An In-Depth Analysis of Public and Private Research Funding in Orthopaedic Surgery from 2015 to 2021.

BACKGROUND: Understanding the trends and patterns of research funding can aid in enhancing growth and innovation in orthopaedic research. We sought to analyze financial trends in public orthopaedic surgery funding and characterize trends in private funding distribution among orthopaedic surgeons and hospitals to explore potential disparities across orthopaedic subspecialties. METHODS: We conducted a cross-sectional analysis of private and public orthopaedic research funding from 2015 to 2021 using the Centers for Medicare & Medicaid Services Open Payments database and the National Institutes of Health (NIH) RePORTER through the Blue Ridge Institute for Medical Research, respectively. Institutions receiving funds from both the NIH and the private sector were classified separately as publicly funded and privately funded. Research payment characteristics were categorized according to their respective orthopaedic fellowship subspecialties. Descriptive statistics, Wilcoxon rank-sum tests, and Mann-Kendall tests were employed. A p value of <0.05 was considered significant. RESULTS: Over the study period, $348,428,969 in private and $701,078,031 in public research payments were reported. There were 2,229 unique surgeons receiving funding at 906 different institutions. The data showed that a total of 2,154 male orthopaedic surgeons received $342,939,782 and 75 female orthopaedic surgeons received $5,489,187 from 198 different private entities. The difference in the median payment size between male and female orthopaedic surgeons was not significant. The top 1% of all practicing orthopaedic surgeons received 99% of all private funding in 2021. The top 20 publicly and top 20 privately funded institutions received 77% of the public and 37% of the private funding, respectively. Private funding was greatest (31.5%) for projects exploring adult reconstruction. CONCLUSION: While the amount of public research funding was more than double the amount of private research funding, the distribution of public research funding was concentrated in fewer institutions when compared with private research funding. This suggests the formation of orthopaedic centers of excellence (CoEs), which are programs that have high concentrations of talent and resources. Furthermore, the similar median payment by gender is indicative of equitable payment size. In the future, orthopaedic funding should follow a distribution model that aligns with the existing approach, giving priority to a nondiscriminatory stance regarding gender, and allocate funds toward CoEs. CLINICAL RELEVANCE: Securing research funding is vital for driving innovation in orthopaedic surgery, which is crucial for enhancing clinical interventions. Thus, understanding the patterns and distribution of research funding can help orthopaedic surgeons tailor their future projects to better align with current funding trends, thereby increasing the likelihood of securing support for their work.

The Top 100 Most Impactful Articles on the Achilles Tendon According to Altmetric Attention Score and Number of Citations.

Background: Achilles tendon injuries often generate substantial discussion in the mainstream media. The Altmetric Attention Score (AAS) measures the online dialogue pertaining to Achilles tendon research that occurs outside scientific journals, which traditional citation-based metrics fail to capture. Purpose: To characterize the top 100 most-cited Achilles tendon articles and compare them with the 100 Achilles tendon articles with the highest AAS. A secondary goal was to gain an improved understanding of the online dissemination and interpretation of Achilles tendon research through this comparison. Study Design: Cross-sectional study. Methods: The Web of Science Clarivate database was queried to isolate the 100 most-cited Achilles tendon articles, and the Altmetric database was queried to identify the Achilles tendon articles with the top 100 AAS values. Data elements were extracted for each article including study type, study topic, and geographic origin. Results: The Web of Science Clarivate database search yielded 10,890 articles published between 1970 and 2021. The 100 most-cited articles were published in 35 journals, with the American Journal of Sports Medicine being the most prevalent. The mean (±SD) number of citations was 214.5 ± 86.47. The most prevalent study type was laboratory (28.0%). The most prevalent study topic was treatment (41.0%). Of these articles, 72.0% were European. The Altmetric database search yielded 3810 articles published between 1957 and 2021. The AAS of the top 100 articles ranged from 37 to 476 with a mean of 98.17 ± 85.53. The selected articles were published in 39 journals, with the British Journal of Sports Medicine being the most prevalent. The most prevalent study type was randomized controlled trial (25.0%). The most common study topic was treatment (40.0%). Of these articles, 46.0% were European. Conclusion: Our findings suggest that, although the scientific community remains committed to high-impact journals with articles backed by high citation numbers, there is an increasing opportunity to consume Achilles tendon literature through social media.

