Partial thickness subfoveal hole in a patient treated with tamoxifen: a case report and review of the literature.

BACKGROUND: We describe a patient presenting with a partial thickness subfoveal hole in the right eye after tamoxifen treatment for breast cancer. CASE PRESENTATION: A 76-year-old Caucasian female presented with a 1-day history of acute central scotoma and blurry vision in the right eye. The patient had been receiving oral tamoxifen for 5 years as adjuvant treatment for stage I lobular breast cancer. Her past ocular history was significant for complete, uneventful, and bilateral posterior vitreous detachment. Clinical examination and optical coherence tomography revealed a new, partial thickness subfoveal hole sparing the inner retinal layers. Observation was recommended. At the last follow-up examination, 1 year after the initial presentation, the subfoveal hole remained stable and visual acuity remained stable. CONCLUSION: Tamoxifen has been associated with a plethora of ophthalmic adverse events, including macular holes, some of which are partial thickness subfoveal holes. Holes with this almost unique morphology are uncommon, and eye care professionals should be aware of this association given the frequency of tamoxifen use, as well as the low success rate of surgical repair with pars plana vitrectomy.

Ganglion Cell Layer Thickness Change in Neovascular Age-Related Macular Degeneration Treated With Anti-VEGF Injections.

Purpose: This work assesses bilateral ganglion cell layer-inner plexiform layer (GCL-IPL) thickness changes in patients with unilateral neovascular age-related macular degeneration (nAMD) treated with antivascular endothelial growth factor (anti-VEGF). Methods: In this single-center, retrospective, cohort study, the medical records of patients with unilateral nAMD treated with anti-VEGF were reviewed. The treated group included eyes with newly diagnosed nAMD that subsequently underwent treatment with intravitreal anti-VEGF injections. The control group was the fellow eye with dry AMD. Eyes receiving at least 10 intravitreal injections were included. Measurement of GCL-IPL thickness was performed at different time points using spectral domain-optical coherence tomography. Results: A total of 216 eyes of 108 patients met the inclusion criteria. The mean age ± SD was 80.1 ± 10.7 years. Eyes in the treated group underwent a mean ± SD of 20.2 ± 7.2 injections in 21.3 ± 6.8 months. At baseline, average mean ± SD of GCL-IPL thickness was 73.71 ± 8.81 µm and 73.84 ± 8.26 µm in the treated and fellow eye, respectively (P = .795). After 10 injections the average thickness was 65.41 ± 14.08 µm and 68.77 ± 13.24 µm in the treated and fellow eye, respectively (P = .007). The absolute decrease in thickness was significantly greater in the treated eye than the fellow eye (mean ± SD, 8.31 ± 11.19 µm vs 5.07 ± 10.83 µm, respectively; P = .002). Conclusions: GCL-IPL thickness decreased significantly in the treated group more than in the control group after 10 anti-VEGF injections. The mechanism and clinical significance of this observation warrants further study.

Characterization of Posterior Glenoid Bone Loss Morphology in Patients With Posterior Shoulder Instability.

PURPOSE: To systemically describe posterior bone defects in the setting of posterior shoulder instability based on several parameters, including surface area, slope and version, defect height from the base of the glenoid, and extent of bone loss at equal intervals along the long axis of the fossa. METHODS: A total of 40 young, active individuals with recurrent posterior shoulder instability and a bony injury confirmed on either computed tomography (n = 18; mean age, 26.3 ± 4.0 years) or magnetic resonance imaging (n = 22; mean age, 20.0 ± 4.9 years) were identified. The posterior glenoid bone defect was characterized using the following measures: (1) percentage of bone loss, (2) glenoid vault version, (3) slope of the posterior defect relative to the glenoid surface, (4) superior-inferior length of the defect, and (5) anterior-posterior width of the defect at 5 intervals along the glenoid fossa. RESULTS: The mean age of the 40 patients was 22.9 ± 5.5 years (range, 14.9-35.5 years). The mean surface area of glenoid bone loss was 9.7% ± 4.7%. Glenoid version measured at 5 equal intervals along the inferior two-thirds of the glenoid was 12.8° ± 4.9°, 11.9° ± 5.0°, 10.1° ± 6.3°, 10.5° ± 6.5°, and 8.7° ± 7.2° from superior to inferior. The mean slope of the posterior defect relative to the glenoid fossa was 26.8° ± 11.5°. The mean superior-inferior height of the bony defect was 21.9 ± 0.4 mm. The anterior-posterior sloped width of the defect at 5 equal intervals along the glenoid fossa was 0.9 ± 1.5 mm, 2.8 ± 2.4 mm, 4.0 ± 1.7 mm, 4.0 ± 2.1 mm, and 2.9 ± 2.6 mm from superior to inferior. Low-grade (<10%) bone loss was diagnosed in most shoulders (23 of 40 evaluated), whereas 15 had moderate bone loss (10% to <20%) and 2 had high-grade bone loss (≥20%). CONCLUSIONS: Posterior glenoid bone loss is characterized by a loss of posterior bony concavity, increased slope from anterior to posterior, and increased posterior version. The most anterior-posterior sloped width was quantified at the third and fourth intervals of 5 equal intervals from superior to inferior. This study highlights that patients with posterior instability have bone loss that is sloped relative to the glenoid fossa and suggests that management must be appropriately tailored given the distinctiveness of posterior bone loss. LEVEL OF EVIDENCE: Level IV, case series.

