Publication Rates of Podium Presentations at an Annual Orthopedic Surgery Resident and Fellow Research Symposium

Introduction Research is an important aspect of residency and fellowship programs across the country. Developing strategies to foster research productivity is worthwhile. An annual research project is one strategy that some programs implement. Methods All resident and fellow (Sports Medicine, Adult Reconstruction, Spine) presentations at an orthopedic surgery department's annual research symposium from June 2016 through June 2021 were identified. Abstract titles, title keywords, and author names were searched in PubMed and Google Scholar to identify the presence of a peer-reviewed publication. Using the total number of research symposium presentations given, the publication rate was calculated for each year, as well as collectively for 2016 to 2021. In addition to publication rate, first author percent, number of citations, Altmetric score, and journal impact factor were recorded. Current PGY-2 through PGY-5 residents completed a survey to assess the perceived value of the annual research symposium. Results Ninety-eight research symposium presentations were reviewed (69 residents, 29 fellows). Forty (58%) resident studies were published and 28 were first-author publications (70%). Thirteen (45%) fellow studies were published and seven were first-author publications (54%). Combining residents and fellows, the overall publication rate was 54% (53/98), and 66% of these (35/53) were first-author publications. There was a wide range of published manuscript journal impact factors, Altmetric scores, and number of citations. All residents surveyed reported finding value in the research symposium. Conclusion The overall publication rate of presentations at an annual orthopedic surgery department research symposium between 2016 and 2021 was 54%, consistent with publication rates reported at National Orthopedic Surgery Society meetings. All residents reported finding value in the annual research symposium. The results of this study support the academic value of implementing a required annual research project and may provide a useful gauge to inform residency and fellowship curricula at other institutions.

Post-operative protein supplementation following orthopaedic surgery: A systematic review

Decreased mechanical loading after orthopaedic surgery predisposes patients to develop muscle atrophy. The purpose of this review was to assess whether the evidence supports oral protein supplementation can help decrease postoperative muscle atrophy and/or improve patient outcomes following orthopaedic surgery. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). PubMed (MEDLINE), Embase, Scopus, and Web of Science were searched for randomized controlled trials that assessed protein or amino acid supplementation in patients undergoing orthopaedic surgery. Two investigators independently conducted the search using relevant Boolean operations. Primary outcomes included functional or physiologic measures of muscle atrophy or strength. Fourteen studies including 611 patients (224 males, 387 females) were analyzed. Three studies evaluated protein supplementation after ACL reconstruction (ACLR), 3 after total hip arthroplasty (THA), 5 after total knee arthroplasty (TKA), and 3 after surgical treatment of hip fracture. Protein supplementation showed beneficial effects across all types of surgery. The primary benefit was a decrease in muscle atrophy compared to placebo as measured by muscle cross sectional area. Multiple authors also demonstrated improved functional measures and quicker achievement of rehabilitation benchmarks. Protein supplementation has beneficial effects on mitigating muscle atrophy in the postoperative period following ACLR, THA, TKA, and surgical treatment of hip fracture. These effects often correlate with improved functional measures and quicker achievement of rehabilitation benchmarks. Further research is needed to evaluate long-term effects of protein supplementation and to establish standardized population-specific regimens that maximize treatment efficacy in the postoperative period.

Autograft Demonstrates Superior Outcomes for Revision Anterior Cruciate Ligament Reconstruction When Compared With Allograft: A Systematic Review

BACKGROUND

Multiple studies have compared outcomes among patients undergoing revision anterior cruciate ligament reconstruction (ACLR) with autograft versus allograft, but these data are inconsistently reported and long-term outcomes depending on graft type are yet to be determined.

PURPOSE

To perform a systematic review of clinical outcomes after revision ACLR (rACLR) with autograft versus allograft.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that compared the outcomes of patients undergoing rACLR with autograft versus allograft. The search phrase used was autograft allograft revision anterior cruciate ligament reconstruction. Graft rerupture rates, return-to-sports rates, anteroposterior laxity, and patient-reported outcome scores (subjective International Knee Documentation Committee, Tegner, Lysholm, and Knee injury and Osteoarthritis Outcome Score) were evaluated.

RESULTS

Eleven studies met inclusion criteria, including 3011 patients undergoing rACLR with autograft (mean age, 28.9 years) and 1238 patients undergoing rACLR with allograft (mean age, 28.0 years). Mean follow-up was 57.3 months. The most common autograft and allograft types were bone-patellar tendon-bone grafts. Overall, 6.2% of patients undergoing rACLR experienced graft retear, including 4.7% in the autograft group and 10.2% in the allograft group (P < .0001). Among studies that reported return-to-sports rates, 66.2% of patients with an autograft returned to sports as opposed to 45.3% of patients with an allograft (P = .01). Two studies found significantly greater postoperative knee laxity in the allograft group as compared with the autograft group (P < .05). Among all patient-reported outcomes, 1 study found 1 significant difference between groups: patients with an autograft had a significantly higher postoperative Lysholm score when compared with patients with an allograft.

CONCLUSION

Patients undergoing revision ACLR with an autograft can be expected to experience lower rates of graft retear, higher rates of return to sports, and less postoperative anteroposterior knee laxity when compared with patients undergoing revision ACLR with an allograft.

A novel non-invasive method for predicting bone mineral density and fracture risk using demographic and anthropometric measures

Fractures are costly to treat and can significantly increase morbidity. Although dual-energy x-ray absorptiometry (DEXA) is used to screen at risk people with low bone mineral density (BMD), not all areas have access to one. We sought to create a readily accessible, inexpensive, high-throughput prediction tool for BMD that may identify people at risk of fracture for further evaluation. Anthropometric and demographic data were collected from 492 volunteers (♂275, ♀217; [44 ​± ​20] years; Body Mass Index (BMI) = [27.6 ​± ​6.0] kg/m2) in addition to total body bone mineral content (BMC, kg) and BMD measurements of the spine, pelvis, arms, legs and total body. Multiple-linear-regression with step-wise removal was used to develop a two-step prediction model for BMC followed by BMC. Model selection was determined by the highest adjusted R2, lowest error of estimate, and lowest level of variance inflation (α ​= ​0.05). Height (HTcm), age (years), sexm=1, f=0, %body fat (%fat), fat free mass (FFMkg), fat mass (FMkg), leg length (LLcm), shoulder width (SHWDTHcm), trunk length (TRNKLcm), and pelvis width (PWDTHcm) were observed to be significant predictors in the following two-step model (p ​< ​0.05). Step1: BMC (kg) = (0.006 3 × HT) ​+ ​(-0.002 4 × AGE) ​+ ​(0.171 2 × SEXm=1, f=0) ​+ ​(0.031 4 × FFM) ​+ ​(0.001 × FM) ​+ ​(0.008 9 × SHWDTH) ​+ ​(-0.014 5 × TRNKL) ​+ ​(-0.027 8 × PWDTH) - 0.507 3; R2 ​= ​0.819, SE ​± ​0.301. Step2: Total body BMD (g/cm2) = (-0.002 8 × HT) ​+ ​(-0.043 7 × SEXm=1, f=0) ​+ ​(0.000 8 × %FAT) ​+ ​(0.297 0 × BMC) ​+ ​(-0.002 3 × LL) ​+ ​(0.002 3 × SHWDTH) ​+ ​(-0.002 5 × TRNKL) ​+ ​(-0.011 3 × PWDTH) ​+ ​1.379; R2 ​= ​0.89, SE ​± ​0.054. Similar models were also developed to predict leg, arm, spine, and pelvis BMD (R2 ​= ​0.796-0.864, p ​< ​0.05). The equations developed here represent promising tools for identifying individuals with low BMD at risk of fracture who would benefit from further evaluation, especially in the resource or time restricted setting.

The Principles of Knee Joint Preservation

The 3 primary factors involved with preservation of the knee joint include joint alignment, meniscal status, and ligament stability (in particular that of the anterior cruciate ligament [ACL]). These factors are interdependent and result in knee joint homeostasis when all factors are stable. When a deficiency exists in one of the factors, it will affect the others. For example, the ACL and posterior horn of the medial meniscus both act as restraints to anterior tibial translation. Thus, medial meniscal deficiency increases the risk for failure of ACL reconstruction, and chronic ACL insufficiency increases the risk for medial meniscus tears. Furthermore, all 3 of the factors of joint preservation have an impact on the articular cartilage status of the knee joint. Studies have shown that cartilage-preservation procedures do not result in optimal outcomes if there is joint malalignment, meniscal deficiency, or ligament deficiency. When evaluating patients with knee cartilage pathology, surgeons should be aware of the various factors involved in knee joint preservation and, if surgery is indicated, all factors should be addressed in order to support a successful result.

Screw Fixation for the Latarjet Procedure May Reduce Risk of Recurrent Instability but Increases Reoperation Rate Compared to Suture-Button Fixation: A Systematic Review

PURPOSE

To perform a systematic review to compare clinical outcomes, complications, and reoperation rates of patients undergoing the Latarjet procedure with screw vs suture-button fixation.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies directly comparing screw vs suture-button fixation for the Latarjet procedure. The search terms used were shoulder screw suture button. Patients were evaluated based on reoperation rate, complication rate, recurrent instability, radiologic outcomes, and patient-reported outcomes. Graft and screw position were assessed via computed tomography.

RESULTS

Seven studies (1 Level II, 6 Level III) met inclusion criteria, with 845 patients undergoing the Latarjet procedure with screw fixation (screw group) and 279 patients with suture-button fixation (suture-button group). Mean patient age ranged from 21.2 to 29.6 years. Mean follow-up time ranged from 6.0 to 40.8 months. The recurrent instability rate ranged from 0% to 2.5% in the screw group and 0% to 8.3% in the suture-button group. The reoperation rate ranged from 0% to 7.7% in the screw group compared to 0% to 1.9% in the suture-button group. One study reported significantly lower visual analog scale pain scores in the suture-button group compared with the screw group (1.5 vs 1.2, P = .003). No other studies reported significant differences in any patient-reported outcomes. There was no significant difference in horizontal or vertical graft position, graft union rate, or complication rate between groups in any study.

