Background:Uniplanar coronal tibiofemoral subluxation (UCTFS) in the setting of multiple ligament knee injury (MLKI) or knee dislocation (KD) has rarely been discussed, and the potential for missed diagnosis may significantly impact long-term outcomes. Purpose:To describe the presentation, injury patterns, possible mechanical barriers for reduction, and management for isolated UCTFS after MLKI/KD. Study Design:Case series; Level of evidence, 4. Methods:A retrospective chart review was conducted at 4 institutions to identify patients with KD or MLKI who were evaluated with or developed subsequent UCTFS from January 2001 to January 2024. UCTFS was defined as medial or lateral translation of the tibial plateau in reference to the femoral condyle as seen on coronal imaging (radiograph, computed tomography scan, or magnetic resonance imaging scan), with normal alignment seen on the sagittal imaging. Medical records were reviewed for demographic data, clinical presentation, physical examination, diagnostic imagining, examination under anesthesia, surgical finding, and procedures performed. Results:A total of 15 cases were included. Of these, 12 patients were subluxed laterally and 3 medially. UCTFS was diagnosed at different time points with 10 patients within 1 week, 2 patients between 1 and 6 weeks, and 3 patients after 6 weeks from injury. The most common mechanism of injury was a fall (33%), and the most common pattern of injury was a KD-3L (26.6%). A mechanical blockage to reduction was found in 9 (60%) cases. These included medial soft tissue sleeve incarceration (n = 4), bucket-handle meniscal tears (n = 3), concomitant patellar dislocation (n = 2), and a displaced tibial spine fracture (n = 1). Some patients experienced subluxation due to several sources of mechanical block. Uniplanar external fixation was utilized in 7 patients for management of their initial ligamentous injuries, coronal instability, or a traumatic vascular injury. Hinged external fixation was utilized in 2 patients who presented in a chronic fashion to counter the propensity to subluxation while allowing early motion. Conclusion:UCTFS is a rare event that has several potential factors contributing to its cause, and ≥1 of these factors may need to be surgically addressed. Tibiofemoral subluxation can be found at various time points from injury, and awareness and monitoring for its development should be factored into the clinical decision-making. UCTFS is a challenging clinical dilemma that may require multiplanar or hinged external fixation to maintain reduction.

BACKGROUND:Acromioclavicular (AC) joint injuries pose significant challenges in clinical management, necessitating consensus guidelines for optimal treatment. There is a lack of consensus in several areas, including imaging protocols, surgical techniques, and rehabilitation timelines. This study aims to develop a consensus regarding the diagnosis, treatment, and rehabilitation of AC joint separations. METHODS:Using the Delphi method to gather expert opinions, 18 fellowship-trained surgeons from the American Shoulder and Elbow Surgeons participated in 3 survey rounds, achieving a 100% response rate over each round. RESULTS:A total of 76 consensus statements were identified in 6 areas: history, physical examination, radiology, treatment, surgical technique, and rehabilitation. Consensus was reached on some of the fundamental principles of AC separation management, such as the importance of a comprehensive history and physical examination, multiple radiographic views of the joint, indications for surgery, and the usefulness of allograft tendon augmentation for repair of the joint when surgery is indicated. CONCLUSION:The Delphi method proved effective in gathering diverse perspectives and quantifying consensus among experts, offering important insights into the management of AC joint injuries. Continued research efforts are warranted to address areas of controversy and establish improved guidelines for the diagnosis and treatment of these injuries.

