Postoperative Opioid Usage and Disposal Strategies After Arthroscopic Procedures in a Young Cohort: A Prospective Observational Study.

Background: Although several studies have noted that patients are routinely overprescribed opioids, few have reported usage after arthroscopic surgery. Purpose: To determine opioid consumption and allocation for unused opioids after common arthroscopic surgeries. Study Design: Case series; Level of evidence, 4. Methods: Patients between the ages of 15 and 40 years who were scheduled to undergo anterior cruciate ligament reconstruction (ACLR), labral repair of the hip or shoulder, meniscectomy, or meniscal repair were prospectively enrolled. Patients were prescribed either 5 mg hydrocodone-325 mg acetaminophen or 5 mg oxycodone-325 mg acetaminophen based on surgeon preference. Patients completed a daily opioid usage survey during the 2-week postoperative period. In addition, patients completed a survey on postoperative day 21 inquiring about continued opioid use and medication disposal, if applicable. Opioid medication consumption was converted to morphine milligram equivalents (MMEs). Results: Of the 200 patients who were enrolled in the study, 176 patients had sufficient follow-up after undergoing 85 (48%) ACLR, 26 (14.8%) hip labral repair, 34 (19.3%) shoulder labral repair, 18 (10.2%) meniscectomy, and 13 (7.4%) meniscal repair procedures. Mean age was 26.1 years (SD, 7.38); surgeons prescribed a mean of 26.6 pills whereas patients reported consuming a mean of 15.5 pills. The mean MME consumption in the 14 days after each procedure was calculated: ACLR (95.7; 44% of prescription), hip labral repair (84.8; 37%), shoulder labral repair (57.2; 35%), meniscectomy (18.4; 27%), and meniscal repair (32.1; 42%). This corresponded to approximately 39% of the total opioid prescription being utilized across all procedures. Mean MME consumption was greatest on postoperative day 1 in hip, shoulder, and meniscal procedures and on postoperative day 2 in ACLR. Only 7.04% of patients reported continued opioid use in the third postoperative week. Patients had a mean of 11 unused pills or 77.7 MMEs remaining. Of the patients with remaining medication, 24.7% intended to keep their medication for future use. Conclusion: The results of our study indicate that patients who undergo the aforementioned arthroscopic procedures consume <75 MMEs in the 2-week postoperative period, translating into a mean of 10 to 15 pills consumed. Approximately 60% of total opioids prescribed went unused, and one-fourth of patients intended to keep their remaining medication for future usage. We have provided general prescribing guidelines and recommend that surgeons carefully consider customizing their opioid prescriptions on the basis of procedure site to balance optimal postoperative analgesia with avoidance of dissemination of excess opioids.

Blood Flow Restriction Therapy After Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament reconstruction (ACLR) rehabilitation necessitates restoration of quadriceps strength to minimize reinjury and optimize return to sport (RTS). Patients recovering from ACLR are limited by pain and activity restrictions, resulting in quadriceps muscle atrophy. Blood flow restriction (BFR) therapy involves performing exercises while a specialized blood pressure cuff is applied to the proximal aspect of the operative extremity and inflated to 40% to 90% of the arterial occlusion pressure, as determined using Doppler ultrasonography. BFR is theorized to induce an anaerobic environment and metabolic stress during exercise, promoting muscle hypertrophy and strength gains. Although the physiological mechanism has not been fully elucidated, it is theorized that BFR combined with low-load resistance training could yield muscle adaptations comparable to those of high-load resistance training. For ACLR patients with pain and restrictions precluding high-intensity strength training, incorporation of BFR into postoperative rehabilitation protocols could help mitigate quadriceps weakness and promote RTS. Randomized controlled trials report a prolonged, dose-dependent relation between BFR use and quadriceps and hamstring strength gains, improved bone and muscle mass, and earlier RTS, whereas other studies report no significant difference in quadriceps size, strength, or patient satisfaction compared with controls. Furthermore, although generally considered safe, there are rare reports of associated adverse events such as rhabdomyolysis, and BFR should be avoided in patients with a history of thromboembolic disease or peripheral vasculopathy. The literature examining BFR after ACLR is heterogeneous; lacks standardization; and contains broad variation in reported cuff pressures, as well as timing and duration of BFR use, among protocols. Although the use of BFR after ACLR shows promise, further study is necessary to elucidate the efficacy, safety, and optimal protocols.

