Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review.

OBJECTIVE: To examine the current evidence regarding return-to-play (RTP) and performance after Achilles tendon rupture in elite athletes treated with operative intervention. DESIGN: Scoping review. DATA SOURCES: Published sources identified through a PubMed search of elite athletes, defined as professional or division one collegiate athletes in baseball, basketball, American football or soccer. METHODS: Our search yielded a total of 2402 studies, with 13 studies fulfilling the study criteria of reporting elite athletes with objective measures of their athletic performance. A total of 709 elite athletes were included from the NBA, NFL, Major League Baseball (MLB), National Collegiate Athletic Association (NCAA) football and professional soccer. RESULTS AND DISCUSSION: Overall, 61%-100% of elite male athletes RTP after Achilles tendon rupture and operative repair. NBA players had inferior performance compared with their preoperative status as well as controls of non-injured players. Studies did not show significantly different performance after Achilles injury for MLB players. Professional soccer, NFL and NCAA football studies reported varying performance after injury. CONCLUSIONS: Evidence suggests that sports with explosive plantarflexion demands, such as basketball, may be associated with a greater decrease in performance despite operative intervention after Achilles rupture.

Revision ulnar collateral ligament reconstruction in Major League Baseball pitchers: effects of fastball velocity and usage.

BACKGROUND: Ulnar collateral ligament (UCL) tears are prevalent in Major League Baseball (MLB) pitchers and can cause significant loss of time with varying reports of impact on performance. Revision UCL reconstruction (UCLR) is becoming increasingly common, with little known about the effects on fastball (FB) velocity and usage (FB%) in this setting. HYPOTHESIS/PURPOSE: The purpose was to evaluate the effect of revision UCLR on MLB pitchers with respect to postoperative FB velocity and FB% at 1 and 2 years after return to play. The hypothesis was postoperative FB velocity and FB% would significantly decrease vs. prerevision levels, and that revision UCLRs would result in significantly decreased FB velocity and FB% in comparison to a matched group of MLB pitchers after primary UCLR. METHODS: Twenty-one pitchers who underwent revision UCLR and returned to MLB play were identified from public records from 2008-2021. The PITCHf(x) system collected FB velocity for 4-seam (4FB) and 2-seam (2FB) fastballs and total FB% for pitchers in the prerevision year as well as the 2 years after return. A matched control group of pitchers who underwent primary UCLR was used for comparison. RESULTS: There were no significant differences in FB velocity between prerevision levels (4FB 92.9 mph, 2FB 91.4 mph) and years 1 (4FB 92.5 mph, 2FB 91.2 mph) and 2 (4FB 93.4 mph, 2FB 91.1 mph) after revision UCLR. FB% decreased from the prerevision season (60.1) and the first (56.2, P = .036) and second years (52.5, P = .002) after return. There were no significant differences between FB velocity and FB% or between the revision and primary UCLR groups. CONCLUSION: Pitchers returning to the MLB level after revision UCLR can expect similar FB velocity to their prerevision FB velocity and to pitchers undergoing primary UCLR; however, they do demonstrate a decrease in FB%, which may suggest less confidence in their FB after RTP.

Short versus long cephalomedullary nailing of intertrochanteric fractures: a meta-analysis of 3208 patients.

OBJECTIVES: The purpose of the study was to compare treatment outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures. DATA SOURCES: A systematic review of perioperative outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures was performed. The following databases were used: using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019). The queries were performed in June 2019. STUDY SELECTION: The following search term query was used: "Intramedullary Nail AND Intertrochanteric Fracture OR "Long OR Short Nail AND intertrochanteric Fracture." Studies were excluded if they were "single-arm" studies (i.e., reporting on either long or short CMN but not both), or did not report at least one of the outcomes being meta-analyzed. Furthermore, cadaveric studies, animal studies, basic science articles, editorial articles, surveys and studies were excluded. DATA EXTRACTION: Two investigators independently reviewed abstracts from all identified articles. Full-text articles were obtained for review if necessary, to allow further assessment of inclusion and exclusion criteria. Additionally, all references from the included studies were reviewed and reconciled to verify that no relevant articles were missing from the systematic review. DATA SYNTHESIS: Short nails were associated with statistically significantly less estimated blood loss and operative time compared to long nails. There were no significant differences in transfusion rates, implant failures or overall re-operation rates between implant lengths. Similarly, there was no significant difference in peri-implant fracture between implant lengths. CONCLUSIONS: Overall, the available clinical evidence supports the use of short cephalomedullary nails for the majority of intertrochanteric femur fractures. STUDY DESIGN/LEVEL OF EVIDENCE: Meta-analysis; Level III, therapeutic.

