Epidemiology of Injuries Identified at the NFL Scouting Combine and Their Impact on Performance in the National Football League: Evaluation of 2203 Athletes From 2009 to 2015.

BACKGROUND: At the annual National Football League (NFL) Scouting Combine, the medical staff of each NFL franchise performs a comprehensive medical evaluation of all athletes potentially entering the NFL. Currently, little is known regarding the overall epidemiology of injuries identified at the combine and their impact on NFL performance. PURPOSE: To determine the epidemiology of injuries identified at the combine and their impact on initial NFL performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All previous musculoskeletal injuries identified at the NFL Combine from 2009 to 2015 were retrospectively reviewed. Medical records and imaging reports were examined. Game statistics for the first 2 seasons of NFL play were obtained for all players from 2009 to 2013. Analysis of injury prevalence and overall impact on the draft status and position-specific performance metrics of each injury was performed and compared with a position-matched control group with no history of injury or surgery. RESULTS: A total of 2203 athletes over 7 years were evaluated, including 1490 (67.6%) drafted athletes and 1040 (47.2%) who ultimately played at least 2 years in the NFL. The most common sites of injury were the ankle (1160, 52.7%), shoulder (1143, 51.9%), knee (1128, 51.2%), spine (785, 35.6%), and hand (739, 33.5%). Odds ratios (ORs) demonstrated that quarterbacks were most at risk of shoulder injury (OR, 2.78; P = .001), while running backs most commonly sustained ankle (OR, 1.39; P = .040) and shoulder injuries (OR, 1.55; P = .020) when compared with all other players. Ultimately, defensive players demonstrated a greater negative impact due to injury than offensive players, with multiple performance metrics significantly affected for each defensive position analyzed, whereas skilled offensive players (eg, quarterbacks, running backs) demonstrated only 1 metric significantly affected at each position. CONCLUSION: The most common sites of injury identified at the combine were (1) ankle, (2) shoulder, (3) knee, (4) spine, and (5) hand. Overall, performance in the NFL tended to worsen with injury history, with a direct correlation found between injury at a certain anatomic location and position of play. Defensive players tended to perform worse compared with offensive players if injury history was present.

Mini-Open Posterior Compartment Release for Chronic Exertional Compartment Syndrome of the Leg.

Chronic exertional compartment syndrome (CECS) is a well-recognized cause of leg pain in endurance athletes. Surgical fasciotomy for posterior leg CECS historically has inferior clinical results compared with anterior and lateral compartment release. Poor surgical technique with inadequate release may contribute to less reliable outcomes. In this Technical Note with accompanying video, we describe a mini-open approach for posterior CECS of the leg.

Latarjet Technique for Treatment of Anterior Shoulder Instability With Glenoid Bone Loss.

Anterior glenohumeral instability is a common clinical entity, particularly among young athletic patient populations. Nonoperative management and arthroscopic treatment of glenohumeral instability have been associated with high rates of recurrence, particularly in the setting of glenohumeral osseous defects. Coracoid transfer, particularly the Latarjet procedure, has become the treatment of choice for recurrent anterior glenohumeral instability in the setting of osseous deficiencies greater than 20% to 30% of the glenoid surface area and may also be considered for the primary treatment of recurrent instability in the high-risk contact athlete, even in the setting of limited osseous deficiency. The following Technical Note provides a diagnostic approach for suspected glenohumeral instability, as well as a detailed description of the congruent-arc Latarjet procedure, performed with a deltoid split, with its postoperative management.

The Impact of Body Mass Index on Outcomes Following Open Sub-Pectoralis Major Biceps Tenodesis.

PURPOSE: Traditionally, biceps tenotomy has been recommended for obese, older, and less active patient populations, while tenodesis is preferred in younger, thinner, and more active individuals. In an effort to better understand the impact obesity has on the surgical management of long head of the biceps tendinopathy, the current study analyzed the effect body mass index had on surgical outcomes following open subpectoralis major biceps tenodesis. METHODS: Patients who underwent biceps tenodesis between June 2006 and December 2013 were identified from our institution's surgical database. They were then contacted to assess their functional outcomes using validated outcome measures. Comparisons were made between the outcomes seen in obese patients (BMI ≥ 30) and non-obese patients (BMI < 30) with subgroup analyses looking at gender, age, and length of follow-up. RESULTS: One hundred and twenty-two patients completed a follow-up assessment with a mean follow-up of 29.3 months. The non-obese cohort was composed of 84 patients with a mean BMI of 25.8. The obese cohort was composed of 38 patients with a mean BMI of 33.4. No significant difference was noted to be present with respect to postoperative outcome measures. Regression analysis with BMI as an independent variable demonstrated poor correlation with outcome measures. CONCLUSIONS: The results of the current study support open subpectoralis biceps tenodesis as an acceptable option for the treatment of LHB pathology irrespective of the treated patient's body mass index. Both obese and non-obese patients demonstrated low postoperative DASH scores and high Oxford Shoulder scores.

