Fatty Infiltration, Tear Size, and Retraction Size Are Significant Risk Factors for Retear After Arthroscopic Rotator Cuff Repair: A Systematic Review.

PURPOSE: To assess the consistency and quality of risk factor reporting for rotator cuff repair (RCR) retear and identify risk factors most frequently associated with retear. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Of the initial 3,158 studies, a total of 31 met the following inclusion criteria: (1) clinical studies regarding RCR failure, (2) arthroscopic procedures involving RCR, (3) reporting of clinical outcomes, (4) publication within the past 5 years, and (5) studies investigating preoperative risk factors for retear. After full-text review, 18 risk factors were analyzed. RESULTS: The most consistently significant risk factors were acromiohumeral distance (80%), critical shoulder angle (67%), tear size (63%), anterior-posterior dimension (60%), fatty infiltration (FI) (58%), and retraction size (56%). FI was analyzed using different methods among studies, with 63% finding significant results and 50% of all studies performing ordinal analysis. Tear size was inconsistently analyzed quantitatively or qualitatively, with 58% of studies finding significant results and 63% of all studies performing quantitative analysis. Risk factors consistently found to be nonsignificant included age, sex, diabetes mellitus, symptom duration, hand dominance, repair technique, smoking, and body mass index. CONCLUSIONS: Tear size, FI, and retraction size were found to be significant risk factors in most of the included studies evaluating rotator cuff retear. Risk factors less likely reported as predictive included repair technique, age, sex, diabetes mellitus, symptom duration, hand dominance, repair technique, smoking, and body mass index. Risk factors that require further investigation include critical shoulder angle, acromiohumeral distance, and anterior-posterior tear dimension. LEVEL OF EVIDENCE: Level III, systematic review of Level III-IV studies.

Editorial Commentary: The Suture-Augmented Anterior Cruciate Ligament Reconstruction Requires Independent Tensioning to Achieve Load Sharing.

Countless variations of anterior cruciate ligament repair or reconstruction plus augmentation have existed for decades, but augmentation was associated with complications such as reactive synovitis, instability, loosening, and rupture. Recently, augmentation with ultra-high molecular weight polyethylene suture or suture tape, however, has not been shown to be associated with these complications. The goal when performing suture augmentation is to provide independent tensioning of the suture augment and graft to allow the suture or suture tape to function as a load-sharing device, allowing the graft to see more strain during earlier levels of graft strain until graft elongation occurs to a critical level, whereby the augment will experience more strain and protect the graft. Although long-term outcome studies are pending, animal and human clinical studies do show that ultra-high molecular weight polyethylene, when used as a suture augment for anterior cruciate ligament surgery, is unlikely to cause a significant intra-articular reaction while also providing biomechanical advantages that could prevent early graft rupture during the revascularization phase of healing.

Machine Learning Algorithms Predict Achievement of Clinically Significant Outcomes After Orthopaedic Surgery: A Systematic Review.

