Perceptions of Orthopaedic Sports Medicine Surgeons About Medical Cannabidiol Use: A Survey Study.

INTRODUCTION: Multiple studies exist identifying cannabidiol (CBD) as an effective part of an orthopaedic patient's pain regimen; however, there is a paucity of studies elucidating orthopaedic surgeons' perception of the use and prescription of CBD in the medical setting. This study surveys orthopaedic sports medicine surgeons about their previous education on and current perceptions and usage of CBD in their medical practice. METHODS: Between April 2023 and July 2023, orthopaedic sports medicine surgeons from across the country were surveyed. This survey was designed in hopes of identifying physician perceptions and current use of CBD as well as their previous education and training on its use. RESULTS: Overall, 75 orthopaedic surgeons responded. More than three-fourths of responders had not received formal education on medical CBD use, nor did they have partners or colleagues who used CBD in their practice. More than half of all surgeons believed that there is a stigma associated with CBD use. A higher proportion of surgeons from CBD legal states recommended CBD to help patients control their pain (53.7% vs. 37.5%). Less than 15% of responders believed that CBD can adversely affect surgical outcomes. Finally, four-fifths of all responders believed that CBD is easy to legally access and affordable to buy by patients who desire it. DISCUSSION: The relative novelty of CBD inclusion in medicine has led to a lack of early education and overall experience with its use among orthopaedic sports medicine surgeons. Still, surgeons believe that CBD is a safe and effective option to control pain. As surgeons continue to gain more familiarity and trust with CBD's medical uses over time, it has the potential to be a mainstay in orthopaedic multimodal pain regimens.

Current Concepts in the Business of Orthopaedics.

Practice management within orthopaedic surgery demands a multifaceted skillset including clinical expertise, technical proficiency, and business acumen, yet the latter is rarely taught during orthopaedic training. As the healthcare system evolves in the United States, surgeons continue to face challenges such as decreasing reimbursements, increased regulatory burdens, and potential for practice acquisition. To remain competitive and provide exceptional care for patients, orthopaedic surgeons must cultivate a business-minded approach. This article highlights the growing significance of the business of orthopaedics and offers guidance on ambulatory surgical center ownership models, effective management of ancillary services, the effect of private equity in orthopaedic practice, real estate investment opportunities in medical office buildings, and the importance of brand recognition. By understanding these concepts, orthopaedic surgeons can exercise greater control over their practice's finances while providing quality care for their patients.

Physician Trainees' Perception of Cannabidiol Use in Medicine: A Survey Study.

PURPOSE: Given the ongoing national opiate crisis, physicians have been challenged with mitigating the risk of opiate dependence in their patients. With current physician efforts to mitigate the risks of treating pain with opioid prescriptions, this study evaluates medical students' and residents' understanding and perceptions regarding cannabidiol (CBD) in current medical care and their future medical practice. METHODS: Orthopedic residents from all American programs and medical students from 50 medical schools, regardless of training year or future specialty plans, were eligible to participate in this survey-based study administered from December 2022 to March 2023. The surveys ask questions about demographic information, what education they receive on CBD utilization in medicine, thoughts on CBD effectiveness in pain control, and future plans on utilizing CBD. RESULTS: A total of 55 residents (1.4%) and 53 medical students (5.1%) responded. Trainees in CBD-legal states were more likely to work with physicians who use CBD in their practice. Most trainees, regardless of location, believe CBD use has a stigma attached to it. Many responders were concerned about the role of CBD in pain control. Finally, most trainees believed that CBD is easy to access if desired and is affordable to purchase. CONCLUSION: The trajectory of CBD use in the United States indicates that the therapeutic benefits of CBD will be targeted, and future physicians are not always provided adequate educational opportunities to learn about its potential medical uses. Continued training as well as interactions with patients may help decrease the stigma surrounding medical CBD use and help solidify its therapeutic use in pain control.

Arthroscopic In Situ Biceps Tenodesis Using a Double Loop-and-Tack Knotless Suture Anchor.

