Female patients have greater improvement in pain symptoms and physical activity after fasciotomy for treatment of chronic exertional compartment syndrome of the lower leg.

PURPOSE: The purpose of this study was to identify sex differences in postoperative outcomes and return-to-sport rates after fasciotomy for treatment of chronic exertional compartment syndrome (CECS) of the lower leg. It was hypothesised that male CECS patients would have a higher rate of return to sport than female CECS patients. METHODS: A retrospective cohort study was conducted involving patients who underwent primary fasciotomy of one to four leg compartments for treatment of CECS at a single centre from 2010 to 2020. Each affected leg was treated as a separate subject. Postoperative outcomes included CECS pain frequency and severity, return to sport and Tegner activity level. Multivariable regression was used to determine if sex was an independent predictor of outcomes after adjusting for demographic and clinical covariates. p < 0.05 were considered significant. RESULTS: Eighty-one legs (44 M, 37 F) of 47 unique patients (34 of whom had bilateral symptoms) were included with a mean follow-up time of 51.5 ± 31.4 months. Male subjects were older (p < 0.001) and had higher body mass index (p < 0.001) compared to female subjects. Most subjects (84.0%) underwent two- or four-compartment fasciotomies. Female sex was found to be predictive of lower overall postoperative pain severity (p = 0.007), higher odds of return to sport (p = 0.04) and higher postoperative Tegner score (p = 0.005). However, female sex was not predictive of postoperative pain frequency, odds of reoperation or odds of return to sport to at least the presymptomatic level (all p < 0.05). CONCLUSION: Female sex is independently predictive of reduced overall pain severity, higher odds of return to sport and higher postoperative improvement in Tegner score following fasciotomy for treatment of lower-limb CECS. LEVEL OF EVIDENCE: III.

Glenohumeral morphological predictors of recurrent shoulder instability following arthroscopic Bankart repair.

PURPOSE: The purpose of this study was to evaluate glenohumeral morphological features on a magnetic resonance arthrogram (MRA) to determine risk factors for recurrence of anterior shoulder instability following arthroscopic Bankart repair (ABR). METHODS: A retrospective review of patients who underwent ABR between 2012 and 2017 was performed to identify patients who had recurrence of instability following stabilisation (Group 1). These were pair-matched in a 2:1 ratio for age, gender and sport with a control (Group 2) who underwent ABR without recurrence. Preoperative MRAs were evaluated for risk factors for recurrence, with glenoid bone loss and Hill-Sachs lesions also measured. Multilinear and multilogistic regression models were used to evaluate factors affecting recurrence. RESULTS: Overall, 72 patients were included in this study, including 48 patients without recurrence and 24 patients with recurrent instability. There was a significant difference between the two groups in mean glenoid bone loss (Group 1: 7.3% vs. Group 2: 5.7%, p < 0.0001) and the rate of off-track Hill-Sachs lesions (Group 1: 20.8% vs. Group 2: 0%, p = 0.0003). Of the variables analysed in logistic regression, increased glenoid anteversion (p = 0.02), acromioclavicular (AC) degeneration (p = 0.03) and increased Hill-Sachs width were associated with increased risk of failure. Increased chondral version (p = 0.01) and humeral head diameter in the anteriorposterior view were found to be protective and associated with a greater likelihood of success. CONCLUSION: Glenoid anteversion was a risk factor for recurrent instability, whereas increased chondral version and humeral head diameter were associated with higher rates of success following ABR. Glenoid bone loss, presence of an off-track Hill-Sachs lesion, increased Hill-Sachs width and AC degeneration were also associated with failure. These findings should be used by surgeons to stratify risk for recurrence following ABR. LEVEL OF EVIDENCE: Level III.

Paresthesia Is Predictive of Symptom Recurrence After Fasciotomy for Exertional Compartment Syndrome of the Leg.