PURPOSE:To systematically review the literature for studies using video analysis to evaluate acute lower extremity injury mechanisms in soccer players. METHODS:The study was preregistered on PROSPERO. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Three databases were searched for Level I to IV studies that quantified lower extremity injury mechanisms in soccer players using video analysis. Data recorded included study demographics, injury type, mechanisms, contact, phase of play, timing, and sagittal plane kinematics. Study methodological quality was analyzed using the Quality Appraisal for Sports Injury Video Analysis Studies scale. Forest plots of proportions were generated for injuries occurring in the first versus second half, defensive versus offensive phase, and contact versus noncontact injury. RESULTS:Nineteen articles (mean Quality Appraisal for Sports Injury Video Analysis Studies score 14.3 ± 1.9; all Level IV evidence, 1,652 videos, 17 professional males, 1 professional female, 1 both male/female) were included. Anterior cruciate ligament (ACL) tears (49% [42%-55%]), muscle strains (hamstring: 71% [47%-87%]), and Achilles tears (80%-83%) had a high percentage of noncontact (NC) injury mechanisms. Direct and indirect contact-predominant injuries include medial collateral ligament sprains (14% NC) and foot/ankle sprains (6% [4%-10%] NC). Most ACL injuries (68% [61%-75%]) occurred while defending, and quadriceps strains (81%-89%) occurred while attacking. CONCLUSIONS:In soccer, video analysis shows that a high proportion of acute ACL, Achilles, and muscle injuries occur through noncontact mechanisms, while medial collateral ligament and foot/ankle injuries usually happen with direct contact. ACL injuries are more likely to be sustained when defending, specifically when pressing/tackling, and muscle injuries result from sprinting, kicking, and lunging. Most noncontact-predominant injuries occurred at a higher percentage in the first half, whereas contact-predominant injuries occurred at a higher percentage in the second half. LEVEL OF EVIDENCE:Level IV, systematic review and meta-analysis of Level IV studies.

INTRODUCTION:The purpose of this study was to investigate whether patellar tendinopathy on preoperative MRI in patients undergoing anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) autograft has an effect on retears, subsequent surgeries, and postoperative patient-reported outcomes (PROs). METHODS:Patients who underwent primary or revision ACL reconstruction with BTB autograft with preoperative MRI and minimum 2 years of follow-up were included. Concomitant procedures, demographic data, retears, and subsequent surgeries were documented. MRI scans were graded for patellar tendinopathy by two independent reviewers. Cohorts were created based on tendinopathy findings (Grade 0-no tendinopathy; Grade 1-mild; Grade 2-moderate; and Grade 3-severe). PRO questionnaires were sent to included patients postoperatively. Multivariable logistic regression evaluated odds of retear and revision surgery between groups. Multivariable linear regression evaluated PROs between tendinopathy grades. RESULTS:Nine hundred nine knees (795 primary, 114 revision; 63% male; 44.4% grade 0, 42.7% grade 1, 11.7% grade 2, and 1.2% grade 3 tendinopathy) were included. A total of 89 subsequent surgeries were included, with 16 revisions. After controlling for covariates, there were no notable differences in odds of ACL retear or revision surgery for grades 1, 2, and 3 tendinopathy compared with no tendinopathy. Concomitant medial meniscus repair at the index procedure was significantly associated with increased odds of revision surgery (odds ratio 2.9 [1.8 to 4.6]; P < 0.001). No significant differences were detected in all PROs between grade 0, 1, and 2 tendinopathy, except for a 5.2-point higher Single Assessment Numeric Evaluation, for grade 1 versus no tendinopathy (P = 0.03). Regardless of tendinopathy status, patients with a subsequent surgery scored markedly worse on all PROs measured, except for the total Knee Injury and Osteoarthritis Outcome Score. CONCLUSION:This large study of over 900 knees demonstrates that patients with evidence of mild-moderate patellar tendinopathy on MRI before undergoing ACL reconstruction with BTB autograft have no notable differences in ACL retear rates and rates of subsequent ipsilateral knee surgery.

