A new DLK1 defect in a family with idiopathic central precocious puberty: elucidation of the male phenotype

PURPOSE

We aimed to investigate a cohort of female and male patients with idiopathic central precocious puberty (CPP), negative for Makorin Ring Finger Protein 3 (MKRN3) defect, by molecular screening for Delta-like 1 homolog (DLK1) defects. DLK1 is an imprinted gene, whose mutations have been described as a rare cause of CPP in girls and adult women with precocious menarche, obesity and metabolic derangement.

METHODS

We enrolled 14 girls with familial CPP and 13 boys with familial or sporadic CPP from multiple academic hospital centers. Gene sequencing of DLK1 gene was performed. Circulating levels of DLK1 were measured and clinical and biochemical characteristics were described in those with DLK1 defects.

RESULTS

A novel heterozygous mutation in DLK1, c.288_289insC (p.Cys97Leufs*16), was identified in a male proband, his sister and their father. Age at onset of puberty was in line with previous reports in the girl and 8 years in the boy. The father with untreated CPP showed short stature. No metabolic derangement was present in the father except hypercholesterolemia. Undetectable Dlk1 serum levels indicated the complete lack of protein production in the three affected patients.

CONCLUSION

A DLK1 defect has been identified for the first time in a boy, underscoring the importance of genetic testing in males with idiopathic or sporadic CPP. The short stature reported by his untreated father suggests the need for timely diagnosis and treatment of subjects with DLK1 defects.

Partial thickness subfoveal hole in a patient treated with tamoxifen: a case report and review of the literature

BACKGROUND

We describe a patient presenting with a partial thickness subfoveal hole in the right eye after tamoxifen treatment for breast cancer.

CASE PRESENTATION

A 76-year-old Caucasian female presented with a 1-day history of acute central scotoma and blurry vision in the right eye. The patient had been receiving oral tamoxifen for 5 years as adjuvant treatment for stage I lobular breast cancer. Her past ocular history was significant for complete, uneventful, and bilateral posterior vitreous detachment. Clinical examination and optical coherence tomography revealed a new, partial thickness subfoveal hole sparing the inner retinal layers. Observation was recommended. At the last follow-up examination, 1 year after the initial presentation, the subfoveal hole remained stable and visual acuity remained stable.

CONCLUSION

Tamoxifen has been associated with a plethora of ophthalmic adverse events, including macular holes, some of which are partial thickness subfoveal holes. Holes with this almost unique morphology are uncommon, and eye care professionals should be aware of this association given the frequency of tamoxifen use, as well as the low success rate of surgical repair with pars plana vitrectomy.

Ganglion Cell Layer Thickness Change in Neovascular Age-Related Macular Degeneration Treated With Anti-VEGF Injections

Purpose:

This work assesses bilateral ganglion cell layer–inner plexiform layer (GCL-IPL) thickness changes in patients with unilateral neovascular age-related macular degeneration (nAMD) treated with antivascular endothelial growth factor (anti-VEGF).

Methods:

In this single-center, retrospective, cohort study, the medical records of patients with unilateral nAMD treated with anti-VEGF were reviewed. The treated group included eyes with newly diagnosed nAMD that subsequently underwent treatment with intravitreal anti-VEGF injections. The control group was the fellow eye with dry AMD. Eyes receiving at least 10 intravitreal injections were included. Measurement of GCL-IPL thickness was performed at different time points using spectral domain–optical coherence tomography.

Results:

A total of 216 eyes of 108 patients met the inclusion criteria. The mean age ± SD was 80.1 ± 10.7 years. Eyes in the treated group underwent a mean ± SD of 20.2 ± 7.2 injections in 21.3 ± 6.8 months. At baseline, average mean ± SD of GCL-IPL thickness was 73.71 ± 8.81 µm and 73.84 ± 8.26 µm in the treated and fellow eye, respectively ( P = .795). After 10 injections the average thickness was 65.41 ± 14.08 µm and 68.77 ± 13.24 µm in the treated and fellow eye, respectively ( P = .007). The absolute decrease in thickness was significantly greater in the treated eye than the fellow eye (mean ± SD, 8.31 ± 11.19 µm vs 5.07 ± 10.83 µm, respectively; P = .002).

Conclusions:

GCL-IPL thickness decreased significantly in the treated group more than in the control group after 10 anti-VEGF injections. The mechanism and clinical significance of this observation warrants further study.

Enhancement of Mitochondrial Function by the Neurogenic Molecule NSI-189 Accompanies Reversal of Peripheral Neuropathy and Memory Impairment in a Rat Model of Type 2 Diabetes

AIMS

Mitochondrial dysfunction contributes to many forms of peripheral and central nervous system degeneration. Therapies that protect mitochondrial number and function have the potential to impact the progression of conditions such as diabetic neuropathy. We therefore assessed indices of mitochondrial function in dorsal root ganglia (DRG) and brain cortex of the Zucker diabetic fatty (ZDF) rat model of type 2 diabetes and tested the therapeutic impact of a neurogenic compound, NSI-189, on both mitochondrial function and indices of peripheral and central neurological dysfunction.

MATERIALS AND METHODS

ZDF rats were maintained for 16 weeks of untreated diabetes before the start of oral treatment with NSI-189 for an additional 16 weeks. Nerve conduction velocity, sensitivity to tactile and thermal stimuli, and behavioral assays of cognitive function were assessed monthly. AMP-activated protein kinase (AMPK) phosphorylation, mitochondrial protein levels, and respiratory complex activities were assessed in the DRG and brain cortex after 16 weeks of treatment with NSI-189.

RESULTS

Treatment with NSI-189 selectively elevated the expression of protein subunits of complexes III and V and activities of respiratory complexes I and IV in the brain cortex, and this was accompanied by amelioration of impaired memory function and plasticity. In the sensory ganglia of ZDF rats, loss of AMPK activity was ameliorated by NSI-189, and this was accompanied by reversal of multiple indices of peripheral neuropathy.

CONCLUSIONS

Efficacy of NSI-189 against dysfunction of the CNS and PNS function in type 2 diabetic rats was accompanied by improvement of mitochondrial function. NSI-189 exhibited actions at different levels of mitochondrial regulation in central and peripheral tissues.

Characterization of Posterior Glenoid Bone Loss Morphology in Patients With Posterior Shoulder Instability

PURPOSE

To systemically describe posterior bone defects in the setting of posterior shoulder instability based on several parameters, including surface area, slope and version, defect height from the base of the glenoid, and extent of bone loss at equal intervals along the long axis of the fossa.

METHODS

A total of 40 young, active individuals with recurrent posterior shoulder instability and a bony injury confirmed on either computed tomography (n = 18; mean age, 26.3 ± 4.0 years) or magnetic resonance imaging (n = 22; mean age, 20.0 ± 4.9 years) were identified. The posterior glenoid bone defect was characterized using the following measures: (1) percentage of bone loss, (2) glenoid vault version, (3) slope of the posterior defect relative to the glenoid surface, (4) superior-inferior length of the defect, and (5) anterior-posterior width of the defect at 5 intervals along the glenoid fossa.

