Lateral Extra-articular Tenodesis: The Onlay Technique.

Tibial anterolateral rotary instability associated with anterior cruciate ligament (ACL) tears is a well-documented and difficult problem with a long history of solutions. The lateral extra-articular tenodesis (LET) has undergone multiple refinements in technique, largely focusing on the femoral site insertion using either an interference screw versus a staple for adequate fixation. In this article, we present an improved technique using a suture anchor as an alternative to a staple or an interference screw with secure fixation to insert the LET graft onto the femur. This technique diminishes the chance of ACL tunnel-LET drilling convergence, minimizes the footprint required for adequate graft fixation, and allows the surgeon to dial in the correct tension necessary for adequate augmentation of an ACL reconstruction.

The Use of Biologics in NFL Athletes: An Expert Consensus of NFL Team Physicians.

Background: There is a lack of published information outlining the use of biologics in National Football League (NFL) athletes and limited data to guide biologic treatment strategies. Purpose: To develop a consensus on the use of biologics among NFL team physicians. Study Design: Consensus statement. Methods: A working group of 6 experts convened a consensus process involving NFL team physicians using validated Delphi methodology. Physicians from 32 NFL teams as well as NFL London were invited to take part. This iterative process was used to define statements on the use of biologics in NFL athletes. A recent scoping review exploring biologics in professional athletes was used to inform the first of 3 rounds of surveys, with statements considered under 7 headings: biologics in general, challenges of treating NFL athletes, terminology/nomenclature, autologous blood products, cell-based therapies, guidance for NFL team physicians, and biologic research in the NFL. In addition to rating agreement, experts were encouraged to propose further items or modifications. Predefined criteria were used to refine item lists after each survey. For a consensus within the final round, defined a priori, items were included in the final information set if a minimum of 75% of respondents agreed and fewer than 10% disagreed. Results: Physicians from 26 NFL teams and NFL London responded to the initial invitation to participate in the Delphi process; 88.9% of participating team physicians completed the round 1 survey, with response rates of 87.5% in round 2 and 95.2% in round 3. After 3 rounds, 47 statements reached a consensus. A consensus was achieved that platelet-rich plasma has a positive impact on patellar tendinopathy and on symptoms in early osteoarthritis but not for other indications. NFL team physicians agreed that while cell therapies have the potential to improve symptoms, the misrepresentation of uncharacterized preparations as "stem cells" has contributed to the widespread use of unproven therapies. Conclusion: This study established an expert consensus on 47 statements relating to the use of biologics in NFL athletes. In addition to providing clinical guidance for the use of biologics in NFL athletes, this study identified key areas for future focus including the development of athlete education materials.

Median Time to Return to Sports After Concussion Is Within 21 Days in 80% of Published Studies.

PURPOSE: To perform a systematic review of the literature and evaluate the return to play (RTP) time frame after a concussion diagnosis. Our secondary purpose was to analyze and compare different prognostic variables affecting concussions, time to return to school, time to symptom resolution of concussive symptoms, and time each patient spent in the RTP protocol. METHODS: A PubMed, Scopus, Medline, Embase, and Cochrane Library database literature review was performed in August 2022. The studies needed to report, in days, the length of time a patient/athlete was removed from play due to concussion management. The Risk of Bias in Non-Randomized Studies of Interventions tool was used for risk of bias for each study, and Methodological Index for Non-Randomized Studies criteria were used for quality assessment. RESULTS: There were 65 studies included in the systematic review and a total of 21,966 patients evaluated. The RTP time intervals ranged from 1 to 1,820 days, with 80.7% of the median RTP time frames for each study within 21 days. Preconcussion risk factors for prolonged RTP included female sex, younger age, presence of psychiatric disorders, and history of previous concussion. Postconcussion risk factors included severe symptom scores at initial clinic visit, loss of consciousness, nonelite athletes, and delayed removal from competition. The most common sports resulting in concussion were contact sports, most commonly football and soccer. Median time to return to school was 3 to 23 days. Median time to symptom resolution ranged from 2 to 11 days. Median time in RTP protocol was 1 to 6 days. CONCLUSIONS: Median time to return to sports after concussion is within 21 days in 80% of published studies. LEVEL OF EVIDENCE: IV, systematic review of Level I to IV studies.

Isolated Tear of the Pectoralis Minor Tendon in a Professional American Football Quarterback: A Case Report.

