No Differences in Exercise Performance, Perceptual Response, or Safety Were Observed Among 3 Blood Flow Restriction Devices

Purpose

To compare 3 separate blood flow restriction (BFR) systems in their capacity to reduce repetitions to failure, impact perceptual responses, and cause adverse events during a low-load free-flow exercise.

Methods

The study included healthy subjects aged 18 years or older who presented to an ambulatory-care sports medicine clinic. On day 1, participants' demographic characteristics and anthropomorphic measurements were recorded. Each participant performed dumbbell biceps curl repetitions to failure using 20% of his or her 1-repetition maximum weight with each arm. Participants were exposed to 3 different tourniquet systems for familiarization. On day 2, each participant's arm was randomized to a cuff system, and the participant performed 2 sets of biceps curl repetitions to failure with the cuff inflated. Repetitions to failure, rating of perceived effort (RPE), rating of perceived discomfort, and pulse oxygenation levels were recorded after each set. On day 3, participants completed a survey of their perceived delayed-onset muscle soreness.

Results

The final analysis was performed on 42 arms, with 14 limbs per system. The study population had a mean age of 28.7 ± 2.4 years and a mean body mass index of 24.9 ± 4.3. All 3 systems successfully reduced repetitions to failure compared with unrestricted low-load exercise from baseline to BFR set 1 and from baseline to BFR set 2. There were no significant between-group differences among BFR systems regarding the number of repetitions to failure performed at baseline versus BFR set 1 or BFR set 2. The Delfi Personalized Tourniquet System (PTS) cohort had the greatest reductions in repetitions to failure from BFR set 1 to BFR set 2 (P = .002) and reported the highest RPE after set 2 (P = .025).

Conclusions

The Delfi PTS, SmartCuffs Pro, and BStrong BFR systems were each safe and were able to significantly reduce repetitions to failure compared with a low-load free-flow condition when used in a BFR exercise protocol. The Delfi PTS system may produce a higher RPE with prolonged use in comparison to the other systems.

Level of Evidence

Level II, prospective cohort study.

Effects of a Perioperative Blood Flow Restriction Therapy Program on Early Quadriceps Strength and Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction

Background

Quadriceps muscle atrophy remains a limiting factor in returning to activity after anterior cruciate ligament reconstruction (ACLR). Blood flow restriction (BFR) therapy may accelerate quadriceps strengthening in the perioperative period.

Purpose

To evaluate postoperative isometric quadriceps strength in patients who underwent ACLR with a perioperative BFR program.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Patients indicated for ACLR were randomized into 2 groups, BFR and control, at their initial clinic visit. All patients underwent 2 weeks of prehabilitation preoperatively, with the BFR group performing exercises with a pneumatic cuff set to 80% limb occlusion pressure placed over the proximal thigh. All patients also underwent a standardized postoperative 12-week physical therapy protocol, with the BFR group using pneumatic cuffs during exercise. Quadriceps strength was measured as peak and mean torque during seated leg extension and presented as quadriceps index (percentage vs healthy limb). Patient-reported outcomes (PROs), knee range of motion, and quadriceps circumference were also gathered at 6 weeks, 3 months, and 6 months postoperatively, and adverse effects were recorded.

Results

Included were 46 patients, 22 in the BFR group (mean age, 25.4 ± 10.6 years) and 24 in the control group (mean age, 27.5 ± 12.0 years). At 6 weeks postoperatively, the BFR group demonstrated significantly greater strength compared with the controls (quadriceps index: 57% ± 24% vs 40% ± 18%; P = .029), and the BFR group had significantly better Patient-Reported Outcomes Measurement Information System-Physical Function (42.69 ± 5.64 vs 39.20 ± 5.51; P = .001) and International Knee Documentation Committee (58.22 ± 7.64 vs 47.05 ± 13.50; P = .011) scores. At 6 weeks postoperatively, controls demonstrated a significant drop in the peak torque generation of the operative versus nonoperative leg. There were no significant differences in strength or PROs at 3 or 6 months postoperatively. Three patients elected to drop out of the BFR group secondary to cuff intolerance during exercise; otherwise, no other severe adverse events were reported.

Conclusion

Integrating BFR into perioperative physical therapy protocols led to improved strength and increased PROs at 6 weeks after ACLR. No differences in strength or PROs were found at 3 and 6 months between the 2 groups.

Registration

NCT04374968 (ClinicalTrials.gov identifier).

The effect of subscapularis-specific rehabilitation following total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial

BACKGROUND

Patients undergoing a total shoulder arthroplasty (TSA) through a deltopectoral approach will require repair of the subscapularis tendon. There are no universal postoperative guidelines for rehabilitation of the subscapularis specifically. We hypothesize that the addition of a subscapularis-specific regimen will result in improved subscapularis strength and function.

METHODS

Adult patients undergoing anatomic TSA for the treatment of primary glenohumeral osteoarthritis were included. Patients were randomized into either the traditional rehabilitation (TR) control group or the subscapularis rehabilitation (SR) group, which consisted of the traditional therapy along with early and additional subscapularis exercises. Baseline demographics, patient-reported outcome measures (PROMs), range of motion (ROM), provocative tests, and subscapularis strength using a handheld dynamometer were measured preoperatively at the initial clinic visit (ICV) as well as 3 months, 6 months, and 1 year postoperatively. The primary outcome of interest was a comparison of subscapularis strength between cohorts relative to preoperative baseline, whereas secondary outcomes were functional, ROM, and PROMs.

