Neither All-Inside, nor Inside-Out, nor Outside-In Repair Demonstrates Superior Biomechanical Properties for Vertical Meniscal Tears: A Systematic Review of Human Cadaveric Studies.

PURPOSE: To systematically review the literature regarding the biomechanical properties of different repair techniques and fixation methods for vertically oriented meniscal tears. METHODS: Human cadaveric studies evaluating the biomechanical properties of different repair techniques for vertically oriented meniscal tears were identified using the PubMed, EMBASE, and Cumulative Index to Nursing & Allied Health databases. Primary outcomes included load to failure, displacement, stiffness, peak contact pressure, and contact area of repaired menisci. Repair techniques from included studies were reclassified into a total of 19 distinct all-inside (AI), inside-out (IO), or outside-in (OI) techniques. RESULTS: Sixteen studies were included (420 total menisci). Contact pressure and area were restored to intact-state values across all 5 compressive load studies at low knee flexion angles but not at greater knee flexion angles (i.e., >60°). There were no significant differences in contact pressure or area between AI, IO, and OI techniques across all studies. Some studies demonstrated statistically significant advantages in tensile properties with IO techniques when compared with AI techniques, whereas others found AI techniques to be superior. No studies directly compared tensile properties of OI techniques with those of AI or IO techniques. Vertical mattress suture configurations resulted in significantly greater load to failure and decreased displacement compared with horizontal mattress configurations in 67% of studies comparing the 2 techniques. There was no difference in the rate of tissue failure in AI (66.97%), IO (60.38%), or OI (66.67%, χ2 = 0.83, P = .66) techniques. CONCLUSIONS: Contact mechanics are reliably restored after repair of vertical meniscal tears at low flexion angles but inconsistently restored at greater flexion angles, regardless of technique. Vertical mattress configurations outperformed horizontal mattress configurations under tensile load. There are conflicting data regarding the comparison of tensile properties between AI and IO techniques. Ultimately, neither AI, IO, nor OI repair demonstrated superior biomechanical properties in the present literature. CLINICAL RELEVANCE: Several repair techniques demonstrate favorable biomechanical properties for vertical meniscal tears under tensile and compressive loads. Neither AI, IO, nor OI repair techniques demonstrate superior biomechanical properties at this time.

Revision and Primary Meniscal Allograft Transplantations Provide Clinical Benefit at Mid-Term Follow-Up: A Matched-Cohort Analysis of Patient-Reported Outcomes, Reoperations, and Failures.

PURPOSE: To report the mid-term outcomes of patients who underwent revision meniscal allograft transplantation (RMAT) and compare survivorship free from reoperation and failure with a matched cohort of patients who underwent primary meniscal allograft transplantation (PMAT). METHODS: A retrospective review of prospectively collected data identified patients who underwent RMAT and PMAT between 1999 and 2017. A cohort of PMAT patients matched at a ratio of 2:1 with respect to age, body mass index, sex, and concomitant procedures served as the control group. Patient-reported outcome measures (PROMs) at baseline and at a minimum of 5 years postoperatively were collected. PROMs and the achievement of clinically significant outcomes were analyzed within groups. Graft survivorship free from meniscal reoperation and failure (arthroplasty or subsequent RMAT) was compared between cohorts using log-rank testing. RESULTS: During the study period, 22 RMATs were performed in 22 patients. Of these RMAT patients, 16 met the inclusion criteria (73% follow-up rate). The mean age of RMAT patients was 29.7 ± 9.3 years, and the mean follow-up period was 9.9 ± 4.2 years (range, 5.4-16.8 years). There were no differences between the RMAT cohort and the 32 matched PMAT patients with respect to age (P = .292), body mass index (P = .623), sex (P = .537), concomitant procedures (P ≥ .286), or baseline PROMs (P ≥ .066). The patient acceptable symptomatic state was achieved by the RMAT cohort for the subjective International Knee Documentation Committee score (70%), Lysholm score (38%), and Knee Injury and Osteoarthritis Outcome Score subscales (Pain [73%], Symptoms [64%], Sport [45%], Activities of Daily Living [55%], and Quality of Life [36%]). In the RMAT cohort, 5 patients (31%) underwent subsequent reoperation at a mean of 4.7 ± 2.1 years (range, 1.7-6.7 years) and 5 patients met the criteria for failure at a mean of 4.9 ± 2.9 years (range, 1.2-8.4 years). There were no significant differences in survivorship free from reoperation (P = .735) or failure (P = .170) between the RMAT and PMAT cohorts. CONCLUSIONS: At mid-term follow-up, most patients who underwent RMAT achieved the patient acceptable symptomatic state for the subjective International Knee Documentation Committee score and the Knee Injury and Osteoarthritis Outcome Score subscales of Pain, Symptoms, and Activities of Daily Living. Additionally, there were no differences in survival free from meniscal reoperation or failure between the PMAT and RMAT cohorts. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort.