Paediatric meningitis in the conjugate vaccine era and a novel clinical decision model to predict bacterial aetiology.

OBJECTIVES: The aims of this study were to assess aetiology and clinical characteristics in childhood meningitis, and develop clinical decision rules to distinguish bacterial meningitis from other similar clinical syndromes. METHODS: Children aged <16 years hospitalised with suspected meningitis/encephalitis were included, and prospectively recruited at 31 UK hospitals. Meningitis was defined as identification of bacteria/viruses from cerebrospinal fluid (CSF) and/or a raised CSF white blood cell count. New clinical decision rules were developed to distinguish bacterial from viral meningitis and those of alternative aetiology. RESULTS: The cohort included 3002 children (median age 2·4 months); 1101/3002 (36·7%) had meningitis, including 180 bacterial, 423 viral and 280 with no pathogen identified. Enterovirus was the most common pathogen in those aged <6 months and 10-16 years, with Neisseria meningitidis and/or Streptococcus pneumoniae commonest at age 6 months to 9 years. The Bacterial Meningitis Score had a negative predictive value of 95·3%. We developed two clinical decision rules, that could be used either before (sensitivity 82%, specificity 71%) or after lumbar puncture (sensitivity 84%, specificity 93%), to determine risk of bacterial meningitis. CONCLUSIONS: Bacterial meningitis comprised 6% of children with suspected meningitis/encephalitis. Our clinical decision rules provide potential novel approaches to assist with identifying children with bacterial meningitis. FUNDING: This study was funded by the Meningitis Research Foundation, Pfizer and the NIHR Programme Grants for Applied Research.

No difference in torque load to failure between split anconeus fascia transfer and autograft palmaris longus tendon for reconstruction of the lateral ulnar collateral ligament.

Background: The split anconeus fascia transfer (SAFT) is an option for reconstruction of the lateral ulnar collateral ligament (LUCL) in chronic posterolateral rotatory instability (PLRI) of the elbow with potential advantages of using only local tissue within the surgical exposure and not requiring ulnar fixation. This study aimed to assess SAFT strength compared to a traditional free graft reconstruction in a PLRI biomechanical model. Methods: To measure biomechanical strength, eight cadaveric upper extremity pairs were utilized. Within each pair, one specimen was randomly assigned to LUCL reconstruction with autograft palmaris longus and the other to SAFT reconstruction. Torque load to failure was assessed on a load frame with the elbow in 30 degrees of flexion, 5 degrees of valgus, and 25 N axial load as the elbow was brought into external rotation. Torque load to failure was compared between the two reconstruction techniques. Results: No difference was found in the torque load to failure between SAFT specimens compared to palmaris longus autograft specimens (mean 14.6 ± 4.4 Nm vs. mean 11.3 ± 3.9 Nm; P = .16). Discussion: In this biomechanical study, the SAFT LUCL reconstruction provided torque load to failure similar to that of the traditional technique. These findings suggest that the SAFT technique warrants continued study as a biomechanically sound option for LUCL reconstruction in the setting of elbow PLRI.

High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review.

