The use of actigraphy to objectively define motion and function before and after shoulder arthroplasty.

Introduction: Actigraphy is a quantitative means of measuring activity data that has proven viable in post-surgery recovery analysis for arthroplasties in lower extremities, but scant literature has been published on the utilization actigraphy to evaluate shoulder motion and function before and after shoulder arthroplasty. The purpose of this prospective cohort study is to identify if actigraphy can serve as a valid means for objective evaluation of shoulder function and motion before and after shoulder arthroplasty. Secondarily, the data collected by the actigraphy can be analyzed with standard patient-reported outcomes to report correlations between the subjective and objective methods used in this study. Materials and methods: Sixty-four subjects wore an actigraphy device for one day at pre-op, six, twelve and twenty-four weeks. In addition, subjects completed three patient-reported outcome surveys at each time-point. Student t-tests were used to compare percent activity preoperatively with 24-weeks and to compare PROs preoperatively with 24-week results; categorical variables were compared with one-way ANOVAs. Results: All Patient reported outcome scores significantly improved following arthroplasty (p-value<0.001). The percent of physical activity was highly correlated with vector magnitude (p-value<0.001), but neither percent activity or the vector magnitude were correlated with any of the PROs: UCLA Pain p-value = 0.656, SANE p-value = 0.328, UCLA Function p-value = 0.532. Conclusions: Actigraphy results from this study mirror findings in previous literature utilizing the technology in similar manners and demonstrate its potential for motion and function analysis before and after total shoulder arthroplasties. Despite both being suitable methods independently for the evaluation of shoulder function, there was no significant correlation between standard actigraphy measurements and PROs at 24-weeks. Future research to determine clinical utility and an overall broader scope for actigraphy monitoring could benefit from improved technology, such as increased battery life for prolonged durations of data collection during observation periods.

Eccentric Hamstring Strength Imbalance among Football and Soccer Athletes.

OBJECTIVES: Hamstring strain injuries (HSI) are common among football and soccer athletes. Eccentric strength imbalance is considered a contributing factor for HSI. There is, however, a paucity of data on hamstring imbalances of soccer and American football athletes as they age and advance in skill level. High school athletes will display greater interlimb discrepancies compared with collegiate and professional athletes. In addition, soccer athletes will exhibit greater hamstring asymmetry than American football athletes. METHODS: Hamstring testing was performed on soccer and American football athletes using the NordBord Hamstring Testing System (Vald Performance, Albion, Australia). Age, sex, weight, sport specialization, and sport level were recorded. Maximum hamstring forces (N), torque (N · m), and work (N · s) were measured. Hamstring imbalance (%) was calculated by dividing the absolute value of the difference in leg forces divided by their sum. One-way analysis of variance and independent sample t tests compared measurements between athlete groups. RESULTS: A total of 631 athletes completed measurements, including 88 high school male soccer, 25 college male soccer, 23 professional male soccer, 83 high school female soccer, 28 college female soccer, 288 high school football, and 96 college football athletes. High school soccer players displayed significantly greater imbalances for torque (P = 0.03) and work (P < 0.01) than football athletes. Imbalances for maximum force (P = 0.035), torque (P = 0.018), and work (P = 0.033) were significantly higher for male soccer athletes in high school compared with college- and professional-level athletes. Female high school soccer players had significantly higher imbalance in torque (P = 0.045) and work (P = 0.001) compared with female collegiate soccer players. Football athletes did not experience significant changes in force imbalances between skill levels. CONCLUSIONS: High school soccer athletes exhibit greater hamstring imbalances than football athletes. Higher levels of play in soccer, for both male and female athletes, correlate with less hamstring asymmetry.

Anterior Cruciate Ligament Reconstruction using Bone-Tendon-Bone Allograft: Surgical Technique Using Augmentation with Bio-Composite Scaffold.