The long head biceps tendon is a common culprit of anterior shoulder pain and dysfunction that can be surgically treated with tenotomy or tenodesis. Many techniques exist for tenodesis. This article submits an arthroscopic technique using two loop-and-tack sutures and a knotless suture anchor to tenodese the long head biceps tendon in the proximal bicipital groove in situ. The advantage of this technique is that it maintains the biceps in its native position by performing tenodesis before tenotomy. Most other techniques attempt to restore native position of the biceps through approximation. The transverse humeral ligament is also released to decompress the bicipital groove. This technique can be used to treat isolated biceps pathology or combined with rotator cuff and labral procedures.

Biomechanical characteristics of a new looping stitch versus the classic Krackow stitch for distal biceps fixation.

Background: The purpose of this study was to quantify the biomechanical characteristics of a new looping stitch, developed with the concepts of a looping, locking stitch that decreases needle penetrations of the tendon, and compare it to a classic Krackow stitch for distal biceps suture-tendon fixation. Methods: The Krackow stitch with No. 2 braided suture and the looping stitch with a No. 2 braided suture loop attached to a 25-mm-length by 1.3-mm-width polyblend suture tape were compared. The Looping stitch was performed with single strand locking loops and wrapping suture around the tendon, resulting in half the needle penetrations through the graft compared to the Krackow stitch. Ten matched pairs of human distal biceps tendons were used. One side of each pair was randomly assigned to either the Krackow or the looping stitch, and the contralateral side was used for the other stitch. For biomechanical testing, each construct was preloaded to 5 N for 60 seconds, followed by cyclic loading to 20 N, 40 N, and 60 N for 10 cycles each, and then loaded to failure. The deformation of the suture-tendon construct, stiffness, yield load, and ultimate load were quantified. Comparisons between the Krackow and looping stitches were performed with a paired t-test using P < .05 as statistically significant. Results: The Krackow stitch and looping stitch had no significant difference in stiffness, peak deformation, or nonrecoverable deformation after 10 cycles of loading to 20 N, 40 N, and 60 N. There was no difference between the Krackow stitch and looping stitch in load applied to displacement of 1 mm, 2 mm, and 3 mm. The ultimate load showed that the looping stitch was significantly stronger compared to the Krackow stitch (Krackow stitch: 223.7 ± 50.3 N; looping stitch: 312.7 ± 53.8 N) (P = .002). The failure modes were either suture breakage or tendon cut through. For the Krakow stitch, there was 1 suture breakage and 9 tendons cut through. For the looping stitch, there were five suture breakages, and five tendons cut through. Conclusions: With fewer needle penetrations, incorporation of 100% of the tendon diameter, and a higher ultimate load to failure compared to the Krackow stitch, the Looping stitch may be a viable option to reduce deformation, failure, and cut-out of the suture-tendon construct.

Biomechanical Characterization of a New Locking Loop Stitch for Graft Fixation versus Krackow Stitch.

Background: The purpose of this study was to quantify and compare the biomechanical characteristics of a new locking loop stitch (LLS), developed utilizing the concepts of both running locking stitch and needleless stitch, to the traditional Krackow stitch. Methods: The Krackow stitch with No.2 braided suture and the LLS with 1.3-mm augmented polyblend suture tape were compared biomechanically. The LLS was performed with single strand locking loops and wrapping suture around the tendon, resulting in half the needle penetrations through the graft compared to the Krackow stitch. Twenty bovine extensor tendons were divided randomly into two groups. The tendons were prepared to match equal thickness and cross-sectional area. Each suture-tendon was stitched and preloaded to 5 N for 60 seconds, cyclically loaded to 20 N, 40 N, and 60 N for 10 cycles each, and then loaded to failure. The deformation of the suture-tendon construct, stiffness, yield load, and ultimate load were measured. Results: The LLS had significantly less deformation of the suture-tendon construct at 100 N, 200 N, 300 N, and at ultimate load compared to the Krackow stitch (Krackow stitch and LLS at 100 N: 1.3 ± 0.1 mm and 1.0 ± 0.2 mm, p < 0.001; 200 N: 3.0 ± 0.3 mm and 1.9 ± 0.2 mm, p < 0.001; 300 N: 5.1 ± 0.6 mm and 2.9 ± 0.4 mm, p < 0.001; ultimate load: 12.8 ± 2.8 mm and 5.0 ± 1.2 mm, p < 0.001). The LLS had significantly greater stiffness (Krackow stitch and LLS: 97.5 ± 6.9 N/mm and 117.2 ± 13.9 N/mm, p < 0.001) and yield load (Krackow stitch and LLS: 66.2 ± 15.9 N and 237.9 ± 93.6 N, p < 0.001) compared to the Krackow stitch. There was no significant difference in ultimate load (Krackow stitch: 450.2 ± 49.4 N; LLS: 472.6 ± 59.8 N; p = 0.290). Conclusions: The LLS had significantly smaller deformation of the suture-tendon construct compared to the Krackow stitch. The LLS may be a viable surgical alternative to the Krackow stitch for graft fixation when secure fixation is necessary.