CONCLUSIONS

The Latarjet procedure with screw fixation may result in a lower risk of recurrent instability compared to suture-button fixation, although screw fixation may also have a higher reoperation rate due to hardware-related complications.

LEVEL OF EVIDENCE

Level III, systematic review of Level II to III studies.

The Principles of Knee Joint Preservation: Operative Treatment Strategies

➤ Joint alignment, meniscal status, and ligament stability are codependent factors involved in knee joint preservation, and any injury or imbalance can impact the knee articular cartilage status and can result in adverse clinical outcomes.➤ Cartilage preservation procedures in the knee will not result in optimal outcomes if there is joint malalignment, meniscal deficiency, or ligamentous instability.➤ Lower-extremity varus or valgus malalignment is a risk factor for the failure of an anterior cruciate ligament (ACL) reconstruction. It represents an indication for a high tibial osteotomy or distal femoral osteotomy in the setting of failed ACL reconstruction, and may even be considered in patients who have an initial ACL injury and severe malalignment.➤ An elevated posterior tibial slope increases the risk of failure of ACL reconstruction, whereas a decreased posterior tibial slope increases the risk of failure of posterior cruciate ligament reconstruction.

All-Arthroscopic Treatment of Off-Track Hill-Sachs Lesions Using Fresh Osteochondral Allograft Plugs: "Rocks in a Stream"

Osteochondral allograft transplantation is a well-described technique for the treatment of large, engaging Hill-Sachs lesions. Traditionally, osteochondral allografts are size-matched to the defect, which can be expensive and time-consuming, and the majority of described techniques require an open approach. This Technical Note describes an all-arthroscopic approach to Hill-Sachs osteochondral allograft transplantation using premade osteochondral allograft plugs, eliminating the need for size-matching and graft harvest. This approach works not by anatomically filling the defect, but rather by bridging the defect to prevent it from engaging the glenoid.

Validated Wearable Device Shows Acute Postoperative Changes in Sleep Patterns Consistent With Patient-Reported Outcomes and Progressive Decreases in Device Compliance After Shoulder Surgery

Purpose

To assess the utility of a validated wearable device (VWD) in examining preoperative and postoperative sleep patterns and how these data compare to patient-reported outcomes (PROs) after rotator cuff repair (RCR) or total shoulder arthroplasty (TSA).

Methods

Male and female adult patients undergoing either RCR or TSA were followed up from 34 days preoperatively to 6 weeks postoperatively. Sleep metrics were collected using a VWD in an unsupervised setting. PROs were assessed using the following validated outcome measures: Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function questionnaire; American Shoulder and Elbow Surgeons self-evaluation questionnaire; visual analog scale assessing pain; and Disabilities of the Arm, Shoulder and Hand questionnaire. Data were analyzed preoperatively and at 2-week intervals postoperatively with χ2 analysis to evaluate device compliance. Sleep metrics and PROs were evaluated at each interval relative to preoperative values within each surgery type with an analysis of variance repeated on time point. The relation between sleep metrics and PROs was assessed with correlation analysis.

Results

A total of 57 patients were included, 37 in the RCR group and 20 in the TSA group. The rate of device compliance in the RCR group decreased from 84% at surgery to 46% by 6 weeks postoperatively (P < .001). Similarly, the rate of device compliance in the TSA group decreased from 81% to 52% (P < .001). Deep sleep decreased in RCR patients at 2 to 4 weeks (decrease by 10.99 ± 3.96 minutes, P = .021) and 4 to 6 weeks postoperatively (decrease by 13.37 ± 4.08 minutes, P = .008). TSA patients showed decreased deep sleep at 0 to 2 weeks postoperatively (decrease by 12.91 ± 5.62 minutes, P = .045) and increased rapid eye movement sleep at 2 to 4 weeks postoperatively (increase by 26.91 ± 10.70 minutes, P = .031). Rapid eye movement sleep in the RCR group and total sleep in the TSA group were positively correlated with more favorable PROs (P < .05).

Conclusions

VWDs allow for monitoring components of sleep that offer insight into potential targets for improving postoperative fatigue, pain, and overall recovery after shoulder surgery. However, population demographic factors and ease of device use are barriers to optimized patient compliance during data collection.

Level of Evidence

Level IV, diagnostic case series.

Shear wave elastography of the ulnar collateral ligament in division IA pitchers across a competitive collegiate season

Background

The ulnar collateral ligament (UCL) is a commonly injured elbow stabilizer during throwing. Shear wave elastography (SWE) is a technique that may reveal structural changes in the UCL that are indicative of ligament health and injury risk. The purpose of this study was to assess preseason and inseason shear wave velocity (SWV) in the UCL of collegiate pitchers and to asses repeatability of this measurement technique in healthy volunteers.

Methods

Seventeen collegiate baseball pitchers and 11 sex-matched volunteers were recruited. Two-dimensional SWE of the UCL was performed by a single radiologist. In pitchers, SWV was measured at the proximal, midsubstance, and distal UCL for dominant and nondominant elbows preseason, midseason, and postseason, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow questionnaire scores were recorded. In volunteers, SWV was measured at UCL midsubstance in dominant elbows at 3 separate occasions over 1 week. An independent samples t-test was used to compare preseason midsubstance measures between pitchers and the healthy volunteers. A mixed-model analysis of covariance (covaried on preseason measures) was used to compare SWV measures at the preseason, midseason, and postseason time points. A similar generalized linear model for nonparametric data was used to compare KJOC scores. Type-I error was set at P < .05.

Results

Mean preseason midsubstance dominant arm UCL SWV did not significantly differ between the pitchers (5.40 ± 1.65 m/s) compared to the healthy volunteers (4.35 ± 1.45 m/s). For inseason measures among the pitchers, a decrease in midsubstance (-1.17 ± 0.99 m/s, P = .021) and proximal (-1.55 ± 0.91 m/s, P = .001) SWV was observed at midseason compared to preseason. The proximal measure was also observed to be significantly lower than the nondominant arm (-1.97 ± 0.95 m/s, P < .001). Proximal SWV remained reduced relative to the preseason and the postseason mark (-1.13 ± 0.91 m/s, P = .015). KJOC scores decreased at midseason compared to preseason (P = .003) but then increased to a similar preseason value at the postseason measurement (preseason = 92 ± 3, midseason = 87 ± 3, postseason = 91 ± 3). The repeatability coefficient of SWE in the volunteer cohort was 1.98 m/s.

Conclusion

Decreased SWV in the proximal and midsubstance of the dominant arm UCL at midseason suggests structural changes indicative of increasing laxity or 'softening' of the UCL. Associated decline in KJOC scores suggests that these changes are associated with functional decline. Future studies with more frequent sampling would be invaluable to further explore this observation and its significance for predicting and managing UCL injury risk.

Isolated Osteotomy Versus Combined Osteotomy and Cartilage Repair for Osteoarthritis or Focal Chondral Defects of the Medial Compartment of the Knee Joint: A Systematic Review

Background

The extent to which concomitant cartilage repair provides an improvement in clinical outcomes after osteotomy is unclear.

Purpose

To compare studies reporting clinical outcomes after isolated osteotomy with or without cartilage repair for osteoarthritis (OA) or focal chondral defects (FCDs) of the knee joint.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, Cochrane Library, and Embase databases. The search was done to identify comparative studies that directly compared outcomes between isolated osteotomy-high tibial osteotomy or distal femoral osteotomy-and osteotomy with concomitant cartilage repair for OA or FCDs of the knee joint. Patients were evaluated based on reoperation rate, magnetic resonance observation of cartilage repair tissue score, macroscopic International Cartilage Regeneration & Joint Preservation Society score, and patient-reported outcomes.

Results

In total, 6 studies-level 2 evidence (n = 2);, level 3 evidence (n = 3);, and level 4 evidence (n = 1)-met the inclusion criteria, including a total of 228 patients undergoing osteotomy alone (group A) and 255 patients undergoing osteotomy with concomitant cartilage repair (group B). The mean patient age was 53.4 and 54.8 years, respectively, and the mean preoperative alignment was 6.6° and 6.7° of varus in groups A and B, respectively. The mean follow-up time was 71.5 months. All studies assessed medial compartment lesions with varus deformity. One study compared osteotomy alone for patients with medial compartment OA versus osteotomy with autologous chondrocyte implantation for patients with FCDs of the medial compartment. Three other studies included a heterogeneous cohort of patients with OA and FCDs in both groups. Only 1 study isolated its comparison to patients with medial compartment OA and 1 study isolated its comparison to patients with FCDs.

Conclusion

There is limited evidence with substantial heterogeneity between studies on clinical outcomes after osteotomy alone versus osteotomy with cartilage repair for OA or FCDs of the knee joint. At this time, no conclusion can be made regarding the role of additional cartilage procedures in treating medial compartment OA or FCDs. Further studies are needed that isolate specific disease pathology and specific cartilage procedures.

Optimal Blood Flow Restriction Occlusion Pressure for Shoulder Muscle Recruitment With Upper Extremity Exercise

BACKGROUND

As blood flow restriction (BFR) utilization continues to rise, it is crucial to define optimal parameters for use. Currently unknown are the effects of occlusion level during BFR on muscle activity in the proximal shoulder.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare electromyographic amplitude (EMGa) of shoulder musculature during exercise using limb occlusion percentages (LOPs). The authors hypothesized that EMGa would increase concurrently with occlusion.

STUDY DESIGN

Controlled laboratory study.

METHODS

α Fifteen healthy adults were recruited and underwent 4 experimental sessions, performing 3 common rotator cuff exercises at low intensity (20% maximal strength) to failure in the following order: cable external rotation (ER), cable internal rotation (IR), and dumbbell scaption. Exercises were completed at a different occlusion pressure (0%, 25%, 50%, and 75% LOP- order randomized) applied at the proximal arm. EMGa was recorded from shoulder musculature proximal to the occlusion site and averaged across 5-repetition intervals and overall for the first 30 repetitions. An analysis of variance repeated on occlusion pressure followed by a Bonferroni post hoc test was used to compare EMGa, repetitions to fatigue, and ratings of discomfort (visual analog scale [VAS], 0-10) between occlusion pressures. The type 1 error was set at α = .05 for all analyses.

