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

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

Editorial Commentary: Pie-Crusting for Medial Meniscal Root Repair Shows Improved Outcomes Without Laxity.

Arthroscopic access to the posterior root of the medial meniscus is often difficult in a tight medial compartment. To facilitate ease of access, partial lengthening of the medial collateral ligament (MCL) "pie-crusting" has been advocated to increase the working space of the medial compartment during arthroscopy. Purported benefits of MCL include increased visualization and decreased misdiagnosis during diagnostic arthroscopy, decreased iatrogenic chondral injuries with instrumentation, and postoperative medial compartment off-loading. Several techniques of MCL lengthening have been described including percutaneous lengthening, transportal lengthening, and mini-open lengthening. The safety of MCL lengthening has been demonstrated. Patients receiving MCL lengthening have no difference in postoperative laxity, postoperative pain, nor damage to surrounding structures. MCL lengthening also shows improved patient outcome scores and decreased rates of retear of medial meniscal root tear repair.

Securing the Root: Meniscus Root Repair with Rip Stop and Cannulated Drilling.

Meniscal root pathology has garnered increased attention over the past decade. Meniscal root tears are considered to essentially represent a meniscus-deficient state, which has led to a rise in the surgical fixation of this pathology. Meniscus root tears are classified as either radial tears within 1 cm of the root insertion, or a direct avulsion of meniscal root. These injuries are important to recognize because they contribute to impaired joint mechanics and rapid articular cartilage degeneration. Given this, there remains significant interest in identifying novel surgical techniques that may facilitate better surgical repair and enhance patient outcomes. The purpose of this technical note is to describe a surgical technique for a medial meniscus root ripstop repair with cannulated drilling. This technique is simple and reproducible, while also allowing for the augmentation of potentially poor tissue quality.

All-Arthroscopic Bone Grafting and Primary Fixation of a Medial Femoral Condyle Osteochondritis Dissecans Lesion.

Treatment of osteochondritis dissecans (OCD) lesions poses a significant challenge for orthopaedic surgeons and can cause debilitating limitations on the activity of patients. Timing of intervention, surgical technique, and selection of graft when needed are all key elements of treatment that need to be considered carefully and discussed with patients. Primary fixation of an OCD fragment with intact subchondral bone has been shown to be beneficial in some cases. There is limited literature, however, on how to approach large chondral lesions in young patients without a large subchondral base attached to the fragment. Treatment of large OCD lesions of the knee with an all-arthroscopic approach provides several benefits, including limited dissection for exposure, improved ability to assess the stability of the OCD lesion during articulation after fixation, and an expedited recovery compared to an open approach. The purpose of this technical note is to detail a technique of performing an all-arthroscopic bone grafting and primary fixation of a medial femoral condyle OCD lesion.

The effect of pre-operative shoulder injections on post-operative opioid use, infection and revision following shoulder arthroplasty.

Background: Treatment of glenohumeral osteoarthritis (GHOA) may include conservative management with use of intraarticular injections, prior to considering total shoulder arthroplasty (TSA). The purpose of this study was to assess trends in the use of preoperative cortisone (CO) and hyaluronic acid (HA) injections, as well as investigate the relationship between injection use and infection or revision arthroplasty following TSA. Methods: Pearl Driver was used to identify all patients undergoing TSA for GHOA between 2010 and 2018. Patients were categorized based on the type and number of injections they received. Outcomes of interest included post-operative opioid use, post-operative infection, and risk of revision surgery within 1 year of the index procedure. Results: The incidence of patients receiving a CO or HA injections within 1 year of their TSA decreased by 83% and 54%, respectively. Patients who had received 1 or more steroid injections had higher odds of prolonged opiate use following surgery. Patients that received 1 or 2 CO injection prior to TSA had an increased risk of needing revision surgery. Discussion: Use of intraarticular injections for the management of GHOA has declined. Patients receiving preoperative injections had increased odds of prolonged opiate use and the need for revision surgery.

Arthroscopic Hip Labral Reconstruction With Fresh Meniscal Allograft.

The acetabular labrum is essential to maintaining the functional health of the hip joint through contributions to joint congruity, stability, and the negative pressure suction seal. Injury, overuse, long-standing developmental disorders, or failed primary labral repair can eventually lead to functional labral insufficiency requiring management via labral reconstruction. While numerous graft options exist for hip labral reconstruction, there is no current gold standard. The optimal graft should best mimic the native labrum with regard to geometry, structure, mechanical properties, and durability. This has led to the development of an arthroscopic technique for labral reconstruction with fresh meniscal allograft tissue.