RESULTS

Sixty-six patients were included in the final analysis (32 TR vs. 34 SR). There were no statistically significant differences between cohorts at the ICV with regard to demographics, baseline subscapularis strength, functional testing, or PROMs. All postoperative time points demonstrated similar subscapularis strength testing between TR and SR groups (P > .05). Additionally, peak and average subscapularis strength testing at 3, 6, and 12 months postoperatively were similar to baseline ICV testing in both groups. Both groups demonstrated improvements across several provocative tests, ROM, and PROM outcome metrics at every postoperative time point as compared to baseline ICV values (P < .05).

CONCLUSIONS

Patients undergoing anatomic TSA return to baseline internal rotation strength by 3 months postoperatively and demonstrate significant improvements in function, ROM, and several patient-reported outcome measures. The addition of early and focused subscapularis strengthening exercises does not appear to significantly impact any outcomes when compared to traditional rehabilitation programs.

Patient factors influencing the choice of opioid versus non-opioid postoperative analgesia following common sports procedures: a prospective survey study

Purpose

Despite established opioid-free protocols for postoperative analgesia after common orthopaedic sports procedures, many patients continue to request opioids postoperatively. The purpose of this study was to elucidate patient factors influencing preferences for opioid versus nonopioid postoperative analgesia.

Methods

Patients (age >/ = 15) without a history of a documented chronic pain disorder who were scheduled for one of ten sports procedure types from August 2020 to May 2021 were eligible for inclusion. Patients were excluded if undergoing revision surgery, had concomitant injuries, had opioids use >3 months preoperatively, or unable to read English. Recruitment ended after 100 patients enrolled. At the patients' preoperative visit, patients were administered a written survey assessing pain medication preferences. Participants completed the Opioid Risk Tool survey, as well as Visual Analog Scale and Patient-Reported Outcome Measurement Information System surveys.

Results

One hundred patients participated in the study. Forty-two patients preferred opioids versus 58 patients preferring nonopioid postoperative analgesia. Patients preferring opiates were more likely to have had previous surgery (90.2% vs. 69.6%, p = 0.023) with post-operative pain managed with opiates (87.5% vs 55.4%, p = 0.003), higher preoperative Visual Analog Scale score (6±3.5 vs. 3±2, p < 0.001), reported post-operative pain as a reason for opioids preference (88.1% vs 20.0%, p < 0.001), and were less concerned about addiction (4.8% vs. 45.5%, p < 0.001) and side effects (11.9% vs. 52.7%, p < 0.001). For every unit increase in Visual Analog Scale score, the odds of preferring opioid pain control increased 1.41 times.

Conclusions

Patients with a history of prior surgery utilizing opioid pain control, higher Visual Analog Scale scores preoperatively, and concern for inadequately managed postoperative pain were more likely to prefer opioid pain control following common orthopaedic sports procedures. Patients may benefit from increased preoperative education about opioid risks and the role of multimodal pain management regimens.

Survey of blood flow restriction therapy for rehabilitation in Sports Medicine patients

Background

Blood flow restriction (BFR) therapy has demonstrated benefits across a spectrum of musculoskeletal injuries, including improved strength, endurance, function, and reduction in pain perception. There is, however, no standardized application of BFR therapy among orthopaedic surgeons within the United States (US).

Hypothesis

The indication and protocol for BFR therapy vary significantly across providers in the US.

Methods

An online survey of 21 multiple-choice questions was sent to 3,281 surgeons listed on a large orthopaedic registry. A cross-sectional study was performed on all surgeons who successfully completed the questionnaire. Surgeons were queried on current or planned use of BFR, indications, contraindications, and peri-operative and non-operative management of sports-related injuries.

Results

Overall, 250 physicians completed the survey, with 149 (59.8%) reporting current BFR use and 75.2% initiating use in the last 1-5 years. Most protocols (78.8%) utilize the modality 2-3 times per week while 15.9% use it only once weekly. Anterior cruciate ligament reconstruction (ACLR) rehabilitation was the most reported indication for initiating BFR therapy (95.7%) along with medial patellofemoral ligament reconstruction (70.2%), multiligamentous knee reconstruction (68.8%), meniscus repair (62.4%), collateral ligament reconstruction (50.4%), Achilles tendon repairs (30.5%), and meniscectomy (27%). Only 36.5% reported using BFR after upper extremity procedures, such as distal biceps repair (19.7%), ulnar collateral ligament elbow reconstruction (17%), rotator cuff (16.8%), and shoulder labrum repair (15.3%). For non-operative injuries, 65.8% of surgeons utilized BFR. Of those not currently using BFR therapy, 33.3% intended to implement its use in the future.

Conclusion

BFR therapy has increased in popularity with most physicians implementing its use in the last 5 years. BFR was commonly utilized after ACLR.

Clinical relevance

BFR allows light-load resistance to simulate high-intensity resistance training. This study describes US orthopaedic surgeons' common practice patterns and patient populations that utilize BFR therapy.

Availability of Consumer Prices for Arthroscopic Meniscus Surgery

The purpose is to examine the availability of consumer pricing information for arthroscopic meniscal surgery in the United States. Secondary objectives were comparing the price of meniscal repair to meniscectomy and regional pricing differences. Orthopaedic sports medicine clinics were sorted by state and randomly selected from American Orthopaedic Society for Sports Medicine's online directory. Following standardized script, each clinic was called a maximum of three times to obtain pricing information for meniscal surgery. A total of 1,008 distinct orthopaedic sport medicine practices were contacted. Six (6%) clinics were able to provide complete bundle pricing, and 183 (18.2%) clinics were able to provide physician-only fees for either meniscectomy or meniscal repair. Physician-only fees and bundle pricing were significantly less for meniscal repairs as compared to meniscectomies. There were no geographic regional differences in pricing for physician-only fees. There is a paucity of information regarding price transparency for arthroscopic meniscal surgery. (Journal of Surgical Orthopaedic Advances 32(2):083-087, 2023).