Statistical fragility of randomized clinical trials in shoulder arthroplasty.

BACKGROUND: The P value is a statistical tool used to assess the statistical significance of clinical trial outcomes in orthopedic surgery. However, the P value does not evaluate research quality or clinical significance. The Fragility Index (FI) is an alternative statistical method that can be used to assess the quality and significance of clinical research and is defined as the number of patients in a study intervention group necessary to convert an outcome from statistically significant to statistically insignificant or vice versa. The primary purpose of this study was to evaluate the statistical robustness of clinical trials regarding shoulder arthroplasty using the FI. The secondary goal was to identify trial characteristics associated greater statistical fragility. METHODS: A systematic review of randomized clinical trials in shoulder arthroplasty was performed. The FI was calculated for all dichotomous, categorical study outcomes discussed in the identified studies. Descriptive statistics and the Pearson correlation coefficient were used to evaluate all studies and characterize associations between study variables. RESULTS: A total of 13 randomized controlled trials were identified and evaluated; these trials had a median sample size of 47 patients (mean, 54 patients; range, 26-102 patients) and a median of 7 patients (mean, 5.8 patients; range, 0-14 patients) lost to follow-up. The median FI was 6 (mean, 5; range, 1-11), a higher FI than what has been observed in other orthopedic subspecialties. However, the majority of outcomes (74.4%) had an FI that was less than the number of patients lost to follow-up, and most outcomes (89.7%) were statistically insignificant. CONCLUSION: Randomized controlled trials in shoulder arthroplasty have comparable statistical robustness to the literature in other orthopedic surgical subspecialties. We believe that the inclusion of the FI in future comparative studies in the shoulder arthroplasty literature will allow surgeons to better assess the statistical robustness of future research.

Is surgical duration associated with postoperative complications in primary shoulder arthroplasty?

BACKGROUND: Surgical duration is an independent predictor of short-term adverse outcomes after a variety of orthopedic procedures, both arthroscopic and open. However, this association in shoulder arthroplasty remains unclear. The purpose of this study was to identify the association between surgical duration and postoperative complications, as well as increased use of health care resources, after shoulder arthroplasty. METHODS: Primary shoulder arthroplasty procedures performed from 2005 to 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Surgical duration was divided into 3 cohorts: (1) surgical procedures lasting less than 90 minutes, (2) those lasting between 90 and 120 minutes, and (3) those lasting more than 120 minutes. Baseline patient characteristics and outcome variables were compared using bivariate analysis. Outcome variables were compared using multivariate analysis. RESULTS: Overall, 14,106 patients were identified. Longer surgical duration was significantly associated with younger age, male patients, higher body mass index, and use of general anesthesia, (P < .001 for each), as well as smoking history (P < .39). Relative to operative times shorter than 90 minutes, surgical procedures lasting more than 120 minutes had higher rates of any complication (P = .002), return to the operating room (P = .008), urinary tract infection (P = .02), non-home discharge (P < .001), blood transfusion (P < .001), and unplanned 30-day hospital readmission (P = .03). CONCLUSION: Increasing surgical duration was associated with a variety of postoperative medical complications and increased use of health care resources including discharge to acute care facilities, blood transfusions, and hospital readmission. These data suggest that surgical duration should be considered for postoperative risk stratification, as well as patient counseling, and may be a surgeon-modifiable risk factor independent of patient risk factors.

Assessing the Readability of Online Information About Hip Arthroscopy.

PURPOSE: To investigate the current readability of online information pertaining to hip arthroscopy. METHODS: The terms "hip arthroscopy" and "hip scope" were entered into the advanced search functions of Google, Yahoo!, and Bing on March 25, 2017, and results from the first 3 pages were analyzed. Results were required to be unique, accessible websites with information about hip arthroscopy conveyed primarily via analyzable text. Two reviewers applied inclusion criteria to the initial 97 results, discussing to reach consensus in cases of disagreement. Overall, 60 unique results were reviewed with 48 meeting inclusion criteria. Websites were categorized as physician-sponsored, academic, commercial, governmental and nonprofit organization (NPO), or unspecified. Readability was measured via 6 different indices: the Flesch-Kincaid grade level (FKGL), Flesch Reading Ease (FRE), Gunning Fog Score, SMOG Index, Coleman-Liau Index (CLI), and Automated Readability Index (ARI) along with an average grade level and readability classification score. RESULTS: Forty-eight unique websites were assessed for readability, with physician-sponsored webpages composing the majority (47.92%) followed by academic sources (35.42%). The webpages' average grade level, incorporating information from all 6 metrics, was 12.79 ± 1.98. CONCLUSIONS: The current readability of online information pertaining to hip arthroscopy is at an inappropriately high reading level compared with the sixth-grade level recommended by the American Medical Association and National Institutes of Health, thus introducing significant barriers to understanding for many patients. Online materials should be edited to reduce word and sentence length and complexity, use simpler terms, and minimize use of passive voice to facilitate patient knowledge acquisition and understanding of online information about hip arthroscopy. CLINICAL RELEVANCE: This study shows that the current readability of online information on hip arthroscopy exceeds the suggested sixth-grade reading level. It also emphasizes the need for simplifying written materials and offers specific suggestions on doing so to increase accessibility of information for patients.

