What's New in Sports Medicine.

Abstract

The field of sports medicine advances at an ever-increasing pace with developments in improvements in outcomes for surgical techniques including procedures involving the anterior cruciate ligament (ACL), meniscus, rotator cuff, and shoulder labrum and hip arthroscopy. In addition, there have been improvements in utilizing orthobiologics and rehabilitation and in decreasing the use of opioids for postoperative pain management. We have included selected studies to update the most relevant recent findings and outcomes to help in adjusting treatment algorithms. Knee ACL Despite improvements in ACL reconstruction, persistent anterolateral rotational instability remains problematic in some patients. In a recent systematic review and meta-analysis of randomized controlled trials (RCTs) of 7 studies and 517 patients, Onggo et al.1 compared ACL reconstruction alone (hamstring or bone-patellar tendon-bone [BPTB]) with ACL reconstruction plus lateral extra-articular tenodesis (LEAT). LEAT is used to decrease anterolateral rotational instability and act as a check rein to instability and includes a heterogenous group of procedures including the modified Lemaire technique2,3, the Marcacci technique4, the Losee tenodesis5, the modified iliotibial band tenodesis6, and the MacIntosh-modified Coker-Arnold procedure7. Although the LEAT group had significantly better Lysholm scores (p = 0.009) and International Knee Documentation Committee (IKDC) scores (p = 0.01), the pooled mean differences were not clinically important. The LEAT group also had significantly less residual positive pivot shift (p = 0.01), but no difference in the positive residual Lachman test. Most importantly, rerupture in the LEAT group was 3 times less likely than in the non-LEAT group overall (relative risk [RR], 0.31; p < 0.001) and for patients treated with hamstring ACL reconstruction alone (RR, 0.31; p < 0.001). Among the 2 studies showing revision rates, a lower rate of revision was found in the LEAT group (1.4%) compared with the non-LEAT group (5.4%)1. To determine the optimal knee flexion angle for graft fixation among patients treated with anatomic single-bundle BPTB ACL reconstruction, Chahal et al.8 performed an RCT with 169 patients comparing graft tibial fixation at 0° and 30° of knee flexion. A significantly greater percentage of the patients with 0° fixation achieved the minimal clinically important difference (MCID) for the Knee injury and Osteoarthritis Outcome Score (KOOS) pain subscale (p = 0.04) and had higher Marx Activity Scores (p = 0.04). Otherwise, there were no differences in outcomes, KT-1000 (MEDmetric) findings, or rates of graft rupture8. Lin et al.9 recently completed an RCT comparing all-inside (24 patients) and anatomic standard (26 patients) ACL reconstruction using quadruple-bundle hamstring tendon autograft. There were no significant differences in the IKDC, Tegner, or Lysholm scores, although there was greater anterior tibial translation in the all-inside reconstruction group (p = 0.048). The all-inside reconstruction group also had significantly lower graft maturity at 6 months, determined by a higher magnetic resonance imaging (MRI) signal/noise quotient (p < 0.05)9. Meniscus The ideal surgical technique for securing meniscal allografts remains controversial. In a meta-analysis of 36 studies, Ow et al.10 assessed the outcomes of meniscal allograft transplantation in 2,604 patients by comparing sutures only (24.7%), bone plugs (43.5%), or bone blocks (31.6%) for fixation. Graft failure, defined as requiring revision meniscal allograft transplantation, conversion to joint arthroplasty, or allograft removal, was the lowest in the bone plug group (6.2%), followed by the suture-only group (6.9%), and was the greatest in the bone bridge group (9.3%). Similarly, the rates of reoperation were the lowest in the bone plug group (5.2%), followed by the suture-only group (13.4%) and the bone bridge group (32.6%). There were no significant differences in MRI-assessed graft extrusion between groups10. To assess the progression of knee function and knee osteoarthritis in patients with degenerative meniscal tears, Noorduyn et al.11 randomized 321 patients into partial meniscectomy or physical therapy and 2 of these patients withdrew from participation directly after the randomization; of the 319 patients remaining, 278 (87.1%) completed the trial, with a mean follow-up of 61.8 months. The initial radiographic assessments and progression of knee osteoarthritis were comparable in both groups, with no significant differences in IKDC knee function, pain, or quality-of-life scores, suggesting that physical therapy is not inferior to partial meniscectomy for patients with degenerative meniscal tears11. Eseonu