RESULTS

The mean age of the 40 patients was 22.9 ± 5.5 years (range, 14.9-35.5 years). The mean surface area of glenoid bone loss was 9.7% ± 4.7%. Glenoid version measured at 5 equal intervals along the inferior two-thirds of the glenoid was 12.8° ± 4.9°, 11.9° ± 5.0°, 10.1° ± 6.3°, 10.5° ± 6.5°, and 8.7° ± 7.2° from superior to inferior. The mean slope of the posterior defect relative to the glenoid fossa was 26.8° ± 11.5°. The mean superior-inferior height of the bony defect was 21.9 ± 0.4 mm. The anterior-posterior sloped width of the defect at 5 equal intervals along the glenoid fossa was 0.9 ± 1.5 mm, 2.8 ± 2.4 mm, 4.0 ± 1.7 mm, 4.0 ± 2.1 mm, and 2.9 ± 2.6 mm from superior to inferior. Low-grade (<10%) bone loss was diagnosed in most shoulders (23 of 40 evaluated), whereas 15 had moderate bone loss (10% to <20%) and 2 had high-grade bone loss (≥20%).

CONCLUSIONS

Posterior glenoid bone loss is characterized by a loss of posterior bony concavity, increased slope from anterior to posterior, and increased posterior version. The most anterior-posterior sloped width was quantified at the third and fourth intervals of 5 equal intervals from superior to inferior. This study highlights that patients with posterior instability have bone loss that is sloped relative to the glenoid fossa and suggests that management must be appropriately tailored given the distinctiveness of posterior bone loss.

LEVEL OF EVIDENCE

Level IV, case series.

Jones Fractures Identified at the National Football League Scouting Combine: Assessment of Prognostic Factors, Computed Tomography Findings, and Initial Career Performance

Background:

Jones fractures result in subsequent dysfunction and remain an issue for athletes.

Purpose:

To (1) describe the epidemiology, treatment, and impact of Jones fractures identified at the National Football League (NFL) Scouting Combine on players’ early careers and (2) establish the value of computed tomography (CT) to determine bony healing after a fracture in prospective players.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

All players who attended the combine between 2009 and 2015 were retrospectively reviewed to identify their history of Jones fractures. The playing position, treatment method, and number of missed collegiate games were recorded. The mean overall draft pick number, number of games started and played, snap percentage, and position-specific performance scores (fantasy score) over the first 2 years in the NFL were compared between players with fractures and controls. An imaging classification system was applied based on grading of each quadrant of the fifth metatarsal (plantar, dorsal, medial, lateral), with a score of 0 for not healed or 1 for healed.

Results:

Overall, the number of Jones fractures identified was 72 in 2285 athletes (3.2%), with all treated via intramedullary screw fixation. The mean overall draft pick number for players with fractures was 111.2 ± 67.9 compared with 99.0 ± 65.9 for controls (P = .12). Performance scores for players with fractures were lower than those for controls across all positions, with a significant difference in running backs (2.6 vs 4.0, respectively; P < .001) and defensive linemen (1.4 vs 2.3, respectively; P = .02). The mean CT score was 2.5 ± 1.3. Of the 32 athletes who underwent imaging, 16 Jones fractures (50.0%) were healed or nearly healed, 12 (37.5%) were partially healed, and 4 (12.5%) showed little or no healing. The plantar cortex demonstrated the least healing (18/32; 56.3%), followed by the lateral cortex (15/32; 46.9%). Players with a mean score <1 were found to have fewer games started (2.7 ± 2.5) than those with 1 to 3 cortices healed (17.4 ± 10.4) or all cortices healed (8.7 ± 11.2).

Conclusion:

Based on CT, 50% of all players with a previous Jones fracture demonstrated incomplete healing. Moreover, position-specific performance scores over the first 2 years of a player’s career were lower across all positions for those with fractures compared with controls. Players with CT scores <1 were found to start fewer games and were drafted later than controls.

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

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

The Epidemiology of Ankle Injuries Identified at the National Football League Combine, 2009-2015

Background:

American football is a leading cause of sports-related injuries, with the knee, ankle, and shoulder most commonly involved.

Purpose/Hypothesis:

The purpose of this study was to describe the epidemiology, characteristics, and imaging findings of ankle injuries in football players at the National Football League (NFL) Combine and determine the relationship to player position. We hypothesized that there would be a high relative incidence of ankle injuries in these players compared with other sports and that there would be a direct correlation between the incidence of ankle injuries and player position.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A retrospective chart review of data collected from NFL Combine participants between 2009 and 2015 was performed. Patient demographics, history, physical examination results, and imaging findings were reviewed.

Results:

Of 2285 players, 1216 (53.2%) had a history of ankle injuries; of these, 987 (81.2%) had unilateral injuries, while 229 (18.8%) had bilateral injuries (total of 1445 ankles injured). This included 1242 ankle sprains (86.0% of ankle injuries): 417 (33.6% of sprains) high and 930 (74.9%) low. The most common soft tissue injuries were to the anterior talofibular ligament (n = 158, 12.7% of sprains) and syndesmosis (n = 137, 11.0%). Of all players at the NFL Combine with radiographs, 131 (10.9%) had evidence of an ankle fracture, all of which had healed. Magnetic resonance imaging (MRI) identified 66 players (28.9% of players at the combine who underwent MRI) with articular cartilage injuries: 62 involving the talus and 16 involving the tibia. Furthermore, 85 players (37.3% of players with MRI) with tendon injuries were identified: 26 Achilles, 55 peroneal, 3 flexor hallucis longus, and 19 posterior tibial. A total of 611 players (50.6% of players with radiographs) had signs of arthrosis on radiography. Running backs (61.9%), offensive linemen (60.3%), and tight ends (59.4%) had the highest rates of ankle injuries by position, while kickers/punters (23.3%) and long snappers (37.5%) had the lowest.

Conclusion:

Prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine. The rate of these ankle injuries varied by player position: offensive linemen, running backs, and tight ends had the highest overall rates, while special teams players had the lowest. Additional prospective work is needed to determine the impact of prior injuries on future playing career.

Prevalence of Shoulder Labral Injury in Collegiate Football Players at the National Football League Scouting Combine

Background

Labral tears confirmed by magnetic resonance imaging (MRI) are a relatively common injury among collegiate athletes and can influence a player's ability to compete at the professional level.

Purpose

To determine the prevalence of MRI-confirmed shoulder labral injuries in collegiate football players entering the National Football League (NFL) Combine and to further describe these injuries by tear location, player position, history of surgical intervention, and associated concomitant shoulder injuries.

Study Design

Descriptive epidemiology study.

Methods

Data from 2009 to 2015 were retrospectively collected through review of the injury data registry available to the medical and training staff of all NFL teams following the completion of the NFL Combine. After players with potential labral tears were identified through history and examination, their MRIs were reviewed by 2 fellowship-trained orthopaedic sports medicine surgeons. Players diagnosed with a labral tear confirmed by MRI were separated for further analysis.

