Rehabilitation and Return to Play Protocols After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review.

BACKGROUND: Rehabilitation after anterior cruciate ligament ACL reconstruction (ACLR) is crucial for safe return to play (RTP) and reducing the chances of a reinjury. Yet, there is no consensus on the ideal functional tests to assess rehabilitation progress in soccer players after ACLR. PURPOSE: The primary objective was to highlight the existing gap in the literature concerning the most effective standardized rehabilitation protocols and testing for facilitating successful RTP among soccer players. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review using PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. Inclusion criteria encompassed original studies (level of evidence 1-4) that examined rehabilitation protocols, metrics of knee rehabilitation, and clinical outcomes after ACLR in soccer players. RESULTS: This review incorporated 23 studies, predominantly retrospective case series, with a total number of 874 soccer players who underwent ACLR and rehabiliation. 5 (21.7%) studies utilized an accelerated rehabilitation protocol, while 7 (30.4%) of studies utilized a criterion-based rehabilitation. A wide heterogeneity of data was extracted including functional tests of rehabilitation and RTP such as strength test batteries, hop test batteries, and movement quality assessments. Of the 23 selected studies, 2 (8.7%) used all 3 test batteries, 8 (34.8%) used 2 test batteries, 12 (52.2%) used 1 test battery, and 1 (4.3%) used 0 of the test batteries. The mean time between surgery and RTP ranged from 3 to 8 months with only 2 (8.7%) studies reporting complications after ACLR. Lastly, out of the total studies examined, 9 (39.1%) assessed patient-reported outcome measures (PROMs), all of which demonstrated significant improvement from the initial assessment to the final follow up. CONCLUSION: Soccer-specific rehabilitation after ACLR lacks standardization. Even though many studies have assessed protocols for optimal RTP and reduced secondary ACL injuries, there is a gap in the literature regarding the most effective protocols and RTP testing. The methodology reported by Kyritsis et al could serve as a foundation for future prospective randomized multicenter studies to establish a standard rehabilitation protocol and enable a successful return to soccer.

Bone bruise vs. non-displaced fracture on MRI: a novel grading system for predicting return-to-play.

OBJECTIVE: To devise an MRI grading scheme for osseous contusion patterns in elite hockey players for predicting return-to-play (RTP). METHODS: A retrospective review was performed to identify traumatic lower extremity osseous injuries in professional hockey players. A total of 28 injuries (17 players) were identified over a 10-year period. All had MRIs acquired at ≥ 1.5 T within a mean interval of 2 days from initial injury. MRIs were retrospectively reviewed by 3 musculoskeletal radiologists for osseous contusion pattern, classified as grade 1 (mild), 2 (moderate), or 3 (severe). Grade 3 contusions were further subdivided by the presence or absence of fracture, defined as discrete cortical disruption on MRI or follow-up CT. RTP was calculated from date of injury to next game played based on game log data. Statistical analysis was performed using ANOVA and post hoc unpaired t test. RESULTS: Mean RTP for grade 1, 2, and 3 injuries was 2.8, 4.5, and 20.3 days, respectively. Grade 3 injuries without and with cortical fractures had mean RTP of 18.3 and 21.4 days, respectively. ANOVA analysis between groups achieved statistical significance (p < 0.001). Post hoc t test demonstrated statistically significant differences between grade 3 and grades 1 (p < 0.001) and 2 (p < 0.001) injuries. There was no statistical difference in RTP between grade 3 subgroups without and with fracture (p = 0.327). CONCLUSION: We propose a novel MRI grading system for assessing severity of osseous contusions and predicting RTP. Clinically, there was no statistically significant difference in RTP between severe osseous contusions and nondisplaced fractures in elite hockey players.

Orthopedists Report High Prevalence of Work-Related Pain and Low Ergonomic Awareness.