Orthopedic Surgery Residency Program Rankings and Gender Diversity.

Background Orthopedic surgery residency programs are some of the least gender-diverse specialty programs in medicine. Despite strong representation at the undergraduate and medical school levels and increased applications to orthopedic surgery residency programs by women, there is still a substantial gender gap at the resident level. This study explores the relationship between the gender diversity of orthopedic surgery residency programs and program rankings. Methodology Program rank, program director gender identity, and gender diversity data were collected for the top 100 programs by reputation in Doximity. Gender diversity was measured as the proportion of female residents in the program and alumni. Results The greatest percentage of women in a program was 33% and the smallest was 3%. After linear regression analysis, we found that there was a statistically significant positive correlation between program rank and the proportion of women. The higher ranked a program was, the greater the proportion of women. There was no significant correlation between program director gender, appointment year, and program rank. Conclusions These results suggest that, although there is still a long way to go before closing the gender gap in orthopedic surgery residency programs, higher-ranked programs are associated with greater gender diversity than their lower-ranked counterparts.

ChatGPT Provides Unsatisfactory Responses to Frequently Asked Questions Regarding Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine whether the free online artificial intelligence platform ChatGPT could accurately, adequately, and appropriately answer questions regarding anterior cruciate ligament (ACL) reconstruction surgery. METHODS: A list of 10 questions about ACL surgery was created based on a review of frequently asked questions that appeared on websites of various orthopaedic institutions. Each question was separately entered into ChatGPT (version 3.5), and responses were recorded, scored, and graded independently by 3 authors. The reading level of the ChatGPT response was calculated using the WordCalc software package, and readability was assessed using the Flesch-Kincaid grade level, Simple Measure of Gobbledygook index, Coleman-Liau index, Gunning fog index, and automated readability index. RESULTS: Of the 10 frequently asked questions entered into ChatGPT, 6 were deemed as unsatisfactory and requiring substantial clarification; 1, as adequate and requiring moderate clarification; 1, as adequate and requiring minor clarification; and 2, as satisfactory and requiring minimal clarification. The mean DISCERN score was 41 (inter-rater reliability, 0.721), indicating the responses to the questions were average. According to the readability assessments, a full understanding of the ChatGPT responses required 13.4 years of education, which corresponds to the reading level of a college sophomore. CONCLUSIONS: Most of the ChatGPT-generated responses were outdated and failed to provide an adequate foundation for patients' understanding regarding their injury and treatment options. The reading level required to understand the responses was too advanced for some patients, leading to potential misunderstanding and misinterpretation of information. ChatGPT lacks the ability to differentiate and prioritize information that is presented to patients. CLINICAL RELEVANCE: Recognizing the shortcomings in artificial intelligence platforms may equip surgeons to better set expectations and provide support for patients considering and preparing for ACL reconstruction.

ChatGPT Can Offer Satisfactory Responses to Common Patient Questions Regarding Elbow Ulnar Collateral Ligament Reconstruction.

Purpose: To determine whether ChatGPT effectively responds to 10 commonly asked questions concerning ulnar collateral ligament (UCL) reconstruction. Methods: A comprehensive list of 90 UCL reconstruction questions was initially created, with a final set of 10 "most commonly asked" questions ultimately selected. Questions were presented to ChatGPT and its response was documented. Responses were evaluated independently by 3 authors using an evidence-based methodology, resulting in a grading system categorized as follows: (1) excellent response not requiring clarification; (2) satisfactory requiring minimal clarification; (3) satisfactory requiring moderate clarification; and (4) unsatisfactory requiring substantial clarification. Results: Six of 10 ten responses were rated as "excellent" or "satisfactory." Of those 6 responses, 2 were determined to be "excellent response not requiring clarification," 3 were "satisfactory requiring minimal clarification," and 1 was "satisfactory requiring moderate clarification." Four questions encompassing inquiries about "What are the potential risks of UCL reconstruction surgery?" "Which type of graft should be used for my UCL reconstruction?" and "Should I have UCL reconstruction or repair?" were rated as "unsatisfactory requiring substantial clarification." Conclusions: ChatGPT exhibited the potential to improve a patient's basic understanding of UCL reconstruction and provided responses that were deemed satisfactory to excellent for 60% of the most commonly asked questions. For the other 40% of questions, ChatGPT gave unsatisfactory responses, primarily due to a lack of relevant details or the need for further explanation. Clinical Relevance: ChatGPT can assist in patient education regarding UCL reconstruction; however, its ability to appropriately answer more complex questions remains to be an area of skepticism and future improvement.