Cell-Based Treatment for the Management of Articular Cartilage Injuries Where Are We?

Articular cartilage is a specialized tissue that lines the surface of joints. Injuries to articular cartilage pose challenges due to poor healing potential. Focal cartilage defects are typically the result of high impact or repetitive loads to the articular surface. They tend to occur in the younger, active population and have been shown to cause swelling, pain, and joint dysfunction. Although the natural history of these lesions has never been definitively elucidated in the literature, clinical experience suggests that if left untreated, these lesions will demonstrate an inability to heal and may lead to prolonged increased articular peak stresses, which in turn may lead to pain and significant limitations in the future. The purpose of the present review is to provide the most current treatment options for these injuries and review the literature supporting their use.

Coronal Malalignment in the Adult Knee.

Coronal plane deformity in the adult patient is a complex clinical problem. Once the hip, knee, and ankle joint centers lose collinerarity, the knee is exposed to abnormal loads across its tibiofemoral compartments, leading to early degenerative changes. Malalignment can coexist with arthrosis and ligamentous instability. High tibial osteotomy and distal femoral osteotomy have been useful tools to realign the adult knee. They can be performed along with ligament reconstruction and cartilage restoration procedures with high success rates. Despite novel techniques and fixation methods, principles of deformity correction should be followed to maximize clinical outcomes.

Arthroscopic Superior Capsule Reconstruction Technique in the Setting of a Massive, Irreparable Rotator Cuff Tear.

Massive, irreparable rotator cuff tears are challenging to treat and associated with pain and severe limitation in shoulder elevation due to the proximal migration of the humeral head and, consequently, subacromial impingement. Furthermore, retraction of the tendons in combination with fat infiltration and muscular weakness results in unpredictable treatment outcomes. While conservative treatment may be warranted for low-demand patients, surgical treatment is often indicated for a successful return to activities of daily living as well as an improved quality of life. The reported failure rate of rotator cuff repair for the treatment of a massive rotator cuff tear varies. However, this failure is often found at the interface between the tendon and tendon footprint. Several techniques have been reported to address this pathology, including muscular transfer, arthroscopic debridement, augmentation procedures, and superior capsule reconstruction. In particular, superior capsule reconstruction has been reported as a safe and effective method to treat a massive, irreparable rotator cuff tear. The purpose of this Technical Note is to describe our preferred technique of a superior capsule reconstruction for the treatment of a massive, irreparable rotator cuff tear.

Superior Labral Anterior-Posterior (SLAP) Tears in the Military.

CONTEXT: Given the notable physical demands placed on active members of the military, comprehension of recent trends in management and outcomes of superior labral anterior-posterior (SLAP) tears in this patient population is critical for successful treatment. EVIDENCE ACQUISITION: Electronic databases, including PubMed, MEDLINE, and Embase, were reviewed for the years 1985 through 2016. STUDY DESIGN: Database review. LEVEL OF EVIDENCE: Level 5. RESULTS: Active members of the military are at increased risk of sustaining shoulder injuries, particularly SLAP tears. Recent trends in management of SLAP lesions have shifted toward operative intervention. In the correct patient population, repairs of superior labrum tears demonstrate improved function and pain. Surgical repair of SLAP tears, especially in young and active military personnel, is supported. CONCLUSION: Military personnel are at greater risk of suffering a SLAP tear in comparison with their civilian counterparts. Surgical repair of these lesions is advocated in this subpopulation when the patient is younger than approximately 36 years of age, and if older, biceps tenodesis is likely superior.

Ankle impingement.

Ankle impingement is a syndrome that encompasses a wide range of anterior and posterior joint pathology involving both osseous and soft tissue abnormalities. In this review, the etiology, pathoanatomy, diagnostic workup, and treatment options for both anterior and posterior ankle impingement syndromes are discussed.

Pitcher's elbow: medial elbow pain in the overhead-throwing athlete.

Overhead athletes subject their elbows to significant valgus stresses throughout the throwing cycle. A steady rise in the number of medial-sided elbow injuries over the years has lead to increased awareness regarding the pathophysiology of the "pitcher's elbow." As our understanding of the functional anatomy and throwing biomechanics has become more sophisticated, we have seen a concurrent improvement in the outcomes associated with managing these injuries. Despite this improvement, continued anatomical and biomechanical research is still needed to further optimize outcomes and return to sport.

Postoperative pain control after arthroscopic rotator cuff repair.