Anterior cruciate ligament (ACL) rupture rates remain high; the incidence of isolated ACL ruptures is 68.6 per 100,000. This Technical Note introduces a technique for ACL reconstruction (ACLR) using a bone-tendon-bone (BTB) allograft augmented with BioBrace, a biocomposite scaffold. The BioBrace scaffold is sutured onto the BTB allograft to reinforce the ligament and accelerate healing. Graft preparation with BioBrace, ACLR, and graft passage is described. This technique aims to reduce re-rupture risk, enhance graft healing, and improve patient-reported outcomes. BioBrace offers advantages over other augmentation approaches and synthetic materials, providing improved remodeling, biologic integration, and increased mechanical strength. Feasibility and efficacy have been demonstrated in animal models and human applications. This technique presents a promising approach to enhance ACLR outcomes.

Impact of Sling Use on Functional Mobility in a Geriatric Population.

OBJECTIVES: Sling immobilization is commonly used following rotator cuff repair. The purpose of this study was to determine the detrimental impact of sling usage on mobility and balance in an older adult population through validated gait and balance testing. The authors hypothesize that sling use will negatively affect balance and stability. METHODS: This institutional review board-approved and registered randomized prospective clinical trial enrolled patients from 2019 to 2021. Following informed consent, patients were randomized into two groups: a sling worn (group 1) and no sling worn (group 2). Participants were assessed via the Edmonton Frail Scale as well as Tinetti gait and balance scoring. RESULTS: Fifty patients were included in the study, 23 (46%) men and 27 (54%) women, with a mean age of 72.2 years. The balance score median was 16.00 for participants not wearing a sling and 15.00 for participants wearing a sling. The gait score median was 12.00 for participants not wearing a sling and 11.50 for participants wearing a sling. The balance and gait scores were significantly greater when patients were not wearing a shoulder sling with P values of 0.006 and 0.011, respectively. The overall combined gait and balance score was significantly greater, with median values of 27.00 for participants not wearing a sling and 26.00 for participants wearing a sling (P = 0.001). Patients reported little to no anxiety about falling while wearing the sling, with a score of 0.16. CONCLUSIONS: Postoperative sling immobilization negatively affects balance and gait in the geriatric population, potentially increasing the risk of postoperative falls in an already at-risk population.

Suspensory fixation for bone transfer procedures in shoulder instability is superior to screws in an angled construct: a biomechanical analysis.

Background: The Latarjet procedure is a common bony augmentation procedure for anterior shoulder instability. Historically, screw fixation is used to secure the coracoid graft to the anterior glenoid surface; however, malpositioning of the graft leads to oblique screw insertion that contributes to complications. Suture buttons (SBs) are a more recent fixation technique that have not been studied alongside standard screw fixation in the context of biomechanical models of angulated fixation. This study aims to compare the biomechanical strength of single and double, screw and SB fixation at various levels of angulation. Methods: Testing was performed using polyurethane models from Sawbones. The graft piece was secured with screw fixation (Arthrex, Naples, FL, USA) or suspensory button (ABS Tightrope, Arthrex, Naples, FL, USA). Single or double constructs of screws and SBs were affixed at 0°, 15°, and 30° angles to the face of the glenoid component. An aluminum testing jig held the samples securely while a materials testing system applied loads. Five constructs were used for each condition and assessed load to failure testing. Results: For single fixation constructs, suspensory buttons were 60% stronger than screws at 0° (P < .001), and 52% stronger at 15° (P = .004); however, at 30°, both were comparable (P = .180). Interestingly, single suspensory button at 15° was equivalent to a single screw at 0° (P = .310). For double fixation, suspensory buttons (DT) were 32% stronger than screws at 0° (P < .001) and 35% stronger than screws at 15° (P < .001). Both double fixation methods were comparable at 30° (P = .061). Suspensory buttons at 15° and 30° were equivalent to double screws at 0 (P = .280) and 15° (P = .772), respectively. Conclusion: These measurements indicate that the suspensory button has a significantly higher load to failure capacity over the screw fixation technique, perpendicularly and with up to 15° of angulation. These analyses also indicate that the suspensory button fixation offers superior strength even when positioned more obliquely than the screw fixation. Therefore, suspensory button fixation may confer more strength while offering greater margin for error when positioning the graft.

Partial rotator cuff repair versus debridement for irreparable rotator cuff tears: A systematic review.

