Which Application Factors Are Associated With Outstanding Performance in Orthopaedic Surgery Residency?

BACKGROUND: Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice. QUESTIONS/PURPOSES: We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance. METHODS: Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program, were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p < 0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values < 0.05 were considered significant. RESULTS: The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ 2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ 2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ 2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study. CONCLUSION: Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought. LEVEL OF EVIDENCE: Level III, therapeutic study.

Femoral Version May Impact Hip Arthroscopy Outcomes in Select Patient Populations: A Systematic Review.

PURPOSE: To provide further clarity regarding the management of patients with abnormal femoral version in the setting of hip arthroscopy and will discuss the definition of femoral version, the diagnostic and clinical evaluation of abnormal femoral version, and several described measurement techniques. METHODS: A systematic review was conducted in literature published before August 2021 that measured femoral version and reported patient-reported outcomes measures or rates of subsequent procedures following hip arthroscopy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and the electronic databases, PubMed, OvidMedLine, Scopus, and Web of Science were searched. Two blinded reviews screened and evaluated data quality using the Newcastle-Ottawa Scale. RESULTS: Eighteen studies were included with 11 studies reporting patient outcomes and 7 studies reporting rates of subsequent procedures. The most commonly used definition of femoral version was 5° to 20° of femoral anteversion. Computed tomography scan was the most commonly used imaging modality. The majority of studies (7 of 11) demonstrated that femoral version does not have an impact on patient-reported outcomes measures and is not predictive of clinically meaningful improvement scores. However, in select studies, patients with femoral retroversion were found to experience slightly inferior outcomes following hip arthroscopy for femoroacetabular impingement. While femoral retroversion may be a risk factor for subsequent procedures, 3 of 7 studies refute this claim. Although in patients with borderline hip dysplasia, excessive femoral anteversion led to greater rates of subsequent hip procedures. CONCLUSIONS: While the majority of studies show that femoral version does not have an impact on patient-reported outcomes following hip arthroscopy, those with femoral retroversion and with excessive anteversion with coexisting borderline hip dysplasia need to be educated on their increased risk of subsequent operation. Ultimately, this review suggests that clinical improvement can likely be achieved regardless of femoral version. LEVEL OF EVIDENCE: IV; systematic review of Level I-IV studies.

Peritransplant VLA-4 blockade inhibits endogenous memory CD8 T cell infiltration into high-risk cardiac allografts and CTLA-4Ig resistant rejection.

Recipient endogenous memory CD8 T cells expressing reactivity to donor class I MHC infiltrate MHC-mismatched cardiac allografts within 24 hours after reperfusion and express effector functions mediating graft injury. The current study tested the efficacy of Very Late Antigen-4 (VLA-4) blockade to inhibit endogenous memory CD8 T cell infiltration into cardiac allografts and attenuate early posttransplant inflammation. Peritransplant anti-VLA-4 mAb given to C57BL6 (H-2b ) recipients of AJ (H-2a ) heart allografts completely inhibited endogenous memory CD4 and CD8 T cell infiltration with significant decrease in macrophage, but not neutrophil, infiltration into allografts subjected to either minimal or prolonged cold ischemic storage (CIS) prior to transplant, reduced intra-allograft IFN-γ-induced gene expression and prolonged survival of allografts subjected to prolonged CIS in CTLA-4Ig treated recipients. Anti-VLA-4 mAb also inhibited priming of donor-specific T cells producing IFN-γ until at least day 7 posttransplant. Peritransplant anti-VLA plus anti-CD154 mAb treatment similarly prolonged survival of allografts subjected to minimal or increased CIS prior to transplant. Overall, these data indicate that peritransplant anti-VLA-4 mAb inhibits early infiltration memory CD8 T cell infiltration into allografts with a marked reduction in early graft inflammation suggesting an effective strategy to attenuate negative effects of heterologous alloimmunity in recipients of higher risk grafts.

Indications and Outcomes of Arthroscopic Labral Reconstruction of the Hip: A Systematic Review.