Jones Fractures Identified at the National Football League Scouting Combine: Assessment of Prognostic Factors, Computed Tomography Findings, and Initial Career Performance.

BACKGROUND: Jones fractures result in subsequent dysfunction and remain an issue for athletes. PURPOSE: To (1) describe the epidemiology, treatment, and impact of Jones fractures identified at the National Football League (NFL) Scouting Combine on players' early careers and (2) establish the value of computed tomography (CT) to determine bony healing after a fracture in prospective players. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All players who attended the combine between 2009 and 2015 were retrospectively reviewed to identify their history of Jones fractures. The playing position, treatment method, and number of missed collegiate games were recorded. The mean overall draft pick number, number of games started and played, snap percentage, and position-specific performance scores (fantasy score) over the first 2 years in the NFL were compared between players with fractures and controls. An imaging classification system was applied based on grading of each quadrant of the fifth metatarsal (plantar, dorsal, medial, lateral), with a score of 0 for not healed or 1 for healed. RESULTS: Overall, the number of Jones fractures identified was 72 in 2285 athletes (3.2%), with all treated via intramedullary screw fixation. The mean overall draft pick number for players with fractures was 111.2 ± 67.9 compared with 99.0 ± 65.9 for controls (P = .12). Performance scores for players with fractures were lower than those for controls across all positions, with a significant difference in running backs (2.6 vs 4.0, respectively; P < .001) and defensive linemen (1.4 vs 2.3, respectively; P = .02). The mean CT score was 2.5 ± 1.3. Of the 32 athletes who underwent imaging, 16 Jones fractures (50.0%) were healed or nearly healed, 12 (37.5%) were partially healed, and 4 (12.5%) showed little or no healing. The plantar cortex demonstrated the least healing (18/32; 56.3%), followed by the lateral cortex (15/32; 46.9%). Players with a mean score <1 were found to have fewer games started (2.7 ± 2.5) than those with 1 to 3 cortices healed (17.4 ± 10.4) or all cortices healed (8.7 ± 11.2). CONCLUSION: Based on CT, 50% of all players with a previous Jones fracture demonstrated incomplete healing. Moreover, position-specific performance scores over the first 2 years of a player's career were lower across all positions for those with fractures compared with controls. Players with CT scores <1 were found to start fewer games and were drafted later than controls.

The Epidemiology of Ankle Injuries Identified at the National Football League Combine, 2009-2015.