BACKGROUND: Exertional compartment syndrome (ECS) is an underdiagnosed cause of lower extremity pain among athletes. The condition can be managed operatively by fasciotomy to relieve excess compartment pressure. However, symptom recurrence rates after fasciotomy are considerable, ranging from 3% to 17%. HYPOTHESIS: Leg paresthesia and its distribution during ECS episodes would be a significant predictor of outcomes after fasciotomy. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 4. METHODS: We conducted a retrospective chart review of patients who underwent fasciotomy for ECS at our center from 2010 to 2020 (institutional review board no. 21-00107). We measured postoperative outcomes including pain frequency and severity, Tegner activity level, and return to sport. Significant predictors of outcomes were identified using multivariable linear and logistic regression. P values <0.05 were considered significant. RESULTS: A total of 78 legs (from 42 male and 36 female participants) were included in the study with average follow-up of 52 months (range, 3-126 months); 33 participants (42.3%) presented with paresthesia. Paresthesia was an independent predictor of worse outcomes, including more severe pain at rest (P = 0.05) and with daily activity (P = 0.04), reduced postoperative improvement in Tegner scores (P = 0.04), and lower odds of return to sport (P = 0.05). Those with paresthesia symptoms in the tibial nerve distribution had worse outcomes than those without paresthesia in terms of preoperative-to-present improvement in pain frequency (P < 0.01), pain severity at rest (P < 0.01) and with daily activity (P = 0.04), and return to sport (P = 0.04). CONCLUSION: ECS patients who present with paresthesia have worse pain and activity outcomes after first-time fasciotomy, but prognosis is worst among those with tibial nerve paresthesia. CLINICAL RELEVANCE: Paresthesia among ECS patients is broadly predictive of more severe recurrent leg pain, reduced activity level, and decreased odds of return to sport after fasciotomy.

Remplissage Procedure Indications, Techniques, and Outcomes.

Hill-Sachs lesions are a challenging clinical problem in the context of anterior shoulder instability. Historically, unless very large, these lesions were thought to be less significant than glenoid defects. Recently, more importance has been placed on whether a Hill-Sachs lesion is on-track or offtrack, with off-track lesions predisposing patients to higher risk of postoperative recurrent instability. Given the high risk for recurrent shoulder instability in patients with Hill-Sachs lesions that are off-track, augmentation procedures, such as the remplissage procedure, are often indicated alongside a Bankart repair. The proposed advantages of the remplissage include directly addressing the Hill-Sachs lesion to prevent engagement, the ability to address any associated intraarticular pathologies during the arthroscopy, and to avoid a more invasive open procedure with a higher complication rate. Remplissage has been shown to reduce the recurrence rate compared to those undergoing arthroscopic Bankart repair alone and to have a comparable recurrence rate to the Latarjet procedure in the appropriately selected patient while also having a much lower complication rate than the Latarjet procedure.

Cost-Effectiveness Analysis of Treatment of Radial Head Subluxation.

PURPOSE: Radial head subluxation (RHS), also called nursemaid's elbow, is a common injury in young children treated by various health care providers. The diagnosis typically does not require radiographs, but they are often ordered in the emergency room. This study aimed to determine if there was a difference in the efficacy, cost, and amount of radiographs taken in RHS treatment according to the provider, specifically between orthopedic surgeons and pediatricians. METHODS: We reviewed the charts of 207 patients presenting with RHS in the emergency department (mean age of presentation = 2.1 years, range: 0.3 to 6.5 years) to determine the provider treating the condition, the number of attempts at reduction, the number of radiographs taken, the post-reduction management, and total hospital cost incurred. RESULTS: One hundred forty-four patients were treated by orthopedic surgeons, 51 by pediatricians, and 13 by residents. The mean number of radiographs obtained was 0.1, 0.8, and 0.5 for groups treated by an orthopedic surgeon, a pediatrician, and a resident, respectively (p = 0.04). The mean cost for reduction of an RHS was $114, $648, and $267 for groups treated by an orthopedic surgeon, a pediatrician, and a resident, respectively (p = 0.04) Conclusion: Although all three groups were effective in treating RHS, there was a significantly reduced hospital cost and a reduced need for radiographs when the provider was an orthopedic surgeon.