RESULTS

Significant effects of the occlusion level on shoulder muscle EMGa were observed for all exercises (P < .05) with diminishing returns above 50% LOP (overall). For ER, elevations in EMGa were observed at ≥50% LOP for the anterior deltoid, middle deltoid, infraspinatus, and trapezius compared with 0% LOP (P < .05). For IR, elevations in EMGa were observed at ≥25% LOP for the anterior deltoid and trapezius compared with 0% LOP (P < .05). For the teres minor, a significant elevation in EMGa occurred at 75% LOP compared with 0%, 25%, and 50% LOP (P < .05). A decrease in EMGa was observed at ≥50% LOP compared with 0% LOP for the posterior deltoid (P < .05). For scaption, an increase in EMGa was observed at ≥25% LOP for the infraspinatus and teres minor muscles, at 75% LOP for the posterior deltoid, and at ≥50% LOP for the trapezius compared with 0% LOP (P < .05). Decreases in repetitions to failure relative to 0% LOP were observed at 75% LOP for ER (0%: 47 ± 5; 75%: 40 ± 2; P = .034), IR (0%: 82 ± 10; 75%: 64 ± 5; P = .017), and scaption (0%: 85 ± 9; 75%: 64 ± 6; P < .001). A significant linear increase in discomfort was observed for all exercises with increasing occlusion pressures (VAS: 0-10, 0% → 75% LOP; ER: 2.2 ± 0.4 → 7.2 ± 0.3; IR: 1.3 ± 0.2 → 6.1 ± 0.6; scaption: 1.3 ± 0.4 → 6.1 ± 0.4; P < .01).

CONCLUSION

There are several differences in muscle activation about the shoulder based on exercise and occlusion when utilizing BFR. Increasing the percentage of limb occlusion leads to heightened EMGa with diminished returns past 50% LOP when considering muscle activation, discomfort, and achievable exercise volume.

CLINICAL RELEVANCE

These findings may be used to refine upper extremity BFR guidelines.

Rotator cuff training with upper extremity blood flow restriction produces favorable adaptations in Division IA collegiate pitchers: a randomized trial

BACKGROUND

Recent evidence indicates that combined upper extremity blood flow restriction (BFR, applied distally to the shoulder) and low-load resistance exercise (LIX) augments clinically meaningful responses in shoulder region tissues proximal to the occlusion site. The purpose of this investigation was to determine the efficacy of BFR-LIX for the shoulder when added to standard offseason training in Division IA collegiate baseball pitchers. We hypothesized that BFR-LIX would augment training-induced increases in shoulder-region lean mass, rotator cuff strength, and endurance. As secondary outcomes, we sought to explore the impact of BFR-LIX rotator cuff training on pitching mechanics.

METHODS

Twenty-eight collegiate baseball pitchers were randomized into 2 groups (BFR^N=15, NOBFR^N=13) that, in conjunction with offseason training, performed 8wks of shoulder LIX [Throwing arm only; 2/wk, 4 sets (30/15/15/fatigue), 20%isometric max] using 4 exercises [cable external and internal rotation (ER/IR), dumbbell scaption, and side-lying dumbbell ER]. The BFR group also trained with an automated tourniquet on the proximal arm (50%-occlusion). Regional lean mass (dual-energy x-ray absorptiometry), rotator cuff strength (dynamometry: IR0&90, ° ER0&90, ° Scaption, Flexion), and fastball biomechanics were assessed pre- and post-training. Achievable workload (sets × reps × resistance) was also recorded. An ANCOVA (covaried on baseline measures) repeated on training timepoint was used to detect within-group and between-group differences in outcome measures (α=0.05). For significant pairwise comparisons, effect size (ES) was calculated using a Cohen's d statistic and interpreted as: 0-0.1, negligible(N); 0.1-0.3, small(S); 0.3-0.5, moderate(M); 0.5-0.7, large(L); >0.7, very large(VL).

RESULTS

Following training, the BFR group experienced greater increases in shoulder-region lean mass [BFR: ↑227±60g, NOBFR: ↑75±37g, P=0.018, ES=1.0(VL)] and isometric strength for IR90° (↑2.4±2.3kg, P=0.041, ES=0.9VL). The NOBFR group experienced decreased shoulder flexion (↓1.6±0.8kg, P=0.007, ES=1.4VL) and IR at 0°(↓2.9±1.5kg, P=0.004, ES=1.1VL). The BFR group had a greater increase in achievable workload for the scaption exercise (BFR: ↑190±3.2kg, NOBFR: ↑90±3.3kg, P=0.005, ES=0.8VL). Only the NOBFR group was observed to experience changes in pitching mechanics following training with increased shoulder external rotation at lead foot contact (↑9.0°±7.9, P=0.028, ES=0.8VL) as well as reduced forward (↓3.6°±2.1, P=0.001, ES=1.2VL) and lateral (↓4.6°±3.4, P=0.007, ES=1.0VL) trunk tilt at ball release.

CONCLUSION

BFR-LIX rotator cuff training performed in conjunction with a collegiate offseason program augments increases in shoulder lean mass as well as muscular endurance while maintaining rotator cuff strength and possibly pitching mechanics in a manner that may contribute to favorable outcomes and injury prevention in baseball pitching athletes.

Patients With Knee Osteoarthritis Who Receive Platelet-Rich Plasma or Bone-Marrow Aspirate Concentrate Injections Have Better Outcomes Than Patients Who Receive Hyaluronic Acid: Systematic Review and Meta-analysis

PURPOSE

To systematically review the literature in order to compare the efficacy and safety of platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and hyaluronic acid (HA) injections for the treatment of knee osteoarthritis (OA).

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I studies that compared the clinical efficacy of at least 2 of the following 3 injection therapies: PRP, BMAC, and HA for knee OA. The search phrase used was knee AND osteoarthritis AND randomized AND ("platelet rich plasma" OR "bone marrow aspirate" OR "hyaluronic acid"). Patients were primarily assessed based on patient-reported outcome scores (PROs) including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) score.

RESULTS

Twenty-seven studies (all Level I) met inclusion criteria, including 1,042 patients undergoing intra-articular injection(s) with PRP (mean age 57.7 years, mean follow-up 13.5 months), 226 patients with BMAC (mean age 57.0 years, mean follow-up 17.5 months), and 1,128 patients with HA (mean age 59.0 years, mean follow-up 14.4 months). Non-network meta-analyses demonstrated significantly better post-injection WOMAC (p < 0.001), VAS (p < 0.01), and Subjective IKDC scores (p < 0.001) in PRP patients when compared to HA patients. Similarly, network meta-analyses demonstrated significantly better post-injection WOMAC (p < 0.001), VAS (p = 0.03), and Subjective IKDC (p < 0.001) scores in BMAC patients when compared to HA patients. There were no significant differences in post-injection outcome scores when comparing PRP to BMAC.

CONCLUSION

Patients undergoing treatment for knee OA with PRP or BMAC can be expected to experience improved clinical outcomes when compared to HA patients.

LEVEL OF EVIDENCE

I, Meta-Analysis of Level I studies.

Cartilage Repair of the Tibiofemoral Joint With Versus Without Concomitant Osteotomy: A Systematic Review of Clinical Outcomes

Background

The extent to which concomitant osteotomy provides an improvement in clinical outcomes after cartilage repair procedures is unclear.

Purpose

To review the existing literature to compare clinical outcomes of patients undergoing cartilage repair of the tibiofemoral joint with versus without concomitant osteotomy.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify studies that directly compared outcomes between cartilage repair of the tibiofemoral joint alone (group A) versus cartilage repair with concomitant osteotomy (high tibial osteotomy [HTO] or distal femoral osteotomy [DFO]) (group B). Studies on cartilage repair of the patellofemoral joint were excluded. The search terms used were as follows: osteotomy AND knee AND ("autologous chondrocyte" OR "osteochondral autograft" OR "osteochondral allograft" OR microfracture). Outcomes in groups A and B were compared based on reoperation rate, complication rate, procedure payments, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale [VAS] for pain, satisfaction, and WOMAC).

Results

Included in the review were 5 studies (1 level 2 study, 2 level 3 studies, 2 level 4 studies) with 1747 patients in group A and 520 patients in group B. The mean patient ages were 34.7 and 37.5 years in groups A and B, respectively, and the mean lesion sizes were 4.0 and 4.5 cm², respectively. The mean follow-up time was 44.6 months. The most common lesion location was the medial femoral condyle (n = 999). Preoperative alignment averaged 1.8° and 5.5° of varus in groups A and B, respectively. One study found significant differences between groups in KOOS, VAS, and satisfaction, favoring group B. The reoperation rates were 47.4% and 17.3% in groups A and B, respectively (P < .0001).

Conclusion

Patients undergoing cartilage repair of the tibiofemoral joint with concomitant osteotomy might be expected to experience greater improvement in clinical outcomes with a lower reoperation rate compared with those undergoing cartilage repair alone. Surgeons preparing for cartilage procedures of the knee joint should pay particular attention to preoperative malalignment of the lower extremity to optimize outcomes.

Effects of Running on the Development of Knee Osteoarthritis: An Updated Systematic Review at Short-Term Follow-up

Background

Some studies have suggested that running increases the risk of knee osteoarthritis (OA), while others believe it serves a protective function.

Purpose

To perform an updated systematic review of the literature to determine the effects of running on the development of knee OA.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies evaluating the effect of cumulative running on the development of knee OA or chondral damage based on imaging and/or patient-reported outcomes (PROs). The search terms used were "knee AND osteoarthritis AND (run OR running OR runner)." Patients were evaluated based on plain radiographs, magnetic resonance imaging (MRI), and PROs (presence of knee pain, Health Assessment Questionnaire-Disability Index, and the Knee injury and Osteoarthritis Outcome Score).