The purpose of this study was to determine the prevalence of work-related pain among practicing orthopedic surgeons, quantify knowledge of operating room (OR) and clinic ergonomics, and examine the use of occupational health resources. A survey was distributed, which included orthopedic surgeons from four states and five institutions. Data collected included years in practice, practice setting, orthopedic subspecialty, hours operating per week, days per week exercising, location and significance of pain, occupational health awareness, and use of OR/clinic ergonomics. One hundred ten of 194 surveys (56.7%) were completed, representing all orthopedic subspecialties. Eighty-three surgeons (75.5%) experienced pain because of occupational responsibilities. The lumbar spine, neck, and shoulders were the most affected areas. Seventeen (20.5%) identified this pain as significant. Ten (12.0%) stated that the pain did subjectively affect their OR performance. Hand surgeons had a statistically significant decreased risk of musculoskeletal pain (P=.007), whereas spine surgeons had a statistically significant increased risk of musculoskeletal pain (P=.028). Forty-nine (44.5%) were not aware of any institutional resources available if an injury was sustained at work. Forty-eight (43.6%) were aware of OR ergonomics, with 34 (30.9%) taking steps to make their OR more ergonomic. The vast majority of orthopedic surgeons experience pain as a result of occupational responsibilities. A clear lack of knowledge regarding institutional resources as well as OR ergonomics implementation was identified. Education in training, at the institutional and national levels, would expand surgeon knowledge and promote surgeon health. [Orthopedics. 2023;46(5):280-284.].

A Scoping Review of Injuries in Amateur and Professional Men's Ice Hockey.

Background: Orthopaedic injuries are common in ice hockey at all levels and can result in physical and psychological adverse effects on these athletes. Purpose: Primarily, to summarize published data on orthopaedic hockey injuries at the junior through professional level. Secondarily, to characterize the literature based on anatomic site injured, return-to-play rates, cause/mechanism of injury, time lost, and treatments used. Study Design: Scoping review; Level of evidence, 4. Methods: PubMed, EMBASE, Cochrane library, and SCOPUS were searched using the terms "hockey" and "injuries" using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and 4163 studies involving orthopaedic injuries were identified. Our inclusion criteria consisted of accessible full-text articles that evaluated orthopaedic injuries in men's ice hockey athletes of all levels. We excluded case reports and articles evaluating women's ice hockey injuries, as well as those evaluating nonorthopaedic injuries, such as concussions; traumatic brain injuries; and facial, dental, and vascular injuries, among others. Studies were divided based on level of play and anatomic site of injury. Level of evidence, year published, country of corresponding author, method of data collection, incidence of injury per athlete-exposure, and time lost were extracted from each article. Results: A total of 92 articles met the inclusion criteria and were performed between 1975 and 2020, with the majority published between 2015 and 2020. These were divided into 8 anatomic sites: nonanatomic-specific (37%), intra-articular hip (20.7%), shoulder (9.8%), knee (8.7%), trunk/pelvis (7.6%), spine (7.6%), foot/ankle (6.5%), and hand/wrist (2.2%). Of these studies, 71% were level 4 evidence. Data were obtained mostly via surveillance programs and searches of publicly available information (eg, injury reports, player profiles, and press releases). Conclusion: This scoping review provides men's hockey players and physicians taking care of elite ice hockey athletes of all levels with a single source of the most current literature regarding orthopaedic injuries. Most research focused on nonanatomic-specific injuries, intra-articular hip injuries, knee injuries, and shoulder injuries, with the majority having level 4 evidence.

Editorial Commentary: Put Me Back Into The Game Coach! It's Time, I'm Ready: Time Is of No Essence After An Anterior Cruciate Ligament Reconstruction.

Retear after an anterior cruciate ligament reconstruction is unavoidable. Many variables contribute to graft failure after anterior cruciate ligament reconstruction. Time from surgery to return to play is not the sole determinant. Graft maturation and symmetrical return of function need to be more carefully evaluated to reduce the risk of reinjury.

Management of Elbow Dislocations in the National Football League.