Introduction: Massive irreparable rotator cuff tears (MIRCT) are a significant cause of shoulder disability and pain, presenting a unique challenge in terms of management with multiple options for care ranging from debridement alone to partial rotator cuff repair. In this study we investigate how clinical outcomes and complications of partial rotator cuff repair compare to simple debridement in the treatment of irreparable rotator cuff tears. Materials and methods: A total of 1594 publications were identified on PubMed from 1946 to 2017 with 16 level III to level IV studies that were reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: A total of 709 shoulders from 706 patients were reviewed, with 380 patients receiving a partial repair and 329 shoulders receiving debridement. Fifteen outcome measures were utilized with visual analog scale (VAS) pain score and patient satisfaction being the most common. Pre- and post-operative mean VAS scores reported in 155 shoulders treated with partial repair were 6.0 (5.1-6.9) and 2.0 (1.7-3.2), respectively. Pre- and post-operative mean VAS scores in 113 shoulders treated with debridement were 6.5 (4.5-7.9) and 1.9 (1-2.9), respectively. Patient satisfaction in 111 shoulders treated with partial repair was reported as 75 % (51.6-92). In 153 shoulders treated with debridement, post-operative satisfaction was 80.7 % (78-83.9). Conclusion: This systematic review study demonstrates that both partial repair and debridement alone can result in acceptable clinical outcomes with no significant differences noted for patients with irreparable rotator cuff tears in short to mid-term follow up.

Posterior lateral meniscal overhang is associated with ACL tears: A retrospective case-control study.

Introduction: There have been several described imaging findings that correlate with anterior cruciate ligament (ACL) injuries. The investigators in this study observed a higher frequency of posterior translation of the lateral meniscus beyond the posterior border of the tibial plateau in patients with ACL tears. The purpose of this study was to assess the frequency and degree of posterior lateral meniscal overhang (LMO) of the lateral meniscus in patients with ACL tears compared to uninjured controls. Materials and methods: Magnetic resonance imaging (MRI) was analyzed in 117 knees with ACL tears and compared to a control group of 89 knees without injury. Lateral meniscus diameter, LMO, knee flexion angle, and lateral tibial plateau diameter were measured and compared between the two groups. Exclusion criteria included displaced and macerated lateral meniscus tears, multi-ligamentous knee injuries, and periarticular fractures. Difference in mean lateral meniscal overhang between ACL injured and control groups was tested using a paired T-test (alpha = 0.01). Assumptions for normality and variance were tested prior to analysis. Results: In patients with ACL tears, average LMO was significantly greater compared to the control group (0.95 mm vs. 0.08 mm; p < 0.001). Additionally, measurable LMO was found in 42.7 % of patients with ACL tears compared to 4.5 % uninjured knees (p < 0.001). Conclusion: Patients with ACL injury show higher incidence of LMO compared to uninjured controls. Future studies are necessary to better understand its clinical significance.

Patient Self-Reported Allergies and Their Correlation with Thoracic Outlet Syndrome Outcomes.

OBJECTIVES: Thoracic outlet syndrome (TOS) is an uncommon neurovascular disorder that presents as neck and upper extremity pain secondary to brachial plexus trunk or subclavian vasculature compression. The orthopedic literature has correlated patient-reported allergies to postoperative patient-reported outcome (PRO) scores for a variety of surgical procedures. We sought to evaluate patient-reported allergies and PROs following surgical decompression for TOS. METHODS: A chart review was conducted after identifying patients who underwent surgical thoracic outlet decompression by a single surgeon. Patients were contacted and administered five PRO questionnaires via telephone: the QuickDASH Outcome Measure questionnaire (disabilities of the arm, shoulder, and hand [DASH]), the Cervical Brachial Symptom Questionnaire, the Single Assessment Numeric Evaluation, the 12-Item Short Form Survey, and the Numeric Rating Scale (a visual analogue scale). A bivariate analysis of Pearson's correlation coefficient (r) was used to determine the associations of allergies with questionnaires and demographic variables. RESULTS: Of the 393 patients (128 males and 265 females) identified in the study, 75 (24%) responded and completed all of the questionnaires, 18 (24%) males and 57 (76%) females. A significant correlation was found between the number of allergies reported and the QuickDASH Outcome Measure questionnaire (r = 0.375, P < 0.001), the Cervical Brachial Symptom Questionnaire (r = 0.295, P = 0.01), change in the Single Assessment Numeric Evaluation score (r = -0.310, P < 0.01), change in the visual analogue scale (r = 0.244, P = 0.035), sex (r = 0.245, P = 0.034), and the number of medications (r = 0.642, P < 0.001). CONCLUSIONS: The increased frequency of patient-reported allergies is significantly associated with worse PRO scores for women undergoing TOS surgical decompression. Better understanding this association can help physicians counsel patients on expected outcomes.