Results

Seventeen studies (6 level 2 studies, 9 level 3 studies, and 2 level 4 studies), with 7194 runners and 6947 nonrunners, met the inclusion criteria. The mean follow-up time was 55.8 months in the runner group and 99.7 months in the nonrunner group. The mean age was 56.2 years in the runner group and 61.6 years in the nonrunner group. The overall percentage of men was 58.5%. There was a significantly higher prevalence of knee pain in the nonrunner group (P < .0001). Although 1 study found a significantly higher prevalence of osteophytes in the tibiofemoral (TF) and patellofemoral (PF) joints within the runner group, multiple studies found no significant differences in the prevalence of radiographic knee OA (based on TF/PF joint-space narrowing or Kellgren-Lawrence grade) or cartilage thickness on MRI between runners and nonrunners (P > .05). One study found a significantly higher risk of knee OA progressing to total knee replacement among nonrunners (4.6% vs 2.6%; P = .014).

Conclusion

In the short term, running is not associated with worsening PROs or radiological signs of knee OA and may be protective against generalized knee pain.

The Most Common Rehabilitation Protocol After Matrix-Assisted Autologous Chondrocyte Implantation Is Immediate Partial Weight-Bearing and Continuous Passive Motion

Purpose

To perform a systematic review of postoperative rehabilitation protocols for third-generation autologous chondrocyte implantation (ACI) of the knee joint.

Methods

A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials that described a rehabilitation protocol following third-generation ACI of the knee joint. The search terms used were: "autologous" AND "chondrocyte" AND "randomized". Data extracted from each study included various components of postoperative rehabilitation, such as initial weight-bearing (WB) status and time to full WB, the use of continuous passive motion (CPM), the time to return to sports, and physical therapy (PT) modalities used and the timing of their initiation.

Results

Twenty-five studies (22 Level I, 3 Level II) met inclusion criteria, including a total of 905 patients undergoing treatment with ACI. The average patient age ranged from 29.1 to 54.8 years, and the mean follow-up time ranged from 3 months to 10.0 years. The average lesion size ranged from 1.9 to 5.8 cm², and the most common lesion location was the medial femoral condyle (n = 494). Twenty studies allowed partial WB postoperatively with all studies permitting full WB within 12 weeks. Twenty studies used CPM in their rehabilitation protocols and initiated its use within 24 hours postoperatively. Among 10 studies that reported time to return to sport, 9 (90%) allowed return by 12 months. While most protocols used strength training as well as the inclusion of proprioceptive training, there was disagreement on the timing and inclusion of specific PT modalities used during the rehabilitation process.

Conclusions

Based on the included studies, most rehabilitation protocols for third-generation ACI initiate CPM within 24 hours postoperatively and allow partial WB immediately following surgery with progression to full WB within 12 weeks. There is variation of the PT modalities used as well as the timing of their initiation.

Level of Evidence

Level II, systematic review of Level I-II studies.

Third-Generation Autologous Chondrocyte Implantation (Cells Cultured Within Collagen Membrane) Is Superior to Microfracture for Focal Chondral Defects of the Knee Joint: Systematic Review and Meta-analysis

PURPOSE

To systematically review randomized controlled trials to compare clinical outcomes of microfracture (MFx) versus third-generation autologous chondrocyte implantation (ACI) for the treatment of focal chondral defects (FCDs) of the knee joint.

METHODS

A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials comparing minimum 2-year clinical outcomes of patients undergoing MFx versus third-generation ACI for FCDs of the knee joint. The search terms used were: "knee" AND "microfracture" AND "autologous chondrocyte" AND "randomized." Patients were evaluated based on treatment failure rates, magnetic resonance imaging, International Cartilage Repair Society scores, and patient-reported outcome scores (Lysholm, Tegner, Knee Injury and Osteoarthritis Outcome Score, modified Cincinnati Knee Rating System, 12-item Short Form Health Survey Physical and Mental, and the EuroQol 5 Dimensions Visual Analog Scale score).

RESULTS

Six studies (5 Level I, 1 Level II) met inclusion criteria, including a total of 238 patients undergoing MFx and 274 undergoing ACI. Two studies had an overlapping cohort of patients and therefore the study with longer follow-up was used in all analyses. The average follow-up among patients ranged from 2.0 years to 6.0 years. Average lesion size ranged from 1.8 cm² to 5.0 cm². Treatment failure ranged from 0% to 1.8% in the ACI group and 2.5% to 8.3% in the MFx group. In 4 studies, ACI patients demonstrated significantly greater improvement in multiple Knee Injury and Osteoarthritis Outcome Score subscores compared with MFx. In 2 studies, patients who received ACI demonstrated significantly greater improvement in the Tegner score compared to MFx, and 1 study showed significantly greater improvement in the Lysholm and ICRS scores for ACI compared with MFx.

CONCLUSIONS

At short-term follow-up, third-generation ACI demonstrates a lower failure rate and greater improvement in patient-reported outcomes compared with MFx for FCDs of the knee joint.

LEVEL OF EVIDENCE

II, systematic review of Levels I-II studies.

Autograft and Nonirradiated Allograft for Anterior Cruciate Ligament Reconstruction Demonstrate Similar Clinical Outcomes and Graft Failure Rates: An Updated Systematic Review

Purpose

To perform an updated systematic review comparing the clinical outcomes of autograft versus nonirradiated allograft for anterior cruciate ligament reconstruction (ACLR).

Methods

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies directly comparing outcomes of primary ACLR with autograft versus nonirradiated allograft with a minimum 2-year follow-up. The search terms used were: “anterior cruciate ligament” AND autograft AND allograft AND (irradiation OR non-irradiated). Patients were evaluated based on graft failure rates, the Objective International Knee Documentation Committee (IKDC) score, anteroposterior laxity, and patient-reported outcomes (Subjective IKDC score, the visual analog scale [VAS], the Cincinnati Knee Rating System, Lysholm, and Tegner scores). Risk of bias was assessed using the ROBINS-I and Cochrane Collaboration’s risk of bias tool for non-randomized and randomized studies, respectively.

Results

Sixteen studies (3 Level I, 7 Level II, 6 Level III) met inclusion criteria, including a total of 15,502 patients undergoing ACLR with autograft and 1,577 with nonirradiated allograft. The average follow-up ranged from 24.0 to 132.0 months. Graft failure ranged from 0% to 9.4% of patients in the autograft group and 0% to 26.5% in the allograft group. Two studies showed greater failure rates among younger patients in the allograft group. There were no significant differences between the Objective IKDC score, anteroposterior laxity, or patient-reported outcomes between the groups within any of the included studies (P > .05).

Conclusions

Autograft and nonirradiated allograft for primary ACLR demonstrate similar patient-reported outcomes and graft failure rates.

Level of Evidence

III, systematic review of level I-III studies.

Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction

BACKGROUND

Muscle atrophy is common after an injury to the knee and anterior cruciate ligament reconstruction (ACLR). Blood flow restriction therapy (BFR) combined with low-load resistance exercise may help mitigate muscle loss and improve the overall condition of the lower extremity (LE).

PURPOSE

To determine whether BFR decreases the loss of LE lean mass (LM), bone mass, and bone mineral density (BMD) while improving function compared with standard rehabilitation after ACLR.

STUDY DESIGN

Randomized controlled clinical trial.

METHODS

A total of 32 patients undergoing ACLR with bone-patellar tendon-bone autograft were randomized into 2 groups (CONTROL: N = 15 [male = 7, female = 8; age = 24.1 ± 7.2 years; body mass index [BMI] = 26.9 ± 5.3 kg/m2] and BFR: N = 17 [male = 12, female = 5; age = 28.1 ± 7.4 years; BMI = 25.2 ± 2.8 kg/m2]) and performed 12 weeks of postsurgery rehabilitation with an average follow-up of 2.3 ± 1.0 years. Both groups performed the same rehabilitation protocol. During select exercises, the BFR group exercised under 80% arterial occlusion of the postoperative limb (Delfi tourniquet system). BMD, bone mass, and LM were measured using DEXA (iDXA, GE) at presurgery, week 6, and week 12 of rehabilitation. Functional measures were recorded at week 8 and week 12. Return to sport (RTS) was defined as the timepoint at which ACLR-specific objective functional testing was passed at physical therapy. A group-by-time analysis of covariance followed by a Tukey's post hoc test were used to detect within- and between-group changes. Type I error; α = 0.05.

RESULTS

Compared with presurgery, only the CONTROL group experienced decreases in LE-LM at week 6 (-0.61 ± 0.19 kg, -6.64 ± 1.86%; P < 0.01) and week 12 (-0.39 ± 0.15 kg, -4.67 ± 1.58%; P = 0.01) of rehabilitation. LE bone mass was decreased only in the CONTROL group at week 6 (-12.87 ± 3.02 g, -2.11 ± 0.47%; P < 0.01) and week 12 (-16.95 ± 4.32 g,-2.58 ± 0.64%; P < 0.01). Overall, loss of site-specific BMD was greater in the CONTROL group (P < 0.05). Only the CONTROL group experienced reductions in proximal tibia (-8.00 ± 1.10%; P < 0.01) and proximal fibula (-15.0±2.50%,P < 0.01) at week 12 compared with presurgery measures. There were no complications. Functional measures were similar between groups. RTS time was reduced in the BFR group (6.4 ± 0.3 months) compared with the CONTROL group (8.3 ± 0.5 months; P = 0.01).

CONCLUSION

After ACLR, BFR may decrease muscle and bone loss for up to 12 weeks postoperatively and may improve time to RTS with functional outcomes comparable with those of standard rehabilitation.

Sex-related Anthropometrics in a Lower-Body Mobility Assessment Among Professional Soccer Athletes

Background

The functional movement screen (FMS™) and Y-balance test (YBT) are commonly used to evaluate mobility in athletes.

Purpose

The primary aim of this investigation was to determine the relationship between demographic and anthropometric factors such as sex, body composition, and skeletal dimension and scoring on YBT and FMS™ in male and female professional soccer athletes.

Study Design

Cross Sectional.

Methods

During pre-season assessments, athletes from two professional soccer clubs were recruited and underwent body composition and skeletal dimension analysis via dual-energy X-ray absorptiometry (DEXA) scans. Balance and mobility were assessed using the YBT and FMS™. A two-tailed t-test was used to compare YBT between sexes. Chi-square was used for sex comparisons of FMS™ scores. Correlation analysis was used to determine if body composition and/or skeletal dimensions correlated with YBT or FMS™ measures. Type-I error; α=0.05.