BACKGROUND: Although much literature exists regarding the treatment and management of elbow dislocations in the general population, little information is available regarding management in the athletic population. Furthermore, no literature is available regarding the postinjury treatment and timing of return to play in the contact or professional athlete. PURPOSE: To review the clinical course of elbow dislocations in professional football players and determine the timing of return to full participation. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All National Football League (NFL) athletes with elbow dislocations from 2000 through 2011 who returned to play during the season were identified from the NFL Injury Surveillance System (NFL ISS). Roster position, player activity, use of external bracing, and clinical course were reviewed. Mean number of days lost until full return to play was determined for players with elbow dislocations who returned in the same season. RESULTS: From 2000 to 2011, a total of 62 elbow dislocations out of 35,324 injuries were recorded (0.17%); 40 (64.5%) dislocations occurred in defensive players, 12 (19.4%) were in offensive players; and 10 (16.1%) were during special teams play. Over half of the injuries (33/62, 53.2%) were sustained while tackling, and 4 (6.5%) patients required surgery. A total of 47 (75.8%) players who sustained this injury were able to return in the same season. For this group, the mean number of days lost in players treated conservatively (45/47) was 25.1 days (median, 23.0 days; range, 0.0-118 days), while that for players treated operatively (2/47) was 46.5 days (median, 46.5 days; range, 29-64 days). Mean return to play based on player position was 25.8 days for defensive players (n = 28; median, 21.5 days; range, 3.0-118 days), 24.1 days for offensive players (n = 11; median, 19 days; range, 2.0-59 days), and 25.6 days for special teams players (n = 8; median, 25.5 days; range, 0-44 days). CONCLUSION: Elbow dislocations comprise less than a half of a percent of all injuries sustained in the NFL. Most injuries occur during the act of tackling, with the majority of injured athletes playing a defensive position. Players treated nonoperatively missed a mean of 25.1 days, whereas those managed operatively missed a mean of 46.5 days.

Osteochondral Autograft Transplantation for Proximal Lunate Articular Defects.

BACKGROUND: No consensus treatment option for focal osteochondral defects of the proximal lunate exist in the literature. Surgical management has thus far been limited to salvage procedures such as proximal row carpectomy and partial arthrodesis. CASE DESCRIPTION: We report our experience using the osteochondral autograft transplantation surgery (OATS) procedure in two young, active patients with focal osteochondral defects of the proximal lunate. At mean follow-up of 6 years, sustained improvements in pain, motion, and function were observed. Both patients reported high levels of satisfaction and neither experienced any complications. LITERATURE REVIEW: To our knowledge, this is the first report describing the use of OATS to treat proximal lunate defects. CLINICAL RELEVANCE: OATS is a valuable surgical option for treating focal chondral defects of the proximal lunate, with positive outcomes at greater than 5 years postoperatively. This may be an especially useful technique for younger, active patients, and those wishing to maintain maximum functionality.

Venous Thromboembolism Within Professional American Sport Leagues.