Publicly Available Anatomic Total Shoulder Arthroplasty Rehabilitation Protocols Show High Variability and Frequent Divergence from the 2020 ASSET Recommendations.

Background: In 2020, the American Society of Shoulder and Elbow Therapists (ASSET) published an evidence-based consensus statement outlining postoperative rehabilitation guidelines following anatomic total shoulder arthroplasty (TSA). Purpose: The purpose of this study was to (1) quantify the variability in online anatomic TSA rehabilitation protocols, and (2) assess their congruence with the ASSET consensus guidelines. Methods: This study was a cross-sectional investigation of publicly available, online rehabilitation protocols for anatomic TSA. A web-based search was conducted in April 2022 of publicly available rehabilitation protocols for TSA. Each collected protocol was independently reviewed by two authors to identify recommendations regarding immobilization, initiation, and progression of passive (PROM) and active range of motion (AROM), as well as the initiation and progression of strengthening and post-operative exercises and activities. The time to initiation of various components of rehabilitation was recorded as the time at which the activity or motion threshold was permitted by the protocol. Comparisons between ASSET start dates and mean start dates from included protocols were performed. Results: Of the 191 academic institutions included, 46 (24.08%) had publicly available protocols online, and a total of 91 unique protocols were included in the final analysis. There were large variations seen among included protocols for the duration and type of immobilization post-operatively, as well as for the initiation of early stretching, PROM, AROM, resistance exercises, and return to sport. Of the 37 recommendations reported by both the ASSET and included protocols, 31 (83.78%) were found to be significantly different between groups (p\<0.05). Conclusion: Considerable variability was found among online post-operative protocols for TSA with substantial deviation from the ASSET guidelines. These findings highlight the lack of standardization in rehabilitation protocols following anatomic TSA. Level of Evidence: 3b.

Psychological Impact and Posttraumatic Stress Disorder Symptomatology After Ulnar Collateral Ligament Injuries in Baseball Players.

Background: Significant psychological impact and prevalence of posttraumatic stress disorder (PTSD) have been well documented in patients sustaining anterior cruciate ligament injury. Purpose: To examine PTSD symptomatology in baseball players after sustaining elbow ulnar collateral ligament (UCL) injury. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Male baseball players of various competition levels (high school through Minor League Baseball [MiLB]) who underwent surgery for a UCL injury between April 2019 and June 2022 participated in the study. Before surgery, patients completed the Impact of Event Scale-Revised (IES-R) to assess PTSD symptomatology. Subgroup analysis was conducted according to level of play and player position. Results: A total of 104 male baseball players with a mean age of 19.4 years (range, 15-29 years) were included in the study; 32 players (30.8%) were in high school, 65 (62.5%) were in college, and 7 (6.7%) were in MiLB. There were 64 (61.5%) pitchers, 18 (17.3%) position players, and 22 (21.2%) 2-way players (both pitching and playing on the field). A total of 30 (28.8%) patients scored high enough on the IES-R to support PTSD as a probable diagnosis, and another 22 patients (21.2%) scored high enough to support PTSD as a clinical concern. Nineteen patients (18.3%) had potentially severe PTSD. Only 4 players (3.8%) were completely asymptomatic. Subgroup analysis revealed college players as significantly more symptomatic than high school players (P = .02), and 2-way players were found to be significantly less susceptible to developing symptoms of PTSD compared with pitchers (P = .04). Conclusion: Nearly 30% of baseball players who sustained a UCL injury qualified for a probable diagnosis of PTSD based on the IES-R. Pitchers and college athletes were at increased risk for PTSD after UCL injury compared with 2-way players and high school athletes, respectively.

Association Between Social Media Activity and Ratings on Physician Review Websites Among Orthopaedic Surgeons With an Active Online Media Presence.

Background: Social media has the potential to play a substantial role in the decision-making of patients when choosing a physician for care. Purpose: The purpose of this study was to determine whether an association exists between physician social media activity and patient satisfaction ratings on physician review websites (PRWs) as well as number of reviews. It was hypothesized that there would be a significant association between physician social media utilization and patient satisfaction ratings. Study Design: Cross-sectional study. Methods: The American Orthopaedic Society for Sports Medicine database was queried for the complete membership list. The online media profile and level of activity of the members were evaluated, and an online media presence score was calculated. The surgeons with the approximately top 10% of online media presence scores were compiled to assess the relationship between social media usage (Twitter, Instagram, YouTube, and Facebook) and patient satisfaction ratings on the Google Reviews, Healthgrades, and Vitals PRWs. Bivariate analysis was performed to compare demographic variables and level of online presence. Results: A total of 325 surgeons were included in the analysis. The most common platform used was Facebook (88.3%). There was no significant relationship between active social media use and overall ratings on any of the PRWs. Active Twitter use was associated with a greater number of ratings on all review websites, a greater number of comments on Google Reviews and Healthgrades, and shorter patient-reported clinic wait times on Healthgrades. Active Instagram use was associated with a greater number of comments on Vitals. No relationships were observed for YouTube or Facebook. Conclusion: For the included sports medicine surgeons who were most active on social media, no significant relationships were found between social media use and overall ratings on PRWs. Of all the platforms assessed, active use of Twitter was the only significant predictor of more reviews on PRWs. Thus, when deciding which form of social media engagement to prioritize in building one's practice, Twitter may serve as a relatively low-demand, high-reward option.