BACKGROUND: The Centers for Disease Control defines work-related musculoskeletal disorders as disorders of the nerves, muscles, tendons, joints, spinal discs, and cartilage that are caused or exacerbated by the environment or nature of work. Previous meta-analyses have characterized work-related musculoskeletal disorders among interventionists, general surgeons, and other surgical subspecialties, but prevalence estimates, prognosis, and ergonomic considerations vary by study and surgical specialty. QUESTIONS/PURPOSES: (1) What is the career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons? (2) What is the treatment prevalence associated with work-related musculoskeletal disorders in orthopaedic surgeons? (3) What is the disability burden of work-related musculoskeletal disorders in orthopaedic surgeons? (4) What is the scope of orthopaedic surgical ergonomic assessments and interventions? METHODS: A systematic review of English-language studies from PubMed, MEDLINE, Embase, and Scopus was performed in December 2022 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that presented prevalence estimates of work-related musculoskeletal disorders or assessed surgical ergonomics in orthopaedic surgery were included. Reviews, case reports, gray literature (conference abstracts and preprints), and studies with mixed-surgeon (nonorthopaedic) populations were excluded. The search yielded 5603 abstracts; 24 survey-based studies with 4876 orthopaedic surgeons (mean age 48 years; 79% of surgeons were men) were included for an analysis of work-related musculoskeletal disorders, and 18 articles were included for a descriptive synthesis of ergonomic assessment. Quality assessment using the Joanna Briggs Institute Tool revealed that studies had a low to moderate risk of bias, largely because of self-reporting survey-based methodology. Because of considerable heterogeneity and risk of bias, prevalence outcomes were not pooled and instead are presented as ranges (mean I 2 = 91.3%). RESULTS: The career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons ranged from 37% to 97%. By anatomic location, the prevalence of work-related musculoskeletal disorders in the head and neck ranged from 4% to 74%; back ranged from 9% to 77%; forearm, wrist, and hand ranged from 12% to 54%; elbow ranged from 3% to 28%; shoulder ranged from 3% to 34%; hip and thigh ranged from 1% to 10%; knee and lower leg ranged from 1% to 31%; and foot and ankle ranged from 4% to 25%. Of orthopaedic surgeons reporting work-related musculoskeletal disorders, 9% to 33% had a leave of absence, practice restriction or modification, or early retirement, and 27% to 83% received some form of treatment. Orthopaedic surgeons experienced biomechanical, cardiovascular, neuromuscular, and metabolic stress during procedures. Interventions to improve orthopaedic surgical ergonomics have been limited, but have included robotic assistance, proper visualization aids, appropriate use of power tools, and safely minimizing lead apron use. In hip and knee arthroplasty, robotic assistance was the most effective in improving posture and reducing caloric expenditure. In spine surgery, proper use of surgical loupes was the most effective in improving posture. CONCLUSION: Although the reported ranges of our main findings were wide, even on the low end of the reported ranges, work-related musculoskeletal disability among orthopaedic surgeons appears to be a substantial concern. We recommend that orthopaedic residency training programs incorporate surgical ergonomics or work injury lectures, workshops, and film review (alongside existing film review of surgical skills) into their curricula. We suggest hospitals engage in shared decision-making with surgeons through anonymous needs assessment surveys to implement wellness programs specific to surgeons' musculoskeletal needs. We urge institutions to assess surgeon ergonomics during routine quality assessment of novel surgical instruments and workflows. LEVEL OF EVIDENCE: Level III, prognostic study.

Systematic Review of Complications Associated With Proximal Hamstring Tendon Repair.

Background: Although several complications of proximal hamstring tendon ruptures have been reported in the literature, few studies have comprehensively analyzed the complication profile of proximal hamstring tendon repair. Purpose: To identify the overall rate of complications following proximal hamstring tendon repair and to differentiate these complications into categories. Study Design: Systematic review; Level of evidence, 4. Methods: Included in this review were studies that examined surgical repair of proximal hamstring tendon ruptures; all studies were in English and had an evidence level of 4 or higher. No restrictions were made regarding publication date or methodological quality. Data regarding complications were extracted to calculate the overall complication rate as well as the rate of major and minor complications. A quantitative data synthesis was conducted using the chi-square test to compare the proportion of patients who experienced complications with the endoscopic versus open approach. Results: A total of 43 articles including 2833 proximal hamstring tendon repairs were identified. The overall postoperative complication rate was 15.3% (n = 433). The rate of major complications was 4.6%, including a 1.7% rate of sciatic nerve injury, 0.8% rate of venous thromboembolism, 0.8% reoperation rate, 0.8% rerupture rate, and 0.4% rate of deep infection. Minor complications included a 2.4% rate of posterior femoral cutaneous nerve injury, 2.3% rate of persistent hamstring myopathy, 2.2% rate of persistent sitting pain, 1.8% rate of peri-incisional numbness, 1.1% rate of superficial infection, and 0.8% rate of hematoma/seroma. Conclusion: Proximal hamstring tendon repair is associated with an overall complication rate of 15.3%, including a 4.6% rate of major complications.