CASE: A 27-year-old right-hand-dominant National Football League (NFL) quarterback injured his right shoulder after falling with the elbow flexed and the shoulder flexed and slightly abducted. He noted an immediate onset of right anterior shoulder pain, but was able to continue playing and throwing without notable deficit. Magnetic resonance imaging of the chest revealed an isolated tear of the pectoralis minor tendon. The patient received nonoperative local treatment and was able to start as quarterback at the next game. CONCLUSION: An isolated pectoralis minor tear in the dominant arm of a professional throwing athlete may be successfully treated with nonoperative local treatment and shoulder strengthening and stabilization exercises, allowing an early return to competition.

National Football League athletes' return to play after surgical reattachment of complete proximal hamstring ruptures.

Although hamstring strains are common among professional football players, proximal tendon avulsions are relatively rare. Surgical repair is recommended, but there is no evidence on professional football players return to play (RTP). We hypothesized that surgical reattachment of complete proximal hamstring ruptures in these athletes would enable successful RTP. Ten proximal hamstring avulsions were identified in 10 National Football League (NFL) players between 1990 and 2008. Participating team physicians retrospectively reviewed each player's training room and clinical records, operative notes, and imaging studies. The ruptures were identified and confirmed with magnetic resonance imaging. Of the 10 injuries, 9 had palpable defects. Each of the ruptures was managed with surgical fixation within 10 days of injury. All of the players reported full return of strength and attempted to resume play at the beginning of the following season, with 9 of the 10 actually returning to play. However, despite having no limitations related to the surgical repair, only 5 of the 10 athletes played in more than 1 game. Most NFL players who undergo acute surgical repair of complete proximal hamstring ruptures are able to RTP, but results are mixed regarding long-term participation. This finding may indicate that this injury is a marker for elite-level physical deterioration.

Quadriceps tendon injuries in national football league players.

BACKGROUND: Distal quadriceps tendon tears are uncommon injuries that typically occur in patients older than 40 years of age, and they have a guarded prognosis. Predisposing factors, prodromal findings, mechanisms of injury, treatment guidelines, and recovery expectations are not well described in high-level athletes. HYPOTHESIS: Professional American football players with an isolated tear of the quadriceps tendon treated with timely surgical repair will return to their sport. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fourteen unilateral distal quadriceps tendon tears were identified in National Football League (NFL) players from 1994 to 2004. Team physicians retrospectively reviewed training room and clinic records, operative notes, and imaging studies for each of these players. Data on each player were analyzed to identify variables predicting return to play. A successful outcome was defined as returning to play in regular-season NFL games. RESULTS: Eccentric contraction of the quadriceps was the most common mechanism of injury, occurring in 10 players. Only 1 player had antecedent ipsilateral extensor mechanism symptoms. Eleven players had a complete rupture of the quadriceps tendon, and 3 had partial tears. There were no associated knee injuries. All ruptures were treated with surgical repair, 1 of which was delayed after failure of nonoperative treatment. Fifty percent of players returned to play in regular-season NFL games. There was a trend toward earlier draft status for those who returned to play compared with those who did not (draft round, 3.1 ± 2.5 vs. 6.0 ± 2.9, respectively; P = .073). For those who returned to play, the average number of games after injury was 40.9 (range, 12-92). CONCLUSION: Quadriceps tendon tears are rare in professional American football players, and they usually occur from eccentric load on the extensor mechanism. Prodromal symptoms and predisposing factors are usually absent. Even with timely surgical repair, there is a low rate of return to play in regular-season games. There is a trend toward early draft rounds for those who successfully return to play.

The cost-effectiveness of single-row compared with double-row arthroscopic rotator cuff repair.

BACKGROUND: Interest in double-row techniques for arthroscopic rotator cuff repair has increased over the last several years, presumably because of a combination of literature demonstrating superior biomechanical characteristics and recent improvements in instrumentation and technique. As a result of the increasing focus on value-based health-care delivery, orthopaedic surgeons must understand the cost implications of this practice. The purpose of this study was to examine the cost-effectiveness of double-row arthroscopic rotator cuff repair compared with traditional single-row repair. METHODS: A decision-analytic model was constructed to assess the cost-effectiveness of double-row arthroscopic rotator cuff repair compared with single-row repair on the basis of the cost per quality-adjusted life year gained. Two cohorts of patients (one with a tear of <3 cm and the other with a tear of ≥3 cm) were evaluated. Probabilities for retear and persistent symptoms, health utilities for the particular health states, and the direct costs for rotator cuff repair were derived from the orthopaedic literature and institutional data. RESULTS: The incremental cost-effectiveness ratio for double-row compared with single-row arthroscopic rotator cuff repair was $571,500 for rotator cuff tears of <3 cm and $460,200 for rotator cuff tears of ≥3 cm. The rate of radiographic or symptomatic retear alone did not influence cost-effectiveness results. If the increase in the cost of double-row repair was less than $287 for small or moderate tears and less than $352 for large or massive tears compared with the cost of single-row repair, then double-row repair would represent a cost-effective surgical alternative. CONCLUSIONS: On the basis of currently available data, double-row rotator cuff repair is not cost-effective for any size rotator cuff tears. However, variability in the values for costs and probability of retear can have a profound effect on the results of the model and may create an environment in which double-row repair becomes the more cost-effective surgical option. The identification of the threshold values in this study may help surgeons to determine the most cost-effective treatment.