Results

40 Participants were successfully recruited: (24 males: 27±5yr, 79±9kg; |16 females: 25±3yr, 63±4kg). YBT: Correlations were found between anterior reach and height (r=-0.36), total lean mass (LM)(r=-0.39), and trunk LM(r=-0.39) as well as between posterolateral reach and pelvic width (PW)(r=0.42), femur length (r=0.44), and tibia length (r=0.51)(all p<0.05). FMS™: The deep squat score was correlated with height(r=-0.40), PW(r=0.40), LM(r=-0.43), and trunk LM (r =-0.40)(p<0.05). Inline lunge scores were correlated with height(r=-0.63), PW(r=0.60), LM(r=-0.77), trunk LM(r=-0.73), and leg LM(r=0.70)(all p<0.05). Straight leg raise scores were correlated with PW (r=0.45, p<0.05). Females scored higher for the three lower body FMS™ measures where correlations were observed (p<0.05).

Conclusions

Lower body FMS™ scores differ between male and female professional soccer athletes and are related to anthropometric factors that may influence screening and outcomes for the FMS™ and YBT, respectively. Thus, these anatomical factors likely need to be taken into account when assessing baseline performance and risk of injury to improve screening efficacy.

Level of Evidence

Level 3b.

Blood Flow Restriction Enhances Rehabilitation and Return to Sport: The Paradox of Proximal Performance

The use of blood flow restriction (BFR) within rehabilitation is rapidly increasing as further research is performed elucidating purported benefits such as improved muscular strength and size, neuromuscular control, decreased pain, and increased bone mineral density. Interestingly, these benefits are not isolated to structures distal to the occlusive stimulus. Proximal gains are of high interest to rehabilitation professionals, especially those working with patients who are limited due to pain or postsurgical precautions. The review to follow will focus on current evidence and ongoing hypotheses regarding physiologic responses to BFR, current clinical applications, proximal responses to BFR training, potential practical applications for rehabilitation and injury prevention, and directions for future research. Interestingly, benefits have been found in musculature proximal to the occlusive stimulus, which may lend promise to a greater variety of patient populations and conditions. Furthermore, an increasing demand for BFR use in the sports world warrants further research for performance research and recovery.

LEVEL OF EVIDENCE

Level V, expert opinion.

Anthropometric Factors Associated With Bone Stress Injuries in Collegiate Distance Runners: New Risk Metrics and Screening Tools?

BACKGROUND

Lower limb bone stress injury (BSI) of the pelvis, femur, and tibia is prevalent in collegiate track and field distance runners. Bone mineral density (BMD), body composition (BComp), and anthropometric parameters before initial collegiate injury have not been compared between runners with BSI and their noninjured counterparts.

PURPOSE

To characterize bone health in relation to BComp and anthropometric measurements from total-body dual x-ray absorptiometry (DXA) scans in collegiate male and female distance runners before BSI and develop BMD prediction models.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Distance runners (N = 79) from a single university track and field team were retrospectively enrolled into this study. The runners completed a DXA scan during the fall season (August-November) and participated in sport activities before the scan. Three months after scanning, electronic medical records were reviewed for the occurrence of BSI. An independent-sample t test was used to compare BMD (total and regional [spine, pelvis, and legs]), BComp (% body fat, fat mass, and lean mass), and anthropometric measurements (shoulder width and leg, arm, and trunk length) between runners with versus without BSI (included subgroup analysis by sex). Multiple linear regression with stepwise removal was used to determine variables most predictive of BMD.

RESULTS

Of the 79 enrolled participants (42 male, 37 female), 18 runners (22.8%; 11 female, 7 male) sustained a lower limb BSI. Compared with the noninjured group, injured runners had lower total and regional BMD (P < .001 for all) and shorter leg and arm lengths (P < .05 for both), whereas injured male runners had lower fat mass and injured female runners had lower lean mass in the legs (P < .05 for both). Injured runners' age-matched total BMD Z score (-0.1 ± 0.6) was considered clinically normal. BComp and anthropometric measures were predictive of total and regional BMD (P < .05; R 2 = 0.64-0.80; percentage error = 3.8%-4.8%).

CONCLUSION

The DXA scans of injured runners prior to incidence indicated lower BMD compared with noninjured runners. Shorter limb lengths, lower fat mass (male), and lower leg lean mass (female) may also be indicative of risk. Certain BComp and anthropometric measures were predictive of BMD.

High Variability of Mesenchymal Stem Cells Obtained via Bone Marrow Aspirate Concentrate Compared With Traditional Bone Marrow Aspiration Technique

Background:

Bone marrow aspirate (BMA) is a common source for harvesting mesenchymal stem cells (MSCs), other progenitor cells, and associated cytokines and growth factors to be used in the biologic treatment of various orthopaedic pathologies. The aspirate is commonly centrifuged into a concentrated volume that can be immediately administered to a patient using commercially available kits. However, the handling and efficacy of BMA concentrate (BMAC) are still controversial.

Purpose:

To characterize BMA versus BMAC for MSC quantity, potency, and cytokine profile.

Study Design:

Controlled laboratory study.

Methods:

From 8 participants (age, 17-68 years), 30 mL of bone marrow was aspirated by a single surgeon from either the proximal humerus or distal femur and was separated into 2 equal samples. One sample was kept as BMA, and the other half was centrifuged into BMAC. The 2 samples then underwent flow cytometry for detection of MSCs, cell analysis for colony-forming units (CFUs), and cytokine profiling. A 2-tailed t test was used to detect differences between MSCs, CFUs, and cytokine density concentrations between BMA and BMAC.

Results:

The average concentration of MSCs in both BMA and BMAC was 0.001%. Average MSC events detected by flow cytometry were significantly higher in BMA versus BMAC (15.1 and 8.1, respectively; P < .045). Expanded MSCs demonstrated similar phenotypes, but CFUs were significantly increased in BMA compared with BMAC (104 vs 68 CFUs, respectively; P < .001). Total protein concentration and cytokine profiling demonstrated great variability between BMA and BMAC and between patients. Most importantly, BMAC failed to concentrate MSCs in 6 of 8 samples.

Conclusion:

There is great variability in MSC concentration, total protein concentration, and cytokine profile between BMA and BMAC.

Clinical Relevance:

When studying the clinical efficacy of BMAC, one must also evaluate the sample itself to determine the presence, concentration, and potency of MSCs if this is to be considered a cell-based therapy. Further standard operating procedures need to be investigated to ensure reproducible results and appropriate treatments.

Limb Occlusion Pressure Versus Standard Pneumatic Tourniquet Pressure in Open Carpal Tunnel Surgery – A Randomized Trial

Introduction: Pneumatic tourniquets are used extensively in orthopedic hand/wrist surgery. Complications, while rare, are associated with elevated pressure and duration of tourniquet use. Limb occlusion pressure (LOP) is the minimum tourniquet pressure at which arterial blood flow is restricted. Therefore, we performed a cross-sectional double-blinded randomized control trial to assess if there is a difference in post-operative pain at the surgical and tourniquet site between LOP and standard tourniquet pressure and if there is a difference in post-operative opioid usage.

Methods: A total of 44 patients (Age 60±13, 30 female, 14 male) were randomized into two groups (LOP, 191±14 mmHg | STP, 250 mmHg) of 22 patients controlling for gender (15 female, seven male). The primary outcome was a visual analog scale (VAS) for pain at the tourniquet and surgical sites, recorded for the first two weeks post-operative. Daily pain medication usage was recorded and quantified using oral morphine milligram equivalents (MME). A group-by-time generalized mixed-model ANOVA was used to detect within-group and between group (LOP vs STP) differences in VAS at the surgical and tourniquet sites as well as medication use. 

Results: LOP significantly decreased post-operative pain medication usage across the first week (-50%; p<0.05). Both groups had similar VAS pain at the surgery site, but the LOP group had 80% reduced pain at the tourniquet site when averaged across the first post-operative week (p<0.05). 

Conclusions: The use of LOP compared to STP elicits reduced post-operative pain at the tourniquet site and reduces post-operative pain medication use in the first post-operative week.

Relationship Between Pitch Volume and Subjective Report of Injury in High School Female Fast-Pitch Softball Pitchers

BACKGROUND

The relationship between pitch volume and injury is well-represented within baseball literature. However, the impact of softball pitch volume on injury epidemiology is limited.

HYPOTHESIS

The purpose was to determine if increased pitch volumes in high school-aged softball pitchers are related to increased rates of subjectively reported pain/injury. We hypothesized that pitchers with increased volumes would have higher pain/injury rates.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 28 female softball pitchers (aged 14-18 years) completed an online survey of questions pertaining to pitching history, pitch volume, and subjective report of pain or injury in the back, shoulder, and elbow. An independent-samples t test was used to (1) compare pitch volumes in those who reported pain in individual body regions (shoulder, elbow, back) compared with those who did not; (2) compare pitch volumes in those who reported pain in 0 or 1 of the regions of interest compared with 2 or 3 regions; and (3) compare the reported percentage of the past year that players reported playing through pain in players who averaged >85 compared with <85 pitches per game. Chi-square analysis was used to compare those who pitched either >85 or <85 pitches per game with regard to frequency of shoulder pain, elbow pain, back pain, seeking of medical attention, and actual injury diagnosis. Type I error was set at α = 0.05.

RESULTS

Weekly and yearly pitch counts were higher in those reporting pain or injury (YES) than those who did not (NO) in the shoulder (pitches per week: NO = 219 ± 35; YES = 429 ± 101; P = 0.027) (pitches per year: NO = 8876 ± 946; YES = 19,195 ± 4944; P = 0.022) and back (pitches per week: NO = 188 ± 16; YES = 426 ± 90; P = 0.014) (pitches per year: NO = 8334 ± 793; YES = 18,252 ± 4340; P = 0.027). Similar results were observed for those with pain or injury reported in 2 or 3 regions compared with 0 or 1 regions (pitches per week: NO = 220 ± 38; YES = 414 ± 95; P = 0.039) (pitches per year: NO = 8765 ± 1010; YES = 18,661 ± 4623; P = 0.028). Those reporting shoulder pain or injury also reported higher pitch counts per game (NO = 71.4 ± 5.2; YES = 83 ± 4; P = 0.049), and those reporting back pain also reported playing more games per week (NO = 2.7 ± 0.2; YES = 5.2 ± 1.1; P = 0.034). Those with pitch counts of >85/game were more than twice as likely to see a physician regarding pain/injury (P = 0.027) and reported playing through pain a higher percentage of the year (>85, 49.3% ± 10%; <85, 25.2% ± 6%; P < 0.05).