PURPOSE: The primary purpose of this investigation was to systematically evaluate the literature for the current indications and outcomes of arthroscopic labral reconstruction of the hip. Our secondary purpose was to evaluate the role of arthroscopic labral reconstruction in the management of reparable labral tears. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using a PRISMA checklist. Studies published between June 2009 and June 2018 that evaluated outcomes after arthroscopic labral reconstruction with a minimum of 1 year of follow-up were included. RESULTS: Eleven studies met the inclusion and exclusion criteria. A total of 373 patients were identified. Of the 11 studies, 9 reported that an irreparable labrum was their indication for reconstruction, with 8 reporting that this was ultimately determined intraoperatively. Substantial variability in surgical technique, graft choice, and concurrent pathology was found. All 11 studies used at least 1 validated functional outcome metric to evaluate surgical outcomes, with all studies reporting improvement greater than the minimal clinically important difference. Donor-site pain was the most common complication, although it was reported in only 2 studies. Reported rates of revision surgery and conversion to arthroplasty were low (range, 0%-9.1% for both). CONCLUSIONS: All 11 studies included in this systematic review reported clinically significant functional improvements after arthroscopic labral reconstruction and low rates of complications, revision surgery, and progression of arthritis, although graft types and concomitant procedures confound the results. The most common indication for reconstruction was a deficient labrum on intraoperative evaluation. The 6 studies that evaluated patient satisfaction reported favorable results, with a range of 6.73 to 8.7. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Transient Surface CCR5 Expression by Naive CD8+ T Cells within Inflamed Lymph Nodes Is Dependent on High Endothelial Venule Interaction and Augments Th Cell-Dependent Memory Response.

In inflamed lymph nodes, Ag-specific CD4(+) and CD8(+) T cells encounter Ag-bearing dendritic cells and, together, this complex enhances the release of CCL3 and CCL4, which facilitate additional interaction with naive CD8(+) T cells. Although blocking CCL3 and CCL4 has no effect on primary CD8(+) T cell responses, it dramatically impairs the development of memory CD8(+) T cells upon Ag rechallenge. Despite the absence of detectable surface CCR5 expression on circulating native CD8(+) T cells, these data imply that naive CD8(+) T cells are capable of expressing surface CCR5 prior to cognate Ag-induced TCR signaling in inflamed lymph nodes; however, the molecular mechanisms have not been characterized to date. In this study, we show that CCR5, the receptor for CCL3 and CCL4, can be transiently upregulated on a subset of naive CD8(+) T cells and that this upregulation is dependent on direct contact with the high endothelial venule in inflamed lymph node. Binding of CD62L and CD11a on T cells to their ligands CD34 and CD54 on the high endothelial venule can be enhanced during inflammation. This enhanced binding and subsequent signaling promote the translocation of CCR5 molecules from intracellular vesicles to the surface of the CD8(+) T cell. The upregulation of CCR5 on the surface of the CD8(+) T cells increases the number of contacts with Ag-bearing dendritic cells, which ultimately results in increased CD8(+) T cell response to Ag rechallenge.

IL-1 Receptor Signaling on Graft Parenchymal Cells Regulates Memory and De Novo Donor-Reactive CD8 T Cell Responses to Cardiac Allografts.

Reperfusion of organ allografts induces a potent inflammatory response that directs rapid memory T cell, neutrophil, and macrophage graft infiltration and their activation to express functions mediating graft tissue injury. The role of cardiac allograft IL-1 receptor (IL-1R) signaling in this early inflammation and the downstream primary alloimmune response was investigated. When compared with complete MHC-mismatched wild-type cardiac allografts, IL-1R(-/-) allografts had marked decreases in endogenous memory CD8 T cell and neutrophil infiltration and expression of proinflammatory mediators at early times after transplant, whereas endogenous memory CD4 T cell and macrophage infiltration was not decreased. IL-1R(-/-) allograft recipients also had marked decreases in de novo donor-reactive CD8, but not CD4, T cell development to IFN-γ-producing cells. CD8 T cell-mediated rejection of IL-1R(-/-) cardiac allografts took 3 wk longer than wild-type allografts. Cardiac allografts from reciprocal bone marrow reconstituted IL-1R(-/-)/wild-type chimeric donors indicated that IL-1R signaling on graft nonhematopoietic-derived, but not bone marrow-derived, cells is required for the potent donor-reactive memory and primary CD8 T cell alloimmune responses observed in response to wild-type allografts. These studies implicate IL-1R-mediated signals by allograft parenchymal cells in generating the stimuli-provoking development and elicitation of optimal alloimmune responses to the grafts.

Novel CD8 T cell alloreactivities in CCR5-deficient recipients of class II MHC disparate kidney grafts.