An Automated Technique for the Measurement of Limb Occlusion Pressure During Blood Flow Restriction Therapy Is Equivalent to Previous Gold Standard

Purpose

Methods

Results

Conclusions

Level of Evidence

Multimodal Nonopioid Pain Protocol Provides Better or Equivalent Pain Control Compared to Opioid Analgesia Following Arthroscopic Rotator Cuff Surgery: A Prospective Randomized Controlled Trial

PURPOSE

To evaluate the efficacy of a multimodal nonopioid analgesic protocol in controlling postoperative pain compared to opioids following a primary arthroscopic rotator cuff repair.

METHODS

Seventy consecutive patients undergoing a primary rotator cuff repair were assessed for eligibility. An observer-blinded prospective randomized controlled trial was designed in accordance with the Consolidated Standards of Reporting Trials 2010 (CONSORT) statement. The two arms of the study included a multimodal nonopioid pain regimen for the experimental group, and a standard of care narcotics for the control group. The primary outcome was visual analog scale (VAS) pain scores for the first 10 postoperative days. Secondary outcomes included PROMIS-PI (Patient-Reported Outcomes Measurement Information System-Pain Interference) scale, patient satisfaction, and adverse drug events.

RESULTS

Thirty patients declined to participate or were excluded, and 40 patients were included in the final analysis. A total of 23 patients were in the traditional group, and 17 patients were in the nonopioid group. Control patients on opioid pain management reported a significantly higher VAS pain score on postoperative day 1 (opioid: 5.7 ± 2, nonopioid: 3.7 ± 2.2; P = .011) and postoperative day 4 (opioid: 4.4 ± 2.7, nonopioid: 2.4 ± 2.2; P = .023). No significant difference was seen on any other postoperative day. When mixed measured models were used to control for confounding factors, the nonopioid group demonstrated significantly lower VAS and PROMIS-PI scores (P < .01) at every time point. Patients in the traditional analgesia group reported significantly more days with constipation (P = .003) and days with upset stomach (P = .020) than those in the nonopioid group.

CONCUSSION

The present study found that a multimodal nonopioid pain protocol provided equivalent or better pain control compared to traditional opioid analgesics in patients undergoing primary arthroscopic rotator cuff repair. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort. All patients reported satisfaction with their pain management.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Patellar Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

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Patellar tendinopathy is an attritional injury of the patellar tendon that is frequently identified in jumping athletes. Through repetitive or explosive movements, considerable loads and high peak strains are generated across the patellar tendon.

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This leads to microinjury of tendon fibers, local mucoid degeneration, and loss of the fibrocartilaginous tissue that attaches tendon to bone.

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Management of patellar tendinopathy often begins with nonoperative modalities: progressive tendon loading and eccentric rehabilitative exercise programs are the most effective. While a variety of additional treatment modalities are available, the comparative efficacy of these supportive treatments is not well differentiated at this time.

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In this article, we analyze the existing literature regarding nonoperative treatment of patellar tendinopathy and provide additional insight on the effectiveness of current modalities.

Lower Extremity Injury After Return to Sports From Concussion: A Systematic Review

Background:

Recent studies have suggested increased rates of lower extremity (LE) musculoskeletal injury after a diagnosed concussion, although significant heterogeneity exists.

Purpose:

To examine the current body of research and determine whether there is an increased risk for LE musculoskeletal injury after a concussion and to identify populations at an increased risk.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review of current literature using MEDLINE and PubMed databases was performed. Keywords included concussion, athlete, lower extremity injury, and return to sport. Inclusion criteria required original research articles written in the English language examining the rate of LE injuries after a diagnosed concussion.

Results:

A total of 13 studies involving 4349 athletes (88.1% male and 11.9% female; mean age, 19.8 years) met inclusion criteria. Athletes were classified as high school (46.1%), collegiate (17.0%), or professional (36.9%). Of the 13 studies, 4 demonstrated an increased risk of LE injury within 90 days of a diagnosed concussion (odds ratio [OR], 3.44; 95% CI, 2.99-4.42), and 6 revealed an elevated risk of injury within 1 year of concussion (OR, 1.85; 95% CI, 1.73-2.84). Increased risk was seen in professional (OR, 2.49; 95% CI, 2.40-2.72) and collegiate (OR, 2.00; 95% CI, 1.96-2.16) athletes compared with high school athletes (OR, 0.97; 95% CI, 0.89-1.05). A stepwise increase in risk of sustaining an LE injury was observed with multiple concussions, with increasing risk observed from ≥2 (OR, 2.29; 95% CI, 1.85-2.83) to ≥3 (OR, 2.86; 95% CI, 2.36-3.48) career concussions.

Conclusion:

An increased incidence of LE injuries was observed at 90 days and 1 year after the diagnosis of a concussion. Higher levels of competition, such as at the collegiate and professional levels, resulted in an increased risk of sustaining a subsequent LE injury after a diagnosed concussion. These results suggest an at-risk population who may benefit from injury prevention methods after a concussion. Future studies should focus on identifying which injuries are most common, during what time period athletes are most vulnerable, and methods to prevent injury after return to sports.

Concussions in the National Hockey League: Analysis of Incidence, Return to Play, and Performance

Background:

Concussion injuries are common in professional hockey; however, their effect on player performance remains unclear.

Purpose:

To quantify the effect of concussions on the performance of position players in the National Hockey League (NHL).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Concussion data from the NHL were collected using publicly available databases for the seasons between 2009-2010 and 2015-2016, coinciding with new NHL concussion rules. Age, body mass index, position, number of concussions during a player’s NHL career, games played, and time on ice were recorded. Basic and advanced performance metrics were collected for 1 season pre- and postconcussion (short-term period) and 3 seasons before and after concussion (long-term period) to assess short- and long-term changes in performance. A control group of players without an identified concussion who competed during the study period was assembled for comparison. Wilcoxon signed rank tests were used to evaluate pre- to postconcussion data in the short- and long-term settings as well as to compare the cohorts at each time point.

