Editorial Commentary: Osteochondral Allograft Transplantation of the Knee Using Nonorthotopic Grafts: A "Mismatch" Made in Heaven.

Osteochondral allograft (OCA) transplantation is a safe and reliable cartilage restoration procedure that has significantly increased in use over the last decade. As clinical studies report improved patient outcomes, sustained return to high-demand physical activity, and excellent long-term graft survivorship, OCA transplantation has become a popular first-line treatment option for symptomatic cartilage defects of the femoral condyle. Unfortunately, the rise in demand has not been met by a concomitant increase in supply, and OCAs remain a limited resource that must be used in a short window of time, or risk being wasted. As such, several studies are now exploring the use of nonorthotopic (e.g., lateral donor for medial defect) OCA grafts to expand graft use and provide more convenient surgical treatment. Imaging studies have proven the capability of nonorthotopic OCA grafts to restore the articular surface within acceptable limits, and midterm clinical studies have had successful patient outcomes, thereby suggesting significant promise for this surgical strategy.

The Assessment of Quality, Accuracy, and Readability of Online Educational Resources for Platelet-Rich Plasma.

PURPOSE: To critically evaluate the quality, accuracy, and readability of readily available Internet patient resources for platelet-rich plasma (PRP) as a treatment modality for musculoskeletal injuries. METHODS: Using the 3 most commonly used Internet search engines (Google, Bing, Yahoo), the search term "platelet rich plasma" was entered, and the first 50 websites from each search were reviewed. The website's affiliation was identified. Quality was evaluated using 25-point criteria based on guidelines published by the American Academy of Orthopaedic Surgeons, and accuracy was assessed with a previously described 12-point grading system by 3 reviewers independently. Readability was evaluated using the Flesch-Kincaid (FK) grade score. RESULTS: A total of 46 unique websites were identified and evaluated. The average quality and accuracy was 9.4 ± 3.4 (maximum 25) and 7.9 ± 2.3 (maximum 12), respectively. The average FK grade level was 12.6 ± 2.4, which is several grades higher than the recommended eighth-grade level for patient education material. Ninety-one percent (42/46) of websites were authored by physicians, and 9% (4/46) contained commercial bias. Mean quality was significantly greater in websites authored by health care providers (9.8 ± 3.1 vs 5.9 ± 4.7, P = .029) and in websites without commercial bias (9.9 ± 3.1 vs 4.5 ± 3.2, P = .002). Mean accuracy was significantly lower in websites authored by health care providers (7.6 ± 2.2 vs 11.0 ± 1.2, P = .004). Only 24% (11/46) reported that PRP remains an investigational treatment. CONCLUSIONS: The accuracy and quality of online patient resources for PRP are poor, and the information overestimates the reading ability of the general population. Websites authored by health care providers had higher quality but lower accuracy. Additionally, the majority of websites do not identify PRP as an experimental treatment, which may fail to provide appropriate patient understanding and expectations. CLINICAL RELEVANCE: Physicians should educate patients that many online patient resources have poor quality and accuracy and can be difficult to read.

Integrating Social Media and Anterior Cruciate Ligament Surgery: An Analysis of Patient, Surgeon, and Hospital Use.

PURPOSE: The purpose of this observational study of social media in sports medicine was to investigate and analyze the presence and shared content of anterior cruciate ligament (ACL) patients, sports surgeons, and top orthopaedic hospitals on popular social media streams. METHODS: A search of 2 public domains (Instagram and Twitter) was performed over a 6-month period. ACL surgery ("#aclsurgery") was selected for the Instagram-based patient analysis after exclusion of veterinary ACL operations. A binary scoring system was used for media format, time (preoperatively or postoperatively), perioperative period (within 1 week of surgery), tone (positive or negative), return-to-work reference, return-to-play reference, rehabilitation reference, surgical-site reference, satisfaction reference, and dissatisfaction reference; perspective of the media was noted as well. A sample of 97 National Football League team surgeons was used for analysis of physician use in social media outlets and quantified by the number of posts. Hospital analysis categorized a sample of the top 50 orthopaedic hospitals by average number of posts and monthly posting rates with regard to orthopaedics, research, education, and personnel focus. RESULTS: In the patient analysis, 3,145 public posts of human subjects were shared on Instagram. Of these, 92% were personal recovery stories, with an emphasis on postoperative photographs (93%) with a positive tone (88%) more than 1 week after surgery (73%). Posts focused on surgical site (25%), return to play (30%), and postoperative rehabilitation (37%). Of the physicians, 16% had Twitter accounts, with an average of 94 posts per surgeon; none had Instagram accounts. Of the hospitals, 96% had Twitter accounts and 32% had Instagram accounts. Most of the hospital-based Instagram content in the sample was centered on patients or celebrities. CONCLUSIONS: Orthopaedic surgery has a large social media presence. Patients emphasize wound appearance, the rehabilitation process, and return to play. Ninety-six percent of hospitals are represented in social media outlets, whereas physicians are relatively under-represented. CLINICAL RELEVANCE: Social media offers a unique window into what truly matters to patients after surgery and may help us better manage expectations, enhance health care delivery, and improve marketing strategies.