The Floating Clavicle: Surgical Technique for Management of an Ipsilateral Acromioclavicular and Sternoclavicular Joint Dislocation.

Bipolar "floating" clavicle injuries are infrequent upper-extremity injuries that occur secondary to a high-energy trauma, which can cause dislocation at the sternoclavicular (SC) and acromioclavicular joints. Given the rarity of this injury, there is not a consensus regarding clinical management. Although anterior dislocations can be managed nonoperatively, posterior dislocations may pose a threat to chest-wall structures and typically are managed surgically. Here, we present our preferred technique for concomitant management of a locked posterior SC joint dislocation with associated grade 3 acromioclavicular joint dislocation. Reconstruction of both ends of the clavicle was performed in this case, using a figure-of-8 gracilis allograft and nonabsorbable suture reconstruction for the SC joint, and an anatomic acromioclavicular joint and coracoclavicular ligament reconstruction with semitendinosus allograft and nonabsorbable suture.

Osteoarthritis in the Upper Extremity.

Osteoarthritis is a common cause of morbidity in an increasingly aging population. Although the weight-bearing joints of the leg and foot are frequently affected by osteoarthritis, degenerative changes in the joints of the upper extremity are likewise common and can be both particularly debilitating for affected individuals and uniquely challenging for the health care providers managing it. The present review seeks to overview the epidemiology, anatomy, diagnosis, and management of osteoarthritis in the joints of the shoulder, elbow, and hand with the intent of providing accessible and relevant information to the range of medical professionals involved in patient care.

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

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

Graft Options for Hip Labral Reconstruction.

➢: Arthroscopic hip labral reconstruction is a complex procedure which is growing in use as indications, techniques, and surgical expertise advance. ➢: Graft selection is an important component of labral reconstruction based on relative advantages and disadvantages of available types of autografts and allografts. ➢: The ideal graft should mimic the native acetabular labrum form and function while also being affordable, readily available, and associated with low morbidity. ➢: High rates of patient satisfaction and positive patient-reported outcomes have been reported after labral reconstruction using several graft types.

Patellar Instability.

➢: Certain anatomic factors, such as patella alta, increased tibial tubercle-trochlear groove distance, rotational deformity, and trochlear dysplasia, are associated with an increased risk of recurrent patellar instability. ➢: The presence of a preoperative J-sign is predictive of recurrent instability after operative management. ➢: Isolated medial patellofemoral ligament reconstruction may be considered on an individualized basis, considering whether the patient has anatomic abnormalities such as valgus malalignment, trochlear dysplasia, or patella alta in addition to the patient activity level. ➢: More complex operative management (bony or cartilaginous procedures) should be considered in patients with recurrent instability, malalignment, and certain anatomic factors.

Descriptive Characteristics and Outcomes of Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction With and Without Tunnel Bone Grafting.

BACKGROUND: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described. PURPOSE: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics. RESULTS: A total of 159 patients (13%) underwent tunnel grafting-64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group (P≤ .001). Patients who required 2-stage grafting had more previous ACLRs (P < .001) and were less likely to have received a bone-patellar tendon-bone or a soft tissue autograft at primary ACLR procedure (P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone-patellar tendon-bone allograft (P≤ .008) and less likely to receive a soft tissue autograft (P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) (P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group. CONCLUSION: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Moderate Return to Play and Previous Performance After SLAP Repairs in Competitive Overhead Athletes: A Systematic Review.

PURPOSE: To perform a systematic review of return to play (RTP) and return to previous level of performance (RPP) in competitive overhead athletes after SLAP repair to identify factors associated with failure to RTP. METHODS: Systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Review was registered with PROSPERO International prospective register of systematic reviews (CRD42020215488). Inclusion criteria were literature reporting RTP or RPP following SLAP repair in overhead athletes were run in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Categories for data collection for each full article included (1) article information; (2) patient demographics; (3) surgical techniques; (4) level of competition; (5) rotator cuff treatment; (6) player position; (7) patient-reported outcome measures; and (8) RTP and RPP rates. The Methodological Index for Non-randomized Studies checklist was used to evaluate quality of all included studies. RESULTS: Eight studies with 333 subjects were identified. Overall RTP and RPP rates were 50% to 83.6% and 35.3% to 64%, respectively. Patients with surgically treated rotator cuff pathology had lower RTP (12.5%-64.7%) rates compared with those without (80.0%-83.6%). Professional athletes had similar RTP rates (62.5%-81.5%) compared with high-school (75.0%-90.0%) and college athletes (12.5%-83.3%). However, professional athletes demonstrated the lowest relative range of reported RPP rates (27.7%-55.6%). Pitchers had lower RTP (62.5%-80.0%) and RPP (52.0%-58.9%) compared with position players (91.3% RTP, 76.3%-78.2% RPP). CONCLUSIONS: Studies reviewed reported moderate RTP and RPP rates following SLAP repairs in competitive overhead athletes. Those with associated rotator cuff tear requiring treatment, and baseball pitchers were less likely to RTP and RPP. Professional athletes had similar RTP to an amateur; however, they were less likely to RPP. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Does native glenoid anatomy predispose to shoulder instability? An MRI analysis.