BACKGROUND: American football is a leading cause of sports-related injuries, with the knee, ankle, and shoulder most commonly involved. PURPOSE/HYPOTHESIS: The purpose of this study was to describe the epidemiology, characteristics, and imaging findings of ankle injuries in football players at the National Football League (NFL) Combine and determine the relationship to player position. We hypothesized that there would be a high relative incidence of ankle injuries in these players compared with other sports and that there would be a direct correlation between the incidence of ankle injuries and player position. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective chart review of data collected from NFL Combine participants between 2009 and 2015 was performed. Patient demographics, history, physical examination results, and imaging findings were reviewed. RESULTS: Of 2285 players, 1216 (53.2%) had a history of ankle injuries; of these, 987 (81.2%) had unilateral injuries, while 229 (18.8%) had bilateral injuries (total of 1445 ankles injured). This included 1242 ankle sprains (86.0% of ankle injuries): 417 (33.6% of sprains) high and 930 (74.9%) low. The most common soft tissue injuries were to the anterior talofibular ligament (n = 158, 12.7% of sprains) and syndesmosis (n = 137, 11.0%). Of all players at the NFL Combine with radiographs, 131 (10.9%) had evidence of an ankle fracture, all of which had healed. Magnetic resonance imaging (MRI) identified 66 players (28.9% of players at the combine who underwent MRI) with articular cartilage injuries: 62 involving the talus and 16 involving the tibia. Furthermore, 85 players (37.3% of players with MRI) with tendon injuries were identified: 26 Achilles, 55 peroneal, 3 flexor hallucis longus, and 19 posterior tibial. A total of 611 players (50.6% of players with radiographs) had signs of arthrosis on radiography. Running backs (61.9%), offensive linemen (60.3%), and tight ends (59.4%) had the highest rates of ankle injuries by position, while kickers/punters (23.3%) and long snappers (37.5%) had the lowest. CONCLUSION: Prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine. The rate of these ankle injuries varied by player position: offensive linemen, running backs, and tight ends had the highest overall rates, while special teams players had the lowest. Additional prospective work is needed to determine the impact of prior injuries on future playing career.

Prevalence of Shoulder Labral Injury in Collegiate Football Players at the National Football League Scouting Combine.

BACKGROUND: Labral tears confirmed by magnetic resonance imaging (MRI) are a relatively common injury among collegiate athletes and can influence a player's ability to compete at the professional level. PURPOSE: To determine the prevalence of MRI-confirmed shoulder labral injuries in collegiate football players entering the National Football League (NFL) Combine and to further describe these injuries by tear location, player position, history of surgical intervention, and associated concomitant shoulder injuries. STUDY DESIGN: Descriptive epidemiology study. METHODS: Data from 2009 to 2015 were retrospectively collected through review of the injury data registry available to the medical and training staff of all NFL teams following the completion of the NFL Combine. After players with potential labral tears were identified through history and examination, their MRIs were reviewed by 2 fellowship-trained orthopaedic sports medicine surgeons. Players diagnosed with a labral tear confirmed by MRI were separated for further analysis. RESULTS: A total of 2285 players were analyzed for the presence of labral tears at the NFL Combine. Overall, 377 shoulders (in 340/2285 players; 14.9%) demonstrated MRI evidence of labral tear; whereas linebackers had the highest rate of labral tear (19.2%), linemen had significantly higher risk for labral injury in at least 1 shoulder (odds ratio, 1.31; 95% CI, 1.02-1.67; P = .029) compared with nonlinemen. Of the 377 shoulders analyzed, 115 (30.5%) exhibited an anterior labral tear, 131 (34.7%) had a posterior labral tear, and 131 (34.7%) had combined anterior and posterior tears. One hundred twenty (31.8%) shoulders had superior labral anterior-posterior (SLAP) tears. A total of 203 (53.8%) shoulders demonstrated evidence of previous surgical intervention on imaging. CONCLUSION: Injury involving the labrum is relatively common among participants at the NFL Combine, especially linebackers and linemen. Further investigation is necessary to determine the impact these injuries have on player draft position and NFL performance.

A History of Anterior Cruciate Ligament Reconstruction at the National Football League Combine Results in Inferior Early National Football League Career Participation.

PURPOSE: To evaluate whether players with a history of an anterior cruciate ligament reconstruction (ACLR) before the National Football League (NFL) Combine played or started fewer games and/or participated in fewer eligible snaps compared with NFL Combine participants without a history of knee injury or surgery. METHODS: We performed a retrospective review of all players who participated in the NFL Combine between 2009 and 2015 and who had a history of an ACLR. NFL Combine participants were included if they had a previous ACLR or combined anterior cruciate ligament (ACL) injury and nonoperatively managed medial collateral ligament injury. The number of games started, number of games played, draft number, overall draft pick, and snap percentage for each position were determined. The mean value of each outcome metric was compared between case and control players. RESULTS: We identified 110 players who had an ACL injury (n = 76) or a combined ACL and medial collateral ligament injury (n = 34). Players in the ACLR group had a significantly worse mean draft pick number (difference of 30.2, P = .002) and mean draft round (difference of 0.8, P = .019) versus controls. Compared with control players, players in the ACLR group started and played significantly fewer games in both season 1 (difference of 2.7 games started, P < .001; difference of 2.7 games played, P < .001) and season 2 (difference of 7.4 games started, P < .001; difference of 3.0 games played, P = .003) and had a significantly lower snap percentage in both season 1 (difference of 23.1%, P < .001) and season 2 (difference of 24.0%, P < .001). CONCLUSIONS: Athletes at the NFL Combine who previously underwent an ACLR had significantly lower early-career NFL player metrics, including fewer games started, fewer games played, and a lower snap percentage, than uninjured controls. Defensive linemen, defensive backs, and linebackers were the 3 most affected positions. Players with a prior ACLR and combined meniscal-chondral pathology had significantly lower numbers of games started and games played in seasons 1 and 2 and a significantly lower season 2 snap percentage. LEVEL OF EVIDENCE: Level III, case-control study.

