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.

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.

Does Prior Hip Arthroscopy Affect Outcomes of Subsequent Hip Arthroplasty? A Systematic Review.

PURPOSE: To compare outcomes of hip arthroplasty in patients with and without a history of hip arthroscopy through a systematic review. METHODS: A comprehensive search of the PubMed (MEDLINE) and Cochrane Central databases was performed using combinations of the keywords "hip," "arthroscopy," "arthroscopic," "arthroplasty," "replacement," and "conversion" in December 2017. Level I through III studies directly comparing outcomes of total or resurfacing hip arthroplasty between patients with and without a history of hip arthroscopy were included in this review if they reported at least 1 outcome measure. RESULTS: Seven retrospective case-control studies collectively evaluating arthroplasty outcomes of 235 patients (104 male and 131 female patients) with a history of hip arthroscopy and 374 matched controls met the inclusion criteria. The mean age in the arthroscopy and control groups was 47.2 years and 49.1 years, respectively. The mean follow-up period after arthroplasty was 3.2 years in the hip arthroscopy group and 3.3 years in the control group. The mean time between arthroscopy and arthroplasty was 1.8 years. A posterior approach was used in 83.6% of arthroplasties. No statistically significant differences were noted in intraoperative measures, postoperative complications, or revision rates, with the exception of 1 study that reported an increased operative time among controls. Most studies reported similar subjective outcomes between groups, with a single study noting worse postoperative findings for the Harris Hip Score, Forgotten Joint Score-12, visual analog scale pain score, and patient satisfaction in the prior hip arthroscopy group. CONCLUSIONS: The current literature suggests that short-term and midterm outcomes of hip arthroplasty are comparable in patients with and without a history of hip arthroscopy. However, the available literature is limited given the small sample sizes and therefore greater potential for ß error. Nevertheless, our findings may be useful for surgeons evaluating risks and prognoses in this patient population. LEVEL OF EVIDENCE: Level III, systematic review of Level III studies.

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

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

Staphylococcal persistence due to biofilm formation in synovial fluid containing prophylactic cefazolin.

Antibiotic prophylaxis is standard for patients undergoing surgical procedures, yet despite the wide use of antibiotics, breakthrough infections still occur. In the setting of total joint arthroplasty, such infections can be devastating. Recent findings have shown that synovial fluid causes marked staphylococcal aggregation, which can confer antibiotic insensitivity. We therefore asked in this study whether clinical samples of synovial fluid that contain preoperative prophylactic antibiotics can successfully eradicate a bacterial challenge by pertinent bacterial species. This study demonstrates that preoperative prophylaxis with cefazolin results in high antibiotic levels. Furthermore, we show that even with antibiotic concentrations that far exceed the expected bactericidal levels, Staphylococcus aureus bacteria added to the synovial fluid samples are not eradicated and are able to colonize model implant surfaces, i.e., titanium pins. Based on these studies, we suggest that current prophylactic antibiotic choices, despite high penetration into the synovial fluid, may need to be reexamined.

Sex-specific analysis of data in high-impact orthopaedic journals: how are we doing?

