Tummala, Sailesh V

Background: Reliable methods for measuring range of motion is important for hand therapists. Currently, there is no gold standard for the measurement of thumb metacarpophalangeal joint (MCPJ) hyperextension. We hypothesised that visual and goniometric measurements of thumb MCPJ hyperextension vary greater than 10° from radiographic measurements, and between observers. Methods: Twenty-six fresh-frozen hands were measured by a senior orthopaedic resident and fellowship trained hand surgeon. Passive thumb MCPJ hyperextension was measured by visual estimation, goniometry and axis measurement on a lateral thumb radiograph. Raters were blinded to each other’s and their own prior measurements. Descriptive statistics were recorded for measurement type and inter-observer agreement using a two-way intra-class correlation coefficient (ICC). Intra-observer agreement was calculated using concordance correlation coefficient (CCC). Bland–Altman plots identified trends, systemic differences or potential outliers. Results: Mean measurements for both raters were similar for visual estimation and radiographic measurements. Mean goniometric measurements were twice as high for Rater B, and closer to radiographic measurements. For both raters, mean radiographic measurements were 10° greater than the other two methods. For inter-rater agreement, measurements were within 10° most frequently with radiographic measurement, then visual estimates, and least by goniometer measurements. Rater B had better agreement comparing visual and goniometric to radiographic measurements. Conclusions: Radiographic measurement has the best inter-observer agreement and precision for evaluating passive thumb MCPJ hyperextension, especially considering adjunct corrective procedures when performing a soft-tissue basal joint arthroplasty. Rater experience improves precision, but there is still poor agreement between visual estimates and goniometer measurements compared to radiographic measurements, as the former two underestimate hyperextension by 10°. Development of a standard method of clinical measurement is needed to improve reliability.

Purpose To compare the 5‐year clinical and functional outcomes of the soft‐tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft. Methods A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft‐tissue QT or double‐tendon HT autograft with at least 5 years of follow‐up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications. Results A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2‐years’ postoperatively. At 5 years’ postoperatively, the QT group demonstrated significantly greater IKDC ( P = .018) and Lysholm ( P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years’ postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications. Conclusions Although the QT autograft demonstrated increased patient‐reported outcome scores when compared with the HT at 5 years’ postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years’ postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid‐term follow‐up. Level of Evidence III, retrospective comparison study.

Purpose To characterize quadriceps tendon injuries over 30 National Basketball Association (NBA) seasons and assess the effects on player performance upon return to play. Methods Partial and complete quadriceps tendon tears in NBA players between the 1990‐1991 and 2021‐2022 seasons were queried from a publicly available database. The primary outcomes were changes in player performance statistics obtained from each player’s preindex season and first 2 postindex seasons. These interseason changes were compared with the changes of a healthy control cohort. Each injured player was matched with 2 controls using position, career length and win shares by season. The secondary measure of this study was the rate of return to play. Results Nine quadriceps tendon tears (6 partial, 3 complete) were identified in NBA players. Seven (78%) of the players returned to play in NBA games, missing 50 ± 30 games and 214 ± 112 calendar days on average. Comparisons between these player’s preindex and first postindex seasons revealed significant declines in games played (73.2 ± 6.6 vs 41.8 ± 10.8, P = .009) and minutes per game (27.2 ± 2.9 vs 23.0 ± 3.7, P = .042). When compared with controls, only the decrease in games played was significant (–31.3 ± 7.6 vs 1.4 ± 8.2, P = .004). These findings were consistent when comparing preindex and second postindex seasons (games played: 79.6 ± 1.9 vs –28.4 ± 5.4, P = .006; minutes per game: 29.3 ± 2.6 vs 51.2 ± 4.6, P = .003). All other player performance metrics including player efficiency rating returned to near‐baseline levels in the first 2 seasons after injury. Conclusion NBA players with quadriceps tendon tears return to play in 78% of cases. These athletes achieved preinjury levels of performance within 1 to 2 seasons, but with reduced games played per season. Level of Evidence IV, therapeutic case series.