Quantitative Assessment of the Coracoacromial and the Coracoclavicular Ligaments With 3-Dimensional Mapping of the Coracoid Process Anatomy: A Cadaveric Study of Surgically Relevant Structures.

PURPOSE: To perform a quantitative anatomic evaluation of the (1) coracoid process, specifically the attachment sites of the conjoint tendon, the pectoralis minor, the coracoacromial ligament (CAL), and the coracoclavicular (CC) ligaments in relation to pertinent osseous and soft tissue landmarks; (2) CC ligaments' attachments on the clavicle; and (3) CAL attachment on the acromion in relation to surgically relevant anatomic landmarks to assist in planning of the Latarjet procedure, acromioclavicular (AC) joint reconstructions, and CAL resection distances avoiding iatrogenic injury to surrounding structures. METHODS: Ten nonpaired fresh-frozen human cadaveric shoulders (mean age 52 years, range 33-64 years) were included in this study. A 3-dimensional coordinate measuring device was used to quantify the location of pertinent bony landmarks and soft tissue attachment areas. The ligament and tendon attachment perimeters and center points on the coracoid, clavicle, and acromion were identified and subsequently dissected off the bone. Coordinates of points along the perimeters of attachment sites were used to calculate areas, whereas coordinates of center points were used to determine distances between surgically relevant attachment sites and pertinent bony landmarks. RESULTS: The CAL had a single consistent acromial attachment (mean area 77 mm [51.9, 102.2]) and then bifurcated into 2 bundles, anterior and posterior, that separately inserted on the lateral aspect of the coracoid. The footprint areas were 54.4 mm2 [31.7, 77.2] and 30.6 mm2 [23.4, 37.7] for the anterior and posterior CAL bundles, respectively. These anterior and posterior bundles attached 10.6 mm [8.4, 12.9] and 24.8 mm [12.3, 27.4] medial and proximal to the apex of the coracoid process, respectively. The minimum distance between the coracoid apex and the trapezoid ligament was 25.1 mm [22.1, 28.1] and was noted to be different in males (28.1 mm [25.1; 31.2]) and females (22.0 mm [18.2, 25.9]). The most lateral insertion of the CC ligaments on the clavicle the AC joint was 15.7 mm [13.1, 18.3]. The distance between the most medial to the most lateral point of the CC ligaments on the clavicle was 25.6 mm [22.3, 28.9], which accounted for 18.2% [15.8, 20.6] of the clavicle length. CONCLUSIONS: In contrast to previous findings, 2 different coracoid attachments (anterior and posterior bundles) of the CAL were consistently identified in all specimens. Moreover, a coracoid osteotomy for a bone graft for the Latarjet procedure should be performed at less than 28.1/22 mm from the apex of the coracoid in male/female patients, respectively. The CC ligaments' attachments on the clavicle were located 15.7 mm from the AC joint, which should be considered for reconstruction. CLINICAL RELEVANCE: During the Latarjet technique, to maintain the integrity of the CC ligaments, precise knowledge of differences between male and female anatomy is necessary during a coracoid osteotomy. Furthermore, when reconstructing the AC joint, the distance from the lateral aspect of the clavicle and the size of the attachments areas should be considered to better replicate the native anatomy.

Body Mass Index Versus Body Fat Percentage in Prospective National Football League Athletes: Overestimation of Obesity Rate in Athletes at the National Football League Scouting Combine.