Results:

Overall, 48 players were identified as having a concussion during the study period. Players missed 17.2 ± 15.1 days (mean ± standard deviation) and 7.5 ± 6.9 games postconcussion. There were no significant differences in any metric when pre- and postconcussion intraseason performance was assessed. Athletes who were concussed demonstrated significantly deceased performance metrics (assists per 60 minutes, points per 60 minutes, Corsi percentage, and Fenwick percentage) in the 3 years after the concussion as compared with the year before injury ( P < .05). However, no difference was found between the concussed group and matched control group in the short- or long-term period. Players with concussion played fewer career games (856.4 ± 287.4 vs 725.7 ± 215.0; P < .05) than did controls.

Conclusion:

A high rate of NHL players were able to return to play after a concussion injury. Players with concussion did not experience a reduction in performance metrics in the short- or long-term setting when compared with matched controls. The concussed cohort maintained a similar workload up to 3 seasons postconcussion but played in fewer career games when compared with matched controls.

Elbow Torque May be Predictive of Anatomic Adaptations to the Elbow After a Season of Collegiate Pitching: A Dynamic Ultrasound Study

Purpose

To determine whether elbow torque was associated with anatomic adaptations of the medial elbow following a season of competitive pitching.

Methods

Pitchers from 3 collegiate baseball teams were recruited during the preseason for participation. Before the season, pitchers were recorded throwing 5 “game-speed” fastball pitches from a standard distance off a mound while wearing a wearable sensor baseball compression sleeve that calculates elbow torque, arm speed, arm slot, and arm rotation. Participants subsequently underwent dynamic ultrasound imaging of the medial elbow, including measurements of the ulnar collateral ligament (UCL) and ulnohumeral joint space to assess elbow laxity. Following a full season of competitive pitching, all testing was repeated, and statistical analysis comparing preseason to postseason sonographic findings was performed.

Results

Twenty-eight collegiate pitchers underwent preseason sonographic and kinematic testing. Nineteen pitchers were available for postseason testing. The average age (standard deviation) and playing experience was 19.9 (1.2) and 14.7 (1.5) years. Compared with preseason, there were significant increases in postseason UCL thickness (1.92 ± 0.09 vs 1.56 ± 0.09 mm, P < .01) and elbow laxity (1.77 ± 0.23 vs 1.15 ± 0.22 mm, P = .028) after a season of pitching. No significant changes in pitching kinematic measurements were observed between preseason and postseason testing. Preseason pitching kinematic measurements were significantly associated with increased UCL thickness (arm slot: beta estimate –0.03 ± 0.01, P = .011) and reduction in elbow laxity (elbow torque: beta estimate –0.03 ± 0.01, P = .04) after a season of pitching. Pitchers with increased body weight and arm length demonstrated reduced medial elbow torque during pitching (P < .05).

Conclusions

After a season of competitive pitching, adaptive changes of the medial elbow were demonstrated on dynamic ultrasound. However, the influence of pitching kinematic measurements on these adaptations are of small magnitude and unknown clinical significance. Although wearable sensor technology may have value in trending individual pitcher kinematics, no discrete threshold appears to predict the development of adaptive changes at the elbow.

Level of Evidence

Level II, prospective observational study.

Older, Heavier, Arthritic, Psychiatrically Disordered, and Opioid-Familiar Patients Are at Risk for Opioid Use After Medial Patellofemoral Ligament Reconstruction

Purpose

To investigate which factors predispose patients for prolonged opioid use after medial patellofemoral ligament (MPFL) reconstruction.

Methods

A retrospective review of all patients who underwent MPFL reconstruction at a single institution between January 2013 and June 2020 was conducted. Opioid consumption before and after surgery was recorded and confirmed using Michigan Automated Prescriptions System monitoring program. Patients were classified into preoperative opioid users and nonusers. Risk factors for continued opioid use were assessed by collecting patient demographic variables, psychiatric history, number of previous patellar dislocations, and operative factors.

Results

A total of 102 patients were included during the time frame of interest. Patients were on average 21.6 ± 8.5 years old with a mean body mass index of 28.2 ± 7.9. Thirty patients (29.0%) sustained >10 dislocations preoperatively. Preoperative opioid use was present in 13 (12.7%) patients. Greater than 10 dislocations (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.12-20.92) and psychiatric history (OR 3.33, 95% CI, 1.2-9.1; P = .016) significantly predicted opioid refills the first month after surgery. Risk factors for opioid refills at 2 to 12 months postoperatively included smoking (OR 4.50, 95% CI 1.13-17.96), preoperative opioid use (OR 7.32, 95% CI 1.88-28.47), psychiatric disorder (OR 3.77, 95% CI 2.3-6.2; P < .001), age >30 years (OR 7.03, 95% CI 3.63-13.61; P < .001), and obesity (OR 2.68, 95% CI 1.40-5.14; P = .002). Compared with Outerbridge 0, a greater percentage of patients with Outerbridge 1 or 2 and 3 or 4 continued using opioids 2 to 12 months after surgery (OR 3.06, 95% CI 1.33-7.02; P = .006 and OR 2.86, 95% CI 1.24-6.59; P = .010, respectively).

Conclusions

For patients undergoing MPFL reconstruction, preoperative opioid use, cartilage damage, age >30 years, smoking history, body mass index >30, and history of psychiatric disorder were found to be significantly associated with prolonged opioid use after surgery. Postoperative opioid refills in this cohort declined after 1 month.

Level of Evidence

Level III, retrospective cohort study.

