Chhabra, Anikar

Background: There is a wide range of literature on patellar tendon injury, making it increasingly difficult to stay informed on the most influential studies in this field. It is essential to be familiar with the foundational articles of patellar tendon injury research to understand the current state of the literature and deliver high quality care. Purpose: To objectively identify the 50 most influential articles relating to patellar tendon injury and conduct a bibliometric analysis to identify key features of these articles. Study Design: Cross-sectional study. Methods: The Clarivate Analytics Web of Knowledge database was utilized to gather metrics on the 50 most cited articles on patellar tendon injury on June 27, 2022. The information extracted from each article included publication year, number of citations, author information, article type, level of evidence, country of origin, journal name, study focus, and industry influence. Results: The top 50 studies were cited a total of 8543 times and published between 1977 and 2015. The majority of articles were published after 2003, and the majority of citations were accrued after 2011. The most prevalent article types were cohort studies (n = 23), and the majority of studies were of evidence level 2 (n = 14) or 4 (n = 13). Australia and the United States (US) each published the most studies (n = 11). Only 4 (8%) studies focused on patellar tendon rupture, and 12 (24%) of the top 50 studies were associated with industry. Conclusion: The majority of the top 50 most influential articles in patellar tendon injury were published and accumulated citations in the past 10 to 20 years. Non-US countries, institutions, and journals published many of the top 50 studies, reflecting a global interest and commitment to research in this field. Patellar tendon rupture and surgical repair represents a minority of research in the top 50 studies and could be a point of growth in the future.

Purpose To determine the most frequently cited articles relating to ice hockey since 2000 and conduct a bibliometric analysis of these publications. Methods The Clarivate Web of Knowledge database was used to gather data and generate a list of publications relating to “ice hockey” on June 20, 2022. Articles were filtered by the total number of citations accrued and were included or excluded on the basis of relevance to ice hockey; no date of publication, language, or journal restrictions. After the 50 most highly cited articles were identified, articles published before the year 2000 were excluded to avoid bias. The information analyzed from each article included author name (first and last), publication year, country of origin, institutional affiliation (of the first and last author), journal name, research design, main research topic, competition level, and the level of evidence. Results Ultimately, 46 studies were included in this analysis. The total number of citations was 8,267 times with an average of 179.7 citations per article. The most cited article was cited 926 times. The articles came from 5 different countries, with the United States and Canada comprising 27 and 13 articles, respectively. All articles were published in English. The American Journal of Sports Medicine published the greatest number of articles. The most studied topic was concussion/traumatic brain injury (n = 26). Professional hockey was the most studied level of competition (n = 15), while college followed (n = 13). Three institutions, University of Calgary, Dartmouth School of Medicine, and University of North Carolina at Chapel Hill were responsible for 32.6% of the top articles (n = 15). Conclusions The majority of the most cited articles relating to ice hockey are cohort studies, review articles, and epidemiological studies originating from the United States or Canada. The majority of publications included in the analysis focused on concussion and traumatic brain injury prevalence, identification, diagnosis, outcomes, and prevention, as well as the most studied level of competition was professional, but the greatest number of participants arose from the youth and high school level. Level of Evidence Level IV, cross‐sectional study

Background: An open Achilles tendon repair is performed in patients who have suffered an acute rupture. All patients with this injury should be counseled on their treatment options, which include open operative repair and functional rehabilitation. We prefer the use of an open repair in high-level athletes and those who have delayed presentation. Typically, this injury—and the resulting open repair—are seen in young or middle-aged patients as well as athletes. Operative repair of a ruptured Achilles tendon is associated with a much faster return to activity/sport when compared with nonoperative alternatives. This surgical procedure is especially useful in allowing this patient population to return to their previous activity level and functional capacity as quickly as possible. Description: Open repair of a ruptured Achilles tendon begins with a 6 to 8-cm incision over the posteromedial aspect of the lower leg. Superficial and deep dissections are performed until the 2 ends of the ruptured tendon are identified. Adhesions are debrided to adequately mobilize and define the proximal and distal segments of the tendon. With use of a fiber tape suture, a modified locking Bunnell stitch is utilized to secure both ends. The fiber tape is tied securely, and the repair is reinforced with Vicryl suture (Ethicon). Once the tendon is repaired, the paratenon layer is identified and repaired with a running 0 or 2-0 Vicryl suture. This is an important step to minimize postoperative wound complications. The wound is then closed, and the extremity is splinted in maximum plantar flexion. Alternatives: Alternative treatments include minimally invasive surgical techniques such as percutaneous Achilles tendon repair and nonoperative treatment with functional rehabilitation, which can provide excellent outcomes but can also lead to a slight decrease in explosiveness as the patient returns to sport 1,2 . Rationale: Nonoperative and operative treatment of Achilles tendon rupture can both result in excellent patient outcomes. Appropriate patient selection is critical. Younger patients hoping to return to more highly competitive athletics should consider operative repair 3 . Possible differences have been identified in peak torque when comparing operative versus nonoperative treatment, with patients who had undergone operative repair having greater peak torque (i.e., explosiveness) 2 . Otherwise, findings are similar between treatment options as long as the patients meet the criteria for nonoperative treatment. Expected Outcomes: Overall, the scientific literature demonstrates that the functional outcomes following operative repair are good to excellent. In a study by Hsu et al. 4 , 88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no reruptures. In a recent meta-analysis by Meulenkamp et al. 5 , the authors found that operative repair of Achilles tendon rupture was associated with a reduced risk of rerupture compared with primary immobilization (i.e., conventional cast immobilization with delayed weight-bearing for at least 6 weeks only). However, open surgical repair, minimally invasive repair, and functional rehabilitation all had similar risk of rerupture 5 . In a review by Ochen et al. 6 that analyzed 29 studies with a total of 15,862 patients, operative repair was associated with a significantly lower risk of rerupture compared with nonoperative treatment (2.3% versus 3.9%, respectively). However, operative treatment was also associated with a significantly higher complication rate compared with nonoperative treatment (4.9% versus 1.6%, respectively) 6 . Finally, in a meta-analysis by Soroceanu et al. 7 , the authors found that if early range-of-motion protocols and functional rehabilitation were utilized, operative and nonoperative treatment resulted in similar outcomes and equivalent rates of rerupture. Important Tips: To prevent rerupture of an Achilles tendon, remind patients to engage in adequate stretching and warming prior to physical activity. Palpate and locate the tendon defect prior to making the first incision. Immobilize the ankle joint in a splint for 2 weeks postoperatively in maximum plantar flexion. Pitfalls include: ○ Poor suture management leading to tangling in the repair. ○ Undertensioning or overtensioning of the repair, which can be avoided by sterilely draping out both legs and checking resting tension intraoperatively. ○ Failure to close the paratenon, causing scarring of the skin or surrounding tissues, which can be avoided by making a relieving incision on the deep surface of the paratenon. ○ Leaving suture knots on the dorsal side of the repair that may aggravate the skin. Acronyms & Abbreviations: MRI = magnetic resonance imaging ESU = electrosurgical unit