Increased Posterior Tibial Slope Increases Force on the Posterior Medial Meniscus Root.

BACKGROUND: Posterior medial meniscus root (PMMR) tears have been associated with increased posterior tibial slope, but this has not been fully evaluated biomechanically. In addition, the effects of knee flexion and rotation on the PMMR are not well understood biomechanically because of technological testing limitations. A novel multiaxial force sensor has made it possible to elucidate answers to these questions. PURPOSE: (1) To determine if increased posterior tibial slope results in increased posterior shear force and compression on the PMMR, (2) to evaluate how knee flexion angle affects PMMR forces, and (3) to assess how internal and external rotation affects force at the PMMR. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen cadaveric knees were tested in all combinations of 3 posterior tibial slopes and 4 flexion angles. A multiaxial force sensor was connected to the PMMR and installed below the posterior tibial plateau maintaining anatomic position. The specimen underwent a 500-N compression load followed by a 5-N·m internal torque and a 5-N·m external torque. The magnitude and direction of the forces acting on the PMMR were measured. RESULTS: Under joint compression, an increased tibial slope significantly reduced the tension on the PMMR between 5° and 10° (from 13.5 N to 6.4 N), after which it transitioned to a significant increase in PMMR compression, reaching 7.6 N at 15°. Under internal torque, increased tibial slope resulted in 4.7 N of posterior shear at 5° significantly changed to 2.0 N of anterior shear at 10° and then 8.2 N of anterior shear at 15°. Under external torque, increased tibial slope significantly decreased PMMR compression (5°: 8.9 N; 10°: 4.3 N; 15°: 1.1 N). Under joint compression, increased flexion angle significantly increased medial shear forces of the PMMR (0°, 3.8 N; 30°, 6.2 N; 60°, 7.3 N; 90°, 8.4 N). Under internal torque, 90° of flexion significantly increased PMMR tension from 2.3 N to 7.5 N. Under external torque, 30° of flexion significantly increased PMMR compression from 4.7 N to 12.2 N. CONCLUSION: An increased posterior tibial slope affects compression and anterior shear forces at the PMMR. An increased flexion angle affects compression, tension, and medial shear forces at the PMMR. CLINICAL RELEVANCE: The increase in compression and posterior shear force when the knee is loaded in compression may place the PMMR under increased stress and risk potential failure after repair. This study provides clinicians with information to create safer protocols and improve repair techniques to minimize the forces experienced at the PMMR.

Meniscotibial Ligament Insufficiency Increases Force on the Posterior Medial Meniscus Root.

BACKGROUND: Posterior medial meniscus root (PMMR) tears are a challenge to assess and treat. However, the forces sustained at the PMMR are yet to be fully characterized. In addition, it has been shown that meniscotibial ligament (MTL) injuries happen before PMMR tears, suggesting that insufficiency of the MTL results in a change of forces acting on the PMMR. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the 3-dimensional forces acting on the PMMR in the intact, MTL cut, and MTL tenodesis states. It was hypothesized that the MTL cut state would increase medial shear forces seen at the PMMR, whereas the medial shear force in the MTL tenodesis state would return PMMR forces to that of the intact state. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen cadaveric knees were tested in 3 states (intact, MTL cut, and tenodesis). A 3-axis load cell was installed below the posterior tibial plateau and attached to the enthesis of the PMMR. The specimen was mounted to a load frame that applied an axial load, an internal torque, and an external torque. The amount of compression-tension, mediolateral shear force, and anteroposterior shear force acting on the PMMR was measured. RESULTS: When the joint was loaded in compression, the MTL cut state significantly increased compression of the PMMR (P = .0368). The tenodesis state did not significantly restore forces of the PMMR (P = .008). When the joint was loaded in external torque, the MTL cut state significantly increased compression (P < .0001) and significantly decreased anterior shear on the PMMR (P = .0003). The tenodesis state did not significantly restore forces on the PMMR to the intact state (P < .0001). Increased flexion angle significantly increased medial shear forces of the PMMR when the joint was loaded in compression (P < .007 at every angle). CONCLUSION: When evaluated biomechanically, MTL insufficiency resulted in increased compressive force at the PMMR. A single-anchor centralization procedure did not restore PMMR forces to that of the intact state. Increased knee flexion angle resulted in increased medial shear force on the PMMR. CLINICAL RELEVANCE: The findings in this study provide clinicians information on PMMR forces when the MTL is disrupted. These data can aid in the decision-making for adding an MTL repair to augment PMMR repairs.