Gender Equity Efforts in Sports Medicine.

Great progress has been made toward gender equality in athletics, whereas true equality has not yet been realized. Concurrently, women orthopedists along with advocate men have paved the way toward gender equity in orthopedics as a whole and more specifically in sports medicine. The barriers that contribute to gender disparities include lack of exposure, lack of mentorship, stunted career development, childbearing considerations and implicit gender bias and overt gender discrimination.

Sex differences in corticospinal excitability and quadriceps performance after anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) ruptures result in lasting quadriceps dysfunction that contributes to secondary injury risk and development of osteoarthritis. There is evidence of persistent reduced nervous system drive (corticospinal excitability [CSE]) to the quadriceps and sex differences in both quadriceps performance and CSE post-ACL reconstruction (ACLR). The purposes of this study were to investigate the differences in CSE and quadriceps dysfunction after ACLR between sexes and relative to controls. Twenty subjects 4-9 months post-ACLR and 20 age, sex, and activity matched controls participated in this study. Quadriceps performance (peak torque, PT; rate of torque development from onset to 100 ms, RTD100; and RTD from 100 to 200ms, RTD200) and CSE (active motor threshold; slope of the stimulus response (SR) curve, SR curve slope) were measured using an isokinetic dynamometer (HUMAC NORM) and transcranial magnetic stimulation respectively. Significant group differences were found for SR curve slope, PT, RTD100, and RTD200 on the surgical limb. Males after ACLR had higher slopes (higher CSE) than females. Females after ACLR had worse surgical limb quadriceps PT than control males and slower RTD100 and RTD200 than control males and control females. Higher CSE in males after ACLR may point to a potentially adaptive neurological change in males post-ACLR and indicate greater need for novel interventions to address cortical drive in females after ACLR.

Stabilization and Gap Formation of Adjustable Versus Fixed Primary ACL Repair With Internal Brace: An in Vitro Full-Construct Biomechanical Cadaveric Study.

Background: A knotless, tensionable primary anterior cruciate ligament (ACL) repair system preloaded with an internal brace has been released. Currently, there is no biomechanical data on the stabilization and gap formation behavior of the adjustable system when compared with fixed repairs in human ACL tissue. Hypothesis: That knotless adjustable suture repair with an internal brace would provide overall higher construct stability and greater load share on the ACL with less gap formation compared with fixed repair. Study Design: Controlled laboratory study. Methods: Human cadaveric knees were utilized for internal braced ACL repair constructs (each group n = 16). Two fixed groups consisting of a single-cinch loop (SCL), cortical button (SCL group), and knotless suture-anchor (anchor group) were compared with an SCL-adjustable loop device (SCL-ALD) group. Testing was performed at 4 different peak loads (50, 150, 250, 350 N) over 4000 cycles at 0.75 Hz including suture repair preconditioning (10 cycles at 0.5 Hz) for SCL-ALD. Specimens were ultimately pulled to failure with a cut internal brace. The final loading situation of the construct and ACL repair with gap formation and ultimate strength were evaluated. Results: Peak elongation at various peak loads showed a significantly higher (P < .001) stabilization of SCL-ALD when compared with both fixed groups. There was a significantly higher (P < .001) load share of SCL-ALD, especially at lower loads (48% of 50 N), and the gap formation remained restricted up to 250 N. With only a little load share on the fixed constructs (<6%) at lower loads (50, 150 N), gap formation in these groups started at a load of 150 N, leading to significantly higher gaps (P < .001). The ultimate failure load for SCL-ALD and anchor groups was significantly increased (P < .001) as compared with SCL. The stiffness of SCL-ALD (62.9 ± 10.6 N/mm) was significantly increased (P < .001). Conclusion: Internal braced knotless adjustable fixation for ACL repair with preconditioning of the suture repaired ligament increased the overall stabilization with higher load share on the ACL and restricted gap formation (<0.5 mm up to 350 N) compared with fixed suture repair. All internal braced repairs restored stability according to native ACL function. Clinical Relevance: Adjustable ACL repair improved the mechanical characteristics and reduced gap formation, but the overall clinical significance on healing remains unclear.

