Buckley, Patrick J.

Background: Quadriceps muscle atrophy remains a limiting factor in returning to activity after anterior cruciate ligament reconstruction (ACLR). Blood flow restriction (BFR) therapy may accelerate quadriceps strengthening in the perioperative period. Purpose: To evaluate postoperative isometric quadriceps strength in patients who underwent ACLR with a perioperative BFR program. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients indicated for ACLR were randomized into 2 groups, BFR and control, at their initial clinic visit. All patients underwent 2 weeks of prehabilitation preoperatively, with the BFR group performing exercises with a pneumatic cuff set to 80% limb occlusion pressure placed over the proximal thigh. All patients also underwent a standardized postoperative 12-week physical therapy protocol, with the BFR group using pneumatic cuffs during exercise. Quadriceps strength was measured as peak and mean torque during seated leg extension and presented as quadriceps index (percentage vs healthy limb). Patient-reported outcomes (PROs), knee range of motion, and quadriceps circumference were also gathered at 6 weeks, 3 months, and 6 months postoperatively, and adverse effects were recorded. Results: Included were 46 patients, 22 in the BFR group (mean age, 25.4 ± 10.6 years) and 24 in the control group (mean age, 27.5 ± 12.0 years). At 6 weeks postoperatively, the BFR group demonstrated significantly greater strength compared with the controls (quadriceps index: 57% ± 24% vs 40% ± 18%; P = .029), and the BFR group had significantly better Patient-Reported Outcomes Measurement Information System–Physical Function (42.69 ± 5.64 vs 39.20 ± 5.51; P = .001) and International Knee Documentation Committee (58.22 ± 7.64 vs 47.05 ± 13.50; P = .011) scores. At 6 weeks postoperatively, controls demonstrated a significant drop in the peak torque generation of the operative versus nonoperative leg. There were no significant differences in strength or PROs at 3 or 6 months postoperatively. Three patients elected to drop out of the BFR group secondary to cuff intolerance during exercise; otherwise, no other severe adverse events were reported. Conclusion: Integrating BFR into perioperative physical therapy protocols led to improved strength and increased PROs at 6 weeks after ACLR. No differences in strength or PROs were found at 3 and 6 months between the 2 groups. Registration: NCT04374968 (ClinicalTrials.gov identifier).

Purpose To evaluate the efficacy of an automated pneumatic torniquet pump and its ability to automatically calculate the limb occlusion pressure (LOP), as compared with the manual Doppler ultrasound technique. Methods Participants presenting to a Sports Medicine clinic were evaluated for study enrollment. Participants were fitted with a pneumatic tourniquet for the upper and lower extremity. LOP measurements were taken with a Doppler ultrasound or automated SmartCuffs PRO device in a randomized order. Results Final analysis was performed on 96 limbs (48 upper extremities and 48 lower extremities). The study population had a mean age 37.1 ± 14.7 years old and a mean body mass index of 25.47 ± 3.80. The mean measured LOP pressure on the upper extremity with Doppler ultrasound was 174.0 ± 48.7 mm Hg with a range from 120 to 282 mm Hg, whereas the mean measured LOP by the automated pump was 184.0 ± 44.9 mm Hg with a range from 135 to 266 mm Hg. There was no statistically significant difference found between the Doppler LOP and the Smart Cuff upper extremity LOP ( P = .29). When evaluating LOP pressure on the lower extremity the mean LOP found with the Doppler ultrasound was 195.0 ± 31.9 mm Hg with a range from 160 to 272 mm Hg, whereas the automated pump the mean LOP was 205.0 ± 27.1 mm Hg with a range from 168 to 278 mm Hg. There was no statistically significant difference found between the Doppler LOP and the automated pump lower extremity LOP ( P = .09). Conclusions No difference in the personalized LOP measurement was found when comparing an automated pump with the current gold standard of manual Doppler ultrasound. No patients companied of pain or discomfort during the LOP measurement. Level of Evidence Level II, diagnostic: prospective cohort study.

» Patellar tendinopathy is an attritional injury of the patellar tendon that is frequently identified in jumping athletes. Through repetitive or explosive movements, considerable loads and high peak strains are generated across the patellar tendon. » This leads to microinjury of tendon fibers, local mucoid degeneration, and loss of the fibrocartilaginous tissue that attaches tendon to bone. » Management of patellar tendinopathy often begins with nonoperative modalities: progressive tendon loading and eccentric rehabilitative exercise programs are the most effective. While a variety of additional treatment modalities are available, the comparative efficacy of these supportive treatments is not well differentiated at this time. » In this article, we analyze the existing literature regarding nonoperative treatment of patellar tendinopathy and provide additional insight on the effectiveness of current modalities.