PURPOSE: To determine what subspecialties have applied machine learning (ML) to predict clinically significant outcomes (CSOs) within orthopaedic surgery and to determine whether the performance of these models was acceptable through assessing discrimination and other ML metrics where reported. METHODS: The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were queried for articles that used ML to predict achievement of the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) after orthopaedic surgical procedures. Data pertaining to demographic characteristics, subspecialty, specific ML algorithms, and algorithm performance were analyzed. RESULTS: Eighteen articles met the inclusion criteria. Seventeen studies developed novel algorithms, whereas one study externally validated an established algorithm. All studies used ML to predict MCID achievement, whereas 3 (16.7%) predicted SCB achievement and none predicted PASS achievement. Of the studies, 7 (38.9%) concerned outcomes after spine surgery; 6 (33.3%), after sports medicine surgery; 3 (16.7%), after total joint arthroplasty (TJA); and 2 (11.1%), after shoulder arthroplasty. No studies were found regarding trauma, hand, elbow, pediatric, or foot and ankle surgery. In spine surgery, concordance statistics (C-statistics) ranged from 0.65 to 0.92; in hip arthroscopy, 0.51 to 0.94; in TJA, 0.63 to 0.89; and in shoulder arthroplasty, 0.70 to 0.95. Most studies reported C-statistics at the upper end of these ranges, although populations were heterogeneous. CONCLUSIONS: Currently available ML algorithms can discriminate the propensity to achieve CSOs using the MCID after spine, TJA, sports medicine, and shoulder surgery with a fair to good performance as evidenced by C-statistics ranging from 0.6 to 0.95 in most analyses. Less evidence is available on the ability of ML to predict achievement of SCB, and no evidence is available for achievement of the PASS. Such algorithms may augment shared decision-making practices and allow clinicians to provide more appropriate patient expectations using individualized risk assessments. However, these studies remain limited by variable reporting of performance metrics, CSO quantification methods, and adherence to predictive modeling guidelines, as well as limited external validation. LEVEL OF EVIDENCE: Level III, systematic review of Level III studies.

Multicenter Outcomes After Primary Hip Arthroscopy: A Comparative Analysis of Two-Year Outcomes After Labral Repair, Segmental Labral Reconstruction, or Circumferential Labral Reconstruction.

PURPOSE: (1) To report minimum 2-year follow-up patient-reported outcome measures in patients undergoing labral repair (LR), segmental labral reconstruction (SLR), or circumferential labral reconstruction (CLR) in the primary setting; and (2) to compare minimum 2-year follow-up patient-reported outcome measures among these groups. METHODS: A retrospective review of a prospectively maintained multicenter database of patients undergoing hip arthroscopy was performed. Inclusion criteria were patients undergoing hip arthroscopy for treatment of labral tear and femoroacetabular impingement syndrome between January 2014 and October 2017, and completion of minimum 2-year postoperative outcome scores. Exclusion criteria were patients undergoing revision hip surgery, labral treatment limited to debridement, lateral center-edge angle <20°, osteoarthritis (Tönnis grade > 1), slipped capital femoral epiphysis, workers compensation status, and patients undergoing concomitant gluteus medius and/or minimus repair. Labral reconstruction patients were matched (1:3) with labral repair patients on age, sex, and body mass index. The labral reconstruction group was further stratified into SLR, and CLR groups. Patient demographic characteristics and clinical outcomes including Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, modified Harris Hip Score, international Hip Outcome Tool, and visual analog scale for pain were analyzed, as well as achievement of the minimal clinical improvement difference (MCID). A P-value less than .05 indicated statistical significance. RESULTS: A total of 416 patients were included (LR, n = 312; SLR, n = 53; CLR, n = 51). The age, body mass index, and sex of the matched cohort were 42.3 ± 11.2 years, 24.7 ± 3.7, and 55.0% female. At a minimum of 2-year after hip arthroscopic surgery, no differences were found in preoperative, postoperative, or the delta visual analog scale for pain, modified Harris Hip Score, Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, or international Hip Outcome Tool. Subsequently, the proportion of patients achieving the MCID and the PASS at latest follow-up were analyzed. This analysis revealed that no significant differences in the rate of MCID or PASS achievement for any outcome measure existed based on labral treatment. CONCLUSIONS: In this multicenter study on labral treatment in the primary setting, patients undergoing LR, SLR, and CLR demonstrated no difference in preoperative or postoperative scores, nor the proportion of patients achieving clinically significant outcome improvement. LEVEL OF EVIDENCE: III; therapeutic outcome study with controls.

Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis.