Return to Sport After Arthroscopic Capsular Repair in Elite Baseball Players.

Background: Chronic attritional midsubstance capsular tears arising from repetitive throwing stress are a rare but important source of pain and dysfunction in elite baseball players; however, little is known regarding outcomes after arthroscopic capsular repair. Purpose: To evaluate the patient-reported outcomes and return-to-sport (RTS) rates after arthroscopic capsular repair in elite baseball players. Study Design: Case series; Level of evidence, 4. Methods: We identified 11 elite-level baseball players who were treated with arthroscopic repair for a midsubstance glenohumeral capsular tear by a single surgeon with a uniform approach and a standardized postoperative protocol between 2012 and 2019. All players had at least 2 years of follow-up data. Demographic data and concomitant surgical procedures were recorded. Preoperative and postoperative Kerlan-Jobe Orthopaedic Clinic (KJOC) scores and Single Assessment Numeric Evaluation (SANE) scores were collected in a subset of the cohort, and statistical comparisons were made. A telephone survey was conducted to determine the patients' RTS level and outcome scores. Statistical comparisons between preoperative and postoperative outcomes scores were made using t tests. Results: Eight major league players, 1 minor league player, and 2 collegiate players were included. There were 9 pitchers, 1 catcher, and 1 outfielder. All patients had debridement of the posterosuperior labrum and rotator cuff. Two pitchers underwent a rotator cuff repair, and 1 outfielder underwent a posterior labral repair. The mean age at the time of surgery was 26.9 years (range, 20-34 years), with a mean follow-up of 3.5 years (range, 2.6-5.9 years). There were significant preoperative versus postoperative improvements in the mean KJOC (20.6 vs 89.8; P = .0002) and SANE (28.3 vs 86.7; P = .001) scores. All patients reported a high degree of satisfaction. At a mean of 16.3 months (range, 6.5-25.4 months), 10 of 11 (90.1%) players met the Conway-Jobe good or excellent criteria for RTS. Conclusion: Arthroscopic capsular repair provided significant improvements in functional outcomes in elite baseball players, high levels of patient satisfaction, and high levels of RTS.

Shoulder surgeon techniques and preferences in treatment of massive rotator cuff tears: current practices for rotator cuff repair and superior capsule reconstruction.

Background: Massive rotator cuff tears can be difficult to manage and consensus regarding treatment is debated. The purpose of this questionnaire study was to examine surgeon techniques and considerations for treatment of massive rotator cuff tears including how they implement superior capsule reconstruction (SCR), when indicated. Methods: A 21-item questionnaire was sent to members of the American Shoulder and Elbow Surgeons and the American Orthopedic Society for Sports Medicine. Questions covered management preferences for massive rotator cuff tears, rotator cuff repair and SCR techniques, beliefs about SCR, implant choices, use of augments, demographics, and patient management scenarios. Results: The questionnaire had 230 respondents. In rotator cuff repair of massive rotator cuff tears, preferred responses were long head biceps tendon preservation (when asymptomatic, 45.3%), routine subacromial decompression (62.1%), solid threaded anchors (71.1%), double row configuration (65.1%), and bone marrow stimulation of the footprint (55.6%). For providers that perform SCR (n = 166), preferred strategies included long head biceps tenodesis (55.4%), human dermal allograft tissue (93.2%), glenoid fixation with 3 implants (71.2%) using solid threaded anchors (42.3%), and humeral fixation with 2 solid threaded anchors medially (71.0%), and 2 solid threaded anchors laterally (46.9%). Other highly recommended strategies were side-to-side repair to the posterior rotator cuff if able (97.6%) and to use the thickest graft available (62.2%). Conclusion: Despite improved techniques and growing interest in SCR, many questions still remain. This study identifies the significant variability in repair constructs and methodology with SCR; further investigation into these variables could be analyzed to identify best practice guidelines.