Provencher, MT, Chahla, J, Sanchez, G, Cinque, ME, Kennedy, NI, Whalen, J, Price, MD, Moatshe, G, and LaPrade, RF. Body mass index versus body fat percentage in prospective national football league athletes: overestimation of obesity rate in athletes at the national football league scouting combine. J Strength Cond Res 32(4): 1013-1019, 2018-Obesity has been previously noted as a major issue in the National Football League (NFL), where it has been shown that 97% of all players demonstrate a body mass index (BMI) of ≥25.0 with a reported obesity rate of 56% (BMI ≥ 30.0). However, BMI does not take into account body composition by mass, and may overestimate prevalence of obesity. The purposes of this study were (a) to determine the validity of BMI as a measure of body fat percentage and obesity in athletes at the NFL Combine, (b) to define the obesity rate based on body fat percentage compared with BMI, and (c) to determine the relationship between draft status and body composition. It was hypothesized that the rate of obesity, as measured by air displacement plethysmography (ADP), would be less than the rate of obesity as measured using BMI. Athletes who competed at the 2010 through 2016 NFL Combines were included in this study. Air displacement plethysmograph testing at the Combine was performed through BOD POD Body Composition Tracking System with collection of the following metrics: body fat percentage (%), and compared with BMI based on weight and height. In addition, the metrics were evaluated for differences over the 7-year study period to determine temporal changes and to determine draft status based on position relative to BOD POD calculations. A total of 1,958 NFL Combine participants completed ADP body composition testing. Based on BMI (≥30.0), the obesity rate was 53.4% versus an 8.9% obesity rate when using ADP. Drafted players demonstrated a significantly lower body fat percentage than undrafted players (p ≤ 0.05), with the exception of quarterbacks and running backs. All 8 positions of play, with the exception of defensive linemen, demonstrated a decrease in body fat percentage between 2010 and 2017. However, total body mass by position of play remained relatively constant with no significant change noted in any position. In conclusion, the obesity rate in prospective athletes at the NFL Combine was overestimated when calculated based on the BMI. Body fat percentage was more valid for determining an NFL player candidate's true body composition. Drafted players demonstrated a significantly lower body fat percentage in 6 of 8 positions compared with undrafted players. This is important to recognize for a strength and conditioning professional to use the correct metric when evaluating NFL players who could have been erroneously categorized in the obese population by their BMI. Furthermore, a higher percentage of fat translates to lower chances of becoming drafted.

Meniscectomy and Resultant Articular Cartilage Lesions of the Knee Among Prospective National Football League Players: An Imaging and Performance Analysis.

BACKGROUND: The effect of prior meniscectomy and the resulting reduction in meniscal tissue on a potential National Football League (NFL) player's articular cartilage status and performance remain poorly elucidated. Purpose/Hypothesis: (1) To determine the epidemiology, imaging characteristics, and associated articular cartilage pathology of the knee among players with a previous meniscectomy who were participating in the NFL Combine and (2) to evaluate the effect of these injuries on performance as compared with matched controls. The hypothesis was that players with less meniscal tissue would have worse cartilage status and inferior performance metrics in their first 2 NFL seasons. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All athletes with a history of a meniscectomy and magnetic resonance imaging scan of the knee who participated in the NFL Combine (2009-2015) were identified. Medical records and imaging were analyzed, and surgical history, games missed in college, position played, and draft position were documented. The conditions of the meniscus and cartilage were graded with modified ISAKOS scores (International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine) and ICRS scores (International Cartilage Repair Society), respectively. Players with a previous meniscectomy of at least 10% of total medial or lateral meniscal volume excised (ISAKOS meniscus grade ≤8) and matched controls without a significant pre-Combine injury were similarly evaluated and compared by position of play through analysis of draft position, number of games played and started, and how many eligible plays they participated in (snap percentage) within the first 2 NFL seasons. RESULTS: Of the 2285 players who participated in the NFL Combine (2009-2015), 287 players (322 knees) had a prior meniscectomy (206 lateral, 81 medial). Among these players, 247 (85%) had a total of 249 chondral lesions, most commonly on the lateral femoral condyle (111 lesions, 45%). There was a significant inverse correlation found between the ISAKOS medial and lateral meniscus grade and the corresponding compartment chondral lesion grade ( P = .001). A poorer meniscus score was also associated with worse chondral pathology, especially in the lateral compartment. After controlling for position of play, the injury-free control group had a significantly greater number of total games played and games started and higher snap percentage versus those with a prior meniscectomy of at least 10% volume (ISAKOS meniscus grade ≤8). Players with severe chondral lesions (ICRS grade 4) in the medial and lateral compartments had significantly worse performance metrics when compared with matched controls. CONCLUSION: Previous meniscectomy of at least 10% of total medial or lateral meniscus volume in prospective NFL players was significantly correlated with larger and more severe chondral lesions. Chondral and meniscal defects of the knee were found to result in a significant decrease in objective performance measures during a player's initial NFL career versus matched controls. Given these findings, players with a prior meniscectomy with evidence of chondral damage should be evaluated carefully for their overall functional levels; however, additional work is needed to fully clarify the effect of prior knee meniscal surgery on overall NFL performance.