et al.12 compared the different management options for acute meniscal root tears identifying 11 studies that compared repair (158 patients who underwent pull-out repair and 13 patients who underwent all-inside repair), partial meniscectomy (176 patients), and nonoperative management (157 patients). The mean ages ranged from 46.1 to 62 years and follow-up ranged from 7.1 to 77 months. All treatment options significantly improved functional outcomes at 12 months. Repair yielded a slower rate of knee osteoarthritis progression when compared with nonoperative treatment and partial meniscectomy, suggesting that meniscal root repair can be considered in the treatment armamentarium in older individuals12. Longer follow-up will be required to further illuminate the functional outcomes for these treatment options. Cartilage and Joint Preservation A focal chondral defect within the knee remains a challenging problem with many surgical treatment options. Fortier et al.13 completed a systematic review and meta-analysis comparing microfracture treatment with and without augmentation for focal chondral defects in the knee, including 14 studies of 744 patients with a mean age of 46.8 years, a mean follow-up of 26.7 months, and a mean chondral lesion size ranging from 1.3 to 4.8 cm2. Microfracture augmentation with orthobiologics (platelet-rich plasma, hyaluronic acid, mesenchymal stem cells) was used in 57% of studies and scaffolds (biomembranes, fibrin-based) were used in 43% of studies. The control groups included isolated microfracture, microfracture with high tibial osteotomy, microfracture with high tibial osteotomy and hyaluronic acid, and microfracture with hyaluronic acid. Microfracture with augmentation resulted in greater improvement by a clinically important margin in Lysholm and MOCART (magnetic resonance observation of cartilage repair tissue) scores; however, there were no differences in the mean improvement in the visual analog scale (VAS) pain, IKDC, or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. A subgroup analysis in which cases with concomitant high tibial osteotomy were excluded demonstrated the same clinical findings13. In a systematic review and meta-analysis of 6 RCTs, Dhillon et al.14 compared 274 patients undergoing third-generation autologous chondrocyte implantation, defined as implantation of cells cultured within a collagen membrane, with 238 patients undergoing microfracture for the management of focal chondral defects. Patients were randomized regardless of lesion size, which ranged from 1.8 to 5.0 cm2. Treatment failures included any reoperation due to symptoms, detachment, or <50% of the repair tissue filling the defect and/or minimal to no improvement in patient-reported outcomes. Treatment failure was higher in the microfracture group, ranging from 2.5% to 8.3%, compared with 0% to 1.8% in the autologous chondrocyte implantation group. Postoperative improvements in Lysholm, Tegner, and subjective IKDC scores were all significantly greater in the autologous chondrocyte implantation group. Although cost-effectiveness was not addressed, third-generation autologous chondrocyte implantation showed promising improvements in patient-reported outcomes and low rates of failure, particularly when compared with microfracture14. In a systematic review and meta-analysis of 33 studies with 876 patients, Ow et al.15 assessed short-term outcomes to compare the efficacy of different acellular scaffolds, with and without bone marrow aspirate concentrate for cartilage repair. Scaffolds were classified as single-layered (Hyalofast; Anika Therapeutics), multilayered (collagen I/III bilayer, Chondro-Gide; Geistlich Pharma), and gel-based, which included acellular collagen (Cartifill; Sewon Cellontech) and acellular chitosan (CarGel; Smith & Nephew). The patients in all scaffold groups had significant improvements between preoperative and postoperative patient-reported outcome measures. VAS pain scores had significantly greater improvement in patients receiving multilayered scaffolds compared with other scaffolds (p = 0.03). Gel-based scaffolds had significantly lower risks of incomplete defect filling when compared with single-layer scaffolds (p = 0.001) and multilayered scaffolds (p < 0.001). Subgroup analysis demonstrated significantly greater Tegner scores (p = 0.02) and lower rates of incomplete defect filling in patients receiving bone marrow aspirate concentrate augmentation compared with those not receiving it. However, for all analyses, improvements were below their respective MCIDs15. Shoulder Rotator Cuff Tears Delay between rotator cuff injury and surgical repair is thought to increase the risk of tendon decompensation and tear size progression, but optimal timing is unclear. In a systematic review