Factors Important to Patient Decision-Making After Ulnar Collateral Ligament Injury in Competitive High School and Collegiate Baseball Players.

Background: Patients are faced with several treatment decisions after an ulnar collateral ligament (UCL) injury: nonoperative versus operative treatment, repair versus reconstruction, and immediate versus delayed surgery. Purpose/Hypothesis: The aim of this study was to investigate the factors important to patients when deciding which treatment to pursue after a UCL injury. We hypothesized that (1) length of time away from sports and seasonal timing would be important to patients and (2) treatment decision-making would be heavily influenced by how many and which seasons of their baseball career would be missed. Study Design: Cross-sectional study. Methods: High school and collegiate baseball players with UCL tears treated at an academic institution were surveyed retrospectively on their sports participation at the time of injury and their UCL injury treatment decisions. Respondents rated the influence of various factors on a 5-point Likert scale, and they selected the top 3 factors and the single most important factor influencing their treatment decisions. Multiple logistic regression analysis was used to assess the relationship between player characteristics and factors important to their treatment decision. Results: A total of 83 athletes completed the survey; 40 were in high school and 43 were in college at the time of injury; 7 were treated nonoperatively and 76 underwent surgery (66 immediately and 10 in a delayed fashion), 10 with UCL repair and 66 with UCL reconstruction. The ability to play competitive baseball in the long term was very important or extremely important to 90% of players, while the ability to play in the short term was very important or extremely important to 17%. Length of recovery and seasonal timing were also important factors for 53% and 54% of players, respectively, and almost all (90%) highly valued advice from a surgeon. Possible failure of nonoperative treatment leading to increased time away and the possible loss of 2 consecutive baseball seasons heavily influenced decision-making in 41% of respondents. Conclusion: Survey respondents were driven by the desire to play baseball in the long term. Treatment decisions were influenced by the length of recovery and by the seasonal timing of their injury, both of which affect how many and which seasons of baseball a player may miss. Patients found advice from their surgeon to be extremely important to decision-making.

Musculoskeletal Injury in American Football: A Bibliometric Analysis of the Most Cited Articles.

Background: Textbook knowledge and clinical dogma are often insufficient for effective evidence-based decision making when treating musculoskeletal injuries in American football players, given the variability in presentation and outcomes across different sports and different levels of competition. Key evidence can be drawn directly from high-quality published articles to make the appropriate decisions and recommendations for each athlete's unique situation. Purpose: To identify and analyze the 50 most cited articles related to football-related musculoskeletal injury to provide an efficient tool in the arsenal of trainees, researchers, and evidence-based practitioners alike. Study Design: Cross-sectional study. Methods: The ISI Web of Science and SCOPUS databases were queried for articles pertaining to musculoskeletal injury in American football. For each of the top 50 most cited articles, bibliometric elements were evaluated: citation count and density, decade of publication, journal, country, multiple publications by the same first author or senior author, article content (topic, injury area), and level of evidence (LOE). Results: The mean ± SD number of citations was 102.76 ± 37.11; the most cited article, with 227 citations, was "Syndesmotic Ankle Sprains" published in 1991 by Boytim et al. Several authors served as a first or senior author on >1 publication, including J.S. Torg (n = 6), J.P. Bradley (n = 4), and J.W. Powell (n = 4). The American Journal of Sports Medicine published the majority of the 50 most cited articles (n = 31). A total of 29 articles discussed lower extremity injuries, while only 4 discussed upper extremity injuries. The majority of the articles (n = 28) had an LOE of 4, with only 1 article having an LOE of 1. The articles with an LOE of 3 had the highest mean citation number (133.67 ± 55.23; F = 4.02; P = .05). Conclusion: The results of this study highlight the need for more prospective research surrounding the management of football-related injury. The low overall number of articles on upper extremity injury (n = 4) also highlights an area for further research.

Three-Grade Magnetic Resonance Imaging-Based Gluteus Medius and/or Minimus Tear Classification System Provides Excellent Inter-Rater Reliability.