BACKGROUND: Numerous reports have described players in professional American sports leagues who have been sidelined with a deep vein thrombosis (DVT) or a pulmonary embolism (PE), but little is known about the clinical implications of these events in professional athletes. PURPOSE: To conduct a retrospective review of injury reports from the National Hockey League (NHL), Major League Baseball (MLB), the National Basketball Association (NBA), and the National Football League (NFL) to take a closer look at the incidence of DVT/PE, current treatment approaches, and estimated time to return to play in professional athletes. STUDY DESIGN: Descriptive epidemiology study. METHODS: An online search of all team injury and media reports of DVT/PE in NHL, MLB, NBA, and NFL players available for public record was conducted by use of Google, PubMed, and SPORTDiscus. Searches were conducted using the professional team name combined with blood clot, pulmonary embolism, and deep vein thrombosis. RESULTS: A total of 55 venous thromboembolism (VTE) events were identified from 1999 through 2016 (NHL, n = 22; MLB, n = 16; NFL, n = 12; NBA, n = 5). Nineteen athletes were reported to have an upper extremity DVT, 15 had a lower extremity DVT, 15 had a PE, and 6 had DVT with PE. Six athletes sustained more than 1 VTE. The mean age at time of VTE was 29.3 years (range, 19-42 years). Mean (±SD) time lost from play was 6.7 ± 4.9 months (range, 3 days to career end). Seven athletes did not return to play. Players with upper extremity DVT had a faster return to play (mean ± SD, 4.3 ± 2.7 months) than those with lower extremity DVT (5.9 ± 3.8 months), PE (10.8 ± 6.8 months), or DVT with PE (8.2 ± 2.6 months) (F = 5.69, P = .002). No significant difference was found regarding time of return to play between sports. CONCLUSION: VTE in professional athletes led to an average of 6.7 months lost from play. The majority of athletes were able to return to play after a period of anticoagulation or surgery. Those with an upper extremity DVT returned to play faster than those with other types of VTE. Further study is needed to look into modifiable risk factors for these events and to establish treatment and return-to-play guidelines to ensure the safety of these athletes.

Anterior Cruciate Ligament Injuries in National Football League Athletes From 2010 to 2013: A Descriptive Epidemiology Study.

BACKGROUND: There is a high incidence of anterior cruciate ligament (ACL) injuries among National Football League (NFL) athletes; however, the incidence of reinjury in this population is unknown. PURPOSE: This retrospective epidemiological study analyzed all publicly disclosed ACL tears occurring in NFL players between 2010 and 2013 to characterize injury trends and determine the incidence of reinjury. STUDY DESIGN: Descriptive epidemiological study. METHODS: A comprehensive online search identified any NFL player who had suffered an ACL injury from 2010 to 2013. Position, playing surface, activity, and date were recorded. Each player was researched for any history of previous ACL injury. The NFL games database from USA Today was used to determine the incidence of ACL injuries on artificial turf and grass fields. Databases from Pro Football Focus and Pro Football Reference were used to determine the injury rate for each position. RESULTS: NFL players suffered 219 ACL injuries between 2010 and 2013. Forty players (18.3%) had a history of previous ACL injury, with 27 (12.3%) retears and 16 (7.3%) tears contralateral to a previous ACL injury. Five players (2.28%) suffered their third ACL tear. Receivers (wide receivers and tight ends) and backs (linebackers, fullbacks, and halfbacks) had significantly greater injury risk than the rest of the NFL players, while perimeter linemen (defensive ends and offensive tackles) had significantly lower injury risk than the rest of the players. Interior linemen (offensive guards, centers, and defensive tackles) had significantly greater injury risk compared with perimeter linemen. ACL injury rates per team games played were 0.050 for grass and 0.053 for turf fields (P > .05). CONCLUSION: In this retrospective epidemiological study of ACL tears in NFL players, retears and ACL tears contralateral to a previously torn ACL constituted a substantial portion (18.3%) of total ACL injuries. The significant majority of ACL injuries in players with a history of previous ACL injury were retears. Skilled offensive players and linebackers had the greatest injury risk, and significantly more ACL tears occurred among interior linemen than perimeter linemen. The month of August had the highest incidence of ACL injuries, probably because of expanded roster sizes at that point in the NFL season.