Force plate jump testing metrics are predictive of performance on a multimodal return to sport testing protocol among anterior cruciate ligament reconstruction patients at minimum six-month follow-up.

BACKGROUND: Force plate-based jump testing may serve as a potential alternative to traditional return to sport (RTS) testing batteries. The purpose of our study was to identify force plate jump metrics that were predictive of RTS test findings in patients who were at least six months postoperative following anterior cruciate ligament reconstruction (ACLR). METHODS: We conducted a cross-sectional study of patients who underwent ACLR at our center and were at least six months postoperative. Subjects completed a multimodal Institutional RTS (IRTS) testing battery which included range of motion (ROM) testing and isokinetic quadriceps strength testing. Subjects also completed a countermovement jump testing protocol on a commercially-available force plate. Jump metrics predictive of IRTS test findings were identified using multivariable linear and logistic regression with stepwise selection. Model significance was assessed at α=0.002. RESULTS: Sixteen patients (7M, 9F) were enrolled in our study with median age of 29 years (range 20-47). Relative concentric impulse was positively predictive of knee flexion active ROM (ß=7.07, P=0.01) and passive ROM (ß=9.79, P=0.003). Maximum power was positively predictive of quadriceps strength at 60 deg/s (ß=3.27, P<0.001) and 180 deg/s (ß=2.46, P<0.001). Center-of-pressure (COP) shift acceleration along the force plate X-axis was negatively predictive of Bunkie lateral test score (ß=-945, P<0.001) and medial test score (ß=-839, P=0.03). CONCLUSIONS: Force plate-derived vertical jump testing metrics are predictive of certain components of a multimodal RTS physical assessment for ACLR patients, including knee flexion ROM, quadriceps strength on isokinetic testing, and Bunkie Test performance.

Clinical Outcomes After Concomitant Hip Arthroscopy and Iliotibial Band Lengthening With Trochanteric Bursectomy Compared to a Matched Cohort.

PURPOSE: This study sought to determine the clinical outcomes of patients that underwent hip arthroscopy for femoroacetabular impingement (FAI) and concomitant arthroscopic iliotibial (IT) band lengthening with trochan- teric bursectomy (TB group) as well as a matched cohort of patients undergoing hip arthroscopy for isolated FAI symptoms (NTB group) from baseline to a minimum of 2-year follow-up. METHODS: Patients who were diagnosed with FAI and symptomatic trochanteric bursitis and who failed con- servative measures and underwent hip arthroscopy and arthroscopic IT band lengthening with trochanteric bur- sectomy were identified. These patients were matched by age, sex, and body mass index (BMI) to a group of patients who underwent surgery for FAI without trochanteric bur- sitis symptoms. Patients were separated into two groups: iliotibial band lengthening with trochanteric bursectomy (TB) and non-trochanteric bursectomy (NTB). The patient reported outcomes (PROs) recorded were the modified Har- ris Hip Score (mHHS) and Non-Arthritic Hips Score (NAHS), which were obtained with a minimum of 2-years follow-up. RESULTS: Each cohort was composed of 22 patients. The TB cohort was composed of 19 females (86%) with a re- ported mean age of 49.3 ± 11.6 years. The NTB cohort was composed of 19 females (86%) with a reported mean age of 49.0 ± 11.7 years. Both cohorts showed significant improve- ment from baseline in the mHHS and NAHS. There was no significant difference in the mHHS and NAHS between the two groups. There was no significant difference between TB and NTB groups with respect to achieving minimal clinically important difference (MCID), [19 (86%) vs. 20 (91%), p > 0.99] or patient acceptable symptom state (PASS), [13 (59%) vs. 14 (64%), p = 0.76]. CONCLUSIONS: There was no difference in PROs of patients with FAI and trochanteric bursitis who underwent hip ar- throscopy with concomitant arthroscopic IT band lengthen- ing with trochanteric bursectomy compared to patients with isolated FAI who underwent hip arthroscopy.

No difference in clinical outcomes between operative and nonoperative management of minimally retracted proximal hamstring ruptures.