Social Media Use Continues to Increase Among Orthopaedic Residency Programs in the United States

Purpose

To evaluate the social media usage of orthopaedic residency programs, program directors (PDs), and department chairs across Instagram, Facebook, and Twitter and to determine which types of social media posts are indicative of increased user following.

Methods

A systematic online search strategy was performed in October 2020 to identify all allopathic orthopaedic surgery residency program accounts on Instagram, Facebook, and Twitter. Instagram posts were further analyzed to evaluate the type of post that significantly correlated with increased follower counts.

Results

Of 158 orthopaedic surgery programs, 69 (43.7%) had Instagram accounts, 52 (32.9%) had Facebook accounts, and 54 (34.2%) had Twitter accounts. Program presence on Instagram and Twitter continued to grow exponentially (R² = 0.99 and R² = 0.95, respectively). Regarding program leadership, a total of 151 PDs and 156 chairs were identified. Of these, 21 PDs (14%) and 8 chairs (5.1%) had Instagram accounts. The number of posts and the numbers of educational, social, program information, and operative posts (P < .01) significantly correlated with increased followers on Instagram.

Conclusions

Fewer than one-half of orthopaedic surgery residency programs and fewer than one-quarter of PDs and department chairs have a social media presence. However, the number of residency programs on social media continues to rise year-over-year. The total number of posts; the amount of educational, social, and program information; and the number of operative posts significantly correlated with increased followers on Instagram.

Clinical Relevance

With the growing prevalence of social media, orthopaedic surgery residency programs have the opportunity to connect with future applicants and disseminate informational content regarding their programs.

Game Utilization and Performance Following RTP From ACL Reconstruction Does not Influence a Subsequent Second ACL Injury in National Football League Players

Purpose

The purpose of this study is to evaluate differences in game utilization or performance following primary anterior cruciate ligament (ACL) reconstruction between National Football League (NFL) players with and without a second ACL injury.

Methods

NFL players who underwent ACL reconstruction between 2013 and 2017 were identified. Players were classified as having one injury (“tear”) or having later sustained a subsequent second (reinjury or contralateral) ACL injury (“retear”). Players were excluded if they tore their ACL prior to the NFL, did not return to play (RTP), did not play the season before injury, or had concomitant injuries. Demographic characteristics, game utilization statistics, and season approximate value (SAV) performance metrics were recorded. Statistical analysis compared data after RTP from primary ACL reconstruction (seasons +1, +2, and +3) relative to the season before injury (season −1) between cohorts using mean differences and relative percentages.

Results

Analysis included a total of 45 players, 32 in the “tear” group and 13 in the “retear” group. Demographics, level of play, and time to RTP after primary ACL reconstruction did not differ between the groups (P > .05). Tear and retear groups demonstrated similar utilization and performance metrics the season prior to injury (−1) and the 3 seasons following RTP (season of injury is “0”). Both groups had a similar decrease (relative percentage) in games played and started, snap counts, and SAV during the 3 seasons following RTP compared to baseline (P > .05). The draft pick position was correlated with the relative percentage of games started the first season after RTP (r = .6, P = .02).

Conclusions

Game utilization and performance metrics following ACL reconstruction were not associated with a subsequent second ACL injury. Players with a higher draft pick position were more likely to return to the starting lineup following primary ACL reconstruction. Ultimately, player game utilization and performance following primary ACL reconstruction is not predictive of a subsequent second ACL injury.

Level of Evidence

Level III, retrospective case-control study

Acromioclavicular Joint Reconstruction with Recessed Clavicular Implant Technique Guide

Acromioclavicular (AC) joint injuries are common and often require operative intervention. Although there are many described surgical techniques, there remains a lack of consensus on the optimal technique. The purpose of this Technical Note is to provide our preferred method of AC reconstruction with a recessed clavicular implant and semitendinosus allograft, which mitigates hardware pain associated with arthroscopic techniques.

Multimodal nonopioid pain protocol provides equivalent pain control versus opioids following arthroscopic shoulder labral surgery: a prospective randomized controlled trial

BACKGROUND

This study aimed to compare postoperative pain and patient satisfaction in patients undergoing primary arthroscopic labral surgery managed with either a nonopioid alternative pain regimen or a traditional opioid pain regimen.

METHODS

Sixty consecutive patients undergoing primary arthroscopic shoulder labral surgery were assessed for participation. In accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement, a prospective randomized controlled trial was performed. The 2 arms of the study were a multimodal nonopioid analgesic protocol as the experimental group and a standard opioid regimen as the control group. The primary outcome was postoperative pain scores (on a visual analog scale [VAS]) for the first 10 days postoperatively. Secondary outcomes included patient satisfaction, patient-reported outcomes, and complications. Randomization was performed with a random number generator, and all data were collected by blinded observers. Patients were not blinded.

RESULTS

Twelve patients did not meet the inclusion criteria or declined to participate. Thus, 48 patients were included in the final analysis: 24 in the nonopioid group and 24 in the opioid group. There was no significant difference in VAS or PROMIS (Patient-Reported Outcomes Measurement Information System) scores between patients in the 2 cohorts on any postoperative day (P > .05). When we controlled for confounding factors with repeated-measures mixed models, the nonopioid cohort reported significantly lower VAS and PROMIS (Patient-Reported Outcomes Measurement Information System) Pain Interference scores (P < .01) at all time points. No difference was found in reported adverse events (constipation, diarrhea, drowsiness, nausea, and upset stomach) between cohorts at any time point (P > .05).

CONCLUSION

This study found that a multimodal nonopioid pain regimen provided, at the minimum, equivalent pain control, an equivalent adverse reaction profile, and equivalent patient satisfaction when compared with a standard opioid-based regimen following arthroscopic shoulder labral surgery.