Influence of graft source and configuration on revision rate and patient-reported outcomes after MPFL reconstruction: a systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review and meta-analysis was to determine the influence of graft source (allograft vs. autograft) and configuration (single-limbed vs. double-limbed) on failure rate and disease-specific patient-reported outcome (Kujala score) after medial patellofemoral ligament (MPFL) reconstruction for patellar instability. METHODS: A systematic review of PubMed, Scopus, and the Cochrane Library was performed. A total of 31 studies met inclusion/exclusion criteria and were used to extract cohorts of patients who underwent ligament reconstruction with various allograft, autograft, single-limbed, and double-limbed constructs. Failure rates and postoperative improvements in Kujala scores were compared between cohorts using inverse-variance weighting in a random-effects analysis model and appropriate comparative statistical analyses (Chi-squared and independent samples t tests). RESULTS: A total of 1065 MPFL reconstructions were identified in 31 studies. Autograft reconstructions were associated with greater postoperative improvements in Kujala scores when compared to allograft (32.2 vs. 22.5, p < 0.001), but there was no difference in recurrent instability (5.7 vs. 6.7 %, p = 0.74). Double-limbed reconstructions were associated with both improved postoperative Kujala scores (37.8 vs. 31.6, p < 0.001) and lower failure rate (10.6 vs. 5.5 %, p = 0.030). CONCLUSION: MPFL reconstructions should be performed using double-limbed graft configurations. While autograft tendon may be associated with higher patient-reported outcomes in the absence of associated connective tissue disorders or ligamentous laxity, patient factors and allograft processing techniques should be carefully considered when selecting an MPFL graft source, as revision rates were no different between graft sources. LEVEL OF EVIDENCE: IV.

Quantitative assessment of patellar vascularity following bone-patellar tendon-bone autograft harvest for ACL reconstruction.

PURPOSE: Recent anatomic studies have suggested that the dominant arterial supply of the patella enters through the inferior pole. Based upon these findings, we hypothesized that bone-patellar tendon-bone graft harvest can significantly diminish patellar vascularity. METHODS: Nine matched pair cadaveric knee specimens (mean age 47.4 years) were dissected and cannulated. A single knee was selected to undergo routine graft harvest, and the contralateral knee was left intact to serve as a control. Gadolinium was injected, and magnetic resonance imaging (MRI) signal enhancement was quantified to determine differences in uptake. Each matched pair was subsequently injected with a urethane polymer compound and dissected to correlate vessel disruption with MRI findings. RESULTS: We identified two predominating patterns of vessel entry. In one pattern, the vessel entered the inferomedial aspect (five o'clock/right, seven o'clock/left) of the patella and was disrupted by graft harvest in 2/9 (22.2 %) pairs. In the second pattern, the vessel entered further medial (four o'clock/right, eight o'clock/left) and was not disrupted (7/9, 78.8 %). The mean decrease in gadolinium uptake following disruption of the predominant vessel measured 56.2 % (range 42.6-69.5 %) compared to an average decrease of 18.3 % (range 7.1-29.1 %) when the dominant arterial supply to the inferior pole remained intact (p < 0.04). CONCLUSION: Medial entry of the predominant vessel precluded vessel disruption. Disruption of the dominant arterial supply can result in a significant decrease in patellar vascularity. Modification of graft harvest techniques and areas of surgical dissection should be explored to minimize vascular insult. Further correlation with clinical studies/outcomes is necessary to determine a potential association between vascular insult and anterior knee pain.