Understanding Batter's Shoulder: Diagnosis, Treatment, and Outcomes.

PURPOSE OF REVIEW: Though most of the attention in recent literature on baseball injuries has been paid to throwers, one often overlooked aspect of the game is the effect of the batter's swing on the shoulder. It is well known that the batter's lead shoulder can experience significant translational forces during the player's swing, and that these are increased following a missed swing. The purpose of this paper is to review the background and pathophysiology as well as clinical presentation and treatment of players with Batter's shoulder. RECENT FINDINGS: Recent studies demonstrate that while nonoperative treatment of Batter's shoulder is still a viable first line of treatment, favorable outcomes have been reported with arthroscopic posterior labral repair for high level athletes. Batter's injury can cause significant pain and dysfunction in baseball hitters, especially during the follow through phase of swing. While conservative care can be attempted early, outcomes following arthroscopic posterior labral repair are favorable with a high rate of return to play.

Suture Tape Augmentation Increases the Time-Zero Stiffness and Strength of Anterior Cruciate Ligament Grafts: A Cadaveric Study.

Purpose: To determine the postsurgical strength and stiffness of anterior cruciate ligament (ACL) reconstructions with (ACLR-SA) and without suture tape augmentation (ACLR) in a human cadaveric model. Methods: Eight matched pairs of cadaveric knees were tested intact and after bone-patellar tendon-bone ACL reconstruction. Specimens were potted and loaded onto a mechanical testing system, and an anterior drawer force of 88N was applied at 0°, 15°, 30°, 60°, and 90° of flexion. Specimens were then loaded to failure, with clinical failure defined as anterior translation greater than 10 mm. Results: ACL-intact knees translated an average of 4.99 ± 0.28 mm across all flexion angles when an 88N anterior load was applied. ACLR knees had significantly greater translation compared to intact specimens. ACLRs with suture augmentation had less of an increase (0.67 mm, 95% confidence interval [CI]: 0.20, 1.14, P < .01) than those without suture augmentation (1.42 mm, 95% CI: 0.95, 1.89, P < .001). ACLR-SA required greater anterior load (170.4 ± 38.1 N) to reach clinical failure compared to ACLR alone (141.8 ± 51.2 N), P = .042. In addition, stiffness of ACLR-SA constructs (23.5 ± 3.3) were significantly greater than ACLR alone (20.3 ± 3.9), P = .003. Conclusion: Augmentation of ACLR with suture tape allowed full range of motion with improved graft stiffness and increased failure load compared to unaugmented ACLR in this time-zero study. Clinical Relevance: Internal bracing may help reinforce ACLR grafts and allow for acceleration of rehabilitation protocols and earlier return to activity.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction With and Without Suture Augmentation.

BACKGROUND: A common concern associated with elbow ulnar collateral ligament (UCL) reconstruction is the amount of time required for recovery and rehabilitation. For example, for Major League Baseball pitchers, the average time to return to competition ranges from 13.8 to 20.5 months. Suture tape augmentation has shown the ability to provide additional soft tissue stability across other joints in the body. By providing an additional checkrein to the UCL reconstruction while the graft is healing, it may be possible to accelerate the rehabilitation process in overhead athletes and thus effect a quicker return to sports. PURPOSE: To compare elbow valgus stability and load to failure between UCL reconstruction with and without suture tape augmentation. STUDY DESIGN: Controlled laboratory study. METHODS: Fresh-frozen cadaveric elbows (N = 24) were dissected to expose the UCL. Medial elbow stability was tested with the UCL intact, deficient, and reconstructed utilizing the 3-strand docking technique with or without suture augmentation. A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion-tracking cameras as the elbow was cycled through a full range of motion. After kinematic testing, reconstructed specimens were loaded to failure at 70° of elbow flexion. RESULTS: UCL-deficient elbows demonstrated significantly greater valgus rotation when compared with intact and internally braced reconstructed elbows at every angle of flexion tested and when compared with unbraced UCL-reconstructed elbows at 50° to 120° of flexion (P < .05). There were no significant differences between intact and UCL-reconstructed elbows with and without suture augmentation at any flexion angle tested. When loaded to failure, unbraced reconstructed elbows failed at a significantly lower torque as compared with elbows with UCL reconstruction with suture tape augmentation (P < .01). CONCLUSION: In this cadaveric model, 3-strand UCL reconstruction with suture augmentation did not overconstrain the elbow throughout all flexion angles when compared with the native state and UCL reconstruction alone, while providing greater load to failure. CLINICAL RELEVANCE: Suture tape augmentation may provide the additional strength necessary to accelerate rehabilitation after UCL reconstruction.