Recipient CD4 T regulatory cells inhibit the acute T cell-mediated rejection of renal allografts in wild-type mice. The survival of single class II MHC-disparate H-2(bm12) renal allografts was tested in B6.CCR5(-/-) recipients, which have defects in T regulatory cell activities that constrain alloimmune responses. In contrast to wild-type C57BL/6 recipients, B6.CCR5(-/-) recipients rejected the bm12 renal allografts. However, donor-reactive CD8 T cells rather than CD4 T cells were the primary effector T cells mediating rejection. The CD8 T cells induced to bm12 allografts in CCR5-deficient recipients were reactive to peptides spanning the 3 aa difference in the I-A(bm12) versus I-A(b) ß-chains presented by K(b) and D(b) class I MHC molecules. Allograft-primed CD8 T cells from CCR5-deficient allograft recipients were activated during culture either with proinflammatory cytokine-stimulated wild-type endothelial cells pulsed with the I-A(bm12) peptides or with proinflammatory cytokine-simulated bm12 endothelial cells, indicating their presentation of the I-A(bm12) ß-chain peptide/class I MHC complexes. In addition to induction by bm12 renal allografts, the I-A(bm12) ß-chain-reactive CD8 T cells were induced in CCR5-deficient, but not wild-type C57BL/6, mice by immunization with the peptides. These results reveal novel alloreactive CD8 T cell specificities in CCR5-deficient recipients of single class II MHC renal allografts that mediate rejection of the allografts.

Experimental models of cardiac transplantation: design determines relevance.

PURPOSE OF REVIEW: Experimental models have contributed enormously to basic immunology. However, the use of reductionist experiments has produced results that are not always successfully translated into the clinic. Recently, incorporation of more realistic clinical parameters in experimental designs has produced new insights relevant to cardiac transplantation. RECENT FINDINGS: Experiments in mice have provided crucial insights into the concept that T cell responses to pathogens generate memory cells with cross-reactive specificities for histocompatibility antigens. These memory T cells are resistant to current immunosuppressive strategies. Memory T cells infiltrate grafts within hours after transplantation, and grafts subjected to clinically relevant periods of cold ischemia are more susceptible to injury by this cellular infiltrate. Early immune responses now can be investigated with improved 'humanized' mice. Mice with multiple knock-in genes for human cytokines support development of human monocytes, macrophages and natural killer cells in increased numbers and with better function. SUMMARY: Better and more clinically relevant experimental designs are providing animal models tailored to address clinic exigencies.

Inflammatory and Immunologic Contributions in Femoroacetabular Impingement Syndrome.

Femoroacetabular impingement (FAI) is one of the most common causes of labral and early cartilage damage in the nondysplastic hip. FAI is increasingly recognized as a cause for hip and groin pain in the young, active patient, and the surgical treatment of FAI with hip arthroscopy has risen exponentially. Although our understanding of FAI and the progression to degenerative osteoarthritis of the hip has historically been considered a mechanical "wear-and-tear" disease of an imperfectly shaped, aspherical, femoral head within a deep or overcovering acetabulum leading to cartilage injury, our understanding of the intrinsic pathophysiologic mechanisms underlying the development of FAI and joint degeneration of the hip remains poor. For example, many patients with FAI morphology may never develop hip pain or osteoarthritis; there remains more to discover regarding the pathophysiology of arthritis in the setting of FAI. Recent work has begun to identify a strong inflammatory and immunologic component to the FAI disease process that affects the hip synovium, labrum, and cartilage and may be detectable from peripheral clinical samples (blood and urine). This review highlights our current understanding of the inflammatory and immunologic contributions to FAI and potential therapeutic strategies to supplement and augment the surgical management of FAI.

The safe zones for endoscopic proximal hamstring repair: a cadaveric assessment of standard portal placement and their relationship to major neurovascular structures.

PURPOSE: To define the anatomical relationship of the major neurovascular structures to the standard endoscopic portals used in endoscopic hamstring repair. A secondary outcome was to determine the safest angle of insertion from each standard portal. METHODS: Endoscopic portals were established in the 3 standard locations (lateral, medial, and inferior) and Steinmann pins inserted at various angles. Each hip was dissected and the distance between the pins and the pertinent anatomy measured. RESULTS: The lateral portal placed the sciatic and posterior femoral cutaneous (PFC) nerves at greatest risk: direct injury to the sciatic nerve was seen in 11/30 (37%) of the lateral portals sited. A lateral portal with an approach at 60° was the most dangerous orientation with a mean distance of 0.36 ± 0.49 mm and 4.30 ± 2.69 mm from the sciatic and PFC nerves, respectively (p < 0.001). The 60° medial portal was the safest of all portals measured, at a mean distance of 67.37 ± 11.06mm (range, 47-78 mm) from the sciatic nerve and 58.90 ± 10.57 mm (range 40-70 mm) from the PFC nerve. CONCLUSIONS: While currently described techniques recommend establishing the standard lateral portal first, this study shows that it carries the highest risk of injury if used blind. We recommend that the standard medial endoscopic portal is established first to identify the neurovascular structures and minimise iatrogenic neurovascular injury. The inferior and lateral portals can then be established created under direct vision. The lateral portal should be inserted in a more horizontal orientation to decrease the risk of nerve injury.