Purpose: To develop a magnetic resonance imaging (MRI)-based classification system integrating tear characteristics including tear thickness (partial vs full) and tear retraction (less than or greater than 2 cm) for gluteus medius and/or minimus tears and to determine the inter-rater reliability of this MRI-based classification for gluteus medius and/or minimus tears. Methods: Patients who underwent primary endoscopic or open repair of gluteus medius and/or minimus tears between 2012 and 2022 were identified to be included in the review of 1.5-T MRI scans. One hundred MRI scans were randomized for review by 2 orthopaedic surgeons and evaluated for tear thickness (partial vs full), extent of retraction, and degree of fatty infiltration according to an applied Goutallier-Fuchs (G-F) classification. Tears were also graded according to the 3-grade MRI-based classification system as follows: grade 1, partial-thickness tears; grade 2, full-thickness tears with less than 2 cm of retraction; grade 3, full thickness with 2 cm or more retraction. Inter-rater reliability was calculated by absolute and relative agreement using Cohen's kappa (κ). Significance was defined by P value <.05. Results: In total, 221 patients were identified, and after application of exclusion criteria and randomization, 100 scans were evaluated. The 3-grade classification system demonstrated high absolute agreement (88%) comparable to the absolute agreement of the G-F classification (67%). The 3-grade classification system demonstrated substantial inter-rater reliability (κ = 0.753), whereas the G-F classification demonstrated moderate inter-rater reliability (κ = 0.489). Conclusions: The proposed 3-grade MRI-based classification system for gluteus medius and/or minimus tears demonstrated substantial inter-rater reliability, comparable with that of the applied G-F classification. Clinical Relevance: It is important to understand how gluteus medius and/or minimus tear characteristics impact postoperative outcomes. The 3-grade MRI-based classification incorporates tear thickness and amount of retraction that can complement previous classification systems to give the provider and patient more information when considering treatment options.

Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopedic Shoulder Arthroplasty: A Matched - Pair Analysis.

Background: There is minimal work defining the economic impact of resident participation in shoulder arthroplasty. Thus, this study quantified the opportunity cost of resident participation in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) by determining differences in operative time, relative value units (RVUs)/hour, and RVUs/case. Methods: A retrospective analysis of shoulder arthroplasty procedures were identified from the ACS-NSQIP database from 2006 to 2014 using CPT codes. Demographic, comorbidity, preoperative laboratory data and surgical procedure were used to develop matched cohorts. Mean differences in operative time, RVUs/case and RVUs/hour between attending-only (AO) cases and cases with resident involvement (RI) were examined. Cost analysis was performed to identify differences in RVUs generated per hour in dollars/case. Results: A total of 1786 AO and 1102 RI cases were identified. With the exception of PGY-3 and PGY-4 cases, RI cases had lower mean operative times compared to AO cases. The cost of RI was highest for PGY-3 ($199.87 per case) and PGY-4 ($9 .2 9) residents with all other postgraduate years providing a cost reduction. Discussion: Involvement of residents was associated with shorter operative times leading to a savings of $29.64 per case. Involvement of intermediate-level (PGY-3) residents were associated with increased costs that ultimately decreased as residents became more senior.

A Comprehensive Meta-analysis of Clinical and Biomechanical Outcomes Comparing Double-Bundle and Single-Bundle Posterior Cruciate Ligament Reconstruction Techniques.

BACKGROUND: Posterior cruciate ligament (PCL) reconstruction techniques have historically focused on single-bundle (SB) reconstruction of the larger anterolateral bundle without addressing the codominant posteromedial bundle. The SB technique has been associated with residual laxity and instability, leading to the development of double-bundle (DB) reconstruction techniques. PURPOSE: To perform a meta-analysis of comparative clinical and biomechanical studies to differentiate the pooled outcomes of SB and DB PCL reconstruction cohorts. STUDY DESIGN: Meta-analysis and systematic review: Level of evidence, 3. METHODS: Six databases were queried in February 2022 for literature directly comparing clinical and biomechanical outcomes for patients or cadaveric specimens undergoing DB PCL reconstruction against SB PCL reconstruction. Biomechanical outcomes included posterior tibial translational laxity, external rotational laxity, and varus laxity at 30° and 90° of knee flexion. Clinical outcomes included the side-to-side difference in posterior tibial translation during postoperative stress radiographs, risk of a major complication, and the following postoperative patient-reported outcome measures: Lysholm, Tegner, and International Knee Documentation Committee (IKDC) subjective and objective scores. A random-effects model was used to compare pooled clinical and biomechanical outcomes between the cohorts. RESULTS: Fifteen biomechanical studies and 13 clinical studies were included in this meta-analysis. The DB group demonstrated significantly less posterior tibial translation at 30° and 90° of knee flexion (P < .00001). Additionally, the DB group demonstrated significantly less external rotation laxity at 90° of knee flexion (P = .0002) but not at 30° of knee flexion (P = .33). There was no difference in varus laxity between the groups at 30° (P = .56) or 90° (P = .24) of knee flexion. There was significantly less translation on stress radiographs in the DB group (P = .02). Clinically, there was no significant difference between the groups for the Lysholm score (P = .95), Tegner score (P = .14), or risk of a major complication (P = .93). DB PCL reconstruction led to significantly higher odds of achieving "normal" or "near normal" objective IKDC outcomes for the included prospective studies (P = .04) and higher subjective IKDC scores (P = .01). CONCLUSION: DB PCL reconstruction leads to superior biomechanical outcomes and clinical outcomes relative to SB PCL reconstruction. Re-creating native anatomy during PCL reconstruction maximizes biomechanical stability and clinical outcomes.

