Although advancements in electronic health records (EHRs) have improved clinical productivity, digital administrative responsibilities have led to increased physician burnout. With the emergence of large language models (LLMs), their incorporation into medicine is a potential solution to the increase in tasks such as charting and responding to patient messages. Previous studies have evaluated the efficacy of LLMs such as Chat Generative Pre-Trained Transformer-4 (ChatGPT-4) in clinical knowledge-based questions. Few studies, however, have evaluated the responses to clinical decision making in sports medicine. This study aims to evaluate the efficiency and clinical accuracy of ChatGPT-4 responses to common sports medicine questions that patients ask in the EHR system. ChatGPT-4 was prompted with few-shot exemplars involving different sports medicine injuries to generate 80 EHR scenarios. Next, ChatGPT-4 was programmed to respond to the 80 EHR scenarios using the created programmed approaches to generate LLM drafts. In stage 1, four board-certified orthopedic surgeons were asked to respond to the EHR responses, followed by a survey evaluating the difficulty and urgency of the situation. In stage 2, they were asked to edit the LLM drafts so that they were clinically acceptable to send to a patient. In stage 1, the assessing physicians found responding to the LLM clinical question to be trivial in 60 out of 80 cases (75%). Most physicians disagreed that the patients in the LLM drafts were experiencing a severe medical event in 58 out of 80 cases (72.50%). In stage 2, the physicians rated the LLM-assisted responses as acceptable without modifications in 58 out of 80 cases (72.50%). Furthermore, the physicians agreed that the unedited LLM-assisted responses had a low chance of causing harm in 75 out of 80 cases (93.75%). Finally, the physicians rated the responses as generated by artificial intelligence in 65 out of 80 cases (81.25%). Surgeons rated the majority of the LLM responses as both clinically accurate and time-saving, with a low risk of causing harm. This finding suggests that LLMs have the potential to provide adequate responses to EHR messages within the field of sports medicine, potentially lessening physician burden and workload.
The rise of Name, Image, and Likeness (NIL) rights has transformed amateur athletics, blurring the lines between high school, collegiate, and professional sports. NIL has introduced unprecedented commercial pressures that extend into sports medicine, where physicians must now navigate new challenges in clinical care, ethics, and liability. To review current concepts related to the impact of NIL on sports medicine and to highlight the evolving risks, responsibilities, and roles of physicians caring for athletes in this new landscape. Narrative review. We reviewed newly published articles and analyzed data collected from publicly available databases addressing NIL policy changes, athlete health, and physician practice. NIL has created an environment in which high school and collegiate athletes face pressure to play through injury, pursue premature or unnecessary interventions, and seek multiple medical opinions influenced by commercial interests. Physicians, in turn, face escalating risks, including exposure to litigation for lost athlete earnings, erosion of clinical autonomy, and growing pressure to align care with financial rather than medical priorities. The NIL era requires a redefinition of the physician's role in sports medicine. Providers must balance athlete advocacy with self-protection in a system where clinical decisions now carry increased ethical, legal, and professional consequences.
Both years of contact sport participation and years of military service are positively related to risk of sustaining multiple mild traumatic brain injuries (mTBIs). Little is known about the additive risk of mTBI exposure by combining premilitary contact sport participation with subsequent military service. To assess the effect of premilitary contact sport participation on the odds of current and former military personnel sustaining mTBI(s) during their lifetime. Cross-sectional study; Level of evidence, 3. This study analyzed data from 2651 individuals from the LIMBIC-PLS. The association between a history of contact sport participation and sustaining an mTBI pre-military service, during military service while not on deployment, or during deployment was estimated using odds ratios. The association between the total number of pre-military service, military service while not on deployment, and deployment-related mTBI events with history of contact sport participation (yes vs no) was estimated using incidence rate ratios (IRRs) and 95% confidence intervals. The authors adjusted those models for demographic factors and then repeated those analyses using years of contact sport exposure, categorized as 0 (referent), >0 to 5, >5 to 10, and >10 years. In this cohort, 62% had a history of contact sport participation and 82% had a history mTBI. Individuals with a history of contact sport participation were more likely to have experienced an mTBI in their lifetime (OR, 1.26; 95% CI, 1.03-1.54; P = .023). This manifested only outside of military combat deployments. Specifically, a history of contact sport exposure was associated with a higher odds of an mTBI before military service (OR, 1.63; 95% CI, 1.39-1.91; P < .001) or a nondeployment mTBI (OR, 1.62; 95% CI, 1.37-1.91; P < .001) Moreover, a higher incidence rate of lifetime mTBI was observed as number of years of contact sport exposure increased. Similar to findings in civilians, these findings suggest that contact sport participation increases the likelihood of experiencing a single or multiple mTBI events among military personnel. These findings suggest that it would be appropriate to screen individuals' mTBI history before joining the military to identify individual potential risks for concerns associated with multiple lifetime mTBI events.
