Hemoglobin A1c Levels >6.6% Are Associated With Higher Postoperative Complications After Anterior Cruciate Ligament Reconstruction.

Purpose: To investigate the relation between hemoglobin A1c (HbA1c) levels and postoperative complications after primary anterior cruciate ligament reconstruction (ACLR). Methods: A retrospective review was performed of consecutive patients with an isolated anterior cruciate ligament tear, preoperative diagnosis of diabetes, and documented HbA1c within 90 days of primary ACLR between 2000 and 2019. Data collected included demographic and surgical characteristics, 90-day medical complications, and subsequent surgeries on the ipsilateral knee. A receiver operating curve was constructed for each HbA1c level in relation to postoperative complications and the optimal cutoff identified via Youden's J statistic. Multivariable logistic regression was performed to assess the relation between postoperative complications and age, sex, graft type, diabetes subtype, and HbA1c. Results: Nineteen patients (7 females, 12 males) fulfilled inclusion criteria with preoperative HbA1c ranging from 5.5 to 10. Complications included septic knee (n = 1) and cyclops lesions requiring arthroscopic lysis (n = 3). Patients with HbA1c of 6.7% or higher were 25 times more likely to experience any postoperative complication (P = .04) and 16 times more likely to require lysis of adhesions (P = .08). On multivariable regression, HbA1c remained significantly associated with any complication (P = .005) and developing arthrofibrosis (P = .02) independent of age, sex, graft type, and diabetes subtype. Conclusions: Diabetic patients undergoing primary ACLR with a preoperative HbA1c of 6.7% or higher were 25 times more likely to require repeat surgical intervention for a postoperative complication. These complications included arthrofibrosis and infection. Strict glycemic control may help minimize the risk of postoperative complications after ACLR. Level of Evidence: Level III, retrospective cohort study.

Editorial Commentary: Utility of Patient-Reported Outcome Threshold Scores to Estimate Patient Satisfaction: 'Let's Ask the Patient!'

The reporting and analysis of patient-reported outcome measures have come a long way. Since the concept of the minimally clinically important difference was first introduced in 1989, threshold scores have grown to include substantial clinical benefit and patient acceptable symptomatic state (PASS). The initial motivation for developing these thresholds was rooted in separating clinical significance from statistical. These thresholds provide insight into the relationship between scores on patient-reported outcome measures (PROM) and patient-reported improvement and satisfaction. It follows that in order to evaluate PROM scores, the best method for deriving the threshold typically uses an anchor-based methodology, i.e., "ask the patient." Specifically, patients are asked how much change they've experienced and whether they consider their current state to be satisfactory. The responses to these questions are compared with the scores on PROMs to find outcome thresholds that best separate patients who reported no improvement from those who reported minimal improvement, substantial improvement, and satisfaction with their current state of health (PASS). The PASS is of particular importance as it speaks to what arguably matters most to patients-a satisfactory state of health. Finally, viewing the PASS from the perspective of variation from study to study rather than as a uniform classifier is needed to make use of the growing number of papers reporting these thresholds. Examining differences in PASS values across papers can provide insight into how well PROM scores reflect patient satisfaction in different settings.

Acromioclavicular Joint Anatomy and Biomechanics: The Significance of Posterior Rotational and Translational Stability.

The shoulder girdle extends from the sternoclavicular joint to the scapular stabilizing muscles posteriorly. It consists of 3 joints and 2 mobile regions. The shoulder girdle is statically stabilized by the acromioclavicular and coracoclavicular capsuloligamentous structures and dynamically stabilized by the trapezius, deltoid, and deltotrapezial fascia. During humerothoracic elevation, the clavicle elevates, protracts, and rotates posteriorly through the sternoclavicular joint while the scapula tilts posteriorly and rotates upward. The purpose of this article is to review the anatomy and biomechanics of the acromioclavicular joint and the shoulder girdle.

The Use of Biologics in NFL Athletes: An Expert Consensus of NFL Team Physicians.