BACKGROUND: It is unclear if native glenohumeral anatomic features predispose young patients to instability and if such anatomic risk factors differ between males and females. The purpose of this study was to compare glenoid and humeral head dimensions between patients with a documented instability event without bone loss to matched controls and to evaluate for sex-based differences across measurements. The authors hypothesized that a smaller glenoid width and glenoid surface area would be significant risk factors for instability, whereas humeral head width would not. METHODS: A prospectively maintained database was queried for patients aged <21 years who underwent magnetic resonance imaging (MRI) for shoulder instability. Patients with prior shoulder surgery, bony Bankart, or glenoid or humeral bone loss were excluded. Patients were matched by sex and age to control patients who had no history of shoulder instability. Two blinded independent raters measured glenoid height, glenoid width, and humeral head width on sagittal MRI. Glenoid surface area, glenoid index (ratio of glenoid height to width), and glenohumeral mismatch ratio (ratio of humeral head width to glenoid width) were calculated. RESULTS: A total of 107 instability patients and 107 controls were included (150 males and 64 females). Among the entire cohort, there were no differences in glenoid height, glenoid width, glenoid surface area, humeral head width, or glenoid index between patients with instability and controls. Overall, those with instability had a greater glenohumeral mismatch ratio (P = .029) compared with controls. When stratified by sex, female controls and instability patients showed no differences in any of the glenoid or humerus dimensions. However, males with instability had a smaller glenoid width by 3.5% (P = .017), smaller glenoid surface area by 5.2% (P = .015), and a greater glenohumeral mismatch ratio (P = .027) compared with controls. CONCLUSION: Compared with controls, males with instability were found to have smaller glenoid width and surface area, and a glenoid width that was proportionally smaller relative to humeral width. In contrast, bony glenohumeral morphology did not appear to be a significant risk factor for instability among females. These sex-based differences suggest that anatomic factors may influence risk of instability for male and female patients differently.

Performance After Concussion in National Basketball Association Players.

Background: Concussions have received national attention in collision sports such as football, soccer, and hockey, but less focus has been placed on basketball. Purpose: To determine return-to-play (RTP) and player performance in the first and second season after concussion in National Basketball Association (NBA) players. Study Design: Descriptive epidemiology study. Methods: An online database of publicly available NBA athlete injuries was queried for instances of "concussion" between 2010 and 2018. The age at injury, team, position, height, weight, body mass index, NBA experience, date of concussion, date of return, and seasons played postconcussion was recorded for each player. Regular-season statistics (games started, games played, minutes played, and player efficiency rating [PER]) were compiled for the season before, and 2 seasons immediately after, injury. Kaplan-Meier survivorship plots were computed for athlete RTP and retirement endpoints. Results: A total of 81 injuries were identified from 2010 to 2018, with a rate of 2.0 concussions per 100 player-years. Overall RTP was 100% after concussion, with nearly all (88%) returning in the season of injury; 12% of players experienced a season-ending concussion. RTP averaged 37.3 days after injury, varying widely (range, 2-291 days). Compared with preinjury season (78.0%), athletes played in significantly fewer overall games in the season of injury (36.6%; P < .0001), as well as 1 (69.5%; P = .0229) and 2 seasons postinjury (73.2%; P = .3192). PER scores were not significantly different across the study period. Each point increase in a player's preinjury PER score was associated with a 2.4% decrease in PER from the preinjury season to season of injury (P = .0016) and a 3.1% decrease from preinjury to season after injury (P = .0053). Each increasing year of age or year of experience was associated with 5% decline in PER score at 1 season after injury. Conclusion: NBA players had a high RTP after concussion, with most returning in the same season as the injury. Players sustaining concussions played significantly fewer games for at least 2 seasons after injury. Performance via PER did not change across the entire cohort; however, players with higher preinjury PER, and older players were more likely to sustain a greater decline in performance after injury.

Biomechanical Role of the Superior Capsule in a Rotator Cuff Sectioned and Repaired State: A Sequential Sectioning Study.