Symptomatic Focal Knee Chondral Injuries in National Football League Combine Players Are Associated With Poorer Performance and Less Volume of Play.

PURPOSE: To (1) describe the magnetic resonance imaging (MRI) characteristics of knee chondral injuries identified at the National Football League (NFL) Combine and (2) assess in-game performance of prospective NFL players with previously untreated knee chondral injuries and compare it with matched controls. METHODS: All players with knee chondral injuries identified at the NFL Combine (2009-2015) were retrospectively reviewed. Players with prior knee surgery were excluded. A knee MRI for each player was reviewed; location, modified International Cartilage Repair Society (ICRS) grade (I-IV), and associated compartment subchondral edema were documented. Position, respective NFL Draft pick selection number, games started, played, snap percentage, and position-specific performance metrics during the first 2 NFL seasons were recorded for the injury and injury-free control group composed of players with (1) no prior knee injury, (2) no significant missed time prior to the NFL (≤2 total missed games in college), (3) no history of knee surgery, and (4) drafted in the respective NFL Draft following the NFL Combine. RESULTS: Of the 2,285 players reviewed, 101 (4.4%) had an injury without prior knee surgery. The patella (63.4%) and trochlea (34%) were most commonly affected. Defensive linemen were at highest risk for unrecognized injuries (odds ratio 1.8, P = .015). Players with previously untreated injuries, compared with controls, were picked later (mean pick: 125.8) and played (mean: 23) and started (mean: 10.4) fewer games during the initial 2 NFL seasons (P < .001 for all). Particularly, subchondral bone edema and full-thickness cartilage injuries were associated with fewer games played (P = .003). CONCLUSIONS: The patellofemoral joint was most commonly affected in NFL Combine participants. Previously untreated knee articular injuries in players at the NFL Combine are associated with poorer early NFL performance in comparison to uninjured players. Subchondral bone edema and full-thickness cartilage injury on MRI were associated with fewer games played during the initial NFL career. LEVEL OF EVIDENCE: Level III, case-control study.

Posterior Cruciate Ligament Injuries of the Knee at the National Football League Combine: An Imaging and Epidemiology Study.

PURPOSE: To determine the epidemiology by player position, examination, imaging findings, and associated injuries of posterior cruciate ligament (PCL) injuries in players participating in the National Football League (NFL) Combine. METHODS: All PCL injuries identified at the NFL Combine (2009-2015) were reviewed. Data were obtained from the database organized by the NFL medical personnel for the compilation of the medical and physical performance examination results of NFL Draftees participating in the NFL Combine from 2009 to 2015. Inclusion criteria were any player with clinical findings or a previous surgery consistent with a PCL injury who participated in the NFL Combine. RESULTS: Of the 2,285 players who participated in the NFL Combine between 2009 and 2015, 69 (3%) had evidence of a PCL injury, of which 11 players (15.9%) were managed surgically. On physical examination, 35 players (52%) had a grade II or III posterior drawer. Concomitant injuries were present frequently and included medial collateral ligament (MCL; 42%), anterior cruciate ligament (ACL; 11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. CONCLUSIONS: Three percent of the players at the NFL Combine presented with a PCL injury, with a significant amount being either running backs (14/69, 20.2%) or offensive linemen (14/69, 20.2%). Approximately half of the players with a PCL tear had a residual grade II or III posterior drawer after sustaining a PCL injury. Concomitant injuries were present frequently and included MCL (42%), ACL (11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. For those players with clinical concern for PCL ligamentous laxity, there should be a complete comprehensive workup that includes plain and PCL stress view radiographs, and magnetic resonance imaging. LEVEL OF EVIDENCE: Level IV, case series.

Qualitative and Quantitative Anatomy of the Proximal Humerus Muscle Attachments and the Axillary Nerve: A Cadaveric Study.