Background: There is a lack of published information outlining the use of biologics in National Football League (NFL) athletes and limited data to guide biologic treatment strategies. Purpose: To develop a consensus on the use of biologics among NFL team physicians. Study Design: Consensus statement. Methods: A working group of 6 experts convened a consensus process involving NFL team physicians using validated Delphi methodology. Physicians from 32 NFL teams as well as NFL London were invited to take part. This iterative process was used to define statements on the use of biologics in NFL athletes. A recent scoping review exploring biologics in professional athletes was used to inform the first of 3 rounds of surveys, with statements considered under 7 headings: biologics in general, challenges of treating NFL athletes, terminology/nomenclature, autologous blood products, cell-based therapies, guidance for NFL team physicians, and biologic research in the NFL. In addition to rating agreement, experts were encouraged to propose further items or modifications. Predefined criteria were used to refine item lists after each survey. For a consensus within the final round, defined a priori, items were included in the final information set if a minimum of 75% of respondents agreed and fewer than 10% disagreed. Results: Physicians from 26 NFL teams and NFL London responded to the initial invitation to participate in the Delphi process; 88.9% of participating team physicians completed the round 1 survey, with response rates of 87.5% in round 2 and 95.2% in round 3. After 3 rounds, 47 statements reached a consensus. A consensus was achieved that platelet-rich plasma has a positive impact on patellar tendinopathy and on symptoms in early osteoarthritis but not for other indications. NFL team physicians agreed that while cell therapies have the potential to improve symptoms, the misrepresentation of uncharacterized preparations as "stem cells" has contributed to the widespread use of unproven therapies. Conclusion: This study established an expert consensus on 47 statements relating to the use of biologics in NFL athletes. In addition to providing clinical guidance for the use of biologics in NFL athletes, this study identified key areas for future focus including the development of athlete education materials.

Editorial Commentary: Fascia Lata Allograft for Shoulder Superior Capsular Reconstruction: In the Fight Over Optimal Graft Choice for Irreparable Rotator Cuff Tears, Superior Capsular Reconstruction Proponents May Be Changing Their Gloves.

Optimal treatment of irreparable rotator cuff tears is still debated. Proponents of the superior capsule reconstruction (SCR) have previously used fascia lata autograft and acellular dermal allograft. Interest is growing in using fascia lata allograft as a new graft material. Well-designed biomechanical studies are important to understand the mechanical properties of the superior capsular tissue and fascia lata allograft. Recent biomechanical research shows that fascia lata allograft has similar initial stiffness (over the first 2 mm) and ultimate load compared to the native superior capsule. That said, ultimate load is the load at which a construct fails, whereas the yield point is the load on the stress-strain curve at which a material transitions from elastic to plastic deformation. In the shoulder where the SCR, for example, is going to be repetitively loaded, it is potentially more meaningful to talk about the yield point in order to stay within the elastic range. Using this framework, the yield point for fascia lata allograft is approximately one third the yield point of native capsular tissue. Additionally, "initial" stiffness is not the entire story. At greater loads, fascia lata allograft has higher displacement compared to native tissue. Of importance, fascia lata allograft failed by sutures slowly cutting through the allograft tissue; this may represent a limitation of the construct that could be addressed using stitch configurations resistant to cut through. Fascia lata allograft is a promising solution for SCR. Biomechanical studies require nuanced interpretation, and most of all, do not evaluate clinical healing.

Epidemiology of Traumatic Posterior Hip Instability in the National Football League.

BACKGROUND: There is a paucity of literature regarding injury incidence, mechanism, and return to play in National Football League (NFL) players who have sustained traumatic posterior hip instability. PURPOSE: To describe the incidence of traumatic posterior hip instability and the rate of return to play in NFL players across 18 seasons. STUDY DESIGN: Descriptive epidemiology study. METHODS: We retrospectively assessed all traumatic posterior hip dislocations/subluxations that occurred during football-related activities in the NFL seasons from 2000 through 2017. Player demographics and injury data (injury mechanism, season of injury, treatment, days missed, and return to play time) were collected from all 32 NFL teams prospectively through a leaguewide electronic health record system. Descriptive statistics are presented. RESULTS: Across the 18 NFL seasons, 16 posterior hip instability injuries in 14 players were reported, with a maximum incidence of 4 (25%) in 2013. Posterior hip instability was predominantly sustained by offensive players (64.3%), with tight ends being the most affected (31.3%). Half of the injuries occurred during the regular season, 43.8% in the preseason, and 6.2% in the offseason. Of all injuries, 37.5% were noncontact, while 56.3% involved contact (direct or indirect), and 6.2% were of unknown mechanism. Among noncontact injuries, 66.7% occurred during cutting and change of direction while sprinting. The time of return to full participation was documented for 11 of the 16 reported injuries (68.8%); among them, the mean time loss was 136.7 ± 83.8 days-143.3 ± 99.6 days if the player underwent surgery (n = 4) and 116.7 ± 76.2 days missed by players without surgery (n = 6)-the treatment modality was unknown in 1 player. CONCLUSION: Although the incidence of traumatic posterior hip instability during the study period was low, all injured athletes missed time from football activities and competitions. Injuries that required surgery led to more missed time than those that did not. Ongoing research to understand risk factors and mechanisms of this injury, in conjunction with improvements to prevention and rehabilitation protocols, is necessary to ensure the safety of professional American football players.