and meta-analysis by van der List et al. of 33 studies and 8,118 patients, the surgical repair had an ideal window of 3 to 6 months, but could be delayed up to 1 year, without a significant difference in the retear rate, American Shoulder and Elbow Surgeons (ASES) score, and Constant-Murley score, compared with a surgical procedure performed more acutely16. With no clear evidence demonstrating superiority of various rotator cuff repair techniques, Lavoie-Gagne et al. performed a meta-analysis of 2,046 shoulders with small to medium complete rotor cuff tears treated with arthroscopic or open repair using double-row or single-row technique, with or without the addition of acromioplasty, platelet-rich plasma, and/or footprint microfracture. No clearly superior technique emerged: arthroscopic, double-row repair with acromioplasty and platelet-rich plasma ranked the highest for minimizing the retear rate and improving the Disabilities of the Arm, Shoulder and Hand (DASH) score, and arthroscopic repair with single-row repair and acromioplasty ranked the highest for pain relief. Arthroscopic single-row repair with footprint microfracture ranked the highest for improving the Constant-Murley score, and acromioplasty with single-row repair ranked the highest for improving the ASES score17. A more focused meta-analysis of 15 trials including 1,096 randomized patients comparing single-row fixation with double-row fixation found the RR of retear with single-row fixation to be 1.56 (95% confidence interval [CI], 1.06 to 2.29) compared with double-row fixation, but with no difference in functional or pain scores at the final follow-up18. No differences in long-term functional outcomes or retear rates were noted when comparing arthroscopic repair with open or mini-open repair19. Superiority among reconstruction techniques for irreparable rotator cuffs also remain unclear. Ono et al. performed a prospective RCT comparing superior capsular reconstruction with bridging human dermal allograft for irreparable rotator cuff tears in 46 patients who had 2-year follow-up. Overall, patients had significantly improved range of motion, patient-reported outcomes, and radiographic outcomes due to the surgical procedure, although there were no differences in the ASES score or QuickDASH (the abbreviated version of the DASH questionnaire) score between patients with and without an intact graft on MRI at 1 year. Almost all patients underwent maximal partial repair of the subscapularis and posterior cuff before grafting. At 24 months, patients with irreparable posterior cuff tears, when compared with repaired or intact posterior cuff tears, had significantly lower ASES scores (65.8 compared with 81.9; p = 0.01) and Western Ontario Rotator Cuff (WORC) scores (57.9 compared with 72.9; p = 0.04), indicating that the ability to achieve a balanced partial repair may have a greater effect than the method for achieving superior stability20. Glenohumeral Instability Operative management for glenohumeral instability has an established benefit in the appropriate population of patients who are at high risk for recurrent instability and are willing to undergo the extensive postoperative rehabilitation. A systematic review and meta-analysis including 5 studies evaluating 259 patients, 15 to 39 years of age, with a first-time anterior shoulder dislocation, compared patients who underwent early surgical stabilization with patients who underwent nonoperative treatment with immobilization. Patients treated operatively experienced significantly lower rates (p < 0.00001) of recurrent instability (6.3%) compared with patients treated nonoperatively (46.6%); patients treated operatively required significantly fewer (p < 0.00001) subsequent instability surgical procedures (4.0%) compared with patients treated nonoperatively (30.8%)21. However, despite technical advances, operative treatment still has high rates of recurrence requiring revision, leading to the questions of whether primary reconstruction would be more effective and whether previous failed labral repair influences outcomes of revision osseous reconstruction. Patients with recurrent anterior shoulder instability following primary labral repair experienced no difference in recurrence when revision labral repair was compared with osseous reconstruction in a systematic review and meta-analysis of 4 studies22. The recurrence rate after primary osseous reconstruction, 4%, was significantly lower than the rate after revision, 10.7% (p < 0.008), but there were no significant differences in return to sport, additional revision surgical procedures, or complications23. Indications and rationale for primary osseous reconstruction continue to vary according to the presence of off-track lesions, critical glenoid bone