Trends associated with distal biceps tendon repair in the United States, 2007 to 2011.

BACKGROUND: Current studies investigating surgical treatment of distal biceps tendon tears largely consist of small, retrospective case series. The purpose of this study was to investigate the current patient demographics, surgical trends, and postoperative complication rates associated with operative treatment of distal biceps tendon tears using a large database of privately insured, non-Medicare patients. METHODS: Patients who underwent surgical intervention for distal biceps tendon tears from 2007 to 2011 were identified using the PearlDiver database. Demographic and surgical data as well as postoperative complications were reviewed. Statistical analysis was performed using linear regression analysis and χ(2) tests, with statistical significance set at P < .05. RESULTS: A total of 1443 patients underwent surgical treatment for distal biceps tendon tears. Men and patients aged 40 to 59 years accounted for 98% and 72% of the cohort, respectively. Regarding surgical technique, reinsertion to the radial tuberosity was preferred (95%) over tenodesis to the brachialis (5%) (P < .01). In total, revision surgery for tendon rerupture occurred in 5.4% of treated patients. The incidence of revision surgery for rerupture in acute and chronic distal biceps tears was 5.1% and 7.0%, respectively (P = .36). Postoperative infection and peripheral nerve injury rates were 1.1% and 0.6%, respectively. CONCLUSION: Surgeons strongly preferred anatomic reinsertion to the radial tuberosity for treatment, regardless of the chronicity of the injury. Postoperative complication rates were similar to those found in prior studies, although the true rate of rerupture may be higher than previously thought.

Are our actions matching our words? A review of trainee ethnic and gender diversity in orthopaedic surgery.

Background: There is a lack of physician ethnic and gender diversity amongst surgical specialties. This study analyzes the literature that promotes diversity amongst surgical trainees. Specifically, this study sought to answer (i) how the number of publications regarding diversity in orthopaedic surgery compares to other surgical specialties, (ii) how the number of publications amongst all surgical subspecialties trends over time and (iii) which specific topics regarding diversity are discussed in the surgical literature. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to query articles from PubMed, Web of Science, Embase and the Cumulative Index to Nursing and Allied Health Literature. Broad inclusion criteria for both ethnic and gender diversity of any surgical specialty were utilized. Results: Our query resulted 1429 publications, of which 408 duplicates were removed, and 701 were excluded on title and abstract screening, leaving 320 to be included. The highest number of related publications was in orthopaedic surgery (n = 73) followed by general surgery (n = 56). Out of 320 total articles, 260 (81.3 %) were published after 2015, and 56 of 73 (76.7 %) orthopaedic-specific articles were published after 2015. Conclusion: Orthopaedic surgery published the most about ethnic and gender diversity, however, still remains one of the least diverse surgical specialties. With the recent increase in publications on diversity in surgical training, close attention should be paid to ethnic and gender diversity amongst surgical trainees over the coming years. Should diversity remain stagnant, diversification efforts may need to be restructured to achieve a diverse surgeon workforce. Key message: Orthopaedic surgery is the surgical subspecialty that publishes the most about trainee ethnic and gender diversity followed by general surgery. With most of this literature being published over the last eight years, it is imperative to pay close attention to the ethnic and gender landscape of the surgeon workforce over the coming years.

Strong Correlation Between Femoral Condyle Radius of Curvature and Anterior-Posterior Length: Implications for Osteochondral Allograft Matching.