CONCLUSION

High pitching volumes commonly prevalent in high school-aged softball pitchers may be associated with increased pain/injury and appear related to cumulative volume.

CLINICAL RELEVANCE

This study provides recommendations for cumulative pitch volume guidelines in softball pitchers.

Performance and Return to Sport After Open Fracture in National Football League Players

Background:

Open fractures are debilitating injuries for athletes. No prior studies have investigated open fractures in National Football League (NFL) players.

Purpose:

To compare outcomes after open fracture in NFL players in terms of (1) time to return to sport (RTS), (2) postinjury career length and games played per season, (3) postinjury performance, and (4) postinjury performance compared with matched controls.

Study Design:

Retrospective comparative series; Level of evidence, 3.

Methods:

Publicly available records were used to identify NFL players who had sustained an open fracture between 1970 and 2018. Controls were matched to injured players by age, experience, position, and preinjury performance. RTS was defined as playing in at least 1 NFL game after open fracture. Comparisons between injured and control players were made using the paired-samples Student t test.

Results:

Injuries in 37 players were analyzed (age, 27.2 ± 3.6 years; experience, 4.4 ± 3.6 seasons).  The 3 most common locations for open fracture were the tibia/fibula (n = 16), hand/finger (n = 12), and forearm/wrist (n = 3). A total of 30 (81%) players had a mean time of RTS of 9.3 ± 8.2 months after open fracture; of these players, 4 (13.3%) who sustained hand/finger open fracture did not undergo surgical treatment. There was no difference in postinjury career length or games played per season between control and injured players. Postinjury performance was similar to preinjury performance in injured players, and postinjury performance scores were similar between injured and control players. There were significant differences between players who sustained upper extremity and lower extremity open fractures in RTS time (4.0 ± 4.8 vs 14.6 ± 7.4 months, respectively; P = .00007) and postinjury performance (6.4 ± 4.3 vs 3.3 ± 2.1, respectively; P = .03).

Conclusion:

RTS after open fracture among NFL players was high. Players who sustained an open fracture had similar games played per season, career length, and performance compared with matched controls. Players who sustained an upper extremity open fracture had a faster RTS time, higher RTS rate, and improved postinjury performance compared with players who sustained a lower extremity open fracture.

Pelvic region bone density, soft tissue mass, and injury frequency in female professional ballet dancers and soccer athletes

We recently observed a high prevalence of low pelvic bone mineral density (BMD) in female professional ballet performers. Because this population is susceptible to musculoskeletal overuse injuries, we aimed to determine which regions of the pelvis may be at greatest risk compared to general population females (GENPOP) as well as professional female soccer players (SOCCER, a comparison to other elite athletes regularly subjected to high degrees of loading). Three groups of age-matched females [(GENPOP; n = 38, 27±1yrs), (BALLET; single company, n = 36, 26±3yrs), (SOCCER; single NWSL® club, n = 34, 25±1yrs)] consented to have their BMD and body composition assessed (DEXA, GE®). In addition to soft tissue and total and regional BMD analyses, a segmental analysis of the pelvis was performed to determine site-specific BMD for the iliac fossa, iliac fossa/iliac crest/ilium combined, pubic bone, ischium, and sacrum. A mixed-model ANOVA followed by a Tukey's post-hoc test was used to compare the groups (Type-I error; α = 0.05). The BALLET group had lower pelvic BMD for all measures (Avg.%Diff. = 15%-27%, p<0.001) compared to the SOCCER group and for the ischium (Avg.%Diff.= 8%; p=0.007) and sacrum (Avg.%Diff. ​= ​7%; p = 0.028) compared to the GENPOP group. The BALLET group had lower lean mass for all measures compared to the other groups (Avg.%Diff. = 12%-18%; p < 0.01). Professional ballet performers exhibit reduced pelvic region soft tissue and site-specific BMD not previously detected using standard DEXA analyses. These findings highlight which pelvic regions may benefit from preventative strength training and/or nutritional interventions.

The Role of Fatigue in Return to Sport Testing Following Anterior Cruciate Ligament Reconstruction

BACKGROUND

Fatigue may play a role in anterior cruciate ligament (ACL) injury, but has not been incorporated into objective test batteries for return to sport decisions following ACL reconstruction (ACLR) surgery. The effect of fatigue on muscle function and performance following surgery and rehabilitation has been poorly studied.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess the effect of fatigue on performance of various hop tests used in clinical rehabilitation settings by examining LSI scores. The authors hypothesized that participants will have worse limb symmetry index scores following the fatigue protocol and that the operative limb (ACLR) will have a greater decline in function than the non-operative limb (CON).

STUDY DESIGN

Cross-Sectional Study.

METHODS

Participants (n=21 [Male = 15, Female = 6]; AGE = 24.6 ± 9.3) were at least six months post ACLR and in rehabilitation. Testing was performed over two separate sessions in either a non-fatigued (NFS) or fatigued state (FS). In the FS, individuals performed a series of exercises to exhaust muscular endurance, strength, and power systems, after which they performed as battery of seven hop tests (single hop for distance, triple hop for distance, crossover hop for distance, 6-meter timed hop, lateral rotation hop for distance, medial rotation hop for distance, and vertical jump for height). A 2(limb) x 2(time) ANOVA was used to compare limbs between each state.

RESULTS

Differences between limbs (CON vs ACLR) were observed for all hop tests in the NFS whereby the ACLR limb was observed to have reduced performance (↓5.4-9.1%, p <0.05). When tested in the FS, significant differences in performance between limbs remained for only the crossover (↓4.9%), medial rotation (↓7.1%), lateral rotation (↓5.5%), and vertical hop (↓10.0%)(p<0.05). When comparing the NFS and FS states, only the CON limb was observed to have significant decreases in performance of the Triple Hop (↓7.4%), Crossover (↓8.7%), and Lateral Rotation (↓5.2%)(p<0.05).

CONCLUSIONS

Following ACL reconstruction, there appears to be a greater loss in jump performance in the CON limb in the FS. These findings suggest it may be crucial to consider and assess the endurance of both limbs rather than just the ACLR limb when determining readiness for return to play.

LEVEL OF EVIDENCE

Level 3.

Factors Affecting Orthopedic Sports Medicine Surgeons' Online Reputation

Physician rating websites (PRWs) rate physicians based on experiences of previous patients. Although a high rating is desirable, it may not correlate with quality of care, experience, or other physician-specific variables. This study examined the impact of physician-specific variables, such as American Board of Orthopaedic Surgery Sports Certificate of Added Qualification (CAQ) status, years in practice, sex, and geographic location, on the PRW patient satisfaction rating and number of ratings. A list of orthopedic sports medicine surgeons was obtained from the American Orthopaedic Society for Sports Medicine database. Demographic data were recorded. Surgeon profiles were gathered from the most commonly used PRWs (Healthgrades and Vitals), and a mean rating value was recorded on a 1- to 5-star scale. The t test and analysis of variance were used for comparisons. Multivariable linear regression was used to identify factors contributing to PRW ratings. Female sex had the biggest positive effect on PRW rating (R=0.04, P=.029). The PRW rating was positively affected by the number of ratings (R=0.04, P<.001) and negatively affected by an increase in years of practice (R=0.04, P<.001). Surgeons with fewer than 10 years in practice had higher PRW ratings than surgeons practicing longer than 10 years. The PRW ratings were not affected by sports CAQ status or geographic location. Fewer years in practice, female sex, and greater number of reviews were associated with higher PRW ratings. Number of reviews was the only modifiable factor. There was no observed association between sports medicine CAQ status and PRW rating. [Orthopedics. 2021;44(2):e281-e286.].

Sex-Related Hip Strength Measures Among Professional Soccer Players

ABSTRACT

Hedt, CA, Pearson, JM, Lambert, BS, McCulloch, PC, and Harris, JD. Sex-related hip strength measures among professional soccer players. J Strength Cond Res 35(7): 1992-1999, 2021-Lower-extremity musculoskeletal injuries in soccer are common among sexes. However, it remains unknown whether differences between sexes exist with regard to absolute or relative hip strength and how these differences may relate to injury. In the current study, we performed a retrospective cross-sectional analysis of pre-season data from male (♂n = 21) and female (♀n = 19) professional United States soccer organizations. Two years of pre-season data were collected for peak strength of lower extremity and hip musculature (no duplicates used). A 2 × 2 multivariate analysis of variance was used to detect differences in hip strength between sexes and dominant compared with nondominant legs. For all significant multivariate effects indicated by Wilks lambda and follow-up univariate analysis, a Tukey's post hoc test was used for pairwise univariate comparisons. A 2-tailed independent-samples T-test was used for comparison of height, body mass, body mass index (BMI), mean leg length, and strength ratios between dominant and nondominant limbs between sexes. Type I error was set at α = 0.05 for all analyses. Height (♂183.1 ± 6.8 cm, ♀170.0 ± 5.5 cm), body mass (♂79.0 ± 8.7 kg, ♀65.1 ± 5.6 kg), BMI (♂23.5 ± 1.3 kg·m-2, ♀22.5 ± 1.4 kg·m-2), and mean leg length (♂95.5 ± 4.34 cm, ♀ 88.3 ± 3.24 cm) differed between groups (p < 0.05). Sex differences (p < 0.05) were also found for hip abduction (dominant ♂19.5 ± 3.6 kg, ♀17.3 ± 2.2 kg; nondominant ♂18.5 ± 3.7 kg, ♀16.0 ± 2.3 kg), adduction (dominant ♂19.8 ± 3.0 kg, ♀16.7 ± 2.3 kg; nondominant ♂20.1 ± 2.9 kg, ♀17.6 ± 2.9 kg), external rotation (dominant ♂21.7 ± 3.4 kg, ♀17.7 ± 2.4 kg; nondominant ♂21.6 ± 3.9 kg, ♀16.8 ± 2.1 kg), and dominant hamstring strength (♂27.9 ± 6.5 kg, ♀23.0 ± 4.9 kg). The ratio of hip internal to external rotation strength differed in the nondominant leg (♂1.1 ± 0.2, ♀0.9 ± 0.2, p < 0.05). No significant differences were found between males and females when measures were normalized to body mass. These findings provide baseline pre-season normative data for professional soccer athletes and indicate that strength differences can be expected among different sexes, but are attenuated with attention to body mass. Further research should indicate how pre-season strength measures relate to injury.