Team Physicians in Men's and Women's Professional Sports Leagues: Gender Representation and Career Path Analysis.

Background: The most common orthopaedic fellowship is for sports medicine, but few fellowship-trained orthopaedic surgeons fill roles as team physicians. Gender disparities within the field of orthopaedics, coupled with male-dominated professional sports leagues in the United States, may lead to lower representation of women as professional team physicians. Purpose: To (1) determine the career path trajectories of current head team physicians in professional sports, (2) quantify gender disparities across team physician representation, and (3) further characterize professional profiles of team physicians appointed to women's and men's professional sports leagues in the United States. Study Design: Cross-sectional study. Methods: This is a cross-sectional study of professional sports head team physicians in 8 major American sports leagues: American football (National Football League), baseball (Major League Baseball), basketball (National Basketball Association and Women's National Basketball Association), hockey (National Hockey League and National Women's Hockey League), and soccer (Major League Soccer and National Women's Soccer League). Online searches were used to compile information on gender, specialty, medical school, residency, fellowship, years in practice, clinical practice type, practice setting, and research productivity. Differences according to league type (men's vs women's leagues) were analyzed with the chi-square test for categorical variables, t test for continuous variables, and Mann-Whitney U test for nonparametric means. Bonferroni correction was applied for multiple comparisons. Results: Within the 172 professional sports teams, 183 head team physicians were identified, including 170 men (92.9%) and 13 women (7.1%). Team physicians in both men's and women's sports leagues were predominantly men. Overall, 96.7% of team physicians in men's leagues were men, and 73.3% of team physicians in women's leagues were men (P < .001). The most common physician specialties were orthopaedic surgery (70.0%) and family medicine (19.1%). Compared with team physicians in women's leagues, those in men's leagues were more likely to be orthopaedic surgeons (40.0% vs 71.9%, respectively; P = .001) and to have more experience (15.9 vs 22.4 years, respectively; P < .001). Conclusion: Study findings indicated disparities in gender, practice experience, and physician specialty representation among team physicians in men's versus women's professional sports leagues.

Outcomes and Patient Satisfaction of Delayed Distal Biceps Repairs without Graft Augmentation: A Systematic Review.

BACKGROUND: Distal biceps tendon tears are responsible for 3% to 10% of all biceps ruptures. Treated nonoperatively, these injuries result in poor endurance, loss of supination strength, and loss of flexion strength compared with those treated operatively with repair or reconstruction. When presenting in a chronic fashion, operative management can involve graft reconstruction or primary repair. When there is adequate tendon excursion and quality, primary repair is preferred. The purpose of this systematic review was to investigate the literature regarding outcomes of direct surgical repair of chronic distal biceps tendon ruptures. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to perform this systematic review and for the presentation of results. A search of the literature was performed on the electronic database Medline, Scopus, and the Cochrane Library. Included studies evaluated subjective and objective outcomes after delayed treatment (≥4 weeks postinjury) for chronic distal biceps tendon ruptures, without use of graft augmentation. Subjective and objective outcome metrics such as functional scores, range of motion, strength, pain level, and return to employment were collected. RESULTS: Eight studies were reviewed. The studies included 124 patients with chronic distal biceps tendon tears, treated surgically after a mean delay to surgery of 121.8 days. Four studies included comparison of patients with acute and chronic tears, whereas the other 4 studies assessed chronic tears only. The findings of these 4 studies suggest that direct repair of chronic tears is correlated with a mildly higher rate of lateral antebrachial cutaneous nerve (LABCN) injury palsy (10/82 [12.1%] chronic vs. 3/38 [7.9%] acute, p = 0.753); however, this complication was overwhelmingly transient. There were only 3 reported reruptures (3.19%) across 5 studies reporting this complication. Overall, patients who had undergone direct repair of chronic distal biceps tears had good patient satisfaction, outcomes, and range of motion. CONCLUSION: Direct repair of chronic distal biceps tendon tears without the use of graft reconstruction is associated with acceptable patient satisfaction, range of motion, and functional outcome scores, although transient LABCN palsy rates may be slightly higher. When sufficient residual tendon is present in the setting of chronic distal biceps rupture, direct repair is a viable treatment option. However, the existing literature regarding direct repair of chronic distal biceps repair is limited, and further prospective assessment directly comparing primary repair vs. reconstruction of chronic distal biceps ruptures is warranted. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Postoperative considerations based on graft type after anterior cruciate ligament reconstruction a narrative review.