Trends in Distal Radius Fixation Reimbursement, Charge, and Utilization in the Medicare Population.

Background Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from -9.2% to -13% for each procedure. Conclusion From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

Adjustable Cortical Fixation Repair Is a Safe and Effective Technique for Quadriceps Tendon Rupture.

Purpose: To report the clinical outcomes of quadriceps tendon repair using adjustable cortical fixation devices at a minimum 2-year follow-up. Methods: A retrospective chart review identified patients who underwent quadriceps tendon repair using adjustable cortical fixation devices between January 2017 and March 2020. Patients with a partial tendon rupture were excluded. Demographic and injury-specific variables were gathered preoperatively and postoperatively from the electronic medical record and patient-reported outcomes (Lysholm Knee Questionnaire, Lower Extremity Functional Scale, and SF-12) were collected via telephone at a minimum of 2 years postoperatively. Results: Fourteen quadriceps tendon repairs were included in a total of 13 patients. The average time to follow-up was 3.5 ± 1.2 years with a range of 1.9 to 5.7 years. The mean age of this cohort was 55.7 ± 11.6 years, and the mean body mass index was 32.9 ± 6.0. Ten injuries (71.4%) were sustained by mechanical fall, 2 patients (14.3%) suffered a direct blow to the knee, and 2 patients (14.3%) reported a noncontact injury mechanism. Thirteen quadriceps ruptures (13/14, 92.9%) underwent surgery within 10 days of their injury. One knee (7.1%) had a postoperative extensor lag of 5°, whereas another knee (7.1%) required a reoperation for manipulation under anesthesia and arthroscopic lysis of adhesions at 3 months' postoperatively. None of the included patients (0.0%) developed a tendon re-rupture, venous thromboembolism, delayed wound healing, surgical-site infection, neuropraxia or nerve injury, hardware irritation, patella fracture, or heterotopic ossification. Conclusions: In this study, adjustable cortical fixation was a safe and effective surgical technique for quadriceps tendon repair, with adequate restoration of quadriceps function and a low rate of adverse events at 2 years postoperatively. Level of Evidence: Level IV, therapeutic case series.

Progression of Osteoarthritis at Long-term Follow-up in Patients Treated for Symptomatic Femoroacetabular Impingement With Hip Arthroscopy Compared With Nonsurgically Treated Patients.