Background: Revision anterior cruciate ligament (ACL) reconstruction is being performed at an increasing rate. Previous literature has suggested that autograft ACL reconstruction is a better option than allograft in revision surgery, although the optimal autograft choice remains unknown. The all–soft tissue quadriceps tendon (ASTQT) autograft has been found to be an effective option for primary ACL reconstruction. However, few studies have evaluated ASTQT autograft in revision ACL reconstruction. Purpose/Hypothesis: The purpose of this study was to evaluate the ASTQT autograft in revision ACL reconstruction in athletes compared with bone–patellar tendon–bone (BTB) autograft. We hypothesized that the ASTQT autograft would lead to similar return to play, time to return to play, retear rate, and patient-reported outcomes compared with BTB autograft. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was performed on all athletes undergoing revision ACL reconstruction between August 2013 and December 2019 at a single institution. Patients participating in high school or college athletics undergoing first-time revision with either ASTQT or BTB autograft with ≥2 years of follow-up were included. Demographic variables, complications, return to sports, and outcome scores including the International Knee Documentation Committee (IKDC) and Lysholm were collected and compared between the 2 cohorts. Results: A total of 58 revision ACL reconstructions were included, with 32 in the ASTQT cohort and 26 in the BTB cohort. Return to sports at the same level occurred in 62.5% of the ASTQT group and 53.8% of the BTB group. The ASTQT group returned to sports significantly faster than the BTB group (8.9 vs 10.3 months; P = .020). There was no difference in retear rates (3.1%, ASTQT; 7.7%, BTB) or other complications between the 2 groups. The IKDC scores were significantly higher at the 6- and 12-month follow-up for the ASTQT autograft group compared with the BTB group (6 months: ASTQT, 71.3; BTB, 61.7, P = .001; 12 months: ASTQT, 82.7; BTB, 78.6; P = .021). Lysholm scores were also greater in the ASTQT cohort at these time points (6 months: ASTQT, 75.1; BTB, 63.6; P < .001; 12 months: ASTQT, 82.0; BTB, 74.5; P < .001). However, IKDC and Lysholm scores were similar between both groups at final follow-up (IKDC: ASTQT, 82.9; BTB, 81.7; P = .344; Lysholm: ASTQT, 83.0; BTB, 81.0; P = .104) There was no significant clinical difference in the absolute difference in scores or rate of achieving clinical thresholds between the 2 cohorts. Conclusion: ASTQT autograft for revision ACL in athletes has similar outcomes compared with BTB autograft. However, the ASTQT may possibly afford quicker return to sports and better early improvements in patient-reported outcomes that normalize by 1 year. The soft tissue quadriceps autograft should be considered a viable graft option in revision ACL reconstruction in athletes.

Background: Health and safety concerns surrounding the coronavirus 2019 (COVID-19) pandemic led the National Basketball Association (NBA) to condense and accelerate the 2020 season. Although prior literature has suggested that inadequate rest may lead to an increased injury risk, the unique circumstances surrounding this season offer a unique opportunity to evaluate player safety in the setting of reduced interval rest. Hypothesis: We hypothesized that the condensed 2020 NBA season resulted in an increased overall injury risk as compared with the 2015 to 2018 seasons. Study Design: Descriptive epidemiology study. Methods: A publicly available database, Pro Sports Transactions, was queried for injuries that forced players to miss ≥1 game between the 2015 and 2020 seasons. Data from the 2019 season were omitted given the abrupt suspension of the league year. All injury incidences were calculated per 1000 game-exposures (GEs). The primary outcome was the overall injury proportion ratio (IPR) between the 2020 season and previous seasons. Secondary measures included injury incidences stratified by type, severity, age, position, and minutes per game. Results: A total of 4346 injuries occurred over a 5-season span among 2572 unique player-seasons. The overall incidence of injury during the 2020 season was 48.20 per 1000 GEs but decreased to 39.97 per 1000 GEs when excluding COVID-19. Despite this exclusion, the overall injury rate in 2020 remained significantly greater (IPR, 1.42 [95% CI, 1.32-1.52]) than that of the 2015 to 2018 seasons (28.20 per 1000 GEs). On closer evaluation, the most notable increases seen in the 2020 season occurred within minor injuries requiring only a 1-game absence (IPR, 1.53 [95% CI, 1.37-1.70]) and in players who were aged 25 to 29 years (IPR, 1.57 [95% CI, 1.40-2.63]), averaging ≥30.0 minutes per game (IPR, 1.67 [95% CI, 1.47-1.90]), and playing the point guard position (IPR, 1.67 [95% 1.44-1.95]). Conclusion: Players in the condensed 2020 NBA season had a significantly higher incidence of injuries when compared with the prior 4 seasons, even when excluding COVID-19–related absences. This rise is consistent with the other congested NBA seasons of 1998 and 2011. These findings suggest that condensing the NBA schedule is associated with an increased risk to player health and safety.