BACKGROUND AND HYPOTHESIS: Ruptures of the distal biceps tendon are most commonly due to traumatic eccentric loading in the middle-aged male population and can result in functional deficits. Although surgical repair has been demonstrated to result in excellent outcomes, there are few comparative studies that show clear functional benefits over nonoperative management. The aim of this systematic review and meta-analysis is to compare the functional outcomes of operative and nonoperative management for these injuries. We hypothesized that operative treatment would be associated with significantly superior outcomes. METHODS: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed using MEDLINE, SPORTDiscus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Registry of Controlled Trials), Embase, and Web of Science databases. Outcomes of interest included range of motion (ROM), strength, endurance, and patient-reported outcomes including Disabilities of the Arm, Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) for pain scores. Summary effect estimates of the mean difference between operative and nonoperative management for each outcome were estimated in mixed effects models. RESULTS: Of an initially identified 6478 studies, 62 reported outcomes for a total of 2481 cases (2402 operative, 79 nonoperative), with an overall average age of 47.4 years (47.3 for operative, 50.3 for nonoperative). There were 2273 (98.5%) males and 35 (1.5%) females among operative cases, whereas all 79 (100%) nonoperative cases were males. Operative management was associated with a significantly higher flexion strength (mean difference, 25.67%; P < .0001), supination strength (mean difference, 27.56%; P < .0001), flexion endurance (mean difference, 11.12%; P = .0268), and supination endurance (mean difference, 33.86%; P < .0001). Patient-reported DASH and MEPS were also significantly superior in patients who underwent surgical repair, with mean differences of -7.81 (P < .0001) and 7.41 (P = .0224), respectively. Comparative analyses for ROM and pain VAS were not performed because of limited reporting in the literature for nonoperative management. CONCLUSION: This study represents the first systematic review and meta-analysis to compare functional and clinical outcomes following operative and nonoperative treatment of distal biceps tendon ruptures. Operative treatment resulted in superior elbow and forearm strength and endurance, as well as superior DASH and MEPS.

Improved outcomes for proximal humerus fracture open reduction internal fixation augmented with a fibular allograft in elderly patients: a systematic review and meta-analysis.

BACKGROUND: To date, no meta-analysis has been performed on the efficacy of fibular allograft augmentation for the management of proximal humerus fractures. The purpose of this study was to evaluate the radiographic and clinical outcomes of proximal humerus fractures treated with a locking compression plate (LCP) with or without fibular allograft augmentation. METHODS: The Cochrane Database of Systematic Reviews, the Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, and SCOPUS were queried in June of 2021 for literature comparing the radiographic and clinical outcomes for patients with proximal humerus fractures that were treated with an LCP only or an LCP augmented with a fibular allograft. Data describing study design, level of evidence, demographic information, final follow-up, radiographic changes in humeral head height (HHH), radiographic changes in neck shaft angle (NSA), final American Shoulder and Elbow Surgeons (ASES) scores, final Constant-Murley scores, and major complications were collected. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS). A meta-analysis was performed using pooled weighted mean differences (WMD) to compare changes in HHH, NSA, final ASES and final Constant-Murley scores between the 2 groups; a pooled odds ratio (OR) was used to compare complications between the groups. RESULTS: Ten studies with a total of 802 patients were identified. There was a significant difference that favored patients augmented with a fibular allograft for change in HHH (WMD = -2.40; 95% confidence interval [CI], -2.49 to -2.31; P < .00001), change in NSA (WMD = -5.71; 95% CI, -6.69 to -4.72; P < .00001), final ASES scores (WMD = 5.08; 95% CI, 3.69-6.48; P < .00001), and OR for developing a major complication (OR = 0.37; 95% CI, 0.23-0.59; P < .0001). There was no significant difference in final Constant-Murley scores (WMD = 3.36; 95% CI, -0.21 to 6.93; P = .06) or revision surgery rate (P = .182) between the 2 groups. CONCLUSION: The pooled WMD and prediction interval suggest that 95% of patients with proximal humerus fractures treated with an LCP augmented with a fibular allograft will have improved radiographic outcomes, improved ASES clinical outcome scores, and decreased odds of a major complication when compared with patients treated with an LCP alone. Limitations of this study include a relatively short average final follow-up time (<2 years) and a potential lack of standardization for radiographic outcomes among included studies.