Rotator Cuff Repair Using Coracoacromial Ligament Autograft for Supraspinatus Footprint Augmentation.

Failure of rotator cuff repair can be a disastrous clinical outcome. Although failure is a multifactorial issue, recent interest has piqued in understanding the biology of the insertional components of the supraspinatus and infraspinatus at the footprint. When the torn tendon is of poor quality, especially if it is diminutive or thin, rotator cuff repair augmentation should be considered to aid in long-term healing. Various allograft options have been described in the past, and more recently, xenografts and synthetics have become more commonly used. The use of autografts in the treatment of insertional footprint deficiency has great potential; however, few grafts have been described. This study describes the surgical technique for footprint augmentation in arthroscopic supraspinatus repair using harvested autologous coracoacromial ligament tissue.

The Impact of COVID-19 on Orthopedic Surgery Fellowship Training: A Survey of Fellowship Program Directors.

Background: The COVID-19 pandemic has had a wide-reaching impact. Graduate medical education of orthopedic surgeons was not spared from the jarring changes. Purpose: We sought to survey fellowship program directors in the field of orthopedic surgery about how the COVID-19 pandemic affected the education of the 2019 to 2020 and 2020 to 2021 fellowship classes and the future of their programs. Methods: In October 2020, an 18-item survey was distributed by an official of the American Academy of Orthopedic Surgeons (AAOS) to the specialty societies that govern fellowship training. Each specialty society then distributed the survey to its respective program directors. A reminder email was sent during the enrollment period. Each respondent was able to complete the survey once. Survey questions were grouped into 3 sections: general information about the fellowship training programs, the impact of COVID-19 on the 2019 to 2020 fellowship class, and the future impact of COVID-19 on the fellowship training programs. Results: Of the 564 accredited orthopedic surgery fellowship programs in the United States, 190 directors responded. Of these, 73.59% reported COVID-19 had a negative impact on the 2019 to 2020 fellowship class. A normal distribution of responses was found regarding didactic and academic learning, research, and mentorship opportunities. A majority of respondents said they believe that there will be no negative impact on patient care the fellows provide in the years to come. Conclusion: Orthopedic surgery fellowship program directors acknowledged that while there were negative effects to training in the pandemic, they did not think these would negatively affect patient care provided by 2019 to 2020 fellows in the short and medium term. They also reported positive outcomes from the experience of the pandemic, including new ways to educate fellows.

Epidemiologic impact of COVID-19 on a multi-subspecialty orthopaedic practice.

The purpose of this study is to report the change in surgical case volume and composition encountered by a multi-subspecialty orthopaedic practice due to COVID-19. We reviewed electronic medical records for patients who had surgery at our institution and collected multiple variables including age and the joint that was operated on. In the post-COVID-19 period, we found a significant increase in the percentage of hip procedures, and a significant decrease in the percentage of hand/wrist procedures. Overall, the total surgical volume of our multi-subspecialty orthopaedic practice decreased due to the COVID-19 pandemic, and the composition of surgical cases changed.

Effect of Patient Height and Sex on the Patellar Tendon and Anterior Cruciate Ligament.

