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Purpose To describe the clinical and radiographic features associated with isolated hypermobile lateral meniscus (HLM), and report patient outcomes following surgically repaired isolated HLM. Methods All patients diagnosed with HLM from 2000 to 2020 at a single academic institution were identified and reviewed. Patients were excluded if they had concomitant ligament injury or lacked 2‐year follow‐up. Preoperative and postoperative visual analog scale (VAS) pain scores were determined from clinical notes. Statistical analysis was performed in JMP, and statistical significance was determined with use of a paired t ‐test. Results Eighteen knees in 17 patients met inclusion criteria. Mean patient age was 24.1 (range: 6‐61) years. Mean follow‐up was 73 months (25‐151 months). All 18 knees reported pain at presentation; 94% (17/18) had mechanical symptoms. All 18 knees had preoperative MRIs, but only 1 (5.6%) knee was correctly diagnosed by a musculoskeletal trained radiologist. Most repairs were performed with an all‐inside technique (61%, 11/18). VAS score improved significantly from 7.2 ± 2.9 preoperatively to 0.7 ± 1.9 postoperatively, with average improvement of VAS score of 6.5 ( P < .001). Only one (5.6%) knee required revision meniscal surgery. Conclusions Hypermobile lateral meniscus patients commonly see multiple providers, fail to have their HLM diagnosed on MRI, and undergo various treatments prior to a successful diagnosis. Localized lateral joint line pain, mechanical symptoms, and absence of distinct meniscus tear on MRI are the most frequent clinical presentations. Surgery with meniscus repair is a reliable solution to improve pain and mechanical symptoms. Level of Evidence Level IV, therapeutic case series.

Purpose To develop a machine learning model capable of identifying subscapularis tears before surgery based on imaging and physical examination findings. Methods Between 2010 and 2020, 202 consecutive shoulders underwent arthroscopic rotator cuff repair by a single surgeon. Patient demographics, physical examination findings (including range of motion, weakness with internal rotation, lift/push‐off test, belly press test, and bear hug test), and imaging (including direct and indirect signs of tearing, biceps status, fatty atrophy, cystic changes, and other similar findings) were included for model creation. Results Sixty percent of the shoulders had partial or full thickness tears of the subscapularis verified during surgery (83% of these were upper third). Using only preoperative imaging‐related parameters, the XGBoost model demonstrated excellent performance at predicting subscapularis tears (c‐statistic, 0.84; accuracy, 0.85; F1 score, 0.87). The top 5 features included direct signs related to the presence of tearing as evidenced on magnetic resonance imaging (MRI) (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology. Conclusions In this study, machine learning was successful in predicting subscapularis tears by MRI alone in 85% of patients, and this accuracy did not decrease by isolating the model to the top features. The top five features included direct signs related to the presence of tearing as evidenced on MRI (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology. Last, in advanced modeling, the addition of physical examination or patient characteristics did not make a significant difference in the predictive ability of this model. Level of Evidence Level III, diagnostic case‐control study.

Background: Platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) have gained popularity in recent years as biologic approaches to potentially augment healing after meniscus repair. There have been few studies comparing outcomes in patients undergoing meniscus repair with versus without biologic augmentation and, furthermore, little clarity on the role of biologic augmentation for meniscus repairs performed with concomitant anterior cruciate ligament reconstruction (ACLR). Purpose: To determine the association of BMAC or PRP augmentation with revision surgery after both isolated meniscus repair and meniscus repair performed concomitantly with ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner dataset was queried to identify all patients who underwent primary meniscus repair, both with and without concomitant ACLR, and who received ipsilateral BMAC or PRP at the time of surgery. Patients who underwent similar surgery but without BMAC or PRP augmentation were then identified and matched in a 5:1 ratio according to age, sex, body mass index, and various comorbidities to 3 separate BMAC/PRP augmentation groups: overall cohort (with and without ACLR), repair with concomitant ACLR, and isolated repair. The primary outcome was revision meniscus surgery (meniscectomy or revision meniscus repair). Results: Overall, 3420 patients (570 with BMAC/PRP augmentation; 2850 matched controls without augmentation) were included. There were no significant differences in the reported demographics or comorbidities between any of the BMAC/PRP groups and their respective matched controls ( P > .05 for all comparisons). There was no difference in revision rate between BMAC/PRP-augmented isolated meniscus repairs and matched controls ( P = .235). Patients who underwent BMAC/PRP-augmented meniscus repair with concomitant ACLR experienced a significantly lower incidence of revision surgery compared with matched controls without BMAC/PRP augmentation (5.2% vs 7.9% respectively; odds ratio, 0.41; 95% CI, 0.27-0.63; P < .001), but the number of revisions was relatively small. Conclusion: There was no association between BMAC or PRP augmentation and the incidence of revision surgery after isolated primary meniscus repair. There was a statistically significant decrease in the rate of revision meniscus surgery when BMAC or PRP was used to augment meniscus repairs in the setting of concurrent ACLR; however, the overall revision rates were small.