Impact of irradiation on load-to-failure in bone-patellar tendon-bone allografts: A systematic review and meta-analysis.

Introduction: To evaluate the impact various levels of irradiation have on bone-patellar tendon-bone (BTB) allograft load-to-failure. Materials and methods: Pubmed, Google Scholar and Embase were searched for studies reporting load-to-failure measurements of BTB allografts following gamma or eBeam irradiation. All systematic reviews, editorials, as well as studies that utilized animal models and/or other graft sources (achilles, hamstring, quadriceps) were excluded. Meta-analysis was performed to compare the impact of low dose (19 ≤ kGy), intermediate (20-49 kGy) and high dose (>50 kGy) gamma and eBeam radiation on load-to-failure. Results: Twelve studies, containing a total of 429 BTB allografts (159 controls, 270 irradiated), were identified. Load-to-failure of BTB allograft was significantly decreased at intermediate (20-49 kGy) doses of radiation, while low (≤19 kGy) and high (>50 kGy) doses did not significantly change load-to-failure. Conclusions: Intermediate doses of radiation may negatively impact the biomechanical integrity of BTB allograft in vitro. Future studies are required to examine clinical outcomes at varying irradiation levels.

A Systematic Review of Screw and Suture Button Glenoid Augmentation Constructs.

Background: Glenohumeral dislocations often lead to glenoid bone loss and recurrent instability, warranting bony augmentation. While numerous biomechanical studies have investigated fixation methods to secure a graft to the glenoid, a review of available constructs has yet to be performed. Purpose: To synthesize the literature and compare the biomechanics of screw and suture button constructs for anterior glenoid bony augmentation. Study Design: Systematic review. Methods: A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. There were 2 independent reviewers who performed a literature search using the PubMed, Embase, and Google Scholar databases of studies published between 1950 and 2020. Studies were included that compared the biomechanical outcomes of fixation for the treatment of anterior shoulder instability with glenoid bone loss. Results: Overall, 13 of the 363 studies screened met the inclusion criteria. The included studies measured the biomechanical strength of screws or suture buttons on a cadaveric or synthetic Latarjet construct. Screws and suture buttons were biomechanically similar, as both constructs exhibited comparable loads at failure and final displacement. Screw type (diameter, threading, or composition) did not significantly affect construct strength, and double-screw fixation was superior to single-screw fixation. Additionally, 2 screws augmented with a small plate had a higher load at failure than screws that were not augmented. Unicortical double-screw fixation was inferior to bicortical double-screw fixation, although construct strength did not significantly decrease if 1 of these screws was unicortical. Further, 2 screws inserted at 15° off axis experienced significantly higher graft displacement and lower ultimate failure loads than those inserted at 0° parallel to the glenoid. Conclusion: Suture buttons provided comparable strength to screws and offer an effective alternative to reduce screw-related complications. Augmentation with a small plate may clinically enhance construct strength and decrease complications through the dispersion of force loads over a greater surface area. Differences in screw type did not appear to alter construct strength, provided that screws were placed parallel to the articular surface and were bicortical.

Variability in physical therapy protocols following total shoulder arthroplasty.

