athletes after ulnar nerve transposition surgery is warranted.

How Do Sports Medicine and Foot and Ankle Specialists Treat Acute Achilles Tendon Ruptures?

Background. The purpose of this study is to evaluate the treatment considerations and surgical techniques utilized by fellowship-trained orthopaedic sports medicine and foot and ankle specialists in the management of Achilles tendon ruptures. Methods. A blinded electronic survey was distributed to 2062 fellowship-trained sports medicine and 1319 fellowship-trained foot and ankle orthopaedic surgeons. The total number of acute Achilles tendon ruptures managed per year, patient-specific factors associated with surgical decision making and surgical techniques were evaluated. Results. Of the 3381 surveys distributed, 524 responses were included for analysis. Only 9% of respondents manage more than 20 acute Achilles tendon ruptures per year with the majority (75%) managing less than 10 per year. Operative management is the treatment of choice for 76% of total respondents with only 8% managing acute ruptures nonoperatively. Activity level and patient age were the single most important factors for 60.8% and 29.3% of surgeons, respectively, with regard to operative versus nonoperative decision making. Socioeconomic status and workers compensation were the least important patient factors. Conclusion. Surgical repair in the young and active patient is the preferred treatment for the majority of fellowship-trained subspecialists who most commonly encounter this pathology.Levels of Evidence: Therapeutic, Level V: Consensus of Expert Analysis.

Ulnar Collateral Ligament Reconstruction in Adolescents: A Systematic Review.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction is an established surgical technique to restore UCL deficiency, especially in the overhead throwing athlete. Over the past decade, the number of patients requiring UCL reconstruction has increased significantly, particularly in the adolescent patient population. Return-to-play rates after UCL reconstruction reported in the literature have ranged from 33% to 92%, and a recent systematic review noted a return-to-play rate of 89.40% in all high school athletes. PURPOSE: To evaluate the outcomes, particularly return-to-play rates and subjective outcome scores, of UCL reconstruction of the elbow in adolescent throwing athletes. STUDY DESIGN: Systematic review. METHODS: A systematic review of the literature was conducted via the electronic databases Embase, PubMed, and Cochrane. Studies that reported on outcomes, particularly return-to-play rates, in adolescent throwing athletes met the inclusion criteria and were included in our analysis. Studies that did not report on adolescent throwing athletes and studies that reported on adolescent throwing athletes but did not specify the return-to-play outcomes for these athletes were excluded from our analysis. RESULTS: Nine studies met the inclusion criteria and were included in this review. There were 404 baseball players and 10 javelin throwers included in our analysis. A total of 349 of the 414 patients (84.30%) were successfully able to return to play at the same level of competition or higher. Successful rates of return to prior performance ranged from 66.67% to 91.49% in our analysis. Javelin throwers had a mean 80.00% rate of return to prior performance, while baseball players had a mean return-to-play rate of 84.40%. Complications were evaluated for 8 (88.9%) studies and 283 (68.4%) patients. There were 11 (3.9%) reported complications and 5 (1.8%) reoperations. CONCLUSION: The findings of this systematic review revealed that adolescent patients are generally able to return to their preinjury level of performance or higher with limited complications. Further investigation is necessary to determine long-term outcomes for return to play after UCL reconstruction of the elbow in adolescent throwing athletes.

Return-to-Play Guidelines After Patellar Instability Surgery Requiring Bony Realignment: A Systematic Review.

BACKGROUND: Recurrent patellar instability can be treated nonoperatively or surgically, and surgical management may vary based on the causative pathology in the structures surrounding the patella. Although isolated soft tissue reconstruction is among the most common operative treatments, certain patient populations require bony realignment for adequate stabilization. PURPOSE: To evaluate postoperative guidelines, including return to play and rehabilitation, after bony procedures involving the tibial tubercle for patellar instability. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review on return-to-play guidelines was conducted with studies published from 1997 to 2019 that detailed procedures involving bony realignment by tibial tubercle osteotomies and tibial tubercle transfers with or without soft tissue reconstruction. Exclusion criteria included animal or cadaveric studies, basic science articles, nonsurgical rehabilitation protocols, and patients with mean age <18 years. Studies were assessed for return-to-play criteria, rehabilitation protocols, and bias. RESULTS: Included in the review were 39 studies with a total of 1477 patients and 1598 knees. Mean patient age ranged from 17.5 to 34.0 years, and mean follow-up ranged from 23 to 161 months. All 39 studies described postoperative rehabilitation; however, only 16 studies specifically outlined return-to-play criteria. The most commonly cited return-to-play criterion was quadriceps strength (62.5%). Range of motion (50.0%), physical therapy protocols (18.8%), and radiographic evidence of healing (18.8%) were other cited objective criteria for return-to-play. Four of 16 (25.0%) studies described subjective criteria for return to play, including pain, swelling, and patient comfort and confidence. Of the 11 studies that described a timeline for return to play, the range was between 2 and 6 months. CONCLUSION: The results revealed that 100% of papers evaluated lacked adequate return-to-play guidelines. Moreover, timelines significantly varied among studies. More clearly defined return-to-play guidelines after tibial tubercle transfer for patellar instability are required.

