Citations

Objectives: Prior literature has shown female soccer athletes are at a higher risk for anterior cruciate ligament (ACL) rupture. This risk persists even after primary ACL reconstruction (ACLR), given increased graft failure rates seen in this population. Thus, augmentation strategies such as lateral extra-articular tenodesis (LET) have gained increasing attention, but there is limited data in high-risk female soccer. The primary outcome of this study was to compare the graft failure rates and patient outcomes of ACLR with LET augmentation compared to isolated ACLR in female soccer players. Methods: A cohort of female soccer athletes who underwent ACLR was retrospectively analyzed. Participants were divided into two groups: those who received ACLR alone (control) and those who received ACLR with LET. Exclusion criteria included patients who were not involved in competitive soccer at the time of surgery or had less than 2-years follow-up. Patient demographics and physical exam findings, including the pivot shift results, were collected. Patient outcomes included graft failure, International Knee Documentation Committee (IKDC) and Lysholm scores, return to sport rates, and complications. Independent t-tests and chi-squared tests were conducted to compare outcomes between the two groups. Results: A total of 133 female soccer players who underwent ACLR and met inclusion criteria were identified, with 43 patients receiving LET and 90 patients undergoing sole ACLR. The LET cohort had a higher mean Beighton score (3.0 vs. 1.5; P<0.001) and greater proportion of generalized ligamentous laxity (48.8% vs. 18.9%; P<0.001). There were no significant differences between the two cohorts in age, level of competition, type of graft used, or meniscal intervention (P>0.05). Average follow-up was 39.0 and 36.1 months in the LET group and the control group, respectively. Final postoperative IKDC scores were greater in patients who received LET compared to those who did not (91.3 vs. 88.3; P=0.012). Further, there was a lower rate of graft failure, indicated by a confirmed ACL re-tear or a positive post-operative pivot shift, in patients who underwent LET compared to the control group (14% vs. 31.1%; P=0.036). The presence of positive post-operative pivot shift was also lower in the LET group compared to the control (9.3% vs. 27.8%; P=0.023). There were no significant differences in the rates of complications between the two groups (P>0.05), except for 9.3% of the LET patients developing a hematoma at the LET site. Conclusions: LET augmentation in ACLR is associated with a reduced graft failure rate and decreased post-operative rotational instability in female soccer athletes regardless of graft type used. This augmentation strategy may enhance the stability of the knee joint and help improve clinical outcomes, suggesting its potential as a standard adjunctive procedure for female soccer players undergoing primary ACLR.

Objectives: To compare ACL reconstruction with quadriceps autograft with or without LET for primary ACL reconstruction Methods: A retrospective study was performed from 2013- 2021 including patient undergoing quadriceps autograft (QA) or QA plus lateral extra-articular tenodesis (LET) for primary ACLR. Exclusion criteria included patients undergoing multi-ligamentous reconstruction, concomitant procedures outside of meniscal work, revision cases, and patients with less than 2 years of follow up. The surgeon favored LET in young (less than 18 years old) females participating in cutting and twisting sports. An additional relative indication was a high-grade pivot shift (2 or 3+). Clincal outcomes incldued IKDC and Lysholm scores, retrun to sport/return to sport at same level and time to return to sport in athletes along with complication rates. Failure rate was determined by rate of graft re-tearing and presence of a residual pivot shift (2+ or higher) at final follow up. Results: A total of 142 patients underwent QA+LET with 18 excluded, leaving 124 patients in this group. The QA group had 371 patients with 57 excluded, leaving 314 for analysis. The QA+LET group had a significantly higher percentage of females, ligamentous laxity, and athletes. IKDC scores were significantly higher in the QA+LET group at final follow up. Lysholm scores were significantly higher in the QA group at 6 months, with no difference at other time points. Graft re-tear rates were similar between the 2 groups. Residual pivot shift at final follow up was significantly higher in the QA group (21% vs. 11%, p = 0.012) as was overall failure rate (24% vs. 14.5%. p = 0.026). Return to sport was similar between the 2 groups, but time to return to sport and return at the same or higher level was significantly higher in the QA+LET group. Hematomas were more common (12.9% vs. 0%) in the QA+LET group. Conclusions: Addition of an LET to QA leads to lower residual pivot shift when compared to QA alone. The addition of a LET to QA may lead to a higher return to sport at same or higher level compared to QA alone. This provides preliminary data that will be built upon with results from the Stability 2 trial.

