Background: Athletic trainers are the primary source of sideline coverage for high school athletic events, providing an essential role in injury recovery and prevention while serving as liaisons to parents and the greater medical community. However, there is a paucity of literature evaluating the existence of state requirements regarding the presence of athletic trainers and mandatory sideline medical coverage of high school athletic events. Purpose: The purpose of this study was twofold: 1) To determine the requirements for the athletic trainers or other healthcare professionals for the provision of sideline medical coverage of high school athletic events in all 50 states and the District of Columbia, and 2) To analyze regional variation in sideline medical coverage for high school sports across the United States. Study Design: Cross-sectional Survey Methods: A 17-question survey was emailed to the executive directors (or analogous position) of the state high school athletic associations for all 50 states and the District of Columbia. The survey was conducted to assess current state regulations regarding the employment of ATCs and the provision of sideline medical coverage for high school athletic events in the United States from 2023-2024. The same survey was sent to the NATA president for those states that did not respond. The primary variables that were of interest included: the presence or absence of sideline medical coverage mandates, any requirements for the presence of athletic trainers for high school athletic events, and whether the state association distinguished between collision and non-collision sports in mandating sideline medical coverage. Secondary variables included distinctions between public and private high schools, school classification, athletic trainer employment level, and the type of healthcare professionals that satisfy the sideline medical coverage mandates, if present. All response options were presented as either a binary choice (yes/no), free-form text, or a “select all that apply” list. All responses were treated as independent observations for analysis. The data were analyzed using descriptive statistical methods, as well as Welch’s t-test with un-pooled variance to explore associations. Results: The overall response rate was 94% (48/51). Of the 48 state associations that responded, 11 (23%) had sideline coverage mandates, including sideline coverage for all events and risk-dependent sideline coverage. A total of 3 states (6%) had complete sideline coverage mandates, while 8 states (17%) had risk-dependent sideline coverage mandates. Of the 48 responding states, 37 (77%) had no sideline coverage mandate. No states required the presence of an athletic trainer at high school athletic events. On average, those states with more high schools were more likely to not have mandatory sideline medical coverage. Similarly, more high schools throughout the country were in states without a sideline medical coverage mandate, which means that approximately 92% of high schools in the United States are in states without a requirement for sideline medical coverage. The Midwest had no states with a sideline coverage mandate. There was no significant difference in the number of states with sideline medical coverage mandates between the West (n=3), Northeast (n=4), and South (n=4) regions. Conclusion: This study found that 77% of states and the District of Columbia do not mandate the presence of an ATC, or any other healthcare professionals, to provide sideline medical coverage for high school athletic events, even for high-risk sports such as football. Consequentially, approximately 92% of U.S. high schools represented in our survey do not have a requirement for sideline medical coverage of their athletic events. This widespread absence of state policies requiring sideline medical coverage for high school athletic events may contribute to disparities in the care and safety of student-athletes. These findings underscore the consideration for state-wide mandates to improve access to trained healthcare professionals, such as ATCs, at high school sporting events, especially for high-risk sports such as football.