Development of a return to play checklist following patellar instability surgery: a Delphi-based consensus.

PURPOSE: To date, there is no consensus for the appropriate timing or functional evaluation for safe return to play following patellar instability surgery. The purpose of this study is to develop a consensus-based return to play checklist following patellar stabilization surgery using the Delphi method. METHODS: A 3-part survey series was conducted following the systematic guidelines of the Delphi technique for gathering consensus from experts in the management of patellofemoral instability. All surveys were completed between July and November of 2017. A literature search was performed in SCOPUS and PubMed to identify existing sources on return to play following patellar instability surgery and determining patellofemoral joint strength in athletes, which served as the basis for the surveys. RESULTS: 12 of the 19 selected participants (63%) completed the first-round survey, 11 of those 12 participants (92%) completed the second-round survey, and 10 of these 11 participants (91%) completed the final survey. Of the final ten participants, there was representation from seven different states in the USA. Nine of the ten (90%) respondents endorsed the final checklist. The final checklist included eight overarching domains with defined and reproducible objective criteria. CONCLUSION: The standardized list of objective and reproducible criteria for rehabilitation outlined below should help practitioners focus more on patient-centred factors and less on arbitrary timelines. No prior study has gathered consensus from experts on this topic; therefore, this study should serve as a benchmark to help guide patients back to sport safely. LEVEL OF EVIDENCE: V.

Reconstruction of Acute Acromioclavicular (AC) Joint Dislocations with or without Tendon Graft: a Retrospective Comparative Study.

BACKGROUND: Reconstructions of acute acromioclavicular (AC) dislocations have been thought to result in superior outcomes than chronic dislocations. The use of tendon graft in reconstructions has demonstrated favorable biomechanical properties. To determine whether utilizing tendon graft during repair of acute AC dislocations results in superior outcomes and lower complication rate. METHODS: A retrospective review of AC reconstructions was conducted. Reconstructions performed within 3 weeks of injury were included. Inclusion criteria included age over 18, grade 3-5 AC joint separation, and no previous ipsilateral shoulder injury. Primary outcome measure was radiographic loss of reduction. Secondary outcomes included ASES and SANE scores. RESULTS: Of 47 reconstructions of acute AC joint separations, 35 utilized fixation without a tendon graft, while 12 underwent an anatomic reconstruction with tendon graft. Repairs without the use of graft resulted in 8 (23%) cases of loss of reduction, while tendon graft augmented repairs resulted in 5 (42%). This difference was not statistically significant (p = 0.22). No patients required reoperation. There was no statistical difference in the ASES and SANE scores between the two groups. Furthermore, we found no significant difference in ASES or SANE scores in patients who maintained reduction postoperatively versus those that lost reduction. CONCLUSION: A greater but not statistically significant rate of loss of reduction was observed in the group reconstructed with the use of a tendon graft. Further research is needed to determine whether the use of tendon graft is beneficial in the treatment of acute AC joint separations. LEVEL OF EVIDENCE: IV.

Repair of a Proximal Hamstring Rupture in a 14-Year-Old Patient: A Case Report.

Proximal hamstring tendon ruptures are rare in children and adolescents. The typical pediatric hamstring injury pattern involves an apophyseal avulsion fracture. We present the case of a 14-year-old male with a widely displaced ischial avulsion fracture and a bony fragment that was too small to allow for bony fixation. The patient presented with left-buttock pain and ecchymosis, as well as tenderness at the ischial tuberosity, following an injury sustained while running 2 weeks prior. Imaging demonstrated an avulsion of the proximal hamstrings with a 4-mm bony fragment, too small to allow for repair. The patient underwent primary repair using two 3-mm suture anchors. The bony fragment was not excised but incorporated into the repair. Although most proximal hamstring injuries in children and adolescents are treated non-operatively, operative treatment may confer a small but clinically important difference in rates of healing and return to play in adolescent athletes. This case demonstrates successful treatment of a proximal hamstring rupture with suture anchor fixation, which may be considered for pediatric and adolescent displaced avulsion fractures when the bony fragment is too small to allow for bony fixation.