The aim of this study was to achieve consensus on important topics related to tenosynovial giant cell tumour (TGCT) and giant cell tumour of bone (GCTB), and to identify areas for future research. In January 2026, a consensus meeting, The Birmingham Orthopaedic Oncology Meeting (BOOM), held in Cape Town, South Africa, gathered 314 delegates from 59 countries to debate 21 consensus statements on tenosynovial giant cell tumour (TGCT) and giant cell tumour of bone (GCTB) through a modified Delphi process. Of the 21 statements, two achieved unanimous consensus, 18 strong consensus, and one moderate consensus. Unanimous consensus was reached for prioritizing joint-preserving intralesional curettage in GCTB when feasible, and for supporting non-surgical approaches in anatomically challenging cases, particularly sacral lesions. The statement addressing the role of denosumab in GCTB achieved only moderate consensus. The use of adjuvants in GCTB, as well as the management of recurrent and systemic GCTB, including long-term use of denosumab, reached strong consensus. Strong consensus was achieved in the surgical and non-surgical management for both primary and recurrent TGCT. Surveillance strategies for both TGCT and GCTB generated substantial discussion despite strong consensus, reflecting ongoing uncertainty and lack in evidence. This international consensus provides practical guidance for the management of TGCT and GCTB while identifying important gaps in evidence. Joint-preserving surgery remains central to the treatment of GCTB, with selective integration of systemic therapies and individualized surveillance. The consensus framework highlights priorities for future collaborative research in orthopaedic oncology.
Acetabular wave signs represent a form of cartilage delamination and may progress to more extensive chondral damage in patients with femoroacetabular impingement (FAI). The current lack of high-quality evidence supporting an optimal surgical strategy underscores the need to investigate reverse microfracture as a viable, safe, cost-effective, and cartilage-preserving treatment option. The purpose of this study is to evaluate the clinical and imaging outcomes of arthroscopic treatment of acetabular wave signs using a reverse drilling technique performed from the supralabral region of the acetabulum without damaging the articular cartilage. It was hypothesized that this technique would provide clinical improvement without additional cartilage damage. Case series; Level of evidence, 4. A total of 40 patients (mean age, 40.2 ± 9.2 years; 24 women and 16 men) underwent hip arthroscopy with concomitant FAI treatment and reverse microfracture, with a minimum follow-up of 2 years. Outcomes included Harris Hip Score (HHS), visual analog scale (VAS), lateral center-edge angle (LCEA), alpha angle, and magnetic resonance imaging (MRI). The HHS increased from 68.88 ± 10.81 to 97.90 ± 2.22 (P < .001), and the VAS score decreased from 7.40 ± 1.03 to 1.35 ± 1.08 (P < .001). The alpha angle decreased from 61.88°± 2.50° to 50.05°± 1.75° (P < .001), and the LCEA decreased from 36.75°± 4.66° to 32.43°± 1.92° (P < .001). MRI demonstrated no deterioration in cartilage quality or additional lesions after the procedure, with cartilage appearance similar to adjacent noninjured areas and no evidence of delamination. Reverse microfracture may represent a potential treatment option for acetabular wave signs. In this retrospective series, the procedure was associated with improvement in pain and functional scores, and no evidence of additional cartilage deterioration was observed on postoperative MRI during a minimum 2-year follow-up. However, given the absence of a control group, the specific contribution of the drilling technique to the observed clinical improvements cannot be determined.Clinical improvement likely reflects the combined effect of comprehensive arthroscopic management of FAI rather than the isolated effect of reverse drilling.
Psychological factors influence return to sport (RTS) and reinjury rates following anterior cruciate ligament (ACL) reconstruction (ACLR). However, many RTS decisions are made without considering psychological factors, or consider psychological and physical factors in isolation, leading to suboptimal RTS and reinjury rates. To identify distinct profiles of psychological and physical readiness to RTS following ACLR using strength- and performance-based measures of physical readiness and to examine the extent to which these readiness domains align. Cross-sectional study; Level of evidence, 3. Data from the ACL Reconstruction Rehabilitation Outcomes Workgroup (ARROW) registry were used to construct patient profiles of psychological and physical readiness to RTS based on established criteria. Psychological readiness was defined by an ACL Return to Sport after Injury Scale (ACL-RSI) score ≥65 points out of 100. Strength-based and performance-based physical readiness was defined by a limb symmetry index ≥90% in isokinetic quadriceps strength and single-limb hop testing, respectively. Frequencies of all profiles were reported, alignment between psychological and physical domains was assessed, and sensitivity analyses were conducted to investigate differences in age, sex, and time since surgery. A total of 822 patients were included in the analysis (age: mean ± SD, 18.8 ± 6.2 years; 51% female). The most common profile represented patients who met psychological (ACL-RSI) and performance-based physical readiness criteria (single-leg hop) but not strength-based physical readiness criteria (quadriceps strength) (32%; 261/822). When considering ACL-RSI, single-leg hop, and quadriceps criteria together, psychological and physical readiness did not align for 69% (571/822) of patients. Patients in the "neither psychologically nor physically ready" profile were older than patients in any other profiles. Male patients obtained psychological and physical readiness scores that aligned more often than female patients. There were a variety of distinct profiles of psychological and physical readiness in patients post-ACLR. Psychological, strength-based, and performance-based physical readiness to RTS criteria aligned for less than one-third of participants. Patients who did not meet psychological or physical readiness criteria tended to be older in age, and male patients were more likely to have alignment between their psychological and physical readiness domains.