BACKGROUND: Graft-tunnel mismatch is an avoidable complication in anterior cruciate ligament (ACL) reconstruction. Patient height and sex may be predictors of patellar tendon length (PTL) and intra-articular ACL length (IAL). Understanding these relationships may assist in reducing graft-tunnel mismatch during ACL reconstruction with bone-patellar tendon-bone (BTB) autograft. PURPOSE: To determine the association of patient height and sex with PTL and IAL. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Magnetic resonance imaging (MRI) studies were obtained on the healthy knees of 100 male and 100 female patients. Patients with prior surgery, open physes, significant degenerative changes, ACL rupture, or extensor mechanism injury were excluded. Three independent readers measured PTL, IAL, and Caton-Deschamps Index (CDI) on MRI. Bivariate and linear regression analysis was performed to detect the association of anthropometric data with anatomic parameters measured on MRI studies. RESULTS: The mean age and body mass index were not significantly different between the male and female patients; however, male patients were significantly taller than female patients (1.75 vs 1.72 m, respectively; P < .001). There was a substantial agreement between the 3 readers for all parameters (κ > 0.75). Overall, female patients had significantly longer PTL (47.38 vs 43.92 mm), higher CDI (1.146 vs 1.071), and shorter IAL (33.05 vs 34.39 mm) (P < .001 for all). Results of the linear regression analysis demonstrated that both height and female sex were predictive of longer PTL. Further, height was independently predictive of IAL but sex was not. CONCLUSION: PTL was correlated more with patient sex than height. IAL was also correlated with patient sex. Longer BTB grafts are expected to be harvested in female patients compared with male patients of the same height despite shorter IAL. These associations should be considered during BTB ACL reconstruction to minimize graft-tunnel mismatch.

Anterior cruciate ligament reconstruction femoral tunnel drilling preference among orthopaedic surgeons.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) technique for femoral tunnel drilling varies substantially, each with advantages and disadvantages. The purpose of this study was to define ACLR femoral tunnel technique predilection among surgeons and to explore factors associated with their preference. METHODS: An 11-question survey regarding ACLR femoral tunnel technique was completed by 560 AANA/AOSSM members. Surgeon and practice demographics and residency and fellowship experiences were evaluated with bivariate and multivariable models for association with surgeon preference. RESULTS: In current practice, 55% of surgeons prefer anteromedial (AM) portal drilling, 32% retrograde, and 14% transtibial (TT). Sports Medicine fellowship experience was the strongest predictor of current practice (p < 0.001), followed by residency technique (p = 0.014). A significant increase in TT drilling was noted for those practicing >15 years TT (29% vs 3%, p < 0.001), with an inverse relationship for retrograde drilling (38% vs 21%, p < 0.001). Number of ACLRs/year and percent Sports specific practice were significant predictors for AM drilling (p < 0.001). Though less than AM and retrograde, TT was more common for those in private practice (17% vs 8%, p < 0.001), and more prevalent in the Midwest/Southeast (19% vs 10%, p = 0.003). Non-significant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and Certificate of Added Qualifications status. CONCLUSION: Surgeon training, practice setting, and years in practice significantly predict preference for femoral tunnel drilling technique. Surgeon comfort and confidence in attaining an anatomic reconstruction should drive choice of technique.

A method for calculating the fragility index of continuous outcomes.

OBJECTIVE: Clinicians' overdependence on p-values to determine significance in clinical trials is common yet potentially misleading. The Fragility Index (FI) describes how robust a significant result is by determining the number of events the statistical significance hinges on. However, this concept cannot be applied to nondichotomous variables. We describe a method to calculate a Continuous Fragility Index (CFI) for continuous variables. We further provide a method to estimate CFI when original data is not available. STUDY DESIGN AND SETTING: An iterative substitution algorithm is described to calculate CFI prospectively from data or retrospectively from summary statistics and its response to variations in the data is reported. We then apply this method to a previously published review as a proof-of-concept. RESULTS: The CFI increases linearly with sample size, logarithmically with mean difference, and decreases exponentially with standard deviation. Forty-eight studies were included of which 30 had significant non-dichotomous outcomes. CFI and FI were uncorrelated and mean CFI was significantly higher than FI (9 vs. 2, P< 0.001). CONCLUSION: Our algorithm extends fragility to continuous outcomes, expanding the applications of the fragility concept. The fragility of outcomes within a single study may vary based on variable type and should be evaluated independently.

Anterior Cruciate Ligament Reconstruction Graft Preference Most Dependent on Patient Age: A Survey of United States Surgeons.