Background:Partial anterior cruciate ligament (ACL) tears, particularly injuries detected with magnetic resonance imaging (MRI) but stable on ligamentous examination, appear to be recognized more frequently; however, there remains no consensus management for this complex pathology. Purpose:To present the results of a survey of a group of international ACL experts on the management of partial ACL injuries. Study Design:Survey study; Level of evidence, 5. Methods:The ACL Study Group is an international group of orthopaedic surgeons with a special interest in the ACL. There are 169 members overall, with 135 clinically active surgeons. A branching logic survey was developed and circulated to members of the ACL Study Group via electronic mail. Categories included member demographics as well as recommended management strategies of partial ACL injuries, including recommendations on return to play. Results:Of the 135 clinically active surgeon members, 113 responded to the survey (84%). Nonoperative management of partial ACL injuries was selected by 92% of respondents. Of those who managed nonoperatively, 75% indicated they would not restrict weightbearing and 59% would not recommend a knee brace. When those who managed the patient nonoperatively determined criteria for return to sports (RTS), 33% would use differential knee laxity, 87% would assess functional testing, 26% would utilize imaging, and 40% selected time from injury. When using time as a guide for RTS, 13% chose RTS between 7 and 11 weeks postinjury, 56% selected no sport before 3 months, and 22% favored waiting 4 to 6 months before allowing an athlete with a partial ACL injury to RTS. With regard to function as a tool to determine RTS, painless Lachman, strength, swelling, and functional performance tests were all chosen by a majority of respondents. Conclusion:This study presented the results of a survey on partial ACL injury management administered to ACL Study Group active surgical members. The majority favored nonoperative management for partial ACL injuries (stable ligament examination but MRI changes in the ligament). Nonoperative treatment and RTS protocols varied and must be customized to the patient.

The ideal rotator cuff repair construct has low tension, maximizes footprint coverage, is biomechanically strong, and optimizes tendon-to-bone healing. However, these principles are not always feasible, especially with larger tear patterns and poor tendon quality, factors that are also associated with higher retear rates. There is a constant effort with often opposing priorities to achieve a tension-free rotator cuff repair while also achieving maximal footprint coverage. This is not always possible, and there are few data to guide surgeons on which factor—tension-free repair or footprint coverage—should be prioritized. Recent studies have reported that achieving a tension-free repair with incomplete medial-to-lateral footprint coverage leads to similar functional and radiographic outcomes to complete footprint coverage using a transosseous-equivalent repair with bone marrow stimulation. Many factors affect rotator cuff tendon-to-bone healing, most notably tear size and retraction, tendon quality/preoperative fatty infiltration, repair construct, patient age, and medical comorbidities. In terms of these factors, achieving a tension-free repair and achieving maximal footprint coverage are some of the only factors we can control during surgery. However, although we may be able to pull the torn tendon edge all the way over to the lateral aspect of the footprint during our reduction maneuver, we know that fixing the tendon in this location creates a significant risk of a type 2 retear due to high tension. In the end, achieving a tension-free repair is probably the most important factor during rotator cuff repair—even if it comes at the cost of a smaller amount of medial-to-lateral footprint coverage.

Background: Matrix-induced autologous chondrocyte implantation (MACI) was developed for knee cartilage restoration involving seeding autologous chondrocytes onto a collagen membrane. Maintaining chondrocyte viability and achieving proper membrane size and contour are crucial for successful outcomes. Scissor cutting (Sc) has traditionally been used to shape the membrane, but recently, custom cutting (CC) have gained popularity for their enhanced preparation efficiency. Purpose: To determine the difference in chondrocyte viability using the Sc versus CC methods. Study Design: Controlled laboratory study. Methods: Using Sc and CC methods, 15 mm–diameter circular specimens were cut from 5 residual membranes. Membranes were stained, and confocal microscopy was used to visualize live/dead cells. Three zones were defined: the impact zone (the outermost zone at the cut edge), the central zone (the least manipulated zone), and the adjacent zone (the intermediate zone between the central and impact zones). For each circular specimen, the following measurements were recorded: the dimension of the impact zone, cell viability (percentage of live cells among total) for each zone, and the total number of cells within each zone (as cell density ×10 5 /cm 2 ). Results: The width of the impact zone (mean ± standard error) was 355 ± 31 μm and 342 ± 24 μm for CC and Sc, respectively, and the impact zone occupied approximately 10% of the specimen. With both cutting techniques, cell viability was significantly lower in the impact zone (mean ± standard error: CC, 36.42% ± 3.85%; Sc, 40.94% ± 2.85%) compared with the adjacent zone (CC, 77.69% ± 2.97%; Sc, 74.17% ± 2.8%). The cell density from all zones varied from 5.84 ± 0.26 to 6.49 ± 0.34 × 10 5 /cm 2 , with no significant difference in cell viability in the impact zones between the cutting methods. Conclusion: Both cutting techniques led to a significant reduction in cell viability in the impact zone compared with other zones of the MACI specimen. There was no significant difference in chondrocyte viability or cell density for membranes cut by Sc or CC. Clinical Relevance: This evaluation of the newly introduced CC method on the chondrocyte viability of the MACI membrane will enable surgeons to make a more informed decision regarding cutting techniques.