PURPOSE: To provide a quantitative and qualitative anatomic analysis of the pectoralis major, teres major, and latissimus dorsi on the humerus, as well as the deltoid tendinous attachments on the proximal humerus and acromion, and to quantitatively characterize the humeral course of the axillary nerve. METHODS: Ten nonpaired, fresh-frozen human cadaveric shoulders were analyzed. A portable coordinate-measuring device quantified the location of bony landmarks and tendon attachment areas. The tendon footprints were recorded by tracing their outlines and center points. The footprint areas of the tendons, the distances between the footprint areas and pertinent osseous and soft-tissue landmarks, and the distance between where the axillary nerve courses across the humerus relative to the acromion and greater tuberosity were measured. RESULTS: Of the 10 specimens, 9 (90%) had 5 distinct tendinous bands attaching the deltoid to the acromion; 1 specimen had 4 bands. The distances between the center of the deltoid footprint on the humerus and the centers of the pectoralis major, latissimus dorsi, and teres major tendon footprints on the humerus were 43.5 mm, 58.5 mm, and 49.4 mm, respectively. The shortest distances from the perimeter of the pectoralis major to the latissimus dorsi and teres major tendon footprints were 3.9 mm and 9.5 mm, respectively. The distance from the superior aspect of the greater tuberosity to the axillary nerve on the humeral shaft was 50.3 mm (95% confidence interval, 47.0-53.5 mm). The distance from the lateral acromion to the axillary nerve was 69.3 mm (95% confidence interval, 64.1-74.5 mm). CONCLUSIONS: The deltoid muscle had 4 to 5 tendinous insertions on the acromion, and the axillary nerve was 50.3 mm from the tip of the greater tuberosity. The distance between the lower border of the pectoralis major and the axillary nerve was 9.4 mm. CLINICAL RELEVANCE: Knowledge of the quantitative anatomy of the tendons of the proximal humerus and axillary nerve can aid in identifying structures of interest during open shoulder surgery and in avoiding iatrogenic axillary nerve injury. Furthermore, this study provides direction to avoid injury to the deltoid tendons during open surgery.

Posterolateral Corner Injuries of the Knee at the National Football League Combine: An Imaging and Outcomes Analysis.

PURPOSE: (1) To determine the epidemiology, examination findings, imaging findings, and associated injuries of posterolateral corner (PLC) injuries in players participating in the National Football League (NFL) Combine and (2) to evaluate the impact of PLC injuries on performance compared with matched controls. METHODS: All PLC injuries identified at the NFL Combine between 2009 and 2015 were reviewed. The inclusion criteria were any player who had clinical findings or a previous surgical procedure consistent with a PLC injury and who participated in medical and performance testing at the NFL Combine. PLC injuries were identified by evaluating the side-to-side difference in lateral-compartment laxity with varus stress and reviewing magnetic resonance imaging studies. NFL performance outcomes (draft position and number of games played or started within the first 2 years) were compared with matched controls. RESULTS: Of the 2,285 players assessed at the NFL Combine, 16 (0.7%) were identified with a history of a grade II or III PLC tear and surgical management whereas 7 additional players (0.3%) had a PLC injury diagnosed on clinical examination, for 23 total PLC injuries (1%). On examination, 13 of 22 knees (59%) were shown to be stable; however, most of those managed surgically had significantly improved stability (13 of 15 stable) versus none of those managed nonsurgically (0 of 7 stable). Surgically managed PLC-injured athletes started significantly fewer games than controls (5.3 vs 10.5, P = .03); the mean draft position for players with surgically treated PLC injuries was 139.7 versus controls' mean draft position of 111.3. Of the 16 athletes treated operatively, 2 reported a PLC injury recurrence; both were managed nonoperatively. CONCLUSIONS: A small percentage of players at the NFL Combine had evidence of a previous PLC injury (1%), with 0.4% having residual varus asymmetry on clinical examination. A worse overall mean draft position for isolated PLC-injured athletes versus controls was found: 132.8 versus 111.3 (P = .02). It is recommended that the use of varus stress radiographs be considered for NFL Combine athletes to objectively determine their grade of injury. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Clinical and Radiologic Outcomes After Scaphoid Fracture: Injury and Treatment Patterns in National Football League Combine Athletes Between 2009 and 2014.