Background and Objective: Graft selection for anterior cruciate ligament reconstruction (ACLR) affects rehabilitation throughout the course of postoperative care. Methods: A search of PubMed and EBSCO was performed and abstracts independently reviewed by two authors. This search was also supplemented with additional evidence relevant to each phase of ACLR rehabilitation. Key Content and Findings: Direct implications of graft type on clinical decisions vary throughout treatment phases, transitioning from potential differences in acute postoperative pain management immediately after surgery to facilitating sufficient and appropriate lower extremity loading in subsequent weeks. Regardless of graft type, surgical limb weakness persists throughout the course of rehabilitation; however, harvest site selection for autografts contributes to disproportionate weakness of the harvested muscle group and the potential for surgical-induced tendinopathy. In later phases of rehabilitation, as athletes are transitioning into return to sport (RTS), treatment decisions and protocols are less affected by graft type but expectations for meeting clinical milestones and the time required to do so does differ between graft types. Conclusions: Targeted strengthening interventions to address muscle weakness following graft harvest in autografts should be continued throughout the rehabilitation process. Lingering deficits in quadriceps strength symmetry may also influence time to meet progression and RTS criteria following graft harvest from the extensor mechanism.

Return to Sport Rates and Subjective Outcomes Are Similar After Open or Endoscopically Assisted Compartment Release for Chronic Lower-Extremity Exertional Compartment Syndrome.

Purpose: To retrospectively compare return to sport rates and subjective outcomes of patients who underwent open or endoscopic compartment release for the surgical management of chronic exertional compartment syndrome. Methods: This was a retrospective review of patients who underwent lower-extremity fasciotomy for chronic exertional compartment syndrome from June 2012 to June 2020. Eligibility included patients 15 to 45 years of age who identified as an athlete and had at least 6 months of follow-up. Fasciotomies for trauma or infection were excluded. One surgeon exclusively performed each type of surgery. Postoperative outcome measures included the Lower Extremity Functional Scale, the Marx Activity Scale, and a return to play survey. Results: In total, 24 patients (13 endoscopically assisted fasciotomies, 11 open fasciotomies) had a mean follow-up of 3.8 ± 2.1 years; 19 patients returned to their sporting activity. No significant difference existed between return to play rates (P = .630) or return to play times (P = .351). There were no significant differences between the groups in the Lower Extremity Functional Scale score, Marx Activity Scale score, Single Assessment Numeric Evaluation score, pain score at rest, and during sporting activity. Overall satisfaction rates were found to be significantly greater in the endoscopically assisted fasciotomy group (P = .041). Conclusions: In this small sample of heterogenous groups of patients, we found no significant differences in return to sport rates or subjective results after surgery. Patients experienced a high subjective recurrence rate. The endoscopically assisted fasciotomy group reported greater subjective patient satisfaction compared with the open fasciotomy group. Level of Evidence: Level III, comparative study, retrospective.

Open Repair of Complete Proximal Hamstring Avulsions in Workers' Compensation Patients.