BACKGROUND: Physical therapy (PT) plays an important role in the recovery of function following anatomic total shoulder arthroplasty (aTSA). While several PT protocols have been published for these patients, there is no standardized protocol for aTSA rehabilitation. This lack of standardization may lead to confusion between patients and physicians, possibly resulting in suboptimal outcomes. This study examines how PT protocols provided by academic orthopedic surgery programs vary regarding therapeutic goals and activities following aTSA. METHODS: PT protocols for aTSA available online from the Accreditation Council for Graduate Medical Education accredited orthopedic surgery programs were included for review. Each protocol was analyzed to evaluate it for differences in recommendation of length of immobilization, range of motion (ROM) goals, start time for and progression of therapeutic exercises, and timing for return to functional activity. RESULTS: Of 175 accredited programs, 25 (14.2%) had protocols publicly available, programs (92%) recommended sling immobilization outside of therapy for an average of 4.4±2.0 weeks. Most protocols gave recommendations on starting active forward flexion (24 protocols, range 1-7 weeks), external rotation (22 protocols, range 1-7 weeks), and internal rotation (18 protocols, range 4-7 weeks). Full passive ROM was recommended at 10.8±5.7 weeks, and active ROM was 13.3±3.9 weeks, on average. ROM goals were inconsistent among protocols, with significant variations in recommended ROM and resistance exercise start times. Only 13 protocols (52%) gave recommendations on resuming recreational activities (mean, 17.4±4.4 weeks). CONCLUSIONS: Publicly available PT protocols for aTSA rehabilitation are highly variable. Level of evidence: IV.

The incidence of shoulder arthroplasty infection presents a substantial economic burden in the United States: a predictive model.

Background: Periprosthetic joint infections (PJIs) are a major cause of morbidity after shoulder arthroplasty. Prior national database studies have estimated the trends of shoulder PJI up to 2012.21 Since 2012, the landscape of shoulder arthroplasty has changed drastically with the expanding popularity of reverse total shoulder arthroplasty. The dramatic growth in primary shoulder arthroplasties is likely paralleled with an increase of PJI case volume. The purpose of this study is to quantify the rise in shoulder PJIs and the economic stress they currently place on the American healthcare system as well as the toll they will incur over the coming decade. Methods: The Nationwide Inpatient Sample database was queried for primary and revision anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemiarthroplasty from 2011-2018. Multivariate regression was used to predict cases and charges through the year 2030 adjusted to 2021 purchasing power parity. Results: From 2011 to 2018, PJI was found to be 1.1% shoulder arthroplasties, from 0.8% (2011) to 1.4% (2018). Anatomic total shoulder arthroplasty experienced the greatest proportion of infections at 2.0%, followed by hemiarthroplasty at 1.0% and reverse total shoulder arthroplasty at 0.3%. Total hospital charges grew 324%, from $44.8 million (2011) to $190.3 million (2018). Our regression model projects 176% growth in cases and 141% growth in annual charges by 2030. Conclusion: This study demonstrates the large economic burden that shoulder PJIs pose on the American healthcare system, which is predicted to reach nearly $500 million in charges annually by 2030. Understanding trends in procedure volume and hospital charges will be critical in evaluating strategies to reduce shoulder PJIs.

Gender Disparities Among Professional Team Sports Medicine Physicians.