Editorial Commentary: The Anterior Cruciate Ligament May Be Safer Wearing a Suture Tape Augmentation Seat Belt: Click It or Ticket.

Bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction has the most data to support its use. However, there may still be room for improvement, and younger age, insufficient rehabilitation, altered neuromuscular patterns, and precocious return to play can increase risk of graft failure. High strength suture augmentation of soft-tissue repair or reconstruction has gained traction in a variety of applications for the knee, including medial collateral and posteromedial corner, lateral collateral ligament, posterior cruciate ligament, and ACL. For ACL reconstruction, the technique consists of using either suture or suture tape fixed at the femoral and tibial ACL footprints to allow for independent tensioning to back up the separately tensioned ACL reconstruction. The static augment serves as a load-sharing device, allowing the graft to see more strain during earlier levels of graft strain, until graft elongation occurs to a critical level whereby the augment will experience more strain than the graft. Hence, the "seat belt" analogy. This is distinct from static augmentation, where the high strength suture is fixed to the graft. Static augmentation (without tensioning separately from the graft) results in a load-sharing device and increased stiffness, but potential stress shielding compared with the "seat belt." If suture tape augmentation improves patient outcome, it is a worthwhile to "click it."

Primary Anterior Cruciate Ligament Repair Using Suture Tape Augmentation: A Case Series of 29 Patients With Minimum 2-Year Follow-Up.

PURPOSE: To evaluate clinical outcomes and patient-reported outcomes of patients who underwent primary anterior cruciate ligament (ACL) repair using suture tape augmentation. METHODS: Patients with a proximal tear of the ACL who underwent primary ACL repair with a minimum 2-year follow-up were included. The exclusion criteria included multiligamentous knee injuries, midsubstance tears, tibial avulsion fractures, and distal tears. Demographic characteristics, injury pattern, concomitant injury pattern, and patient-reported outcome measures were recorded. Patients were evaluated at a minimum 2-year follow-up for clinical success, defined as stability not requiring revision ACL reconstruction, and for patient-reported outcome measurements. Failure was defined as the need for revision surgery. RESULTS: The mean follow-up period was 2.8 ± 0.9 years. Thirty-five patients met the inclusion criteria, with an average age of 32.2 ± 7.2 years, and 2-year follow-up was obtained for 29 of these patients. Revision surgery was required in 2 of the 29 patients (6.9%); successful treatment was achieved in the remaining 93.1%. The Single Assessment Numeric Evaluation score and Knee Injury and Osteoarthritis Outcome Score for the 27 successfully treated patients were recorded, with 70.4% having Single Assessment Numeric Evaluation scores of 80 or greater. CONCLUSIONS: This case series shows that primary surgical repair of proximal ACL tears using suture tape augmentation results in a low rate of revision surgery. LEVEL OF EVIDENCE: Level IV, prospective case series.

Short-term outcomes of reverse shoulder arthroplasty using a custom baseplate for severe glenoid deficiency.