Purpose To identify the clinical practice preferences of orthopaedic surgeons regarding anterior cruciate ligament reconstruction (ACLR) rehabilitation through a survey of members of the Arthroscopy Association of North American (AANA) and the American Orthopaedic Society for Sports Medicine (AOSSM). Methods An online survey was distributed to members of AANA and AOSSM between November 2020 and September 2021. Participants reported on their clinical preferences for ACLR protocol development and patient selection, use of technology in ACLR recovery and rehabilitation, and preferences for advancing through multiple phases of the rehabilitative process. Results Responses from 46 orthopaedic surgeons were analyzed. Patient‐reported outcome measures were not found to be utilized often at various phases of the perioperative period. Thirty‐eight (82.6%) participants reported utilization of postoperative bracing. There was no consensus on when participants allow their patients to advance through rehabilitation, but most report waiting 3 to 4 months for advancement to jogging/lateral movement, 6 to 8 months for return to noncontact sport, and 9 months of more for return to unrestricted sport. Many participants utilize functional and strength testing with associated limb symmetry indices to determine patient readiness to return to sport, with 18, 26, and 25 participants reporting use of functional testing and 28, 26, and 27 participants reporting use of strength testing at the return to jogging/lateral movements, noncontact return to sport, and unrestricted return‐to‐sport phases, respectively. Conclusions This study provides an insight into the rehabilitative protocols and modalities utilized for ACLR by orthopaedic surgeons in practice across the United States. There is notably substantial variation in rehabilitative patterns and preferences, particularly with regards to what constitutes criteria for progressing patients through the phases of returning to unrestricted sport. Additionally, our findings show that while many surgeons believe that quantitative assessment technology could be beneficial in decision‐making for returning patients to sport, there are still many barriers that stand in the way of its implementation into clinical practice. Clinical Relevance Postoperative rehabilitative protocols after ACLR vary by surgeon.

Purpose To determine structural knee injury rates and to identify risk factors and the number of games missed associated with these injuries in National Basketball Association (NBA) players from the 2015 to 2020 seasons. Methods Publicly available player records of active NBA players between the 2015 and 2020 seasons (excluding the shortened 2019 season) were reviewed to identify players with a knee injury associated with missing one or more games. Player demographics, anthropometric measurements, statistics, injury characteristics, and history of other lower‐extremity injuries were recorded. We sought factors associated with having a structural knee injury in bivariate analysis and multivariable logistic regression. Negative binomial regression was conducted to evaluate factors associated with the total number of games missed. Results Two hundred twelve players (of 1,011, 21%) sustained a structural knee injury. Accounting for potential confounders, having a structural knee injury was associated with more minutes per game played (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0‐1.2; P = .002), a greater usage rate (OR 1.1; 95% CI 1.0‐1.2; P = .004), and a lower player efficiency rating (OR 0.94; 95% CI 0.89‐1.0; P = .041). A greater number of missed games was associated with more minutes per game (regression coefficient [RC] 0.065; 0.028‐0.10; P = .001), fewer points per game (RC –0.078; –0.14 to –0.017; P = .013), and greater usage rate (RC 0.032; 0.0040‐0.060; P = .025). Conclusions Structural knee injuries occurred in 21% of players in this study with an overall rate of 5.42 injuries per 1,000 game exposures. Significant risk factors associated with injury were minutes per game, usage rate, and true shooting percentage. Player efficiency was significantly associated with a decreased risk of injury. Increased minutes per game and usage rate were significantly associated with a longer duration of game loss. Level of Evidence Level IV, case series.