Patellar instability is common in skeletally immature patients; however, the presence of open physes presents unique challenges to surgical management. To (1) assess the safety and efficacy of anatomic medial patellofemoral ligament reconstruction (MPFL-R) in a skeletally immature patient population at short-, mid-, and long-term follow-up and (2) determine the influence of patient factors and surgical and radiographic characteristics on the risk of recurrent instability and clinical outcomes after surgery. Case series; Level of evidence, 4. A retrospective analysis was conducted of the records of skeletally immature patients who underwent primary, anatomic MPFL-R with concomitant procedures at a single academic institution between 2010 and 2019. Patients with <2 years of follow-up were excluded. Demographic data, preoperative radiographic parameters, and surgical details were collected through chart review. Recurrent instability, growth disturbance, and return-to-sport rates were documented via telephone follow-up. The final follow-up included assessment of Kujala, Lysholm, and International Knee Documentation Committee (IKDC) scores. Subgroup analysis focused on patients undergoing isolated MPFL-R. A total of 54 knees in 51 skeletally immature patients with a mean age of 15.6 years (range, 10-18 years) were available for analysis. At a mean follow-up of 8.15 years (range, 55-152 months), 4 of 54 (7.4%) knees experienced subsequent patellar subluxation events. There were no confirmed patellar dislocations, and no patients underwent reoperation for patellar stabilization or growth disturbance. At the final follow-up, the mean Kujala, Lysholm, and IKDC scores were 85.7 (range, 11-100), 83.6 (range, 14-100), and 76.1 (range, 10-95.4), respectively. Patients with a younger age at the time of surgery (hazard ratio, -0.83; 95% CI, -1.53 to -0.14; P = .018) and an increased patellar tendon-to-lateral trochlear ridge (PT-LTR) distance (13.46 vs 8.59 mm; P = .043) demonstrated an increased risk of recurrent patellar instability. Three of 23 (13.0%) knees undergoing isolated MPFL-R, experienced subsequent patellar subluxation events. In subgroup analysis, high-grade trochlear dysplasia (P = .002) and PT-LTR distance >5.55 mm (P = .004) correlated with an increased risk of recurrent instability events. Anatomic MPFL-R paired with concomitant procedures as indicated is a safe, efficacious, and durable treatment option for lateral patellar instability in adolescent patients with an open or partially open distal femoral physis.
To evaluate the effectiveness of using a bioinductive patch on tendon healing, functional recovery, and safety in arthroscopic rotator cuff repair. A non-concurrent controlled study with prospective enrollment of the intervention group and retrospective collection of the control group was conducted. Patients with rotator cuff injuries admitted between June 2024 and March 2025 were enrolled. The sample size was calculated using G*Power software. A total of 60 patients meeting the selection criteria were enrolled, including 30 patients in the patch group (receiving arthroscopic rotator cuff repair combined with bioinductive patch implantation) and 30 patients in the control group (receiving arthroscopic rotator cuff repair only). There was no significant difference between groups ( P>0.05) in baseline data, including age, gender, affected side, disease duration, DeOrio-Cofield classification, degree of fatty infiltration, proportion involving the subscapularis, proportion of revision surgeries, and preoperative visual analogue scale (VAS) score, Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, and University of California, Los Angeles (UCLA) score. The following indicators were compared between groups: the tendon healing rate at 6 months postoperatively and postoperative pain VAS score, functional scores (Constant-Murley, ASES, UCLA), imaging indicators (tendon thickness, footprint coverage, effusion), and patient-reported outcomes [12-Item Short-Form Health Survey (SF-12) physical/mental component score, SF-36 overall score, simple shoulder test (SST), satisfaction]. Additionally, subgroup analyses were performed based on whether the tear involved the subscapularis preoperatively, the degree of fatty infiltration (Goutallier grades Ⅰ, Ⅱ/Ⅲ, Ⅳ), and primary/revision surgery to compare tendon healing outcomes. A multiple linear regression model was used to analyze independent influencing factors of Constant-Murley score improvement at 6 months postoperatively. Incisions in both groups healed by first intention. All patients were followed up, with follow-up time of (13.0±1.8) months in the patch group and (12.8±1.9) months in the control group, showing no significant difference ( t=0.415, P=0.680). The pain and shoulder joint function of the two groups gradually improved over time, and the corresponding scores showed significant differences between different time points ( P<0.05). The pain relief and functional recovery improvement in the patch group was better than that in the control group, and there were significant differences in all scores between groups at 1 and 6 months ( P<0.05). At 6 months postoperatively, the patch group had significantly better SF-12 physical component scores, SF-36 overall scores, and SST scores than the control group ( P<0.05), while the SF-12 mental component score and patient's