Background: Several studies have reported excellent results after surgical repair of proximal hamstring avulsions. However, the effect on these patients of receiving workers' compensation has not yet been explored. Hypothesis: Workers' compensation patients undergoing proximal hamstring repair of complete tears will have similar outcomes when compared with a matched control group of non-workers' compensation patients. Study Design: Cohort study; Level of evidence, 3. Methods: Workers' compensation patients who underwent complete proximal hamstring avulsion open repair between 2010 and 2019 were identified (WC group). A control group was matched by age (±3 years), sex, and body mass index (BMI; ±3). Demographics and patient-reported outcome measures were compared, including standard and custom Marx activity rating scale (MARS), standard and custom lower extremity functional scale (LEFS), and visual analog scale (VAS) for pain. Rate and time to return to work were recorded. Results: The WC group was composed of 20 patients (8 men, 12 women) with a mean age of 52.3 years and BMI of 32.4. The 20 matched controls (8 men, 12 women) who underwent repair had a mean age of 50.6 years and a mean BMI of 31.2. There was no difference between the groups regarding age (P = .924), sex (P > .999), or BMI (P = .330). The WC group reported similar mean MARS (3.3 vs 5.4; P = .174), custom MARS (87.5 vs 97.0; P = .215), and VAS pain (3.3 vs 3.8; P = .698) scores compared with controls. However, the WC group had significantly lower standard LEFS (69.1 vs 94.1; P < .001) and custom LEFS (62.3 vs 87.9; P < .001) scores, returned to work at a lower rate (70.0% vs 94.1%; P = .039), and required more time to return to work after repair (4.3 vs 3.5 months; P = .029) compared with controls. Conclusion: Workers' compensation patients who underwent open proximal hamstring repair for complete avulsions experienced inferior patient-reported outcomes, required more time to return to work, and returned to work at a lower rate than a matched control group.

Beach Chair Versus Lateral Decubitus Surgical Positioning for Arthroscopic Anterior Shoulder Stabilization: A Retrospective Comparison of Clinical and Patient-Reported Outcomes.

Background: Surgical positioning can affect both perioperative and postoperative complication rates. It is unclear whether beach-chair versus lateral decubitus positioning affects outcomes in patients undergoing arthroscopic anterior shoulder stabilization surgery. Purpose: The purpose of this study was to compare recurrent instability, complications, and patient-reported outcomes between patients who underwent arthroscopic anterior shoulder stabilization in the beach-chair versus the lateral decubitus positions. It was hypothesized that recurrent instability, complications, and patient-reported outcomes would not be affected by surgical positioning. Study Design: Cohort study; Level of evidence, 3. Methods: The authors reviewed the medical records of patients who underwent shoulder stabilization (Current Procedural Terminology codes 29806 and 29807) from 2015 to 2019. Patients were included only if anterior instability was confirmed, arthroscopic surgery was performed in response to shoulder instability, and a minimum of 2 years of follow-up data were available. Data collected for eligible patients included perioperative and postoperative complications, recurrent instability, reoperation, and revision. Patients also completed surveys for the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Oxford Shoulder Instability (OSI) score, and a return to any level of sport (RTS) questionnaire. Results: Overall, 294 patients (162 lateral decubitus and 132 beach-chair positions) were included, with an average follow-up of 2.4 ± 1.6 years. There were no significant differences in demographics between groups, nor were there differences in the rates of postoperative dislocations, subjective instability, reoperations, revisions, or complications. There was a trend toward a higher revision rate in the beach-chair group (beach-chair, 6.1% vs lateral decubitus, 1.9%; P = .069). There was no significant difference between groups regarding RTS rates or postoperative ASES, SANE, and OSI scores at 3.3 ± 1.1 years postoperatively. Conclusion: Surgical positioning for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, and patient-reported outcomes. Both beach-chair and lateral decubitus positioning provided good outcomes for anterior shoulder stabilization, with an overall recurrent dislocation rate of 7.8% at a mean of 3.3 years after surgery.

Beach-Chair Versus Lateral Decubitus Positioning for Arthroscopic Posterior Shoulder Labral Repair: A Retrospective Comparison of Clinical and Patient-Reported Outcomes.