Physiological Parameters of Bone Health in Elite Ballet Dancers

Stress fractures are common among elite ballet dancers whereby musculoskeletal health may be affected by energy balance and overtraining.

PURPOSE

This study aimed to characterize bone health in relation to stress fracture history, body composition, eating disorder risk, and blood biomarkers in professional male and female ballet dancers.

METHODS

A single cohort of 112 dancers (male: 55, 25 ± 6 yr; female: 57, 24 ± 6 yr) was recruited. All participants underwent bone and body composition measures using dual-energy x-ray absorptiometry. In a subset of our cohort (male: 30, 24 ± 6 yr; female, 29, 23 ± 5 yr), a blood panel, disordered eating screen, menstrual history, and stress fracture history were also collected. Age-matched Z scores and young-adult T scores were calculated for bone mineral density (BMD) and body composition. Independent-samples t-tests and Fisher's exact tests were used to compare BMD, Z-scores, T scores, and those with and without history of stress fractures. A 1 × 3 ANOVA was used to compare BMD for those scoring 0-1, 2-6, and 7+ using the EAT26 questionnaire for eating disorder risk. Regression was used to predict BMD from demographic and body composition measures.

RESULTS

Female dancers demonstrated reduced spinal (42nd percentile, 10%T < -1) and pelvic (16th percentile, 76%T < -1) BMD. Several anthropometric measures were predictive of BMD (P < 0.05, r = 0.65-0.81, standard error of estimate = 0.08-0.10 g·cm, percent error = 6.3-8.5). Those scoring >1 on EAT26 had lower BMD than did those with a score of 0-1 (P < 0.05).

CONCLUSIONS

Professional female ballet dancers exhibit reduced BMD, fat mass, and lean mass compared with the general population whereby low BMD and stress fractures tend to be more prevalent in those with a higher risk of disordered eating. Anthropometric and demographic measures are predictive of BMD in this population.

Wearable positive end-expiratory pressure valve improves exercise performance

We tested a PEEP (4.2 cmH₂O) mouthpiece (PMP) on maximal cycling performance in healthy adults. Experiment-1, PMP vs. non-PMP mouthpiece (CON) [n = 9 (5♂), Age = 30 ± 2 yr]; Experiment-2, PMP vs. no mouthpiece (NMP) [n = 10 (7♂), Age = 27 ± 1 yr]. At timepoint 1 in both experiments (mouthpiece condition randomized) subjects performed graded cycling testing (GXT) (Corival® cycle ergometer) to determine V˙O_{2peak (ml∗kg∗min}⁻¹), O₂pulse _(mlO2∗bt⁻¹), GXT endurance time (GXT-T_(s)), and V˙O_{2(ml∗kg∗min}⁻¹)-at-ventilatory-threshold (V˙O₂ @VT). At timepoint 2 72 h later, subjects completed a ventilatory-threshold-endurance-ride [VTER_(s)] timed to exhaustion at V˙O₂ @VT power _(W). One week later at timepoints 3 and 4 (time-of-day controlled), subjects repeated testing protocols under the alternate mouthpiece condition. Selected results (paired T-test, p<0.05): Experiment 1 PMP vs. CON, respectively: V˙O_2peak ​= ​45.2 ​± ​2.4 vs. 42.4 ​± ​2.3 p<0.05; V˙O₂@VT ​= ​33.7 ​± ​2.0 vs. 32.3 ​± ​1.6; GXT-TTE ​= ​521.7 ​± ​73.4 vs. 495.3 ​± ​72.8 (p<0.05); VTER ​= ​846.2 ​± ​166.0 vs. 743.1 ​± ​124.7; O2pulse ​= ​24.5 ​± ​1.4 vs. 23.1 ​± ​1.3 (p<0.05). Experiment 2 PMP vs. NMP, respectively: V˙O_2peak ​= ​43.3 ​± ​1.6 vs. 41.7 ​± ​1.6 (p<0.05); V˙O₂@VT ​= ​31.1 ​± ​1.2 vs. 29.1 ​± ​1.3 (p<0.05); GXT-TTE ​= ​511.7 ​± ​49.6 vs. 486.4 ​± ​49.6 (p<0.05); VTER 872.4 ​± ​134.0 vs. 792.9 ​± ​122.4; O₂pulse ​= ​24.1 ​± ​0.9 vs. 23.4 ​± ​0.9 (p<0.05). Results demonstrate that the PMP conferred a significant performance benefit to cyclists completing high intensity cycling exercise.

An Injury Prevention Program for Professional Ballet: A Randomized Controlled Investigation

BACKGROUND

Few investigations have examined dance-specific injury prevention programs (IPPs), and no published randomized controlled trials are available that evaluate IPPs for dance.

HYPOTHESIS

The implementation of an IPP will significantly reduce the risk of injury in professional ballet dancers.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A randomized controlled trial was designed that entailed a superiority model for the intervention group. All professional dancers from a single ballet company were eligible to participate. Randomization and allocation were performed before the start of the season. The control group practiced and performed without change to preexisting standard operating practice. The IPP group was instructed to perform a 30-minute exercise program 3 times per week over the 52-week study period. Injuries were recorded. Standard continuous and categorical data comparisons and correlations were used. Cox proportional hazards regression models for recurrent failures were used wherein the hazard ratio indicates the relative likelihood of injury in the control versus intervention groups.

RESULTS

Of the 52 eligible dancers, 75% (n = 39) participated. Of these 39 dancers, 19 (9 males, 10 females; mean age, 26.6 ± 4.0 years) were randomized to the control group and 20 (11 males, 9 females; mean age, 25.1 ± 5.1 years) to the IPP group. No significant (P > .05) difference was found in baseline demographics between groups. A total of 116 injuries were recorded for the entire study population (49 IPP; 67 control). Traumatic and chronic injuries accounted for 54% and 46% of injuries, respectively. The injury rate was 82% less (IPP hazard ratio, 0.18; z = -2.29; P = .022) in the IPP group after adjustment for confounding variables, and time between injuries was 45% longer (IPP hazard ratio, 0.55; z = -2.20; P = .028) than for controls.

CONCLUSION

The present study is the first prospective randomized controlled investigation of an IPP for professional ballet. The results showed an 82% decrease in injury rate for the intervention group and an extended period from previous injury to subsequent injury.

REGISTRATION

NCT04110002 (ClinicalTrials.gov identifier).

Progression of Hamate Hook Stress Reactions in Elite Baseball Players

Background:

Hamate hook fractures can occur as a result of repetitive contact with the knob of the bat used in the sport of baseball. Hamate hook excision has resulted in excellent outcomes and return to sport (RTS) in elite baseball players. The ideal treatment for hamate stress response before the development of a fracture line is unknown.

Purpose:

To report the outcomes of elite baseball players with hamate bone edema.

Study Design:

Case series; Level of evidence, 4.

Methods:

We reviewed the medical records of all elite baseball players with hamate bone edema consistent with a stress response at 2 institutions. Players were eligible for inclusion if they played collegiate or professional baseball at the time of initial injury, had magnetic resonance imaging (MRI) showing hamate bone edema, and had no radiographic evidence of acute fracture lines at initial presentation.

Results:

A total of 4 players with a mean age of 22.8 years were included. All injuries occurred in the nondominant hand. All athletes had normal initial wrist radiographs and MRI showing hamate edema but no fracture line. Patients returned to play as tolerated and developed an acute injury at an average of 25.8 days (range, 10-56 days) from the initial presentation. Repeat radiographs demonstrated acute hamate hook fractures in all 4 (100%) athletes. All 4 athletes underwent hamate hook excision. There were no postoperative complications. All athletes returned to sport at their previous level of competition at a mean of 5.3 weeks (range, 3.6-7.3 weeks).

Conclusion:

There is a high rate of hamate bone edema progression to acute hamate hook fracture in elite baseball players, with 100% RTS at preinjury level after hamate hook excision. We therefore recommend against prolonged rest. Continuation of play with hamate bone edema followed by hamate hook excision for acute fracture limits the time missed and obtains a faster RTS in elite baseball players.

Acute Physiologic Effects of Performing Yoga in The Heat on Energy Expenditure, Range of Motion, and Inflammatory Biomarkers

Performing yoga in a heated environment (HY) is a popular exercise mode purported to improve range of motion (ROM), body composition, and aerobic fitness. The purpose of this investigation was to compare a session of HY to room temperature yoga (RTY) with regards to ROM, oxygen consumption, caloric expenditure, and biomarkers of acute stress and inflammation. Sixteen experienced yoga practitioners (F14, M2; 40 ± 11yr; 22.6 ± 1.8 kg/m2) completed a 1-hour standardized Bikram sequence in HY (105°F, 40°C) and RTY (74°F, 23.3°C) conditions (order of conditions randomized, humidity standardized at 40%). Intra-exercise metabolic gas exchange and heart rate (HR) was monitored using a metabolic cart. ROM measures were taken pre and post-exercise at the elbow, shoulder, hip, and knee. Cytokines interleukin 6,10 (IL-6, IL-10) and tumor-necrosis-factor alpha (TNF-α) were analyzed from blood samples collected pre- and 30-minutes post-exercise. Intra-exercise metabolic gas exchange and heart rate (HR) was monitored using a metabolic cart. Both bouts elicited similar acute changes in ROM although HY elicited a greater increase in hip abduction (RTYΔ° = 2.3 ± 1.3|HYΔ° = 6.6 ± 1.5; p < 0.05). Mean VO2, peak VO2, %VO2max, HR, and kcal expenditure did not differ between conditions. RER was lower during the HY (RTY = 0.95 ± 0.02| HY = 0.89 ± 0.02; p < 0.05) with a concomitant elevation in fat oxidation (RTY = 0.05 ± 0.01|HY = 0.09 ± 0.01, g·min-1; p < 0.05) and decrease in carbohydrate oxidation (RTY = 0.51 ± 0.04|HY = 0.44 ± 0.03, g·min-1; p < 0.05). Serum IL-6 was increased (15.5 ± 8.0-fold) following HY only (p < 0.05). HY does not significantly elevate aerobic energy cost compared to RTY but may acutely increase fat substrate utilization and hip ROM. Future studies remain needed to establish dose-response relationships for including HY or RTY into well-rounded fitness programs.