Systematic Review of the Anatomic Descriptions of the Glenohumeral Ligaments: A Call for Further Quantitative Studies.

PURPOSE: To perform a systematic review of the glenohumeral ligament anatomic attachments on the glenoid and humeral neck. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase from 1980 to present. The inclusion criteria were as follows: cadaveric or clinical anatomic studies that qualitatively or quantitatively described the glenoid and humeral attachments of the glenohumeral ligaments in the English-language literature. Imaging and animal studies, editorial articles, and surveys were excluded from this study. RESULTS: The 15 included studies analyzed a total of 983 shoulders. Only 5 studies reported quantitative measurements. The most common glenoid superior glenohumeral ligament attachment described was in the anterolateral region of the supraglenoid tubercle and was inserting on the humerus in close vicinity to the subscapularis tendon insertion. The superior labrum and lesser tuberosity were the most commonly reported middle glenohumeral ligament attachments. The inferior glenohumeral ligament was most commonly described to attach between the 2- and 4-o'clock positions of the glenoid and distally near the surgical neck of the humerus. CONCLUSIONS: There were limited quantitative data on the attachments of the glenohumeral ligaments. Although the literature was discordant, the most common descriptions of the attachments were as follows: The anterolateral region of the supraglenoid tubercle, the superior labrum, and the glenoid (between the 2- and 4-o'clock positions) were the medial attachments for the superior glenohumeral ligament, middle glenohumeral ligament, and inferior glenohumeral ligament, respectively. Laterally, they inserted on the humerus in close vicinity to the subscapularis tendon insertion, on the lesser tuberosity, and near the surgical neck of the humerus, respectively. CLINICAL RELEVANCE: The glenohumeral ligaments are important anatomic structures contributing to the dynamic stability of the glenohumeral joint. Further detailed quantitative descriptions of their attachments are required for truly anatomically based repairs.

Editorial Commentary: Double Bundle the Coracoclavicular Ligaments for Success: The More the Better?

Injuries to the acromioclavicular joint are common across all levels of sport and activity. Overall, a consensus exists regarding Rockwood grade I and II injuries (conservative approach) and Rockwood grades IV to VI (best treated surgically). However, grade III injuries are heterogeneous and thus respond differently to nonoperative and operative treatment. Regardless of the acromioclavicular injury grade, these are widely prevalent injuries, and there is a lack a consensus as to which operative fixation methods yield the best outcomes for patients. Although K-wires and plates were historically used to achieve rigid fixation, recent evidence supports the use of soft tissue grafts to reconstruct the coracoclavicular ligaments and restore vertical and anteroposterior and rotational stability with a more biological approach.

Acromioclavicular and Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Instability: A Systematic Review of Clinical and Radiographic Outcomes.

PURPOSE: To perform a systematic review of the available literature on clinical and radiographic outcomes after surgical treatment for acromioclavicular (AC) joint instability. METHODS: A systematic review was performed according to PRISMA guidelines. Inclusion criteria were AC joint and coracoclavicular (CC) ligament reconstruction outcomes, English language, human studies, more than 10 patients in the study and a 2-year minimum follow-up. Exclusion criteria were animal studies, cadaveric studies, clinical studies without reported follow-up period or patient-reported outcomes, clinical studies of nonoperative treatment, AC reconstructions with concurrent lateral clavicle fracture, editorial articles, abstracts, presentations, reviews, case reports, and surveys. RESULTS: The systematic review identified 34 studies (939 patients) after inclusion and exclusion criteria application. Postoperative American Shoulder and Elbow Surgeons (ASES) scores ranged from 93.8 to 96, 81.8 to 97.8, and 88.1 for free tendon graft, suspensory devices, and modified Weaver-Dunn techniques, respectively. Postoperative Constant scores were 76.4 to 96.0, 82.6 to 97.8, 85.9 to 97.0, 81 to 96 and 83.0 to 94.6 for free tendon graft, suspensory devices, synthetic ligament devices, modified Weaver-Dunn, and hook plate/K-wires techniques, respectively. All treatment modalities improved patient outcomes; however, hook plates and K-wires had the highest rate of complications (26.3%). Unplanned reoperation rates were 1.2%, 2.8%, 0.9%, 5.4%, and 2.6% in free tendon graft, suspensory devices, synthetic ligament devices, modified Weaver-Dunn, and hook plate/K-wires techniques, respectively. CONCLUSIONS: Comparable subjective outcomes after surgical treatment of AC joint instability was reported for all modalities, with relatively low unplanned reoperation rates. Treatment with hook plate/K-wires was associated with the highest complication rates, and modified Weaver-Dunn had the highest unplanned reoperation rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Increased Accuracy of Varus Stress Radiographs Versus Magnetic Resonance Imaging in Diagnosing Fibular Collateral Ligament Grade III Tears.