Age Significantly Affects Response Rate to Outcomes Questionnaires Using Mobile Messaging Software

Purpose

To investigate the demographic factors that influence time to respond (TTR), time to completion (TTC), and response rate when using a text messaging-based system and to determine the feasibility and applicability of mobile messaging-based services for collection of patient-reported outcomes among orthopaedic sports medicine patients.

Methods

On the day of surgery, patient mobile phone number was collected and the automated mobile messaging service (MOSIO, Seattle, WA) messaged patients for 10 ``days postoperatively. Patient visual analog scale (VAS) scores were collected 3 times daily, side effects were asked each evening, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) Short Form was collected on postoperative day 3 and 7.

Results

A total of 177 patients were enrolled in the study. The overall response rate to the survey questions was 75.0%. For all patients, the average TTR of questions was 35.09 ± 12.57 minutes. The TTC was 2.75 ± 3.56 minutes for PROMIS-PI, 3.51 ± 1.26 minutes for VAS, and 3.80 ± 6.87 for side-effect questions. When patients were stratified into age groups, the youngest group, 16 to 32 years, had the greatest response rate of 85.2% and patients in the 49 to 59 years group had the lowest response rate of 68.4% and 69.1%, respectively (P < .001). There was no significant difference in the TTR or TTC for VAS, PROMIS-PI, or side-effect questions when patients were stratified by age or sex groups (P > .05).

Conclusions

Collectively, all age groups successfully achieved a mean response rate of 75%; however, significantly lower response rates were observed for patients >49 years old. Differences in age and sex did not impact the overall TTR or TTC for VAS, PROMIS-PI, or side-effect questions. Mobile-based applications present as an emerging opportunity to track postoperative outcome scores and reduce clinic survey load.

Level of Evidence

Case series, level of evidence IV.

High Return to Play Rate and Reduced Career Longevity Following Surgical Management of Athletic Pubalgia in National Basketball Association Players

Purpose

To assess the effects of surgical treatment of athletic pubalgia (AP) on game use and performance metrics in National Basketball Association (NBA) players.

Methods

A retrospective review of all NBA players who underwent surgical management for AP from 1996 to 2018 was performed. A matched control group was created for comparison. The index period was defined as the entire NBA season in which surgery occurred, including the corresponding offseason. Player demographics, use (games played, games started, and minutes per game) and performance (player efficiency rating) metrics were collected for all players. Statistical analysis was performed to compare data before and after return to play.

Results

Thirty players with a history of surgical management for AP were included in the final analysis. Following surgery for AP, NBA players were found to have a return to play (RTP) rate of 90.91% (30/33). The average RTP following surgery was 4.73 ± 2.62 months. Compared with control athletes, athletes in the AP group played significantly fewer seasons postinjury (4.17 ± 2.70 vs 5.49 ± 3.04 seasons, respectively; P = .02). During the first year following RTP, NBA players experienced significant reductions in game use and performance, both when compared with the year prior and matched control athletes (P < .05). At 3-year follow-up, players continued to demonstrate significant reductions in game use (minutes per game, P < .05) but not performance.

Conclusions

Following surgical treatment of AP, NBA players demonstrated a high RTP rate, but shortened career. A short-term reduction in game use and performance metrics was found the year of return following surgery. However, 3-year follow-up performance metrics normalized when compared with healthy controls.

Study Design

Level III; retrospective case-control study.

Simultaneous repair of bilateral pectoralis major tendons: A case report

BACKGROUND

Injuries to the pectoralis major are infrequent, with only a few hundred cases currently recorded in the literature.

CASE SUMMARY

We report a case of a patient who sustained bilateral pectoralis major tendon ruptures. While other cases of bilateral pectoralis major tears have been reported in the literature, the operative management in this report differs. Due to delayed presentation of the patient right and left pectoralis major repairs were performed simultaneously.

CONCLUSION

Patients with delayed presentation of bilateral pectoralis major tendon ruptures can undergo simultaneous repair of both tendon with a good postoperative outcome and high patient satisfaction.

Impact of Patellar Tendinopathy on Player Performance in the National Basketball Association

Background:

The extent to which patellar tendinopathy affects National Basketball Association (NBA) athletes has not been thoroughly elucidated.

Purpose:

To assess the impact patellar tendinopathy has on workload, player performance, and career longevity in NBA athletes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

NBA players diagnosed with patellar tendinopathy between the 2000-2001 and 2018-2019 seasons were identified through publicly available data. Characteristics, return to play (RTP), player statistics, and workload data were compiled. The season of diagnosis was set as the index year, and the statistical analysis compared post- versus preindex data acutely and in the long term, both within the injured cohort and with a matched healthy NBA control cohort.

Results:

A total of 46 NBA athletes were included in the tendinopathy group; all 46 players returned to the NBA after their diagnosis. Compared with controls, the tendinopathy cohort had longer careers (10.50 ± 4.32 vs 7.18 ± 5.28 seasons; P < .001) and played more seasons after return from injury (4.26 ± 2.46 vs 2.58 ± 3.07 seasons; P = .001). Risk factors for patellar tendinopathy included increased workload before injury (games started, 45.83 ± 28.67 vs 25.01 ± 29.77; P < .001) and time played during the season (1951.21 ± 702.09 vs 1153.54 ± 851.05 minutes; P < .001) and during games (28.71 ± 6.81 vs 19.88 ± 9.36 minutes per game; P < .001). Players with increased productivity as measured by player efficiency rating (PER) were more likely to develop patellar tendinopathy compared with healthy controls (15.65 ± 4.30 vs 12.76 ± 5.27; P = .003). When comparing metrics from 1 year preinjury, there was a decrease in games started at 1 year postinjury (−12.42 ± 32.38 starts; P = .028) and total time played (−461.53 ± 751.42 minutes; P = .001); however, PER at 1 and 3 years after injury was unaffected compared with corresponding preinjury statistics.