A cost-effectiveness analysis comparing 3 anterior cruciate ligament graft types: bone-patellar tendon-bone autograft, hamstring autograft, and allograft.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction, despite being one of the most common surgical interventions, is also one of the least agreed upon surgeries when it comes to optimum graft choice. Three graft choices stand among the most widely used in this procedure: (1) bone-patellar tendon-bone autograft (BPTB), (2) quadruple hamstring tendon autograft (HS), and (3) allograft. HYPOTHESIS: Bone-patellar tendon-bone ACL reconstruction is the most cost-effective method of ACL reconstruction. STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: A simplified decision tree model was created with theoretical patients assigned equally to 1 of 3 ACL reconstruction cohorts based on graft type. These treatment arms were further divided into outcome arms based on probabilities from the literature. The terminal outcomes were assigned a health state/utility score and a societal cost. Utilities were calculated from real clinic patients via the time trade-off questionnaire. Costs were literature based. An incremental cost-effectiveness ratio of $50 000/quality-adjusted life year (QALY) was used as the threshold for cost-effectiveness. RESULTS: Hamstring tendon autograft was the least costly ($5375/surgery) and most effective (0.912) graft choice, dominating both BPTB and allograft reconstructions. Allograft was both the most costly and least effective strategy for the average patient undergoing ACL reconstruction. However, if baseline costs of BPTB could be reduced (by $500) or the effectiveness increased (anterior knee pain <15% or postoperative instability <7%), then BPTB became an incrementally cost-effective choice. In addition, if the effectiveness of HS could be reduced (instability >29% or revision rates >7%), then BPTB also became incrementally cost-effective. CONCLUSIONS: This model suggests that hamstring autograft ACL reconstruction is the most cost-effective method of surgery for the average patient with ACL deficiency. However, specific clinical scenarios that change postoperative probabilities of the different complications may sway surgeons to choose either allografts or BPTB. Cost-effectiveness analysis is not intended to replace individual clinician judgment but rather is intended to examine both the effectiveness and costs associated with theoretical groups undergoing specific multifactorial decisions.

Patellar tendon ruptures in National Football League players.

BACKGROUND: Although knee injuries are common among professional football players, ruptures of the patellar tendon are relatively rare. Predisposing factors, mechanisms of injury, treatment guidelines, and recovery expectations are not well established in high-level athletes. HYPOTHESIS: Professional football players with isolated rupture of the patellar tendon treated with timely surgical repair will return to their sport. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-four ruptures of the patellar tendon in 22 National Football League (NFL) players were identified from 1994 through 2004. Team physicians retrospectively reviewed training room and clinic records, operative notes, and imaging studies for each of these players. Player game statistics and draft status were analyzed to identify return to play predictors. A successful outcome was defined as participating in 1 regular-season NFL game. RESULTS: Eleven of the 24 injuries had antecedent symptoms. The most common mechanism of injury was an eccentric overload to a contracting extensor mechanism. Physical examination demonstrated a palpable defect in all players. Twenty-two were complete ruptures, and 2 were partial injuries. Three of the 24 cases had a concomitant anterior cruciate ligament (ACL) injury. In 19 of the 24 injuries, the player returned to participate in at least 1 game in the NFL. Players who returned were drafted, on average, in the fourth round, while those who failed to return to play were drafted, on average, in the sixth round. Of those players who returned to play, the average number of games played was 45.4, with a range of 1 to 142 games. CONCLUSION: Patellar tendon ruptures can occur in otherwise healthy professional football players without antecedent symptoms or predisposing factors. The most common mechanism of injury is eccentric overload. Close attention should be paid to stability examination of the knee given the not uncommon occurrence of concomitant ACL injury. Although this is usually a season-ending injury when it occurs in isolation, acute surgical repair generally produces good functional results and allows for return to play the following season. Players chosen earlier in the draft are more likely to return to play.