satisfaction showed no significant difference between groups ( P>0.05). At 12 months postoperatively, the surgical success rate was significantly higher in the patch group than in the control group ( P<0.05). Imaging review showed no significant difference between groups in tendon healing rate, retear rate, complete footprint coverage rate, or effusion degree at 6 months postoperatively ( P>0.05), but the increase in tendon thickness was significantly greater in the patch group than in the control group ( P<0.05). Subgroup analysis showed that for revision surgery patients, there was no significant difference in retear rate based on patch use ( P>0.05); however, primary surgery patients had a significantly higher tendon healing rate with patch use ( P<0.05). For patients with Goutallier grade Ⅰ, Ⅱ fatty infiltration, patch use resulted in a significantly higher tendon healing rate ( P<0.05), while for those with grade Ⅲ, Ⅳ fatty infiltration, the difference was not significant ( P>0.05). For patients with or without involvement of the subscapularis, there was no significant difference in tendon healing rate based on patch use ( P>0.05). Multiple linear regression analysis showed that independent influencing factors of Constant-Murley score improvement at 6 months postoperatively included the use of bioinductive patch, age, and fatty infiltration degree ( P<0.05). The bioinductive patch can effectively promote joint functional recovery and structural improvement after rotator cuff repair with good safety. 评估关节镜下肩袖修复术中使用生物诱导型补片对肌腱愈合、功能恢复及安全性的影响。. 采用前瞻性收集干预组+回顾性对照的非同期对照研究，以2024年6月—2025年3月收治的肩袖损伤患者为研究对象，通过G*Power软件计算样本量，共纳入60例符合选择标准患者，分为补片组（接受关节镜下肩袖修复联合生物诱导型补片植入）和对照组（仅接受关节镜下肩袖修复）。两组患者年龄、性别、患肢侧别、病程、DeOrio-Cofield分级、脂肪浸润程度、累及肩胛下肌构成比及翻修手术构成比，以及术前疼痛视觉模拟评分（VAS）、Constant-Murley评分、美国肩肘外科协会（ASES）评分及美国加州大学洛杉矶分校（UCLA）评分等基线资料比较，差异均无统计学意义（ P>0.05），具有可比性。比较两组以下指标：术后6个月肌腱愈合率，以及术后疼痛VAS评分、功能评分（Constant-Murley、ASES、UCLA）、影像学指标（肌腱厚度、足印区覆盖、积液）、患者主观评价 ［简单肩关节测试（SST）、12 条目健康调查简表（SF-12）生理/心理评分、SF-36总体评分、手术满意度］。同时，两组根据术前撕裂是否累及肩胛下肌、脂肪浸润程度（Goutallier Ⅰ、Ⅱ级/Ⅲ、Ⅳ级）、首次/翻修手术进行亚组分析，比较肌腱愈合情况；采用多重线性回归模型分析术后6个月Constant-Murley评分改善独立影响因素。. 两组术后切口均Ⅰ期愈合。患者均获随访，随访时间补片组（13.0±1.8）个月，对照组（12.8±1.9）个月，差异无统计学意义（ t=0.415， P=0.680）。两组患者疼痛与肩关节功能随时间延长逐渐改善，相应评分不同时间点间差异均有统计学意义（ P<0.05）；且补片组疼痛缓解和功能恢复改善优于对照组，术后1、6个月评分组间差异有统计学意义（ P<0.05）。术后6个月补片组SF-12生理评分、SF-36总体评分、SST评分均优于对照组（ P<0.05），SF-12心理评分及患者满意度组间差异无统计学意义（ P>0.05）。术后12个月补片组手术成功率高于对照组，差异有统计学意义（ P<0.05）。影像学复查示，术后6个月补片组肌腱愈合率及再撕裂率、足印区完全覆盖率、积液程度差异均无统计学意义（ P>0.05），但补片组肌腱厚度增加值高于对照组（ P<0.05）。亚组分析示，对于翻修手术患者，是否使用补片再撕裂率差异无统计学意义（ P>0.05）；但首次手术患者使用补片后肌腱愈合率更高（ P<0.05）。脂肪浸润Goutallier Ⅰ、Ⅱ级患者使用补片后肌腱愈合率更高（ P<0.05），而Ⅲ、Ⅳ级患者差异无统计学意义（ P>0.05）。对于是否累及肩胛下肌患者，是否使用补片肌腱愈合率差异均无统计学意义（ P>0.05）。多重线性回归分析示，术后6个月Constant-Murley评分改善的独立影响因素包括使用生物诱导型补片、年龄、脂肪浸润程度（ P<0.05）。. 生物诱导型补片可有效促进肩袖修复术后关节功能恢复与结构改善且安全性好。.
As indications for anterior cruciate ligament reconstruction (ACLR) expand to older and more metabolically comorbid patients, diabetes mellitus (DM) has emerged as a potential determinant of surgical outcomes. However, existing evidence remains fragmented, with limited pooled data quantifying postoperative risk. The purpose was to systematically review evidence comparing postoperative complications between patients with and without DM undergoing ACLR. It was hypothesized that DM would be associated with an increased incidence of overall complications, but not of revision. Systematic review and meta-analysis; Level of evidence, 3. The PubMed, Embase, Web of Science, and Scopus databases were searched through March 2025 following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analysis Of Observational Studies in Epidemiology) guidelines. Observational studies reporting postoperative outcomes in patients with and without DM undergoing ACLR were included. Pooled risk ratios (RRs) with 95% CIs were calculated using fixed- or random-effects models, as appropriate. The primary outcome was revision, and secondary outcomes included infection, surgical-site infection (SSI), readmission, and venous thromboembolism (VTE). For studies with zero events in 1 arm, a continuity correction of 0.5 was applied to enable computation of pooled estimates and avoid division-by-zero errors. Risk of bias assessment across included studies was conducted using the Risk of Bias Assessment tool for Non-randomized Studies of Interventions Version 2. A total of 25 studies met the inclusion criteria. Compared with patient without DM, those with DM had significantly higher risks of postoperative infection (after sensitivity analysis, RR, 7.25 [95% CI, 3.07-17.08]; P < .001; I 2 = 17.9%), SSI (RR, 3.18 [95% CI, 1.74-5.81]; P = .0002; I 2 = 0%), readmission (RR, 2.04 [95% CI, 1.66-2.50]; P < .0001; I 2 = 0%), and VTE (RR, 2.19 [95% CI, 1.48-3.25]; P < .0001; I 2 = 0%). Revision rates did not differ significantly (RR, 0.68 [95% CI, 0.41-1.14]; P = .15; I 2 = 22.2%). Among the included studies, 18 had a moderate risk of bias, 5 had a low risk of bias, and 2 had a serious risk of bias. DM is associated with substantially increased risks of infection, SSI, readmission, and VTE after ACLR, although there was no significant difference in revision rates. These findings highlight the need for optimized perioperative strategies, including strict glycemic control, thoughtful graft selection, and tailored surgical protocols to improve safety and outcomes in patients with DM. CRD420251119493.