PURPOSE: To evaluate the diagnostic accuracy of magnetic resonance imaging and varus stress radiographs for fibular collateral ligament (FCL) tears, and compare these modalities to intraoperative findings. METHODS: All patients who underwent an isolated FCL or combined anterior cruciate ligament (ACL)/FCL reconstruction by a single surgeon between 2010 and 2017 with preoperative varus stress radiographs and magnetic resonance imaging (MRI) were included in this study. A control group was composed of patients with an MRI and intact ACL and FCL. Sensitivity and specificity of diagnosing FCL injuries on MRI were determined based on review by a fellowship-trained musculoskeletal radiologist, blinded to the pathology associated with each patient (FCL injury vs control), and compared with the gold standard of examination under anesthesia, followed by surgical confirmation of an FCL tear at the time of FCL reconstruction. The sensitivity of diagnosing an FCL injury based on varus stress radiographs was also determined. Furthermore, the ability of both imaging modalities to identify an FCL injury was stratified based on acute versus chronic etiology. RESULTS: A total of 232 patients were included: 98 patients in the FCL tear group (mean age: 33.6 ± 12.2 years) and 134 patients in the control group (mean age: 44.0 ± 17.2 years). Varus stress radiographs were determined to be more sensitive in diagnosing FCL injuries compared with MRI, with an overall sensitivity of 70% compared with 66%, respectively. Based on MRI, overall specificity was 68%. Based on chronicity of the injuries, MRI was more accurate for detecting acute FCL injuries than chronic injuries (P = .002), and varus stress radiographs were more accurate for detecting chronic FCL injuries than acute injuries (P = .041). CONCLUSIONS: The results support the use of both varus stress radiographs and MRI in diagnosing FCL injuries, because MRI is more sensitive in diagnosing an acute FCL tear, and varus stress radiographs are more sensitive in diagnosing a chronic FCL tear. Both imaging modalities are recommended to diagnose both acute and chronic FCL injuries. LEVEL OF EVIDENCE: Level II, case-control study.

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

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

Primary Versus Revision Anterior Cruciate Ligament Reconstruction: Patient Demographics, Radiographic Findings, and Associated Lesions.

PURPOSE: The purpose of this study was to evaluate the differences in intra-articular pathology, demographic characteristics, and radiographic characteristics of the knee associated with primary anterior cruciate ligament reconstruction (ACLR) versus revision ACLR at the time of initial presentation with either a native anterior cruciate ligament tear or an anterior cruciate ligament graft tear. Secondarily, we aimed to investigate risk factors for concomitant medial and lateral meniscal tears and cartilage injuries at the time of ACLR. METHODS: This was a retrospective review of patients who underwent primary or revision ACLR by a single surgeon. The exclusion criteria were as follows: skeletally immature patients; patients with an intra-articular fracture; patients with an ipsilateral knee infection; or patients who underwent an osteotomy, cartilage restoration procedure, or meniscal transplantation either previously or concomitantly with the ACLR. Detailed patient demographic data, radiographic long-standing alignment, tibial slope, and intraoperative findings including articular cartilage injury grade and meniscus integrity were documented at surgery. RESULTS: There were 487 patients included in this study (363 with primary ACLR and 124 with revision ACLR). There were no significant differences in age (P = .119), sex (P = .917), body mass index (P = .468), allograft versus autograft reconstruction (P = .916), or prevalence of meniscal tears (P = .142) between the primary and revision groups. Patients who underwent revision ACLR had a significantly increased medial tibial slope (P = .048) and a higher prevalence of chondral defects on both the medial (P < .001) and lateral (P = .003) femoral condyles when compared with primary ACLR patients. Logistic regression showed that a decreased tibial slope was correlated with femoral medial-sided chondral injuries and that varus or valgus coronal-plane malalignment was correlated with lateral meniscal tears in both groups. CONCLUSIONS: The findings of this study show that patients undergoing a revision ACLR have significantly more chondral lesions, as well as higher-grade chondral lesions, at the time of presentation. Furthermore, coronal malalignment and a decreased tibial slope may contribute to injury patterns of the lateral meniscus and medial compartment cartilage, respectively. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