BACKGROUND: The radius of curvature (ROC) of the femoral condyle is a factor in potential cartilage incongruities following osteochondral allograft (OCA) transplantation. Accurate restoration of the chondral surface may be achievable by using "best-fit" donor-recipient matching based on linear femorotibial dimensions, such as the femoral condyle anterior-posterior length (APL), femoral condyle width (lateral-medial length, LML), femoral hemicondyle width (HCW), and tibial plateau width (TPW), particularly if they correlate well with the ROC. This study aimed to investigate the correlative relationship between femorotibial dimensions and the ROC. METHODS: Computed tomography (CT) scans from 49 patients (31 men 28 ± 10 years old and 18 women 27 ± 6 years old) were analyzed. Axial images were used for APL and LML measurements, while coronal images were used for HCW and TPW. True sagittal images of the medial femoral condyle (MFC) and lateral femoral condyle (LFC) were used to calculate their individual ROCs by determining the best-fit circles along the condylar surface. Linear regression models were used to determine the relationship between the femorotibial dimensions and ROC. Measurements were repeated for a randomly selected subset of the data, and intraclass correlation coefficients (ICCs) were calculated to investigate intra- and interobserver reliability. RESULTS: All femorotibial dimensions showed significant correlations with the MFC and LFC ROCs (p < 0.01). The ROC correlations with femorotibial dimensions were found to be in the following descending order: APL (R2 ≥ 0.83), LML (R2 ≥ 0.52), TPW (R2 ≥ 0.36), and HCW (R2 ≥ 0.27). The intra- and interobserver reliabilities for the APL (ICC > 0.98) and ROC (ICC > 0.94) were excellent. CONCLUSIONS: The ROC was strongly correlated with the APL of the MFC and LFC. Donor-recipient APL matching in OCA transplantation may provide a level of matching similar to that achievable by direct ROC measurements. CLINICAL RELEVANCE: Determining the most predictive femorotibial dimension for ROC restoration in the OCA matching process may improve clinical outcomes, particularly for patients with large osteochondral lesions.

Outcomes of Blood Flow Restriction Training After ACL Reconstruction in NCAA Division I Athletes.

Background: Blood flow restriction training (BFRT) is a safe and potentially effective adjunctive therapeutic modality for postoperative rehabilitation related to various knee pathologies. However, there is a paucity of literature surrounding BFRT in high-performance athletes after anterior cruciate ligament reconstruction (ACLR). Purpose: To (1) compare the overall time to return to sports (RTS) in a cohort of National Collegiate Athletic Association (NCAA) Division I athletes who underwent a standardized rehabilitation program either with or without BFRT after ACLR and (2) identify a postoperative time interval for which BFRT has the maximum therapeutic benefit. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 55 student-athletes who underwent ACLR between 2000 and 2023 while participating in NCAA Division I sports at a single institution were included in this study. Athletes were allocated to 1 of 2 groups based on whether they participated in a standardized postoperative rehabilitation program augmented with BFRT (BFRT group; n = 22) or completed the standardized protocol alone (non-BFRT group [control]; n = 33). Our primary outcome measure was time to RTS. The secondary outcome measure was handheld dynamometry quadriceps strength testing at various postoperative time points, converted to a limb symmetry index (LSI). Quadriceps strength was not tested between the BFRT and non-BFRT groups because of the limited amount of data on the control group. Results: The mean age at the date of surgery was 18.59 ± 1.10 years for the BFRT group and 19.45 ± 1.30 years for the non-BFRT group (P = .011), and the mean RTS time was 409 ± 134 days from surgery for the BFRT group and 332 ± 100 days for the non-BFRT cohort (P = .047). For the BFRT group, the mean quadriceps strength LSI increased by 0.67% (95% CI, 0.53%-0.81%) for every week of rehabilitation, and there was a significantly positive rate of change in quadriceps strength in weeks 13-16 compared with weeks 9-12 (ΔLSI, 8.22%; P < .001). Conclusion: In elite NCAA Division I athletes, a statistically significant delay was observed in RTS with BFRT compared with standardized physical therapy alone after undergoing ACLR. There also appeared to be an early window during the rehabilitation period where BFRT had a beneficial impact on quadriceps strength.

Functional outcomes following revision ulnar collateral ligament reconstruction in Major League Baseball pitchers.