OBJECTIVE: Although recent trends from the Accreditation Council for Graduate Medical Education (ACGME) present encouraging growth of female representation in sports medicine, the field is still lagging behind other specialties. This study investigates gender disparities among physicians providing care for professional sports teams in male and female sports leagues. DESIGN: Information regarding physicians providing sports medicine care to professional teams obtained by database queries (May 2021). Chi-square analysis compared gender data of orthopaedic team physicians with American Orthopaedic Society for Sports Medicine (AOSSM) and American Academy of Orthopaedic Surgeons (AAOS) membership, residency, and fellowship census data. Primary care sports medicine physicians were compared with American Medical Society for Sports Medicine (AMSSM) and primary-care sports medicine fellowship census data. SETTING: Professional sports health care. STUDY POPULATION: Professional league physicians. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Gender, residency, and fellowship training of professional league physicians. RESULTS: Among a total of 608 team physicians, 572 (93.5%) were male and 40 (6.5%) were female. Orthopedic surgeons comprised 64.7% of the physicians. Fourteen (3.6%) team orthopedic surgeons were female. Thirty-five percent of team physicians were primary care sports medicine physicians. Twenty-six primary care sports medicine physicians (11.6%) were female. Orthopaedic female team physician representation overall was comparable with AOSSM and AAOS membership but significantly less than orthopaedic surgery residents and sports medicine fellows ( P < 0.01). Women's National Basketball Association orthopaedic team physicians were more represented than female membership among AOSSM, AAOS, and orthopaedic sports medicine fellows ( P < 0.01). Except for the WNBA, Premiere Hockey Federation, National Women's Soccer League, and United States Football League, female primary care sports medicine physicians were underrepresented in professional sports compared with AMSSM membership and primary care sports fellows ( P < 0.01). CONCLUSION: Overall, female representation is poor among orthopaedic surgeons and primary care physicians providing sports medicine care to professional teams. Leagues encompassing female athletes tend to have better representation of female physicians. LEVEL OF EVIDENCE: IV.

Home-based physical therapy results in similar outcomes to formal outpatient physical therapy after reverse total shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Outcomes following reverse total shoulder arthroplasty (RTSA) are influenced by surgical indications, surgical technique, implant design, and patient variables. The role of self-directed postoperative physical therapy after RTSA is poorly understood. The purpose of this study was to compare the functional and patient-reported outcomes (PROs) of a formal physical therapy (F-PT) program vs. a home therapy program after RTSA. METHODS: One hundred patients were prospectively randomized into 2 groups: F-PT and home-based physical therapy (H-PT). Patient demographic variables, range of motion (ROM) and strength measurements, and outcomes (Simple Shoulder Test, American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, visual analog scale, and Patient Health Questionnaire-2 scores) were collected preoperatively and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Patient perceptions regarding their group assignment, F-PT vs. H-PT, were also assessed. RESULTS: Seventy patients were included for analysis, with 37 in the H-PT group and 33 in the F-PT group. Thirty patients in both groups had a minimum of 6 months' follow-up. The average length of follow-up was 20.8 months. Forward flexion, abduction, internal rotation, and external rotation ROM did not differ between groups at final follow-up. Strength did not differ between groups with the exception of external rotation, which was greater by 0.8 kilograms-force (kgf) with F-PT (P = .04). PROs at final follow-up did not differ between therapy groups. Patients receiving home-based therapy appreciated the convenience and cost savings, and the majority believed home therapy was less burdensome. CONCLUSION: Formal physical therapy and home-based physical therapy programs after RTSA result in similar improvements in ROM, strength, and PRO scores.

The Mechanism of Anterior Cruciate Ligament Injuries in the National Football League: A Systematic Video Review.

Introduction Anterior cruciate ligament (ACL) injuries are common among American football athletes, although few studies have performed video analyses of ACL injuries to better understand the injury mechanism. This work aims to characterize the mechanism of ACL injury during professional football competitions using video analysis. We hypothesize that football-specific injury trends will emerge, including high rates of contact injuries and associations with shallow knee and hip flexion angles (0°-30°). Methods Videos of professional football players suffering ACL injuries from 2007 to 2016 were analyzed. Injured players were identified using the injured reserve (IR) lists of the National Football League (NFL), and videos were discovered via a systematic Google search. Descriptive statistics and frequency analyses were performed on all variables using the Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM SPSS Statistics, Armonk, NY, USA). Results Of the 429 ACL injuries identified, 53 (12%) videos were available. Deceleration was the most common injury maneuver, present in 32 (60%) athletes. Thirty-one (58%) players suffered contact injuries. Twenty-eight (53%) injuries demonstrated valgus collapse of the knee, and 26 (49%) had neutral knee rotation. Defensive backs (26%) and wide receivers (23%) were the most frequently injured positions. Conclusion Overall, we found that most ACL injuries had preceding contact, deceleration, shallow hip and knee flexion, and heel strike, and subsequent valgus collapse and neutral knee rotation. This understanding of American football-specific ACL tear mechanisms could help direct the focus of future injury prevention training modalities.