Although many clinical trials are conducted on rotator cuff tears, a significant number of patient-enrolled studies remain unpublished, resulting in potential gaps in the sharing of scientific knowledge. To analyze the publication rate and discontinuation percentage of registered trials involving rotator cuff pathology. Cross-sectional study. A search for clinical trials was conducted in 4 different registries in a retrospective cohort study. Nontherapeutic studies, trials based on rehabilitation or anesthesia, or studies that had not completed recruitment and analysis before 2022 were excluded. The studies were classified according to their topic of interest, status in the registry, and funding. The sample size and study methods were also documented.The existence of an indexed publication in PubMed and Embase was verified, along with the final sample size included and the type of study. The corresponding authors of unpublished studies were contacted to explore the fate of the research project. The reasons for trial discontinuation were registered. Of the 152 included trials, 60 (39.47%) were not published in an indexed journal and 36 (23.68%) were discontinued. Studies of biological treatments presented a greater risk of discontinuation than trials on other topics (38.18% vs 15.46%; P = .03). One-third of published trials (27.17%) presented major inconsistencies concerning the original registry data. Approximately 40% of the trials on rotator cuff tears were not published. Research on biological therapies showed a higher rate of discontinuation.
Ulnar collateral ligament (UCL) reconstruction (UCLR) of the elbow is common in throwing athletes and reliably allows return to play. The literature supports stress imaging of the elbow to evaluate the integrity of the UCL. The FEVER view (flexion, external rotation, and valgus stress) was developed to improve the diagnostic accuracy of UCL pathology in throwing athletes with stress magnetic resonance imaging (MRI). The present study sought to evaluate FEVER MRI imaging findings, primarily ulnohumeral joint space widening, in patients with and without a history of UCLR. The authors hypothesize that on the FEVER view there would be no difference in joint space widening between pitchers with a history of UCLR and those without. Cross-sectional study; Level of evidence, 3. Pitchers in 2 Major League Baseball franchises who underwent preseason screening MRIs with standard and FEVER views were included. All images were read by 2 fellowship-trained musculoskeletal radiologists. Findings included gross UCL appearance, UCL edema, location of edema, type of signal, grade of injury, ligament retraction, and amount of ulnar-sided joint space opening (absolute opening, the joint space widening in the FEVER stress view; relative opening, the difference between joint space widening in the FEVER view and standard view joint space widening). Time from surgery was evaluated for impact on imaging findings. There was a statistically significant increase in absolute medial-sided joint space opening in players with a history of UCLR (n = 18; mean, 4.5 ± 3.4 years between UCLR and MRI) versus no UCLR (n = 76) (4.3 vs 3.8 mm; P = .04) and increased grade of UCL signal (P = .034) in patients with a history of UCLR. There was no difference in the other imaging parameters, including relative joint space opening (2.2 vs 1.9 mm; P = 0.11). Time from surgery was not associated with any outcome variables. Valgus stress MRI (the FEVER view) showed a slight, but significant increase in absolute joint space opening after UCLR and an increased grade of intrasubstance UCL signal. However, there was no difference in relative joint space opening, and the clinical significance of these findings is unclear and warrants further study.
Anterior cruciate ligament reconstruction (ACLR) is time-sensitive, as surgical delays exceeding 120 days are associated with an increased risk of secondary meniscal injury. Insurance type is a known determinant of health care access; however, its specific impact on time to ACLR is poorly characterized. To determine the effect of insurance type on the known increased risk of surgical delay >120 days in patients undergoing ACLR. Cohort study; Level of evidence, 3. A dual-center retrospective cohort study was conducted, including 2030 patients (age, 9-73 years) who underwent primary ACLR between 2013 and 2023 at 2 centers. Patients were stratified by insurance type: private (n = 1619), public (n = 362), self-pay (n = 27), and workers' compensation (n = 22). The primary outcome was surgical delay, defined as >120 days from injury to surgery. This threshold was selected a priori based on institutional data linking this threshold to increased risk of secondary meniscal injury. Multivariable logistic regression, including 2008 patients (private, public, and self-pay), was used to estimate adjusted odds ratios (aORs) with 95% CIs for the risk of delay. The model compared patients with public insurance and self-pay status to those with private insurance (the reference group) and was adjusted for confounding effects of patient age, biological sex, and injury type (sports-related vs nonsports-related). The multivariable logistic regression was restricted to patients with private, public, and self-pay insurance; the workers' compensation cohort was omitted from this analysis due to sample size considerations. Descriptive statistics revealed substantial differences in median wait times by insurance type: privately insured patients (median, 55 days [interquartile range, IQR, 90.5]), publicly insured patients (median, 106 days [IQR, 247]), self-pay patients (median, 145 days [IQR, 420]), and workers' compensation (median, 97.5 days [IQR, 136]). Multivariable logistic regression confirmed that insurance type was a significant factor for surgical delay (>120 days). Compared with patients with private insurance, those with public insurance were 1.86 times more likely (95% CI, 1.43-2.43; P < .001), and self-pay patients were 2.75 times more likely (95% CI, 1.25-6.27; P = .013) to experience surgical delay. This study demonstrates that insurance status is a significant independent factor of delayed ACLR. Patients with public or self-pay insurance experience significantly longer wait times and are at markedly higher risk of surgical delays exceeding 120 days compared with privately insured patients, highlighting a substantial inequity in access to timely orthopaedic sports medicine care.