BACKGROUND: Both beach-chair and lateral decubitus patient positioning are often utilized for shoulder arthroscopy, with each offering its unique advantages and disadvantages. The surgical position is often selected according to each surgeon's preference, with no clear superiority of one position over the other. PURPOSE/HYPOTHESIS: The purpose was to compare clinical and patient-reported outcomes between patients who underwent arthroscopic posterior labral repair in the beach-chair versus the lateral decubitus position. We hypothesized that patient positioning would not affect clinical and patient-reported outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A list of all patients diagnosed with the Current Procedural Terminology codes 29806 and 29807 between 2015 and 2019 was obtained from the medical records. Patients were only included if arthroscopic posterior labral repair with or without concomitant superior labral anterior to posterior repair was confirmed. Data collected for eligible patients included the number of anchors used, perioperative and postoperative complications, redislocations, subjective instability, reoperation, and revision. Patients were also contacted to complete several patient-reported outcome surveys. Preoperative data, perioperative data, and postoperative outcomes were compared between patients who underwent surgery in the beach-chair versus lateral decubitus position. RESULTS: Overall, 126 patients were included-69 patients underwent surgery in the lateral decubitus position and 57 in the beach-chair position-with a mean follow-up of 2.6 ± 1.7 years. There were no significant pre- or perioperative differences between groups. Rates of postoperative dislocations, subjective instability, reoperations, revisions, all complications, and return to sports rates also did not differ between groups (all, P > .05). Finally, there was no difference between groups regarding postoperative pain, function, and subjective instability scores (all, P > .05). Results of the multivariate regression analysis showed that increased age was a weak independent risk factor for subjective recurrent posterior shoulder instability (odds ratio, 1.04; P = .036). CONCLUSION: Surgical positioning for arthroscopic posterior shoulder labral repair did not affect postoperative clinical and patient-reported outcomes. Both beach-chair and lateral decubitus position provided good outcomes for posterior shoulder labral repair, with an overall recurrence rate of 8.7%. Increased age was a weak independent risk factor for subjective recurrent instability.

Knotted Versus Knotless Medial-Row Transosseous-Equivalent Double-Row Rotator Cuff Repairs Have Similar Clinical and Functional Outcomes.

Purpose: To retrospectively investigate the clinical and functional outcomes of patients who underwent knotted medial-row rotator cuff repair (KT-RCR) compared with patients who underwent knotless medial-row rotator cuff repair (KL-RCR). Methods: A retrospective chart review of patients who underwent double-row transosseous-equivalent rotator cuff repair in 2016 was performed at a single institution with 2-year follow-up. Information regarding demographic characteristics, preoperative tear size (magnetic resonance imaging), surgical variables (including method of suture stabilization), preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) scores, and all complications (e.g., cuff failure, adhesive capsulitis, and persistent pain) was compiled. Results: A total of 189 patients met the inclusion criteria: 72 in the KL-RCR group and 117 in the KT-RCR group. No significant difference in preoperative ASES scores was found between the KL-RCR and KT-RCR groups (48.3 vs 45.4, P = .327). Postoperative ASES scores did not differ between the groups (82.4 for KL-RCR vs 78.8 for KT-RCR, P = .579). We found no significant difference in cuff failure rates after 2 years, determined by magnetic resonance imaging (5.6% for KL-RCR vs 6.1% for KT-RCR, P > .999), or complication rates (11.1% for KL-RCR vs 8.6% for KT-RCR, P = .743). Conclusions: The knotted approach and knotless approach to double-row rotator cuff repair showed similar outcome scores, cuff failure rates, and complication rates at minimum 2-year follow-up. Level of Evidence: Level III, retrospective therapeutic comparative trial.

Safer Return to Play After Anterior Cruciate Ligament Reconstruction: Evaluation of a Return-to-Play Checklist.

Background: Questions remain regarding the traditional protocols used in rehabilitation and clearance for return to sports after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: To investigate the impact on injury rates after return to sports by developing and validating a Safer Return to Play Following ACL Reconstruction Checklist consisting of subjective and objective functional tests that can be quickly and easily implemented into a sports medicine practice. It was hypothesized that patients who successfully passed the checklist before returning to sports would experience lower rates of ipsilateral and contralateral knee injuries at a 2-year follow-up as compared with patients who returned to play before completing the checklist. Study Design: Cohort study; Level of evidence, 2. Methods: First, a systematic review was performed to generate a list of the most common outcome measures used to assess return to play after ACLR. To refine our checklist, we conducted a survey with an expert panel of 10 medical professionals utilizing the Delphi technique. After the creation of the checklist, validation was performed by prospectively evaluating patients who had undergone ACLR for injury of the ipsilateral or contralateral knee, with a minimum 2-year follow-up. Results: After our systematic review of 60 studies, 7 criteria were included in the final checklist. During the period studied, October 2014 to December 2017, a total of 222 patients met the inclusion criteria and were enrolled in the study. At a minimum 2 years of follow-up, there were 146 patients who successfully passed the checklist and 38 who did not. Overall, 24 (16.4%) patients who had passed the checklist sustained an injury to either knee, as compared with 10 (26.3%) from the group that did not pass the checklist (P = .162). Of the group that passed the checklist, 8 (5.5%) patients sustained an injury to the ipsilateral knee, as compared with 7 (18.4%) in the group that did not pass (P = .017). Conclusion: Prospective validation of our checklist demonstrated that patients who successfully passed the checklist before returning to play experienced a significantly lower incidence of ipsilateral anterior cruciate ligament injury as compared with patients who did not pass the checklist.