Background:Medial and lateral epicondylitis, characterized by repetitive microtraumas to common flexor and extensor tendons, respectively, are common causes of elbow pain in adults. Though symptoms are generally self-limiting, 10% of cases are refractory to conservative management, persisting for greater than 18 months, and leading to surgery, which can have increased risk of complications. There is minimal data on sustained pain relief and functional benefit for newer nonsurgical management options, such as minimally invasive needle tenotomy (MINT), and platelet-rich plasma (PRP) for chronic elbow epicondylitis. Additionally, no previously established correlation exists between magnetic resonance imaging (MRI) severity of chronic epicondylitis with pain and functional improvement in MINT- and PRP-treated patients. Methods:A retrospective review of 51 adults (n = 23 for MINT; n = 28 for PRP) was conducted to investigate long-term outcomes in pain relief (via visual analog scale or VAS) and improvements in upper extremity function (via quick disability of the arm, shoulder, and hand questionnaire or qDASH). These outcomes were correlated with radiographic evidence of epicondylitis severity, assessed by the grade of epicondylitis and percentage thickness of tendon tears. Results:There were significant improvements in pain (VAS), but no significant differences in function (qDASH) following MINT and PRP. On average, VAS score improved by 2.6 (P < .001) post-MINT and by 3.8 (P < .001) post-PRP combined for all follow-up time points. No adverse events were reported over the entire study. A significantly higher percentage of patient-reported pain relief was noted post-MINT at all follow-up time points. VAS and qDASH outcomes post-MINT and post-PRP were not correlated with the initial MRI severity of epicondylitis. Conclusions:There are multifactorial benefits of both MINT and PRP as safe, nonopen surgical modalities that can be used, despite MRI severity, to provide sustained pain relief for patients with refractory elbow epicondylitis.

ObjectivesImage-guided ultrasound or fluoroscopic glenohumeral injections have high accuracy rates, but require training, equipment, cost, and radiation exposure (fluoroscopy). In contrast, landmark-guided glenohumeral injections do not require additional subspecialist referral or equipment. An optimal technique would be safe, accurate, and have few barriers to implementation. The purpose of this study was to define the accuracy of glenohumeral needle placement via an anterior landmark-guided approach as assessed by direct arthroscopic visualization.MethodsA consecutive series of adult patients undergoing shoulder arthroscopy in the beach chair position were included in this study. Demographic and procedural data were collected. Time required to perform the injection, precise location of the needle-tip, and factors that affected accuracy of injection were also assessed.ResultsA standardized anterior landmark-guided glenohumeral joint injection was performed in the operating room prior to surgery and location of the needle tip was documented by arthroscopic visualization with a low complication profile and few barriers to implementation. A total of 81 patients were enrolled. Successful intra-articular glenohumeral needle placement by Sports Medicine and Shoulder/elbow fellowship trained orthopaedic surgeons was confirmed in 93.8% (76/81) of patients. Average time to complete the procedure was 24.8 seconds. There were no patient-related variables associated with non-intra-articular injection in the cohort.ConclusionsThis study demonstrated a technique of anterior landmark-guided glenohumeral injection has an accuracy of 93.8% and requires less than 30 seconds to perform. This method is safe, yields similar accuracy to image-guided procedures with improved cost-and time-efficiency, and less radiation exposure. No patient-related factors were associated with inaccurate needle placement. Anterior landmark-guided glenohumeral injections may be utilized with confidence by providers in the clinical setting.Level of EvidenceLevel 5.