PURPOSE: The indications for surgical treatment of proximal hamstring ruptures are continuing to be refined. The purpose of this study was to compare patient-reported outcomes (PROs) between patients who underwent operative or nonoperative management of proximal hamstring ruptures. METHODS: A retrospective review of the electronic medical record identified all patients who were treated for a proximal hamstring rupture at our institution from 2013 to 2020. Patients were stratified into two groups, nonoperative or operative management, which were matched in a 2:1 ratio based on demographics (age, gender, and body mass index), chronicity of the injury, tendon retraction, and number of tendons torn. All patients completed a series of PROs including the Perth Hamstring Assessment Tool (PHAT), Visual Analogue Scale for pain (VAS), and the Tegner Activity Scale. Statistical analysis was performed using multi-variable linear regression and Mann-Whitney testing to compare nonparametric groups. RESULTS: Fifty-four patients (mean age = 49.6 ± 12.9 years; median: 49.1; range: 19-73) with proximal hamstring ruptures treated nonoperatively were successfully matched 2:1 to 27 patients who had underwent primary surgical repair. There were no differences in PROs between the nonoperative and operative cohorts (n.s.). Chronicity of the injury and older age correlated with significantly worse PROs across the entire cohort (p < 0.05). CONCLUSIONS: In this cohort of primarily middle-aged patients with proximal hamstring ruptures with less than three centimeters of tendon retraction, there was no difference in patient-reported outcome scores between matched cohorts of operatively and nonoperatively managed injuries. LEVEL OF EVIDENCE: Level III.

Despite Equivalent Clinical Outcomes, Patients Report Less Satisfaction With Telerehabilitation Versus Standard In-Office Rehabilitation After Arthroscopic Meniscectomy: A Randomized Controlled Trial.

Purpose: To evaluate functional outcomes and satisfaction in patients who underwent telerehabilitation (telerehab) compared with in-person rehabilitation after arthroscopic meniscectomy. Methods: A randomized-controlled trial was conducted including patients scheduled to undergo arthroscopic meniscectomy for meniscal injury by 1 of 5 fellowship-trained sports medicine surgeons between September 2020 and October 2021. Patients were randomized to receive telerehab, defined as exercises and stretches provided by trained physical therapists over a synchronous face-to-face video visit or in-person rehabilitation for their postoperative course. International Knee Documentation Committee Subjective Knee Form (IKDC) score and satisfaction metrics were collected at baseline and 3 months postoperatively. Results: Analysis was conducted on 60 patients with 3-month follow-up outcomes. There were no significant differences in IKDC scores between groups at baseline (P = .211) and 3 months' postoperatively (P = .065). Patients were more likely to report being satisfied with their rehabilitation group 73% vs. 100% (P = .044) if there were in the in-person group. Satisfaction differed significantly between the 2 groups at the end of their rehabilitation course, and only 64% of those in the telerehab group would elect to undergo telerehab again for future indications. Furthermore, they believed that future rehabilitation would benefit from a hybrid model. Conclusions: Telerehab showed no difference versus traditional in-person rehabilitation in terms of functional outcomes up to 3 months after arthroscopic meniscectomy. However, patients were less satisfied with telerehab. Level of Evidence: I, randomized controlled trial.

The Majority of Sports Medicine and Arthroscopy-Related Randomized Controlled Trials Reporting Nonsignificant Results Are Statistically Fragile.