BACKGROUND: There is a paucity of data regarding outcomes following revision ulnar collateral ligament (UCL) reconstruction in Major League Baseball (MLB) pitchers. A single case series comprised of 4 MLB pitchers has reviewed outcomes in this cohort and reported a 75% rate of return to pitching. We hypothesize that MLB pitchers demonstrate a low rate of return to their pre-injury pitch workload following revision surgery. METHODS: Clinical outcomes were reviewed with an emphasis on return to pre-injury pitch workload. Utilizing MLB player performance statistics, the postoperative pitch workload (appearances for relief pitchers and games started/innings pitched for starting pitchers) was calculated to determine if players were able to resume pre-injury throwing activity. Position-specific analyses for pitchers (starter vs relief) were also performed utilizing objective pitching statistics. RESULTS: Overall, 78% (14/18) of pitchers were able to return to MLB play within 2 full seasons. Relief pitchers were able to resume 50% of their pre-injury pitch workload, while starting pitchers only reached 35% of their prior workload (P = .52). Relievers demonstrated better pitching statistics (ERA [earned run average], K/9 [strikeouts per 9 innings], and BB/9 [walks per 9 innings]) when compared to starters. Two starting pitchers were reassigned to relief roles by their teams, resulting in improvement in their postoperative pitch workload (mean 94%). CONCLUSION: The overall rate of return to pre-injury pitch workload following revision UCL reconstruction is low among professional pitchers. Starting pitchers may be at higher risk for treatment failure in the revision setting, given the increased demands of the position, and may benefit from reassignment to a relief role.

Gender and Racial Diversity Among the Head Medical and Athletic Training Staff of Women's Professional Sports Leagues.

Background: Despite increased awareness for promoting diversity, orthopaedics remains one of the least diverse specialties. Studying health care providers in women's professional sports provides a unique opportunity to analyze gender and racial diversity. Hypotheses: There would be low female and minority representation across the various women's professional sports leagues. There would be an increased number of female head certified athletic trainers (ATCs) when compared with head team physicians (HTPs). Study Design: Cross-sectional study. Methods: We evaluated the perceived race and sex of designated HTPs and ATCs in the Women's National Basketball Association, National Women's Soccer League, and National Women's Hockey League. Type of doctorate degree, specialty, and years in practice were also collected. Kappa (κ) coefficient measurements were used to determine interobserver agreement on race. Categorical and continuous variables were analyzed using chi-square and t tests, respectively. Results: There were significantly more female ATCs than female HTPs (74.1% vs 37.5%; P = .01). Minority representation between HTPs and ATCs was not significantly different (20.8% vs 40.7%; P = .13). Black HTPs (12.5%) and Black ATCs (22.2%) composed the largest proportion among the minority groups. There was high interobserver agreement of perceived race across HTPs (κ = 1.0) and ATCs (κ = 0.95). Conclusion: Although there were more female ATCs than HTPs in women's professional sports leagues, both cohorts lack perceived racial diversity. These data suggest an opportunity for diversification in medical and training staff of women's professional sports.

Impact of the COVID-19 Pandemic Hiatus From Sports Activities on Injuries Observed Among Division I NCAA Athletes.

Background: The coronavirus disease 2019 (COVID-19) pandemic significantly disrupted athletic activities, including those in the Pacific 12 (Pac-12) Conference of the National Collegiate Athletic Association. It is currently unknown how the disruption in training and competition impacted athletes' risk of injury upon resumption of activities. Purpose: To describe and compare the rate, timing, mechanism, and severity of injuries among collegiate athletes across multiple sports in the Pac-12 Conference before and after the COVID-19 pandemic-associated hiatus of intercollegiate athletic activities. Study Design: Descriptive epidemiology study. Methods: Descriptive and injury data among intercollegiate athletes from both the season before the hiatus and the season after the hiatus were acquired from the Pac-12 Health Analytics Program database. Injury elements (timing of injury onset, injury severity, mechanism, recurrence, outcome, need for procedural intervention, and event segment during which the injury took place) were compared by time using the chi-square test and a multivariate logistic regression model. Subgroup analyses were performed on knee and shoulder injuries among athletes participating in sports with traditionally high rates of knee and shoulder injuries. Results: A total of 12,319 sports-related injuries across 23 sports were identified, with 7869 pre-hiatus injuries and 4450 post-hiatus injuries. There was no difference in the overall incidence of injury between the pre-hiatus and post-hiatus seasons. However, the proportion of noncontact injuries was higher in the post-hiatus season for football, baseball, and softball players, and the proportion of nonacute injuries in the post-hiatus season was higher among football, basketball, and rowing athletes. Finally, the overall proportion of injuries sustained by football players in the final 25% of competition or practice was higher in the post-hiatus season. Conclusion: Athletes competing in the post-hiatus season were observed to have higher rates of noncontact injuries and injuries sustained in the final 25% of competition. This study demonstrates that the COVID-19 pandemic has had varied effects on athletes from different sports, suggesting that many factors must be considered when designing return-to-sports programs for athletes after an extended absence from organized training.