Management of Elbow Dislocations in the National Football League.

BACKGROUND: Although much literature exists regarding the treatment and management of elbow dislocations in the general population, little information is available regarding management in the athletic population. Furthermore, no literature is available regarding the postinjury treatment and timing of return to play in the contact or professional athlete. PURPOSE: To review the clinical course of elbow dislocations in professional football players and determine the timing of return to full participation. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All National Football League (NFL) athletes with elbow dislocations from 2000 through 2011 who returned to play during the season were identified from the NFL Injury Surveillance System (NFL ISS). Roster position, player activity, use of external bracing, and clinical course were reviewed. Mean number of days lost until full return to play was determined for players with elbow dislocations who returned in the same season. RESULTS: From 2000 to 2011, a total of 62 elbow dislocations out of 35,324 injuries were recorded (0.17%); 40 (64.5%) dislocations occurred in defensive players, 12 (19.4%) were in offensive players; and 10 (16.1%) were during special teams play. Over half of the injuries (33/62, 53.2%) were sustained while tackling, and 4 (6.5%) patients required surgery. A total of 47 (75.8%) players who sustained this injury were able to return in the same season. For this group, the mean number of days lost in players treated conservatively (45/47) was 25.1 days (median, 23.0 days; range, 0.0-118 days), while that for players treated operatively (2/47) was 46.5 days (median, 46.5 days; range, 29-64 days). Mean return to play based on player position was 25.8 days for defensive players (n = 28; median, 21.5 days; range, 3.0-118 days), 24.1 days for offensive players (n = 11; median, 19 days; range, 2.0-59 days), and 25.6 days for special teams players (n = 8; median, 25.5 days; range, 0-44 days). CONCLUSION: Elbow dislocations comprise less than a half of a percent of all injuries sustained in the NFL. Most injuries occur during the act of tackling, with the majority of injured athletes playing a defensive position. Players treated nonoperatively missed a mean of 25.1 days, whereas those managed operatively missed a mean of 46.5 days.

Contact Versus Noncontact Anterior Cruciate Ligament Injuries: Is Mechanism of Injury Predictive of Concomitant Knee Pathology?

PURPOSE: To determine if mechanism of injury is predictive of concomitant knee pathology found at the time of anterior cruciate ligament (ACL) reconstruction. METHODS: All patients aged 16 to 35 who underwent ACL reconstruction at our institution between January 2009 and December 2015 were retrospectively reviewed. Mechanism of injury was determined from patient history. The presence of meniscal or chondral damage was determined from operative records, while collateral ligament injuries were determined by the treating surgeon's diagnosis after physical examination and their review of magnetic resonance imaging findings. Patients with inadequate documentation, history of a subsequent instability episode following the initial injury, or prior history of knee pathology were excluded. RESULTS: Six hundred eighty-seven patients (169 contact and 518 noncontact) were included. A 2-fold increase in the incidence of collateral ligament injury was identified between the 2 groups with 114 (67.5%) in the contact group and 175 (33.8%) in the noncontact group (P < .001). Twenty-six patients (15.4%) in the contact group compared with 9 (1.7%) in the noncontact group had a grade III collateral ligament injury (P < .001). Chondral injury was identified in 41 (24.3%) patients in the contact group and 87 (16.8%) in the noncontact group (P = .05) with 9 (5.3%) grade IV lesions in the contact group and 4 (0.8%) in the noncontact group (P < .001). Eleven patients in the contact group (6.5%) and 15 in the noncontact group (2.9%) had a chondral injury to the lateral femoral condyle (P = .04). CONCLUSIONS: Although we found no difference in the incidence or type of meniscal tears, we found a significant increase in the incidence of grade IV chondral injury, chondral injury to the lateral femoral condyle, and grade III collateral ligament damage in the setting of contact ACL injuries. This knowledge can aid surgeons in preoperative planning and patient counseling. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Return-to-Play Guidelines After Medial Patellofemoral Ligament Surgery for Recurrent Patellar Instability: A Systematic Review.