Clavicle Fractures With Associated Acute Neurovascular Injury.

Descriptions of acute neurovascular injury after clavicle fracture are limited to case reports. The objectives of this study were to assess both the prevalence of acute neurovascular injury after midshaft clavicle fracture and the outcomes of early fracture stabilization. A retrospective chart review was conducted of all adult patients with midshaft clavicle fracture who were treated surgically at 2 tertiary care referral centers from January 2010 to March 2019. The records of patients who were identified as having clinical or radiographic evidence of neurovascular compromise were reviewed to assess for deficits on physical examination on presentation, relevant radiographic and electro-diagnostic findings, timing and type of fixation, and time until resolution of symptoms and radiographic union postoperatively. Of the 443 adult patients undergoing surgical treatment for displaced midshaft clavicle fracture, 3 (1%) experienced acute neurovascular compromise and underwent early fixation. In all cases, fracture displacement caused compression of adjacent neurovascular structures in the costoclavicular space. No lacerations of underlying neurovascular structures were encountered intraoperatively, suggesting a pattern of nerve contusion or vascular compression from the initial injury and fracture displacement. Postoperatively, 2 patients had full recovery of preoperative neurologic deficits and 1 patient experienced partial recovery of motor deficits with persistent neuropathic pain. There were no instances of symptomatic vascular insufficiency at final follow-up. Acute neurovascular injury as a result of compression of underlying structures in the costoclavicular space is a rare complication of displaced midshaft clavicle fracture. Early surgical decompression of compressed neurovascular structures and rigid clavicle osteosynthesis can lead to significant postoperative functional improvement. [Orthopedics. 2021;44(3):e390-e394.].

Does computerized CT-based 3D planning of the humeral head cut help to restore the anatomy of the proximal humerus after stemless total shoulder arthroplasty?

BACKGROUND: Restoration of proximal humeral anatomy (RPHA) after total shoulder arthroplasty (TSA) has been shown to result in better clinical outcomes than is the case in nonanatomic humeral reconstruction. Preoperative virtual planning has mainly focused on glenoid component placement. Such planning also has the potential to improve anatomic positioning of the humeral head by more accurately guiding the humeral head cut and aid in the selection of anatomic humeral component sizing. It was hypothesized that the use of preoperative 3-dimensional (3D) planning helps to reliably achieve RPHA after stemless TSA. METHODS: One hundred consecutive stemless TSA (67 males, 51 right shoulder, mean age of 62 ±9.4 years) were radiographically assessed using pre- and postoperative standardized anteroposterior radiographs. The RPHA was measured with the so-called circle method described by Youderian et al. We measured deviation from the premorbid center of rotation (COR), and more than 3 mm was considered as minimal clinically important difference. Additionally, pre- and postoperative humeral head diameter (HHD), head-neck angle (HNA), and humeral head height (HHH) were measured to assess additional geometrical risk factors for poor RPHA. RESULTS: The mean distance from of the premorbid to the implanted head COR was 4.3 ± 3.1 mm. Thirty-five shoulders (35%) showed a deviation of less than 3 mm (mean 1.9 ±1.1) and 65 shoulders (65%) a deviation of ≥3 mm (mean 8.0 ± 3.7). Overstuffing was the main reason for poor RPHA (88%). The level of the humeral head cut was responsible for overstuffing in 46 of the 57 overstuffed cases. The preoperative HHD, HHH, and HNA were significantly larger, higher, and more in valgus angulation in the group with accurate RPHA compared with the group with poor RPHA (HHD of 61.1 mm ± 4.4 vs. 55.9 ± 6.6, P < .001; HHH 8.6±2.2 vs. 7.6±2.6, P = .026; and varus angulation of 134.7° ±6.4° vs. 131.0° ±7.91, P = .010). CONCLUSION: Restoration of proximal humeral anatomy after stemless TSA using computed tomography (CT)-based 3D planning was not precise. A poorly performed humeral head cut was the main reason for overstuffing, which was seen in 88% of the cases with inaccurate RPHA. Preoperative small HHD, low HHH, and varus-angulated HNA are risk factors for poor RPHA after stemless TSA.

Effect of Posterior Glenoid Labral Tears at the NFL Combine on Future NFL Performance.