HYPOTHESIS AND BACKGROUND: Complex glenoid bone loss and deformity present a challenge for the shoulder arthroplasty surgeon. Eccentric reaming, bone grafting, augmented glenoid components, and salvage hemiarthroplasty are common strategies for managing these patients. The glenoid vault reconstruction system (VRS; Zimmer-Biomet) is a novel solution for both primary and revision arthroplasty using a custom glenoid baseplate. We hypothesized that patients undergoing reverse shoulder arthroplasty (RSA) with VRS would have acceptable short-term outcomes and complication rates. METHODS: Patients who underwent RSA with VRS for severe glenoid deformity or bone loss by one of 4 board-certified, fellowship-trained shoulder and elbow surgeons at 3 academic tertiary referral centers between September 2015 and November 2018 were eligible for inclusion. Patient data were obtained via medical record review and telephone questionnaires. The Numeric Pain Rating Scale (NPRS), Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Penn Shoulder Scores, and range of motion (ROM) measurements were obtained pre- and postoperatively. Radiographs were reviewed at final follow-up for evidence of component loosening or hardware failure. Any complication was documented. Outcomes were compared using Wilcoxon signed-rank tests with P <. 05 considered significant. RESULTS: Twelve shoulders (11 patients) were included with a mean age of 68 years; 7 were primary arthroplasties and 5 were revisions. At an average follow-up time of 30 months, median improvement in NPRS score was 7 points, SANE score 43%, ASES score 45 points, and Penn Shoulder Score 49 points. There were statistically significant improvements in median ROM measurements (forward elevation 20°, external rotation 40°, internal rotation 2 spinal levels). At final follow-up, all implants were radiographically stable without loosening. There were no complications. DISCUSSION AND CONCLUSION: This study demonstrates that RSA using the custom VRS glenoid implant is a safe and effective technique addressing complex glenoid deformity or bone loss in both primary and revision settings. At short-term follow-up, all patient-reported outcomes and ROM measures improved significantly, and there were no complications. Future work should determine mid- and long-term outcomes, preferably in a prospective manner with defined patient populations.

Suture Augmented Versus Standard Anterior Cruciate Ligament Reconstruction: A Matched Comparative Analysis.

PURPOSE: To compare outcomes between standard anterior cruciate ligament reconstruction (ACLR) using hamstring grafts with and without suture augmentation (SA). METHODS: Patients who underwent ACLR with hamstring autografts or allografts with minimum 2-year follow-up were retrospectively reviewed. Patients undergoing ACLR with SA were matched 1:1 by age, gender, body mass index, graft type, and revision status to standard ACLR. Range of motion, pain, postoperative activity, patient-reported outcome measures (PROMs), and complications were collected. Paired 2-tailed Student's t-tests and Pearson's χ2-tests were used for continuous and categorical variables, respectively. A multivariate analysis of variance was conducted. Return to preinjury activity level was assessed using Spearman's rho and Pearson's χ2-tests. RESULTS: Sixty patients at a mean age of 29.50 ± 6.60 years, 43.4% male, body mass index 26.27 ± 3.37, and follow-up of 29.54 ± 5.37 months were included. Preoperative PROMs were not significantly different (P >. 05). Postoperative range of motion was similar between groups (P = .457). Postoperative average daily (0.60 ± 1.25 vs 1.66 ± 1.90) and maximum daily pain (1.57 ± 1.83 vs 3.35 ± 2.28) were significantly lower for SA (P < .014). SA predicted improvement in PROMs (P < .05) and maximum pain scores (P = .001). SA was significantly correlated with improved time to return to preinjury activity level (9.17 ± 2.06 vs 12.88 ± 3.94 months; P = .002) and percentage of preinjury activity level (93.33% ± 13.22% vs 83.17% ± 17.69%; P = .010). There was a trend toward improved rate of return to preinjury activity level for SA (76.7% vs 56.7%; P = .100). CONCLUSIONS: Our study demonstrates that SA hamstring ACLRs were associated with improved PROMs, less pain, and a higher percentage of and earlier return to preinjury activity level when compared with standard hamstring ACLRs without evidence of overconstraint. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Fantasy football points capture performance declines in National Football League offensive skill players following an ankle injury.