Career Duration and Performance Levels of Professional Male Soccer Players in the Top Four English Football Leagues Mary Jones, Arman Motesharei, Sam Church, Simon Ball, Andy Williams Objectives Greater understanding of the ‘average’ professional soccer player’s career in terms of longevity and performance level would provide a baseline against which treatments could be measured. Therefore, the aims of this study are to determine the career longevity and performance metrics of male professional footballers playing in the top 4 English football leagues and to demonstrate how these vary according to age, playing position and level played. Methods Football appearance data of all male footballers playing in the top 4 English football leagues between 2005 and 2010 was retrieved from www.fbref.com. Players were grouped into 5 ability levels (English Premier League and international (PLI), Premier league (PL), Championship (C), English Football League 1 (L1) and English Football League 2(L2)) based on the highest level played and career trajectory was tracked according to age. Univariate and multivariate analyses were used to determine differences by position and ability. Kaplan-Meier survival curves were generated to illustrate predicted career lengths. Results Of the 4117 footballers included 3778 (91.8%) were on field players. 1795 (43.6%) played in a minimum of 3 games in the premier league and of these, 856 (47.7%) made at least one appearance for their national side. Goalkeepers had older mean first and last appearance ages (21.8 +3.9 vs 20.0 +3.0 years, p=<0.01 and 33.3 +5.1 vs 30.5 +4.7 years, p=<0.01 respectively) and a longer overall career length (12.4 +4.9 vs 11.6 + 4.7 years, p=<0.01) than on-field players. On-field players reached their highest level at an earlier age (22.0 + 4.0 vs 24.1 +4.5 years, p=<0.01) than goalkeepers and continued to play at their high level for similar periods (4.3 +3.8 vs 4.4 +3.9 year, NS). On-field footballers in the PLI group play at their highest level for over 3 years longer than players in the lower leagues (Figure1). At 5 years PLI and PL on field players have a 60% and 40% probability of continuing to play at their highest level respectively compared to less than 20% chance in the Championship and lower leagues. At 10 years the probability of still playing at their highest level is 40% and 18% in the PLI and PL respectively compared to less than 2% in the lower leagues. Conclusion Career duration in soccer players is affected by the position played and ability level with lower league players having a less than 2% chance of playing at 10 years compared to 40% in international players. These findings can be compared with career longevity and performance after injury to fully understand effectiveness of treatment interventions. To illustrate the value of this data the present study compared it with the published literature reporting career longevity in professional soccer players after ACLR and shows that “still playing” rates in post ACLR players with a mean age of 30 years are up to 12.9% lower than the average “still playing” rates for players of the same age.

Highlight our recent results at a nonaddictive pain control after ACLR. The goal is not just reduce the use of opoids but elimnate them in the majority of patients. Further nonaddictive approaches should not use other addictive agents like gapabentin, benzodiazapines, and tramadol. The plan is to demonstrate our internal data on results, discuss results systematic reviews, provide details on a current double blind RCT, and on a prospective cohort. The discussion will be facilitated by trying to establish a future multicenter double blind study to change the practice of using narcotics in sports arthroescopic surgery.

This investigation evaluates the impact of learners and their post-graduate year (PGY) levels on patient satisfaction in the orthopedic outpatient clinic, an area with limited prior research. A retrospective cohort study was conducted using data from July 2020 to December 2022, involving 2,484 patients, with a 39% response rate. Satisfaction was measured via NRC Health surveys, focusing on the likelihood of recommending the provider or clinic based on the presence of learners, categorized as none, present in the clinic, or involved in patient care. Non-parametric statistical analysis revealed significant reductions in satisfaction when learners were involved in care, with top-box scores for recommending providers and clinics decreasing notably (p = 0.030 for providers, p = 0.018 for clinics). The decrease was 7.9% for provider recommendations and 7.2% for clinic recommendations when learners were involved, compared to their absence. Notably, PGY-4 learners were associated with the highest satisfaction levels, highlighting the varied impact of PGY level on patient perceptions. In summary, the presence and involvement of learners in patient care significantly influence patient satisfaction in orthopedic clinics, with the impact varying by the learners PGY level. This suggests a complex interplay between learner engagement and patient satisfaction, emphasizing the need for targeted strategies to enhance educational experiences and patient outcomes in these settings.

15 Years in The Ring: The Medical Aspects of Professional Wrestling As the medical director or co-medical director for WWE for the past 15 years, the expansion of services, clinical skills, injury prevention, and risk mitigation through a global pandemic have been a few of the issues that have required my attention. The clinical nature of the in-ring injuries has also been a subject of my attention, and I am happy to share these experiences with our society if you think this would be valuable. I will get permission from WWE for any presentation.