Changes in joint contact force distribution after injury are 1 factor driving tissue degeneration. Although clinical interventions aim to restore forces to their uninjured state, inconsistent outcomes suggest that patient variability in joint contact mechanics remains poorly understood, despite the use of patient-specific computational models that are too labor-intensive to be widely adopted. A more practical solution may involve grouping knees by commonalities in force distribution, enabling recognition of heterogeneity without requiring fully individualized models. The objective of this study was to determine whether human cadaveric knees can be grouped based on differences in joint contact force distribution across the tibial plateau during the stance phase of simulated gait. We hypothesized that a subset of knees would heavily rely on the meniscus ("meniscal-dominant loaders") and another subset of knees would distribute more force through cartilage-to-cartilage contact ("cartilage-dominant loaders"). Our secondary hypothesis was that cartilage-dominant loaders would have their peak contact stress in the cartilage-cartilage contact region, and those with meniscal-dominant loading would have peak contact stress primarily located in the meniscus footprint. Descriptive laboratory study. Cartilage-cartilage and meniscal footprints were identified on contact force data across the tibial plateaus of cadaveric knees (n = 44) subjected to simulated gait. Knees were grouped based on force distribution on the medial or lateral plateaus using K-means clustering. They were characterized as meniscal dominant loaders if >50% of the compartment load was acting through the meniscus for >50% of the simulated gait cycle. Knees were characterized as cartilage-dominant loaders if >50% of the compartment load was acting through the cartilage-to-cartilage contact zone for most of the gait cycle. On the medial plateau, 4 clusters were identified. These clusters ranged from cartilage-dominant loaders (Cluster 1 [7% of knees]) to meniscal loaders (Cluster 4 [48% of knees]). Knees in Cluster 2 (20% of knees) and 3 (25% of knees) were meniscal-dominant loaders in early stance and switched to cartilage-dominant loading in late stance. The peak contact stress shifted from the cartilage-cartilage region in cartilage-dominant loaders to the meniscus footprint in meniscal-dominant loaders. On the lateral plateau, 3 clusters were identified. These clusters again ranged from cartilage-dominant loaders (Cluster 1 [11% of knees]) to meniscal-dominant loaders (Cluster 3 [72% of knees]). Knees in Cluster 2 (17% of knees) equally shared load between the cartilage and meniscus. No differences were found in peak stress between cartilage-dominant loaders and meniscal-dominant loaders on the lateral plateau. We confirmed that human cadaveric knees can be stratified based on the distribution of load through menisci and that peak pressures were higher in the cartilage-dominant loading knees. This study identifies heterogeneity in how human cadaveric knees distribute forces during simulated gait. This information is fundamental to understanding and improving upon the biomechanical variability in the knee's response to injury and repair.
Shoulder dislocation injuries may require prolonged recovery and absence from play, with risks of recurrent instability. The impact of shoulder dislocation on return-to-play (RTP) time and player performance in professional soccer athletes remains poorly defined. To determine the rate and timing of RTP, risk of recurrence, and player performance after shoulder dislocation in elite professional soccer athletes. Descriptive Epidemiology Study. Professional soccer athletes who sustained a shoulder dislocation between 2010 and 2024 across the 5 major European soccer leagues with a minimum 1-year follow-up were identified using publicly available records. Injured athletes were matched by position, age, height, season, experience, and preinjury minutes played and compared to uninjured controls. RTP rates, recurrence, field time, and performance up to 4 seasons after injury were assessed. A total of 118 soccer athletes with shoulder dislocations were included (38% defenders, 23% attackers, 20% goalkeepers, and 19% midfielders). Mean age at time of injury was 26.2 ± 4.2 years. Overall, 87% returned to the same level within 2 seasons after shoulder dislocation. Injured athletes missed a median of 68 days and 10 games, with goalkeepers missing more days (124 vs 60, P < .001) and games (21 vs 8, P < .001) compared to outfield players. Recurrence occurred in 18% at a mean time of 2.6 ± 2.4 years, with a higher risk in athletes ≤25 years (26% vs 12%, P = .046). By treatment, 59% and 41% underwent operative and nonoperative management, respectively, with similar recurrence rates (17.1% vs 18.8%, P = .823) but longer time to recurrence in the operative group (3.82 ± 2.91 vs 1.41 ± 0.69 years, P = .009). Injured athletes played significantly fewer games, total minutes, and minutes per game during the index season and at 1 and 2 seasons after shoulder injury compared with matched controls. However, performance metrics and RTP rates in all seasons after injury remained comparable to matched controls across all positions and treatment groups. Professional soccer athletes returned to play at a high rate and a median of 68 days after shoulder dislocation, with an 18% recurrence rate. Despite reduced field time for up to 2 seasons after injury, overall player performance and RTP were not adversely affected.
The optimal graft choice for anterior cruciate ligament reconstruction (ACLR) remains a subject of ongoing debate. In practice, graft selection in ACLR is multifactorial, with patient characteristics, activity level, and surgeon preference/training background all playing a crucial role in the clinical decision-making process. While graft trends have been reported across select professional sports leagues, none have focused specifically on professional soccer. To report current trends in graft preference for ACLR among Major League Soccer (MLS) surgeons. Cross-sectional study. A 39-question survey was distributed to 27 orthopaedic surgeons affiliated with MLS teams in January 2025. The questionnaire captured each respondent's preferences regarding ACLR management in both the general population and high-level/professional soccer athletes. Descriptive statistics were used to summarize responses. Surgeons averaged 7.7 years caring for MLS teams and performed a mean of 80 ± 27 ACLRs annually. In primary ACLR for professional soccer athletes, the bone-patellar tendon-bone (BPTB) autograft was preferred (74%), followed by the quadriceps tendon (QT) autograft (22.2%). The hamstring tendon (HT) autograft was uncommon (3.7%). Similar trends were reported for the general population: BPTB autograft (70%), QT autograft (22.2%), and HT autograft (3.7%). For revision procedures, QT autograft was favored (48.2%), followed by BPTB autograft (25.9%) and BPTB allograft (11.1%). Contralateral autografts were more common in revisions (44.4%) than in primary cases (7.4%). Lateral extra-articular augmentation (LEA) was performed in 31.5% of primary cases and 76% of revision cases; iliotibial band tenodesis was favored over anterolateral ligament reconstruction (74.1% vs 25.9%). LEA utilization increased compared with 5 years prior (6.4% vs 29.4%). Among orthopaedic surgeons caring for MLS athletes, BPTB autografts were the preferred graft for primary ACLR. QT autografts were preferred over HT autografts in primary ACLR, and QT autografts were most commonly used in revision surgery. HT autografts were rarely used in primary ACLR and were not preferred in revision scenarios. LEA procedures were widely used among professional soccer athletes.