Objectives: Background: Arthroscopic diagnosis and treatment of femoroacetabular pathology has been increasingly used in the past thirty years with interventions resulting in improved hip function and ultimate delay of hip arthroplasty in a minimally invasive manner. Unfortunately, previous investigations have observed decreased rates of access, utilization of, and outcomes following orthopedic interventions such as hip arthroplasty in underrepresented patients. The purpose of this study is to examine racial differences in procedural rates, outcomes, and complications in patients undergoing hip arthroscopy. Methods: The State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) of New York were queried for patients undergoing hip arthroscopy from 2011 to 2017. The primary outcomes investigated were utilization over time, total charges billed per encounter, 90-day emergency department visits, and revision hip arthroscopy. Patients were stratified into White and non-White race, and intergroup differences were evaluated with descriptive statistics. Subgroup analysis was performed with linear mixed-effects models to identify significant interactions between race and individual variables that contributed to any differences in the outcomes of interest. Temporal trends in utilization of hip arthroscopy and concomitant procedures between the two groups were analyzed with Poisson regression modeling. Finally, targeted maximum likelihood estimation (TMLE) was performed to provide nonparametric estimates of the specific differences in the outcomes studied using machine learning ensembles while controlling for patient risk factors. Results: A total of 9,745 patients underwent hip arthroscopy during the study period, with 1,081 patients of non-White race (11.9%). Results of Poisson regression demonstrated an annual increase of 1.11 in the incidence rate of hip arthroscopy among White patients, compared to 1.03 for non-White patients (p<0.001), with this disparity projected to increase by 2040. Based on TMLE utilizing an ensemble of machine learning models, non-White patients were significantly more likely to incur higher costs (OR: 1.30, 95% CI: 1.24-1.37, p<0.001) and visit the emergency department within 90-days (OR: 1.09, 95% CI: 1.01, 1.18, p=0.05), but had negligible differences in reoperation rates at 90 days to 2 years (OR: 1.13, 95% CI: 0.78-1.63, p=0.53). Subgroup analysis identified higher likelihood for 90-day emergency department admissions among non-White patients compared to White patients, which were significantly compounded by Medicare insurance (OR: 2.95, 95% CI 1.46-5.95, p=0.002), median income in the lowest quartile (OR: 1.84, 95% CI: 1.2-2.61, p=0.012), and residence in low-income neighborhoods (OR: 2.05, 95% CI: 1.31-3.2, p=0.006). Subgroup analysis for charges billed and reoperation did not identify significant findings. Conclusions: Hip arthroscopy remains an increasingly utilized surgical technique for the treatment of a myriad of hip disorders. Unfortunately, racial disparities exist and are worsening over time. Irrespective of insurance status, non-white patients undergo hip arthroscopy at a lower rate, incur higher costs, and more frequently experience unexpected returns to the emergency department. Improved initiatives to improve the disparity in access to and outcomes following hip arthroscopy must be addressed to further its utility for all patients.

Objectives: The purpose of this study was to assess return to play (RTP), patient-reported outcomes (PRO), and reoperation rates following patellofemoral stabilization surgeries (PSS) for recurrent patellar instability (RPI) in a cohort of competitive wrestlers. Methods: All competitive wrestlers with a history of an RPI and subsequent PSS at a single institution between 2000 and 2020 were identified. Primary PSS ranged from MPFL reconstruction (n = 31; 50%) or MPFL repair (n = 22; 33.5%), and other PSS (n = 9; 14.5%) in the form of tibial tubercle osteotomy (TTO), lateral retinaculum release (LRR), and medial retinaculum reefing (MRR). Exclusion criteria included revision PSS, or concomitant anterior cruciate ligament reconstruction or multi ligament knee injury. All patients were contacted for determination of reinjury rates, current sport status, and PROs. Surgical failure defined as subsequent patellar dislocation despite operative management or need for secondary PSS. Results: Ultimately, 62 knees in 56 wrestlers were included at a mean follow-up time of 6.6 years (range, 2.0 – 18.8 years). RTP occurred in 55.3% of wrestlers at a mean of 8.8 ± 6.7 months. Among the PSS no differences were observed between rates of RTP (P = .676), postoperative pain (P = .176), Tegner activity level (P = .801), International Knee Documentation Committee (P = .378), Lysholm (P = .402), or Kujala scores (P = .370). Recurrent patellar instability was the most common complication in 21% of knees. Among PSS types, MPFL reconstruction had the lowest rate of RPI (6.5% vs. 27.3% vs. 55.6%; P = .005), and surgical failure (9.7% vs. 31.8% vs. 55.6%; P = .008). Kaplan-Meier survivorship free from surgical failure of the entire cohort was 91.9% at 1 year, 77.7% at 5 years, and 65.7% at 15 years. MPFL reconstruction had the highest survivorship when compared to MPFL repair and other PSS up to 10 years after the index surgery (90.3% vs. 64.1% vs. 27.8%; P = .048). Conclusions: Recurrent patellar instability remains a concern for competitive wrestlers after PSS. MPFL reconstruction may serve as a more durable surgical treatment option with lower rates of RPI and failure when compared to other PSS up to 10 years after surgery. [Table: see text]