Ulnar Collateral Ligament (UCL) Reconstruction With Proximal Single-Tunnel Suspensory Fixation.

Ulnar collateral ligament (UCL) reconstruction of the medial elbow is considered to be the gold standard for treating valgus instability seen in overhead throwing athletes. The first UCL construction was performed by Frank Jobe in 1974, and this procedure has evolved over time to include multiple techniques that improved the biomechanical strength of the graft fixation and maximize the rate of return to athletic competition for these patients. The most common UCL-reconstruction technique used today is the docking technique. The purpose of this Technical Note is to describe our technique, including pearls and pitfalls, which combines the many advantages of the docking technique with a proximal single-tunnel suspensory fixation technique. This method allows for optimal tensioning of the graft, allowing for secure fixation that relies on metal implants as opposed to tying sutures over a proximal bone bridge.

Value Challenge: A Bottoms-Up Approach to Minimizing Cost and Waste in Orthopaedic Surgery.

Astronomical increases in medical expenses and waste produce widespread financial and environmental impacts. Minor changes to minimize costs within orthopaedics, the most used surgical subspecialty, could result in substantial savings. However, few orthopaedic surgeons are educated or experienced to implement cost containment strategies. This study aims to investigate cost containment opportunities and provide a framework for educating and incorporating residents into cost-saving initiatives. Methods: Orthopaedic surgical residents from an academic program with a Level I trauma center were queried during 2019 to 2022 regarding suggestions for cost containment opportunities. Based on feasibility and the estimated impact, 7 responses were selected to undergo cost-saving analyses. Results: The proposed initiatives fell into 2 categories: minimizing waste and optimizing patient care. Eliminating nonessential physical therapy/occupational therapy consults led to the greatest estimated savings ($8.6M charges/year), followed by conserving reusable drill bits ($2.2M/year) and reducing computed tomography scans on lower extremity injuries ($446K/year). Conclusion: Current medical training provides limited formal education on cost-effective care. Efforts to mitigate the growing financial and environmental costs of health care should include encouraging and incorporating resident feedback into cost reduction strategies. This tactic will likely have a positive impact on the behavior of such resident surgeons as they enter practice and have more awareness of costs and value. Level of Evidence: V (cost-minimization study).

Biomechanical comparison of ulnar collateral ligament reconstruction with single-tunnel proximal suspensory fixation versus modified docking technique.

Background: Despite technical advancement, elbow ulnar collateral ligament (UCL) reconstruction is a challenging procedure due to the limitations regarding the challenging tunnel placement and potential injury to the ulnar nerve. Furthermore, current techniques for reconstruction and repair are inferior functionally and biomechanically when compared to native UCL tissue. A modified docking technique using a single-tunnel proximal suspensory fixation may reduce complications and potentially provide a technique for UCL reconstruction that is biomechanically superior. Decreasing the number of bone tunnels decreases the number of places that bone tear through could occur. The purpose was to evaluate and compare the biomechanical performances for 2 elbow UCL reconstruction techniques: (1) standard docking technique (SD) and (2) a proximal single tunnel (PST) technique using a suspensory fixation. We hypothesized that the PST technique would be biomechanically superior to the SD technique. Methods: Twelve matched pairs of cadaveric elbows were dissected and fixed at 70 degrees for biomechanical testing. Gracilis grafts were used for a docking reconstruction and the modified reconstruction with a PST suspensory fixation. A cyclic valgus torque protocol was used to precondition specimens for either reconstruction technique and the ulnohumeral gapping was then assessed. Following gapping measurements, postsurgical specimens underwent a valgus rotation applied at a rate of 5°/s until the anterior band of the UCL failed or fracture occurred. Ultimate load to failure, stiffness, and mode of failure were recorded. Results: There were no statistical differences between the two groups. Mean rotational stiffness of the SD (2.3 ± 0.6 Nm/deg) compared to the PST (1.9 ± 0.7 Nm/deg) (P = .41) and mean ultimate failure torque of the SD (30.5 ± 9.2 Nm) compared to the PST (30.9 ± 8.6 Nm) (P = .86) were similar. There was also no statistically significant difference (P = .83) when comparing the native UCL ulnohumeral gapping (6.0 ± 2.0 mm) to the mean ulnohumeral gapping of the SD reconstruction (6.0 ± 1.8 mm). Conclusions: This study compares the biomechanical strength of elbow UCL reconstructions performed using the SP technique to that of a PST technique. Among all tested parameters, including ultimate failure torque, stiffness, and ulnohumeral gapping, there were no statistically significant differences between the 2 techniques.