BACKGROUND: Posterior labral injuries have been recognized as a particularly significant clinical problem in collision and contact athletes. PURPOSE: To evaluate the effect that posterior labral tears have on early National Football League (NFL) performance based on position, associated injuries, and operative versus nonoperative management. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of all participants in the NFL Combine from 2009 to 2015 was performed using medical and imaging reports documented at the combine. Magnetic resonance imaging scans were analyzed for tear location, associated injuries, and evidence of previous surgical interventions. Each player's NFL draft position, as well as number of games played, number of games started, and snap percentage in his first 2 NFL seasons were collected for performance analysis and were compared with a control group of uninjured counterparts. RESULTS: Players with posterior labral tears were selected significantly later in the draft than those in the control group (draft position, 171.6 vs 156.1, respectively; P = .017). Although no single individual position was significantly affected by posterior labral tears, linemen (both offensive and defensive) with posterior labral tears were drafted significantly later than those without tears (draft position, 164.0 vs 137.7, respectively; P = .018) and had a significantly lower percentage of snaps in their first NFL season (23.8% vs 27.7%, respectively; P = .014). Players who underwent surgical management before the combine had a significantly higher percentage of snaps in their second NFL season than those who were managed conservatively (31.4% vs 22.3%, respectively; P = .022). None of the concomitant injuries recorded (superior labral anterior-posterior tears, glenoid bone loss, reverse Hill-Sachs lesions, rotator cuff tears, reverse humeral avulsions of the glenohumeral ligament, and posterior labral tears combined with anterior tears) significantly affected the draft position, number of games played, number of games started, or snap percentage for the cohort as a whole or any specific position. CONCLUSION: Posterior labral tears did negatively and significantly affect early NFL outcomes for collegiate football players across several different metrics, especially among linemen. While operative management did not produce significantly superior performance in most outcome measures, it may allow for better longevity of the shoulder and warrants further investigation. Concomitant shoulder injuries did not significantly affect early NFL outcomes in this cohort.

Jones Fractures Identified at the National Football League Scouting Combine: Assessment of Prognostic Factors, Computed Tomography Findings, and Initial Career Performance.

BACKGROUND: Jones fractures result in subsequent dysfunction and remain an issue for athletes. PURPOSE: To (1) describe the epidemiology, treatment, and impact of Jones fractures identified at the National Football League (NFL) Scouting Combine on players' early careers and (2) establish the value of computed tomography (CT) to determine bony healing after a fracture in prospective players. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All players who attended the combine between 2009 and 2015 were retrospectively reviewed to identify their history of Jones fractures. The playing position, treatment method, and number of missed collegiate games were recorded. The mean overall draft pick number, number of games started and played, snap percentage, and position-specific performance scores (fantasy score) over the first 2 years in the NFL were compared between players with fractures and controls. An imaging classification system was applied based on grading of each quadrant of the fifth metatarsal (plantar, dorsal, medial, lateral), with a score of 0 for not healed or 1 for healed. RESULTS: Overall, the number of Jones fractures identified was 72 in 2285 athletes (3.2%), with all treated via intramedullary screw fixation. The mean overall draft pick number for players with fractures was 111.2 ± 67.9 compared with 99.0 ± 65.9 for controls (P = .12). Performance scores for players with fractures were lower than those for controls across all positions, with a significant difference in running backs (2.6 vs 4.0, respectively; P < .001) and defensive linemen (1.4 vs 2.3, respectively; P = .02). The mean CT score was 2.5 ± 1.3. Of the 32 athletes who underwent imaging, 16 Jones fractures (50.0%) were healed or nearly healed, 12 (37.5%) were partially healed, and 4 (12.5%) showed little or no healing. The plantar cortex demonstrated the least healing (18/32; 56.3%), followed by the lateral cortex (15/32; 46.9%). Players with a mean score <1 were found to have fewer games started (2.7 ± 2.5) than those with 1 to 3 cortices healed (17.4 ± 10.4) or all cortices healed (8.7 ± 11.2). CONCLUSION: Based on CT, 50% of all players with a previous Jones fracture demonstrated incomplete healing. Moreover, position-specific performance scores over the first 2 years of a player's career were lower across all positions for those with fractures compared with controls. Players with CT scores <1 were found to start fewer games and were drafted later than controls.

Medial Collateral Ligament Injuries Identified at the National Football League Scouting Combine: Assessment of Epidemiological Characteristics, Imaging Findings, and Initial Career Performance.