Objectives: Ulnar Collateral Ligament (UCL) tears are common in baseball players. When non-operative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics, or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs reconstruction. Methods: Twenty-six orthopaedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intra-operatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (peri-ligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, mid-substance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95%CI) helped identify significant predictors for both queries. Results: The odds of recommending surgical treatment compared to non-operative treatment were 2.4x more likely for a proximal partial-thickness tear, 3.2x for distal partial-thickness tear, 5.1x for distal full- thickness tear, and 7.0x for proximal full-thickness tear (p<0.001). Significant indications for repair included distal partial (OR=1.6, 95%CI 1.0, 2.1, p<0.001) and full-thickness tears (OR=1.7, 95%CI 1.1, 2.3, p<0.001). Repair was 3x less likely recommended for mid-substance full-thickness tears (OR=3.0, 95%CI - 5.0, -1.0, p=0.004). Ultrasound stress testing was requested in 78% of partial tears. Conclusions: Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial- thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete mid-substance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes. [Table: see text]

Objectives: Baseball pitchers often participate in throwing programs that involve throwing at reduced effort levels to gradually increase the amount of stress experienced across the elbow. It is currently unknown how reduced effort pitching compares to maximum effort with respect to elbow stress and ball velocity. The purpose of this study is to determine whether elbow stress and ball velocity correlate with reduced effort pitching, whether elbow stress and ball velocity decrease proportionally while throwing at a reduced effort, and to assess intrathrower reliability. Methods: Ten healthy male high school baseball pitchers threw 5 pitches from a regulation pitching mound at 3 effort levels: maximum effort, 75% effort, and 50% effort. Elbow stress, specifically elbow varus torque, was calculated for all pitches using a marker-based 3D motion capture system. Ball velocity was measured using a Doppler radar gun. Intrathrower variability was calculated for each effort level. Results: Elbow stress and ball velocity decreased with reduced effort throws (p<0.001 and p=0.003, respectively). However, the reductions in elbow stress and ball velocity were not proportional. At 75% effort throws, elbow stress decreased only 19% and ball velocity decreased only 10%. At 50% effort throws, elbow stress decreased only 25% and ball velocity decreased only 15%. Intrathrower reliability was excellent for elbow stress and ball velocity, with intraclass correlation coefficients all greater than or equal to 0.80. Conclusions: Pitching at a reduced effort level resulted in decreased elbow stress and ball velocity. However, for every 25% reduction in perceived effort, elbow stress decreased by a mean of 13% and ball velocity decreased 8%. When baseball pitchers attempt to throw at a reduced effort of maximum, throwing metrics do not decrease proportionately. While pitching at a reduced effort of maximum decreases elbow stress and ball velocity, the decrease is not proportional, subjecting the elbow to more stress than intended. This has significant clinical importance to pitchers, coaches, and medical professionals in the setting of injury prevention and return to sport. [Table: see text]

Objectives: While pitch count and rest guidelines have been promoted for youth and adolescent baseball players for nearly two decades, compliance with guidelines remains poorly understood. The purpose of this study was to determine the frequency of compliance with Pitch Smart guidelines, as well as the association between compliance and range of motion, strength, velocity, injury, and pitcher utilization. Methods: This study was a prospective, multi-center study of high school pitchers, encompassing each region of the United States. Pre-season pitchers were surveyed about their compliance with current off- season rest-related guidelines and history of injury. Pre-season, pitchers underwent standardized physical examinations and pitch velocity was measured. During the high school season that followed, both pitch counts and injury incidence were collected. Results: One hundred and fifteen pitchers participated. Based upon pre-season data, 84% of pitchers had previously violated current pitch recommendation guidelines. During the season, 14% had at least one instance of a violation of the current pitch counts guidelines. Across both the pre-season survey and in-season pitch counts, 89% of players had at least one violation of the current Pitch Smart guidelines. While there were no significant differences in range of motion or strength, those pitchers who were non-compliant with guidelines in the pre-season had higher max pitch velocity (mean±standard deviation 74±8 miles per hour vs. 69±5 miles per hour, p=0.009). Pitchers self-reported their peak velocity at 7 MPH greater than the actual measured velocity. Only a single injury occurred during the season, precluding a comparison between groups. There were no significant differences in the incidence of a history of injury between those pitchers who were noncompliant with between-season rest guidelines (p=0.285). Conclusions: Most high school pitchers are non-compliant with current Pitch Smart guidelines, and they tend to overestimate their peak velocity by 7 MPH. Pitchers with greater velocity were at the highest risk for violating current pitch count recommendations. Since both increased throwing volume and pitch velocity are known risk factors for injury, these athletes may be at particular risk for subsequent injury. research is necessary to understand whether taking three consecutive month rest between seasons prevents pitching-related injury.

