Factors associated with humeral avulsion of glenohumeral ligament lesions in patients with anterior shoulder instability: An analysis of the MOON shoulder instability cohort

BACKGROUND: Humeral avulsion of the glenohumeral ligament (HAGL) lesions are an uncommon cause of anterior glenohumeral instability and may occur in isolation or combination with other pathologies. As HAGL lesions are difficult to detect via magnetic resonance imaging (MRI) and arthroscopy, they can remain unrecognized and result in continued glenohumeral instability. PURPOSE: To compare patients with anterior shoulder instability from a large multicenter cohort with and without a diagnosis of a HAGL lesion and identify preoperative physical examination findings, patient-reported outcomes, imaging findings, and surgical management trends associated with HAGL lesions. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients with anterior glenohumeral instability who underwent surgical management between 2012 and 2020 at 11 orthopaedic centers were enrolled. Patients with HAGL lesions identified intraoperatively were compared with patients without HAGL lesions. Preoperative characteristics, physical examinations, imaging findings, intraoperative findings, and surgical procedures were collected. The Student RESULTS: A total of 21 HAGL lesions were identified in 915 (2.3%) patients; approximately one-third (28.6%) of all lesions were visualized intraoperatively but not identified on preoperative MRI. Baseline characteristics did not differ between study cohorts. Compared with non-HAGL patients, HAGL patients were less likely to have a Hill-Sachs lesion (54.7% vs 28.6%; CONCLUSION: Approximately one-third of HAGL lesions were missed on preoperative MRI. HAGL patients were less likely to exhibit preoperative imaging findings associated with anterior shoulder instability, such as Hill-Sachs lesions or anterior labral pathology. These patients underwent open procedures more frequently than patients without HAGL lesions

Operative versus nonoperative treatment of acute Achilles tendon ruptures: A pilot economic decision analysis

Background: The operative treatment of Achilles tendon ruptures has been associated with lower rerupture rates and better function but also a risk of surgery-related complications compared with nonoperative treatment, which may provide improved outcomes with accelerated rehabilitation protocols. However, economic decision analyses integrating the updated costs of both treatment options are limited in the literature. Purpose: To compare the cost-effectiveness of operative and nonoperative treatment of acute Achilles tendon tears. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: An economic decision model was built to assess the cost-utility ratio (CUR) of open primary repair versus nonoperative treatment for acute Achilles tendon ruptures, based on direct costs from the practices of sports medicine and foot and ankle surgeons at a single tertiary academic center, with published outcome probabilities and patient utility data. Multiway sensitivity analyses were performed to reflect the range of data. Results: Nonoperative treatment was more cost-effective in the average scenario (nonoperative CUR, US$520; operative CUR, US$1995), but crossover occurred during the sensitivity analysis (nonoperative CUR range, US$224-US$2079; operative CUR range, US$789-US$8380). Operative treatment cost an extra average marginal CUR of US$1475 compared with nonoperative treatment, assuming uneventful healing in both treatment arms. The sensitivity analysis demonstrated a decreased marginal CUR of operative treatment when the outcome utility was maximized, and rerupture rates were minimized compared with nonoperative treatment. Conclusion: Nonoperative treatment was more cost-effective in average scenarios. Crossover indicated that open primary repair would be favorable for maximized outcome utility, such as that for young athletes or heavy laborers. The treatment decision for acute Achilles tendon ruptures should be individualized. These pilot results provide inferences for further longitudinal analyses incorporating future clinical evidence

Stress radiography Is a reliable method to quantify posterior cruciate ligament insufficiency: A systematic review