Performance-Enhancing Drugs in Healthy Athletes: An Umbrella Review of Systematic Reviews and Meta-analyses.

CONTEXT: Many clinicians, trainers, and athletes do not have a true understanding of the effects of commonly used performance-enhancing drugs (PEDs) on performance and health. OBJECTIVE: To provide an evidence-based review of 7 commonly used pharmacological interventions for performance enhancement in athletes. DATA SOURCES: PubMed and Scopus databases were searched on April 8, 2022. STUDY SELECTION: Systematic reviews (SRs) and meta-analyses (MAs) assessing the performance-enhancing effects of the following interventions were included: androgenic anabolic steroids (AAS), growth hormone (GH), selective androgen receptor modulators (SARMs), creatine, angiotensin-converting enzyme (ACE)-inhibitors, recombinant human erythropoietin (rHuEPO), and cannabis. STUDY DESIGN: Umbrella review of SRs and MAs. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Primary outcomes collected were (1) body mass, (2) muscle strength, (3) performance, and (4) recovery. Adverse effects were also noted. RESULTS: A total of 27 papers evaluating 5 pharmacological interventions met inclusion criteria. No studies evaluating SARMs or ACE-inhibitors were included. AAS lead to a 5% to 52% increase in strength and a 0.62 standard mean difference in lean body mass with subsequent lipid derangements. GH alters body composition, without providing a strength or performance benefit, but potential risks include soft tissue edema, fatigue, arthralgias, and carpel tunnel syndrome. Creatine use during resistance training can safely increase total and lean body mass, strength, and performance in high-intensity, short-duration, repetitive tasks. Limited evidence supports rHuEPO benefit on performance despite increases in both VO2max and maximal power output, and severe cardiovascular risks are documented. Cannabis provides no performance benefit and may even impair athletic performance. CONCLUSION: In young healthy persons and athletes, creatine can safely provide a performance-enhancing benefit when taken in controlled doses. AAS, GH, and rHuEPO are associated with severe adverse events and do not support a performance benefit, despite showing the ability to change bodily composition, strength, and/or physiologic measures. Cannabis may have an ergolytic, instead of ergogenic, effect.

Evaluation of Social Media and Online Utilization Among Members of the American Orthopaedic Society for Sports Medicine: Implications in Practice.

Background: Social media has the potential to act as an avenue for patient recruitment, patient and surgeon education, and expansion of the physician-patient relationship. Purpose: To evaluate the existing social media presence among members of the American Orthopaedic Society for Sports Medicine (AOSSM) to describe trends in different subgroups within the membership. Study Design: Cross-sectional study. Methods: The AOSSM database was queried for a complete membership list. Members were excluded from analysis if they were not orthopaedic sports medicine surgeons practicing in the United States. Demographic characteristics, online media profiles, and levels of online presence were evaluated, and an online media presence score was calculated. Bivariate analysis was performed to compare demographic variables and levels of online presence. Results: A total of 2870 surgeons were included in the analysis. LinkedIn was the most used platform (56%), while YouTube was the least used (10%). Surgeons in academic practice had a significantly greater overall social media presence than their private practice counterparts. Female surgeons had a more significant active online presence on Twitter, Instagram, and Facebook than male surgeons. Surgeons practicing in the Northeast had a greater social media presence than those in any other United States region, and surgeons in the earlier stages of practice (0-14 years) were more likely to utilize social media than their more senior colleagues (≥15 years of practice). On multivariate analysis, surgeons in the earlier stages of practice were more likely to have active Twitter, Instagram, and Facebook accounts, and female surgeons were more likely to have an active Facebook account. Additionally, multivariate analysis revealed that a greater number of ResearchGate publications were associated with male sex and having an academic practice. Comparatively, active Twitter and Instagram use was associated with having an academic practice. Conclusion: The most used platform in this surgeon population was LinkedIn. Orthopaedic surgeons in academic practice, female surgeons, those early in their career, and those practicing in the Northeast highlighted a subset of the sports medicine community who were more likely to have an active online presence compared to the rest of the AOSSM.

Subacromial Balloon Spacer: Indications, Rationale, and Technique.