Objectives: An increased posterior tibial slope (PTS) corresponds with an increased risk of graft failure following anterior cruciate ligament reconstruction (ACLR). Validated methods of human PTS measurements are subject to interobserver variability and can be inefficient on large-scale sets of images. The purpose of this study is to develop a deep learning artificial intelligence technique for the automated measurement of PTS from standard lateral knee radiographs. Methods: A deep learning U-Net model was developed on a cohort of 300 postoperative short leg lateral radiographs from ACLR patients to segment the tibial shaft, tibial joint surface, and tibial tuberosity. The model was trained via a random split following an 80:20 train-validation scheme. Masks for training images were manually segmented and the model was trained for 400 epochs. An image processing pipeline was then deployed to annotate and measure the PTS using the predicted segmentation masks. Finally, the performance of this combined pipeline was compared to human measurements performed by two study personnel using a previously validated manual technique for measuring PTS on short leg lateral radiographs on an independent test-set consisting of both preoperative and postoperative images. Results: The U-Net semantic segmentation model achieved a mean Dice similarity coefficient of 0.885 on the validation cohort. The mean difference between human-made and computer-vision measurements was 1.92⁰ (σ = 2.81⁰, P=0.24). Extreme disagreements between human and machine measurements as defined by differences ≥5⁰ occurred less than 5% of the time. The model was incorporated into a web based digital application for demonstration purposes which can provide measurement of an uploaded image in portable network graphics format in less than 5 seconds. Conclusions: We developed an accurate and reliable deep learning computer vision algorithm to automate the measurement of PTS on lateral knee radiographs. This tool will be deployed for clinical use on an institution-wide basis and, pending external validation, be made available to outside orthopaedic surgeons. This will provide an efficient and accurate tool to measure PTS during the preoperative assessment of ACL-injured patients.

Objectives: Desirable outcomes following surgery for anterior shoulder instability (ASI) include a multitude of functional and clinical functions, yet it remains uncertain if all of these outcomes are simultaneously achievable (i.e. can patients have full motion and no instability; does excellent stability coincide with stiffness?). The purpose of this study was to employ unsupervised machine learning techniques to define the actual "optimal observed outcome” for patients undergoing surgical treatment for ASI and to identify predictors of obtaining this outcome. Methods: Patients <40 years with an initial diagnosis of ASI from 1994 -2016 were included. Four unsupervised machine learning clustering algorithms were evaluated to partition subjects into “optimal observed outcome” or “suboptimal outcome” based on combinations of actually observed outcomes. Demographic, clinical, and treatment variables were compared between groups using descriptive statistics and Kaplan-Meier survival curves; multivariate stepwise logistic regression evaluated variable prognostic value. Results: 200 patients with a mean follow-up of 11 years were included. 146 (64%) obtained the “optimal observed outcome”, characterized by significantly (P <0.001) lower rates of: recurrent postoperative pain (23% vs 52%), recurrent instability (12% vs 41%), revision surgery (10% vs 24%), progression to osteoarthritis (OA) (5% vs. 19%), and mildly restricted motion (161° vs. 168°). Stepwise multivariate logistic regression identified time from initial instability to presentation (OR: 0.96, 95% CI: 0.92-0.98) and habitual instability (OR: 0.17, 95%CI: 0.04-0.77) as negative predictors of “observed optimal outcome”. Increased rate of subluxation over frank dislocation pre-operatively (OR: 1.30, 95% CI: 1.02-1.65) was a positive predictor. Type of surgery performed was not a significant predictor. Conclusions: Following surgical treatment for ASI, an appropriate “optimal observed outcome” can be defined as: minimal postoperative pain, absence of recurrent instability, low rates of revision surgery, absence of OA, and increased ROM. This “optimal observed outcome” was achieved in over 2/3rds of the cohort and this work demonstrated the synergistic relationship of these. The most significant predictors included shorter time to presentation and history of subluxations over frank dislocations pre-operatively. This definition of the “optimal observed outcome” may be more appropriate for surgical decision making and setting appropriate expectations. [Table: see text][Table: see text]