Mental health disorders are increasingly acknowledged as significant factors influencing surgical outcomes. However, their effect on recovery after Achilles tendon repair (ATR) remains inadequately defined. Psychosocial elements may modify pain perception, opioid consumption, adherence to rehabilitation protocols, and overall utilization of health care services. To evaluate the postoperative complications among patients with preexisting mental health diagnoses in the context of ATR. Cohort study; Level of evidence, 3. A retrospective analysis was performed using the TriNetX Research Network on August 14, 2025. Patients with a mental health disorder diagnosis within 1 year before ATR were identified using the International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes. These patients were compared with controls without a documented diagnosis of mental health disorders. Propensity score matching (1:1) was performed for age, sex, body mass index, and other important comorbidities. The initial search identified 11,787 patients who underwent ATR. Outcomes at 3, 6, 12, and 24 months included ankle pain, stiffness, complex regional pain syndrome (CRPS), wound complications, opioid use, and revision repair. Odds ratios (OR) with 95% CIs were calculated. After matching, 1767 patients were included in each group. At 3 months, the mental health cohort had 1.59 times higher odds of wound complications (7.2% vs 4.6% [95% CI, 1.19-2.1]; P = .01), 1.39 of ankle stiffness (5.2 vs 3.8% [95% CI, 1.01-1.92]; P = .04), and 1.56 of ankle pain (22 vs 15% [95% CI, 1.32-1.86]; P < .001) compared with the control group. Additionally, the mental health group had higher incidence of emergency department visits (OR, 1.50 [95% CI, 1.19-1.9]; P = .001), reoperation for any reason (OR, 1.51 [95% CI, 1.15-1.99]; P = .003), readmission (OR, 1.76 [95% CI, 1.24-2.50]; P = .001), and opioid use (OR, 1.58 [95% CI, 1.37-1.81]; P < .001). At 6 months, all these differences persisted (all P < .05). At 1 year, ankle pain (12.4% vs 9.3%) and opioid use (22.8% vs 16.4%) remained significantly elevated in the mental health cohort. At 2 years, ankle pain, opioid use, and CRPS (1.4% vs 0.6%; OR, 2.52 [95% CI, 1.20-5.26]; P = .01) were significantly more common. Revision rates did not differ between groups at any time point. Our study showed that mental health disorders are associated with an increase in postoperative complications after ATR. The persistence of pain and opioid dependence over 2 years underscores the significant long-term impact of psychosocial factors on the recovery process. These findings support the incorporation of routine psychosocial screening and perioperative mental health support into comprehensive care strategies to reduce complications and enhance functional outcomes.
Psychological responses to injury are common after anterior cruciate ligament (ACL) injury and reconstruction (ACLR) and have been linked to knee-related pain during early recovery. However, it remains unknown whether anxiety and depression symptoms are associated with knee pain severity at later stages of recovery, when unresolved or recurrent psychological distress may persist. The purpose of this study was to examine the association of anxiety and depression symptoms with knee pain severity in individuals 3 to 12 months after ACLR. It was hypothesized that individuals who exhibited more severe anxiety and depression symptoms would report more knee pain. Cross-sectional study; Level of evidence, 3. In total, 131 individuals who were 3 to 12 months after primary, unilateral ACLR (time since ACLR = 5.7 ± 1.7 months; age = 18.3 ± 2.1 years; 37.4% male) were included. Anxiety and depression symptoms were measured with the Patient-Reported Outcomes Measurement Information System Anxiety and Depression 4-item short forms, respectively, where higher scores reflect more severe symptoms. Knee pain was measured with the Knee injury and Osteoarthritis Outcome Score Pain subscale, where higher scores indicate less or no knee pain. Separate multiple hierarchical regression analyses were conducted to examine the association of self-reported anxiety and depression symptoms with knee pain severity. Sex, age, and time since ACLR were entered in step 1 of each model. Anxiety and depression symptom scores were entered in step 2 of their respective models, and the change in R 2 was examined. Sex, age, and time since ACLR explained 3% of the variance in knee pain severity (R 2 = 0.031, P = .23). Anxiety symptoms accounted for an additional 25.7% of the variance in knee pain severity (ΔR 2 = 0.257, P < .001), while depression symptoms accounted for an additional 15.7% of the variance in knee pain severity (ΔR 2 = 0.157, P < .001). Self-reported anxiety and depression symptoms were significantly associated with knee pain severity in individuals 3 to 12 months after ACLR. These findings support assessment of anxiety, depression, and knee pain, even in the later phases of ACLR rehabilitation, to help inform clinical decision-making.