loss, and failed prior surgical procedures as well as on the basis of regional preferences, as shown by a systematic review of 72 open coracoid transfer studies24. The surgical technique widely differed as well with respect to subscapularis and capsular management and the number of screws used. Furthermore, the comparison of outcomes was inconclusive because of variability in how recurrence was measured and limited reporting of subjective stability, apprehension, or subluxation24. Free bone graft for critical-sized glenoid defects was more commonly autograft (iliac crest, free coracoid process, or scapular spine transplantation) than allogeneic (distal tibia, iliac crest, or femoral head). In a single-covariate, meta-regression analysis of 840 patients, the outcome after free bone grafting was not affected by the mean age at the time of the surgical procedure, length of follow-up, sex, graft type, or surgical approach. In the overall group, there were low rates of recurrent instability-related complications (3.4%) and non-instability-related complications (5.6%). Autograft and open procedures yielded higher rates of recurrent instability and complications. Forty-nine percent of patients had undergone a previous surgical procedure; revision Latarjet procedures and repeated instability procedures were associated with the highest recurrent instability rate (10.3% for both)22. Biceps Operative strategies for managing biceps pathology continues to be controversial. Shin et al. performed a systematic review and meta-analysis comparing SLAP (superior labrum anterior to posterior) repair with biceps tenodesis in overhead athletes; the 6 tenodesis studies had 92 patients with a mean age of 41.08 ± 6.71 years, and the 8 SLAP repair studies had 221 patients with a mean age of 26.4 ± 3.69 years. The study did not find any significant differences in outcomes between the 2 groups. However, there was a trend toward better outcomes in the tenodesis group (ASES scores, rate of return to sport and to preinjury level of sport, and complication rates). Biceps tenodesis was noninferior to SLAP repair for this population, but the sample size may have been too small to find significance25. Distal Clavicle and Acromioclavicular Joint In a multicenter RCT, no differences in DASH scores, Constant-Murley scores, or VAS pain scores were seen between the operatively and nonoperatively treated Type-II Neer distal clavicular fractures at any of the time points up to 1 year. However, the nonoperatively treated group reported greater dissatisfaction with shoulder appearance at 6 weeks (33% compared with 4%; p = 0.006) and 3 months (24% compared with 0%; p = 0.01), which did not persist at later time points, and a lower rate of return to full sport and recreational activity at 6 months (44% compared with 78%; p = 0.015). The union rate was 63% in the nonoperatively treated group, with 15% having symptomatic nonunions requiring a surgical procedure. The union rate was 93% in the operatively treated group, but 44% of operatively treated patients required a second procedure for the removal of the implant (2 precontoured distal clavicular plates and 10 hook plates)26. Coracoclavicular fixation is increasingly being utilized for the management of distal clavicular fractures and type-III or V acromioclavicular joint dislocations27. In a prospective RCT comparing a hook plate with a locking plate augmented with coracoclavicular fixation in 30 patients, all patients achieved union by 12 months, with no difference in DASH scores and Constant-Murley scores. Significant improvement continued from 6 to 12 months in the hook plate group, but no changes were seen in the locking plate group after 6 months, suggesting that those patients achieved functional mobility earlier. The mean surgical time was significantly longer (p < 0.001) for the locking plate and coracoclavicular fixation group (76 ± 17 minutes) than the hook plate group (48 ± 10 minutes), but all patients in the hook plate group required implant removal28. The optimal management of subacromial pathology remains unclear after publication of the FIMPACT (Finnish Shoulder Impingement Arthroscopy Controlled Trial) intermediate-term results of 184 patients with subacromial pain randomized to arthroscopic subacromial decompression, diagnostic arthroscopy with placebo surgical intervention, or exercise therapy. No difference in return to work was seen at 2 and 5 years, leading the authors to conclude that arthroscopic subacromial decompression provides no benefit over diagnostic arthroscopy or exercise therapy with respect to return to work29. Hip The U.K. FASHIoN (Full trial of Arthroscopic Surgery for Hip Impingement compared with Nonoperative care) multicenter RCT spanning 23 hospitals sought to compare the