Tummala, Sailesh V.

Background: There is limited evidence related to the effects of autograft type on functional performance after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: This study aimed to compare biomechanical outcomes during a drop vertical jump (DVJ) between patients with a hamstring tendon (HT) autograft, quadriceps tendon (QT) autograft with bone block, QT autograft without bone block, and bone–patellar tendon–bone autograft at 6 months postoperatively in an adolescent population. The authors’ hypothesized there would be differences in DVJ biomechanics between athletes depending on the type of autograft used. Study Design: Controlled laboratory study. Methods: Patients aged 8 to 18 years who underwent primary ACLR were included for analysis. Kinematic and kinetic data collected during a DVJ using a 3-dimensional computerized marker system were assessed at 6 months after ACLR and compared with the uninjured contralateral limb. Results: A total of 155 participants were included. There were no significant differences in terms of age, sex, or affected leg ( P≥ .1973) between groups. The HT group was significantly associated with a larger knee valgus moment at initial contact compared with the QT group (28 × 10 –2 vs −35 × 10 –2 N·m/kg, respectively; P = .0254) and a significantly larger maximum hip adduction moment compared with the QT with bone block group (30 × 10 –2 vs −4 × 10 –2 N·m/kg, respectively; P = .0426). Both the QT with bone block (–12 × 10 –2 vs −3 × 10 –2 N·m/kg, respectively; P = .0265) and QT (–13 × 10 –2 vs −3 × 10 –2 N·m/kg, respectively; P = .0459) groups demonstrated significantly decreased mean knee extension moments compared with the HT group. Conclusion: The findings of this study suggest that utilizing an HT autograft resulted in a significantly increased knee valgus moment at initial contact compared with a QT autograft without bone block at 6 months after ACLR in adolescent patients performing a DVJ. A QT autograft was found to be associated with significantly decreased extensor mechanism function compared with an HT autograft. Clinical Relevance: This study adds unique kinematic and kinetic information regarding various ACLR autograft options and highlights the biomechanical deficits that should be taken into consideration in rehabilitation.

Purpose To evaluate how arthroscopic meniscectomy utilization, reimbursement, physician billing practices, and patient populations have changed within the Medicare population from 2013 to 2021 at a national level and regional level. Methods The Medicare Physician & Other Practitioners database was queried for all episodes of 2‐compartment and single‐compartment arthroscopic meniscectomy between 2013 and 2021. Utilization per 10,000 beneficiaries and average inflation‐adjusted reimbursement were assessed. Physician practice styles, measured through changes in the services billed, and Medicare beneficiary demographic characteristics were extracted each year. The Kruskal‐Wallis test was performed to compare regions. Results Between 2013 and 2021, two‐compartment meniscectomy utilization per 10,000 Medicare beneficiaries declined by 54.9% and single‐compartment meniscectomy utilization declined by 54.2%. Average reimbursement declined by 9.3% and 12.5% for 2‐compartment meniscectomy and single‐compartment meniscectomy, respectively. In 2021, the South had the highest utilization of both 2‐compartment (3.8/10,000) and single‐compartment (4.7/10,000) meniscectomies while having the lowest average reimbursement for 2‐compartment meniscectomy ($383.02, P < .001). Nationally, the average number of beneficiaries per surgeon performing single‐compartment meniscectomy declined by 3.8% whereas the average number of billable services performed per beneficiary increased by 46.6%. The comorbidity risk score of these patients decreased by 8.7%, with the West having the healthiest patients in 2021. Conclusions Meniscectomy utilization and reimbursement have been declining nationally within the Medicare population. Surgeons in the South performed the most meniscectomies while having among the lowest reimbursement. The practice patterns of surgeons performing meniscectomies have been changing, with surgeons performing nearly 50% more total billable services per beneficiary while performing fewer unique billable services. Additionally, the patient population of surgeons who perform meniscectomy was healthier in 2021 than in 2013. Clinical Relevance This study highlights changes in meniscectomy utilization and reimbursement over time in the face of changing evidence of meniscectomy use in elderly patients and new Medicare legislature regarding reimbursement.