PURPOSE: To evaluate the robustness of sports medicine and arthroscopy related randomized controlled trials (RCTs) reporting nonsignificant results by calculating the reverse fragility index (RFI) and reverse fragility quotient (RFQ). METHODS: All sports medicine and arthroscopic-related RCTs from January 1, 2010, through August 3, 2021, were identified. Randomized-controlled trials comparing dichotomous variables with a reported P value ≥ .05 were included. Study characteristics, such as publication year and sample size, as well as loss to follow-up and number of outcome events were recorded. The RFI at a threshold of P < .05 and respective RFQ were calculated for each study. Coefficients of determination were calculated to determine the relationships between RFI and the number of outcome events, sample size, and number of patients lost to follow-up. The number of RCTs in which the loss to follow-up was greater than the RFI was determined. RESULTS: Fifty-four studies and 4,638 patients were included in this analysis. The mean sample size and loss to follow-up were 85.9 patients and 12.5 patients, respectively. The mean RFI was 3.7, signifying that a change of 3.7 events in one arm was needed to flip the results of the study from non-significant to significant (P < .05). Of the 54 studies investigated, 33 (61%) had a loss to follow-up greater than their calculated RFI. The mean RFQ was 0.05. A significant correlation between RFI with sample size (R2 = 0.10, P = .02) and the total number of observed events (R2 = 0.13, P < .01) was found. No significant correlation existed between RFI and loss to follow-up in the lesser arm (R2 = 0.01, P = .41). CONCLUSIONS: The RFI and RFQ are statistical tools that allow the fragility of studies reporting nonsignificant results to be appraised. Using this methodology, we found that the majority of sports medicine and arthroscopy-related RCTs reporting nonsignificant results are fragile. CLINICAL RELEVANCE: RFI and RFQ serve as tools that can be used to assess the validity of RCT results and provide additional context for appropriate conclusions.

Factors impacting time to total shoulder arthroplasty among patients with primary glenohumeral osteoarthritis and rotator cuff arthropathy managed conservatively with corticosteroid injections.

BACKGROUND: The purpose of this study was to identify predictors of the time from initial presentation to total shoulder arthroplasty (TSA) in patients with primary glenohumeral osteoarthritis (OA) and rotator cuff (RTC) arthropathy who were conservatively managed with corticosteroid injections. METHODS: We conducted a retrospective cohort study of patients who underwent TSA from 2010 to 2021. Kaplan-Meier survival analysis was used to estimate median time to TSA for primary OA and RTC arthropathy patients. The Cox proportional hazards model was used to identify significant predictors of time to TSA and to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Statistical significance was set at P<0.05. RESULTS: The cohort included 160 patients with primary OA and 92 with RTC arthropathy. In the primary OA group, median time to TSA was 15 months. Significant predictors of shorter time to TSA were older age at presentation (HR, 1.02; 95% CI, 1.00-1.04; P=0.03) and presence of moderate or severe acromioclavicular joint arthritis (HR, 1.45; 95% CI, 1.05-2.01; P=0.03). In the RTC arthropathy group, median time to TSA was 14 months, and increased number of corticosteroid injections was associated with longer time to TSA (HR, 0.87; 95% CI, 0.80-0.95; P=0.003). CONCLUSIONS: There are distinct prognostic factors for progression to TSA between primary OA patients and RTC arthropathy patients managed with corticosteroid injections. Multiple corticosteroid injections are associated with delayed time to TSA in RTC arthropathy patients.

Elbow Ulnar Collateral Ligament Tears: A Modified Consensus Statement.

PURPOSE: To establish consensus statements on the treatment of ulnar collateral ligament (UCL) injuries and to investigate whether consensus on these distinct topics could be reached. METHODS: A modified consensus technique was conducted among 26 elbow surgeons and 3 physical therapists/athletic trainers. Strong consensus was defined as 90% to 99% agreement. RESULTS: Of the 19 total questions and consensus statements 4 achieved unanimous consensus, 13 achieved strong consensus, and 2 did not achieve consensus. CONCLUSIONS: There was unanimous agreement that the risk factors include overuse, high velocity, poor mechanics, and previous injury. There was unanimous agreement that advanced imaging in the form of either magnetic resonance imaging or magnetic resonance arthroscopy should be performed in a patient presenting with suspected/known UCL tear that plans to continue to play an overhead sport, or if the imaging study could change the management of the patient. There was unanimous agreement regarding lack of evidence for the use of orthobiologics in the treatment of UCL tears as well as the areas pitchers should focus on when attempting a course of nonoperative management. The statements that reached unanimous agreement for operative management were regarding operative indications and contraindications for UCL tears, prognostic factors that should be taken into consideration in when performing UCL surgery, how to deal with the flexor-pronator mass during UCL surgery, and use of an internal brace with UCL repairs. Statements that reached unanimous agreement for return to sport (RTS) were regarding portions of the physical examination should be considered when determining whether to allow a player to RTS; unclear how velocity, accuracy, and spin rate should be factored into the decision of when players can RTS and sports psychology testing should be used to determine whether a player is ready to RTS. LEVEL OF EVIDENCE: V, expert opinion.