clinical effectiveness and cost-effectiveness of hip arthroscopy with those of the best conservative care. Patients ≥16 years of age with femoroacetabular impingement were randomized to hip arthroscopy with postoperative physical therapy (171 patients) or physical therapy with an individualized physical therapist-led program (177 patients) and had a follow-up of 3 years. Patients and physicians were not blinded to treatment arms. Outcomes were measured by the patient-reported International Hip Outcome Tool (iHOT-33) at 12 months after the intervention. Patients who underwent hip arthroscopy improved from 39.2 ± 20.9 points to 58.8 ± 27.2 points, and the physical therapy group improved from 35.6 ± 18.2 points to 49.7 ± 25.5 points. Thus, after adjusting for impingement type, sex, baseline scores, and the medical center where the intervention took place, there was a mean 6.8-point greater improvement with hip arthroscopy as the intervention compared with physical therapy. This 6.8-point increase was larger than the MCID of 6.1, supporting hip arthroscopy as being a more beneficial intervention modality by a clinically important margin. More importantly, 24% of the patients undergoing physical therapy crossed over to hip arthroscopy between 1 and 3 years after the randomization. The cost-effectiveness of surgical intervention was not demonstrated in a 12-month follow-up, but may be elucidated with longer follow-up in the future30. Foot and Ankle In a systematic review and meta-analysis of 10 RCTs of 522 patients (260 who underwent an open surgical procedure and 262 who underwent a minimally invasive surgical procedure [MIS]), Attia et al.31 compared the 2 procedures to treat Achilles tendon ruptures and found that there was no significant difference in the postoperative American Orthopaedic Foot & Ankle Society (AOFAS) score, total complication rate (deep infection, skin necrosis, wound dehiscence, scar adhesion, or keloid scar), and mean rerupture rate. However, the MIS group had a significantly higher rate of sural nerve injury (3.4% compared with 0% [odds ratio (OR), 0.16 (95% CI, 0.03 to 0.46); p = 0.02; I2 = 0%]), whereas the open surgical procedure group had a significantly higher rate of superficial infection (6.0% compared with 0.4% [OR, 5.70 (95% CI, 1.80 to 18.02); p < 0.001; I2 = 0%]) and mean surgical time (51 compared with 29.7 minutes)31. Johannsen et al. compared combination exercise therapy and ultrasound-guided corticosteroid injection with exercise therapy and placebo injection to treat Achilles tendinopathy. The authors found that the group that underwent exercise therapy and corticosteroid injection had an increase of 17.7 points (95% CI, 8.4 to 27.0 points; p < 0.001) in Victorian Institute of Sport Assessment-Achilles (VISA-A) scores at 6 months compared with the group that underwent placebo injection with exercise. The group that underwent exercise therapy and corticosteroid injection in the management of Achilles tendinopathy also had no adverse events over 2 years32. Elbow Distal biceps tendon ruptures that were operatively treated had significantly higher elbow flexion and supination strength and endurance than those that were nonoperatively treated. Operative treatment was also associated with superior DASH scores and Mayo Elbow Performance Scores33. Distal triceps tendon rupture can be treated with a variety of surgical techniques, with an overall complication rate of 14.9%. Fixation with transosseous sutures was the most common technique (49%), followed by suture anchors (25%) and direct repair (4.2%). Suture anchors had the lowest rate of complication (7.7%), followed by transosseous sutures (15.2%) and direct repair (29.2%). Transosseous sutures had the highest rate of rerupture (4.3%) compared with suture anchors (2.3%) or direct repair (0%), which correlates with biomechanical studies demonstrating transosseous sutures to have weaker fixation strength and greater displacement with cyclic loading when compared with suture anchor fixation34. Rehabilitation Optimal postoperative rehabilitation protocols for knee surgery remain an area of active research. Wengle et al.35 identified 10 studies (235 patients) that assessed the effects of blood flow restriction for recovery after ACL reconstruction, 4 (95 patients) of which were included in their systematic review and meta-analysis. There were no significant differences between the postoperative blood flow restriction and control groups for any of the KOOS subdomains. However, the cross-sectional area of the quadriceps was significantly larger in the patients with blood flow restriction compared with the control group (p = 0.04), suggesting that postoperative blood flow restriction reduces quadriceps atrophy even though it does not provide a clear