BACKGROUND: Femoroacetabular impingement (FAI) is a common cause of hip pain, especially in young patients. When left untreated, it has been demonstrated to be a risk factor for the onset or progression of osteoarthritis (OA) and has been identified as one of the main contributors leading to the need for total hip arthroplasty (THA) at a young age. While the short-term therapeutic potential of hip arthroscopy is widely recognized, little is known regarding its potential mid- to long-term preventive effect on the progression of hip OA. PURPOSE: To (1) report clinical outcomes of arthroscopically treated FAI syndrome with a minimum 5-year follow-up and compare the results to a cohort with FAI treated nonsurgically and (2) determine the influence of hip arthroscopy on the onset and progression of hip OA in patients diagnosed with FAI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who had hip pain and were diagnosed with FAI were included. Exclusion criteria were (1) previous or concomitant hip surgery, (2) <5 years of follow-up, and (3) insufficient radiographs. Patients treated with hip arthroscopy were compared with a cohort of patients with FAI who were treated nonsurgically. Kaplan-Meier estimates of failure (defined as conversion to THA) were performed. Bivariate analysis and Cox regression were used to identify factors associated with inferior clinical and radiographic outcomes. RESULTS: A total of 957 patients (650 female, 307 male; 1114 hips) (mean age, 28.03 ± 8.9 years [range, 6.5-41.0 years]) with FAI were included. A total of 132 hips underwent hip arthroscopy and 982 hips were nonoperatively treated. The mean follow-up was 12.5 ± 4.7 years (range, 5.0-23.4 years). At the final follow-up, the rate of OA progression was 26.5% in the operative group and 35.2% in the nonoperative cohort (P < .01). Conversion to THA was performed in 6.8% of the surgical patients and 10.5% of the initially nonsurgical patients (P = .19). Additionally, there was no significant difference in the risk of failure between the operatively and nonoperatively treated patients. Male sex, increased age at initial diagnosis, presence of cam morphology, and increased initial Tönnis grade were risk factors for failure (male sex: hazard ratio [HR], 2.3; P < .01; per year of increased age: HR, 1.1; P < .01; presence of cam: HR, 3.5; P < .01; per Tönnis grade: HR, 4.0; P < .01). CONCLUSION: At a mean follow-up of nearly 13 years, 7% of patients of the surgical group experienced progression to THA, compared with 11% of the nonoperative control group. While most of the operative group showed little to no OA at final follow-up, moderate OA (Tönnis grade 2) was present in 12% of the cohort compared with 22% of nonsurgical patients. Increased age at diagnosis, male sex, presence of a cam morphology, and presence of initial arthritic joint changes were found to be risk factors for failure. The results of this study demonstrated evidence for a preventive effect of hip arthroscopy on the development and progression of OA in young patients with FAI at mid- to long-term follow-up.

Inflammatory and Immunologic Contributions in Femoroacetabular Impingement Syndrome.

Femoroacetabular impingement (FAI) is one of the most common causes of labral and early cartilage damage in the nondysplastic hip. FAI is increasingly recognized as a cause for hip and groin pain in the young, active patient, and the surgical treatment of FAI with hip arthroscopy has risen exponentially. Although our understanding of FAI and the progression to degenerative osteoarthritis of the hip has historically been considered a mechanical "wear-and-tear" disease of an imperfectly shaped, aspherical, femoral head within a deep or overcovering acetabulum leading to cartilage injury, our understanding of the intrinsic pathophysiologic mechanisms underlying the development of FAI and joint degeneration of the hip remains poor. For example, many patients with FAI morphology may never develop hip pain or osteoarthritis; there remains more to discover regarding the pathophysiology of arthritis in the setting of FAI. Recent work has begun to identify a strong inflammatory and immunologic component to the FAI disease process that affects the hip synovium, labrum, and cartilage and may be detectable from peripheral clinical samples (blood and urine). This review highlights our current understanding of the inflammatory and immunologic contributions to FAI and potential therapeutic strategies to supplement and augment the surgical management of FAI.

Graft Augmentation of Rotator Cuff Repair Improves Load to Failure But Does Not Affect Stiffness or Gap Formation: A Meta-analysis of Biomechanical Studies.

PURPOSE: To examine the biomechanical properties of rotator cuff repair with graft augmentation (RCR-G) with regard to ultimate load to failure, gap displacement, and stiffness. METHODS: A systematic review was performed by searching PubMed, the Cochrane library, and Embase using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that analyzed the biomechanical properties of RCR-G. The search string implemented used the concepts "rotator cuff" and "graft," and "biomechanical" OR "cadaver." Meta-analysis was performed to provide a quantitative comparison of the 2 techniques. Primary outcome measures were ultimate load to failure (N), gap displacement (mm), and stiffness (N/mm). RESULTS: Our initial search yielded 1,493 articles for review. Following screening for inclusion criteria, 8 studies were included in the meta-analysis, including a total of 191 cadaveric specimens (106 RCR-G, 85 RCR). The pooled analysis from 6 studies reporting on ultimate load to failure revealed a statistically significant difference in favor of RCR-G compared with RCR (P < .001). Pooled analysis from 6 studies reporting on gap displacement failed to reveal a difference between RCR-G and RCR (P = .719). Pooled analysis from 4 studies reporting on stiffness failed to reveal a difference between RCR-G and RCR (P = .842). CONCLUSIONS: Graft augmentation of RCR in vitro resulted in significantly increased ultimate load to failure, with no influence on gap formation or stiffness. CLINICAL RELEVANCE: The biomechanical advantage of RCR with graft augmentation demonstrated via increased ultimate load to failure in cadaveric studies may provide an explanation for the decreased RCR retear rates and improved patient reported outcomes reported in the clinical literature regarding graft augmentation.