Background: Recent studies have suggested increased rates of lower extremity (LE) musculoskeletal injury after a diagnosed concussion, although significant heterogeneity exists. Purpose: To examine the current body of research and determine whether there is an increased risk for LE musculoskeletal injury after a concussion and to identify populations at an increased risk. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review of current literature using MEDLINE and PubMed databases was performed. Keywords included concussion, athlete, lower extremity injury, and return to sport. Inclusion criteria required original research articles written in the English language examining the rate of LE injuries after a diagnosed concussion. Results: A total of 13 studies involving 4349 athletes (88.1% male and 11.9% female; mean age, 19.8 years) met inclusion criteria. Athletes were classified as high school (46.1%), collegiate (17.0%), or professional (36.9%). Of the 13 studies, 4 demonstrated an increased risk of LE injury within 90 days of a diagnosed concussion (odds ratio [OR], 3.44; 95% CI, 2.99-4.42), and 6 revealed an elevated risk of injury within 1 year of concussion (OR, 1.85; 95% CI, 1.73-2.84). Increased risk was seen in professional (OR, 2.49; 95% CI, 2.40-2.72) and collegiate (OR, 2.00; 95% CI, 1.96-2.16) athletes compared with high school athletes (OR, 0.97; 95% CI, 0.89-1.05). A stepwise increase in risk of sustaining an LE injury was observed with multiple concussions, with increasing risk observed from ≥2 (OR, 2.29; 95% CI, 1.85-2.83) to ≥3 (OR, 2.86; 95% CI, 2.36-3.48) career concussions. Conclusion: An increased incidence of LE injuries was observed at 90 days and 1 year after the diagnosis of a concussion. Higher levels of competition, such as at the collegiate and professional levels, resulted in an increased risk of sustaining a subsequent LE injury after a diagnosed concussion. These results suggest an at-risk population who may benefit from injury prevention methods after a concussion. Future studies should focus on identifying which injuries are most common, during what time period athletes are most vulnerable, and methods to prevent injury after return to sports.

Purpose To investigate which factors predispose patients for prolonged opioid use after medial patellofemoral ligament (MPFL) reconstruction. Methods A retrospective review of all patients who underwent MPFL reconstruction at a single institution between January 2013 and June 2020 was conducted. Opioid consumption before and after surgery was recorded and confirmed using Michigan Automated Prescriptions System monitoring program. Patients were classified into preoperative opioid users and nonusers. Risk factors for continued opioid use were assessed by collecting patient demographic variables, psychiatric history, number of previous patellar dislocations, and operative factors. Results A total of 102 patients were included during the time frame of interest. Patients were on average 21.6 ± 8.5 years old with a mean body mass index of 28.2 ± 7.9. Thirty patients (29.0%) sustained >10 dislocations preoperatively. Preoperative opioid use was present in 13 (12.7%) patients. Greater than 10 dislocations (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.12‐20.92) and psychiatric history (OR 3.33, 95% CI, 1.2‐9.1; P = .016) significantly predicted opioid refills the first month after surgery. Risk factors for opioid refills at 2 to 12 months postoperatively included smoking (OR 4.50, 95% CI 1.13‐17.96), preoperative opioid use (OR 7.32, 95% CI 1.88‐28.47), psychiatric disorder (OR 3.77, 95% CI 2.3‐6.2; P < .001), age >30 years (OR 7.03, 95% CI 3.63‐13.61; P < .001), and obesity (OR 2.68, 95% CI 1.40‐5.14; P = .002). Compared with Outerbridge 0, a greater percentage of patients with Outerbridge 1 or 2 and 3 or 4 continued using opioids 2 to 12 months after surgery (OR 3.06, 95% CI 1.33‐7.02; P = .006 and OR 2.86, 95% CI 1.24‐6.59; P = .010, respectively). Conclusions For patients undergoing MPFL reconstruction, preoperative opioid use, cartilage damage, age >30 years, smoking history, body mass index >30, and history of psychiatric disorder were found to be significantly associated with prolonged opioid use after surgery. Postoperative opioid refills in this cohort declined after 1 month. Level of Evidence Level III, retrospective cohort study.

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

Purpose To evaluate the social media usage of orthopaedic residency programs, program directors (PDs), and department chairs across Instagram, Facebook, and Twitter and to determine which types of social media posts are indicative of increased user following. Methods A systematic online search strategy was performed in October 2020 to identify all allopathic orthopaedic surgery residency program accounts on Instagram, Facebook, and Twitter. Instagram posts were further analyzed to evaluate the type of post that significantly correlated with increased follower counts. Results Of 158 orthopaedic surgery programs, 69 (43.7%) had Instagram accounts, 52 (32.9%) had Facebook accounts, and 54 (34.2%) had Twitter accounts. Program presence on Instagram and Twitter continued to grow exponentially ( R 2 = 0.99 and R 2 = 0.95, respectively). Regarding program leadership, a total of 151 PDs and 156 chairs were identified. Of these, 21 PDs (14%) and 8 chairs (5.1%) had Instagram accounts. The number of posts and the numbers of educational, social, program information, and operative posts ( P < .01) significantly correlated with increased followers on Instagram. Conclusions Fewer than one‐half of orthopaedic surgery residency programs and fewer than one‐quarter of PDs and department chairs have a social media presence. However, the number of residency programs on social media continues to rise year‐over‐year. The total number of posts; the amount of educational, social, and program information; and the number of operative posts significantly correlated with increased followers on Instagram. Clinical Relevance With the growing prevalence of social media, orthopaedic surgery residency programs have the opportunity to connect with future applicants and disseminate informational content regarding their programs.

Abstract Posterolateral corner (PLC) reconstruction has been shown to be an effective treatment for PLC injuries. Acute anatomical repair of the PLC has the same potential to stabilize the knee; however, outcomes are less defined. Surgical repair minimizes graft harvest morbidity and allows for the maintenance of native tissue proprioception. Furthermore, augmentation with a flat‐braided suture (SutureTape; Arthrex) portends additional repair strength and protection. The purpose of this Technical Note and video is to provide our preferred method of PLC repair in a patient with an acute knee dislocation and injury to the biceps femoris, lateral collateral ligament, iliotibial band, popliteofibular ligament, and the meniscocapsular attachment of the lateral meniscus. Technique Video video See video under supplementary data.