Irreparable rotator cuff tears are those that cannot be restored back to their native footprint or those in which any repair will "almost certainly" lead to a structural failure as a result of poor tissue quality, degeneration, or retraction1-3. The InSpace subacromial balloon spacer (Stryker) was developed as a temporary spacer to restore anatomic relationships between the glenoid, humerus, and acromion to improve function and reduce pain associated with this challenging pathology. Description: First, a diagnostic arthroscopy is performed. In addition to evaluating the rotator cuff, care is taken to evaluate the tendinous insertion of the subscapularis as well as the long head of the biceps tendon, the labrum, and the articular cartilage of the joint. Synovectomy, bursectomy, and biceps tenodesis or tenotomy are performed as appropriate. For cases with an intact or repairable subscapularis, an acromioplasty is performed. The balloon size is determined with use of a probe through the lateral portal, measured from 1 cm medial to the superior glenoid rim to the lateral border of the acromion. The balloon-insertion device is advanced through the lateral portal, and the balloon is inflated with sterile saline solution after appropriate subacromial positioning. The balloon is then sealed and detached from the insertional device. Alternatives: Most treatment algorithms attempt to reduce pain and dysfunction with initial nonoperative treatment options4. For cases in which nonoperative treatment has failed, several surgical techniques have been described. These include partial rotator cuff repair, graft interposition, graft augmentation, superior capsular reconstruction, tendon transfers, and reverse total shoulder arthroplasty5. Rationale: Ideal candidates for this procedure are patients with irreparable symptomatic rotator cuff tears. These patients should primarily complain of pain and have a preserved range of motion. Alternatively, if they have reduced range of motion because of pain, then their range of motion should improve after a corticosteroid injection. It is also important that the patient has an intact or repairable subscapularis. The balloon is beneficial in patients with medical comorbidities that would limit the use of other techniques dependent on biologic tissue healing or that would limit the use of arthroplasty. Poor candidates would be patients with pseudoparalysis, axillary nerve palsy, irreparable subscapularis tears, or severe glenohumeral arthritis (Hamada grade ≥3). Expected Outcomes: A recent randomized clinical trial demonstrated the 2-year efficacy, safety, and benefits of the InSpace subacromial balloon spacer6. The authors reported significant early clinical benefit that was maintained over 2 years. Additionally, this benefit was equivalent or superior to the partial-repair control group at all included time points. The multiyear clinical efficacy of the subacromial balloon spacer in that study was similar to that reported by Familiari et al. and Senekovic et al. at 3 and 5 years postoperative, respectively1,7. Together, these studies would suggest that the initial benefit of the subacromial balloon spacer lasts beyond its biodegradation at 12 months postoperatively. Important Tips: Proper placement of the lateral portal should be made parallel to the supraglenoid tubercle. Such placement allows easy insertion and orientation of the balloon at the midpoint of the supraglenoid tubercle.Arthroscopic evaluation of the subscapularis must be performed. For cases with a torn subscapularis, partial or complete repair is recommended to maximize anteroposterior coupling forces that are critical to the function of the balloon.Preservation of the medial bursa and coracoacromial ligament will provide structural constraints against medial migration of the balloon into the supraspinatus fossa.Acromioplasty can be performed to create a smooth articulating surface and minimize friction on the implant, but should only be done in cases in which there is an intact or repairable subscapularis to minimize the risk of anterior escape.Adequate debridement, with acromioplasty as needed, will provide full visualization of the subacromial space to allow proper sizing of the spacer. Proper implant sizing will reduce the risk of subsequent balloon displacement postoperatively.If the measurement of the balloon is between 2 sizes, the larger spacer can be selected to limit displacement.Overinflation of the balloon can cause excessive tension on the deltoid. Underinflation increases the risk of escape. To optimize inflation of the balloon, the senior author prefers to fill the balloon to the recommended maximum volume and then remove saline solution until the balloon reaches the recommended final volume.If there is partial tearing of the long head of the biceps, a tenotomy or tenodesis is recommended. Acronyms and Abbreviations: ROM = range of motionRCT = randomized clinical trialTSA = total shoulder arthroplastySCR = superior capsular reconstructionRC = rotator cuffISP = infraspinatusSSP = supraspinatusSSC = subscapularisRI = rotator intervalCAL = coracoacromial ligamentCA = coracoacromialC = coracoidMRI = magnetic resonance imagingSAD = subacromial decompressionPRO = patient-reported outcomeFDA = U.S. Food and Drug Administration.

Arthroscopic all - Inside repair of meniscal ramp lesions.

Meniscal ramp lesions are disruptions of the posterior meniscotibial attachment of the medial meniscus and are commonly associated with anterior cruciate ligament injuries. However, they can be frequently missed when reviewing standard magnetic resonance imaging and difficult to treat. In this presentation, we describe our approach to repair a meniscal ramp lesion using a minimally invasive all-inside technique. We use this technique for the following surgical indications: meniscal tears involving the peripheral and meniscocapsular attachment of the posterior horn resulting in increased meniscal translation. The procedure is performed using standard arthroscopic portals along with a posteromedial portal placed using spinal needle localisation to ensure access around the lesion. Advantages of this technique include a minimally invasive repair that avoids the typical medial knee incision and dissection needed for traditional inside-out repairs, as well as direct visualisation of the repair site to ensure an appropriately tensioned anatomic repair. Technical pearls including adequate arthroscopic visualisation of the posteromedial compartment allowing the creation of a posteromedial working portal, direct passage of sutures through the edges of the ramp lesion facilitating an anatomic repair, and tensioning of the repair with arthroscopic knots to ensure restoration of the posterior horn stability are all critical to a good outcome. Furthermore, the use of two different curve directions for more displaced tears may be necessary to achieve an anatomic repair. In this case and in our experience, we use a Corkscrew SutureLasso 45° curve left for the meniscus bite and right for the capsular bite, as well as a long 8.25 mm by 70 mm twist-in cannula to accommodate the passing of insertion instrumentation in larger patients.