A Genetic Test Predicts Providence Brace Success for Adolescent Idiopathic Scoliosis When Failure Is Defined as Progression to >45 Degrees.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To determine whether a genetic test is associated with successful Providence bracing for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Genetic factors have been defined that predict the risk of progression of AIS in a polygenic fashion. From these data, a commercially available genetic test, ScoliScore, was developed. It is now used in clinical practice for counseling and to guide clinical management. Bracing is a mainstay of treatment for AIS. Large efforts have been made recently to reduce potential confounding across studies of different braces; however, none of these have considered genetics as a potential confounder. In particular, ScoliScore has not been evaluated in a population undergoing bracing. METHODS: We conducted a retrospective cohort study in which we identified a population of AIS patients who were initiated with Providence bracing and followed over time. Although these patients did not necessarily fit the commercial indications for ScoliScore, we contacted the patients and obtained a saliva sample from each for genetic analysis. We then tested whether ScoliScore correlated with the outcome of their bracing therapy. RESULTS: We were able to contact and invite 25 eligible subjects, of whom 16 (64.0%) returned samples for laboratory analysis. Patients were followed for an average of 2.3 years (range, 1.1-4 y) after initiation of the Providence brace. Eight patients (50.0%) progressed to >45 degrees, whereas the other 8 patients (50.0%) did not. The mean ScoliScore among those who progressed to >45 degrees was higher than that among those who did not (176 vs. 112, P=0.030). CONCLUSIONS: We demonstrate that a genetic test correlates with bracing outcome. It may be appropriate for future bracing studies to include analysis of genetic predisposition to limit potential confounding.

Return to play after treatment of shoulder labral tears in professional hockey players.

OBJECTIVES: Shoulder labral injuries in professional hockey players are often treated surgically to minimize missed ice time. Previous studies have shown that post-operative outcomes in these players are favorable, although they have not specifically focused on athletic performance and time to return to sport. Our objective was to report time to return to play and post-operative on-ice performance metrics after shoulder labral repair in professional ice hockey players. METHODS: We performed a retrospective review of the clinical records of all professional hockey players (NHL) who underwent arthroscopic shoulder labral repair by one surgeon between January 2004 and December 2008. Operative data included labral injury type, number of anchors used, concomitant pathology, and complications. Player information included position, shooting hand, games played before and after surgery, date of return to play (RTP), time on ice (TOI) and shots on goal before and after surgery. Paired sample t-test and independent sample t-tests or their non-parametric equivalents were used to compare pre-and post-operative player performance variables using the SPSS statistical package. RESULTS: Eleven NHL Players (13 shoulders) were included in the study. The average follow-up was 19.4 months (12.7-37 months, SD 7.4) and average age was 29 years (20-36, SD 5.1). Of the 13 shoulders, there were various types of labral tears including three Bankart tears, three superior (SLAP) tears, two posterior tears, three combined anterior/posterior tears, and two panlabral tears. All 11 players returned to play (RTP) after surgery at an average time of 4.3 months. There were no significant differences between time to RTP for players with dominant-sided injuries (4.2 months) and non-dominant injuries (4.6 months), p = 0.632. Five players had increased time-on-ice (TOI) and five players had decreased TOI after surgery, though this difference was not significant (p = 0.3804). On average, the shots on goal per game played (SOG/GP) decreased by 0.13 after surgery which was not significantly different (p = 0.149). There were no post-operative complications observed. CONCLUSION: Professional ice hockey players can safely return to full competition at an average of 4.3 months after arthroscopic shoulder labral repair without significant decline in player performance.

Triceps Tendon Ruptures Requiring Surgical Repair in National Football League Players.

BACKGROUND: Complete triceps tendon ruptures are relatively rare in the general population but slightly more prevalent in professional football. One prior study found 11 complete ruptures over a 6-season period. HYPOTHESIS: Triceps ruptures occur more commonly in football linemen due to forced elbow flexion during an eccentric contraction and may occur more commonly with the increasing size and speed of professional players. Surgical repair allows full return to sports, but with a lengthy recovery time. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A search of the National Football League Injury Surveillance System (NFLISS) found a total of 37 triceps tendon ruptures requiring surgical repair from the years 2000 to 2009. Data were obtained for setting of injury, player position, activity causing injury, play type, time of game when injury occurred, height, weight, body mass index (BMI), and number of days lost from football. RESULTS: There were 37 players requiring surgical repair for triceps tendon ruptures over the 10-season period. The average height, weight, and BMI of the players were 75 inches, 292 pounds, and 36.5 kg/m(2), respectively. The majority of players were linemen (86%): 16 defensive, 15 offensive, and 1 tight end. The injury took place while blocking or being blocked in 29 players (78%) and while tackling or being tackled in 5 players (14%). Players missed an average of 165 days (range, 49-318 days) from football as a result of their injury and surgery. CONCLUSION: Triceps tendon tears requiring surgical repair are more common in professional football players than in the general population and are occurring more commonly than previously reported. Surgical repair allows return to play. CLINICAL RELEVANCE: Our study identifies the rate of triceps tendon tears requiring repair in the NFL according to position, identifying which players may be most at risk for this injury.