Purpose To determine the incidence rates and associated risk factors of season‐ending injuries (SEIs) in the National Basketball Association (NBA) from the 2015‐20 seasons. Methods Publicly available records of active NBA players between the 2015‐16 and 2020‐21 seasons were reviewed to identify players with an SEI. In this study, SEI was classified as any injury that resulted in failure to return at least 5 games before the end of the team’s game schedule. Injury data from the 2019‐20 NBA season, shortened because of the coronavirus disease 2019 pandemic, were omitted. The primary outcome was the incidence of SEIs reported per 1,000 game exposures (GEs). Player demographics, basketball statistics, injury characteristics, and timing of injury were recorded. Secondary analysis, including bivariate analysis and multivariate logistic regression, was performed to investigate factors associated with having an SEI. Results In total, 196 players (15.6% of all players) sustained a combined 238 SEIs between the 2015‐16 and 2020‐21 seasons, indicating a rate of 1.74 SEIs per 1,000 GEs. When characterized by body part, knee injuries were found to be the most frequent SEI, at a rate of 0.47 injuries per 1,000 GEs. Accounting for potential confounders, having an SEI was significantly associated with more minutes per game played (odds ratio, 1.06, 95% confidence interval, 0.99‐1.01, P < .001). Conclusions SEIs occurred in 15.6% of players in this study, with an overall rate of 1.74 SEIs per 1,000 GEs. The most significant risk factor associated with injury was minutes per game. SEI was more likely to occur in the third and fourth quartiles of the NBA season than in the first or second quartile. Level of Evidence : Level III, retrospective comparative prognostic investigation.

Purpose To systematically review the existing literature on the functional performance of athletes at the time of return‐to‐sport (RTS) clearance after anterior cruciate ligament reconstruction (ACLR). Methods A systematic literature search of the MEDLINE, EMBASE, Scopus, and Web of Science databases was performed. The inclusion criteria were original research reports with study populations of athletes who had undergone ACLR and had undergone objective functional testing immediately after clearance to RTS. Functional testing was stratified by hop tests, strength tests, kinetic assessment, and kinematic assessment, and data were extracted from each study using a standardized template. Results Of the 937 unique studies identified, 46 met the inclusion criteria. The average time between ACLR and functional testing was 7.9 months among the included studies. In 10 of 17 studies, patients were found to have an average quadriceps strength limb symmetry index of less than 90%. However, only 2 of 12 studies found the average hop test limb symmetry index to be less than 90%. Kinematics included reduced knee flexion angle and increased trunk flexion on landing in ACLR patients compared with matched controls. On evaluation of kinetics, ACLR patients showed reduced peak vertical ground reaction force, lower peak knee extension and knee flexion moments, and altered energy absorption contribution compared with matched controls. Conclusions This systematic review suggests that athletes show functional deficits at the time of RTS at an average of 7.9 months after ACLR. Traditional functional tests, such as strength and hop tests, are not able to accurately identify patients who continue to show deficits. The most common biomechanical deficits that persist after RTS clearance include diminished peak knee extension moment, decreased knee flexion angle, increased trunk flexion angle, reduced vertical ground reaction force, and increased hamstring central activation ratio during various functional gait and landing tasks. Level of Evidence Level III, systematic review of Level I to III studies.

Purpose To systematically review the relationship between functional testing at the time of return to sport (RTS) and short‐term outcomes, such as second anterior cruciate ligament (ACL) tear and return to a preinjury level of sport, among athletes who underwent anterior cruciate ligament reconstruction (ACLR). Methods A systematic literature search was performed in MEDLINE, EMBASE, Scopus, and Web of Science to identify studies examining athletes who underwent functional RTS testing and were followed for at least 12 months following ACLR. Studies were screened by 2 reviewers. A standardized template was used to extract information regarding study characteristics, ACLR information, functional test results, and risk factors associated with retear or reduced RTS. Results Of the 937 studies identified, 22 met the inclusion criteria. The average time between ACLR and RTS testing was 8.5 months. Single leg hop for distance performance had no association with retear risk in any study and no association with RTS rates in most studies. Quadriceps strength had conflicting results in relation to retear risk, whereas it had no relationship with RTS rates. Rates of reinjury and RTS were similar between patients who passed and did not pass combined hop and strength batteries. Asymmetric knee extension and hip moments, along with increased knee valgus and knee flexion angles, demonstrated increased risk of retear. Conclusions Individual hop and strength tests that are often used in RTS protocols following ACLR may have limited and inconsistent value in predicting ACL reinjury and reduced RTS when used in isolation. Combined hop and strength test batteries also demonstrate low sensitivity and negative predictive value, highlighting conflicting evidence to suggest RTS testing algorithm superiority. Level of Evidence Level IV, systematic review of Level I‐IV studies.