Results

A total of 2285 players were analyzed for the presence of labral tears at the NFL Combine. Overall, 377 shoulders (in 340/2285 players; 14.9%) demonstrated MRI evidence of labral tear; whereas linebackers had the highest rate of labral tear (19.2%), linemen had significantly higher risk for labral injury in at least 1 shoulder (odds ratio, 1.31; 95% CI, 1.02-1.67; P = .029) compared with nonlinemen. Of the 377 shoulders analyzed, 115 (30.5%) exhibited an anterior labral tear, 131 (34.7%) had a posterior labral tear, and 131 (34.7%) had combined anterior and posterior tears. One hundred twenty (31.8%) shoulders had superior labral anterior-posterior (SLAP) tears. A total of 203 (53.8%) shoulders demonstrated evidence of previous surgical intervention on imaging.

Conclusion

Injury involving the labrum is relatively common among participants at the NFL Combine, especially linebackers and linemen. Further investigation is necessary to determine the impact these injuries have on player draft position and NFL performance.

Quantitative Assessment of the Coracoacromial and the Coracoclavicular Ligaments With 3-Dimensional Mapping of the Coracoid Process Anatomy: A Cadaveric Study of Surgically Relevant Structures

PURPOSE

To perform a quantitative anatomic evaluation of the (1) coracoid process, specifically the attachment sites of the conjoint tendon, the pectoralis minor, the coracoacromial ligament (CAL), and the coracoclavicular (CC) ligaments in relation to pertinent osseous and soft tissue landmarks; (2) CC ligaments' attachments on the clavicle; and (3) CAL attachment on the acromion in relation to surgically relevant anatomic landmarks to assist in planning of the Latarjet procedure, acromioclavicular (AC) joint reconstructions, and CAL resection distances avoiding iatrogenic injury to surrounding structures.

METHODS

Ten nonpaired fresh-frozen human cadaveric shoulders (mean age 52 years, range 33-64 years) were included in this study. A 3-dimensional coordinate measuring device was used to quantify the location of pertinent bony landmarks and soft tissue attachment areas. The ligament and tendon attachment perimeters and center points on the coracoid, clavicle, and acromion were identified and subsequently dissected off the bone. Coordinates of points along the perimeters of attachment sites were used to calculate areas, whereas coordinates of center points were used to determine distances between surgically relevant attachment sites and pertinent bony landmarks.

RESULTS

The CAL had a single consistent acromial attachment (mean area 77 mm [51.9, 102.2]) and then bifurcated into 2 bundles, anterior and posterior, that separately inserted on the lateral aspect of the coracoid. The footprint areas were 54.4 mm² [31.7, 77.2] and 30.6 mm² [23.4, 37.7] for the anterior and posterior CAL bundles, respectively. These anterior and posterior bundles attached 10.6 mm [8.4, 12.9] and 24.8 mm [12.3, 27.4] medial and proximal to the apex of the coracoid process, respectively. The minimum distance between the coracoid apex and the trapezoid ligament was 25.1 mm [22.1, 28.1] and was noted to be different in males (28.1 mm [25.1; 31.2]) and females (22.0 mm [18.2, 25.9]). The most lateral insertion of the CC ligaments on the clavicle the AC joint was 15.7 mm [13.1, 18.3]. The distance between the most medial to the most lateral point of the CC ligaments on the clavicle was 25.6 mm [22.3, 28.9], which accounted for 18.2% [15.8, 20.6] of the clavicle length.

CONCLUSIONS

In contrast to previous findings, 2 different coracoid attachments (anterior and posterior bundles) of the CAL were consistently identified in all specimens. Moreover, a coracoid osteotomy for a bone graft for the Latarjet procedure should be performed at less than 28.1/22 mm from the apex of the coracoid in male/female patients, respectively. The CC ligaments' attachments on the clavicle were located 15.7 mm from the AC joint, which should be considered for reconstruction.

CLINICAL RELEVANCE

During the Latarjet technique, to maintain the integrity of the CC ligaments, precise knowledge of differences between male and female anatomy is necessary during a coracoid osteotomy. Furthermore, when reconstructing the AC joint, the distance from the lateral aspect of the clavicle and the size of the attachments areas should be considered to better replicate the native anatomy.

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

PURPOSE

To determine the epidemiology by player position, examination, imaging findings, and associated injuries of posterior cruciate ligament (PCL) injuries in players participating in the National Football League (NFL) Combine.

METHODS

All PCL injuries identified at the NFL Combine (2009-2015) were reviewed. Data were obtained from the database organized by the NFL medical personnel for the compilation of the medical and physical performance examination results of NFL Draftees participating in the NFL Combine from 2009 to 2015. Inclusion criteria were any player with clinical findings or a previous surgery consistent with a PCL injury who participated in the NFL Combine.

RESULTS

Of the 2,285 players who participated in the NFL Combine between 2009 and 2015, 69 (3%) had evidence of a PCL injury, of which 11 players (15.9%) were managed surgically. On physical examination, 35 players (52%) had a grade II or III posterior drawer. Concomitant injuries were present frequently and included medial collateral ligament (MCL; 42%), anterior cruciate ligament (ACL; 11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment.

CONCLUSIONS

Three percent of the players at the NFL Combine presented with a PCL injury, with a significant amount being either running backs (14/69, 20.2%) or offensive linemen (14/69, 20.2%). Approximately half of the players with a PCL tear had a residual grade II or III posterior drawer after sustaining a PCL injury. Concomitant injuries were present frequently and included MCL (42%), ACL (11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. For those players with clinical concern for PCL ligamentous laxity, there should be a complete comprehensive workup that includes plain and PCL stress view radiographs, and magnetic resonance imaging.

LEVEL OF EVIDENCE

Level IV, case series.

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

PURPOSE

To (1) describe the magnetic resonance imaging (MRI) characteristics of knee chondral injuries identified at the National Football League (NFL) Combine and (2) assess in-game performance of prospective NFL players with previously untreated knee chondral injuries and compare it with matched controls.

METHODS

All players with knee chondral injuries identified at the NFL Combine (2009-2015) were retrospectively reviewed. Players with prior knee surgery were excluded. A knee MRI for each player was reviewed; location, modified International Cartilage Repair Society (ICRS) grade (I-IV), and associated compartment subchondral edema were documented. Position, respective NFL Draft pick selection number, games started, played, snap percentage, and position-specific performance metrics during the first 2 NFL seasons were recorded for the injury and injury-free control group composed of players with (1) no prior knee injury, (2) no significant missed time prior to the NFL (≤2 total missed games in college), (3) no history of knee surgery, and (4) drafted in the respective NFL Draft following the NFL Combine.

RESULTS

Of the 2,285 players reviewed, 101 (4.4%) had an injury without prior knee surgery. The patella (63.4%) and trochlea (34%) were most commonly affected. Defensive linemen were at highest risk for unrecognized injuries (odds ratio 1.8, P = .015). Players with previously untreated injuries, compared with controls, were picked later (mean pick: 125.8) and played (mean: 23) and started (mean: 10.4) fewer games during the initial 2 NFL seasons (P < .001 for all). Particularly, subchondral bone edema and full-thickness cartilage injuries were associated with fewer games played (P = .003).