Multicenter Analysis of the Epidemiology of Injury Patterns and Return to Sport in Collegiate Gymnasts.

Background: Gymnastics requires intense year-round upper and lower extremity strength training typically starting from an early age. As such, the injury patterns observed in these athletes may be unique. Purpose: To characterize the types of injuries and provide return-to-sport data in male and female collegiate gymnasts. Study Design: Descriptive epidemiology study. Methods: A conference-specific injury database was utilized to perform a retrospective review of injuries for male and female National Collegiate Athletic Association (NCAA) Division I gymnasts within the Pacific Coast Conference between 2017 and 2020 (N = 673 gymnasts). Injuries were stratified by anatomic location, sex, time missed, and injury diagnoses. Relative risk (RR) was used to compare results between sexes. Results: Of the 673 gymnasts, 183 (27.2%) experienced 1093 injuries during the study period. Injuries were sustained in 35 of 145 male athletes (24.1%) as compared with 148 of 528 female athletes (28.0%; RR, 0.86 [95% CI, 0.63-1.19]; P = .390). Approximately 66.1% (723/1093) of injuries occurred in a practice setting, compared with 84 of 1093 injuries (7.7%) occurring during competition. Overall, 417 of 1093 injuries (38.2%) resulted in no missed time. Shoulder injuries and elbow/arm injuries were significantly more common in male versus female athletes (RR, 1.99 [95% CI, 1.32-3.01], P = .001; and RR, 2.08 [95% CI, 1.05-4.13], P = .036, respectively). In total, 23 concussions affected 21 of 673 athletes (3.1%); 6 concussions (26.1%) resulted in the inability to return to sport during the same season. Conclusion: For the majority of musculoskeletal injuries, the gymnasts were able to return to sport during the same season. Male athletes were more likely to experience shoulder and elbow/arm injuries, likely because of sex-specific events. Concussions occurred in 3.1% of the gymnasts, highlighting the need for vigilant monitoring. This analysis of the incidence and outcomes of injuries observed in NCAA Division I gymnasts may guide injury prevention protocols as well as provide important prognostic information.

Diagnostic biopsy of the pronator teres and a motor branch of the median nerve: indications and technique.

PURPOSE: Biopsy of muscle tissue and motor nerve is helpful in the neurological evaluation of patients who present with upper limb and/or diffuse motor weakness. The procedure is indicated to supplement clinical, serological, and imaging diagnostic work-up of myopathic and neuropathic disorders. We describe a surgical technique and clinical series of biopsy of the pronator teres muscle and a motor branch of the median nerve. METHODS: We performed a retrospective review of 20 patients who underwent biopsy of the pronator teres and a motor branch of the median nerve as part of a clinical, serological, and radiographic evaluation for weakness of the upper extremity. All of the biopsies were performed by a single surgeon. The surgical technique is described. Follow-up visits with both the surgeon and the neurologist were reviewed to evaluate preoperative and postoperative neurological function to identify any changes in nerve or muscle function and any postoperative complications. RESULTS: Biopsied tissue was sufficient for pathological diagnosis in all 20 patients. Diagnoses included multifocal motor neuropathy in 14 patients, amyotrophic lateral sclerosis in 3 patients (2 sporadic; 1 familial), inclusion body myositis (1 patient), inflammatory myopathy (1 patient), and chronic inflammatory demyelinating polyneuropathy (1 patient). At a mean follow-up of 11 weeks (range, 5-31 wk), there were 6 minor surgical complications, all of which were superficial hematomas that resolved with use of a compressive wrap. CONCLUSIONS: Biopsy of the pronator teres and a motor branch of the median nerve was safe and effective. The technique is particularly useful when considering the diagnosis of multifocal motor neuropathy affecting the upper extremity.

The docking technique for lateral ulnar collateral ligament reconstruction: surgical technique and clinical outcomes.