PURPOSE: To report on the clinical and radiologic outcomes and complications after surgical treatment in National Football League (NFL) Combine athletes with a history of a scaphoid fracture. METHODS: The medical records of 2,285 athletes participating in the NFL Combine from 2009 to 2015 were evaluated for a history of scaphoid, hand, or wrist injury. Clinical outcomes, including grip strength, pinch test, range of motion, and presence of pain and stiffness, were recorded. Imaging studies were evaluated for the percentage of healing, fixation treatment type, hardware complications, radiographic deformity, and presence of osteoarthritis. RESULTS: Of the 2,285 athletes evaluated, 56 presented with a history of a scaphoid fracture. Most fractures were in the middle and proximal aspects of the scaphoid. Of the scaphoid fractures, 76% (43 players) were treated with screw fixation. Of the athletes, 36 (72%) had normal range of motion of the affected wrist, 52 (93%) reported no pain, and 44 (83%) reported no stiffness in the affected wrist. The grip strength and pinch strength were 91% and 96%, respectively, of the uninjured side. The fracture was healed in 75% of the cases; however, 34% had degenerative changes. Hardware complications were found in 15% of the athletes. CONCLUSIONS: Good clinical outcomes can be achieved after scaphoid fractures in prospective NFL athletes. However, the rates of nonunion (25%), degenerative changes (34%), and hardware complications (15%) in this study suggest the need for close postoperative radiographic follow-up in this population of patients because their athletic demands may lead to higher rates of the aforementioned complications. LEVEL OF EVIDENCE: Level IV, retrospective study.

Medial Patellofemoral Ligament Reconstruction in a Revision Setting: Anchor and Interference Screw Fixation.

Recurrent patellar instability is a common pathology and typically affects younger and more active patients. To prevent complete lateral dislocation of the patella, several osseous and soft-tissue procedures have been previously described, including reconstruction of the medial patellofemoral ligament (MPFL), which has been identified as the primary medial stabilizer of the patella. Several techniques have been reported for reconstruction of the MPFL, sometimes in conjunction with other procedures, with the majority showing success in the treatment and resolution of patellar instability. However, MPFL reconstruction is not free of complications, with previous reports of recurrence of medial patellar instability and patellar fracture after surgery. The objective of this Technical Note is to describe our preferred technique, comprising anchor as well as interference screw fixation, for reconstruction of the MPFL in a primary or revision setting.

Osteochondral Allograft Transplantation for Treatment of Focal Patellar Osteochondral Lesion.

Patellar osteochondral lesions are common and particularly disabling injuries that can affect young and highly active patients. If enough functional impairment, ranging from difficulty climbing stairs to pain with squatting, is present, surgical treatment may be warranted. For the treatment of these lesions, various techniques have been described, including autologous osteochondral transplantation, as well as microfracture surgery. However, these are not without disadvantages. Although morbidity is noted in cases of autologous osteochondral transplantation, uncertain and possibly unsustainable results are associated with the microfracture procedure. Therefore, we present an alternative surgical treatment option for this pathology. The objective of this Technical Note is to describe our preferred approach for an osteochondral allograft transplant procedure to treat a focal patellar osteochondral lesion.

Concomitant Reverse Hill-Sachs Lesion and Posterior Humeral Avulsion of the Glenohumeral Ligament: Treatment With Fresh Talus Osteochondral Allograft and Arthroscopic Posterior Humeral Avulsion of the Glenohumeral Ligament and Labrum Repair.

Chronic posterior glenohumeral joint instability can be a challenging clinical entity for patients and surgeons alike. In the setting of a posterior dislocation, a large anterior humeral impaction injury (reverse Hill-Sachs [HS]) may occur, leading to engagement of the humerus with the posterior glenoid bone, especially during internal rotation of the joint. A reverse HS is especially debilitating because of the significant portion of affected humeral head cartilage, and is made worse in the setting of ligamentous disruption such as a posterior humeral avulsion of the glenohumeral ligament (HAGL) lesions. Although several nonanatomic procedures to address these defects have been previously described, recent interest in anatomic reconstructions capable of restoring the cartilage surface of the humeral head has led to the use of bone grafts (autografts and allografts) to restore the articular contour of the humeral head in conjunction with anatomic repair of associated soft tissue injuries. We present our preferred technique for an anatomic repair of a posterior HAGL lesion in combination with reconstruction of an engaging reverse HS lesion using an unmatched hemitalar allograft.