Use of Computed Tomography in the Evaluation of Anterior Shoulder Instability: Possible Effect on Surgical Management.

BACKGROUND: Glenoid bone loss is a critical factor in the management of anterior shoulder instability (ASI). Computed tomography (CT) is often considered the gold standard to evaluate glenoid bone loss, but it is associated with negative factors such as radiation. Thus, interest exists as to when orthopaedic surgeons need a CT scan to guide decision-making when treating ASI. PURPOSE: To determine whether information gained from a shoulder CT scan alters orthopaedic surgeons' management plan for ASI and, secondarily, to determine whether surgeon- and patient-specific factors affect whether a CT scan changes treatment and which clinical factors are most important in surgical decision-making. STUDY DESIGN: Cross-sectional study. METHODS: A questionnaire composed of 24 ASI vignettes was administered to Herodicus Society members, American Shoulder and Elbow Surgeons Neer Circle members, and sports medicine fellowship-trained orthopaedic surgeons. Participants chose their recommended surgical treatment from the options of arthroscopic Bankart repair, open Bankart repair, bony reconstruction procedure, or other based on patient history, radiographs, and magnetic resonance imaging. Participants were then shown CT images and asked whether their treatment plan changed and, if not, whether the CT scan was not necessary or had reinforced their decision. Generalized linear mixed-effects logistic regression modeling was performed to assess the influence of vignette and respondent characteristics on treatment decisions. RESULTS: A total of 74 orthopaedic surgeons completed the survey; 96% were fellowship trained (sports medicine, 50%; shoulder and elbow surgery, 41%), and 66% practiced in academic settings. CT imaging did not change the selected treatment strategy in 75.6% of responses. In cases when management did not change, surgeons reported that the CT scan reinforced their decision in 53.4% of responses and was not necessary for decision-making in 22.2% of responses. Decision-making was more likely to be changed after CT in male patients and those with off-track lesions. CONCLUSION: Information gained from a CT scan did not alter treatment decision-making in three-quarters of vignettes among surgeons experienced in the management of ASI. The finding that CT scans did alter the treatment plan in nearly a quarter of cases is not insignificant, and it appears that in patients with borderline glenoid track status and few other risk factors for recurrence after arthroscopic stabilization, CT imaging is more likely to change management.

Posterior Root Tears of the Lateral Meniscus Only Affect Tibiofemoral Contact Forces when the Meniscofemoral Ligament Is Involved: A Cadaveric Study.

Purpose: The objective of this study was to examine the impact of progressive radial tears in the lateral meniscal root on the lateral compartment contact forces and joint surface area through a range of motion of knee and evaluate the role of the meniscofemoral ligament (MFL) in preventing adverse tibiofemoral joint forces. Methods: Ten fresh frozen cadaveric knees were tested using 6 experimental conditions (0% lateral meniscal posterior root tear, 25% tear, 50% tear, 75% tear, 100% tear, 100% tear and resection of MFL) at five flexion angles (0°, 30°, 45°, 60°, and 90°) under 100-1,000-N axial load. Contact joint pressure and lateral compartment surface area were measured using Tekscan sensors. Statistical analysis, including descriptive, ANOVA, and post hoc Tukey analysis, was performed. Results: Progressive radial tears of the lateral meniscal root were not associated with an increase in tibiofemoral contact pressure or decrease in lateral compartment surface area. Complete lateral root tear and resection of MFL were associated with increased joint contact pressure (P < .001) at knee flexion angles of 30, 45, 60, and 90° and decreased lateral compartment surface (P < .001) at all knee flexion angles area compared to complete lateral meniscectomy alone. Conclusion: Isolated complete tears of lateral meniscus root and progressive radial tears of the lateral meniscus posterior root were not associated with any change to tibiofemoral contact forces. However, additional resection of the MFL increased contact pressure and decreased lateral compartment surface area.