CONCLUSIONS

The patellofemoral joint was most commonly affected in NFL Combine participants. Previously untreated knee articular injuries in players at the NFL Combine are associated with poorer early NFL performance in comparison to uninjured players. Subchondral bone edema and full-thickness cartilage injury on MRI were associated with fewer games played during the initial NFL career.

LEVEL OF EVIDENCE

Level III, case-control study.

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

PURPOSE

(1) To determine the epidemiology, examination findings, imaging findings, and associated injuries of posterolateral corner (PLC) injuries in players participating in the National Football League (NFL) Combine and (2) to evaluate the impact of PLC injuries on performance compared with matched controls.

METHODS

All PLC injuries identified at the NFL Combine between 2009 and 2015 were reviewed. The inclusion criteria were any player who had clinical findings or a previous surgical procedure consistent with a PLC injury and who participated in medical and performance testing at the NFL Combine. PLC injuries were identified by evaluating the side-to-side difference in lateral-compartment laxity with varus stress and reviewing magnetic resonance imaging studies. NFL performance outcomes (draft position and number of games played or started within the first 2 years) were compared with matched controls.

RESULTS

Of the 2,285 players assessed at the NFL Combine, 16 (0.7%) were identified with a history of a grade II or III PLC tear and surgical management whereas 7 additional players (0.3%) had a PLC injury diagnosed on clinical examination, for 23 total PLC injuries (1%). On examination, 13 of 22 knees (59%) were shown to be stable; however, most of those managed surgically had significantly improved stability (13 of 15 stable) versus none of those managed nonsurgically (0 of 7 stable). Surgically managed PLC-injured athletes started significantly fewer games than controls (5.3 vs 10.5, P = .03); the mean draft position for players with surgically treated PLC injuries was 139.7 versus controls' mean draft position of 111.3. Of the 16 athletes treated operatively, 2 reported a PLC injury recurrence; both were managed nonoperatively.

CONCLUSIONS

A small percentage of players at the NFL Combine had evidence of a previous PLC injury (1%), with 0.4% having residual varus asymmetry on clinical examination. A worse overall mean draft position for isolated PLC-injured athletes versus controls was found: 132.8 versus 111.3 (P = .02). It is recommended that the use of varus stress radiographs be considered for NFL Combine athletes to objectively determine their grade of injury. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Qualitative and Quantitative Anatomy of the Proximal Humerus Muscle Attachments and the Axillary Nerve: A Cadaveric Study

PURPOSE

To provide a quantitative and qualitative anatomic analysis of the pectoralis major, teres major, and latissimus dorsi on the humerus, as well as the deltoid tendinous attachments on the proximal humerus and acromion, and to quantitatively characterize the humeral course of the axillary nerve.

METHODS

Ten nonpaired, fresh-frozen human cadaveric shoulders were analyzed. A portable coordinate-measuring device quantified the location of bony landmarks and tendon attachment areas. The tendon footprints were recorded by tracing their outlines and center points. The footprint areas of the tendons, the distances between the footprint areas and pertinent osseous and soft-tissue landmarks, and the distance between where the axillary nerve courses across the humerus relative to the acromion and greater tuberosity were measured.

RESULTS

Of the 10 specimens, 9 (90%) had 5 distinct tendinous bands attaching the deltoid to the acromion; 1 specimen had 4 bands. The distances between the center of the deltoid footprint on the humerus and the centers of the pectoralis major, latissimus dorsi, and teres major tendon footprints on the humerus were 43.5 mm, 58.5 mm, and 49.4 mm, respectively. The shortest distances from the perimeter of the pectoralis major to the latissimus dorsi and teres major tendon footprints were 3.9 mm and 9.5 mm, respectively. The distance from the superior aspect of the greater tuberosity to the axillary nerve on the humeral shaft was 50.3 mm (95% confidence interval, 47.0-53.5 mm). The distance from the lateral acromion to the axillary nerve was 69.3 mm (95% confidence interval, 64.1-74.5 mm).

CONCLUSIONS

The deltoid muscle had 4 to 5 tendinous insertions on the acromion, and the axillary nerve was 50.3 mm from the tip of the greater tuberosity. The distance between the lower border of the pectoralis major and the axillary nerve was 9.4 mm.

CLINICAL RELEVANCE

Knowledge of the quantitative anatomy of the tendons of the proximal humerus and axillary nerve can aid in identifying structures of interest during open shoulder surgery and in avoiding iatrogenic axillary nerve injury. Furthermore, this study provides direction to avoid injury to the deltoid tendons during open surgery.

Fighting for Equity and Community in an Urban Research University

The equity lens evaluates institutional barriers that prevent students of color from gaining access to resources for college success (Bensimon, 2005). The first-generation college students at the University of Southern California are 16% of the total student body and students of color comprise two-thirds of this population. Since 2008, how to support first generation college students of color in their academic achievement and college success once in college has expanded the discussion beyond access.  By evaluating institutional structures through the equity lens, the response has been to create intentional academic and social programs for first generation college students of color that bridge the academic and student services divide.  Through descriptions of actual programs and stories from students affected by these programs, this essay will discuss innovative approaches to serving first-generation students of color at predominantly white universities.

Meniscectomy and Resultant Articular Cartilage Lesions of the Knee Among Prospective National Football League Players: An Imaging and Performance Analysis

BACKGROUND

The effect of prior meniscectomy and the resulting reduction in meniscal tissue on a potential National Football League (NFL) player's articular cartilage status and performance remain poorly elucidated. Purpose/Hypothesis: (1) To determine the epidemiology, imaging characteristics, and associated articular cartilage pathology of the knee among players with a previous meniscectomy who were participating in the NFL Combine and (2) to evaluate the effect of these injuries on performance as compared with matched controls. The hypothesis was that players with less meniscal tissue would have worse cartilage status and inferior performance metrics in their first 2 NFL seasons.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All athletes with a history of a meniscectomy and magnetic resonance imaging scan of the knee who participated in the NFL Combine (2009-2015) were identified. Medical records and imaging were analyzed, and surgical history, games missed in college, position played, and draft position were documented. The conditions of the meniscus and cartilage were graded with modified ISAKOS scores (International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine) and ICRS scores (International Cartilage Repair Society), respectively. Players with a previous meniscectomy of at least 10% of total medial or lateral meniscal volume excised (ISAKOS meniscus grade ≤8) and matched controls without a significant pre-Combine injury were similarly evaluated and compared by position of play through analysis of draft position, number of games played and started, and how many eligible plays they participated in (snap percentage) within the first 2 NFL seasons.

RESULTS

Of the 2285 players who participated in the NFL Combine (2009-2015), 287 players (322 knees) had a prior meniscectomy (206 lateral, 81 medial). Among these players, 247 (85%) had a total of 249 chondral lesions, most commonly on the lateral femoral condyle (111 lesions, 45%). There was a significant inverse correlation found between the ISAKOS medial and lateral meniscus grade and the corresponding compartment chondral lesion grade ( P = .001). A poorer meniscus score was also associated with worse chondral pathology, especially in the lateral compartment. After controlling for position of play, the injury-free control group had a significantly greater number of total games played and games started and higher snap percentage versus those with a prior meniscectomy of at least 10% volume (ISAKOS meniscus grade ≤8). Players with severe chondral lesions (ICRS grade 4) in the medial and lateral compartments had significantly worse performance metrics when compared with matched controls.