Arthroscopic rotator cuff repair (ARCR) can provide excellent clinical results for patients who fail to respond to conservative management of symptomatic rotator cuff tears. ARCR, however, can be associated with severe postoperative pain and discomfort that requires adequate analgesia. As ARCR continues to shift toward being performed as an outpatient procedure, it is incumbent on physicians and ambulatory surgical centers to provide appropriate pain relief with minimal side effects to ensure rapid recovery and safe discharge. Although intravenous and oral opioids are the cornerstone of pain management after orthopedic procedures, they are associated with drowsiness, nausea, vomiting, and increased length of hospital stay. As health care reimbursements continue to become more intimately focused on quality, patient satisfaction, and minimizing of complications, the need for adequate pain control with minimal complications will continue to be a principal focus for providers and institutions alike. We present a review of alternative modalities for pain relief after ARCR, including cryotherapy, intralesional anesthesia, nerve blockade, indwelling continuous nerve block catheters, and multimodal anesthesia. In choosing among these modalities, physicians should consider patient- and system-based factors to allow the efficient delivery of analgesia that optimizes recovery and improves patient satisfaction.

Osteotomies about the knee: AAOS exhibit selection.

Varus or valgus malalignment of the lower extremity can alter the load distribution across the knee and hasten the development of focal osteoarthritis. Although knee arthroplasty remains an effective option for end-stage arthritis, it is not typically recommended in the young, active patient. In the setting of painful unicompartmental cartilage injury in a mechanically malaligned limb, alignment correction by osteotomy has been shown to slow the progression of osteoarthritis and lessen pain. In this review, we will discuss the different options, indications, and techniques for osteotomies about the knee.

Current trends in the management of recurrent anterior shoulder instability.

The glenohumeral joint is innately complex and comprised of both static and dynamic stabilizers. Anterior glenohumeral instability has been estimated to have an incidence of 11.2 cases per 100,000 persons and typically follows a traumatic injury. Although there are specific instances when conservative management is advocated, a majority of these patients are treated with operative stabilization. Recent advancements in arthroscopy have created a shift from the traditional open stabilization procedures towards more minimally invasive arthroscopic stabilization procedures. This comprehensive review will summarize current concepts involved in evaluating patients with anterior glenohumeral instability and specifically focus on those patients who suffer from recurrent instability.

Patellar tendinopathy - recent developments toward treatment.

Patellar tendinopathy (PT) is a clinical and chronic overuse condition of unknown pathogenesis and etiology marked by anterior knee pain typically manifested at the inferior pole of the patella. PT has been referred to as "jumper's knee" since it is particularly common among populations of jumping athletes, such as basketball and volleyball players. Due to its common refractory response to conservative treatment, a variety of new treatments have emerged recently that include dry-needling, sclerosing injections, platelet-rich plasma therapy, arthroscopic surgical procedures, surgical resection of the inferior patellar pole, extracorporeal shock wave treatment, and hyperthermia thermotherapy. Since PT has an unknown pathogenesis and etiology, PT treatment is more a result of physician experience than evidence-based science. This review will summarize the current literature on this topic, identify current research efforts aimed to understand the pathological changes in abnormal tendons, provide exposure to the emerging treatment techniques, and provide suggested direction for future research.

Closed sagittal band injury due to low energy trauma.

Sagittal band injury is a relatively common cause of extensor tendon subluxation caused by inflammatory disease or high-energy trauma. However, there are few reports in the literature describing sagittal band injury due to low energy trauma. In this report, we describe successful nonsurgical management of a closed sagittal band injury and extensor tendon subluxation associated with low-energy trauma. Patients in 2 cases had no rheumatoid arthritis or history of inflammatory diseases. Conservative treatment resulted in relief of symptoms and corrected the instabilities with no complications.

External fixation of distal radius fractures: effect of distraction and duration.

