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t visit within 90 days.

III, retrospective matched cohort.

III, retrospective matched cohort.

To assess statewide prevalence of medical access, concussion reporting, and concussion clearance rates of high school athletic departments in Massachusetts after the implementation of state-wide concussion legislation.

A random sample of 50 athletic directors (ADs) from Massachusetts high schools with an enrollment of >150 students was selected. A 10-minute electronic survey about access to athletic trainers and physicians, and concussion reporting and clearance practices was administered. Responses were anonymous.

The response rate was 80% (n= 40). In total, 90% of respondents were male. Median age and experience of respondents was 52 years old and 10 years, respectively. The median school size was 637 students, represented from all Massachusetts geographic athletic districts. ADs disclosed that on average, 12% (95% confidence interval 7%-20%) of concussions go unreported at their schools. In total, 16% of respondents reported that at least 1 in 4 of concussed athletes at their school returned to pl safer in situations where a concussion may have occurred.

To evaluate clinical and biomechanical outcomes after knee extensor mechanism reconstruction (KEMR).

Patients who underwent KEMR at our institution from 2011 to 2018 were identified. Patient-reported outcomes (Kujala, Lysholm, Tegner Activity Scale) were compiled at clinical follow-up. Isokinetic testing was conducted using the BioDex system 4 pro dynamometer at slow (60°/s), intermediate (180°/s), and fast (300°/s) speeds in a 9-patient subset.

From 2011 to 2018, 12 patients (12 knees, 10 male, 5 right, mean age 54.3 ± standard deviation 15.2 years) with KEM injuries requiring tendon reconstruction with a 1-year minimum follow up were identified. Postoperative follow-up was 42.6 months (range 12.0-93.0 months). Procedures included patellar (7) and quadriceps tendon reconstruction (5). Postoperative versus preoperative Tegner Activity Scale scores demonstrated significant improvement (3.5 ± 2.5 vs 1.5 ± 1.2, n= 8,

= .05). Postoperative versus preoperative Kujala scores significantly improved (70.3 ± 11.7 vs 43.6 ± 15.7, n= 8,

= .010). There was significant improvement in preoperative to postoperative KEMR extension lag (29.4 ± 22.2° vs 0.83 ± 1.9°,

= .002). Clinically, there was no difference in passive range of motion between the operative and contralateral knee. BioDex testing demonstrated decreased maximum work generated from the operative versus contralateral knee at slow (70.4 ± 30.4 Joules vs 101.9 ± 40.6 J;

= .028), intermediate (52.0 ± 45.4 J vs 69.8 ± 63.7 J;

= .038), and fast (43.8 ± 41.7 J vs 57.5 ± 53.8 J;

= .050) speeds. Range of motion was less in the operative versus contralateral knee at all speeds

= .011, .038, and .024. The average peak torque generated per body weight was smaller in the operative versus contralateral knee at slow speed (

= .038).

Patients undergoing KEMR in this study have significantly improved clinical outcomes despite having strength deficits that persist postoperatively.

Therapeutic Case Series, Level IV.

Therapeutic Case Series, Level IV.

The aim of this study was to assess the nature of the middle deltoid muscle insertion onto the lateral acromion by macroscopic, MRI and histologic examination and to, therefore, assess the potential impact of a vertical lateral acromioplasty on the deltoid origin.

We assessed the acromial origin of the deltoid in 6 cadaver shoulders by macroscopic, MRI and histologic examination. The cadavers were scanned with T1 and proton density-weighted sequences. H&E- and Masson trichrome-stained histologic sections through the acromion were taken and visualized under polarized microscopy.

The enthesis of the deltoid muscle consisted of dense birefringent bundles of collagen that blended with the bony endplate of the acromion at all points on its lateral wall. A prominent band of collagen was seen on both MRI and histologic slices, traversing the superior surface of the acromion. It was continuous with the deltoid origin and blended with the superficial fascia of the deltoid laterally.

The middle deltoid muscle occupies the entire lateral acromion.

A high critical shoulder angle is associated with rotator cuff tears. A lateral acromioplasty resects the lateral acromion and aims to normalize the critical shoulder angle. However, a vertical lateral acromioplasty may release the middle deltoid origin from the lateral acromion. The superior band of collagen may anchor the middle deltoid to the superior acromion and prevent retraction.

A high critical shoulder angle is associated with rotator cuff tears. A lateral acromioplasty resects the lateral acromion and aims to normalize the critical shoulder angle. However, a vertical lateral acromioplasty may release the middle deltoid origin from the lateral acromion. The superior band of collagen may anchor the middle deltoid to the superior acromion and prevent retraction.

To evaluate the patient-reported and objective functional outcomes of patients undergoing multiple-revision anterior cruciate ligament (ACL) reconstruction surgery. The secondary purpose was to determine failure rates and factors associated with failure, with a focus on posterior tibial slope.

All patients who underwent a repeat revision ACL reconstruction with a single surgeon over a 13-year period were identified. Chart data were obtained, including radiographic findings, operative details and findings, and postoperative examination findings. Failure was defined as subjective instability with evidence of graft incompetence on physical examination and MRI. Patients completed the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF) and Tegner Activity Level Scale. Patients who had outcomes scores completed a minimum of 2 years postoperatively were included.

Fourteen patients were available for follow-up; 12 underwent secondary revision procedures, and 2 underwent tertiary revisions. Three patients (21%) had subsequent failure of the revision graft with mean time to failure of 27 months. Posterior tibial slope was significantly higher in the failures than in the nonfailures (13.3˚; 95% CI 10.1-16.6 versus 10.1˚; 95% CI 6.7-11.4;

= 0.049). Eleven patients completed outcomes measures at a mean of 42 months postoperatively (range 24-79 months). BBN The mean Tegner activity score was 6.3 at follow-up, compared with 8.3 prior to the original ACL injury. The mean IKDC-SKF score was 70 at follow-up.

Multiple revision ACL reconstruction surgery appears to have reasonable functional outcomes but is associated with a relatively high failure rate. Activity level following repeat revision surgery is diminished compared to the preinjury state, but most patients are able to return to recreational sports.

Therapeutic Study, Level IV.

Therapeutic Study, Level IV.