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

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

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

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

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

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

Midterm outcomes following anatomic-based popliteus tendon reconstructions.

PURPOSE: The purpose of this study was to document subjective outcomes following anatomic-based reconstruction of the popliteus tendon when the popliteus tendon was the only injured posterolateral knee structure. It was hypothesized that popliteus tendon reconstruction would result in improved patient outcomes after surgery regardless of the concurrent ligamentous or intra articular pathology. METHODS: A consecutive series of 5 patients with a median age of 23 years (range, 22-36 years) who underwent anatomic popliteus tendon reconstruction along with concomitant ligament reconstruction or meniscus repair (if needed) were included in this study. All patients completed pre-operative and post-operative subjective questionnaires, which included the Lysholm score to document function, the Tegner activity scale to document activity level, and a patient satisfaction with outcome question. RESULTS: All patients were available for a final follow-up at a median time of 2.8 years (range, 2-3.9 years) following the index surgery. Three patients had a combined popliteus tendon and posterior cruciate ligament reconstruction. Two of the three PCL reconstructions were revision procedures. The Lysholm score improved to from 53 (range, 34-90) to 91 (range, 44-100) at post-operative follow-up. The median pre-operative Tegner activity scale improved from 3 (range, 0-9) to a median score of 4.8 (range, 2-7) at post-operative follow-up. The median patient satisfaction with outcome was 9 (range, 7-10). The dial test at 30° and 90° improved in all patients following surgery. CONCLUSIONS: Anatomic-based popliteus tendon reconstructions resulted in improved outcomes and a high patient satisfaction in patients with a complete tear of the popliteus tendon and symptomatic knee instability. LEVEL OF EVIDENCE: IV, case series.

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

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

Medial Patellar Instability: A Systematic Review of the Literature of Outcomes After Surgical Treatment.

PURPOSE: To perform a systematic review of literature reporting on outcomes after surgical treatment of medial patellar instability. METHODS: A systematic review was performed according to PRISMA guidelines. Inclusion criteria were as follows: the outcomes and complications of medial patellar instability repair with a follow-up greater than 12 months, English language, and human studies. We excluded cadaveric studies, animal studies, basic science articles, editorial articles, review articles, and surveys. RESULTS: Searches identified 1,116 individual titles. After inclusion and exclusion criteria were applied, a total of 8 studies were identified. Three studies exclusively included patients with previous lateral release; 1 included patients with chronic instability; 1 included patients with both previous lateral release and other surgical causes; 1 study had patients with previous lateral release, spontaneous instability, and instability due to injury; 1 study included patients after tibial tubercle transfer surgery; and 1 study did not report the etiology of instability. CONCLUSIONS: Good to excellent outcomes were reported postoperatively in 85% of the patients after surgical treatment of medial patellar instability. However, clinical outcomes data for medial patellar ligament reconstruction is sparse and highly heterogeneous. There is inconsistency in the literature in regard to the indication, timing, and procedure. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Anterolateral Ligament Reconstruction Techniques, Biomechanics, and Clinical Outcomes: A Systematic Review.