Elective Hand Surgery Is Delayed among Private Insurance Holders.

OBJECTIVES: Patients with private healthcare plans often defer nonemergent or elective procedures toward the end of the year once they have met their deductible. No previous studies have evaluated how insurance status and hospital setting may affect surgical timing for upper extremity procedures. Our study aimed to evaluate the influence of insurance and hospital setting on end-of-the-year surgical cases for elective carpometacarpal (CMC) arthroplasty, carpal tunnel, cubital tunnel, and trigger finger release, and nonelective distal radius fixation. METHODS: Insurance provider and surgical dates were gathered from two institutions' electronic medical records (one university, one physician-owned hospital) for those undergoing CMC arthroplasty, carpal tunnel release, cubital tunnel release, trigger finger release, and distal radius fixation from January 2010 to December 2019. Dates were converted into corresponding fiscal quarters (Q1-Q4). Using the Poisson exact test, comparisons were made between the case volume rate of Q1-Q3 and Q4 for private insurance and then for public insurance. RESULTS: Overall, case counts were greater in Q4 than the rest of the year at both institutions. There was a significantly greater proportion of privately insured patients undergoing hand and upper extremity surgery at the physician-owned hospital than the university center (physician owned: 69.7%, university: 50.3%; P < 0.001). Privately insured patients underwent CMC arthroplasty and carpal tunnel release at a significantly greater rate in Q4 compared with Q1-Q3 for both institutions. Publicly insured patients did not experience an increase in carpal tunnel releases during the same period at both institutions. CONCLUSIONS: Privately insured patients underwent elective CMC arthroplasty and carpal tunnel release procedures in Q4 at a significantly greater rate than publicly insured patients. This finding suggests private insurance status, and potentially deductibles, influence surgical decision making and timing. Further work is needed to evaluate the impact of deductibles on surgical planning and the financial and medical impact of delaying elective surgeries.

Extensor Mechanism Reconstruction for Chronic Patellar Tendon Tears.

OBJECTIVES: Reconstruction for a chronic patellar tendon rupture in a native knee is an uncommon surgical procedure. Although there have been case series investigating patient-reported outcomes, there is no systematic review of these studies to date. The purpose of this review is to synthesize the literature on this procedure to better understand its outcomes, complications, and surgical technique options. METHODS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that reported outcomes and techniques of patellar tendon reconstruction for chronic disruption in native knees. Searches were conducted through MEDLINE using PubMed, Cochrane Database of Systematic Reviews, and clinicaltrials.gov. RESULTS: Ten studies with 103 patients and 105 knees were included. Results for nonnative (arthroplasty) knees were excluded. The mean patient age was 40.3 years, and the mean postsurgical follow-up time was 53.8 months. Of the 105 knees, 75% received a hamstring tendon graft, whereas 13% received a bone-tendon-bone graft and 7% received a whole extensor mechanism allograft. The mean preoperative range of motion was 113.8°, which improved to 126.0° postoperatively. The mean preoperative Lysholm score was 58.6, which improved to 86.0 postoperatively; 100% of patients returned to their normal work activities and 76% returned to their prior level of physical activity. There were no major complications reported in any of the included studies. CONCLUSIONS: Chronic patellar tendon disruption in a native knee is an uncommon injury that can result in significant limitations for patients. Although more research is needed to better elucidate which graft is best, outcomes after patellar tendon reconstruction for chronic tears appear to be satisfactory with current techniques.

The Relationship Between Posterior Tibial Slope and Pediatric Tibial Eminence Fractures.

