Tokish, John M.

Background: Functional bracing is often used as an adjunct to nonoperative treatment of anterior shoulder instability, but no study has evaluated the effectiveness of in-season bracing. The purpose of this study was to examine successful return to play in a nonoperative cohort of adolescent athletes with in-season shoulder instability and compare those athletes treated with bracing to those who were not. Hypothesis: The use of functional bracing will improve success rates in a cohort of athletes treated nonoperatively for in-season shoulder instability. Study Design: Cohort study. Level of Evidence: Level 3. Methods: A total of 97 athletes with anterior shoulder instability were followed for a minimum of 1 year. The mean age was 15.8 ± 1.4 years (range, 12.0-18.0 years). All athletes were treated with initial nonoperative management. Twenty athletes (21%) were also treated with bracing while 77 (79%) were not. The athlete completing the current season and 1 subsequent season without surgery or time lost from shoulder injury was defined as a successful outcome. Results: There was no statistical difference in nonoperative success rates between the braced and nonbraced athletes ( P = 0.33). Braced athletes (n = 20) returned to play 80% of the time, while nonbraced athletes (n = 77) returned at a rate of 88%. Of the braced athletes, 85% were football players (n = 17). A football-only comparison demonstrated no difference between braced failures (26%) and nonbraced failures (16%) ( P = 0.47). Conclusion: This is the first study to evaluate the utility of functional bracing in returning an athlete to sport and completing a full subsequent season without surgery or time loss due to injury of the shoulder. In adolescent athletes with shoulder instability treated nonoperatively, functional bracing did not result in increased success rates when compared with no bracing. Clinical Relevance: The data from this study indicate that functional bracing may not improve success rates for athletes with shoulder instability.

Objectives: Anterior cruciate ligament reconstruction (ACLR) remains one of the most readiness-impairing surgical conditions treated in the US Military. Greater time from the index injury to surgical management (ACLR) unnecessarily prolongs the total time of limited duty. Additionally, prolonged wait times from the index injury to ACLR may increase the patient’s likelihood of sustaining concomitant or secondary intraarticular pathologies (e.g., cartilage and meniscus damage). The optimal timing for surgical reconstruction following ACL injury is debated. The purpose of this study was to determine the impact of prolonged time from injury to surgery on medical separation within five years of primary ACLR. We hypothesized that longer durations from injury to primary ACLR would be associated with greater medical separation risk within five years following surgery. Methods: We conducted a retrospective database review using data from the Military Health System Data Repository (MDR) of primary ACLR without and with concomitant procedures (meniscus [M] and/or cartilage [C]) performed within Military Treatment Facilities (MTF) from fiscal year 2009 to and/or cartilage [C]) performed within Military Treatment Facilities (MTF) from fiscal year 2009 to 2011. At the time of the ACLR, ADSMs had to be continuously enrolled for two years prior to the surgery with no history of knee surgeries in direct care (i.e., MTFs) or purchased care to ensure a higher likelihood of the index event being a primary ACLR and not an ACLR revision. A total 2,809 active duty service members were included with primary ACLR. The MDR was queried for baseline demographic, military service, and surgical information at the time of ACLR. Duty status at the time of the ACLR and cause of separation up to five years after primary ACLR were abstracted. The time from the index injury diagnosis to the primary ACLR was calculated and grouped as follows: Acute = 0-42 days, Subacute = 43-91 days, Delayed = 92-179 days, Chronic ≥ 180 days. Kaplan-Meier survivability curves were estimated and evaluated with Log-rank. Cox Proportional Hazard Models calculated Hazard Ratios (HR) with 95% confidence intervals (95% CI) to identify time from injury to surgery, demographic, and military status factors that influenced medical separation risk for patients with primary ACLR (ACLR, ACLR+M, ACLR+C, ACLR+M+C). Results: The index surgical events were categorized by isolated ACLR (48%), ACLR+M (42%), ACLR+C (5%), and ACLR+M+C (4%). Overall, the time from diagnosis to ACLR was approximately equivalent across all time categories: Acute (19%), Subacute (31%), Delayed (23%), and Chronic (25%). The probability of medical separation 5 years following primary ACLR (ACLR, ACLR+M, ACLR+C, ACLR+M+C) was highest for the delayed [92-179 days] group (17%) and lowest for the acute [0-42 days] group (12%). Patients in the delayed group were over 51% more likely to medically separate in the 5 years following the primary ACLR than those who were treated within 42 days from injury (acute group). The difference between the acute group and subacute or chronic was not statistically significant. Those in infantry and combat support related military occupation classifications were 27% more likely to medically separate. Service members in the Army were more than 4.5 times more likely to medically separate compared to those in the Air Force. Smoking and BMI over 29 also increased the risk of medical separation within 5 years by 42% and 91%, respectively. The type of injury at the index event (ACLR, ACLR+M, ACLR+C, ACLR+M+C) did not significantly influence the likelihood of medical separation risk. Conclusion: Delay in treatment from injury to primary ACLR increases the number of limited duty days, effects medical readiness of ADSM, and military retention rates post ACLR. Specifically, when primary ACLR is delayed 3 to 6 months from injury, ADSM have a 51% increased likelihood of military medical separation risk in the 5 years following the ACLR than if they would have been treated within 41 days of injury. Early recognition of ACL tears as well as availability of surgeons and Operative Rooms (ORs) should be evaluated to determine their contribution to the delay in ACLR in the MHS.