Purpose To characterize the prevalence and incidence of in‐game hand and wrist injuries in the National Basketball Association (NBA), to determine the factors associated with an equal or greater player efficiency rating (PER), and to determine the factors associated with an equal or greater true shooting percentage (TS%) 2 years after a hand and wrist injury using a large‐scale national database of NBA players. Methods Injury data from seasons 2015‐2016 to 2020‐2021, with exclusion of the 2019‐2020 because of abbreviated play due to the coronavirus disease 2019, were extracted from a public online database, Pro Sports Transactions. Injury characteristics and NBA player demographic information were assessed using descriptive statistics. Poisson logistic regression analyses were performed to identify risk factors associated with equal or increased PER and TS% 2years after injury. Results There were 214 reported hand and wrist injuries, and of these injuries, 173 (81%) were classified as structural. The most common injury types were a strain or sprain (0.63 per 1,000 game exposures), followed by fractures (0.37 per 1,000 game exposures). Older age (relative risk [RR] 0.89; 95% confidence interval [CI] 0.84‐0.95) and more years played in the NBA were modestly associated with relative risk of having a decreased PER at 2 years after injury. Increased weight (RR 1.02; 95% CI 1‐1.05) and increased body mass index (RR 1.14; 95% CI 1.01‐1.29) were also modestly associated with having a decreased PER and TS%, respectively at 2 years after injury. Conclusions Strains/sprains and fractures are the most common hand and wrist injuries sustained by NBA players. Regardless of dominant or nondominant hand and wrist injuries, NBA players are likely to return to baseline overall player efficiency based on PER and TS% within 2 years of injury. Clinical Relevance Our study characterizes hand and wrist injuries of NBA players and provides an understanding for these injuries on player performance at 2 years.

Case: We present a case report of a 64-year-old man who developed a rare Bipolaris species fungal periprosthetic joint infection (PJI) after revision arthroplasty for complications associated with a metal-on-metal total hip arthroplasty. The patient underwent a 2-stage debridement with antibiotic bead placement and implant retention, along with chronic antifungal suppression. At the 2-year follow-up, the patient remained asymptomatic. Conclusion: Fungal PJI with filamentous fungi such as Bipolaris species is a rare clinical entity. This case report highlights the clinical presentation and management of this rare condition.

Background: Shoulder and elbow function is essential to basic basketball actions. Outside of anterior shoulder instability, injuries in these joints are not well characterized in National Basketball Association (NBA) players. Purpose: To describe the epidemiology and associated risk factors of shoulder and elbow injuries in NBA players and identify factors that influence player performance upon return to play. Study Design: Descriptive epidemiology study. Methods: Historical injury data from the 2015-2020 NBA seasons were retrieved from Pro Sports Transactions, a public online database. An injury was defined as a health-related concern resulting in an absence of ≥1 NBA games. Primary measures included pre- and postinjury player efficiency rating (PER) and true shooting percentage (TS%) with interquartile ranges (IQRs), stratified by extremity dominance. Multivariate logistic regression analyses with stepwise regression were performed to identify risk factors associated with return-to-play performance. Results: A total of 192 shoulder and elbow injuries were sustained among 126 NBA athletes, with incidence rates of 1.11 per 1000 game exposures (GEs) and 0.30 per 1000 GEs, respectively. Sprain/strain and general soreness were the most common injury types in both the shoulder and the elbow. In the 2 years after injury, baseline PER was achieved in all groups, except for players with dominant shoulder injuries (baseline PER, 16 [IQR, 14-18] vs 2-year PER, 13 [IQR 11-16]; P = .012). Younger age was associated with quicker return to baseline PER (odds ratio, 0.77 [95% CI, 0.67-0.88]). Shoulder and elbow injuries did not negatively influence TS% upon return to play (baseline TS%, 0.55% [IQR, 0.51%-0.58%] vs 1-year TS%, 0.55% [IQR, 0.52%-0.58%]; P = .13). Conclusion: Dominant shoulder injuries negatively influenced PER during the first 2 seasons upon return to play in NBA players. Therefore, expectations that players with this type of injury immediately achieve baseline statistical production should be tempered. Shooting accuracy appears to remain unaffected after shoulder or elbow injury.