Long-term outcomes after multilevel surgery including rectus femoris, hamstring and gastrocnemius procedures in children with cerebral palsy.

BACKGROUND/AIMS: Multilevel surgical intervention is a common approach for the correction of gait abnormalities in children with cerebral palsy (CP). The short-term outcomes for the combination of rectus femoris transfer, hamstring lengthening and gastrocnemius lengthening have been well documented using three-dimensional motion analysis. However, the impact of time, growth, and puberty on these short-term outcomes of this combination of procedures is not well understood. The purpose of this study was to evaluate the long-term outcomes of these procedures on gait in patients with CP. METHODS: Twenty-two patients underwent rectus femoris transfers, medial hamstring lengthenings and gastrocnemius lengthenings in combination with a selection of other soft tissue and/or bony procedures of the lower limb. All patients had a pre-operative motion analysis and post-operative analysis one and 11 years following surgery. RESULTS: Significant changes in both clinical and gait variables from pre to 1 year post surgery confirmed the short-term gait benefits of this combination of surgical procedures. Long-term follow-up data indicated that the passive range of motion gains noted 1 year after surgery were lost at the knee and ankle. However, the improvements in ankle dorsiflexion and knee extension at initial contact were maintained over 11 years. As well, peak ankle dorsiflexion in stance was maintained and peak ankle plantar flexor moments and powers did not show declines long-term. Peak knee flexion showed a decline over the long-term, however, the timing of peak knee flexion in swing was maintained. CONCLUSION: When compared to declines in gait kinematics in persons with CP without surgery, these results demonstrate the possible long-term benefits of surgical intervention.

Results of ACL reconstruction with tibial Retroscrew fixation: Comparison of clinical outcomes and tibial tunnel widening.

UNLABELLED: ACL reconstruction with the RetroScrew™ shows superior clinical outcomes compared to historical Achilles allograft studies with antegrade screws. Addition of antegrade screw augmentation to retrograde fixation causes an increase in tibial tunnel widening. INTRODUCTION: In traditional antegrade screw fixation of Anterior cruciate ligament (ACL) soft tissue allografts, the screw is secured in the opposite direction of graft tension, potentially altering the appropriate tension on the graft. The RetroScrew (Arthrex) is a bioabsorbable screw placed in a retrograde fashion, potentially improving the tension of the graft by placing the screw in a proximal-to-distal direction. In addition, the RetroScrew theoretically decreases tibial tunnel widening by closing the aperture of the tibial tunnel, which prevents ingress of synovial fluid. Early tunnel expansion has been implicated due to excessive transverse and longitudinal graft motion. The clinical effects of tunnel expansion have yet to be fully understood. The purpose of this study is to assess the clinical results and tunnel width after ACL soft tissue fixation in the tibia with the RetroScrew. METHODS: Fifty-nine patients who underwent ACL reconstruction performed by two surgeons using the RetroScrew device returned for postoperative evaluation at an average of 25 months following surgery with a minimum follow-up of 12 months. Clinical evaluation, SF-36, IKDC and KT-1000 scores were recorded, and knee radiographs were used to measure tibial tunnel widening. Thirty-five patients had backup antegrade screw fixation in conjunction with the RetroScrew, and 24 patients had RetroScrew fixation alone. The results were compared to two previously reported studies on ACL reconstruction with Achilles tendon allograft that used antegrade screws. RESULTS: The average IKDC score was 87 (range: 44-100), with mean KT-1000 side-to-side difference of 1.2 mm (range: 0-5 mm). Tibial tunnel widening was 4.93 mm (SD 3.32) on AP radiographs and 4.40 mm (SD 2.72) on lateral radiographs greater than the native tunnel drilling. Patients with additional backup fixation had significantly more tunnel widening than patients without backup fixation (P < 0.05). There was one failure based on KT-1000 measurements. When compared to previous studies using ACL allografts, RetroScrew patients had statistically superior Lachman exams, KT-1000 side-to-side differences and decreased tibial tunnel widening (P < 0.05) when antegrade fixation was excluded. CONCLUSION: Patients who underwent Achilles allograft ACL reconstruction with the RetroScrew had improved clinical results compared to historical controls using antegrade fixation. Tibial tunnel widening was increased when using additional antegrade screw fixation, suggesting that the amount of bioabsorbable material within the tibial tunnel was related to the degree of tunnel widening.