PURPOSE: The purpose of this study was to define the anterior cruciate ligament (ACL) reconstruction (ACLR) graft preference of surgeons and to explore factors associated with their predilection. METHODS: A 15-question survey regarding ACLR graft preference in various situations was completed by 514 American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America surgeons. Surgeon and practice demographics, along with various patient factors, were evaluated with bivariate and multivariable models for association with surgeon preference. Surgeons were also queried about their preference for their own ACLR. For surgeons who personally sustained an ACL, an additional 6 questions inquired about their experience. RESULTS: Surgeons reported the 5 most important factors in patient graft choice, in order: patient age, graft failure in literature and practice, pivot sport, and patient preference. Autograft patellar and quadriceps tendon were strongly preferred for younger, pivoting athletes (P < .001), among those with fellowship training (47% vs 33%, P = .006), in academic practices (52% vs 44%, P = .003), and in more sports medicine-specific practices, with a higher number of ACLRs performed per year (P < .001). Northeast, Southeast, Midwest, and Southwest surgeons had lower hamstring autograft preference (P < .001). Non-fellowship-trained surgeons preferred hamstring autograft (P = .010). Allograft was preferred for older patients (P < .001). Nonsignificant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and years in practice. No factors were associated with surgeon preference for their own ACLR despite deeming these factors important for patients. ACL tears were reported by 13% of respondents, with 86% stating it influenced their decision to enter orthopaedics. CONCLUSIONS: Patient age was the most important factor in graft choice, with patellar and quadriceps tendon autograft the preferred graft for ACLR for younger, pivoting athletes. Fellowship training and practice demographics were also correlated with graft choice for patients. CLINICAL RELEVANCE: Graft preference for ACLR varies among surgeons and is associated with surgeon experience and patient characteristics, including patient age, type of sport, and patient preference.

Ulnar Collateral Ligament Repair of the Elbow-Biomechanics, Indications, and Outcomes.

PURPOSE OF REVIEW: Traditionally medial elbow injuries in overhead athletes have been treated with ulnar collateral ligament (UCL) reconstruction as first described by Dr. Frank Jobe. Recent literature has shown favorable outcomes in select patients treated with UCL repair. Newer techniques utilizing suture augmentation demonstrate biomechanical profiles as good or better than the native state and/or reconstruction. This review aims to evaluate these biomechanical studies and the clinical outcomes of ulnar collateral ligament repair with suture augmentation. RECENT FINDINGS: UCL repair has favorable outcomes in select patients with specific tear type patterns. Clinical outcomes have shown return to play rates of 92-97% with mean time of 2.5-6 months post-operatively. Biomechanical data comparing UCL repair to reconstruction techniques have shown improved resistance to common forces applied to the elbow during overhead activities. Additionally, suture tape augmentation dramatically improves stability of ligament repair without over-constraining the elbow. Initial ulnar collateral ligament repair data was poor, and thus UCL reconstruction became the mainstay of treatment for overhead athletes. Recent studies evaluating the biomechanical properties as well as clinical outcomes have demonstrated favorable data when UCL repair is performed. When considering the drawbacks of a prolonged recovery associated with reconstruction, UCL repair is a viable option in select patients.

Biomechanical Comparison of UCL Repair Using Suspensory Fixation Versus UCL Reconstruction.

BACKGROUND: Medial ulnar collateral ligament (mUCL) repair is growing in popularity as a treatment for younger athletes with mUCL tears. One of the most recent techniques utilizes a collagen-coated suture tape to augment the repair. The most popular repair technique uses a screw for proximal fixation in the humerus. We present an alternative technique that uses suspensory fixation in the proximal humerus. PURPOSE: To biomechanically compare elbow valgus stability and load to failure of a novel alternative repair technique with suspensory fixation to an mUCL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Eighteen fresh-frozen cadaveric elbows were dissected to expose the mUCL. Medial elbow stability was tested with the mUCL in an intact, deficient-either repaired or reconstructed-state. The repair technique used a suspensory fixation with suture augmentation, and the docking technique was used on all reconstructions. A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion tracking cameras as the elbow was cycled through a full range of motion. After kinematic testing, specimens were loaded to failure at 70° of elbow flexion. RESULTS: Both ulnar collateral ligament reconstruction and repair restored valgus stability to levels that were not statistically different from intact at all angles of flexion. There was no significant difference in the ultimate torque to failure between repaired and reconstructed mUCLs. CONCLUSION: There was no significant difference in the valgus strength between the mUCL repair with suspensory fixation and the mUCL reconstruction. CLINICAL RELEVANCE: Suspensory fixation is an alternative method for proximal fixation in the mUCL without compromising the strength of the construct.