CONCLUSION

Previous meniscectomy of at least 10% of total medial or lateral meniscus volume in prospective NFL players was significantly correlated with larger and more severe chondral lesions. Chondral and meniscal defects of the knee were found to result in a significant decrease in objective performance measures during a player's initial NFL career versus matched controls. Given these findings, players with a prior meniscectomy with evidence of chondral damage should be evaluated carefully for their overall functional levels; however, additional work is needed to fully clarify the effect of prior knee meniscal surgery on overall NFL performance.

Clinical and Radiologic Outcomes After Scaphoid Fracture: Injury and Treatment Patterns in National Football League Combine Athletes Between 2009 and 2014

PURPOSE

To report on the clinical and radiologic outcomes and complications after surgical treatment in National Football League (NFL) Combine athletes with a history of a scaphoid fracture.

METHODS

The medical records of 2,285 athletes participating in the NFL Combine from 2009 to 2015 were evaluated for a history of scaphoid, hand, or wrist injury. Clinical outcomes, including grip strength, pinch test, range of motion, and presence of pain and stiffness, were recorded. Imaging studies were evaluated for the percentage of healing, fixation treatment type, hardware complications, radiographic deformity, and presence of osteoarthritis.

RESULTS

Of the 2,285 athletes evaluated, 56 presented with a history of a scaphoid fracture. Most fractures were in the middle and proximal aspects of the scaphoid. Of the scaphoid fractures, 76% (43 players) were treated with screw fixation. Of the athletes, 36 (72%) had normal range of motion of the affected wrist, 52 (93%) reported no pain, and 44 (83%) reported no stiffness in the affected wrist. The grip strength and pinch strength were 91% and 96%, respectively, of the uninjured side. The fracture was healed in 75% of the cases; however, 34% had degenerative changes. Hardware complications were found in 15% of the athletes.

CONCLUSIONS

Good clinical outcomes can be achieved after scaphoid fractures in prospective NFL athletes. However, the rates of nonunion (25%), degenerative changes (34%), and hardware complications (15%) in this study suggest the need for close postoperative radiographic follow-up in this population of patients because their athletic demands may lead to higher rates of the aforementioned complications.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Revision Acromioclavicular-Coracoclavicular Reconstruction: Use of Precontoured Button and 2 Allografts

Injuries to the acromioclavicular (AC) joint are common, particularly in the young and active population. Approximately 9% of all shoulder girdle injuries involve the AC joint, and AC joint dislocations represent approximately 8% of all joint dislocations throughout the body. AC joint injuries are graded as type I through type VI according to the Rockwood classification. Type I and II injuries are typically treated nonoperatively, whereas type IV, V, and VI injuries are most often treated surgically. A variety of surgical techniques have been described, including anatomic and nonanatomic reconstruction. However, up to 80% of patients go on to lose radiographic reduction, and between 20% and 30% have complications leading to reoperation. Therefore, the objective of this Technical Note is to describe our preferred technique for the treatment of AC joint instability in the revision setting. This technique uses a Dog Bone Button (Arthrex, Naples, FL) and 2 allografts.

Arthroscopic Labral Repair in the Setting of Recurrent Posterior Shoulder Instability

Posterior shoulder instability, although relatively rare in the general population, is more commonly seen in athletes, especially those in contact sports. Although nonoperative treatment has been associated with satisfactory results in the setting of posterior shoulder instability, conservative management may ultimately fail and lead to recurrence particularly in young, male patients. Both arthroscopic and open repair techniques to address posterior instability have been described, with each showing positive patient-reported outcomes, low risk of recurrence, and considerably high return-to-sport rates. In particular, arthroscopic treatment includes the following: capsular plication and knotted and/or knotless suture anchor fixation. The purpose of this technique is to describe our preferred technique to treat recurrent posterior shoulder instability through arthroscopic labral repair using knotless suture anchor fixation.

Superior Capsular Reconstruction With Superimposition of Rotator Cuff Repair for Massive Rotator Cuff Tear

Massive rotator cuff tears are particularly challenging to treat and severely limit the function of the shoulder. Compared with a small rotator cuff tear, massive tears are more unpredictable and usually present with low tendon quality. When performing an anatomical repair of the rotator cuff, the surgical treatment is often associated with failure of the construct. An alternative procedure that can be performed in the setting of a massive tear is superior capsular reconstruction (SCR), using an autograft or allograft. This procedure has been shown to be effective and is associated with positive treatment outcomes. Moreover, the combination of an SCR with an anatomic repair of the rotator cuff tendon may provide a stronger fixation for the rotator cuff and ultimately lead to a lower likelihood of retear and failure. The purpose of this Technical Note is to describe our preferred procedure for the treatment of a massive rotator cuff tear through SCR with superimposition of the repair of the native rotator cuff tendons.

Pectoralis Major Repair: A Biomechanical Analysis of Modern Repair Configurations Versus Traditional Repair Configuration

BACKGROUND

Pectoralis major (PM) ruptures are increasingly common, and a variety of surgical techniques have been described. However, tested techniques have demonstrated diminished strength with inadequate restoration of the footprint and suture failure at relatively low loads. Purpose/Hypothesis: The purpose was to biomechanically compare PM transosseous suture repair (current gold standard) to modern PM repair techniques that use larger caliber sutures, suture tape, and unicortical button fixation (UBF). The null hypothesis was that there would be no mechanical difference between repair techniques and no difference in the amount of footprint restoration.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-four fresh-frozen cadaveric shoulders controlled for age and bone mineral density were randomized equally to 4 groups: (1) UBF, suture tape; (2) UBF, No. 5 suture, suture tape; (3) bone trough with No. 2 suture; and (4) native PM tendon group; all groups were tested to failure. The specimens were tested under cycling loads (10 N to 125 N) with a final load-to-failure test at 1 mm/s. Failure modes were classified by location and cause of rupture based on optical markers, while tendon footprint length was measured to determine amount of footprint restoration.

RESULTS

For fixation strength, the mean peak load was significantly greater in the native tendon (1816 ± 706 N) versus UBF/No. 5 suture/suture tape (794 ± 168 N), UBF/suture tape (502 ± 201 N), and bone trough (492 ± 151 N) ( P < .001 for all). UBF/No. 5 suture/suture tape featured the lowest displacement superiorly (1.09 ± 0.47 mm) and inferiorly (1.14 ± 0.39 mm) with a significant difference compared with bone trough. With regard to tendon footprint reapproximation, cortical button fixation best approximated native tendon footprint length versus bone trough.

CONCLUSION

Based on peak failure load, the UBF/No. 5 suture/suture tape construct demonstrated 61% greater construct strength than a traditional bone trough technique. Moreover, displacement after cyclic loading was by far smallest in the UBF/No. 5 suture/suture tape construct. Therefore, repair constructs with larger caliber suture and suture tape provide a measurable improvement in construct strength versus traditional PM repair techniques in a biomechanical model and may be advantageous for repair.