Background: The ankle is one of the anatomic sites most frequently injured in National Football League (NFL) players. Ankle injuries have previously been shown to have long-lasting negative impacts, and have been associated with impaired athletic performance. The aim of this study was to use fantasy football points as a metric to evaluate the impact of ankle injuries on NFL offensive skill player performance. Methods: An open-access online database was used to identify NFL players who sustained ankle injuries from 2009 to 2020. Another public online database was used to determine fantasy points and other performance metrics for injured offensive skill players in the seasons before and after their ankle injury. Injured players were matched to a healthy control by position, age, and BMI. Paired T-tests were performed to evaluate performance metrics before and after the ankle injury. An ANCOVA was performed to assess the effect of return to play (RTP) time and injury type on fantasy performance. Results: 303 players with ankle injuries were included. Fantasy output, including average points per game (PPG) and total fantasy points accrued in one season, significantly decreased in the season following a player's ankle injury (p < 0.0001). In running backs, tight ends, and wide receivers, performance significantly decreased in every metric evaluated (p < 0.0001). In quarterbacks, there was no significant change in performance, except for a decrease in the number of games played (p = 0.0033) and in the number of interceptions thrown (p = 0.029). Conclusion: Assessing fantasy football output revealed a decrease in player performance in the season following an ankle injury, especially in route-running players. These results can be used to inform injury prevention and rehabilitation practices in the NFL.

The Top 100 Most Impactful Articles on the Achilles Tendon According to Altmetric Attention Score and Number of Citations.

Background: Achilles tendon injuries often generate substantial discussion in the mainstream media. The Altmetric Attention Score (AAS) measures the online dialogue pertaining to Achilles tendon research that occurs outside scientific journals, which traditional citation-based metrics fail to capture. Purpose: To characterize the top 100 most-cited Achilles tendon articles and compare them with the 100 Achilles tendon articles with the highest AAS. A secondary goal was to gain an improved understanding of the online dissemination and interpretation of Achilles tendon research through this comparison. Study Design: Cross-sectional study. Methods: The Web of Science Clarivate database was queried to isolate the 100 most-cited Achilles tendon articles, and the Altmetric database was queried to identify the Achilles tendon articles with the top 100 AAS values. Data elements were extracted for each article including study type, study topic, and geographic origin. Results: The Web of Science Clarivate database search yielded 10,890 articles published between 1970 and 2021. The 100 most-cited articles were published in 35 journals, with the American Journal of Sports Medicine being the most prevalent. The mean (±SD) number of citations was 214.5 ± 86.47. The most prevalent study type was laboratory (28.0%). The most prevalent study topic was treatment (41.0%). Of these articles, 72.0% were European. The Altmetric database search yielded 3810 articles published between 1957 and 2021. The AAS of the top 100 articles ranged from 37 to 476 with a mean of 98.17 ± 85.53. The selected articles were published in 39 journals, with the British Journal of Sports Medicine being the most prevalent. The most prevalent study type was randomized controlled trial (25.0%). The most common study topic was treatment (40.0%). Of these articles, 46.0% were European. Conclusion: Our findings suggest that, although the scientific community remains committed to high-impact journals with articles backed by high citation numbers, there is an increasing opportunity to consume Achilles tendon literature through social media.

The Effect of Greater Area Deprivation and Medicaid Insurance Status on Timing of Care and Rate of Reinjury After Anterior Cruciate Ligament Reconstruction.

Background: Lower socioeconomic status and public insurance lead to a longer delay to surgery and a higher likelihood of concomitant pathology before undergoing anterior cruciate ligament reconstruction (ACLR). However, few studies have examined the influence of community deprivation on ACLR timing and outcomes. Purpose/Hypothesis: The primary aim of this study was to define the effect of the area deprivation index (ADI) and insurance classification on access to orthopaedic care after an ACL rupture, and the secondary aim was to determine whether these variables were associated with a second ACL injury after primary ACLR. It was hypothesized that patients with a greater national ADI percentile and Medicaid insurance would experience longer delays to care and an increased risk of reinjury after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was performed to evaluate patients undergoing primary ACLR between 2016 and 2019. The national ADI percentile was obtained utilizing the Neighborhood Atlas website. The relationship between national ADI percentile and care characteristics (eg, time to specialized care) was investigated using the Spearman rho correlation coefficient (r). The association between patient and care characteristics and second ACL injury after the index procedure (ie, graft rerupture or contralateral ACL rupture) was investigated using binary logistic regression. Results: A total of 197 patients met the inclusion criteria. Longer times from injury to surgery (r = 0.238; P < .001) and from specialized care to surgery (r = 0.217; P = .002) were associated with a greater national ADI percentile. The second injury group reported significantly greater national ADI (P = .026) and included a greater percentage of patients with Medicaid insurance (31.3%) compared with the no second injury group. Patients experienced 5.1% greater odds of a second ACL injury for each additional month between evaluation and surgery. Conclusion: Greater national ADI percentile and Medicaid insurance status were associated with adverse ACLR timing and outcomes. Patients with a greater national ADI percentile took significantly longer to obtain surgery after ACL injury. Those who sustained a second ACL injury after ACLR had an overall higher mean national ADI percentile and included a greater proportion of patients with Medicaid compared with those who did not sustain a second ACL injury. Future studies should critically investigate the underlying factors of these associations to reach equity in orthopaedic care.

