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Background: Ankle injuries are more common in the National Basketball Association (NBA) compared with other professional sports. Purpose/Hypothesis: The purpose of this study was to report the incidence and associated risk factors of ankle injuries in NBA athletes. It was hypothesized that factors associated with an increased physiologic burden, such as minutes per game (MPG), usage rate, and associated lower extremity injury, would be associated with increased ankle injury risk and time loss. Study Design: Descriptive epidemiology study. Methods: Ankle injury data from the 2015-2016 through 2020-2021 NBA seasons were evaluated. The truncated 2019-2020 season due to the COVID-19 pandemic was omitted. The primary outcome was the incidence of ankle injuries, reported per 1000 game-exposures (GEs). Secondary analysis was performed to identify risk factors for ankle injuries through bivariate analysis and multivariable logistic regression of player demographic characteristics, performance statistics, injury characteristics, and previous lower extremity injuries. Factors influencing the time loss after injury were assessed via a negative binomial regression analysis. Results: A total of 554 ankle injuries (4.06 injuries per 1000 GEs) were sustained by NBA players over 5 NBA seasons, with sprain/strain the most common injury type (3.71 injuries per 1000 GEs). The majority of ankle injury events (55%) resulted in 2 to 10 game absences. The likelihood of sustaining an ankle injury was significantly associated with a greater number of games played (P = .029) and previous injury to the hip, hamstring, or quadriceps (P = .004). Increased length of absence due to ankle injury was associated with greater height (P = .019), MPG (P < .001), usage rate (P = .025), points per game (P = .011), and a prior history of foot (P = .003), ankle (P < .001), and knee injuries (P < .001). Conclusion: The incidence of ankle injuries was 4.06 per 1000 GEs in professional basketball players. Games played and prior history of hip, hamstring, or quadriceps injuries were found to be risk factors for ankle injuries. Factors associated with physiologic burden such as MPG and usage rate were associated with an increased time loss after injury.

Background: Medicare reimbursement is rapidly declining in many specialties. An in-depth analysis of Medicare reimbursement for routinely performed diagnostic imaging procedures in the United States is warranted. Purpose/Hypothesis: The purpose of this study was to evaluate Medicare reimbursement trends for the 20 most common lower extremity imaging procedures performed between 2005 and 2020, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). We hypothesized that Medicare reimbursement for imaging procedures would decline substantially over the studied period. Study Design: Cohort study. Methods: The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was analyzed for reimbursement rates and relative value units associated with the top 20 most utilized Current Procedural Terminology (CPT) codes in lower extremity imaging from 2005 to 2020. Reimbursement rates were adjusted for inflation and listed in 2020 US dollars using the US Consumer Price Index. To compare year-to-year changes, the percentage change per year and compound annual growth rate were calculated. A 2-tailed t test was used to compare the unadjusted and adjusted percentage change over the 15-year period. Results: After adjusting for inflation, mean reimbursement for all procedures decreased by 32.41% (P = .013). The mean adjusted percentage change per year was –2.82%, and the mean compound annual growth rate was –1.03%. Compensation for the professional and technical components for all CPT codes decreased by 33.02% and 85.78%, respectively. Mean compensation for the professional component decreased by 36.46% for radiography, 37.02% for CT, and 24.73% for MRI. Mean compensation for the technical component decreased by 7.76% for radiography, 127.66% for CT, and 207.88% for MRI. Mean total relative value units decreased by 38.7%. The commonly billed imaging procedure CPT 73720 (MRI lower extremity, other than joint, with and without contrast) had the greatest adjusted decrease of 69.89%. Conclusion: Medicare reimbursement for the most billed lower extremity imaging studies decreased by 32.41% between 2005 and 2020. The greatest decreases were noted in the technical component. Of the modalities, MRI had the largest decrease, followed by CT and then radiography.

ObjectivesPerform a comprehensive video analysis of all anterior cruciate ligament (ACL) injuries in National Basketball Association (NBA) athletes from 2006 to 2022 to determine the associated biomechanics, injury mechanism and game situation.MethodsNBA players diagnosed with an ACL tear from 2006 to 2022 were identified and videos of each injury evaluated by two reviewers. Visual evaluation included assessment of joint kinematics at three time points: initial contact of the injured leg with the ground (IC), 33 milliseconds later (IC+33) and 66 milliseconds later (IC+66). Game situation was assessed qualitatively.ResultsVideos of 38 out of 47 (80.9%) ACL tears were obtained. 9 injuries were non-contact, while 29 involved indirect contact. Between IC and IC+33, average knee valgus increased from 5.1° to 12.0° and knee flexion increased from 12.6° to 32.6°. At all time points, the majority of injuries involved trunk tilt and rotation towards the injured leg, hip abduction and neutral foot rotation. The most common game situations for injury included the first step when attacking the basket following picking up the ball (n=13), landing following contact in the air (n=11) and jump stop (n=5).ConclusionThree major mechanisms predominate ACL tears in NBA players: the first step following picking up the ball when attacking, landing and jump stops. None of the injuries reviewed demonstrated direct contact to the knee, emphasising the importance of body kinematics in this injury pattern. The increase in knee valgus and knee flexion between IC and IC+33 should be noted as a possible precipitant to injury.