Rotator cuff tear (RCT) is the most common cause of disability in the upper extremity. It results in 4.5 million physician visits in the United States every year and is the most common etiology of shoulder conditions evaluated by orthopedic surgeons. Over 460,000 RCT repair surgeries are performed in the United States annually. Rotator cuff (RC) retear and failure to heal remain significant postoperative complications. Literature suggests that the retear rates can range from 29.5% to as high as 94%. Weakened and irregular enthesis regeneration is a crucial factor in postsurgical failure. Although commercially available RC repair grafts have been introduced to augment RC enthesis repair, they have been associated with mixed clinical outcomes. These grafts lack appropriate biological cues such as stem cells and signaling molecules at the bone-tendon interface. In addition, they do little to prevent fibrovascular scar tissue formation, which causes the RC to be susceptible to retear. Advances in tissue engineering have demonstrated that mesenchymal stem cells (MSCs) and growth factors (GFs) enhance RC enthesis regeneration in animal models. These models show that delivering MSCs and GFs to the site of RCT enhances native enthesis repair and leads to greater mechanical strength. In addition, these models demonstrate that MSCs and GFs may be delivered through a variety of methods including direct injection, saturation of repair materials, and loaded microspheres. Grafts that incorporate MSCs and GFs enhance anti-inflammation, osteogenesis, angiogenesis, and chondrogenesis in the RC repair process. It is crucial that the techniques that have shown success in animal models are incorporated into the clinical setting. A gap currently exists between the promising biological factors that have been investigated in animal models and the RC repair grafts that can be used in the clinical setting. Future RC repair grafts must allow for stable implantation and fixation, be compatible with current arthroscopic techniques, and have the capability to deliver MSCs and/or GFs.

BACKGROUND:Patient-reported outcome measures (PROMs) were originally developed as research tools; however, there is increasing interest in using PROMs to inform clinical care. Prior work has shown the benefits of implementing PROMs at the point of care, but a patient's health numeracy (their ability to understand and work with numbers) may affect their ability to interpret PROM results. MATERIALS AND METHODS:We recruited patients presenting to an outpatient orthopedic clinic. Forty-nine patients completed a survey that included demographic information, the short-form General Health Numeracy Test, and accuracy questions about four PROM displays (bar graph, table, line graph, pictograph) that indicated the same PROM results. RESULTS:Patients with higher health numeracy answered all display accuracy questions correctly (P=.016). Patients who preferred using the table were more likely to answer display accuracy questions incorrectly (odds ratio, 0.013, P=.024). The two most frequently preferred PROM formats were bar graphs and tables, and most patients preferred to learn about their PROM function scores via a combination of displays and verbal discussions. CONCLUSION:Patient health numeracy is associated with the ability to correctly interpret visual displays of PROMs. Implementation of PROMs at point of care currently does not account for health numeracy. Efforts to account for health numeracy when using PROMs at point of care may improve the efficacy of using PROMs to improve outcomes in orthopedic surgery. [Orthopedics. 2024;47(5):e255-e260.].