The lecture will examine the complex legacy of medical practices during the Nazi regime. It will highlight surgical advances as well as horrific ethical violations. There will be a discussion of the development of anabolic steroids. These drugs were given to athletes as well as to Hitler

Abstract Background: Revision anterior cruciate ligament (ACL) reconstruction has been demonstrated to have inferior outcomes compared with primary ACL reconstructions in terms of patient-reported outcomes, return to activity and sport, and graft rupture rates. However, the long-term assessment of patients undergoing revision ACL reconstruction remains unknown. Hypothesis: The purpose was to assess long-term outcomes, including graft failure, and signs and symptoms of knee osteoarthritis (OA) at 10 years post-operatively. Methods: Patients were brought back for onsite physical evaluation, which included bilateral range of motion, KT-1000, radiographs and a physical exam by independent blinded sports medicine physicians. Validated PROMs including IKDC, KOOS, WOMAC, and Marx activity rating scale were also obtained. Symptomatic OA was defined by the KOOS Pain subscale < 70 points. Structural OA was defined as a Kellgren-Lawrence grade of 3 or 4 on radiographs. Multivariate regression models were used to determine the predictors for structural and symptomatic OA at 10 years follow-up, controlling for patient’s age, sex, BMI, baseline PROMs, ACL graft choice, prior and current meniscal pathology and treatment at the time of revision surgery, chondral pathology at the time of revision surgery, and incidence of any subsequent surgeries. Results: 205 patients (107 [52.4%] females) returned at average 12-year follow-up (range, 10-16 years). The mean (SD) age at the time of onsite evaluation was 40.2 (10.4) years with a BMI of 25.7 (range, 17.0 – 42.0). Physical exam demonstrated loss of extension in 118 (58%) and extension less than full in 84 (41%). A soft Lachman endpoint was noted in 41 (20%), Lachman >5mm in 20 (10%) and 26 patients (13%) had a grade 2 pivot shift and 4 (2%) had a grade 3 pivot shift. KT-1000 measurements demonstrated 23 (11%) patients with 5mm or greater side-to-side difference. The blinded surgeons in their opinion detected 37 (18%) with a nonfunctional ACL. Radiographs demonstrated that 115 (56%) exhibited joint space narrowing of the tibiofemoral joint (K-L grades 3-4) in their involved knee compared to 28 (14%) in their uninvolved knee. The significant drivers of a higher KL grade (structural OA) at 10 years were found to be higher age, higher baseline BMI, having a medial meniscus excision performed either prior to or at the time of revision surgery, having a prior lateral meniscal excision, or a subsequent surgery (p<0.05). Sex, baseline activity level, graft choice, and chondral pathology at the time of revision were not significant. There were 40 onsite subjects (20%) that reported KOOS pain scores of < 70 points (defined as symptomatic OA), while 91 subjects (44%) reported KOOS pain scores over 90 points (defined as no pain). Conclusion: Outcomes in this revision ACL cohort at minimum 10 years follow-up demonstrates worrisome outcomes at a still young age. This study demonstrated a loss of ROM in 41-58% of the cohort, an 18% graft failure rate, 56% who exhibited KL grades of 3-4, and 20% who reported KOOS pain scores of less than 70 points, which collectively, all emphasize the challenge of managing the revision ACL reconstruction patient.

Acute single-stage surgery for MLKIs can restore stability but can also result in high rates of complications, including arthrofibrosis. Instead, treating the torn MCL and PCL nonoperatively and acutely repairing the torn lateral structures for lateral side MLKIs, before doing an ACLR, can be beneficial. Following this treatment philosophy for MLKIs can result in outcomes similar to patients with isolated ACL tears in regard to postoperative laxity, ROM, subjective scores, return to sport, scar resection rate, and graft tear rate.