PURPOSE: To assess the effects of the amount of distraction across the wrist and the duration of fixator placement on the clinical outcome of patients with distal radius fractures treated with external fixation. METHODS: A total of 42 patients with closed distal radius fractures were treated with a spanning external fixator plus supplementary percutaneous K-wires over a 6-year period. All fractures were extra-articular (A type) or simple intra-articular (C type). Twenty-four of these patients were evaluated retrospectively for clinical and radiographic outcomes at an average follow-up time of 22 months (range, 4-49 months). The amount of distraction attained by the fixator was determined by measuring the carpal height ratio on plain radiographs. Wrist and forearm range of motion were recorded, as well as grip and pinch strength. Standard radiographs were taken to evaluate healing and bony alignment. RESULTS: Using the Gartland Werley classification, there were 11 excellent, 10 good, and 3 fair results. Statistical analysis indicated that a higher carpal height ratio at the initial reduction positively correlated (p = .041) with an excellent outcome. Duration of external fixation did not have a significant impact on the final outcome within the parameters studied (p = .891). Average wrist range of motion at follow-up was as follows: flexion, 54.1 degrees (75% of the contralateral side); extension, 59.0 degrees (78%); radial deviation, 18.0 degrees (85%); ulnar deviation, 22 degrees (73%); pronation, 79.0 degrees (95%); and supination, 76.6 degrees (93%). None of the individual components of range of motion were negatively correlated with higher carpal height ratio at fixator application or duration of fixation, within the parameters studied. CONCLUSIONS: Moderately increased distraction of the carpus at the initial fracture reduction is correlated with improved clinical outcome and does not have an adverse affect on subsequent wrist range of motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Accuracy of fluoroscopy in closed reduction and percutaneous fixation of simulated Bennett's fracture.

PURPOSE: Restoration of joint congruity has been shown to be an important factor in the prevention of arthritis in patients with Bennett's fracture. It is for this reason that surgical management is generally recommended for displaced intra-articular fractures of the base of the thumb metacarpal. Adequacy of closed reduction after pinning of Bennett's fracture is usually evaluated by fluoroscopic examination. The purpose of this study is to determine the accuracy of fluoroscopic examination compared to plain radiographs and direct visualization in closed reduction and percutaneous pin fixation of simulated Bennett's fractures. METHODS: In 8 fresh-frozen cadaveric hands, Bennett's fractures were created and the incisions were closed. Under fluoroscopic visualization the fractures were close reduced and pinned using 1.14-mm (0.045-in) K-wires. These reductions were all judged to be acceptably aligned with fracture stepoff and displacement less than 1.5 mm under fluoroscopy. Anteroposterior and lateral plain radiographic films were then taken to assess the reduction. Finally, the carpometacarpal joint was opened and visualized to directly assess the reduction for fracture stepoff, displacement, and gap. RESULTS: After percutaneous fixation, all closed reductions were deemed acceptable. Examination with plain radiographs demonstrated an average anteroposterior view displacement of 0 mm, lateral view gap of 0.1 mm, and articular stepoff of 1.1 mm. Direct examination of the joints showed an average articular gap of 0.9 mm, stepoff of 2.1 mm, and displacement of 3.1 mm. The values for stepoff and displacement were significantly different when the direct measurements were compared to the fluoroscopic measurements. Radiographic measurements were significantly different from direct measurements for displacement of the fracture fragments. CONCLUSIONS: After closed reduction and percutaneous pinning of simulated Bennett's fractures in a cadaver model, the assessment of the articular gap, stepoff, and displacement as detected by fluoroscopy is often in error compared to that detected by plain radiographs and direct examination.

Hemicondylar hamate replacement arthroplasty for proximal interphalangeal joint fracture dislocations: an assessment of graft suitability.

PURPOSE: Proximal interphalangeal (PIP) joint fracture-dislocations are complex injuries, and successful surgical treatment can be challenging. The hamate appears to be an appropriate graft based on its general shape and dimensions. The purpose of this study was to evaluate the rationale and suitability of the hamate as an autograft for proximal interphalangeal joint fracture-dislocations and to determine the inherent stability of the donor site after graft harvesting. METHODS: Fresh-frozen cadaveric hand specimens were used to evaluate the hamate as a suitable graft source for defects of the middle phalanx based on macroscopic, radiographic, and biomechanical properties. Radiographic measurements were made of the articular contours of the hamate and the base of middle phalanx of digits 2 through 5. Hemicondylar hamate replacement arthroplasty (HHRA) was performed in cadavers for defects created in the middle phalanges. Biomechanical stability testing of the hamate-metacarpal joint was then assessed in additional specimens before and after HHRA. Fluoroscopic examination with a 22.2-N load applied in a 45 degrees dorsal-proximal direction was used to assess stability of the carpometacarpal joints. A servohydraulic testing machine was then used to determine the amount of translation induced with a similarly directed force before and after harvesting of the hamate graft. RESULTS: The cadaveric HHRA reconstructions restored joint stability with no tendency to subluxate. Radiographic measurement showed that the hamate has a central ridge and bicondylar facet with articular contours that are similar to the base of the middle phalanx. The removal of a central portion of the hamate did not induce dislocation or create obvious clinical instability of the carpometacarpal joint. CONCLUSIONS: The HHRA technique is used for treatment of fracture-dislocations of the proximal interphalangeal joint. This study demonstrated the suitability of using the dorsal portion of the hamate as an osteochondral autograft for middle phalangeal base fractures; the technique creates minimal donor site morbidity.