BACKGROUND: The medial collateral ligament (MCL) is one of the most commonly injured structures in the knee, especially in young athletes. The impact of MCL injury on National Football League (NFL) performance in elite collegiate athletes has not yet been described in the literature. PURPOSE: We aim to (1) describe the prevalence and severity of MCL injuries in NFL Combine participants, (2) detail injury management, and (3) analyze the impact of MCL injury on NFL performance in terms of draft position, games played, games started, and snap percentage. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of all NFL Combine participants from 2009 to 2015 was performed by reviewing medical records and imaging reports from the combine to identify all players with MCL injuries. A control group was developed from the players evaluated at the combine without MCL injury. For each affected knee, the MCL injury was classified by location and severity based on results of magnetic resonance imaging (MRI). Each player's respective NFL draft position, number of NFL games played, number of NFL games started, and NFL snap percentage for the first 2 seasons in the league were collected through the use of NFL.com and Pro-Football-Focus, which are web-based, publicly accessible, comprehensive sports statistics databases. RESULTS: A total of 2285 players participated in the NFL Combine between 2009 and 2015. Three hundred one athletes (13.2%) were identified as having MCL injuries; 36 (12%) of the athletes with MCL injury presented with bilateral injuries, for a total of 337 MCL injuries. Additional soft tissue injury was identified on 187 of 337 (55%) MRIs. Players with a history of MCL injury were more likely to play at least 2 years in the NFL compared with those in the control group (P = .003). Players who had isolated MCL injury performed significantly better compared with athletes who had combined injuries with regard to draft position (P = .034), proportion playing at least 2 seasons in the NFL (P = .022), games played (P = .014), and games started (P = .020) in the first 2 years. No significant difference was found between players who underwent operative versus nonoperative management of their MCL injury. CONCLUSION: A relatively high percentage of players at the NFL Combine had evidence of MCL injury (13%). A prior history of MCL tear had no negative impact on an athlete's NFL performance. Players who had isolated MCL injury performed significantly better compared with athletes who had combined injuries with regard to draft position, proportion playing 2 seasons or more in the NFL, and games played and started in the first 2 years.

Effect of Anterior Glenoid Labral Tears and Glenoid Bone Loss at the NFL Combine on Future NFL Performance.

BACKGROUND: Anterior glenohumeral instability is a common abnormality in the young, athletic population, especially in those participating in contact or collision sports. PURPOSE: To examine the effect of anterior labral tears, their associated injuries, and their management on future National Football League (NFL) performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of all NFL Combine participants from 2009 to 2015 was performed using medical and imaging reports compiled at the NFL Combine. These notes and images were reviewed and analyzed for involved structures, associated injuries, and evidence of previous surgical interventions. The respective NFL draft position, number of NFL games played, number of NFL games started, and NFL snap percentage for each player's first 2 seasons were collected and compared with a control group and within subgroups. RESULTS: Of the 2285 players at the NFL Combine between 2009 and 2015, there were 206 (9%) anterior labral tears confirmed by magnetic resonance imaging, 20 of which were bilateral, for a total of 226 affected shoulders. There were 908 players who fit the criteria for inclusion in the control group. Overall, there were no significant differences between players with anterior labral tears and the control players in terms of draft position (P = .259), games played in their first 2 NFL seasons (P = .391), games started in their first 2 NFL seasons (P = .486), or snap percentage in their first (P = .268) and second (P = .757) NFL seasons. In general, sustaining a concomitant injury with an anterior labral tear (superior labrum from anterior to posterior [SLAP] tear, glenoid bone loss, Hill-Sachs lesion, rotator cuff tear, humeral avulsion of the glenohumeral ligament, and anterior tear combined with posterior tear) negatively affected a player's NFL draft position when compared with those with an isolated anterior labral tear (P = .003). There was no significant difference between operative and nonoperative management for anterior labral tears in terms of any performance metric. CONCLUSION: A history of anterior labral tears was not significantly associated with future NFL performance. While players with isolated injuries were drafted significantly earlier than those with concomitant injuries, combined injuries did not affect players' games played, games started, or snap percentage in their first 2 NFL seasons. Glenoid bone loss did significantly decrease draft position; however, the severity of bone loss did not affect draft position, and there were no significant associations between glenoid bone loss and games played, games started, or snap percentage.

The Epidemiology of Ankle Injuries Identified at the National Football League Combine, 2009-2015.