We present a case of an 82-year-old female with a history of right total knee arthroplasty 11 years prior. She was admitted after a ground-level fall and developed progressive pain and swelling of her right knee. She had no history of complications with her total knee replacement. Radiographs of the knee and hip were negative for acute fracture, dislocation, or hardware malalignment. Knee aspiration was performed and revealed inflammatory exudate, synovial fluid consistent with crystal arthropathy, and no bacterial growth. She was diagnosed with an acute gout flare, and her symptoms significantly improved with steroids and anti-inflammatory treatment. Orthopedic surgeons should be aware of the potential for crystal arthropathy in the setting of total joint arthroplasty and evaluate for crystals before treating a presumed periprosthetic joint infection.

Purpose of Review Massive irreparable rotator cuff tears (MIRCTs) present treatment challenges. Recently, superior capsule reconstruction (SCR) and anterior cable reconstruction have emerged as surgical options, but no single approach is superior. This review provides an overview of SCR and cable reconstruction techniques, including biomechanical studies, clinical outcomes, and surgical considerations. Recent Findings Biomechanical studies show SCR with autografts or allografts improves glenohumeral stability and mechanics. Clinical outcomes of SCR demonstrate improved range of motion, function scores, and pain relief in short-term studies. Anterior cable reconstruction reduces superior humeral head translation and subacromial pressures in biomechanical models. Early clinical studies report improved rotator cuff healing and outcomes for cable reconstruction in specific irreparable tear patterns . Summary SCR and cable reconstruction are viable surgical options for MIRCTs based on early encouraging results. However, higher-level comparative studies with long-term follow-up are still needed. Careful consideration of tear pattern, patient factors, and surgical goals is required to optimize treatment of MIRCTs. Further research is necessary to determine the optimal role for these procedures.

Objective To analyze and quantify the change in United States of America Medicare reimbursement rates for the 30 most commonly performed spinal imaging procedures. Materials and methods The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was utilized to find and extract the 28 most billed spinal imaging procedures. All data was adjusted for inflation and listed in 2020 US dollars. Percent change in reimbursement and Relative Value Units between 2005 and 2020, both unadjusted and adjusted, were calculated and compared. Additionally, percent change per year and compound annual growth rate were calculated and compared. Results After adjusting for inflation, the average reimbursement for all analyzed spinal imaging procedures between the years 2005 and 2020 decreased by 45.9%. The adjusted reimbursement rate for all procedures decreased at an average 4.3% per year and experienced an average compound annual growth rate (CAGR) of − 4.4%. Magnetic resonance imaging (MRI) had the most substantial adjusted decline of all imaging modalities at − 72.6%, whereas x-ray imaging had the smallest decline at − 27.33%. The average total RVUs per procedure decreased by 50.1%, from 7.96 to 3.97. Conclusion From the years 2005 to 2020, Medicare reimbursement significantly decreased for all advanced imaging modalities involving the most common spinal imaging procedures. Among all practices, imaging procedures may be experiencing some of the largest decreases from Medicare reimbursement cutbacks.

Objectives: To compare ACL reconstruction with quadriceps autograft with or without LET for primary ACL reconstruction Methods: A retrospective study was performed from 2013- 2021 including patient undergoing quadriceps autograft (QA) or QA plus lateral extra-articular tenodesis (LET) for primary ACLR. Exclusion criteria included patients undergoing multi-ligamentous reconstruction, concomitant procedures outside of meniscal work, revision cases, and patients with less than 2 years of follow up. The surgeon favored LET in young (less than 18 years old) females participating in cutting and twisting sports. An additional relative indication was a high-grade pivot shift (2 or 3+). Clincal outcomes incldued IKDC and Lysholm scores, retrun to sport/return to sport at same level and time to return to sport in athletes along with complication rates. Failure rate was determined by rate of graft re-tearing and presence of a residual pivot shift (2+ or higher) at final follow up. Results: A total of 142 patients underwent QA+LET with 18 excluded, leaving 124 patients in this group. The QA group had 371 patients with 57 excluded, leaving 314 for analysis. The QA+LET group had a significantly higher percentage of females, ligamentous laxity, and athletes. IKDC scores were significantly higher in the QA+LET group at final follow up. Lysholm scores were significantly higher in the QA group at 6 months, with no difference at other time points. Graft re-tear rates were similar between the 2 groups. Residual pivot shift at final follow up was significantly higher in the QA group (21% vs. 11%, p = 0.012) as was overall failure rate (24% vs. 14.5%. p = 0.026). Return to sport was similar between the 2 groups, but time to return to sport and return at the same or higher level was significantly higher in the QA+LET group. Hematomas were more common (12.9% vs. 0%) in the QA+LET group.  Conclusions: Addition of an LET to QA leads to lower residual pivot shift when compared to QA alone. The addition of a LET to QA may lead to a higher return to sport at same or higher level compared to QA alone. This provides preliminary data that will be built upon with results from the Stability 2 trial.