Distal Biceps Tendon Repair Using a Double Tension Slide Technique

Distal biceps tendon ruptures are thought to be secondary to an acute forceful eccentric load on a degenerative tendon. Nonoperative treatment following rupture leads to significantly decreased forearm supination and elbow flexion strength. There are several techniques described in the literature for repair. This article describes, with video illustration, distal biceps tendon repair using a double tension slide technique with 2 No. 2 high-tension nonabsorbable composite sutures.

The Measurement of Orthopaedic Surgeon Burnout Using a Validated Wearable Device

Purpose

The purpose of this study was (1) to determine the prevalence of burnout in orthopaedic surgeons and (2) to determine whether there is an association or correlation between subject-specific variables (age, attending physician, resident, postgraduate year level, gender, number of calls, total hours worked, and total hours of sleep) and burnout.

Methods

Surgeons were prospectively enrolled and provided with a validated wearable device. Subject-specific variables were recorded. Participants completed the Maslach Burnout Inventory and Patient-Reported Outcomes Measurement Information System (PROMIS-29) weekly. Burnout and burnout risk were defined. Multivariate analysis and bivariate correlations were used to determine the association and correlation between subject-specific variables and burnout. Residents were compared to attending surgeons.

Results

Of the 26 enrolled subjects, 21 (15 males, 6 females; mean age 37.2 ± 10.9) completed the 4-week study. Residents worked significantly more hours per week than attending surgeons (68.5 ± 15.2 versus 49.9 ± 7.5, P = 0.009). Of the orthopaedic surgeons, 6 (28.6%) experienced burnout, and 7 (33.3%) orthopaedic surgeons were at risk for burnout. There was no significant difference in burnout rates between residents and attending surgeons (P > 0.05). The number of overnight calls was significantly correlated with increased burnout (r = 0.435, P = 0.049). Female gender was significantly associated (P = 0.041) and correlated (r = 0.558, P = 0.009) with burnout. There was no significant association with burnout between the number of hours worked and hours of sleep.

Conclusions

The rate of burnout was less than 50% among orthopaedic surgeons. The number of overnight calls and female gender are significantly correlated with increased burnout. There was no significant correlation between hours worked and hours of sleep in surgeon burnout.

Clinical Relevance

Burnout is an increasingly common problem among orthopaedic surgeons, and it can have significant negative effects on surgeons' health and patients' outcomes. Identifying the predictors of burnout would allow surgeons to address these risk factors and reduce burnout.

Performance and Return to Sport After Hip Arthroscopy in the National Basketball Association

PURPOSE

To determine: (1) return to sport (RTS) rate in National Basketball Association (NBA) players following hip arthroscopy, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players.

METHODS

NBA athletes who underwent hip arthroscopy and matched controls were identified. RTS was defined as playing in at least 1 game after surgery. Player efficiency ratings were used for performance evaluation. Continuous variables of each group were compared using a 2-tailed paired samples Student t test for normally distributed data. χ² was used to analyze categorical data. RTS was used as the primary outcome with statistical significance defined by a P value < .05. A Bonferroni correction was used to control for the remaining multiple comparisons with statistical significance defined by a P value ≤.008.

RESULTS

Twenty-three players (24 hips) were analyzed (mean age 27.5 ± 3.1 years; mean experience in the NBA 5.8 ± 2.8 years at time of surgery). Small forwards (n = 8, 33.3%) represented the largest proportion of players that underwent hip arthroscopy. Twenty players (21 surgeries, 87.5%) were able to RTS in NBA at an average of 5.7 ± 2.6 months. The overall 1-year NBA career survival rate of players undergoing hip arthroscopy was 79.2%. Players in the control group (5.2 ± 3.5 years) had a similar career length as (P = .068) players who underwent surgery (4.4 ± 3.0 years). There was no significant (P = .045) decrease in games per season following surgery. There was no significant difference in performance postoperatively compared with preoperatively (P = .017) and compared with matched controls following surgery (P = .570).

CONCLUSIONS

The RTS rate for NBA athletes after hip arthroscopy is high. There was no decrease in games played, career lengths, or performance following hip arthroscopy in NBA players versus preoperatively and matched controls.

LEVEL OF EVIDENCE

Level III case-control study.

Early Return to Play With Thumb Spica Gauntlet Casting for Ulnar Collateral Ligament Injuries Complicated by Adjacent Joint Dislocations in Collegiate Football Linemen

Background: Treatment of thumb ulnar collateral ligament (UCL) ruptures in elite athletes aims to restore thumb stability while minimizing lost playing time. Thus, surgical repair with early protected return to play in a thumb spica cast has been advocated. The purpose of this study was to document adjacent joint dislocations after primary surgical repair sustained during protected return to play with thumb spica casting in elite-level football players. Methods: Three Division I collegiate starting linemen sustaining adjacent joint dislocations in thumb spica casts following acute surgical repair of ipsilateral thumb UCL ruptures were retrospectively reviewed. Demographic data were recorded as well as the timeline for injury, treatment, and subsequent return to sport. Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were obtained at final follow-up. Results: The mean time from thumb UCL injury to surgical repair was 8.7 days, and the mean return to sport was 13.3 days from surgery. There were 4 simple dislocations including 3 proximal interphalangeal (PIP) joints and 1 elbow. Each PIP dislocation was close reduced and treated with buddy straps with immediate return to play. The elbow dislocation was close reduced and splinted with return to play 22 days after injury. The mean QuickDASH score was 2.3 at 12 month follow-up. Conclusions: This report highlights that while thumb spica casting protects the surgically repaired thumb UCL and allows for earlier return to play, it risks placing additional stress upon adjacent joints and therefore adjacent injury. Appropriate counseling of the risks and benefits of this treatment strategy is essential.

High Prevalence of Connective Tissue Gene Variants in Professional Ballet

BACKGROUND

There is a high prevalence of hypermobility spectrum disorder (HSD) in dancers. While there is no known genetic variant for HSD, hypermobile Ehlers-Danlos syndrome is a genetic disorder that exists within HSD. There are many connective tissue disorders (CTDs) with known (and unknown) genes associated with hypermobility. Hypermobility has distinct advantages for participation in flexibility sports, including ballet.

PURPOSE

To determine the prevalence of gene variants associated with hypermobility in a large professional ballet company.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

In this cross-sectional investigation, 51 professional male and female dancers from a large metropolitan ballet company were eligible and offered participation after an oral and written informed consent process. Whole blood was obtained from peripheral venipuncture, and DNA was isolated. Isolated DNA was subsequently enriched for the coding exons of 60 genes associated with CTD that included hypermobility as a phenotype, including Ehlers-Danlos syndromes, osteogenesis imperfecta, Marfan syndrome, and others. Genes were targeted with hybrid capture technology. Prepared DNA libraries were then sequenced with next-generation sequencing technology. Genetic database search tools (Human Gene Mutation Database and e!Ensembl, http://useast.ensembl.org/ ) were used to query specific variants. Descriptive statistics were calculated.

RESULTS

Of 51 dancers, 32 (63%) agreed to participate in DNA analysis (mean ± SD age, 24.3 ± 4.4 years; 18 men, 14 women). Twenty-eight dancers had at least 1 variant in the 60 genes tested, for an 88% prevalence. A total of 80 variants were found. A variant in 26 of the 60 genes was found in at least 1 dancer. Among the 28 dancers with variants, 16 were found in the TTN gene; 10 in ZNF469; 5 in RYR1; 4 in COL12A1; 3 in ABCC6 and COL6A2; 2 in ADAMTS2, CBS, COL1A2, COL6A3, SLC2A10, TNC, and TNXB; and 1 in ATP6V0A2, B4GALT7, BMP1, COL11A1, COL5A2, COL6A1, DSE, FBN1, FBN2, NOTCH1, PRDM5, SMAD3, and TGFBR1. Nine variants found in this population have never been reported. No identified variant was identical to any other variant. No identified variant was known to be disease causing. In the general population, the prevalence of each variant ranges from never reported to 0.33%. In the study population, the prevalence of each variant was 3.13%. There was no association between hypermobility scores and genetic variants.

CONCLUSION

Genetic variants in CTD-associated genes are highly prevalent (88%) in professional ballet dancers. This may significantly account for the high degree of motion in this population.

Performance and Return to Sport After Femoroacetabular Impingement Surgery in National Football League Players

The purpose of this study was to determine the (1) return-to-sport rate for National Football League (NFL) players following femoroacetabular impingement surgery, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. National Football League athletes who underwent hip arthroscopy for femoroacetabular impingement and matched controls were identified. A Bonferroni correction was used to control for multiple comparisons, with statistical significance set at P≤.007. Fifty-five players (63 surgeries) were analyzed (mean age, 27.5±3.4 years; mean years in NFL at time of surgery, 4.7±2.9). Forty-seven (53 surgeries, 84.1%) NFL players returned to sport at a mean of 6.7±3.8 months following surgery. There was no difference (P>.007) in the mean career length of players in the control group (3.7±2.2 years) vs players who underwent hip arthroscopy (3.5±2.1 years). There was no difference (P>.007) in mean games played per season of players in the control group (12.5±3.1) vs those who underwent hip arthroscopy (12.1±4.0). Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls (P=.007). The return-to-sport rate is high for NFL athletes after hip arthroscopy for femoroacetabular impingement. There were similar games per season and career lengths postoperatively compared with preoperatively and matched controls. Quarterbacks had significantly better postoperative performance when compared with matched controls. All other positions had similar postoperative performance compared with preoperatively and matched controls. [Orthopedics. 2019; 42(5):e423-e429.].