Conclusion:

NBA players with a higher PER and significantly more playing time were more likely to be diagnosed with patellar tendinopathy. Player performance was not affected by the diagnosis of patellar tendinopathy, and athletes were able to RTP without any impact on career longevity.

YouTube Is a Poor-Quality Source for Patient Information on Rehabilitation and Return to Sports After Hip Arthroscopy

Purpose

To investigate the information quality on YouTube regarding rehabilitation and return to sport (RTS) after hip arthroscopy.

Methods

By use of private browsing and predefined search terms, 217 unique videos regarding RTS and rehabilitation after hip arthroscopy were included and systematically reviewed. A total of 164 videos were included in the final analysis. Videos were scored using 4 scoring systems: (1) Journal of the American Medical Association benchmark criteria, (2) the Global Quality Score, (3) a score for RTS after hip arthroscopy, and (4) a score for rehabilitation after hip arthroscopy.

Results

A large majority of the included videos provided substandard information quality, dependability, and precision. RTS videos that were uploaded by physicians had a significantly higher Journal of the American Medical Association score, Global Quality Score, and RTS score compared with commercial and personal testimony videos (P = .0003, P = .0021, and P = .0005, respectively). Physician videos pertaining to RTS were also significantly longer than videos in other categories (P = .0397).

Conclusions

The quality and reliability of video content on YouTube pertaining to rehabilitation and RTS after hip arthroscopy are generally poor. The educational content of YouTube videos produced by physicians is of significantly higher quality as compared with non-physicians, patient testimonials, and commercials.

Clinical Relevance

The quality of the information patients receive on rehabilitation and RTS after hip arthroscopy is important for successful outcomes.

Informed Consent for the Orthopaedic Surgeon

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In the United States, orthopaedic surgeons have a legal obligation to obtain informed consent from patients before performing surgery; it is a process that includes a signed written document.

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There are specific legal requirements that vary somewhat by state but generally include disclosure and documentation of the diagnosis, an explanation of the recommended procedure, a conversation about the risks and benefits of the procedure, and a discussion about alternative treatments.

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Inadequate disclosure of risks and alternatives is associated with increased indemnity risk.

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Studies have shown that many consent processes and forms are suboptimal.

Association of Prior Anterior Cruciate Ligament Tear With Decreased Career Longevity in Women's National Basketball Association

Background

The incidence of anterior cruciate ligament (ACL) injuries in women's basketball exceeds that of men. There is a paucity of data regarding career performance in Women's National Basketball Association (WNBA) athletes with a history of ACL reconstruction.

Purpose

To determine whether WNBA athletes with a history of ACL injury prior to professional play have reduced career game utilization, defined as games played and started and minutes per game (MPG), as well as statistical performance, defined by player efficiency rating (PER).

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 42 WNBA players from 1997 to 2018 who had a history of ACL reconstruction before entering professional leagues. Body mass index (BMI), age, and position were collected for each player. Career data and performance statistics were likewise collected for each player's entire WNBA career. A control group of WNBA players with no history of ACL injury were matched by position, BMI, and age at the time of WNBA debut. Statistics compared game utilization and performance to assess the impact of ACL reconstruction.

Results

Athletes who sustained an ACL tear before entering the league played in fewer games per season in their first 3 professional seasons compared with healthy controls (24.2 ± 8.4 vs 28.2 ± 6.1; P = .02). Among athletes with a history of ACL reconstruction, 11 (26.2%) played only a single WNBA season, while no control athletes played in just 1 season. Additionally, athletes who had a previous ACL tear started significantly fewer games per season (9.0 ± 9.4 vs 14.0 ± 9.0; P < .01) and played fewer MPG (15.5 ± 7.2 vs 20.7 ± 5.5; P < .01) during their WNBA career. Athletes with a history of ACL tear had significantly shorter WNBA careers (4.8 ± 4.1 vs 8.1 ± 3.3 seasons; P < .001). Total professional play duration (WNBA + overseas) was significantly reduced in players with an ACL tear compared with controls (P < .05). PER was not significantly different between cohorts at any time point.

Conclusion

WNBA athletes with a history of an ACL tear before professional play had decreased career game utilization and workload throughout their career despite having similar PER compared with healthy controls.

Anterior Cruciate Reconstruction with Quadriceps Autograft using QuadLink Anterior Cruciate Ligament FiberTag TightRope Implant

Quadriceps tendon autografts have been shown to be a reliable option for anterior cruciate ligament (ACL) reconstruction. The graft allows for optimal functional outcomes while reducing donor site morbidity. Although quadriceps graft fixation can be achieved using a variety of techniques, there is a lack of consensus on the optimal technique. Additionally, femoral fixation techniques have variance in durability and reproducibility. The purpose of this Technical Note and video is to provide our preferred method of quadriceps tendon autograft preparation and fixation using the Quad Link ACL FiberTag TightRope Implant in a single-bundle ACL reconstruction.

Scapulothoracic Dyskinesis: A Concept Review

PURPOSE OF REVIEW

Scapulothoracic dyskinesis (SD) occurs when there is a noticeable disruption in typical position and motion of the scapula, which can result in debilitating pain. The purpose of this review is to describe the current knowledge regarding the diagnosis and management of scapulothoracic dyskinesis by providing an evidence-based overview of clinical exams and treatment modalities available for orthopedic surgeons and provide insight into which treatment modalities require further investigation.