Introduction: Away rotations have become a critical factor for a successful orthopaedic surgery residency match. Away rotations significantly improve an applicant's chance of matching into an orthopaedic residency. Away rotations were limited during the 2020 to 2021 academic year because of the COVID-19 pandemic. During the 2021 to 2022 academic year, the American Association of Medical Colleges coalition recommended students only complete 1 rotation outside their home institution, whereas the American Orthopaedic Association Council of Residency Directors argued that multiple rotations should be allowed. We sought to quantify the impact of these restrictions on orthopaedic surgery applicants during the 2020 to 2021 residency application cycle. Methods: An online survey was sent to all applicants applying to the authors' home orthopaedic surgery program. The survey asked respondents to indicate how many away rotations they completed and how many they planned to complete but were unable to complete in the 2020 to 2021 application cycle. Historical match data were obtained from the National Resident Matching Program's publicly accessible Main Residency Match Data and Reports . Results: Survey responses were collected from 650 of 812 applicants (80%) to our program. Over a third of respondents (38.1%) reported completing 3 subinternship rotations during the 2020 to 2021 application cycle. Nearly a quarter of respondents (24.0%) reported completing 4 rotations. Most applicants (50.9%) were unable to complete 5 previously planned rotations because of pandemic-related restrictions, and 25.2% reported an inability to complete 4 rotations. Fewer applicants reported canceling 3 rotations (9.2%), 2 rotations (6.8%), or 1 (7.8%) rotation. Conclusions: Away rotations have been a traditional component of the orthopaedic surgery application process. Restrictions on away rotations in the 2020 to 2021 residency application cycle had affected the number of rotations that applicants were able to complete. However, despite those restrictions, over a third of applicants were able to complete at least 3 rotations. This suggests that the away rotation experience is variable for students and may be multifactorial; however, our study did not investigate the reasons for this. Accordingly, limiting away rotations may support an inequitable environment for medical students applying to orthopaedic surgery, and creating a consensus definition among medical schools, program directors, and orthopaedic chairs of away rotations, their duration, and the maximum number allowed would enhance fairness and reduce inconsistencies.

Background: Social media and online resources have been used in graduate medical education for years. In addition to an official residency program website, many orthopaedic surgery programs have an established social media presence to interact, educate, and engage with prospective applicants. The role of social media in orthopaedic surgery has significantly expanded in recent years. Despite its increasing use, the specific impact of social media on orthopaedic surgery residency applicants remains unknown. Methods: Applicants to the home institution's orthopaedic surgery residency program were sent an optional online survey during the 2020 to 2021 application cycle. No incentive was provided in exchange for participation. Results: Of 812 orthopaedic surgery applicants, 650 (80%) completed the survey. Program-based social media is widely accessed by applicants. Instagram is used by most applicants (61.9%), and nearly a third (28.7%) rely on it as their main resource when researching prospective residency programs. The majority (66.9%) agreed that social media can be successfully used to inform and interact with applicants. Most of the applicants (60.6%) also reported that social media had a positive impact on their perception of the associated program. Only 5.7% of respondents indicated that social media had a negative influence. The most effective uses of social media seem to be in allowing a program to display its culture and transparency. Conclusion: Social media plays a substantial role in the orthopaedic surgery residency application process, and its use continues to grow. Programs can use it to effectively engage with and inform prospective applicants. The impact of social media is positive on most of the applicants. Instagram is the preferred social media platform used by applicants, and nearly one-third rely on it as their main resource when researching programs. Investing time and resources into a social media presence seems to be a worthwhile pursuit for orthopaedic surgery programs as an important piece to a well-rounded recruitment effort of modern orthopaedic surgery applicants.

Abstract Glenohumeral bone loss is a significant risk factor for recurrent instability after shoulder dislocation. The Hill‐Sachs lesion is an osseous defect of the posterior humeral head that is commonly recognized after anterior shoulder dislocation. Several procedures exist to address humeral‐sided bone loss, including soft tissue filling procedures, osteoarticular allografts, bone plugs, rotation osteotomies, and humeral head replacements. However, among the most common of these procedures is the arthroscopic remplissage. This technique involves capsulotenodesis of the posterior shoulder capsule and infraspinatus tendon into a Hill‐Sachs lesion. Previously described techniques use knotted suture anchors. In this report, we describe a modified technique for remplissage using knotless, all‐suture anchors to perform capsulotenodesis of a Hill‐Sachs lesion. Benefits of this technique include a single skin incision, improved bone preservation, and easier facilitation of revision surgery if required. Technique Video video See video under supplementary data.