Knee osteotomies have emerged as one of the most effective strategies for cartilage repair in the knee, offering both biomechanical and biological benefits whereby only addressing underlying malalignment issues that contribute to cartilage degeneration. By redistributing mechanical loads and promoting a more physiological joint environment, osteotomies not only prevent further cartilage degradation but also stimulate intrinsic cartilage repair. Biomechanical Superiority of Osteotomies Knee osteoarthritis and cartilage defects often result from malalignment, where excessive load is concentrated on specific compartments of the knee. High tibial osteotomy (HTO) and distal femoral osteotomy (DFO) serve to redistribute forces more evenly across the joint, reducing focal stress and minimizing further cartilage breakdown. Unlike focal cartilage restoration techniques, which only target localized defects without addressing mechanical contributors, osteotomies provide long-term structural improvements that benefit the entire knee joint. The senior author looks back to 50 yrs. of Osteotomy Experience. He stated the quotation as in this title when ICRS was founded in Fribourg Switzerland in 1997. Roland P. Jakob, Robin Martin

Patient-specific instrumentation (PSI) has become a state-of-the-art tool that offers more precise and customized planning for osteotomies. PSI optimizes bone realignment treatments by utilizing 3D printing, computer-aided design, and preoperative imaging. With the advent of PSI, osteotomy now is on the precipice of approaching the level of technology that is already utilized in arthroplasty. This technology shifts osteotomy from a largely subjective, intraoperative decision-making process to a precise, reproducible approach. As we refine and validate these cutting-edge techniques, PSI has the potential to become the gold standard for osteotomy planning. It improves accuracy in coronal osteotomies for high tibial osteotomy (HTO), sagittal/slope osteotomies for restoring posterior tibial slope (PTS), rotational osteotomies for torsional deformities and tibial tubercle osteotomies for patellar instability. Advantages include enhanced accuracy in bone cuts, reduced surgical time, lower radiation exposure, and improved patient-specific corrections. This integration enhances surgical accuracy, minimizes soft tissue disruption, and improves patient outcomes. Preliminary data suggests improved accuracy when PSI is implemented in sagittal/slope and rotational osteotomies, with a 0.6° error in PTS and -0.2° torsional mean error or -0.2°, respectively. As there is a current paucity of literature on PSI’s role in osteotomy planning, further investigation is essential. We will present our preliminary data and literature review findings as well as demonstrate novel cutting edge techniques for slope correction, tibial tubercle, and derotational osteotomies.

Please insert description of presentation or research.

Should We Use Platelet-Poor Plasma Rather than PRP for Muscle Injury?

Background: Bipolar osteochondral allograft transplantation (BOAT) of the trochlea and patella has emerged as a promising surgical intervention for patients suffering from ICRS grade 3 and 4 cartilage defects and osteochondral lesions of the trochlea and patella. This procedure aims to restore the articular surface, alleviate pain, and improve knee function, thus enhancing the overall quality of life for affected individuals. Osteochondral allograft (OCA) transplantation is an effective treatment option for bipolar chondral and osteochondral defects of the trochlea and patella. Hypothesis: Patients treated with OCAs for bipolar lesions of the trochlea and patella would demonstrate significant clinical improvement. Study Design: Case series; Level of evidence, 4. Methods: Between 2020 and 2025, OCAs were implanted for bipolar chondral lesions in 9 patients (10 knees). The 3 male and 6 female patients averaged 34 years of age (range, 20-50 years). Ten knees (100%) had undergone a mean of 2.5 previous surgeries (range, 1-6). The mean allograft area was 18.0 cm². Clinical evaluation included radiographic imaging at time zero, 6, 12, and 18 weeks, and the International Knee Documentation Committee (IKDC) pain and function, and SANE scores. Further surgeries on the operative joint were documented. Results: Survivorship of the bipolar OCA was 90% at up to 3 years. Two knees underwent further surgery related to the patellofemoral joint and were considered failures (1 OCA revision, 1 patellofemoral arthroplasty). Among patients whose OCA was still in situ at follow-up, the mean follow-up was 2.5 years (range, 8 months to 5 years). Radiographs confirmed good incorporation of all grafts. The mean IKDC pain score improved from 4.7 to 7.5, and the mean IKDC function score improved from 3.4 to 7.0. The mean SANE score improved from 61 to 88. The latest scores will be updated at the meeting. Conclusion: Bipolar osteochondral allograft transplantation of the trochlea and patella offers a viable solution for patients with refractory osteochondral lesions, providing substantial pain relief and functional improvement. Low reoperation and failure rates were observed, and patients with surviving allografts showed significant clinical improvement. While the procedure is associated with certain risks and complications, careful patient selection, refined surgical techniques, and comprehensive post-operative care can mitigate these challenges. Further research, particularly long-term studies, is essential to fully establish the durability and efficacy of BOAT in appropriately indicated patients.