Evaluation of cartilage degeneration in a rat model of rotator cuff tear arthropathy.

BACKGROUND AND HYPOTHESIS: Rotator cuff tears are the most common injury seen by shoulder surgeons. Glenohumeral osteoarthritis develops in many late-stage rotator cuff tear patients as a result of torn cuff tendons, termed "cuff tear arthropathy." However, the mechanisms of cuff tear arthropathy have not been fully established. It has been hypothesized that a combination of synovial and mechanical factors contribute equally to the development of cuff tear arthropathy. The goal of this study was to assess the utility of this model in investigating cuff tear arthropathy. MATERIALS AND METHODS: We used a rat model that accurately reflects rotator cuff muscle degradation after massive rotator cuff tears through either infraspinatus and supraspinatus tenotomy or suprascapular nerve transection. Using a modified Mankin scoring system, we found significant glenohumeral cartilage damage after both rotator cuff tenotomy and suprascapular nerve transection after only 12 weeks. RESULTS: Cartilage degeneration was similar between groups and was present on both the humeral head and the glenoid. Denervation of the supraspinatus and infraspinatus muscles without opening the joint capsule caused cartilage degeneration similar to that found in the tendon transection group. CONCLUSIONS: Our results suggest that altered mechanical loading after rotator cuff tears is the primary factor in cartilage degeneration after rotator cuff tears. Clinically, understanding the process of cartilage degeneration after rotator cuff injury will help guide treatment decisions in the setting of rotator cuff tears. LEVEL OF EVIDENCE: Basic science study, animal model.

Anterior cruciate ligament bracing: evidence in providing stability and preventing injury or graft re-rupture.

Ligamentous knee injuries are common and costly, both in financial terms and time missed from work and recreational activities. Furthermore, ligamentous injuries appear to predispose patients to future osteoarthritis and other morbidities. Therefore, prevention strategies are important in limiting the potential impact of these injuries. Knee braces are one of the most often prescribed devices in the billion-dollar orthotic industry. Despite widespread use of prophylactic and functional knee braces, the evidence supporting their efficacy in reducing and/or preventing injury remains limited. Knee braces have been shown to be more effective in preventing medial collateral ligament injuries than anterior cruciate ligament injuries in both cadaveric and clinical studies. The use of functional braces after anterior cruciate ligament reconstruction has been supported and refuted in both postoperative and long-term studies.

Multiple Ankle Injuries Are Associated With an Increased Risk of Subsequent Concussion in National Football League Players.