BACKGROUND: Tibial eminence fractures are bony avulsions of the anterior cruciate ligament from its insertion on the intercondylar eminence. Numerous anatomic factors have been associated with anterior cruciate ligament injuries, such as posterior tibial slope, but there are few studies evaluating the association with tibial eminence fracture. PURPOSE: To compare posterior tibial slope of pediatric patients with and without tibial eminence fractures. We hypothesized that a steeper posterior tibial slope would be associated with tibial eminence fracture. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent surgical treatment of tibial eminence fracture were retrospectively identified between January 2000 and July 2021. Adults aged >20 years and those without adequate imaging were excluded. Controls without gross ligamentous or osseous pathology were identified. Descriptive information and Meyers and McKeever classification were recorded. Posterior tibial slope measurements were obtained by 2 independent orthopaedic surgeons twice, with measurements separated by 3 weeks. Chi-square tests and independent-samples t tests were used to compare posterior tibial slope and patient characteristics. Inter- and intrareviewer variability was determined via the intraclass correlation coefficient. RESULTS: A total of 51 patients with tibial eminence fractures and 57 controls were included. By sex, tibial eminence fractures occurred among 34 male and 17 female patients with a mean age of 10.9 years. The posterior tibial slope among those with tibial eminence fractures (9.7°) was not significantly greater than that of controls (8.8°; P = .07). Male patients with a tibial eminence fracture had significantly steeper slopes compared with controls (10.0° vs 8.4°; P = .006); this difference was not observed between female patients and female controls. Patients with a slope ≥1 SD above the mean (12.0°) had 3.8 times greater odds (95% CI, 1.3-11.6; P = .017) of having a tibial eminence fracture. Male patients with a posterior tibial slope >12° had 5.8 times greater odds (95% CI, 1.1-29.1; P = .034) of having a tibial eminence fracture compared with male controls. CONCLUSION: Male patients undergoing surgical fixation of a tibial eminence fracture had an increased posterior tibial slope as compared with case-controls. Increased posterior tibial slope may be a risk factor for sustaining a tibial eminence fracture, although the clinical significance of this deserves further investigation.

Variability in the Processing of Fresh Osteochondral Allografts.

The indications for fresh osteochondral allograft continue to increase. As a result, variations in graft processing and preservation methods have emerged. An understanding of these techniques is important when evaluating the optimal protocol for processing fresh osteochondral allografts prior to surgical implantation. The aim of this study is to review the literature and understand various tissue processing protocols of four leading tissue banks in the United States. Donor procurement, serological and microbiological testing, and storage procedures were compared among companies of interest. Similarities between the major tissue banks include donor screening, aseptic processing, and testing for microorganisms. Variability exists between these companies with relation to choice of storage media, antibiotic usage, storage temperature, and graft expiration dates. Potential exists for increased chondrocyte viability and lengthened time-to-expiration of the graft through a protocol of delicate tissue handling, proper choice of storage medium, adding hormones and growth factors like insulin growth factor-1 (IGF-1) to serum-free nutrient media, and storing these grafts closer to physiologic temperatures.

Orthopedic consequences of modern gladiators: a systematic review of lower extremity musculoskeletal issues in retired NFL players.

OBJECTIVES: The stressors that National Football League (NFL) athletes face are well-described and documented with regard to multisystem afflictions and injury prevalence. However, the majority of literature discusses the short-term effects rather than long-term outcomes of playing professional football. The purpose of this study was to characterize the long-term musculoskeletal issues in the retired NFL population. METHODS: Publications from CENTRAL, Scopus, Medline, PubMed, Embase, and Google Scholar were searched from database inception to February 2021. A total of 9 cohort studies evaluating lower extremity arthritis in retired NFL athletes were included for review. Two reviewers extracted data from the individual studies, including demographic information (age, body mass index, length of career, position), injury descriptions (location of injury, number of injuries, diagnoses), and procedure (total knee and or hip arthroplasty) frequency. RESULTS: Arthritis in retired NFL players was more than twice as prevalent than the general United States male population (95% CI: 2.1-2.3). Ankle osteoarthritis was directly correlated with the number of foot and ankle injuries. Players <50 years of age had a 16.1 and 13.8 times higher risk of undergoing TKA and THA, respectively, when compared to the general population. In older age groups, this trend held with retired NFL players being at least 4.3 and 4.6 times more likely than members of the general population to undergo TKA and THA, respectively. CONCLUSION: This review demonstrates that the effects of NFL-related lower extremity injuries extend beyond the players' careers and present a higher risk for early-onset osteoarthritis and overall frequency of undergoing total knee and hip arthroplasty.