The presentation will explore the risk factors for osteochondral allograft failure. Previous studies have demonstrated excellent clinical outcomes after osteochondral allograft transplantation. However, a subset of patients experience graft failure/rejection. We hypothesize that donor-recipient sex mismatch may pose as a risk factor for osteochondral allograft failure.

Presentation will discuss meniscus repair versus meniscectomy, emphasizing newer technologies for root repair and other types of tears previously difficult to repair. The presentation will include ample video showing new techniques for repair and augmentation.

Traveling Fellowship Presentation

Traveling Fellowship Presentation

Traveling Fellowship Presentation

Objectives: The objective of this study was to quantify the rate and timing of recurrent ulnar collateral ligament (UCL) injuries among elite baseball players. Whereas several prior works focused on rates of return to play and performance after UCL reconstruction, the literature lacks evidence on recurrence rates for UCL injuries, especially for non-operative injuries. Addressing this literature gap is important because of the emphasis that team physicians place on UCL injury history as a determinant of future UCL injury risk. In a landmark study that surveyed Major League Baseball (MLB) team physicians and achieved an 80% response rate, McGahan et al. found that 60% of team physicians rated any prior UCL injury (regardless of injury severity or treatment modality) as “moderate risk” for future injury among pitchers entering the MLB draft. In the same survey, 52% of team physicians rated recent UCL strain as a “severe risk” for future injury among the same player cohort. The present study is the first to use comprehensive data from MLB on UCL injuries to quantify the frequency of recurrence and when these injuries are likely to recur. Quantifying the recurrence rate of UCL injuries is important for players at all levels of competition, including those without a documented injury history. For example, one singlecenter study found that 34% of asymptomatic MLB and Minor League Baseball (MiLB) players screened with a pre-signing MRI had evidence of UCL signal heterogeneity. Alternatively, if the recurrence rate of UCL injuries is relatively low, then players and teams may be inappropriately weighting prior injury as a predictor of future injury risk. This study builds on the work of McGahan et al. by quantifying the recurrence rate of UCL injuries in professional baseball players and defines the typical number of seasons until recurrence. These data will provide critical information to players, team management, and team physicians at all levels of competition with an eye toward better informing health and safety decisions. Methods: This study uses data supplied by Major League Baseball’s Health and Injury Tracking System (HITS) on all MLB and MiLB players from 2010-2021. A comprehensive list of UCL injuries (regardless of severity or initial treatment modality) was generated by reviewing every elbow injury in MLB and MiLB during the study period. Use of this data source marks an important departure from prior studies on similar topics that relied on public injury reports to determine if a player had a UCL injury. Instead, these data are generated by the athletic trainers, team surgeons, and league office and are therefore more comprehensive than earlier studies of similar questions. Within HITS, each player is given a unique player identifier and each injury event is given a unique injury event identifier. Thus, if a player is injured in two separate seasons, the player ID would be present in both years but the event ID would be different. This differentiation allows player tracking over time and to determine when an injury recurs. We calculated the number of UCL injuries in each season of 2010-2016 and then determined the five year recurrence rate. We chose the five year time point because the median professional baseball career length is 5 seasons. We therefore present data on the five year recurrence rate for the 2010-2016 seasons, but rely on data from throughout the study period (2010-2021) to determine those rates. We subsequently determined the median and interquartile range for when a recurrence was most likely to occur. Next, we calculated the five recurrence rate among players whose initial injury was managed non-operatively. Finally, we quantified the rate at which recurrent injuries were managed operatively stratified by initial treatment modality. Results: Throughout the study period (2010-2016), there were 1,766 documented UCL injuries. Of these injuries, 820 (46%) were managed initially with surgery, 177 (10.0%) recurred within five years, with a median of two seasons (Interquartile range [IQR] 1-3 seasons) until recurrence. When a recurrence occurred, 107 players (60.5%) underwent surgery, regardless of initial treatment modality. Among injuries that were initially treated non-operatively (946 injuries), 126 players (13.3%) experienced a recurrence within five years, with a median of two seasons (IQR 1-3 seasons) until recurrence, and 87 players (69.0%) underwent surgery to treat the recurrence. Conclusions: The present study offers the most comprehensive data to date on the natural history of UCL injuries among elite baseball players. As McGahan et al. showed, many team physicians use a history of UCL injury as an indicator of future UCL injury risk. It is therefore important to identify the risk of injury recurrence during the typical professional baseball career. We found a relatively low recurrence rate of 10% within the median professional baseball career length of five years. Even players who were initially treated non-operatively (identified by McGahan et al. as being perceived to be more likely to sustain a future UCL injury) had a relatively low five-year recurrence rate of 13.3%. Importantly, the majority of recurrences underwent surgery, suggesting that the risk tolerance for future recurrences beyond the first recurrence is similarly low. These results highlight the importance of understanding the natural history of common injuries among athletes across all levels of competition, and can be used to inform risk reduction plans for athletes across the competitive landscape.