BACKGROUND: American football is a leading cause of sports-related injuries, with the knee, ankle, and shoulder most commonly involved. PURPOSE/HYPOTHESIS: The purpose of this study was to describe the epidemiology, characteristics, and imaging findings of ankle injuries in football players at the National Football League (NFL) Combine and determine the relationship to player position. We hypothesized that there would be a high relative incidence of ankle injuries in these players compared with other sports and that there would be a direct correlation between the incidence of ankle injuries and player position. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective chart review of data collected from NFL Combine participants between 2009 and 2015 was performed. Patient demographics, history, physical examination results, and imaging findings were reviewed. RESULTS: Of 2285 players, 1216 (53.2%) had a history of ankle injuries; of these, 987 (81.2%) had unilateral injuries, while 229 (18.8%) had bilateral injuries (total of 1445 ankles injured). This included 1242 ankle sprains (86.0% of ankle injuries): 417 (33.6% of sprains) high and 930 (74.9%) low. The most common soft tissue injuries were to the anterior talofibular ligament (n = 158, 12.7% of sprains) and syndesmosis (n = 137, 11.0%). Of all players at the NFL Combine with radiographs, 131 (10.9%) had evidence of an ankle fracture, all of which had healed. Magnetic resonance imaging (MRI) identified 66 players (28.9% of players at the combine who underwent MRI) with articular cartilage injuries: 62 involving the talus and 16 involving the tibia. Furthermore, 85 players (37.3% of players with MRI) with tendon injuries were identified: 26 Achilles, 55 peroneal, 3 flexor hallucis longus, and 19 posterior tibial. A total of 611 players (50.6% of players with radiographs) had signs of arthrosis on radiography. Running backs (61.9%), offensive linemen (60.3%), and tight ends (59.4%) had the highest rates of ankle injuries by position, while kickers/punters (23.3%) and long snappers (37.5%) had the lowest. CONCLUSION: Prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine. The rate of these ankle injuries varied by player position: offensive linemen, running backs, and tight ends had the highest overall rates, while special teams players had the lowest. Additional prospective work is needed to determine the impact of prior injuries on future playing career.

Body Mass Index Versus Body Fat Percentage in Prospective National Football League Athletes: Overestimation of Obesity Rate in Athletes at the National Football League Scouting Combine.

Provencher, MT, Chahla, J, Sanchez, G, Cinque, ME, Kennedy, NI, Whalen, J, Price, MD, Moatshe, G, and LaPrade, RF. Body mass index versus body fat percentage in prospective national football league athletes: overestimation of obesity rate in athletes at the national football league scouting combine. J Strength Cond Res 32(4): 1013-1019, 2018-Obesity has been previously noted as a major issue in the National Football League (NFL), where it has been shown that 97% of all players demonstrate a body mass index (BMI) of ≥25.0 with a reported obesity rate of 56% (BMI ≥ 30.0). However, BMI does not take into account body composition by mass, and may overestimate prevalence of obesity. The purposes of this study were (a) to determine the validity of BMI as a measure of body fat percentage and obesity in athletes at the NFL Combine, (b) to define the obesity rate based on body fat percentage compared with BMI, and (c) to determine the relationship between draft status and body composition. It was hypothesized that the rate of obesity, as measured by air displacement plethysmography (ADP), would be less than the rate of obesity as measured using BMI. Athletes who competed at the 2010 through 2016 NFL Combines were included in this study. Air displacement plethysmograph testing at the Combine was performed through BOD POD Body Composition Tracking System with collection of the following metrics: body fat percentage (%), and compared with BMI based on weight and height. In addition, the metrics were evaluated for differences over the 7-year study period to determine temporal changes and to determine draft status based on position relative to BOD POD calculations. A total of 1,958 NFL Combine participants completed ADP body composition testing. Based on BMI (≥30.0), the obesity rate was 53.4% versus an 8.9% obesity rate when using ADP. Drafted players demonstrated a significantly lower body fat percentage than undrafted players (p ≤ 0.05), with the exception of quarterbacks and running backs. All 8 positions of play, with the exception of defensive linemen, demonstrated a decrease in body fat percentage between 2010 and 2017. However, total body mass by position of play remained relatively constant with no significant change noted in any position. In conclusion, the obesity rate in prospective athletes at the NFL Combine was overestimated when calculated based on the BMI. Body fat percentage was more valid for determining an NFL player candidate's true body composition. Drafted players demonstrated a significantly lower body fat percentage in 6 of 8 positions compared with undrafted players. This is important to recognize for a strength and conditioning professional to use the correct metric when evaluating NFL players who could have been erroneously categorized in the obese population by their BMI. Furthermore, a higher percentage of fat translates to lower chances of becoming drafted.

Meniscectomy and Resultant Articular Cartilage Lesions of the Knee Among Prospective National Football League Players: An Imaging and Performance Analysis.