HYPOTHESIS: Lateral ulnar collateral ligament (LUCL) reconstruction is a commonly used surgical approach for the treatment of posterolateral rotatory instability (PLRI). We hypothesized that favorable clinical results could be obtained using the docking technique. MATERIALS AND METHODS: Between 1996 and 2009, the docking technique was used for surgical reconstruction of the LUCL in 8 patients with purely ligamentous posterolateral rotatory instability of the elbow. The clinical results of these patients were retrospectively reviewed. RESULTS: At a mean follow-up of 7.1 years (range, 5.2-9.4 years), 6 patients (75%) demonstrated complete resolution of lateral elbow instability, and 2 (25%) reported occasional instability with activities of daily living. The mean Mayo Elbow Performance Score was 87.5 (range, 75-100). Subjective assessment revealed that all patients were satisfied with their clinical outcome. CONCLUSION: LUCL reconstruction using the docking technique facilitates simple graft tensioning and excellent graft fixation. Clinical results are comparable with previously reported studies with a low complication rate.

Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes.

PURPOSE OF REVIEW: Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury. RECENT FINDINGS: Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving. Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.

Assessment of Characteristics and Methodological Quality of the Top 50 Most Cited Articles on Platelet-Rich Plasma in Musculoskeletal Medicine.

Background: The wide range of clinical applications and controversial scientific evidence associated with platelet-rich plasma (PRP) therapy in musculoskeletal medicine requires an examination of the most commonly cited studies within this field. Purpose: To identify the 50 most cited articles on PRP, assess their study design, and determine any correlations between the number of citations and level of evidence (LoE) or methodological quality. Study Design: Cross-sectional study. Methods: The Web of Science database was queried to identify the top 50 most cited articles on PRP in orthopaedic surgery. Bibliometric characteristics, number of citations, and LoE were recorded. Methodological quality was evaluated using the Modified Coleman Methodology Score (MCMS), Methodological Index for Non-randomized Studies (MINORS), and Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO). The Pearson correlation coefficient and Spearman correlation coefficient (r S) were used to determine the degree of correlation between the number of citations or citation density and LoE, MCMS, MINORS score, and MIBO score. Student t tests were performed for 2-group comparisons. Results: The top 50 articles were published between 2005 and 2016 in 21 journals. The mean number of citations and citation density were 241 ± 94 (range, 151-625) and 23 ± 8, respectively, and the mean LoE was 2.44 ± 1.67, with 15 studies classified as LoE 1. The mean MCMS, MINORS score, and MIBO score were 66.9 ± 12.6, 16 ± 4.7, and 12.4 ± 3.7, respectively. No correlation was observed between the number of citations or citation density and LoE, MCMS, MINORS score, and MIBO score. A significant difference (P = .02) was noted in LoE in articles from the United States (3.56 ± 1.7) versus outside the United States (2 ± 1.5). Seven of the 8 in vivo studies were published between 2005 and 2010, whereas 19 of the 25 clinical outcome investigations were published between 2011 and 2016. Studies that were published more recently were found to significantly correlate with number of citations (r S = -0.38; P = .01), citation density (r S = 0.36; P = .01), and higher LoE (r S = 0.47; P = .01). Conclusion: The top 50 most cited articles on PRP consisted of high LoE and fair methodological quality. There was a temporal shift in research from in vivo animal studies toward investigations focused on clinical outcomes.

Quality and Variability of Physical Therapy Protocols Varies Widely for Osteochondral Allograft Transplantation of the Femoral Condyles.

OBJECTIVE: To assess the quality and variability of osteochondral allograft (OCA) transplantation rehabilitation protocols associated with academic orthopedic programs in the United States. DESIGN: A systematic review was performed to collect all publicly available online rehabilitation protocols for femoral condyle OCA transplant from US academic orthopedic programs participating in the Electronic Residency Application Service. These protocols were evaluated for inclusion of different rehabilitation components as well as timing of suggested initiation of these activities. RESULTS: A total of 22 protocols were included. Although 91% of protocols recommended bracing, wide variation exists in total time of utilization. Median time for full weight bearing (FWB) was 7 weeks (range 4-8). On average, each protocol mentioned 9 (range 2-18) different strengthening exercises. The median time suggested to return to high-impact activities was 9 months (range 8-12). Only 3 protocols (14%) offered criteria of advancement for each phase as well as criteria for discharge. CONCLUSION: Very few of the academic orthopedic programs have published online rehabilitation protocols following OCA transplantation. Although there is wide variation between the protocols, it allowed the identification of trends or patterns that are more common. However, there is need for more standardized evidence-based rehabilitation protocols which are easy to understand and follow by patients.