Abstract Resilience is a psychological factor that has been shown to affect outcomes after stressful events. Recent work has detected a correlation between patient resilience and surgical outcome. Issues of postoperative pain response, patient‐reported outcomes, and ultimate outcomes may all be affected by resilience, and thus research into these relationships and how to optimize psychologic fitness as part of a perioperative plan are of interest.

Background The purpose was to evaluate the relationship of component size and position to postoperative range of motion following reverse shoulder arthroplasty. The hypothesis was that increased lateralization, larger glenospheres, and a decreased acromiohumeral distance would be associated with excellent postoperative range of motion. Methods A retrospective multicenter study was performed at a minimum of one year postoperatively on 160 patients who underwent primary reverse shoulder arthroplasty with a 135° humeral component. Outcomes were stratified based on postoperative forward flexion and external rotation into excellent ( n = 42), defined as forward flexion >140° and external rotation > 30°, or poor ( n = 36), defined as forward flexion <100° and external rotation < 15°. Radiographic measurements and component features were compared between the two groups. Results A larger glenosphere size was associated with an excellent outcome ( p = 0.009). A 2-mm posterior offset humeral cup ( p = 0.012) and an increased inferior glenosphere overhang (3.1 mm vs 1.4 mm; p = 0.002) were also associated with excellent outcomes. Humeral lateralization and distalization were not associated with an excellent outcome. Conclusion: Larger glenosphere size and inferior positioning as well as posterior humeral offset are associated with improved postoperative range of motion following reverse shoulder arthroplasty. Level of Evidence Level 3, retrospective comparative study.

Background: Ultrasound-guided fascia iliaca blocks have been used for pain control after hip arthroscopy. There is little evidence regarding their effectiveness in comparison with other pain control modalities in patients who have undergone hip arthroscopy. Purpose: To compare the efficacy of ultrasound-guided fascia iliac block with intra-articular ropivacaine in controlling pain after hip arthroscopy. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Between 2015 and 2017, patients (N = 95) undergoing hip arthroscopy were randomly assigned to 2 groups. The first group received an ultrasound-guided fascia iliaca block with 50 to 60 mL of 0.35% ropivacaine. The second group received an intra-articular injection of 20 mL of 0.5% ropivacaine at the completion of the surgical case. Primary outcomes were postoperative pain scores in the recovery room; at postanesthesia care unit (PACU) discharge; and at 2 weeks, 6 weeks, and 3 months. Secondary outcomes included intraoperative and PACU narcotic usage (converted to morphine equivalent use) as well as readmission rates, PACU recovery time, and postoperative nausea and vomiting. Results: Postoperative pain across all points did not significantly differ between the groups. Intraoperative and PACU narcotics did not differ significantly between the groups. Readmission rates, PACU recovery time, and postoperative nausea and vomiting did not significantly differ between the groups. There were no associated complications in either group. Conclusion: Ultrasound-guided fascia iliaca block for hip arthroscopy had no clinical advantage when compared with onetime intra-articular ropivacaine injection. Registration: NCT02365961 (ClinicalTrials.gov identifier).

Abstract Glenoid bone loss remains a significant risk factor for recurrent instability after shoulder dislocation. Several options exist for glenoid bone graft augmentation, including autograft and allograft options. Strengths and weaknesses exist for each. Graft fixation with screws remains a key concern for technical viability requiring a medial portal as well as the risk of graft osteolysis. Suture button suspensory fixation is a new technique recently described for arthroscopic iliac crest bone graft; however, no description exists concerning osteochondral graft fixation. We describe an arthroscopic technique for distal tibial allograft glenoid augmentation with suspensory suture button fixation. The rationale and technical aspects of this procedure are discussed. Technique Video video See video under supplementary data.