Objectives: Tobacco use is a known modifiable risk factor for postoperative complications and revision surgery after anterior cruciate ligament reconstruction (ACLR). Prior studies focus on “tobacco” as a broad categorization of traditional cigarette smoking, smokeless tobacco, and other forms of nicotine use. It is unclear if differences in the type of nicotine used lead to similar adverse outcomes after ACLR. Thus, the purpose of this study was to (1) assess the incidence of postoperative complications among ACLR patients who use smokeless tobacco, and (2) compare these outcomes with those of patients who do not use tobacco and those who smoke cigarettes. Methods: A retrospective cohort study utilizing a large insurance database was conducted. Patients undergoing primary ACLR without concomitant knee procedures with a minimum 2-year follow-up were included. Smokeless tobacco only users, cigarette only users, and non-tobacco users were matched based on demographic variables and comorbidities. Postoperative complications within 90 days of surgery and subsequent knee surgery within 2 years were compared among groups. Multivariable logistic regressions were employed to control for confounding variables. Results: After applying exclusion criteria, there were 241,194 ALCR patients eligible for analysis. Of these, there were 898 (0.37%) patients that used smokeless tobacco only, 22,062 (9.1%) patients that exclusively used cigarettes, and 207,462 (86%) patients that did not use any tobacco products. Compared to non-users, smokeless tobacco users demonstrated increased risk of emergency department (ED) utilization (20.4% vs 8.7%, OR: 6.29; 95% CI: 3.70-10.9, p<0.001), pneumonia (1.2% vs 0.5%, OR: 3.36; 95% CI: 1.41-7.90, p=0.005), and acute kidney injury (AKI) (1.2% vs 0.1%, OR:12.7; 95% CI: 3.77-52.8, p<0.001) within 90 days of surgery. Additionally, smokeless tobacco users had a markedly increased risk of subsequent ACLR (13.5% vs 3.2%, OR: 4.75; 95% CI: 3.60-6.26, p<0.001) and meniscus surgery (12.9% vs 4.9%, OR: 2.89; 95% CI: 2.23-3.73, p<0.001) within 2 years compared to controls. When compared to cigarette smokers, smokeless tobacco users showed increased risk of ED visits (20.6% vs 19.3%, OR: 1.55; 95% CI: 1.25-1.90, p<0.001), pneumonia (1.2% vs 0.6%, OR: 3.25; 95% CI: 1.33-7.78, p=0.008), and AKI (1.3% vs 0.3%, OR: 7.63; 95% CI: 2.72-22.5, p<0.001) within 90 days. They also demonstrated a significantly increased risk of subsequent ACLR (13.4% vs 4.1%, OR: 4.81; 95% CI: 3.58-6.47, p<0.001) and meniscus surgery (12.8% vs 5.5%, OR: 2.45; 95% CI: 2.45-4.26, p<0.001) within 2 years when compared to cigarette smokers. Conclusions: Smokeless tobacco use was associated with increased risk of medical complications, ED utilization, and subsequent procedures compared to non-user controls and traditional smokers. These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR.

Objectives: Non-steroidal anti-inflammatory drugs (NSAID) are widely used for pain control in musculoskeletal conditions. The purpose of this study was to determine if long-term use of NSAIDs increases the incidience of rotator cuff tears. Methods: A retrospective comparative study using a national insurance database was performed. All patients who had a diagnosis of long-term NSAID use with active records in the database for at least 1 year or 2 years were identified. These patients were matched 1:1 to controls without NSAID use based on age, gender, and Elixhauser comorbidity index. Rotator cuff tendon tear rates were compared between each group. Sub-group analyses in the following age-ranges for each sex was also done: 35-45, 46-55, 56-65, 66-75. Results: A total of 499,240 patients who had a history of long-term NSAID use were evaluated. 10,180 patients sustained a rotator cuff tear compared to 7,471 control patients (2.04% vs. 1.50%, respectively), with an adjusted OR of 1.18 (95% CI: 1.14-1.21; P<0.001). Male chronic NSAID users in the 46 to 55 age range had higher rates of rotator cuff tears compared to control patients of the same demographics (OR: 1.41; 95% CI 1.30 – 1.52; P<0.001). Female chronic NSAID users in the 46 to 55 age range had higher rates of rotator cuff tears compared to control patients of the same demographics (OR: 1.40; 95% CI 1.31 – 1.49; P<0.001). Comparable results were seen in the 56-65 age range for both males and females. Further, chronic NSAID users (n=1,888; 18.5%) underwent rotator cuff repair at higher rates compared to controls (n=1,223; 16.4%). Conclusions: Long-term NSAID use significantly increases the rates of rotator cuff tendon tears at the 1-year and 2-year follow-up periods, which is particularly notable in the middle-aged population. These findings suggest that middle aged patients with long-term NSAID use may be at a higher risk for rotator cuff tendon tears.