RECENT FINDINGS

SD is highly prevalent in athletes, particularly those participating in overhead activities (e.g., baseball, tennis, and swimming) and can coexist with several shoulder pathologies. A holistic approach in the diagnosis of SD has been supported in the literature; however, it is important to recognize that diagnosis is currently limited to the absence of a quantitative SD clinical assessment. The main goal of the treatment of SD is to regain proper scapular positioning and dynamics. The standard of care for the management of SD is conservative interventions aimed at optimizing scapular kinematics. Surgical intervention is only considered in the presence of concomitant pathology requiring surgery. Due to the complexity of coordinated movement of the shoulder girdle, recent literature has begun to move away from the use of traditional orthopedic tests, in favor of a more system-based approach for the diagnosis of SD. We present a concise review of clinical exams and treatment modalities available for orthopedic surgeons in the management of SD.

The Use of Biologics for Hip Preservation

PURPOSE OF REVIEW

A wide array of nonoperative modalities to treat hip pain are aimed at restoring and maintaining the structural and physiologic characteristics of the joint. The purpose of this review is to describe the current understanding of biologics in hip pathology by providing an evidence-based overview of treatment modalities available for orthopedic surgeons.

RECENT FINDINGS

The use of biologics as a primary treatment or adjunct to traditional management has shown encouraging results for the treatment of hip pain. Studies have demonstrated safety with minimal complications when using platelet rich plasma, hyaluronic acid, or stem cells to treat hip pain caused by osteoarthritis, femoroacetabular impingement syndrome, tendinopathy, or osteonecrosis of the femoral head. Several studies have been able to demonstrate meaningful clinical results that can improve treatment standards for hip pain; however, more work must be performed to better delineate the appropriate protocols, indications, and limitations of each modality. Recent advances have inspired renewed interest in biologics for patients with hip pain. We present a concise review of platelet rich plasma, hyaluronic acid, stem cells, and matrix metalloprotease inhibitors and their applicability to hip preservation surgery.

Effect of Achilles Tendon Rupture on Player Performance and Longevity in National Basketball Association Players

Background:

National Basketball Association (NBA) players who return to sport (RTS) after Achilles tendon rupture have been reported to have poor outcomes.

Purpose:

To evaluate the effect of Achilles tendon ruptures on player performance and career longevity in NBA athletes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

NBA players who sustained Achilles tendon ruptures between 1970 and 2019 were identified using publicly available resources and were matched 1:1 to a healthy control group by age, position, height, and body mass index. Demographic characteristics, player utilization (games and minutes), and performance efficiency rating (PER) were documented for all athletes. The season of Achilles tendon rupture was set as the index year, and statistical analysis compared postindex versus preindex data both acutely and in the long term. Percentages relative to preoperative values were calculated to compare the injured and control groups in a standardized fashion.

Results:

Of 47 players, 34 (72.3%) with Achilles tendon ruptures returned to play at the NBA level after surgical intervention. A total of 7 players were excluded from the study. No differences were found in demographic characteristics or PER (2 years before injury) between the remaining 27 players and matched controls. The injured players had significantly shorter careers compared with control players (3.1 ± 2.3 vs 5.8 ± 3.5 seasons, respectively; P < .05). Injured players demonstrated significant declines in games per season (GPS), minutes per game (MPG), and PER at 1 year and 3 years after RTS compared with preindex baseline (P < .05). Injured players, compared with control players, had reduced relative percentages of games started (GS) (50% vs 125%, respectively), MPG (83% vs 103%), and PER (80% vs 96%) at 1 year after return (P < .05), but reductions at extended 3-year follow-up were seen only in GPS (71% vs 91%) and GS (39% vs 99%) (P < .05).

Conclusion:

Our study found that 72.3% of NBA players returned to play after Achilles tendon repair, but they had shorter careers compared with uninjured controls. Players returning from Achilles tendon repairs had decreased game utilization and performance at all time points relative to their individual preindex baseline. However, for the injured players when compared with controls, game utilization but not performance was found to be decreased at 3-year follow-up.

Effect of Workload After ACL Reconstruction on Rerupture Rates in NBA Players

Background:

Rupture of the anterior cruciate ligament (ACL) is a common and potentially career-altering injury sustained by players in the National Basketball Association (NBA). Strategies have been employed by the league to prevent reinjury of players after ACL reconstruction (ACLR), including minute restrictions and rest games; however, it remains unknown whether workload metrics after ACLR influence the risk for reinjury and revision surgery.

Purpose:

To evaluate whether workload changes after return to play (RTP) from primary ACLR influences the risk of rerupture in NBA players.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We identified NBA players from 1975 to 2018 who underwent primary ACLR as well as those who required revision ACLR. Primary outcomes included workload measures such as games played, games started, and minutes per game. Secondary outcomes included in-game performance statistics. Statistical analysis was used to compare relative workload and performance 3 years before and 3 years after undergoing primary ACLR. Workload was also compared between the control group of NBA players who underwent primary ACLR and those who required revision ACLR.

Results:

A total of 68 players who underwent primary ACLR were included, 8 of whom subsequently required revision ACLR. In their first season upon RTP, control players (primary ACLR) demonstrated a significant reduction in all workload metrics relative to the season before injury (P < .001), while the revision group demonstrated an unchanged to increased workload. In a comparison between the primary and revision groups during the first season after RTP, the primary group demonstrated significantly fewer games started (mean ± SD, 22.2 ± 3.0 vs 35.8 ± 8.3; P = .039) and minutes per game (20.5 ± 1.1 vs 27.0 ± 3.1; P = .048) than revision players. The primary ACLR group demonstrated reduced cumulative workload trends for the first 3 years after RTP relative to 3 years before injury, which was not demonstrated in the revision ACLR group, albeit statistically insignificant.

Conclusion:

Our study found that after ACLR, a reduction in workload parameters relative to preinjury baseline was associated with players who did not sustain rerupture. Further study is required to determine if workload measures following RTP from primary ACLR should be individualized relative to preinjury baseline.