Bariatric surgery (BS) is an increasingly utilized intervention for the treatment of obesity. However, BS is also associated with postoperative nutritional deficiencies that may affect healing rates after orthopaedic procedures. To compare failure rates and patient-reported outcomes after arthroscopic rotator cuff repair (RCR) between patients with and without a history of BS. Cohort study; Level of evidence: 3. Patients in a single institution with a history of BS who underwent arthroscopic RCR for full-thickness supraspinatus tears were identified. These patients were matched in a 1:3 ratio by age, sex, and body mass index to patients without a history of BS who underwent arthroscopic RCR. The minimum follow-up was 24 months. The primary outcome was surgical failure. Secondary outcomes assessed included the numeric rating scale (NRS) score for pain, Single Assessment Numeric Evaluation (SANE) score, American Shoulder and Elbow Surgeons (ASES) Shoulder Score, need for manipulation under anesthesia (MUA) or arthroscopic lysis of adhesions (LOA), infection requiring reoperation, and conversion to reverse total shoulder arthroplasty (rTSA). A total of 34 arthroscopic patients with a history of BS who underwent RCR were matched to 102 patients without BS. The BS group had significantly higher overall failure rates (20.6% vs 6.9%; P = .044) than patients without BS. The BS group had significantly higher postoperative NRS pain scores (3.9 vs 1.3; P < .001), lower SANE scores (77.7 vs 87.7; P = .041), and lower ASES scores (72.6 vs 90.4; P < .001) at the final follow-up. Rates of revision RCR, reoperation for MUA or LOA, and conversion to rTSA were not statistically significantly different (P > .050 for all). No postoperative infections were reported. A history of BS is associated with increased failure rates, worse postoperative pain, and worse patient-reported outcomes after arthroscopic RCR. Patients with a history of BS and those considering BS before arthroscopic RCR should be counseled regarding a possible risk for inferior outcomes after surgery.
Posterior cruciate ligament (PCL) injuries may lead to significant anteroposterior and rotational knee instability. Traditional reconstruction techniques, including single-bundle (SB) and double-bundle (DB) approaches, have limitations in terms of restoring full biomechanical function. A posterolateral tenodesis (PLT) augmentation associated with PCL reconstruction has been described, consisting of a nonanatomic bundle that shares the PCL tibial tunnel, courses along the posterior aspect of the lateral femoral condyle from an intra-articular to an extra-articular position, and is fixed at the lateral femoral epicondyle to provide additional control of tibial external rotation. To determine the impact of adding a posterolateral tenodesis (PLT) to a PCL reconstruction to restore knee rotational and posterior stability. Controlled laboratory study. In total, 24 embalmed cadaveric human knees were randomized into 3 main groups: intact (control), isolated PCL-deficient, and combined PCL + posterolateral corner (PLC)-deficient (Fanelli type A). Each group underwent sequential reconstructions using SB and DB PCL techniques, with and without the addition of PLT. Biomechanical testing included measurements of posterior tibial translation (PTT) and external tibial rotation (ER) at 30° and 90° of flexion using a custom-built robotic testing machine and inertial sensors. Porcine flexor tendons were used as grafts. Sectioning the PCL significantly increased both PTT and ER, with values peaking in the combined PCL + PLC-deficient group (PTT: 10.3 ± 0.8 mm; ER: -30.4°± 0.8° at 90° of flexion). SB and DB reconstructions alone partially restored stability, but residual laxity persisted, especially in the rotational parameters. The addition of PLT significantly reduced both PTT and ER. In the DB + PLT group with combined PCL + PLC injury, the PTT and ER values (3.2 ± 0.3 mm and -12.5°± 0.3°, respectively) were statistically indistinguishable from the intact group (P > .05). Combined PCL and PLC injuries result in marked rotational and posterior instability. When added to SB or DB PCL reconstruction, PLT significantly improves biomechanical function, particularly regarding rotational control. These findings support the inclusion of PLT in surgical protocols addressing complex PCL-related instability. Adding a posterolateral tenodesis to PCL reconstruction may reduce residual instability and improve outcomes in complex ligament injuries.
Recurrent anterior shoulder instability is a common problem in athletes, especially those in contact, collision, or overhead sports. Anterior shoulder instability remains the predominant injury pattern in athletes, accounting for the majority of subluxations and dislocations. Return-to-sport (RTS) outcomes vary across techniques, and the relative effectiveness of these procedures in athletes has not been well established. Our study aimed to compare rates of RTS after anterior shoulder stabilization surgery. It was hypothesized that the Bristow-Latarjet procedure would have the highest RTS. Systematic review; level of evidence, 3. A systematic review and meta-analysis of randomized controlled trials and cohort studies were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies on surgical stabilization of anterior shoulder instability in athletes that reported return to sport were included. Nineteen studies met the inclusion criteria, comprising 1,850 patients with an average age of 22.8 (13-46). Pooled proportions for RTS were calculated. Subgroup analysis was performed based on the surgical procedure. Full RTS across all patients was 79% (95% CI, 0.70-0.87). Full cessation of sport was 10% (95% CI, 0.04-0.16). Although indications for procedures varied, the Bristow-Latarjet stabilization demonstrated a significantly higher full RTS rate compared with Bankart (0.92; 95% CI, 0.83-0.98, versus 0.71; 95% CI, 0.56-0.83; respectively, P = .002). Athletes undergoing surgical stabilization for anterior shoulder instability achieved high rates of RTS. The Bristow-Latarjet procedure was associated with significantly higher rates of full RTS than Bankart repairs in anterior shoulder instability, despite variability in patient indications across procedures.