CLINICAL RELEVANCE

Cortical button fixation with larger caliber suture and suture tape allows for a significantly better PM repair than more traditional techniques at the time of surgery, which may ultimately result in improved clinical outcomes if implemented in surgical practice.

Multicompartmental Osteochondral Allografts of Knee and Concomitant High Tibial Osteotomy

Chondral lesions of the knee can occur secondary to limb malalignment. To address these interrelated problems, a high tibial osteotomy with concomitant osteochondral allograft transfer may be performed. It is important to address these chondral lesions as they often affect the young and active population and cause morbidity in an otherwise healthy population. Although numerous approaches for the treatment of chondral lesions have been described, long-term results demonstrating regeneration of hyaline cartilage have yet to be reported. Furthermore, larger, full-thickness cartilage defects, which can be caused by limb malalignment, have proven to be particularly challenging to treat. This Technical Note details our technique for multicompartmental osteochondral allograft transplantation with concomitant high tibial osteotomy in a patient with 2 focal cartilage lesions in the knee.

Reverse Total Shoulder Arthroplasty With Humeral Head Autograft Fixed Onto Glenoid for Treatment of Severe Glenoid Retroversion

Advanced glenohumeral osteoarthritis can transform glenoid morphology and, in some cases, is found in association with severe glenoid retroversion. The associated glenoid retroversion leads to difficulty in fixation of the glenoid component in reverse total shoulder arthroplasty. In the context of extreme glenoid wear, structural grafts can be used to restore glenoid volume and version in order for the glenoid component of the reverse total shoulder arthroplasty to be more easily implanted. Nevertheless, literature regarding structural grafts remains limited, with optimal graft choice and technique still controversial at best. This article details our technique for humeral head autograft transplantation before reverse total shoulder arthroplasty in the context of extreme glenoid retroversion with advanced osteoarthritis.

Repair of an Isolated Coracoid Fracture With Suture Anchor Fixation

Coracoid fractures are rare injuries, which may occur in isolation or in association with other shoulder pathology. The mechanism of trauma consists of a strong contraction of the conjoint tendon as a result of direct trauma. The diagnosis is usually difficult and many times overlooked, thereby requiring a high level of suspicion. In many cases, standard trauma series shoulder radiographs are unable to provide a definitive and reliable diagnosis. Therefore, other imaging modalities may be necessary to confirm the diagnosis. Although uncommon, if left untreated, a coracoid fracture will result in chronic pain and shoulder disability. Both conservative and surgical techniques have been previously reported and shown positive outcomes. In regard to the surgical technique, most reports describe the use of screw fixation, which has been associated with full recovery and high patient satisfaction. Nevertheless, the purpose of this Technical Note is to describe our preferred method to treat an isolated type II displaced coracoid process fracture through suture anchor fixation.

Volatile metabolite profiling reveals the changes in the volatile compounds of new spontaneously generated loquat cultivars

In recent years, the advantageous traits of three new loquat cultivars have drawn the attention of breeders and growers. All three have spontaneously arisen from the 'Algerie' cultivar: the new 'Xirlero' cultivar is a bud mutant of 'Algerie', while 'Amadeo' and 'Raúl' arose as chance seedlings. Following a non-targeted approach based on HS-SPME-GC-MS, the volatile compounds profile of the fruits from the new cultivars were obtained and compared to the original 'Algerie' cultivar. Carboxylic acids clearly dominated the volatile profile of all the loquat cultivars, but esters, aldehydes, ketones and alcohols were also predominant compounds. Interestingly when the bud mutant event did not lead to marked changes in the volatile compounds complement, pronounced changes in the volatile composition of chance seedling-generated cultivars 'Amadeo' and 'Raúl' were observed. 'Amadeo' fruits showed lower levels of 2-methyl butanoic acid and much higher levels of methylhexanoate, methylbutanoate and 2-hydroxy-5-methylacetophenone. The 'Raúl' cultivar also had a distinctive volatile profile characterised by high levels of C6-aldehydes, (E)-2-hexanal, 2-hexenal, (Z)-3-hexenal and hexanal, and several carotenoid-derived volatiles; e.g. 2-pentene-1,4-dione 1-(1,2,2-trimethylcyclopentyl), (S)-dihydroactinidiolide, isodurene, cis-geranyl acetone, β-damascenone, β-ionone, α-ionone and 3,4-dehydro-β-ionone. These changes in volatiles were associated with a more intense flavour in cultivars 'Amadeo' and 'Raúl', according to the sensory evaluation of the flavour intensity carried out by a semi-trained panel. A metabolomic correlation network analysis provided insights as to how volatiles were regulated, and revealed that the compounds modified in 'Amadeo' were uncoupled from the rest of the volatilome, while the volatiles modified in 'Raul' changed according to specific groups. To conclude, this work provides a holistic view of how the loquat volatilome was affected, and this information was integrated with the physical-chemical-sensory attributes to understand the changes that occur in the new cultivars.

The Latarjet Procedure at the National Football League Scouting Combine: An Imaging and Performance Analysis

Background:

The Latarjet procedure is commonly performed in the setting of glenoid bone loss for treatment of recurrent anterior shoulder instability; however, little is known regarding the outcomes of this procedure in elite American football players.

Purpose:

(1) Determine the prevalence, clinical features, and imaging findings of elite college football athletes who present to the National Football League (NFL) Combine with a previous Latarjet procedure and (2) describe these athletes’ performance in the NFL in terms of draft status and initial playing time.

Study Design:

Case series; Level of evidence, 4.

Methods:

After review of all football players who participated in the NFL Combine from 2009 to 2016, any player with a previous Latarjet procedure was included in this study. Medical records, position on the field, and draft position were recorded for each player. In addition, imaging studies were reviewed to determine fixation type, hardware complications, and status of the bone block. For those players who were ultimately drafted, performance was assessed based on games played and started, total snaps, and percentage of eligible snaps in which the player participated during his rookie season.

Results:

Overall, 13 of 2617 (<1%) players at the combine were identified with a previous Latarjet procedure. Radiographically, 8 of 13 (61%) showed 2-screw fixation, while 5 of 13 (39%) had 1 screw. Of the 13 players, 6 (46%) players demonstrated hardware complications. All players had evidence of degenerative changes on plain radiographs, with 10 (77%) graded as mild, 1 (8%) as moderate, and 2 (15%) as severe according to the Samilson Prieto classification. Six of the 13 (46%) players went undrafted, while the remaining 7 (54%) were drafted; however, no player participated in more than half of the plays for which he was eligible during his rookie season.

Conclusion:

Only a small percentage of players at the NFL Combine (<1%) had undergone a Latarjet procedure. High rates of postoperative complications and radiographically confirmed degenerative change were observed. Athletes who had undergone a Latarjet procedure demonstrated a variable amount of playing time, but none participated in more than half of their eligible plays during their rookie season.