PURPOSE: To perform a systematic review of the described anterolateral ligament (ALL) reconstruction techniques, biomechanical performance, and clinical outcomes of ALL reconstruction in the setting of concurrent anterior cruciate ligament (ACL) reconstruction. METHODS: A systematic review was performed according to PRISMA guidelines using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase, from 1980 to present. Inclusion criteria were as follows: ALL reconstruction techniques, ALL reconstruction biomechanical studies, ALL surgical outcomes, English language, human studies with at least 2 years of follow-up, and cadaveric studies. Exclusion criteria were lateral extra-articular tenodesis, ALL anatomic studies, ALL radiographic studies, animal studies, clinical studies with <2 years of follow-up, editorial articles, and surveys. RESULTS: The systematic review identified 12 articles that met the inclusion criteria: 6 techniques, 5 biomechanical studies, and 1 outcome study were available. Five studies described ALL reconstruction in the setting of ACL reconstruction, whereas 1 study described isolated ALL reconstruction. Femoral tunnel location was most commonly placed posterior and proximal to the lateral epicondyle, whereas 2 studies reported a distal tunnel location. There was little variability in tibial tunnel location. The most common ALL reconstruction graft used was the gracilis tendon. Review of the biomechanical studies revealed internal rotation overconstraint with the posterior/proximal femoral tunnel position but not anterior/distal, although fixation angle and graft tension were inconsistent. Only 1 clinical study with 2 years' follow-up was available and reported improvement in the majority of cases. Complications occurred in 15 patients, including a residual pivot shift in 8% of patients at 2 years after a combined ACL and ALL reconstruction. CONCLUSIONS: There is inconsistency in the selection of ALL graft femoral attachment location as well as in the biomechanical performance of ALL reconstruction techniques. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

The Heel Height Test: A Novel Tool for the Detection of Combined Anterior Cruciate Ligament and Fibular Collateral Ligament Tears.

PURPOSE: To determine the exact value of side-to-side difference (SSD) in heel height that was associated with combined anterior cruciate ligament (ACL) and fibular collateral ligament (FCL) tears (compared with an isolated ACL tear) and determine the clinical utility of heel height SSD in the assessment of this injury pattern. METHODS: Two patient groups were identified: (1) patients with isolated ACL tears and (2) patients with combined ACL-FCL tears but without additional collateral or cruciate ligament injuries. Determination of the amount of the heel height SSD was determined during the outpatient clinic visit. Receiver operator characteristic curves were used to evaluate the accuracy of diagnostic tests by plotting the true-positive (sensitivity) rate against the false-positive (1-specificity) rate at various thresholds. In addition, magnetic resonance imaging (MRI) reports were reviewed to calculate the sensitivity of MRI for the detection of FCL injury. MRI sensitivity was then compared with the sensitivity of the heel height examination. RESULTS: One hundred and fifty-eight patients (71 men, 87 women) in the isolated ACL tear patient group and 117 patients (60 men, 57 women) in the combined ACL-FCL tear patient group were reviewed. A 3-cm or greater SSD was found in 13 of the 158 (8.2%) isolated ACL tear patients and 84 of the 117 (72%) ACL-FCL tear patients. The sensitivity, specificity, positive predictive value, and negative predictive value of the heel height test were 72%, 92%, 86%, and 86%, respectively. The area under the receiver operator characteristic curve was found to be 0.876. After review of all preoperative MRI musculoskeletal radiology reports for patients in the ACL-FCL patient group, a sensitivity of 48% was found. CONCLUSIONS: The clinical heel height test resulted in high sensitivity and excellent specificity for the diagnosis of combined ACL-FCL tears compared with the sensitivity and specificity of the MRI detection of FCL injury. The information presented in the current study will improve diagnostic ability through a simple physical examination and avoid missed injuries that are known to compromise surgical outcomes. LEVEL OF EVIDENCE: Level III, cross-sectional.

Iatrogenic Trochlear Chondral Defects After Anterolateral Placement of Retrograde Femoral Nails.

Femoral shaft fractures are common injuries with an incidence of 37.1 per 100,000 person-years in the United States. Retrograde femoral nailing is an increasingly used treatment strategy to manage these injuries, particularly in fractures below stemmed hip prostheses, in supracondylar or distal femur fractures, in fractures in pregnant or obese patients, and when concomitant ipsilateral acetabular/pelvic ring fractures are present. Retrograde fixation has been shown to be a viable option with union rates comparable to antegrade intramedullary nailing. Despite having excellent results in the treatment of femoral fractures, retrograde femoral nails have been associated with iatrogenic patellofemoral chondral damage that may occur because of malpositioning of the intramedullary nail at the entry point. The objective of this case report is to describe 2 patients who suffered iatrogenic trochlear chondral defects after retrograde femoral nailing and subsequently underwent osteoarticular allograft transplantation surgery.