The Efficacy of Tranexamic Acid for the Treatment of Traumatic Hip Fractures: A Network Meta-Analysis.

OBJECTIVES: To compare the efficacy of different dosages of intravenous (IV) tranexamic acid (TXA) in the treatment of traumatic hip fractures against that of the control group of no TXA. DATA SOURCES: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to perform a network meta-analysis on the use of TXA for the treatment of hip fractures. The study team used Ovid MEDLINE, Cochrane Reviews, Scopus, Embase, and Web of Science databases to perform the search. Studies that were published in English between the years 2010 and 2020 were selected. STUDY SELECTION/DATA EXTRACTION: For inclusion in this study, selected articles were required to be randomized controlled trials with at least 1 control group that had no antifibrinolytic intervention to serve as a control, and IV formulations of TXA were used as part of the treatment group. Furthermore, all study participants must have undergone surgical intervention for traumatic hip fractures. Studies that did not immediately meet criteria for inclusion were saved for a review by the full investigating team and were included based on consensus. DATA SYNTHESIS: All statistical analyses conducted for this study were performed using R software (R Foundation for Statistical Computing, Vienna, Austria). Network meta-analyses were conducted with a frequentist approach with a random-effects model using the netmeta package version 0.9-6 in R. The frequentist equivalent to surface under the cumulative ranking probabilities, termed " P score," was used to rank different treatments. CONCLUSION: The use of TXA in the surgical management of traumatic hip fractures reduces the number of transfusions and perioperative blood loss, with minimal to no increased incidence of thrombotic events when compared with those in controls. When comparing formulations, no route of administration is clearly superior in reducing perioperative blood loss. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Reverse Fragility Index: Interpreting the Current Literature on Long-Term Survivorship of Computer-Navigated Versus Conventional TKA: A Systematic Review and Cross-Sectional Study of Randomized Controlled Trials.

BACKGROUND: Despite the most recent American Academy of Orthopaedic Surgeons clinical practice guideline making a "strong" recommendation against the use of intraoperative navigation in total knee arthroplasty (TKA), its use is increasing. We utilized the concept of the reverse fragility index (RFI) to assess the strength of neutrality of the randomized controlled trials (RCTs) comparing the long-term survivorship of computer-navigated and conventional TKA. METHODS: A systematic review was performed including all RCTs through August 3, 2021, comparing the long-term outcomes of computer-navigated and conventional TKA. Randomized trials with mean follow-up of >8 years and survivorship with revision as the end point were included. The RFI quantifies the strength of a study's neutrality by calculating the minimum number of events necessary to flip the result from nonsignificant to significant. The RFI at a threshold of p < 0.05 was calculated for each study reporting nonsignificant results. The reverse fragility quotient (RFQ) was calculated by dividing the RFI by the study sample size. RESULTS: Ten clinical trials with 2,518 patients and 38 all-cause revisions were analyzed. All 10 studies reported nonsignificant results. The median RFI at the p < 0.05 threshold was 4, meaning that a median of 4 events would be needed to change the results from nonsignificant to significant. The median RFQ was 0.029, indicating that the nonsignificance of the results was contingent on only 2.9 events per 100 participants. The median loss to follow-up was 27 patients. In all studies, the number of patients lost to follow-up was greater than the RFI. CONCLUSIONS: The equipoise in long-term survivorship between computer-navigated and conventional TKA rests on fragile studies, as their statistical nonsignificance could be reversed by changing the outcome status of only a handful of patients--a number that was always smaller than the number lost to follow-up. Routine reporting of the RFI in trials with nonsignificant findings may provide readers with a measure of confidence in the neutrality of the results. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Minimal Clinically Important Difference: A Review of Clinical Significance.