Arthroscopic Superior Capsule Reconstruction Technique in the Setting of a Massive, Irreparable Rotator Cuff Tear

Massive, irreparable rotator cuff tears are challenging to treat and associated with pain and severe limitation in shoulder elevation due to the proximal migration of the humeral head and, consequently, subacromial impingement. Furthermore, retraction of the tendons in combination with fat infiltration and muscular weakness results in unpredictable treatment outcomes. While conservative treatment may be warranted for low-demand patients, surgical treatment is often indicated for a successful return to activities of daily living as well as an improved quality of life. The reported failure rate of rotator cuff repair for the treatment of a massive rotator cuff tear varies. However, this failure is often found at the interface between the tendon and tendon footprint. Several techniques have been reported to address this pathology, including muscular transfer, arthroscopic debridement, augmentation procedures, and superior capsule reconstruction. In particular, superior capsule reconstruction has been reported as a safe and effective method to treat a massive, irreparable rotator cuff tear. The purpose of this Technical Note is to describe our preferred technique of a superior capsule reconstruction for the treatment of a massive, irreparable rotator cuff tear.

Subpectoral Biceps Tenodesis: Interference Screw and Cortical Button Fixation

Bicep tendon pathology often arises from chronic overuse injuries, acute trauma, or degenerative changes in the glenohumeral joint. These injuries can cause significant shoulder pain, and can greatly limit range of motion and, in turn, activities of daily living. The diagnosis of biceps pathologies can be challenging, because patients often present with nonspecific symptoms. Some bicep tendon pathologies may be treated nonoperatively; however, biceps tendon subluxation and the presence of rotator cuff or SLAP lesions require surgical management. One of the options for the treatment of bicep tendon pathology includes miniopen subpectoral biceps tenodesis. The purpose of this Technical Note is to describe in detail our preferred operative technique for miniopen subpectoral biceps tenodesis with 2 different fixation methods.

Hot infusions and risk of colorectal cancer in Uruguay: a case-control study

BACKGROUND/OBJECTIVES

The evidence of possible roles for the most common hot infusions intake (tea and coffee) in the risk of colorectal cancer (CRC) needs additional data. Regarding 'mate' intake (infusion of Ilex paraguariensis herb), a previous multi-site study reported lack of association for its highest intake on CRC risk. The present study was conducted to better understand the associations between the intake of this and other infusions and CRC risk.

SUBJECTS/METHODS

Patients (611 CRC incident cases and 2394 controls, all belonging to public hospitals) were interviewed through a questionnaire, including socio-demographic, reproductive and lifestyle variables, and a food-frequency questionnaire of 64 items, analyzing tea, 'mate' and coffee intake (consumer status, daily intake, age at start and at quit). Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated through unconditional logistic regression, adjusting for relevant potential confounders.

RESULTS

Tea and coffee intake displayed significant and inverse associations with CRC risk, mainly among men (OR=0.54, 95% CI 0.38-0.76 for tea and OR=0.59, 95% CI 0.41-0.85 for coffee). Mate intake showed a significant inverse association among women (OR=0.50, 95% CI 0.33-0.77), with a marginal heterogeneity between sexes (P=0.07). Concerning age strata, tea intake displayed inverse associations in all ages, whereas 'mate' and coffee intake showed stronger inverse associations for age ⩾70, suggesting a gradient along time.

CONCLUSIONS

We found evidence of different significant inverse associations for tea, 'mate' and coffee intake and CRC risk. To our knowledge, this is the first epidemiologic study reporting inverse results on 'mate' intake and CRC, which are explained by a stronger association among women.European Journal of Clinical Nutrition advance online publication, 23 August 2017; doi:10.1038/ejcn.2017.130.

Pectoralis Major Transfer for Treatment of Serratus Anterior Dysfunction in the Setting of Long Thoracic Nerve Palsy

Symptomatic scapular winging resulting in scapular dyskinesia leads to a wide spectrum of clinical complaints, most notably periscapular pain. The malpositioning of the scapula, termed through use of the acronym SICK (scapular malposition, inferior-medial border prominence, coracoid pain and malposition, and dyskinesia of scapular movement), is due to the irregular activity of one or more of the periscapular muscles. In particular, the serratus anterior, innervated by the long thoracic nerve, is a key muscle that stabilizes the scapula and provides coordinated scapulohumeral rhythm. If the long thoracic nerve is injured, this results in significant shoulder dysfunction and scapular winging that may require surgical intervention. The purpose of this Technical Note is to present our preferred technique to treat symptomatic scapular winging due to long thoracic nerve palsy through transfer of the pectoralis major with its bone insertion to the inferior edge of the scapula.

Epidemiology of Navicular Injury at the NFL Combine and Their Impact on an Athlete's Prospective NFL Career

Background:

Navicular injuries can result in persistent pain, posttraumatic osteoarthritis, and diminished performance and function.

Purpose:

To determine the epidemiology of navicular fracture in players participating in the National Football League (NFL) Scouting Combine and evaluate the impact of a navicular injury on the NFL draft position and NFL game play compared with matched controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data were collected on players who previously sustained a navicular injury and participated in the NFL Combine between 2009 and 2015. The epidemiology of navicular injury was determined through an evaluation of the number of injuries, surgeries, and collegiate games missed as well as the position played, a physical examination, the surgical technique, and imaging findings. Players with a previous navicular injury (2009-2013) were compared with a set of matched controls. NFL performance outcomes included the draft position, career length ≥2 years, and number of games played and started within the first 2 years.

Results:

Between 2009 and 2015, 14 of 2285 (0.6%) players were identified as having sustained a navicular injury. A total of 11 of 14 (79%) athletes had sustained an overt navicular fracture, while 3 of 14 (21%) were diagnosed with stress reactions on magnetic resonance imaging. Eight patients who sustained a navicular fracture underwent surgery. There was evidence of ipsilateral talonavicular arthritis in 75% of players with a navicular fracture versus only 60% in the uninjured foot (odds ratio, 1.3; P = .04). Fifty-seven percent of players with navicular injury (72.7% of fractures) were undrafted versus 30.9% in the control group (P = .001). Overall, 28.6% of players with navicular fracture played ≥2 years in the NFL compared with 69.6% in the control group (P = .02).

Conclusion:

A previous navicular fracture results in a greater risk of developing posttraumatic osteoarthritis. Although only a low prevalence of navicular injury in prospective NFL players was noted, players with these injuries had a greater probability of not being drafted and not competing in at least 2 NFL seasons when compared with matched controls without an injury history to the NFL Combine.

Acromioclavicular Joint Dislocation: Repair Through Open Ligament Transfer and Nonabsorbable Suture Fixation

Acromioclavicular (AC) joint instability is a fairly common and particularly limiting injury that may result in persistent pain and reduced quality of life. In most cases, conservative management is successful. However, in the case of a severe AC joint dislocation, surgical intervention may be warranted. Previous surgical techniques for treatment of AC joint instability include screw fixation between the coracoid and clavicle, coracoacromial ligament transfer from its acromial insertion to the clavicle, and reconstruction of the coracoacromial and/or coracoclavicular ligaments. The purpose of this Technical Note is to describe our preferred technique for the treatment of a high-grade AC dislocation through coracoacromial ligament transfer to the lateral clavicle and nonabsorbable suture fixation between the coracoid process and clavicle.