Abstract Like all diagnoses and comorbidities, patients with hip pain should be managed with individualized treatment plans. Patients with fibromyalgia undergoing hip arthroscopy are no different. Even if their absolute scores remain lower than those without fibromyalgia, these patients can achieve clinically meaningful improvements in patient‐reported outcomes after treatment of femoroacetabular impingement. As orthopaedic providers, we should be aware of potential bias against patients with chronic musculoskeletal pain and critically evaluate the literature that supports clinically relevant improvement after surgical intervention. Fibromyalgia should not be viewed as a condition that excludes or increases the threshold for hip arthroscopy but rather as a factor requiring nuanced, multidisciplinary perioperative care and realistic goal‐setting.

Purpose To evaluate which patient factors are associated with specific metrics of poor access to care in patients with a rotator cuff tear (RCT). Methods The All of Us Database was utilized to form a cohort of patients with RCT between May 2018 and May 2023. Patients with a diagnosis of RCT using Systematized Nomenclature of Medicine clinical terms were included. The association of RCT diagnosis and patient‐specific factors on self‐reported outcomes of “delayed care,” “could not afford care,” “skipped medication,” and “have not seen provider in more than 1 year” were analyzed. Statistical tests performed were univariate regression and multivariable logistic regression. Results In total, 4,265 patients with RCT who completed the access to care survey were included. In the RCT cohort, 26.7% reported delayed care, 24.9% reported an inability to afford care, 12.1% reported skipped medications, and 1.7% reported not seeing a provider in more than 1 year. Multivariable analysis of patient treatment and demographic features revealed younger age, female sex, lower income, poor physical health, and poor mental health to be strongly associated with higher reported rates of delayed care, inability to afford care, and skipped medications. History of rotator cuff repair, marital status, and sexual orientation were not associated with reported poor access to care. Conclusions A quarter of patients with rotator cuff tears report delays in overall medical care and inability to afford care. Among patients diagnosed with RCT, patients of younger age, female sex, low income, and poor physical and mental health have higher odds of decreased access to health care. Clinical Relevance Health care disparities and access to care are topics that should be investigated to reduce them.

Background: The number of multiply revised anterior cruciate ligament reconstructions (rrACLRs) performed each year continues to increase. The most reliable graft type and surgical technique in the young, active patient remains to be determined. Purpose: To determine the outcomes of rrACLR using quadriceps tendon (QT) autograft with lateral extra-articular tenodesis (LET). Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was performed of all competitive athletes undergoing rrACLR with QT autograft and LET at a single institution with a minimum follow-up of 2 years. Patient demographics, physical examination, and radiological findings, and previous surgical details were documented. Patient outcomes were noted, including the International Knee Documentation Committee (IKDC) and Lysholm scores, ability to return to sport and return at the same level of play, retear rate, and other complications. Results: A total of 19 rrACLRs were performed and met inclusion criteria in the 10-year study period. All participants were high school, collegiate, or professional athletes with a mean age of 22 years, and 63.2% were female. The mean follow-up was 42.3 months, and IKDC scores increased from 51.6 preoperatively to 74.7 at the final follow-up ( P < .001). Likewise, the Lysholm score increased significantly from a preoperative value of 53.6 to 76.8 at the final follow-up ( P < .001). Return to play was possible in 52.6% of the patients at a mean of 11.5 months, with 31.6% returning to the same or higher level of play. One (5.3%) patient experienced a recurrent ACL tear, and 2 (10.5%) experienced a contralateral tear. Arthrofibrosis requiring surgical intervention occurred in 26.3% of the athletes. Conclusion: Short- to midterm results demonstrated that competitive athletes who received an rrACLR using a QT autograft with LET had statistically significant improvements in both IKDC and Lysholm scores, with more than half of patients being able to return to sport and nearly a third returning at the same or higher level of play. In the setting of a third ACL reconstruction, quadriceps tendon autograft with LET is a reasonable option even in high-risk patients.