Background: Bibliometric citation analyses have been widely used in medicine to help researchers gain foundational knowledge about a topic and identify subtopics of popular interest for further investigations. Purpose: To identify the 50 most cited research publications related to American football. Study Design: Cross-sectional study. Methods: The Clarivate Analytics Web of Science database was used to generate a list of publications relating to football. Articles were filtered by the total number of citations, and the top 50 most cited articles studying the sport of football were selected for this analysis. Articles were analyzed by author, publication year, country of origin, institution affiliation, journal, article type, main research topic area, competitive level, and the level of evidence. A total of 247 articles were reviewed to reach the top 50 articles. Results: The most studied topic within the top 50 articles was concussion/chronic traumatic encephalopathy (n = 40). Collegiate football was the most studied level of competition (n = 25). The journal publishing the greatest number of top articles was Neurosurgery. Two institutions, the University of North Carolina at Chapel Hill and Boston University School of Medicine, produced over one-third of top 50 articles (n = 18). Conclusion: Our analysis indicated that most of the top 50 publications related to the sport of football focused on concussion and CTE, were observational, and were published during or after 2000. The most studied level of competition was collegiate football.

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: 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.

Background: Bibliometric citation analyses have been widely used in medicine to help researchers gain foundational knowledge about a topic and identify subtopics of popular interest for further investigations. There is a lack of similar research in collegiate athletics. Purpose: To identify the 100 most-cited research publications related to collegiate athletics. Study Design: Cross-sectional study. Methods: The Clarivate Analytics Web of Knowledge database was used to generate a list of articles relating to collegiate athletics on January 24, 2022. Articles were filtered by the total number of citations, and the 100 most-cited articles were selected. For each article, we identified and analyzed the following: author name, publication year, country of origin, journal name, article type, main research topic area, competitive level, sex of study population, and level of evidence. Results: Of the top 100 most-cited articles, 63 were related to medicine. In total, 96% of articles were published in the United States, and 80% were published in the year 2000 or later. Of the top 100 articles, 85 were observational; only 5 were experimental. The sport most represented was soccer, followed by football, baseball, and basketball. Of the top 100 articles, 21 were published in a single journal, the American Journal of Sports Medicine. Ten authors published ≥5 of the top 100 most-cited studies. Conclusion: The majority of top 100 articles were published in the United States after 1999 and primarily focused on medicine-related topics. Soccer was studied by more articles than football, baseball, and basketball. An author’s prestige may have influenced the likelihood of citation. The top 100 most-cited studies provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions to the literature on collegiate athletics.

Purpose The purpose of this study is to examine the effects of scribe use on physicians, nurses, and patients in an orthopaedic sports medicine clinic. Methods Surveys containing validated outcome measures relating to physician well‐being and workplace satisfaction, among other variables, were used to assess the influence of medical scribes on clinic function. These surveys were collected for 8 months from all patients, nurses, and orthopaedic surgeons working in one orthopaedic sports medicine clinic. Time during a half‐day clinic (i.e., 20 or more patients) was documented by surgeons after the last patient was seen. Results The average time spent per half day of clinic was 104 minutes on nonscribe days and 25 minutes on scribe days. Additionally, the time spent documenting encounters per half day of clinic was 87 minutes on average without scribes and 26 minutes on average with scribes. The average surgeon single assessment numeric evaluation (SANE) score was 48.1 without scribes, and 89.3 with scribes. The overall assessment of the clinic by nurses was 73.4 out of 100 on average without scribes and 87.7 out of 100 on average with scribes. Patients did not report a significant change in rating of overall experience (4.7/5.0 with scribes and 4.8/5.0 without scribes, ( P = .27) or wait time between scheduled appointment time and surgeon arrival (15.1 minutes with scribes and 18.1 minutes without scribes; P = .12). Conclusions We found the use of scribes in a high‐volume orthopaedic sports medicine clinic to have a favorable impact on physicians, nurses, and trainees. The use of a scribe also significantly reduced the time required by surgeons for documentation during clinic and at the end of each clinic day. Patients also reported no significant difference in patient clinic experience scores. Clinical Relevance Orthopaedic surgeons spend a substantial amount of time on paperwork. The results of this study could provide information on whether the use of a scribe helps to reduce administrative burden on orthopedic surgeons.