Failure of Costimulatory Blockade-induced Regulatory T Cells to Sustain Long-term Survival of High Ischemic Allografts.

BACKGROUND: Costimulatory blockade-induced allograft tolerance has been achieved in rodent models, but these strategies do not translate well to nonhuman primate and clinical transplants. One confounder that may underlie this discrepancy is the greater ischemic inflammation imposed on the transplants. In mice, cardiac allografts subjected to prolonged cold ischemic storage (CIS) before transplant have increased ischemia-reperfusion injury, which amplifies infiltrating endogenous memory CD8 T-cell activation within hours after transplantation to mediate acute graft inflammation and cytotoxic lymphocyte-associated molecule-4 immunoglobulin-resistant rejection. This study tested strategies inhibiting memory CD8 T-cell activation within such high ischemic allografts to achieve long-term survival. METHODS: A/J (H-2 a ) hearts subjected to 0.5 or 8 h of CIS were transplanted to C57BL/6 (H-2 b ) recipients and treatment with peritransplant costimulatory blockade. At 60 d posttransplant, regulatory T cells (Treg) were depleted in recipients of high ischemic allografts with anti-CD25 monoclonal antibody (mAb) or diphtheria toxin. RESULTS: Whereas peritransplant (days 0 and +1) anti-lymphocyte function-associated antigen-1 mAb and anti-CD154 mAb prolonged survival of >60% allografts subjected to minimal CIS for >100 d, only 20% of allografts subjected to prolonged CIS survived beyond day 80 posttransplant and rejection was accompanied by high titers of donor-specific antibody. Peritransplant anti-lymphocyte function-associated antigen-1, anti-tumor necrosis factor-α, and anti-CD154 mAb plus additional anti-CD154 mAb on days 14 and 16 obviated this donor-specific antibody and promoted Treg-mediated tolerance and survival of 60% of high ischemic allografts beyond day 100 posttransplant, but all allografts failed by day 120. CONCLUSIONS: These studies indicate a strategy inducing prolonged high ischemic allograft survival through Treg-mediated tolerance that is not sustained indefinitely.

Surgical Technique of the "Up-The-Neck" View During Hip Arthroscopy for Femoroacetabular Impingement.

In the setting of femoroacetabular impingement, arthroscopy versus open surgery confers many advantages. However, inadequate bony resection remains a concern and is the leading cause of revision surgery. Several strategies have been described to ensure a more-complete resection during hip arthroscopy. In this current technique article, the authors describe a modified anterior portal site view called the "up-the-neck" view. This view allows for greater visualization of the femoral head-neck junction and alleviates challenges faced when assessing resection intraoperatively. The "up-the-neck" view is achieved by placing a 70° arthroscope in the anterior lateral portal and subsequently rotating the camera 90°. The head-neck junction will appear horizontally, rather than vertically, on this view, which allows for the easy identification of missed imperfections. This may reduce the need for revision surgery and future investigation is necessary to determine the reoperation rates following this technique.

Arthroscopic Rotator Cuff Repair and Subpectoral Biceps Tenodesis in the Lateral Decubitus Position.

Arthroscopic rotator cuff repair can be performed with the patient in the beach-chair or lateral decubitus position. Patient positioning in shoulder arthroscopy is a critical step in surgical preparation and remains a debated topic. The lateral decubitus position is a reliable, safe, and effective position in which to perform nearly all types of shoulder arthroscopic procedures. The purpose of this Technical Note is to describe our preferred technique for performing arthroscopic rotator cuff repair with the patient in the lateral decubitus position, which portends several advantages, such as improved visualization of the glenohumeral space, ergonomic positioning, a low risk of cerebral hypoperfusion, and a shorter operating time.