PURPOSE: To perform a systematic review of posterior tibial stress radiography techniques and radiographic measurement methods to compare their accuracy and efficacy to aid clinicians in quantifying posterior cruciate ligament laxity. METHODS: Electronic databases, including PubMed, MEDLINE, Embase.com 1947- , Ovid Medline 1946- , Scopus 1823- , Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov 1997- were queried in December 2020. The abstracts of articles were reviewed by 2 authors for published studies comparing posterior tibial stress radiography techniques, describing, and comparing radiographic measurement methods, and comparing stress radiographs with instrumented knee testing. RESULTS: The systematic review included 13 studies that satisfied the inclusion and exclusion criteria. There were 3 studies comparing stress radiography with instrumented knee devices, 6 studies comparing stress radiography techniques, and 5 studies evaluating the reliability of radiographic measurements. Stress radiography was more sensitive for detecting posterior tibial translation than KT-1000 and KT-2000 and was similar to the Rolimeter knee arthrometer. The majority of studies found TELOS stress radiography to be more sensitive than gravity or hamstring contraction stress views. Kneeling stress radiographs were found to be equivalent to TELOS in one study and superior in another. All reported methods of radiographic measurement for posterior tibial translation showed good-to-excellent intraobserver and interobserver reliability, and no single technique demonstrated clear superiority. CONCLUSIONS: The results of this systematic review indicate that posterior stress radiography with TELOS and kneeling stress radiography are the most reliable methods to evaluate posterior cruciate ligament laxity. Gravity stress and hamstring contraction can be used but may underestimate posterior tibial translation. Radiographic measurement methods are reliable and no single method is clearly superior. CLINICAL RELEVANCE: This information will allow clinicians to use various radiographic methods to objectively measure posterior tibial translation to formulate a treatment plan

Isolated, full-thickness proximal rectus femoris injury in competitive athletes: A systematic review of injury characteristics and return to play

BACKGROUND: Characteristics regarding mechanism of injury, management, and return-to-play (RTP) rate and timing are important when treating and counseling athletes with rectus femoris tears. PURPOSE: To systematically review the literature to better understand the prevalence, sporting activity, injury mechanisms, and treatment of patients with rectus femoris injury and to provide prognostic information regarding the rate and timing of RTP. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we queried PubMed/MEDLINE, Cochrane, OVID, EMBASE, and Google Scholar in March 2022 for studies reporting on athletes sustaining isolated, full-thickness tearing, or bony avulsion injuries to the proximal rectus femoris during sporting activity. Excluded were studies without evidence of full-thickness tearing or avulsion, with athletes sustaining concomitant injuries, or with injuries occurring from nonsporting activities. The percentage of athletes sustaining injuries was calculated based on sport, injury mechanism, and management (nonoperative versus operative). RESULTS: Of 132 studies initially identified, 18 were included, comprising 132 athletes (mean age, 24.0 ± 5.4 years; range, 12-43 years). The most common sporting activities were soccer (70.5%) and rugby (15.2%). The most reported mechanisms of injury were kicking (47.6%) and excessive knee flexion/forced hip extension (42.9%). Avulsion injuries were reported in 86% (n = 114) of athletes. Nonoperative management was reported in 19.7% of athletes, with operative management performed in 80.3%. The mean follow-up time was 21.4 ± 11.4 months (range, 1.5-48 months). The RTP rate was 93.3% (n = 14) in nonoperatively treated and 100% (n = 106) in operatively treated athletes, and the mean RTP time was 11.7 weeks (range, 5.5-15.2 weeks) in nonoperatively treated and 22.1 weeks (range, 14.0-37.6 weeks) in operatively treated athletes. Complications were reported in 7.7% (2/26) of nonoperatively treated and 18% (n = 19/106) of operatively treated athletes. CONCLUSION: Full-thickness proximal rectus femoris injuries occurred most frequently in athletes participating in soccer and rugby secondary to explosive, eccentric contractions involved in kicking and sprinting. Operative management was performed in the majority of cases. Athletes who underwent operative repair had a 100% RTP rate versus 93.3% in athletes treated nonoperatively

Lower extremity-specific measures of disability and outcomes in orthopaedic surgery

Outcome measures may consist of simple questions or they may be more complex instruments that evaluate multiple interrelated domains that influence patient function. Outcome measures should be relevant to patients, easy to use, reliable, valid, and responsive to clinical changes. The Disabilities of the Arm, Shoulder and Hand score can be used to measure disability for any region of the upper limb. Joint and disease-specific outcome measures have been developed for the shoulder, the elbow, and the wrist and hand. Many of these measures would benefit from further research into their validity, reliability, and optimal applicability