Treatment of magnetic resonance imaging-documented isolated grade III lateral collateral ligament injuries in National Football League athletes.

BACKGROUND: Isolated high-grade tears of the lateral collateral ligament (LCL) of the knee are rare, as most injuries are part of a broader pattern of damage to the posterolateral corner. Limited data exist in the literature about the ideal management of isolated LCL injuries, especially in elite-level athletes. HYPOTHESIS: Operative and nonoperative treatment of MRI-documented isolated grade III LCL injury can produce equal results in terms of return to play in the National Football League (NFL). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The NFL Injury Surveillance System was used to identify all players with lateral ligament injuries of the knee from 1994 to 2004. In addition, the medical staffs of all NFL clubs were surveyed about injuries during the same period. Nine players with MRI-documented isolated grade III LCL injuries were identified through this process. The medical staff for each respective player then completed a data questionnaire. Statistics were analyzed using 1-way analysis of variance. RESULTS: Four players underwent direct surgical repair of their injuries; they missed an average of 14.5 weeks of play and did not return within the same season. Five players were managed nonoperatively and missed an average of 2.0 weeks (P = .0001). Four of the 5 players in the nonoperative group returned within the same season at an average of 10 days; 1 missed the rest of the season. All 9 players were able to return to play the following season, and played for an average total of 2.8 (operative) and 4.4 (nonoperative) additional seasons (P = .253). CONCLUSION: Nonoperative management of MRI-documented isolated grade III lateral collateral ligament injuries in NFL athletes results in more rapid return to play without subjecting the player to the risks of surgery, while achieving an equal likelihood of return to play at the professional level.

Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes.

BACKGROUND: Acute complete ruptures of the proximal adductor longus tendon are rare but challenging injuries to treat. The limited literature supports operative treatment, but data from management of chronic groin pain in athletes indicate that anatomical attachment of the tendon to the pubis may not be required for high-level function. HYPOTHESIS: Nonoperative management of complete adductor rupture can provide equal results to surgical repair in terms of return to play in the National Football League. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Using the National Football League Injury Surveillance System, adductor tendon ruptures documented by magnetic resonance imaging were identified in 19 National Football League players from 1992 to 2004. The team physician for each respective player completed a survey with information about history, physical examination, magnetic resonance imaging findings, treatment, and outcomes. Statistics were analyzed with a Student unpaired t test. RESULTS: Fourteen players were treated nonoperatively, and 5 players were treated with surgical repair using suture anchors. In both groups, all players eventually returned to play in the National Football League. Mean time for return to play was 6.1 +/- 3.1 weeks (range, 3-12 weeks) for the nonoperative group and 12.0 +/- 2.5 weeks (range, 10-16 weeks) for the operative group (P = .001). One player in the operative group suffered the complication of a draining wound and heterotopic ossification. Players represented a variety of positions, and 12 of 19 (63%) had experienced prior symptoms or events. CONCLUSION: Nonoperative treatment of proximal adductor tendon rupture results in a statistically significantly faster return to play than does operative treatment in athletes competing in the National Football League and avoids the risks associated with surgery while providing an equal likelihood of return to play at the professional level.

Reliability of heel-height measurement for documenting knee extension deficits.

BACKGROUND: Heel-height difference has been used to detect subtle knee flexion contractures, but the effects of thigh circumference differences and patient positioning during testing have not been evaluated. HYPOTHESIS: Differences in thigh circumference measurements and whether the patient's patellae are on or off the examination table during heel-height difference measurement will not affect the accuracy of detecting knee flexion contracture. STUDY DESIGN: Prospective cohort study. METHODS: Bilateral knee range of motion, prone heel-height difference with the patellae on and off the table, and thigh circumference at 5 and 15 cm proximal to the proximal pole of the patella were measured by one investigator on 50 consecutive patients who had undergone unilateral anterior cruciate ligament reconstruction. RESULTS: A high degree of correlation was demonstrated between the heel-height difference and the standard range of motion measurement. Differences in thigh girth and patellar position did not statistically affect the accuracy of the heel-height difference as an indicator of knee flexion contracture. CONCLUSION: Heel-height difference is a valid method of documenting knee flexion contractures. Compared with traditional goniometer assessment, this test is a more meaningful and easier way for detecting subtle knee flexion contractures of less than 10 degrees.