Osteochondral Allograft Transplantation for Treatment of Medial Femoral Condyle Defect

Chondral lesions of the knee can affect the young, active population, thereby causing severe morbidity and a large economic burden. Although numerous approaches have been described in the literature, restoration of hyaline cartilage has yet to be shown. Specifically, larger, full-thickness cartilage defects remain a challenge. This Technical Note details our technique for biologic unicompartmental osteochondral allograft transplantation for the treatment of large femoral condyle articular cartilage defects.

Osteotomy of the Tibial Tubercle for Anteromedialization

Patellofemoral instability is a common cause of anterior knee pain, especially in younger and more active patients. Treatment of instability varies considerably depending on the patient's symptoms as well as the cause of the instability. Lateral instability has a particularly broad spectrum of treatment algorithms including patellar taping, arthroscopy, lateral release, medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, and osteotomy of the tibial tubercle for realignment. Acute traumatic lateral dislocation is commonly associated with a tear of the MPFL and, therefore, needs to be addressed. However, patients who show lateralization of the tibial tubercle with an increased tibial tubercle-to-trochlear groove distance, tibial tubercle-to-posterior cruciate ligament distance, and Q-angle measurements often display chronic instability even after an MPFL reconstruction. In these cases, an osteotomy of the tibial tubercle is required to establish proper alignment and minimize the risk of recurrence of instability. The objective of this Technical Note is to describe our preferred method to complete a Fulkerson tibial tubercle osteotomy for anteromedialization and treatment of chronic patellar instability.

Epidemiology of Injuries Identified at the NFL Scouting Combine and Their Impact on Performance in the National Football League: Evaluation of 2203 Athletes From 2009 to 2015

Background:

At the annual National Football League (NFL) Scouting Combine, the medical staff of each NFL franchise performs a comprehensive medical evaluation of all athletes potentially entering the NFL. Currently, little is known regarding the overall epidemiology of injuries identified at the combine and their impact on NFL performance.

Purpose:

To determine the epidemiology of injuries identified at the combine and their impact on initial NFL performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

All previous musculoskeletal injuries identified at the NFL Combine from 2009 to 2015 were retrospectively reviewed. Medical records and imaging reports were examined. Game statistics for the first 2 seasons of NFL play were obtained for all players from 2009 to 2013. Analysis of injury prevalence and overall impact on the draft status and position-specific performance metrics of each injury was performed and compared with a position-matched control group with no history of injury or surgery.

Results:

A total of 2203 athletes over 7 years were evaluated, including 1490 (67.6%) drafted athletes and 1040 (47.2%) who ultimately played at least 2 years in the NFL. The most common sites of injury were the ankle (1160, 52.7%), shoulder (1143, 51.9%), knee (1128, 51.2%), spine (785, 35.6%), and hand (739, 33.5%). Odds ratios (ORs) demonstrated that quarterbacks were most at risk of shoulder injury (OR, 2.78; P = .001), while running backs most commonly sustained ankle (OR, 1.39; P = .040) and shoulder injuries (OR, 1.55; P = .020) when compared with all other players. Ultimately, defensive players demonstrated a greater negative impact due to injury than offensive players, with multiple performance metrics significantly affected for each defensive position analyzed, whereas skilled offensive players (eg, quarterbacks, running backs) demonstrated only 1 metric significantly affected at each position.

Conclusion:

The most common sites of injury identified at the combine were (1) ankle, (2) shoulder, (3) knee, (4) spine, and (5) hand. Overall, performance in the NFL tended to worsen with injury history, with a direct correlation found between injury at a certain anatomic location and position of play. Defensive players tended to perform worse compared with offensive players if injury history was present.

Concomitant Reverse Hill-Sachs Lesion and Posterior Humeral Avulsion of the Glenohumeral Ligament: Treatment With Fresh Talus Osteochondral Allograft and Arthroscopic Posterior Humeral Avulsion of the Glenohumeral Ligament and Labrum Repair

Chronic posterior glenohumeral joint instability can be a challenging clinical entity for patients and surgeons alike. In the setting of a posterior dislocation, a large anterior humeral impaction injury (reverse Hill-Sachs [HS]) may occur, leading to engagement of the humerus with the posterior glenoid bone, especially during internal rotation of the joint. A reverse HS is especially debilitating because of the significant portion of affected humeral head cartilage, and is made worse in the setting of ligamentous disruption such as a posterior humeral avulsion of the glenohumeral ligament (HAGL) lesions. Although several nonanatomic procedures to address these defects have been previously described, recent interest in anatomic reconstructions capable of restoring the cartilage surface of the humeral head has led to the use of bone grafts (autografts and allografts) to restore the articular contour of the humeral head in conjunction with anatomic repair of associated soft tissue injuries. We present our preferred technique for an anatomic repair of a posterior HAGL lesion in combination with reconstruction of an engaging reverse HS lesion using an unmatched hemitalar allograft.

Arthroscopic Bony Resection for Treatment of Symptomatic Bipartite Patella

Bipartite patella is a common pathology, affecting 2% to 3% of the population. Usually these cases are bilateral and asymptomatic. However, a patient with a bipartite patella may complain of pain, which is most likely related to fragment mobility. Conservative treatment with physiotherapy, immobilization, and nonsteroidal drugs are encouraged during the initial 6 months following diagnosis. This option is effective in most patients. For patients who do not improve with these conservative measures, surgical intervention is indicated. Many surgical treatment options have been described including excision of the fragment, as well as fixation. Fragment excision has demonstrated positive outcomes and is associated with an asymptomatic return to sport activities. The purpose of this Technical Note is to describe our preferred arthroscopic technique for the treatment of symptomatic bipartite patella.

Osteochondral Allograft Transplantation for Treatment of Focal Patellar Osteochondral Lesion

Patellar osteochondral lesions are common and particularly disabling injuries that can affect young and highly active patients. If enough functional impairment, ranging from difficulty climbing stairs to pain with squatting, is present, surgical treatment may be warranted. For the treatment of these lesions, various techniques have been described, including autologous osteochondral transplantation, as well as microfracture surgery. However, these are not without disadvantages. Although morbidity is noted in cases of autologous osteochondral transplantation, uncertain and possibly unsustainable results are associated with the microfracture procedure. Therefore, we present an alternative surgical treatment option for this pathology. The objective of this Technical Note is to describe our preferred approach for an osteochondral allograft transplant procedure to treat a focal patellar osteochondral lesion.

Medial Patellofemoral Ligament Reconstruction in a Revision Setting: Anchor and Interference Screw Fixation

Recurrent patellar instability is a common pathology and typically affects younger and more active patients. To prevent complete lateral dislocation of the patella, several osseous and soft-tissue procedures have been previously described, including reconstruction of the medial patellofemoral ligament (MPFL), which has been identified as the primary medial stabilizer of the patella. Several techniques have been reported for reconstruction of the MPFL, sometimes in conjunction with other procedures, with the majority showing success in the treatment and resolution of patellar instability. However, MPFL reconstruction is not free of complications, with previous reports of recurrence of medial patellar instability and patellar fracture after surgery. The objective of this Technical Note is to describe our preferred technique, comprising anchor as well as interference screw fixation, for reconstruction of the MPFL in a primary or revision setting.