Purpose To investigate the biomechanical effects of superior capsule reconstruction with subacromial allograft spacer on superior humeral head translation and subacromial contact pressure. Methods Eight cadaveric shoulder specimens were tested in 4 conditions: (1) intact rotator cuff, (2) supraspinatus tear and superior capsule excision, (3) superior capsule reconstruction with human dermal allograft, and (4) superior capsule reconstruction with subacromial resurfacing using human dermal allograft. In each condition, specimens were tested at 0, 30, 60, and 90° of shoulder abduction in balanced and unbalanced loaded states for subacromial contact pressure and superior humeral head translation. Statistical comparisons were made using a repeated‐measures analysis of variance test, followed by a Tukey post hoc test for pairwise comparisons. A P value <.05 was set as statistically significant. Results Superior humeral head translation and subacromial contact pressure were increased after irreparable rotator cuff tear ( P = .001). There was no significant difference between superior capsule reconstruction and intact cuff in regard to superior humeral head translation and subacromial contact pressure at all abduction angles. Superior capsule reconstruction with subacromial resurfacing decreased superior humeral head translation relative to intact (0°, P = .004; 30°, P = .02; 60°, P = .08; 90°, P = .01), superior capsule reconstruction (0°, P = .001; 30°, P = .003; 60°, P = .019; 90°, P = .001), and cuff‐deficient states ( P = .001). Superior capsule reconstruction with subacromial resurfacing resulted in nonsignificant increases in subacromial contact pressure relative to intact cuff at 0 to 90° abduction angles. Conclusions Superior capsule reconstruction with subacromial resurfacing using human dermal allograft results in decreased superior humeral head translation relative to superior capsule reconstruction with human dermal allograft only, while increasing subacromial contact pressure. Clinical Relevance Superior capsule reconstruction with subacromial resurfacing using human dermal allograft reduces superior humeral head translation while increasing subacromial contact pressure in a cadaveric model.

ContextSport specialization is thought to be a primary contributor to the throwing-related injury risk in youth baseball players.ObjectiveTo (1) establish arm-injury incidence in a cohort of male youth (9–12 years old) baseball players and (2) examine sport specialization and the frequency of arm injuries in the same cohort.DesignCohort study.SettingGreenville, South Carolina, youth baseball programs and tournaments.Patients or Other ParticipantsA total of 159 asymptomatic youth baseball players (age = 11.1 ± 1.1 years) were physically assessed and then were prospectively followed for 6.7 ± 1.5 months.Main Outcome Measure(s)Athlete demographics and playing and injury histories were initially recorded. Athlete-exposures and presence of arm injury were prospectively tracked. All injuries were physically confirmed by a licensed physical therapist.ResultsYouth players demonstrated an arm-injury incidence rate of 2.22 per 1000 athlete-exposures. Parents and players underestimated sport-specialization status based on the standard research definition (self versus research based: 31% versus 83%, respectively; P = .001). The frequency of arm injuries was higher in specialized players (100%) than in nonspecialized players (80%, P = .03) but did not differ between pitchers and position players (13.2% each, P = 1.00).ConclusionsSport specialization was associated with throwing-related arm injuries in a small cohort of youth baseball players. It is concerning that 57.9% of parents and specialized players were unaware of the athletes' status. Larger studies with longer follow-up periods are needed to further evaluate injury-risk profiles in physically developing youth populations.

Purpose To report the return‐to‐duty rate and surgical outcomes in a military population after mini‐open arthroscopic‐assisted surgery for femoroacetabular impingement (FAI) in an effort to affirm its efficacy. Methods A retrospective review of consecutive active‐duty patients receiving mini‐open arthroscopic‐assisted surgery for FAI between 2007 and 2011 was performed. Patients younger than 18 years, non–active‐duty patients, and patients with prior hip surgery were excluded. Demographic, radiographic, and duty‐status data were collected. The primary outcome measure was a return to duty. Outcome scores were obtained in a proportion of the cohort, including the modified Harris Hip Score, Single Assessment Numeric Evaluation score, Western Ontario and McMaster Universities Osteoarthritis Index score, patient satisfaction score, and Veterans RAND 12 (VR‐12) score. All patients had achieved a minimum of 1 year of follow‐up at the time of assessment. All P values for significance were set at .05 or lower. Results Of 182 patients (average age, 30.4 years), 156 (86%) were available for follow‐up with return‐to‐duty data at an average of 2.8 years (range, 1‐6 years). Of the patients, 78% returned to full duty (53%) or returned to duty with restrictions (25%). Outcome scores were available for 101 of 182 patients (55%) with duty rates similar to the total cohort (81% who returned to duty: 58% with no restrictions and 23% with restrictions). Return to duty correlated with improved outcomes compared with those who were medically discharged with respect to the modified Harris Hip Score (68.2 vs 54.5, P < .03), Single Assessment Numeric Evaluation score (48.2 vs 25.3, P < .02), and VR‐12 physical (39.7 vs 33.2, P < .05) and VR‐12 mental (54.5 vs 43.4, P < .005) scores. Conclusions Mini‐open arthroscopic‐assisted surgery for FAI is successful in returning most service members to duty at short‐term follow‐up. Return correlates with improved outcome scores, although previously reported minimally clinical important difference and patient acceptable symptomatic state threshold values were not uniformly achieved. Level of Evidence Level IV, retrospective case series.

Resilience, the capacity to recover from a setback or adversity, is a concept that has received considerable recent attention. An individual’s resilience predicts their life trajectory following stressful events and this has increasingly been shown in a wide variety of applications. Our understanding of the degree to which we can modify our resilience, and the optimal means to do so, remains in its infancy. The US military has embraced extensive efforts to quantify and build resilience in service members in an effort to preserve the fighting force. We specifically look at the understanding of resilience as it relates to the athletes in terms of competition and return from injury. This article explores the concept of resilience, the efforts to build resilience, lessons learned from the military and applications of the resilience concept to surgical and trauma patients.