Background: Injury to the posterior vasculature is a potential complication in orthopaedic knee surgery that may be associated with variations in its anatomy, such as the type II-A2 variant, which places the anterior tibial artery (ATA) in closer proximity to the tibia. However, how close surgical instrumentation comes to injuring the ATA is not well described. Purpose: To determine how the type II-A2 variant of the popliteal vasculature affects proximity of the ATA to instrumentation for orthopaedic knee procedures. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 222 knee magnetic resonance imaging (MRI) scans from a single academic tertiary referral center were evaluated, and ATA branching patterns were characterized. The distances from the ATA to simulated instrumentation of high tibial osteotomy (HTO), posterolateral corner anatomic reconstruction, posterior cruciate ligament (PCL) reconstruction, lateral meniscus posterior horn repair, and lateral meniscus posterior root repair on axial plane MRI scans were measured by 2 authors independently using imaging software. Intrarater and interrater reliability of the measurements was calculated using the intraclass correlation coefficient. Results: ATAs with the type II-A2 pattern passed anterior to the popliteus on 3.15% (n = 7) of the 222 MRI scans. The distance between the ATA and the simulated instrumentation was significantly closer in type II-A2 compared with normal (type I) knees for the lateral meniscus posterior root repair tunnel (11.1 vs 15.7 mm; P = .014), HTO cuts (0.6 vs 8.2 mm; P < .001), and PCL reconstruction tunnel (4.1 vs 11.7 mm; P < .001). Interrater reliability was good to excellent for all measurements, and intrarater reliability ranged from moderate to excellent. Conclusion: HTO cut, PCL reconstruction tunnel, and lateral meniscus posterior root tunnel instrumentation were significantly closer to the ATA in knees with type II-A2 anatomy compared with normal (type I) anatomy. Careful analysis of vasculature using MRI may be of utility for select surgery about the knee to guide surgical technique.

Though some controversy remains regarding the place of the 12 lead Electrocardiogram (ECG) in the routine screening of young athletes and how and where the pre-participation examination should be performed, studies continue to support the ECG and properly organized mass screening. The purpose of this paper is to provide brief historical perspective, the experiences at our institution and our view of the future application of computerized Electrocardiography in screening for cardiovascular risk. The focus is on the process and improvement of Electrocardiographic criteria for estimating the cardiovascular risk of young athletes.

High tibial osteotomy is a dynamic operation, used as an effective procedure in both joint preservation and knee stability. Applications and indications are expanding, with good results in the treatment of malalignment associated with arthrosis, knee instability, meniscus deficiency or transplants, and/or cartilage restoration. Appropriate patient selection and preoperative planning are critical to achieving good outcomes after surgery. Coronal and sagittal plane corrections made through the proximal tibia can effectively alter joint mechanics creating a more favorable environment for cartilage, meniscus, and ligamentous structures about the knee. Advancing techniques and technologies have allowed for more precise planning and execution of osteotomies.

BACKGROUND:Current options for reconstruction of large glenoid defects in reverse total shoulder arthroplasty (RTSA) include structural bone grafting, use of augmented components, or 3D-printed custom implants. Given the paucity in the literature on structural bone grafts in RTSA, this study reflects our experience on clinical and radiographic outcomes of structural bone grafts used for glenoid defects in RTSA. METHODS:We identified 33 consecutive patients who underwent RTSA using structural bone grafts for glenoid bone loss between 2008 and 2019. Twenty-six patients with a mean clinical follow-up of 4.4 ± 3.9 years and a mean radiographic follow-up of 2.7 ± 3.2 years were included. Patient demographic data, perioperative functional outcomes, radiographic outcomes, complications, and reoperation rates were determined. RESULTS:Between 2008 and 2019, 26 RTSAs were performed using structural autograft or allograft for glenoid defects. There were 20 females (77%) and 6 males (23%), with a mean presenting age of 68 years (range 41-86), mean BMI of 29 (range 21-44), and mean Charlson Comorbidity Index of 3 (range 0-8). There were 19 cases of central glenoid defects, and 7 were combined central and peripheral defects. Structural grafts included humeral head autograft (7), proximal humerus autograft (7), iliac crest autograft (7), distal clavicle autograft (2), and femoral head allograft (3). All 18 revision RTSA cases had simultaneous humeral-sided revision. There was significant postoperative improvement in American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores (27.0 ± 12.6 preoperation vs. 59.8 ± 24.1 postoperation; P < .001) and visual analog scale scores (8.1 ± 3.6 preoperation vs. 3.0 ± 3.2 postoperation; P < .001). Range of motion improved significantly for active forward elevation (63° ± 36° preoperation vs. 104° ± 36° postoperation; P < .001) and external rotation (21° ± 20° preoperation vs. 32° ± 23° postoperation, P = .036). Eighty-eight percent of cases (23 of 26) had successful reconstruction of the glenoid, defined as no visible radiolucent lines nor glenoid component migration at final follow-up. The reoperation rate was 19% (5 of 26). Postoperative complications included 2 cases of acromial stress fractures that were treated nonoperatively, for a total complication rate (including reoperation) of 27% (7 of 26 cases). CONCLUSIONS:The use of structural bone autografts and allografts in RTSA was associated with improved outcome scores and range of motion. A reoperation rate of 19% and total complication rate of 27% were reported for these challenging cases. However, 86% of these complications were not related to structural glenoid reconstruction failure. Structural grafts are a reasonable option for glenoid reconstruction in RTSA cases with glenoid bone loss.