BACKGROUND: In 2001, the Institute of Medicine released a report stating that sex must be considered in all aspects and at all levels of biomedical research. Knowledge of differences between males and females in responses to treatment serves to improve our ability to care for our patients. QUESTIONS/PURPOSES: The purpose of our study was to determine (1) if there is an increase in the proportion of sex-specific reporting from 2000 to 2005 and to 2010; and (2) whether there is a proportional difference in such reporting based on journal type: subspecialty versus general orthopaedics. We hypothesize that assessment of the role of sex in outcomes has improved during the past 15 years and that the proportion of studies with of sex-specific analyses has increased with awareness of the role of sex in clinical outcomes and disease states. We additionally hypothesized that the reporting of sex would be similar between subspecialty and general orthopaedic journals. METHODS: Five high-impact orthopaedic journals, consisting of two general and three subspecialty journals, were chosen for review. Issues from even-numbered months during three calendar years (2000, 2005, 2010) were critically assessed for the presence of sex-specific analyses and reporting by two separate reviewers. Retrospective and prospective clinical studies, with a minimum of 20 patients, were included for analysis. Cadaveric, biomechanical, and in vitro studies were excluded. Review articles and clinical studies with less than 20 patients were excluded. A total of 821 studies that met inclusion criteria were analyzed: 206 in 2000, 277 in 2005, and 338 in 2010. RESULTS: Overall, the proportion of sex-specific analyses increased during the three times studied (19%, 40/206, [95% CI, 0.14-0.25] of the studies in 2000; 27%, 77/277, [95% CI, 0.23-0.33] in 2005; and 30%, 102/338, [95% CI, 0.25-0.35] in 2010). The increase in the proportion of sex-specific analysis was significant between 2000 and 2005 (p = 0.033), but was not significant between 2005 and 2010 (p = 0.518). During each of the three specific years studied, general and subspecialty journals increased in the proportions that reported sex-based analyses, but specialty journals had significantly higher reporting rates only in 2000 (2000: 11.9%, 13/109, [95% CI, 0.06-0.18] and 27.8%, 27/97, [95% CI, 0.19-0.37], p = 0.004; 2005: 22.9%, 33/144, [95% CI, 0.16-0.30], and 33.1%, 44/133, [95% CI, 0.25-0.41], p = 0.059; 2010: 28.2%, 51/181, [95% CI, 0.22-0.35] and 32.5%, 51/157, [95% CI, 0.25-0.40], p = 0.390). CONCLUSIONS: Our findings indicate that inclusion of sex-specific analysis and reporting in the orthopaedic literature improved during our study period, but are present in less than 1/3 of the studies. Although subgroup analysis and reporting are required by NIH guidelines, it is important that such analyses be published in non-NIH-funded studies to generate hypotheses regarding sex differences for subsequent research. These data also are important as they can be used in systematic reviews where large independent studies may not be available in the literature. CLINICAL RELEVANCE: Where evaluating conditions that affect males and females, studies should be designed with sufficient sample size to allow for subgroup analysis by sex to be performed, and they should include sex-specific differences among the a priori research questions.

Outcomes for ulnar collateral ligament reconstruction: a retrospective review using the KJOC assessment score with two-year follow-up in an overhead throwing population.

BACKGROUND: Injury to the ulnar collateral ligament (UCL) often results in valgus elbow instability requiring reconstruction. No standardized and validated outcome measure has compared outcomes between surgical techniques and institutions in the overhead throwing athlete. The aim of this study was to use the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score (KJOC score) to report functional outcomes in overhead throwing athletes undergoing UCL reconstruction. We predict that the KJOC score in our general throwing population will provide an accurate assessment of postoperative outcomes consistent with previously published reports. METHODS: A retrospective review of 33 patients undergoing UCL reconstruction was carried out during a 5-year period between 2004 and 2009. Minimum follow-up was 2.2 years with an average of 3.7 years. All surgeries were performed by fellowship-trained surgeons using either the docking (n = 12) or modified Jobe technique (n = 21). Age, sport, position, and return to play status were obtained. The KJOC score was administered to assess final functional outcome. RESULTS: A total of 33 athletes underwent UCL reconstruction-30 baseball players and 3 javelin throwers. Of these, 27 (82%) returned to their sport at their previous level in an average of 12.25 months. The overall average KJOC score was 76. Athletes who returned to their previous level of play had a mean KJOC score of 77. Those who were unable to return to play had a mean score of 69. CONCLUSION: Our study demonstrates consistent outcomes for UCL reconstruction using the KJOC shoulder and elbow score compared with previously reported data.

The approach to elbow pain in the pediatric and adolescent throwing athlete.

Elbow pain in pediatric throwing athletes can be very concerning and challenging to diagnose. Diagnosis involves determining whether the injury is chronic or acute in nature and the anatomical location of the pain. Physicians should be aware of the sport-specific forces that predispose athletes with immature skeletons to injury and should be familiar with the common presentations of these injuries. In order to narrow the diagnosis, physicians should gather a detailed history of how and when the pain occurred in addition to performing a thorough physical exam that includes tests, such as the modified milking maneuver and the moving valgus stress test. Appropriate imaging helps physicians to confirm the diagnosis and elucidates any associated pathology in patients. In most cases, the treatment given to patients is conservative and involves rest, ice, non-steroidal anti-inflammatory drugs for pain, and an appropriate physical therapy regimen with a progressive return to play when symptoms have resolved. When patients fail to respond to conservative treatment, surgical intervention may be needed. Knowing when to refer patients for orthopedic evaluation helps athletes return to play quickly and safely.

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.

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.

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.

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.

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.

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.

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.

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.

Revision ACL reconstruction in skeletally mature athletes younger than 18 years.