Evaluation of Rotator Cuff Repair With and Without Concomitant Biceps Intervention: A Retrospective Review of Patient Outcomes.

BACKGROUND: Biceps tendon pathology is common in patients with rotator cuff tears. Leaving biceps pathology untreated in rotator cuff repairs (RCRs) may lead to suboptimal outcomes. PURPOSE/HYPOTHESIS: The purpose was to compare clinical outcomes between patients who underwent isolated RCR versus patients who underwent RCR with concomitant biceps treatment. It was hypothesized that there would be no difference in clinical outcomes between groups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 244 patients who underwent RCR in 2016 were included. Patient characteristics, presence of concomitant biceps pathology, pre- and postoperative American Shoulder and Elbow Surgeons (ASES) scores, rotator cuff failure, revision surgery, and complications were recorded. RESULTS: There were no significant differences between patients who underwent isolated RCR (n = 143) and those who underwent RCR with biceps treatment (n = 101) at 2 years postoperatively in ASES scores (RCR, 81.5; RCR+biceps treatment, 79.5; P = .532), cuff failure rate (5.6% vs 4.0%; P = .760), revision RCR rate (3.5% vs 2.0%; P = .703), or complication rate (11.9% vs 5.0%; P = .102). Furthermore, when comparing concomitant biceps tenotomy (n = 30) versus concomitant biceps tenodesis (n = 71), there were no differences in ASES scores (P = .149), cuff failure rate (P > .999), revision RCR rate (P > .999), or complication rate (P > .999) postoperatively. Finally, when comparing arthroscopic biceps tenodesis (n = 50) versus subpectoral biceps tenodesis (n = 21), there were no differences in ASES scores (P > .592), cuff failure rate (P > .999), revision RCR rate (P = .507), or complication rate (P > .999) 2 years postoperatively. CONCLUSION: Addressing biceps pathology when performing RCR resulted in similar rates of cuff failure, revision RCR, and complications, as well as a similar improvement in patient-reported outcomes when compared with isolated RCR at 2 years postoperatively. Furthermore, when comparing tenotomy versus tenodesis and arthroscopic versus subpectoral tenodesis, comparable outcomes with regard to rate of rotator cuff repair failure, revision RCR, complications, and patient-reported outcomes were found.

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.

Prospective Randomized Study Examining Preoperative Opioid Counseling on Postoperative Opioid Consumption after Upper Extremity Surgery.

Background: Rates of opioid addiction and overdose continue to climb in the United States, increasing pressure on prescribers to identify solutions to decrease postoperative opioid consumption. Hand and upper extremity surgeries are high-volume surgeries with a predilection for inadvertent overprescribing. Recent investigations have shown that preoperative opioid counseling may decrease postoperative opioid consumption. In order to test this hypothesis, a prospective randomized trial was undertaken to determine the effect of preoperative opioid counseling on postoperative opioid consumption. Methods: Eligible patients undergoing outpatient upper extremity surgery were randomized to either receive preoperative opioid counseling or to receive no counseling. Surgeons were blinded to their patient's counseling status. Preoperatively, patient demographics, surgical and prescription details were recorded. Postoperatively, patients' pain experience including opioid consumption, pain levels, and satisfaction was recorded. Results: There were 131 total patients enrolled, with 62 in the counseling group and 69 in the control group. Patients receiving counseling consumed 11.8 pills compared to 17.4 pills in the control group (P = .007), which translated to 93.7 Morphine Equivalent Units (MEU) in the counseling group compared to 143.2 MEU in the control group (P = .01). There was no difference in pain scores at any time point between groups. Among all study patients a total of 3767 opioid pills were prescribed with approximately 50% left unused. Conclusion: Patients receiving preoperative counseling consumed significantly fewer opioids postoperatively. Inadvertant overprescribing remains high. Routine use of preoperative counseling should be implemented along with prescribing fewer opioids overall to prevent overprescribing.