Treatment of the 'The Naked Humeral Head': Repair of Supraspinatus Avulsion, Subscapularis Tear, and Humeral Avulsion of the Glenohumeral Ligament.

A humeral avulsion of the glenohumeral ligament, or HAGL, lesion is a rare yet debilitating shoulder injury, which can lead to recurrent instability, pain, and overall shoulder dysfunction. The diagnosis is often difficult, requiring both high clinical suspicion, as well as identification on magnetic resonance imaging. In patients with an anterior HAGL, repair often requires an open approach. In extremely rare circumstances, the initial traumatic event that causes a HAGL can also cause disruption of the supraspinatus and subscapularis insertions on the humeral head. We have termed this the "naked humeral head". The purpose of this technical note is to describe our preferred technique to surgically treat the naked humeral head by repairing a supraspinatus avulsion fracture, HAGL lesion, and complete subscapularis tear.

A Review of Commercially Available Point-of-Care Devices to Concentrate Platelet-Rich Plasma.

Platelet-rich plasma (PRP) is a promising therapy treatment option for multiple orthopedic conditions, which has demonstrated expanding clinical use. With increased clinical use of PRP, there has been a greater demand for point-of-care (POC) biologic devices. For this review, publicly available information provided by the device corporations, PubMed, Medline, and Embase databases were searched for studies related to POC device function. A scoping review study design was selected to explore the breadth of knowledge in the literature regarding PRP POC devices. ProofPoint Biologics demonstrated the highest laboratory platelet increase (5.2 ± 0.28-fold) and the longest processing time (49 ± 1.4 minutes). Celling demonstrated the lowest laboratory platelet increase (2.7 ± 0.8-fold), while AcCELLerated had the fastest processing time (18 ± 1.4 minutes for PurePRP® AB60 Pure (Pure Accelerated Biologics, Tequesta, FL) and 13.5 ± 2.1 minutes for AbsolutePRP® (Emcyte Corporation, Fort Myers, FL)). Celling had the lowest cost out of the various biologic devices. There is significant variability in the technical features, cost, processing time, and centrifugation parameters of the different commercially available point-of-care devices.

Current State of Platelet-Rich Plasma and Cell-Based Therapies for the Treatment of Osteoarthritis and Tendon and Ligament Injuries.

➤: Orthobiologics encompass numerous substances that are naturally found in the human body including platelet-rich plasma (PRP), isolated growth factors, and cell therapy approaches to theoretically optimize and improve the healing of cartilage, fractures, and injured muscles, tendons, and ligaments. ➤: PRP is an autologous derivative of whole blood generated by centrifugation and is perhaps the most widely used orthobiologic treatment modality. Despite a vast amount of literature on its use in osteoarthritis as well as in tendon and ligament pathology, clinical efficacy results remain mixed, partly as a result of insufficient reporting of experimental details or exact compositions of PRP formulations used. ➤: Mesenchymal stromal cells (MSCs) can be isolated from a variety of tissues, with the most common being bone marrow aspirate concentrate. Similar to PRP, clinical results in orthopaedics with MSCs have been highly variable, with the quality and concentration of MSCs being highly contingent on the site of procurement and the techniques of harvesting and preparation. ➤: Advances in novel orthobiologics, therapeutic targets, and customized orthobiologic therapy will undoubtedly continue to burgeon, with some early promising results from studies targeting fibrosis and senescence.

The Current Status of Concussion Assessment Scales: A Critical Analysis Review.

¼: Concussion is a complex pathophysiologic process that affects the brain; it is induced by biomechanical forces, with alteration in mental status with or without loss of consciousness. ¼: Concussion assessment tools may be broadly categorized into (1) screening tests such as the SAC (Standardized Assessment of Concussion), the BESS (Balance Error Scoring System), and the King-Devick (KD) test; (2) confirmatory tests including the SCAT (Sport Concussion Assessment Tool), the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), and the VOMS (Vestibular Oculomotor Screening); and (3) objective examinations such as brain network activation (BNA) analysis, imaging studies, and physiologic markers. ¼: The KD, child SCAT3 (cSCAT3), child ImPACT (cImPACT), and VOMS tests may be used to evaluate for concussion in the pediatric athlete. ¼: Future work with BNA, functional magnetic resonance imaging, diffusion tensor imaging, and serum biomarkers may provide more objective assessment of concussion, neurologic injury, and subsequent recovery.