Clinical and radiographic outcomes of supracondylar humerus fractures treated surgically by pediatric and non-pediatric orthopedic surgeons.

PURPOSE: This study compares clinical and radiographic outcomes of operatively managed pediatric supracondylar humerus fractures between patients treated by pediatric orthopedists (POs) and patients treated by non-pediatric orthopedists (NPOs). PATIENTS AND METHODS: A retrospective cohort study of pediatric patients with surgically managed supracondylar humerus fractures was conducted. For clinical outcomes analyses, 3 months of clinical follow-up were required, resulting in a sample size of 90 patients (33 treated by NPOs, 57 by POs). For radiographic outcomes analyses, 3 months of both clinical and radiographic follow-up were required, resulting in a sample size of 57 patients (23 treated by NPOs, 34 by POs). RESULTS: The rate of inadequate fracture fixation was higher for patients treated by NPOs (43.5 %) than for patients treated by POs (14.7 %; p = 0.030), but rates of clinical complications, malreduction, and postoperative loss of reduction did not differ. Treatment with open reduction was more common for patients treated by NPOs (33.3 %) than for patients treated by POs (3.5 %; p < 0.001). Total operating room time was longer for patients treated by NPOs (110.9 min) than for patients treated by POs (82.9 min; p < 0.001). CONCLUSIONS: While patients treated by POs differed from patients treated by NPOs with respect to several intermediate outcomes, including having a lower rate of open reduction and a lower rate of inadequate fracture fixation, there were no differences between POs and NPOs in the rates of the more meaningful and definitive outcomes, including clinical complications, malreduction, and postoperative loss of reduction.

Effectiveness of Providence nighttime bracing in patients with adolescent idiopathic scoliosis.

Interest has increased in adolescent idiopathic scoliosis braces that are worn only part time. One such brace, the Providence brace, is being used with increasing frequency despite limited literature evaluating its ability to alter the natural course of disease. The authors retrospectively identified 34 patients meeting modified Scoliosis Research Society (SRS) inclusion criteria who were treated with the Providence brace. In accordance with SRS criteria, patients were followed for progression more than 5°, progression to more than 45°, and recommendation for or performance of surgical fusion. Seventeen (50%) patients progressed more than 5°, and 9 (26%) progressed to more than 45° and had fusion surgery recommended or performed. Noncompliance was associated with progression to more than 45° (P=.045) and having fusion surgery recommended or performed (P=.045). Males had a higher rate of progression more than 5° than did females (100% vs 41%; P=.015). This is only the second study of the Providence brace to be guided by SRS criteria. The somewhat higher rates of progression more than 5° reported in these 2 studies compared with those reported in earlier studies likely result from this distinction. This study suggests a rate of progression that is similar to or lower than rates reported in natural history studies, possibly supporting the efficacy of the Providence brace. Additional studies using SRS criteria, including high-quality randomized, controlled trials, will be important to further understanding the relative effectiveness of this and other bracing protocols.