BACKGROUND: The effect of prior meniscectomy and the resulting reduction in meniscal tissue on a potential National Football League (NFL) player's articular cartilage status and performance remain poorly elucidated. Purpose/Hypothesis: (1) To determine the epidemiology, imaging characteristics, and associated articular cartilage pathology of the knee among players with a previous meniscectomy who were participating in the NFL Combine and (2) to evaluate the effect of these injuries on performance as compared with matched controls. The hypothesis was that players with less meniscal tissue would have worse cartilage status and inferior performance metrics in their first 2 NFL seasons. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All athletes with a history of a meniscectomy and magnetic resonance imaging scan of the knee who participated in the NFL Combine (2009-2015) were identified. Medical records and imaging were analyzed, and surgical history, games missed in college, position played, and draft position were documented. The conditions of the meniscus and cartilage were graded with modified ISAKOS scores (International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine) and ICRS scores (International Cartilage Repair Society), respectively. Players with a previous meniscectomy of at least 10% of total medial or lateral meniscal volume excised (ISAKOS meniscus grade ≤8) and matched controls without a significant pre-Combine injury were similarly evaluated and compared by position of play through analysis of draft position, number of games played and started, and how many eligible plays they participated in (snap percentage) within the first 2 NFL seasons. RESULTS: Of the 2285 players who participated in the NFL Combine (2009-2015), 287 players (322 knees) had a prior meniscectomy (206 lateral, 81 medial). Among these players, 247 (85%) had a total of 249 chondral lesions, most commonly on the lateral femoral condyle (111 lesions, 45%). There was a significant inverse correlation found between the ISAKOS medial and lateral meniscus grade and the corresponding compartment chondral lesion grade ( P = .001). A poorer meniscus score was also associated with worse chondral pathology, especially in the lateral compartment. After controlling for position of play, the injury-free control group had a significantly greater number of total games played and games started and higher snap percentage versus those with a prior meniscectomy of at least 10% volume (ISAKOS meniscus grade ≤8). Players with severe chondral lesions (ICRS grade 4) in the medial and lateral compartments had significantly worse performance metrics when compared with matched controls. CONCLUSION: Previous meniscectomy of at least 10% of total medial or lateral meniscus volume in prospective NFL players was significantly correlated with larger and more severe chondral lesions. Chondral and meniscal defects of the knee were found to result in a significant decrease in objective performance measures during a player's initial NFL career versus matched controls. Given these findings, players with a prior meniscectomy with evidence of chondral damage should be evaluated carefully for their overall functional levels; however, additional work is needed to fully clarify the effect of prior knee meniscal surgery on overall NFL performance.

Symptomatic Focal Knee Chondral Injuries in National Football League Combine Players Are Associated With Poorer Performance and Less Volume of Play.

PURPOSE: To (1) describe the magnetic resonance imaging (MRI) characteristics of knee chondral injuries identified at the National Football League (NFL) Combine and (2) assess in-game performance of prospective NFL players with previously untreated knee chondral injuries and compare it with matched controls. METHODS: All players with knee chondral injuries identified at the NFL Combine (2009-2015) were retrospectively reviewed. Players with prior knee surgery were excluded. A knee MRI for each player was reviewed; location, modified International Cartilage Repair Society (ICRS) grade (I-IV), and associated compartment subchondral edema were documented. Position, respective NFL Draft pick selection number, games started, played, snap percentage, and position-specific performance metrics during the first 2 NFL seasons were recorded for the injury and injury-free control group composed of players with (1) no prior knee injury, (2) no significant missed time prior to the NFL (≤2 total missed games in college), (3) no history of knee surgery, and (4) drafted in the respective NFL Draft following the NFL Combine. RESULTS: Of the 2,285 players reviewed, 101 (4.4%) had an injury without prior knee surgery. The patella (63.4%) and trochlea (34%) were most commonly affected. Defensive linemen were at highest risk for unrecognized injuries (odds ratio 1.8, P = .015). Players with previously untreated injuries, compared with controls, were picked later (mean pick: 125.8) and played (mean: 23) and started (mean: 10.4) fewer games during the initial 2 NFL seasons (P < .001 for all). Particularly, subchondral bone edema and full-thickness cartilage injuries were associated with fewer games played (P = .003). CONCLUSIONS: The patellofemoral joint was most commonly affected in NFL Combine participants. Previously untreated knee articular injuries in players at the NFL Combine are associated with poorer early NFL performance in comparison to uninjured players. Subchondral bone edema and full-thickness cartilage injury on MRI were associated with fewer games played during the initial NFL career. LEVEL OF EVIDENCE: Level III, case-control study.

Posterior Cruciate Ligament Injuries of the Knee at the National Football League Combine: An Imaging and Epidemiology Study.