Background: There is a gap in the literature regarding musculoskeletal risk factors for concussion within the National Football League (NFL), which is an avenue that must be explored to promote player safety given the high incidence of both injury types. This study aims to observe if ankle injuries are associated with an increased risk of subsequent concussion in NFL players. Methods: The public online database ProFootballReference.com was used to identify ankle injuries and concussions in NFL players from the 2009-2010 to 2019-2020 seasons. Multivariable logistic regression for subsequent concussion and ankle injury was performed, adjusting for body mass index (BMI), age, and player position. For descriptive statistics, unpaired t tests with unequal variance were performed for continuous variables, including BMI and age. χ2 testing was performed for categorical variables, including player position, and whether the position was offensive, defensive, or on special teams. Results: Of the 5538 NFL players included in the study, 941 had an ankle injury, 633 had a concussion, and 240 had both an ankle injury and a subsequent concussion. The adjusted odds ratio (aOR) for concussion following a single ankle injury was 0.90 (95% CI 0.72-1.14, P = .387); however, the aOR for concussion following multiple ankle injuries was 2.87 (95% CI 1.23-6.75, P = .015). Special teams players had the lowest risk for concussion (aOR 0.17, 95% CI 0.069-0.36, P < .001) following ankle injury, and there was no significant difference in risk between offense and defense (aOR 0.91, 95% CI 0.77-1.08, P = .295). Conclusion: Multiple ankle injuries were associated with an increased risk of a subsequent concussion after adjusting for BMI; player position; and offense, defense, or special teams designation. These findings can inform injury prevention practices in the National Football League. Level of Evidence: Level III, retrospective comparative study.

Recurrence of Hamstring Injuries and Risk Factors for Partial and Complete Tears in the National Football League: An Analysis From 2009-2020.

PURPOSE: To (1) characterize hamstring injury (HSI) recurrence rates across the 2009-2010 to 2019-2020 NFL seasons and (2) to identify HSI recurrence risk factors among positions and determine the weekly return to play (RTP) recurrence risk. We hypothesized that older players, skill position players, and players returning to play faster were most at risk. METHODS: Public data from the 2009-2010 to 2019-2020 seasons were reviewed to identify HSIs. Player characteristics were collected before and two seasons following injury. A week-by-week analysis of recurrence risk was evaluated with linear and logarithmic trendlines of the best fit. RESULTS: A total of 2075 HSI were identified with a mean age of 26.2 years (20.0-43.0), BMI of 29.6 (22.7-43.5), and 3.4 seasons of experience (0-17), with 1826 strains (88.0%), 236 partial tears (11.3%), and 13 complete tears (0.63%). Of the 2075 injuries, 796 (38.4%) were recurrent, with 247 (11.9%) being a same-season reinjury. Logistic regression found that fewer weeks before RTP, in-game injury, and lower BMI were risk factors for same-season recurrence. For any recurrence, logistic regression identified more recent year of injury, lower BMI, and longer playing experience as significant risk factors. Wide receivers were found to be at risk for same-season recurrence. For any-season recurrence, defensive backs, linebackers, running backs, tight ends, and wide receivers were at risk. Week-by-week recurrence analysis determined the greatest risk to be when players returned within 2 weeks (13.4%). CONCLUSIONS: There is a high rate of HSI recurrence in the NFL. Risk factors for same-season injury include shorter time to RTP, in-game injury, lower BMI, and playing wide receiver. Risk factors for any-season recurrence were more recent year of injury, lower BMI, longer playing experience, and playing defensive back, linebacker, running back, tight end, or wide receiver. The greatest risk factor for HSI recurrence was RTP within 2 weeks.

Lower extremity injuries in the baseball athlete.

Baseball is unique in its multiple facets: pitching, hitting, base rounding, and fielding are distinct activities that require different athletic skills to perform at a high level. Likewise, these different aspects of the game can contribute to a multitude of varying injuries. While high-velocity overhead throwing, along with batting, can produce a plethora of upper extremity injuries that often garner attention, injuries to the lower extremity can severely impact a player's performance and ability to compete. The rigors of the short, explosive sprinting required for base running, as well as the dynamic movement required for fielding, create ample opportunity for lower limb injury, and even subtle pathology can affect a pitcher's ability to perform or increase their long-term risk of injury. Chronic injury from conditions such as femoroacetabular impingement and hip labral tears can also occur. The purpose of the present review is to summarize the relevant epidemiology, pathophysiology, and treatment of lower extremity injuries in baseball athletes, with reference to current research into the prevention and management of such injuries.