Pectoralis major ruptures in professional American football players.

BACKGROUND: Pectoralis major injuries are an infrequent shoulder injury that can result in pain, weakness, and deformity. These injuries may occur during the course of an athletic competition, including football. The purpose of this study was to determine the incidence of pectoralis major ruptures in professional football players and time lost from the sport following injury. We hypothesized that ruptures most frequently occur during bench-press strength training. METHODS: The National Football League Injury Surveillance System was reviewed for all pectoralis major injuries in all players from 2000 to 2010. Details regarding injury setting, player demographics, method of treatment, and time lost were recorded. RESULTS: A total of 10 injuries-complete ruptures-were identified during this period. Five of the 10 were sustained in defensive players, generally while tackling. Nine occurred during game situations, and 1 occurred during practice. Specific data pertinent to the practice injury was not available. No rupture occurred during weight lifting. Eight ruptures were treated operatively, and 2 cases did not report the method of definitive treatment. The average days lost was 111 days (range, 42-189). The incidence was 0.004 pectoralis major ruptures during the 11-year study period. CONCLUSIONS: Pectoralis major injuries are uncommon while playing football. In the National Football League, these injuries primarily occur not during practice or while bench pressing but rather during games. When pectoralis major ruptures do occur, they are successfully treated operatively. Surgery may allow for return to full sports participation. LEVEL OF EVIDENCE: IV, case series.

Incarcerated medial epicondyle fracture following pediatric elbow dislocation: 11 cases.

PURPOSE: To describe outcomes after surgical management of pediatric elbow dislocation with incarceration of the medial epicondyle. METHODS: We conducted a retrospective case review of 11 consecutive children and adolescents with an incarcerated medial epicondyle fracture after elbow dislocation. All patients underwent open reduction internal fixation using a similar technique. We characterized outcomes at final follow-up. RESULTS: Average follow-up was 14 months (range, 4-56 mo). All patients had clinical and radiographic signs of healing at final follow-up. There was no radiographic evidence of loss of reduction at intervals or at final follow-up. There were no cases of residual deformity or valgus instability. Average final arc of elbow motion was 4° to 140°. All patients had forearm rotation from 90° supination to 90° pronation. Average Mayo elbow score was 99.5. Four of 11 patients had ulnar nerve symptoms postoperatively and 1 required a second operation for ulnar nerve symptoms. In addition, 1 required a second operation for flexion contracture release with excision of heterotopic ossification. Three patients had ulnar nerve symptoms at final follow-up. Two of these had mild paresthesia only and 1 had both mild paresthesia and weakness. CONCLUSIONS: Our results suggest that open reduction internal fixation of incarcerated medial epicondyle fractures after elbow dislocation leads to satisfactory motion and function; however, the injury carries a high risk for complications, particularly ulnar neuropathy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical measurement of patellar tendon: accuracy and relationship to surgical tendon dimensions.

Patellar tendon width and length are commonly used for preoperative planning for anterior cruciate ligament reconstruction (ACLR). In the study reported here, we assessed the accuracy of preoperative measurements made by palpation through the skin, and correlated these measurements with the actual dimensions of the tendons at surgery. Before making incisions in 53 patients undergoing ACLR with patellar tendon autograft, we measured patellar tendon length with the knee in full extension and in 90° of flexion, and tendon width with the knee in 90° of flexion. The tendon was then exposed, and its width was measured with the knee in 90° of flexion. The length of the central third of the tendon was measured after the graft was prepared. Mean patellar tendon length and width with the knee in 90° of flexion were 39 mm and 32 mm, respectively. No clinical difference was found between the estimated pre-incision and surgical widths. However, the estimated pre-incision length with the knee in full extension and in 90° of flexion was significantly shorter than the surgical length. Skin measurements can be used to accurately determine patellar tendon width before surgery, but measurements of length are not as reliable.