Background: The optimal graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in the high-level cutting and pivoting athlete remains controversial. Studies have shown similar outcomes when directly comparing bone-patellar tendon-bone (BPTB) autograft versus quadriceps soft tissue (QST) autograft in the general population. However, no studies have directly compared these 2 grafts in athletes participating in cutting and pivoting sports. Hypothesis: It was hypothesized that, compared with BPTB autograft, the QST autograft would result in similar patient-reported outcomes and rates of retear, return to sport, and complications. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on athletes participating in cutting and pivoting sports (soccer, American football, lacrosse, and basketball) who underwent primary ACLR with either BPTB autograft or QST autograft chosen by the athlete between January 2015 and January 2019. The International Knee Documentation Committee (IKDC) subjective knee evaluation and Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. Return-to-sport and complication rates were identified. Descriptive statistics were expressed using Mann-Whitney test or Student t test for continuous variables and the chi-square test for categorical variables. Results: A total of 68 athletes (32 QST, 36 BPTB) were included for analysis. The percentage follow-up was 89% (32/36) for the QST autograft group and 86% (36/42) for the BPTB autograft group. The 2-year IKDC score (QST, 90.5 ± 6.6 vs BPTB, 89.7 ± 7.8) and 2-year Lysholm score (QST, 91.3 ± 7.5 vs BPTB, 90.5 ± 8.6) were similar between groups. The percentage of athletes able to return to sport within the follow-up period was also similar (88% vs 83%; P = .63). There were 2 retears requiring revision in the BPTB group (6%) and no retears in the QST group ( P = .18). One contralateral ACL rupture occurred in the QST group (3%) and 4 in the BPTB group (11%) ( P = .21). Conclusion: The QST and BPTB autografts demonstrated similar patient-reported outcomes, return-to-sport rates, and complication rates after primary ACLR at 2-year follow-up. Both autografts appear to be reliable and consistent options for ACLR in the cutting and pivoting athlete.

Background: Meniscal root repair can improve patient outcomes significantly; however, several contraindications exist, including arthritic change to the medial or lateral tibiofemoral compartments. Purpose/Hypothesis: The purpose of this study was to evaluate the outcomes of meniscal root repair in patients with advanced patellofemoral chondromalacia (PFC). It was hypothesized that the presence of advanced PFC would not significantly affect the postoperative outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was conducted of patients who underwent meniscal root repair with at least 2 years of follow-up data. Patients with chondromalacia as determined by arthroscopic visualization (defined as Outerbridge grade 3 or 4) were placed in the PFC group; patients with Outerbridge grade 0 to 2 chondromalacia were placed in the non-PFC group. Outcomes were measured by the Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) Subjective Knee Form. Clinical outcomes including complications were also recorded. Quantitative data between the groups were analyzed using the 2-tailed independent-samples t test. Results: Overall, this study included 81 patients (35 in the PFC group, 46 in the non-PFC group). The mean follow-up times were 25.1 months in the PFC group and 24.8 months in the non-PFC group. In both groups, Lysholm and IKDC scores improved significantly with 24-month Lysholm scores averaging 85.86 in the PFC group and 86.61 in the non-PFC group ( P = .62) and 24-month IKDC scores averaging 77.66 for the PFC group and 79.59 for the non-PFC group ( P = .45). The cohorts demonstrated similar rates of retear, arthrofibrosis, infection, and progression to total knee arthroplasty. Conclusion: The presence of advanced PFC was not associated with inferior outcomes in patients who underwent posterior meniscal root repair, and rates of recurrent tears, postoperative infection, arthrofibrosis, and conversion to total knee arthroplasty were similar between the study groups. These findings suggest that PFC may not significantly alter the results of meniscal root repair and should not be considered an absolute contraindication for this procedure.