Purpose To evaluate the effectiveness of adding lateral extra‐articular tenodesis (LET) to primary anterior cruciate ligament reconstruction (ACLR) in competitive female soccer athletes with greater preoperative generalized ligamentous laxity. Methods A retrospective review of female high school and collegiate soccer players who underwent primary ACLR from 2013 to 2021, with a minimum of 2 years of follow‐up, was conducted. Participants were divided into 2 groups: those who received ACLR alone and those who received ACLR with LET. Generalized ligamentous laxity was defined as a Beighton score ≥4 and was not considered an indication for LET. Anterior cruciate ligament (ACL) autografts included the quadriceps, bone−patellar tendon−bone, and hamstrings in both groups. Patient demographics and physical examination findings, including pivot shift results, were collected. Positive pivot‐shift refers to a grade ≥2. Patient outcomes included graft failure (defined as ACL retear), International Knee Documentation Committee score, Lysholm score, return to sport, and complications. Independent t tests, χ 2 tests, and Mann‐Whitney U tests were conducted to compare outcomes between the 2 groups. Minimally clinical important difference was calculated from preoperative to final follow‐up. Results A total of 133 female soccer players who underwent ACLR met inclusion criteria, including 43 patients that received an ACLR + LET and 90 patients who underwent isolated ACLR. Average follow‐up was 39.0 and 36.1 months in the LET group and the control group, respectively. Patients who underwent LET had a greater generalized ligamentous laxity rate (48.8% vs 18.9%; P < .001) and greater median Beighton score (3.0 vs 1.0; P < .001) than those without LET. There was a similar rate of graft failure in patients who underwent LET compared with the control group (4.7% vs 3.0%; P = .658). On the basis of minimally clinical important difference thresholds, there were no clinically relevant differences in International Knee Documentation Committee or Lysholm scores noted between the 2 groups. Return‐to‐sport rates also were comparable between the LET and control cohorts (90.7% vs 85.6%; P = .807). Conclusions The addition of LET during ACLR in female soccer players with preoperative generalized ligamentous laxity yields graft retear and return‐to‐sport rates comparable with those of athletes without ligamentous laxity. Level of Evidence Level III, retrospective comparative study.

Background: Concussions have previously been shown to have persistent neurological changes represented by altered reaction time and postural stability in high-level athletes. The effects of concussions on professional basketball players’ performance and subsequent injuries during the 90 days after return to play (RTP) have not been investigated. Purpose/Hypothesis: the purpose of this study was to evaluate player statistical performance and risk of musculoskeletal (MSK) injury within 90 days of RTP from a diagnosed concussion. It was hypothesized that within the 90 days after RTP from a concussion, players would be at a greater risk for MSK injury with an associated decrease in player statistical performance. Study Design: Descriptive epidemiology study. Methods: Concussions sustained by National Basketball Association (NBA) players between the 2015-2016 and 2021-2022 seasons, excluding the 2019-2020 season, were evaluated using a publicly available database. The database was queried to identify any MSK injury in the 90-day post-RTP period after a concussion, along with time loss after subsequent injury. Performance statistics were obtained from each player’s preindex season and postindex season, as well as defined time points within the 90-day post-RTP period. Each concussed player was matched 1 to 1 with a nonconcussed control using position, win shares, player efficiency rating, and points per game. MSK injury incidence and player statistics in the concussion group were compared with controls using unpaired Student t tests. Results: A total of 70 concussions were identified in 70 professional basketball players and included in this analysis. A total of 49 players sustained an MSK injury in the 90-day post-RTP period (70%). Compared with controls, the odds of sustaining an MSK injury in the concussed cohort were 11.3 times greater (95% CI, 5.04-25.2; P < .001). Games missed after subsequent MSK injury were similar between the concussed and control groups ( P = .687). Comparisons over the 90-day post-RTP period did not reveal any significant changes in points per game, minutes per game, or true shooting percentage ( P > .05). When compared with controls, no changes in performance statistics were significantly different ( P > .05). Conclusion: Our analysis demonstrates that basketball players who sustain concussions are at a significantly increased risk for subsequent MSK injury within the 90-day post-RTP period but not player performance. Knowledge of this increased risk of MSK injury in concussed athletes can help guide concussion management for proper RTP and targeted rehabilitation in professional basketball players.