Thoracic Outlet Syndrome in Major League Baseball Pitchers: Return to Sport and Performance Metrics After Rib Resection.

Background: Thoracic outlet syndrome (TOS) is a rare injury that affects Major League Baseball (MLB) pitchers and is often corrected with surgical resection of the first rib. There are limited return-to-play (RTP) data for this surgery in MLB pitchers. Hypothesis: It was hypothesized that MLB pitchers who undergo first rib resection for TOS will show (1) a high rate of RTP, (2) no difference in postoperative career length compared with controls, (3) no difference in pre- and postoperative performance, and (4) no difference in postoperative performance compared with controls. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective cohort study evaluated MLB pitchers with neurogenic or vascular TOS who underwent rib resection surgery between January 1, 2001, and December 31, 2019. Players were identified through public injury reports from press releases, the MLB website, MLB team injury reports, and blogs. A demographics- and performance-matched control group was generated for comparison. Each player in the control group was given an index year that corresponded to the surgery year of the case group. Performance data included innings pitched (IP), games played (GP), earned run average (ERA), complete GP, shutouts, saves, hits, runs, home runs (HR), walks, strikeouts (K), walks plus hits per IP (WHIP), and earned runs (ER). Results: We identified 26 MLB pitchers who underwent rib resection for neurogenic or vascular TOS; 21 players (81%) had a successful RTP. Pitchers were 30 ± 3.6 years old at the time of surgery and had played 6.2 ± 3.5 seasons before undergoing surgery. Average postoperative career length was 3.1 ± 2.0 seasons, with an average time from surgery to RTP being 10 ± 4.7 months. Pitchers who RTP showed no significant differences in performance metrics compared with controls. Players pitch 0.94 (P < .05) more IP/GP in the season directly following RTP compared with the season before surgical intervention. Conclusion: MLB pitchers undergoing rib resection for TOS demonstrated (1) high RTP rates following rib resection, (2) no difference in postoperative career length compared with controls, (3) improvement in postoperative performance, and (4) no difference in postoperative performance compared with controls.

Clinical Outcomes of Meniscal Allograft Transplantation With Respect to the Minimal Clinically Important Difference.

BACKGROUND: Arthroscopic-assisted meniscal allograft transplantation (MAT) has become a viable and effective treatment option for young active patients with postmeniscectomy pain. The minimal clinically important difference (MCID) of patient-reported outcome measures (PROMs) is imperative to evaluate the clinical significance of surgical interventions and inform clinical practice guidelines in orthopaedic surgery. PURPOSE: To perform a systematic review of clinical outcome studies of patients undergoing MAT and compare postoperative improvement with established MCID thresholds. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: A systematic review was performed using the PubMed, Web of Science, and Cochrane Library databases. A meta-analysis was performed using data obtained from studies reporting patient-reported outcomes. Subgroup analysis was performed on patients undergoing isolated lateral MAT using fresh-frozen grafts. Weighted mean postoperative improvements in the International Knee Documentation Committee (IKDC), Lysholm, and visual analog scale for pain (VAS pain) were calculated and compared with MCID values to determine if they met the MCID threshold. RESULTS: A total of 35 studies were identified, including 1658 unique patients. Weighted mean postoperative score improvements exceeded MCID thresholds for the VAS pain, IKDC, and Lysholm. Subgroup analysis of patients undergoing isolated lateral fresh-frozen MAT demonstrated postoperative improvements exceeding the MCID for the Lysholm and VAS pain. CONCLUSION: Evaluating postoperative PROMs with respect to the MCID is crucial to evaluate the effect of MAT on functional improvement. The results of the present meta-analysis suggest that postoperative improvements after MAT are clinically meaningful as reflected by PROMs exceeding the MCID threshold for the IKDC, Lysholm, and VAS pain.