Minimally Invasive Surgical Approach for Open Common Peroneal Nerve Neurolysis in the Setting of Previous Posterior Schwannoma Removal.

The common peroneal nerve (CPN) runs laterally around the fibular neck and enters the peroneal tunnel, where it divides into the deep, superficial, and recurrent peroneal nerves. CPN entrapment is the most common neuropathy of the lower extremity and is vulnerable at the fibular neck because of its superficial location. Schwannomas are benign, encapsulated tumors of the nerve sheath that can occur sporadically or in cases of neurocutaneous conditions, such neurofibromatosis type 2. In cases with compressive neuropathy resulting in significant or progressive motor loss, decompression and neurolysis should be attempted. We present a technical note for the treatment of CPN compressive neuropathy in the setting of a previous ipsilateral schwannoma removal with a minimally invasive surgical approach and neurolysis of the CPN at the fibular neck.

Rehabilitation Variability Following Osteochondral Autograft and Allograft Transplantation of the Knee.

OBJECTIVE: The aim of this study is to assess the variability of postoperative rehabilitation protocols used by orthopedic surgery residency programs for osteochondral autograft transplantation (OAT) and osteochondral allograft transplantation (OCA) of the knee. DESIGN: Online postoperative OAT and OCA rehabilitation protocols from US orthopedic programs and the scientific literature were reviewed. A custom scoring rubric was developed to analyze each protocol for the presence of discrete rehabilitation modalities and the timing of each intervention. RESULTS: A total of 16 programs (10.3%) from 155 US academic orthopedic programs published online protocols and a total of 35 protocols were analyzed. Twenty-one protocols (88%) recommended immediate postoperative bracing following OAT and 17 protocols (100%) recommended immediate postoperative bracing following OCA. The average time protocols permitted weight-bearing as tolerated (WBAT) was 5.2 weeks (range = 0-8 weeks) following OAT and 6.2 weeks (range = 0-8 weeks) following OCA. There was considerable variation in the inclusion and timing of strength, proprioception, agility, and pivoting exercises. Following OAT, 2 protocols (8%) recommended functional testing as criteria for return to sport at an average time of 12.0 weeks (range = 12-24 weeks). Following OCA, 1 protocol (6%) recommended functional testing as criteria for return to sport at an average time of 12.0 weeks (range = 12-24 weeks). CONCLUSION: A minority of US academic orthopedic programs publish OAT and OCA rehabilitation protocols online. Among the protocols currently available, there is significant variability in the inclusion of specific rehabilitation components and timing of many modalities. Evidence-based standardization of elements of postoperative rehabilitation may help improve patient care and subsequent outcomes.

Disparities in Telemedicine Utilization During COVID-19 Pandemic: Analysis of Demographic Data from a Large Academic Orthopaedic Practice.

Background: The coronavirus-19 (COVID-19) pandemic has prompted a shift in health-care provision toward implementation of telemedicine. This study investigated demographic information on orthopaedic telemedicine utilization at a single academic orthopaedic institution in an effort to identify factors associated with telemedicine usage. Methods: Demographic and appointment data were collected from the electronic medical record during equivalent time periods prior to the onset of the COVID pandemic (pre-COVID) and during the COVID pandemic (peri-COVID). Multivariate analyses were performed to identify demographic and socioeconomic correlates of telemedicine utilization. Results: There was a significant increase in telemedicine visits between the eras of study, with significant differences in telemedicine usage in association with age, sex, marital status, English as the primary language, and insurance type (p < 0.001). Multivariate analyses found American Indian/Alaska Native (adjusted odds ratio [aOR] = 0.487, p = 0.004), Black/African American (aOR = 0.622, p < 0.001), Native Hawaiian/other Pacific Islander (aOR = 0.676, p = 0.003), and Asian (aOR = 0.731, p < 0.001) race to be significantly associated with decreased telemedicine usage. Additionally, male sex (aOR = 0.878, p < 0.001) and a non-commercial insurance plan (p < 0.001) were significantly associated with decreased telemedicine usage. Conclusions: Non-White race, non-commercial insurance plans, and male sex were associated with decreased telemedicine utilization. Further investigation is needed to characterize and better identify underlying factors contributing to disparities in telemedicine access and utilization.