BACKGROUND: Individual contributions of the rotator cuff (RC) and superior capsule (SC) to prevent superior translation of the humerus are not well understood. PURPOSE: To evaluate the relative contributions of the SC and RC to normal and pathologic shoulder biomechanics by determining their independent effects on superior humeral translation. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve cadaveric shoulders were tested at 0º, 45º, and 90º of abduction under 5 conditions: intact RC/SC, RC sectioned first, SC sectioned first, both structures sectioned, and RC repair. Matched pairs were randomly assigned to the second or third testing condition (RC or SC sectioned first). Specimens were tested under 2 static conditions (40-N deltoid load [balanced load], 80-N deltoid load [superiorly directed load]) and 1 dynamic condition during active abduction. A mixed-design 2-way repeated-measures analysis of variance with Bonferroni adjustments was performed to compare testing conditions. Paired t tests were used to compare specimens in the intact state versus the repaired state. Significance was set at P < .05. RESULTS: During balanced deltoid loading at 0° and 45º, there was significantly greater humeral translation when both structures were sectioned as compared with the intact state and with both isolated sectioned states (P < .05 for all). No significant differences were observed between or within groups at 90º of abduction. These effects remained consistent with superiorly directed loading. Dynamic testing of both groups showed a significant increase in superior translation for specimens in which the RC was deficient versus the intact state (P = .027), with no difference when the SC was sectioned. The RC repair state returned translation to values similar to the intact state at all abduction angles and loading conditions (P > .05). CONCLUSION: In this cadaveric study, the SC and RC played an important role in preventing superior humeral translation; however, dynamic testing suggested preferential contribution of the RC. RC repair was effective in preventing superior humeral translation, even with a sectioned SC at the level of the glenohumeral joint. CLINICAL RELEVANCE: RC repair was effective in preventing superior humeral translation, even in the presence of a sectioned SC at the level of the glenohumeral joint in this cadaveric model. Our data lay the groundwork for future studies investigating the clinical effect of RC repair in an SC sectioned state.

Lower extremity injuries in the baseball athlete.

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

Technical Note: Arthroscopic Rotator Cuff Repair with Patch Augmentation with Acellular Dermal Allograft.

Rotator cuff tears are one of the most common causes of shoulder pain and dysfunction seen by orthopaedic surgeons. Although rotator cuff repair (RCR) has been shown to provide optimal outcomes, retear rates average roughly 60% and have been reported to exceed 90%. Retear after RCR is especially prevalent in patients with large, multitendon tears with poor tissue quality. Allograft augmentation of RCR may reinforce anatomically reparable tears, particularly in patients with poor tissue quality. Although various techniques of patch augmented RCR have been described, the procedure remains challenging. This Technical Note describes RCR augmented with acellular dermal allograft using the CuffMend system (Arthrex Inc, Naples, FL), which significantly decreases surgeon demand and helps avoid the pitfalls common with this procedure.

Rehabilitation, Restrictions, and Return to Sport After Cartilage Procedures.

The ability to return to sport (RTS) after articular cartilage injury is of vital importance to athletes. Discussing the likelihood of returning to sport with patients is necessary, yet patients should be informed of the heterogeneous nature of the variables associated with successful RTS and the methodologic limitations behind current RTS rate estimates. Patient-specific factors affecting RTS are numerous and, in most cases, their isolated effect on RTS rates have yet to be examined and will remain difficult to do so. The purpose of this review is to discuss current RTS rates, explore factors leading to successful RTS, and examine the variability in physical therapy protocols after cartilage procedures, including microfracture, osteochondral allograft transplantation (OCA), autologous chondrocyte implantation (ACI), and meniscal allograft transplantation (MAT). The senior author's postoperative protocols will also be presented, as with a discussion on using RTS as a metric of patient and procedural success. Overall, there is significant variation in reported RTS rates among procedures examined, and providers must continue managing patient expectations when discussing treatment options.

The "Not" Good, the Bad and the Ugly: Prevention and Management of Common Intraoperative and Delayed Complications in Orthopedic Sports Medicine Surgical Procedures.

Despite advances in techniques designed to make arthroscopic sports medicine procedures simple, complications still arise in the operating room; even in the most trained hands. However, what marks a skilled surgeon is not just the ability to steer the ship amidst smooth seas, but a knack for getting out of trouble once things deviate from the set course. Each surgical case presents a unique challenge, and no 2 are the same. For this reason, a true expert surgeon must know how to deal with "complications" ranging from a mild swell to a raging storm. In this review we present strategies to prevent and navigate some of the most common, and fearsome complications a sports medicine surgeon may face during surgery. A great surgeon is one that acknowledges that throughout their career it is not a question of "if" these situations will arise, but "when"; and preparation is the key to success.