Lower Extremity Injury Rates on Artificial Turf Versus Natural Grass Playing Surfaces: A Systematic Review.

BACKGROUND: No study has provided a comprehensive systematic review of sports injuries on artificial turf versus natural grass. PURPOSE: To comprehensively examine the risk of overall injuries and multiple types of lower extremity injuries across all sports, all levels of competition, and on both old-generation and new-generation artificial turf. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A systematic review of the English-language literature was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All included articles compared overall injury rates or lower extremity (hip, knee, or foot and ankle) injury rates on artificial turf and natural grass. All sports, levels of competition, and turf types were included. Studies were excluded if they did not include overall injury rates or lower extremity injury rates. Because of the heterogeneity of the included studies, no attempt was made to aggregate risk ratios to conduct a quantitative meta-analysis. RESULTS: A total of 53 articles published between 1972 and 2020 were identified for study inclusion. Most studies on new-generation turf (13/18 articles) found similar overall injury rates between playing surfaces. When individual anatomic injury locations were analyzed, the greatest proportion of articles reported a higher foot and ankle injury rate on artificial turf compared with natural grass, both with old-generation (3/4 articles) and new-generation (9/19 articles) turf. Similar knee and hip injury rates were reported between playing surfaces for soccer athletes on new-generation turf, but football players, particularly those at high levels of competition, were more likely to sustain a knee injury on artificial turf than on natural grass. CONCLUSION: The available body of literature suggests a higher rate of foot and ankle injuries on artificial turf, both old-generation and new-generation turf, compared with natural grass. High-quality studies also suggest that the rates of knee injuries and hip injuries are similar between playing surfaces, although elite-level football athletes may be more predisposed to knee injuries on artificial turf compared with natural grass. Only a few articles in the literature reported a higher overall injury rate on natural grass compared with artificial turf, and all of these studies received financial support from the artificial turf industry.

Joint consensus statement on the vaccination of adult and paediatric haematopoietic stem cell transplant recipients: Prepared on behalf of the British society of blood and marrow transplantation and cellular therapy (BSBMTCT), the Children's cancer and Leukaemia Group (CCLG), and British Infection Association (BIA).

Haematopoietic stem cell transplant (HSCT) recipients have deficiencies in their adaptive immunity against vaccine preventable diseases. National and International guidance recommends that HSCT recipients are considered 'never vaccinated' and offered a comprehensive course of revaccination. This position statement aims to draw upon the current evidence base and existing guidelines, and align this with national vaccine availability and licensing considerations in order to recommend a pragmatic and standardised re-vaccination schedule for adult and paediatric HSCT recipients in the UK.

Effect of Poly-L-Lactic Acid Mesh Augmentation on Cyclic Gap Formation in Transosseous Patellar Tendon Repair: A Biomechanical Study.

No previous study has investigated poly-L-lactic acid (PLLA) surgical mesh augmentation in the repair of inferior pole patellar tendon rupture. We compared the biomechanical properties of transosseous patellar tendon repair with PLLA surgical mesh augmentation to transosseous repair without augmentation. Ten matched pairs of cadaveric knees were used. Specimens in each pair were randomized to undergo the transosseous technique alone or the transosseous technique augmented with a PLLA surgical mesh. An inferior pole patellar tendon rupture was simulated and the repair procedure was performed. Specimens were cyclically loaded for 500 cycles. Gap formation was measured using two sensors placed medial and lateral to the repair site. After cyclic loading, load to failure was determined by pulling the tendon at a constant rate until a sudden decrease in load occurred. The primary outcome measure was cyclic gap formation at the medial and lateral sensors. Compared with controls, specimens that underwent PLLA mesh-augmented repair had significantly lower medial gap formation at all testing intervals up to 500 cycles (p < 0.05) and significantly lower lateral gap formation at all testing intervals from 10 to 500 cycles (p < 0.05). Transosseous patellar tendon repair augmented with a PLLA woven mesh device provided significantly greater resistance to gap formation compared with transosseous repair alone. These results suggest that PLLA mesh augmentation of the transosseous technique is biomechanically effective for patellar tendon repair.