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction and repair continue to gain acceptance as viable treatment options for recurrent patellar instability in patients who wish to return to sports after surgery. Return-to-play guidelines with objective or subjective criteria for athletes after MPFL surgery, however, have not been uniformly defined. PURPOSE: To determine whether a concise and objective protocol exists that may help athletes return to their sport more safely after MPFL surgery. STUDY DESIGN: Systematic review. METHODS: The clinical evidence for return to play after MPFL reconstruction was evaluated through a systematic review of the literature. Studies that measured outcomes for isolated MPFL surgery with greater than a 12-month follow-up were included in our study. We analyzed each study for a return-to-play timeline, rehabilitation protocol, and any measurements used to determine a safe return to play after surgery. RESULTS: Fifty-three studies met the inclusion criteria, with a total of 1756 patients and 1838 knees. The most commonly cited rehabilitation guidelines included weightbearing restrictions and range of motion restrictions in 90.6% and 84.9% of studies, respectively. Thirty-five of 53 studies (66.0%) included an expected timeline for either return to play or return to full activity. Ten of 53 studies (18.9%) in our analysis included either objective or subjective criteria to determine return to activity within their rehabilitation protocol. CONCLUSION: Most studies in our analysis utilized time-based criteria for determining return to play after MPFL surgery, while only a minority utilized objective or subjective patient-centric criteria. Further investigation is needed to determine safe and effective guidelines for return to play after MPFL reconstruction and repair.

A prospective cohort study investigating the effect of generalized joint hypermobility on outcomes after arthroscopic anterior shoulder stabilization.

OBJECTIVES: Generalized joint laxity has been proposed as a significant risk factor for failure after arthroscopic anterior shoulder stabilization. The purpose of this study was to prospectively measure joint mobility in patients undergoing arthroscopic anterior shoulder stabilization and to determine whether hypermobility is a risk factor for worse outcomes compared with patients having normal joint mobility. METHODS: Patients with anterior shoulder instability were prospectively enrolled. Generalized joint hypermobility was measured using the Beighton Hypermobility Score and the Rowe, UCLA, SANE, SST, and WOSI scores were administered and reported as patient outcomes preoperatively and following arthroscopic anterior shoulder stabilization at 6 weeks, 6 months, 12 months, and 24 months postoperatively. Patients were stratified into two groups based on their Beighton Hypermobility Score, with scores ≥ 4/9 indicative of joint hypermobility. RESULTS: Sixteen patients with joint hypermobility (JH) and 18 non-hypermobile patients (NJH) were enrolled. At baseline, there were no significant differences in demographic characteristics or baseline patient-reported outcomes. Significantly more patients in the NJH group had SLAP tears (n = 10) compared to the JH group (n = 2) (p = .013). At all follow-up times, there were no significant differences between the NJH and JH groups with regard to patient-reported outcome scores (p > .05). In the JH group, 17% of patients reported recurrent instability at two years postoperatively compared to 25% of patients in the NJH group. There was no significant difference in failure rate (p = .67). CONCLUSION: There was no significant difference in patient-reported outcomes or recurrent instability in patients with versus without joint hypermobility undergoing arthroscopic anterior shoulder stabilization.

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft versus allograft in skeletally mature patients aged 25 years or younger.

PURPOSE: The purpose of this study is to evaluate the clinical outcomes and revision rates of skeletally mature patients aged 25 years or younger who have undergone either BPTB autograft or deep-frozen, non-irradiated BPTB allograft ACL reconstruction by a single surgeon. METHODS: Two hundred and twenty-four patients aged 25 or younger at the time of surgery were identified as having a transtibial ACL reconstruction with either a BPTB autograft or deep-frozen, non-irradiated BPTB allograft by one senior surgeon (101 autografts vs. 123 allografts) over the study time period. Primary outcome measure included the need for ACL revision. One hundred and nineteen patients with at least 2-year clinical follow-up agreed to participate in secondary outcome measurement arm of the study and were administered the Lysholm Knee Scoring Scale and IKDC Subjective Knee Evaluation Form. RESULTS: The median Lysholm scores were 95 (40-100) and 95 (68-100) and the median IKDC scores were 95.4 (54.0-100) and 95.4 (72.4-100) in the allograft and autograft groups, respectively. The differences in the Lysholm scores and the IKDC scores were not statistically significant (P = n.s.). There were 13 patients requiring ACL revision, 12 allograft versus one autograft (P = 0.005). CONCLUSION: Although there is no significant difference in patient-rated outcome between ACL reconstructions using BPTB autografts versus BPTB allografts, a significantly higher rate of ACL revision was found in allograft patients. The results of our study support a growing body of literature that BPTB autograft reconstruction leads to lower retear rates in younger individuals, an important factor in the graft selection process for these patients. LEVEL OF EVIDENCE: III.