PURPOSE: To determine the epidemiology by player position, examination, imaging findings, and associated injuries of posterior cruciate ligament (PCL) injuries in players participating in the National Football League (NFL) Combine. METHODS: All PCL injuries identified at the NFL Combine (2009-2015) were reviewed. Data were obtained from the database organized by the NFL medical personnel for the compilation of the medical and physical performance examination results of NFL Draftees participating in the NFL Combine from 2009 to 2015. Inclusion criteria were any player with clinical findings or a previous surgery consistent with a PCL injury who participated in the NFL Combine. RESULTS: Of the 2,285 players who participated in the NFL Combine between 2009 and 2015, 69 (3%) had evidence of a PCL injury, of which 11 players (15.9%) were managed surgically. On physical examination, 35 players (52%) had a grade II or III posterior drawer. Concomitant injuries were present frequently and included medial collateral ligament (MCL; 42%), anterior cruciate ligament (ACL; 11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. CONCLUSIONS: Three percent of the players at the NFL Combine presented with a PCL injury, with a significant amount being either running backs (14/69, 20.2%) or offensive linemen (14/69, 20.2%). Approximately half of the players with a PCL tear had a residual grade II or III posterior drawer after sustaining a PCL injury. Concomitant injuries were present frequently and included MCL (42%), ACL (11.6%), and chondral injuries (31.8%), especially in the lateral tibiofemoral compartment. For those players with clinical concern for PCL ligamentous laxity, there should be a complete comprehensive workup that includes plain and PCL stress view radiographs, and magnetic resonance imaging. LEVEL OF EVIDENCE: Level IV, case series.

The Latarjet Procedure at the National Football League Scouting Combine: An Imaging and Performance Analysis.

BACKGROUND: The Latarjet procedure is commonly performed in the setting of glenoid bone loss for treatment of recurrent anterior shoulder instability; however, little is known regarding the outcomes of this procedure in elite American football players. PURPOSE: (1) Determine the prevalence, clinical features, and imaging findings of elite college football athletes who present to the National Football League (NFL) Combine with a previous Latarjet procedure and (2) describe these athletes' performance in the NFL in terms of draft status and initial playing time. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: After review of all football players who participated in the NFL Combine from 2009 to 2016, any player with a previous Latarjet procedure was included in this study. Medical records, position on the field, and draft position were recorded for each player. In addition, imaging studies were reviewed to determine fixation type, hardware complications, and status of the bone block. For those players who were ultimately drafted, performance was assessed based on games played and started, total snaps, and percentage of eligible snaps in which the player participated during his rookie season. RESULTS: Overall, 13 of 2617 (<1%) players at the combine were identified with a previous Latarjet procedure. Radiographically, 8 of 13 (61%) showed 2-screw fixation, while 5 of 13 (39%) had 1 screw. Of the 13 players, 6 (46%) players demonstrated hardware complications. All players had evidence of degenerative changes on plain radiographs, with 10 (77%) graded as mild, 1 (8%) as moderate, and 2 (15%) as severe according to the Samilson Prieto classification. Six of the 13 (46%) players went undrafted, while the remaining 7 (54%) were drafted; however, no player participated in more than half of the plays for which he was eligible during his rookie season. CONCLUSION: Only a small percentage of players at the NFL Combine (<1%) had undergone a Latarjet procedure. High rates of postoperative complications and radiographically confirmed degenerative change were observed. Athletes who had undergone a Latarjet procedure demonstrated a variable amount of playing time, but none participated in more than half of their eligible plays during their rookie season.

Total Elbow Arthroplasty in the United States: Evaluation of Cost, Patient Demographics, and Complication Rates.

Total elbow arthroplasty (TEA) is utilized in the treatment of rheumatoid and post-traumatic elbow arthritis. TEA is a relatively low volume surgery in comparison to other types of arthroplasty and therefore little is known about current surgical utilization, patient demographics and complication rates in the United States. The purpose of our study is to evaluate the current practice trends and associated in-patient complications of TEA at academic centers in the United States. We queried the University Health Systems Consortium administrative database from 2007 to 2011 for patients who underwent an elective TEA. A descriptive analysis of demographics was performed which included patient age, sex, race, and insurance status. We also evaluated the following patient clinical benchmarks: hospital length of stay (LOS), hospital direct cost, in-hospital mortality, complications, and 30-day readmission rates. Our cohort consisted of 3146 adult patients (36.5% male and 63.5% female) with an average age of 58 years who underwent a total elbow arthroplasty (159 academic medical centers) in the United States. The racial demographics included 2334 (74%) Caucasian, 285 (9%) black, 236 (7.5%) Hispanic, 16 (0.5%) Asian, and 283 (9%) other patients. The mean LOS was 4.2±5 days and the mean total direct cost for the hospital was 16,300±4000 US Dollars per case. The overall inpatient complication rate was 3.1% and included mortality <1%, DVT (0.8%), re-operation (0.5%), and infection (0.4%). The 30-day readmission rate was 4.4%. TEA is a relatively uncommon surgery in comparison to other forms of arthroplasty but is associated with low in-patient and 30-day perioperative complication rate. Additionally, the 30-day readmission rate and overall hospital costs are comparable to the traditional total hip and knee arthroplasty surgeries.