Single-Bundle and Double-Bundle Posterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-analysis of 441 Patients at a Minimum 2 Years' Follow-up.

PURPOSE: To perform a systematic review on the techniques and a meta-analysis on the functional and objective outcomes after single-bundle (SB) versus double-bundle (DB) posterior cruciate ligament (PCL) reconstructions. METHODS: A systematic review of the techniques, as well as functional and objective outcomes of clinical studies comparing SB versus DB PCL reconstruction with a mean follow-up of at least 24 months and minimum level of evidence of III were performed. After review of the literature, a quality analysis of the studies (Detsky score) and a meta-analysis comparing raw mean differences in data between SB and DB PCL groups were performed. Clinical outcome measures included in the meta-analysis were functional outcomes (Lysholm, Tegner, and objective International Knee Documentation Committee [IKDC] scores) and objective measurements (arthrometer and stress radiographs). RESULTS: The systematic search identified 11 studies (441 patients). Three studies were prospective randomized controlled trials and the other 8 studies were case-control studies. Two hundred thirty-two patients were treated with SB PCL reconstruction, whereas 209 were treated with DB PCL reconstruction. Only 4 studies satisfied the threshold for a satisfactory level of methodologic quality (>75%). There were no significant differences between SB and DB PCL reconstructions in postoperative Lysholm (P = .6, 95% confidence interval [CI], -0.98, 2.18) or Tegner scores (P = .37, 95% CI, -0.19, 0.92). DB PCL reconstruction provided significantly better objective posterior tibial translation stability than the SB technique using the Telos technique at 90° (P = -.58, 95% CI, -1.06, -0.10). CONCLUSIONS: Improved patient-reported outcomes and knee stability were achieved with both SB and DB PCL reconstruction surgery. DB PCL reconstruction provided significantly improved objective posterior tibial stability and objective IKDC scores when compared with SB PCL reconstruction in randomized clinical trials. No significant difference was found for the other patient-reported outcomes. LEVEL OF EVIDENCE: Level III, systematic review and meta-analysis of Level II and III studies.

Proximal Tibiofibular Joint Instability and Treatment Approaches: A Systematic Review of the Literature.

PURPOSE: To evaluate the treatment options, outcomes, and complications associated with proximal tibiofibular joint (PTFJ) instability, which will aim to improve surgical treatment of PTFJ instability and aid surgeons in their decision making and treatment selection. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Inclusion criteria were as follows: PTFJ instability treatment techniques, PTFJ surgical outcomes, English language, and human studies. Exclusion criteria were cadaveric studies, animal studies, basic science articles, editorial articles, review articles, and surveys. Furthermore, we excluded studies that did not report patient follow-up time and studies without any patient-reported, clinical or radiographic outcomes at the final follow-up. RESULTS: The systematic review identified 44 studies (96 patients) after inclusion and exclusion criteria application. For the treatment of PTFJ instability, there were 18 studies (35 patients) describing nonoperative management, 3 studies (4 patients) reported on open reduction, 11 studies (25 patients) reported on fixation, 4 studies (10 patients) that described proximal fibula resection, 3 studies (11 patients) reported on adjustable cortical button repair, 2 studies (3 patients) reported on ligament reconstructions, and 5 (8 patients) studies reported on biceps femoris tendon rerouting. The most (77% to 90%) PTFJ dislocations and instability were anterolateral/unspecified anterior dislocation or instability. Improved outcomes after all forms of PTFJ instability treatment were reported; however, high complication rates were associated with both PTFJ fixation (28%) and fibular head resection (20%). CONCLUSIONS: Improved outcomes can be expected after surgical treatment of PTFJ instability. Proximal tibiofibular ligament reconstruction, specifically biceps rerouting and anatomic graft reconstruction, leads to improved outcomes with low complication rates. Nonoperative treatment is associated with persistent symptoms, whereas both fixation and fibular head resection are associated with high complication rates. LEVEL OF EVIDENCE: Level IV, systematic review of level IV studies.