Background: The optimal graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in the high-level cutting and pivoting athlete remains controversial. Studies have shown similar outcomes when directly comparing bone-patellar tendon-bone (BPTB) autograft versus quadriceps soft tissue (QST) autograft in the general population. However, no studies have directly compared these 2 grafts in athletes participating in cutting and pivoting sports. Hypothesis: It was hypothesized that, compared with BPTB autograft, the QST autograft would result in similar patient-reported outcomes and rates of retear, return to sport, and complications. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on athletes participating in cutting and pivoting sports (soccer, American football, lacrosse, and basketball) who underwent primary ACLR with either BPTB autograft or QST autograft chosen by the athlete between January 2015 and January 2019. The International Knee Documentation Committee (IKDC) subjective knee evaluation and Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. Return-to-sport and complication rates were identified. Descriptive statistics were expressed using Mann-Whitney test or Student t test for continuous variables and the chi-square test for categorical variables. Results: A total of 68 athletes (32 QST, 36 BPTB) were included for analysis. The percentage follow-up was 89% (32/36) for the QST autograft group and 86% (36/42) for the BPTB autograft group. The 2-year IKDC score (QST, 90.5 ± 6.6 vs BPTB, 89.7 ± 7.8) and 2-year Lysholm score (QST, 91.3 ± 7.5 vs BPTB, 90.5 ± 8.6) were similar between groups. The percentage of athletes able to return to sport within the follow-up period was also similar (88% vs 83%; P = .63). There were 2 retears requiring revision in the BPTB group (6%) and no retears in the QST group (P = .18). One contralateral ACL rupture occurred in the QST group (3%) and 4 in the BPTB group (11%) (P = .21). Conclusion: The QST and BPTB autografts demonstrated similar patient-reported outcomes, return-to-sport rates, and complication rates after primary ACLR at 2-year follow-up. Both autografts appear to be reliable and consistent options for ACLR in the cutting and pivoting athlete.

We report the case of an achondroplastic female who presented with acute neurologic decline following epidural anesthesia for an elective cesarean section. Achondroplasia presents unique anatomical challenges to anesthesiologists in perioperative management, and cesarean sections are standard for achondroplastic pregnancies. High rates of spinal stenosis and lumbar radiculopathy in this patient population make administration of epidural analgesia technically challenging and may increase the risk of neurologic injury. Ultrasound is an effective means of administering epidural anesthesia for most patients; however, its utility is user-dependent and more challenging for those with obesity and abnormal spinal anatomy, both of which are common in achondroplasia. Cephalic and thoracic anatomical features in achondroplasia can also make general anesthesia challenging. Therefore, preoperative imaging may help guide preoperative planning based on patient anatomy and individual risk factors to reduce the risks of complications in this patient population. This report includes details from the patient’s prenatal care, cesarean section, and 18 months of follow-up.

Background: Decreases in Medicare reimbursement have been noted among many medical specialties. An in-depth analysis of the subspecialty of orthopaedic sports medicine is needed to determine changes in Medicare reimbursement in this field. Purpose/Hypothesis: The purpose was to elucidate the trends in inflation-adjusted Medicare reimbursement for orthopaedic sports medicine procedures between 2000 and 2020. It was hypothesized that Medicare reimbursement decreased substantially during the study period. Study Design: Economic decision and analysis; Level of evidence, 4. Methods: The Physician Fee Schedule Look-up Tool was used to extract Medicare reimbursement information between 2000 and 2020 for 67 procedures related to orthopaedic sports medicine. These values were adjusted for inflation using the Consumer Price Index. The compound annual growth rate (CAGR) was calculated to measure the annual rate of change, and descriptive analyses were performed using the Student t test. Results: Between 2000 and 2020, inflation-adjusted Medicare reimbursement for the 67 included procedures decreased by an average of 33% (CAGR = –2.2%; R 2 = 0.78). Reimbursement decreased for procedures related to the shoulder and elbow by 34% (CAGR = –2.3%; R 2 = 0.80), for hip-related procedures by 23% (CAGR = –1.4%; R 2 = 0.77), for knee-related procedures by 31% (CAGR = –2.0%; R 2 = 0.81), and for procedures relating to the foot and ankle by 38% (CAGR = –2.5%; R 2 = 0.79). Conclusion: Study findings indicated that inflation-adjusted Medicare reimbursement decreased substantially between 2000 and 2020 for orthopaedic sports medicine procedures, ranging from a 23% decrease for hip-related procedures to a 38% decrease for foot and ankle–related procedures. The results of this study could be used to provide further context for health care policy decisions and help ensure sustainable financial environments for orthopaedic sports medicine surgeon.