BACKGROUND: The minimal clinically important difference (MCID) is a term synonymous with orthopaedic clinical research over the past decade. The term represents the smallest change in a patient-reported outcome measure that is of genuine clinical value to patients. It has been derived in a myriad of ways in existing orthopaedic literature. PURPOSE: To describe the various modalities for deriving the MCID. STUDY DESIGN: Narrative review; Level of evidence, 4. METHODS: The definitions of common MCID determinations were first identified. These were then evaluated by their clinical and statistical merits and limitations. RESULTS: There are 3 primary ways for determining the MCID: anchor-based analysis, distribution-based analysis, and sensitivity- and specificity-based analysis. Each has unique strengths and weaknesses with respect to its ability to evaluate the patient's clinical status change from baseline to posttreatment. Anchor-based analyses are inherently tied to clinical status yet lack standardization. Distribution-based analyses are the opposite, with strong foundations in statistics, yet they fail to adequately address the clinical status change. Sensitivity and specificity analyses offer a compromise of the other methodologies but still rely on a somewhat arbitrarily defined global transition question. CONCLUSION: This current concepts review demonstrates the need for (1) better standardization in the establishment of MCIDs for orthopaedic patient-reported outcome measures and (2) better study design-namely, until a universally accepted MCID derivation exists, studies attempting to derive the MCID should utilize the anchor-based within-cohort design based on Food and Drug Administration recommendations. Ideally, large studies reporting the MCID as an outcome will also derive the value for their populations. It is important to consider that there may be reasonable replacements for current derivations of the MCID. As such, future research should consider an alternative threshold score with a more universal method of derivation.

The COVID lockdown and its effects on soft tissue injuries in Premier League Athletes.

BACKGROUND: During the COVID impacted 2020-2021 season of the English soccer league, there was an appreciable number of injuries experienced by players. These injuries, however, have not been quantified against previous seasons to highlight the altered season as a causative factor. METHODS: A review of an online database was conducted to search for injuries to football players in the Premier League across three seasons; 2018-2019, 2019-2020, and 2020-2021, to compare for difference in injury rates across the years and assess for higher rates in this current season, where athletes have had less play time due to COVID-19. Injury number and injury characteristics were abstracted from the online database Transfermarkt, with the provided information allowing for the sorting of the data into muscular and ligamentous injuries and skeletal injuries. RESULTS: Overall 226, 260, and 289 muscular and ligamentous injuries were observed across the 2018/2019, 2019/2020, and 2020/2021 seasons, respectively. There were 495 minutes on average played leading up to first injury in the 2020/2021 season, compared with 521 minutes in the 2019/2020 season and 536 minutes in the 2018/2019. There was an average of games played to injury of 5.6 games in the 2020/2021 year, with 6.0 in the 2019/2020 year and 6.1 in the 2018/2019 year. Additionally, there was a significantly shorter time in between games was noted during the COVID-affected season with a mean time of 6.8 days in-between games played during the 2020-2021 season as compared to the previous years of 9.12 and 7.12 days. CONCLUSION: Our study found that there were more injuries and a decreased time to first injury observed during the COVID-impacted 2020-2021 season than the two preceding seasons, perhaps demonstrating a link between fixture congestion and athlete injuries as evidenced by the significantly shorter time between games. It is therefore prudent to retain fixture spacing for athlete recovery even against the backdrop of an overall shortened season.

Increased time from injury to surgical repair in patients with proximal hamstring ruptures is associated with worse clinical outcomes at mid-term follow-up.