Treatment of acute acromioclavicular (AC) joint separations is dependent on a variety of factors including severity, acuity, patient demographics, activity level, and surgeon preferences. For more severe or unstable separations (Rockwood types IIIB, IV, V, and VI), surgical intervention is typically recommended. Over 160 surgical techniques have been described, but none have emerged as a gold standard. Arthroscopic-assisted or all-arthroscopic fixation of the coracoclavicular (CC) ligaments with suture buttons has become increasingly popular due to lower complication rates compared to more rigid fixation. Configurations include single-bundle (SB) constructs and double-bundle (DB) configurations that more anatomically reconstruct the conoid and trapezoid ligaments but with longer operative times. Clinical studies with short-term follow-up have demonstrated improved maintenance of fixation for DB compared to SB constructs, but no significant differences in clinical outcomes. In our experience, single bundle suture-button-only constructs lead to unacceptable failures due to loss of reduction. We recommend either a single suture-button construct augmented with allograft or double bundle suture-button constructs for the treatment of acute AC joint separations.

Background:There is a lack of published information outlining the use of biologics in National Football League (NFL) athletes and limited data to guide biologic treatment strategies. Purpose:To develop a consensus on the use of biologics among NFL team physicians. Study Design:Consensus statement. Methods:A working group of 6 experts convened a consensus process involving NFL team physicians using validated Delphi methodology. Physicians from 32 NFL teams as well as NFL London were invited to take part. This iterative process was used to define statements on the use of biologics in NFL athletes. A recent scoping review exploring biologics in professional athletes was used to inform the first of 3 rounds of surveys, with statements considered under 7 headings: biologics in general, challenges of treating NFL athletes, terminology/nomenclature, autologous blood products, cell-based therapies, guidance for NFL team physicians, and biologic research in the NFL. In addition to rating agreement, experts were encouraged to propose further items or modifications. Predefined criteria were used to refine item lists after each survey. For a consensus within the final round, defined a priori, items were included in the final information set if a minimum of 75% of respondents agreed and fewer than 10% disagreed. Results:Physicians from 26 NFL teams and NFL London responded to the initial invitation to participate in the Delphi process; 88.9% of participating team physicians completed the round 1 survey, with response rates of 87.5% in round 2 and 95.2% in round 3. After 3 rounds, 47 statements reached a consensus. A consensus was achieved that platelet-rich plasma has a positive impact on patellar tendinopathy and on symptoms in early osteoarthritis but not for other indications. NFL team physicians agreed that while cell therapies have the potential to improve symptoms, the misrepresentation of uncharacterized preparations as "stem cells" has contributed to the widespread use of unproven therapies. Conclusion:This study established an expert consensus on 47 statements relating to the use of biologics in NFL athletes. In addition to providing clinical guidance for the use of biologics in NFL athletes, this study identified key areas for future focus including the development of athlete education materials.