BACKGROUND: Young, active, skeletally mature patients have higher failure rates after various surgical procedures, including stabilization for shoulder instability and primary ACL reconstruction. It is unclear whether young, active, skeletally mature patients share similarly high failure rates after revision ACL reconstruction. QUESTIONS/PURPOSES: We therefore determined whether revision ACL reconstruction restores knee stability and allows young (younger than 18 years), active, skeletally mature patients to return to preinjury activity levels. PATIENTS AND METHODS: We retrospectively identified 36 patients who had an initial ACL reconstruction between the ages of 12 and 17 years (mean, 15.4 years) and subsequent revision between the ages of 13 and 18 years (mean, 16.9 years); of these, 2-year followup was available for 21 (75%). Mechanisms of primary graft failure included traumatic rerupture (23 noncontact, seven contact), persistent instability (five), and infection (one). One patient had open physes at the time of revision. All revisions were single-stage transosseous reconstructions. The minimum followup was 24 months (mean, 36 months; range, 24-63 months). RESULTS: At last followup, 19 of 21 patients had a negative or IA Lachman and 20 of 21 had a negative pivot shift. Mean International Knee Documentation Committee subjective score was 89 (range, 64-99). Eleven of the 21 patients returned to the same or higher activity/sport level as before their original injury. Two patients reported subjective knee instability, with two having repeat revision reconstruction for failure. CONCLUSIONS: Single-stage transosseous revision ACL reconstruction in young, active, skeletally mature patients restores knee stability but returns only 52% of patients to their prior level of activity or sport. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement.

PURPOSE: The purpose of this study was to identify the incidence of symptoms consistent with athletic pubalgia (AP) in athletes requiring surgical treatment for femoroacetabular impingement (FAI) and the frequency of surgical treatment of both AP and FAI in this group of patients. METHODS: Thirty-eight consecutive professional athletes, with a mean age of 31 years, underwent arthroscopic surgery for symptomatic FAI that limited their ability to play competitively. In all cases a cam and/or focal rim osteoplasty with labral refixation or debridement was performed. In 1 case concomitant intramuscular lengthening of the psoas was performed. Retrospective data regarding prior AP surgery and return to play were collected. RESULTS: Thirty-two percent of patients had previously undergone AP surgery, and 1 patient underwent AP surgery concomitantly with surgical treatment of FAI. No patient returned to his previous level of competition after isolated AP surgery. Thirty-nine percent had AP symptoms that resolved with FAI surgery alone. Of the 38 patients, 36 returned to their previous level of play; all 12 patients with combined AP and FAI surgery returned to professional competition. The mean duration before return to play was 5.9 months (range, 3 to 9 months) after arthroscopic surgery. CONCLUSIONS: There is a high incidence of symptoms of AP in professional athletes with FAI of the hip. This study draws attention to the overlap of these 2 diagnoses and highlights the importance of exercising caution in diagnosing AP in a patient with FAI. LEVEL OF EVIDENCE: Level IV, therapeutic, retrospective case series.

Anteromedial versus central single-bundle graft position: which anatomic graft position to choose?

PURPOSE: To compare the time-zero stability of an anatomic anteromedial (AM) single-bundle ACL reconstruction to an anatomic central (CTR) single-bundle ACL reconstruction. METHODS: Twelve (6 paired) hip to knee cadaveric specimens were studied. Using custom ACL computer navigation software, a Lachman test and a previously validated, navigated mechanized pivot shift test were performed on 4 separate experimental groups in each specimen: (1) intact ACL, (2) ACL deficient with total medial and lateral meniscectomy, (3) following anatomic AM single-bundle ACL reconstruction, and (4) after anatomic CTR single-bundle ACL reconstruction. Maximum anterior tibial translation in each group was measured. RESULTS: Lachman: No significant difference was observed between the AM and CTR reconstructions (n.s.) or between reconstruction and the intact ACL (3.4 ± 1.7 mm) (n.s.). Pivot Shift: Both the AM and CTR ACL reconstructions significantly reduced anterior translation relative to the ACL/menisci-deficient condition (lateral compartment: 8.9 ± 3.8 mm and 6.75 ± 4.6 mm vs. 17.25 ± 3.5 mm, respectively; P < 0.001 and medial compartment: -3.0 ± 5.3 mm vs. -3.7 ± 5.7 mm vs. 6.2 ± 6.7 mm, P < 0.05). There was also a significant difference between the AM (P < 0.001) and CTR (P < 0.05) ACL reconstructions and the intact ACL (2.8 ± 4.4 mm) for lateral compartment translation. Further, no difference was found between lateral or medial compartment translations in the AM versus CTR reconstructions (n.s.). CONCLUSIONS: It has been shown that there was no difference in the time-zero biomechanical stability between an anatomic anteromedial and anatomic central single-bundle ACL reconstruction. Given the current debate on the best anatomic ACL reconstruction technique, anatomic socket position in either the anteromedial or central locations provides similar time-zero biomechanics.