INTRODUCTION: Prior studies of hamstring tendon tears have reported varied findings on whether increased delay from injury to surgery is associated with worse outcomes. The purpose of this study was to determine whether increased time from injury to surgical repair is associated with worse clinical outcomes in patients with proximal hamstring ruptures. MATERIALS AND METHODS: Patients who underwent surgical repair of a proximal hamstring rupture from 2010 to 2019 were followed for a minimum of 24 months from surgery. A cutoff of 6 weeks from injury to the time of surgery was used to distinguish between acute and chronic ruptures. All patients completed patient-reported outcome measures (PROs) at the final follow-up. Multiple factors were analyzed for their effects on PROs including time to surgery, amount of tendon retraction, and demographics such as sex and age. RESULTS: Complete data sets were obtained for 38 patients at a mean follow-up of 4.9 years. All data is reported as a mean ± standard deviation. Patients who underwent acute repair of proximal hamstring ruptures had significantly greater Perth Hamstring Assessment Tool (PHAT) scores than those who underwent chronic repair (76.9 ± 18.8 vs 60.6 ± 18.2, p = 0.01). Increased time to surgery was significantly correlated with worse PHAT scores (ρ = - 0.47, p = 0.003). There was no difference in PROs based on the amount of tendon retraction, number of tendons torn, sex, smoking status, or BMI. CONCLUSIONS: This study found that acute repair performed within 6 weeks of injury appears to yield improved PROs compared to chronic repair. These data highlight the importance of timely and accurate diagnosis of proximal hamstring ruptures and early operative intervention for surgical candidates.

Return to Work After Primary Hip Arthroscopy: A Systematic Review and Meta-analysis.

BACKGROUND: Hip arthroscopy is a procedure commonly performed to correct various hip pathologies such as femoroacetabular impingement and labral tears. These hip pathologies commonly affect young, otherwise healthy patients. The recovery after hip arthroscopy can prevent patients from returning to work and impair performance levels, having significant economic repercussions. To date, there has been no cumulative analysis of the existing literature on return to work after hip arthroscopy. PURPOSE: The purpose of this study was to perform a systematic review of the existing literature regarding return to work after hip arthroscopy and analysis of factors associated with the ability to return to work and time to return to work. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: A literature search of the MEDLINE, EMBASE, and Cochrane Library databases was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies assessing functional outcomes and return to work, including return to military duty, after hip arthroscopy were included. Patients' ability to return to work, as well as time to return, was compared between selected studies. Where available, workers' compensation status as well as type of work was compared. All statistical analysis was performed using SPSS, Version 22. P < .05 was considered statistically significant. RESULTS: Twelve studies with 1124 patients were included. Patients were followed for an average of 17.6 months. Using weighted means, the average rate of return to work was 71.35%, while full return to previous work duties was achieved at a rate of 50.89%. Modification to work duties was required at a rate of 15.48%. On average, the time to return to work was 115 days (range, 17-219 days). Rate of return by patients with workers' compensation status was found to be 85.15% at an average of 132 days (range, 37-211 days). Rate of return to work in workers performing professions reported as strenuous vs light (ie, mostly sedentary) jobs showed a statistically higher return to work in light professions (risk ratio, 0.53; 95% CI, 0.41-0.69). CONCLUSION: After hip arthroscopy, there is a high rate of return to work at an average of 115 days after surgery. However, full return to work was achieved by only half of patients upon final follow-up.

The tension of the iliopsoas tendon more than doubles during extension of the dysplastic hip in open reduction.

The role of the iliopsoas as an obstructing and re-dislocating factor in developmentally dislocated hips is unclear. The purpose of this article is to determine the change in the iliopsoas' tension during flexion and extension when performing an open reduction. We evaluated 34 hips undergoing an anterior open reduction for a developmental dislocation. At the time of surgery, we identified the iliopsoas, and before sectioning it as part of the open reduction, we measured the tension while cycling the reduced hip through flexion and extension. We performed statistical analysis using Pearson and Spearman correlation tests. We created an initial tension artificially at 20 N with the hip held in 90º of flexion, which then doubled to a mean of 42 N when placed in extension. We found a significant increase in tension when the hip went below 20º of flexion. We also found the correlation between the angle of the hip and the force of tension to be statistically significant ( P = 0.003). This study provides quantitative support that the tension of the iliopsoas tendon increases significantly in extension when performing an open reduction of a developmentally dislocated hip.