Purpose: Massive rotator cuff tears (MRCT) remain a significant clinical challenge and several treatment options are available, including superior capsular reconstruction (SCR) and lower trapezius tendon transfer (LTT). The purpose of this study was to compare the biomechanical effectiveness of SCR and LTT to restore the native shoulder kinematics in MRCT using a dynamic shoulder testing system in a unique cadaveric model that incorporates the scapulothoracic articulation including hemithorax and preserves normal scapular muscle attachments, rather than rigidly fixing the scapula to a frame. Methods: Eight fresh-frozen cadaveric hemithoraces were tested using a custom-made dynamic shoulder testing system. The conditions tested are intact, supraspinatus tear, MRCT (supraspinatus and infraspinatus tear), LTT with Achilles allograft, SCR combined with LTT, and SCR alone. Measurements included cumulative deltoid force, humeral head translation (HHT), and subacromial peak pressure during humeral abduction at various angles. Results: Significant reductions in cumulative deltoid force were observed from intact to MRCT conditions (p = 0.023). LTT alone significantly improved deltoid force compared to its combination with SCR (p = 0.017) and outperformed SCR alone (p = 0.023). The intact condition showed increasing subacromial peak pressure with higher abduction angles, peaking at 541 kPa at 90 degrees. MRCT exhibited the highest HHT and peak pressure, indicating significant instability. LTT reduced HHT and peak pressure compared to MRCT, indicating partial restoration of stability. The combined LTT + SCR condition demonstrated HHT values close to the intact condition and lower peak pressures, indicating substantial restoration of glenohumeral stability. Conclusions: Simulated active unconstrained humeral abduction in the scapular plane using an entire hemithorax model suggests that LTT can restore dynamic stability and deltoid function in MRCTs, while SCR offers static stability without restoring deltoid function. Combining LTT and SCR may result in lower subacromial peak pressures on the undersurface of the acromion than either procedure alone. Clinical Relevance: This study introduces a unique method of assessing shoulder kinetics including the scapulothoracic articulation, and will contribute to understanding shoulder kinetics concerning current surgical techniques and suggest a dynamic concept of shoulder biomechanics testing.