benefit with respect to patient outcomes35. The COVID pandemic led to a rise in virtual health-care delivery platforms. However, even before this necessity, a digital platform for physical therapy with gamifying protocols to increase engagement in home therapy and decrease burden on the health-care system was being developed. The Medical Interactive Recovery Assistant (MIRA) software pairs with Microsoft Kinect, a markerless, commercially available, motion capture system that tracks 3-dimensional body movement and has been validated to accurately measure range of motion in the shoulder36. Patients are guided through games to target different physiotherapy goals. An RCT comparing the MIRA-Kinect (exergames) with conventional physiotherapy following arthroscopic shoulder surgical procedures found no significant differences in range of motion, DASH scores, and EuroQol-VAS (EQ-VAS) scores, suggesting that exergames can be an effective alternative for postoperative rehabilitation37. Opioid-Sparing Analgesia Considerable efforts have been made to utilize nonopioid medication in the management of pain following painful orthopaedic procedures. Many studies have been performed to determine the efficacy of peripheral nerve blocks and multimodal pain regimens with respect to the reduction of opioid consumption after procedures involving the hip38, knee39, and shoulder40–43. Peripheral Nerve Block An analysis of 8 RCTs concluded that patients who underwent a peripheral nerve block for hip arthroscopy did not have decreased postoperative opioid consumption or VAS scores for the first 24 hours postoperatively when compared with patients who received local infiltration of analgesics38. Extended-release liposomal bupivacaine nerve block injections are increasingly utilized. In an RCT comparing liposomal bupivacaine plus bupivacaine for interscalene nerve block with bupivacaine alone in arthroscopic rotator cuff repair, Flaherty et al. found that adding liposomal bupivacaine did not reduce opioid consumption or reduce maximum VAS pain scores at 24 hours (1 in the liposomal bupivacaine group compared with 3 in the bupivacaine-only group; p = 0.02) or at 72 hours (3 in the liposomal bupivacaine group compared with 4 in the bupivacaine-only group; p = 0.03), which was a significant change but not the MCID, but adding liposomal bupivacaine did increase the quality-of-recovery score at 72 hours (p = 0.01)40. Similarly, a systematic review and meta-analysis of 11 RCTs of 846 patients comparing liposomal bupivacaine with conventional bupivacaine or ropivacaine peripheral nerve blocks for shoulder surgery showed no significant difference in VAS pain scores at 24 and 48 hours, opioid consumption, length of hospital stay, or complications43. Multimodal Pain Regimens Sixty-two patients undergoing ACL reconstruction with autograft hamstring or BPTB were prospectively randomized to a scheduled multimodal nonopioid medication regimen of ketorolac (followed by meloxicam), diazepam, gabapentin, and acetaminophen or a traditional opioid regimen. Patients who received the multimodal regimen had significantly lower VAS pain scores in the early postoperative period (p < 0.05) and outcomes comparable with those of the traditional opioid group over time39, demonstrating that pain after ACL reconstruction can be effectively managed without the use of opioids. Multimodal nonopioid pain regimens are also effective following arthroscopic shoulder surgery. Patients who received ketorolac, acetaminophen, gabapentin, and methocarbamol for arthroscopic rotator cuff repair had significantly reduced pain scores (p < 0.01) compared with patients who received oxycodone41. Similarly, in patients undergoing arthroscopic shoulder labral surgery, a similar regimen with the addition of meloxicam after the discontinuation of ketorolac also led to decreased pain scores at all postoperative time points compared with standard hydrocodone-acetaminophen (p < 0.01)42. Cannabidiol (CBD) products have gained popularity for use in controlling postoperative pain, but there has been a paucity of literature evaluating their efficacy and safety. Alaia et al. performed a double-blinded RCT evaluating the effect of buccally absorbed CBD in patients undergoing arthroscopic rotator cuff repair and found that, although there was no significant difference in opioid consumption, the CBD group had significantly lower VAS pain scores on postoperative day 1 and greater satisfaction with pain control on postoperative days 1 and 2. The trend persisted but was no longer significant at postoperative days 7 and 14. No harmful side effects were found to be associated with the use of buccally absorbed CBD44. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 13 other articles with a higher Level of Evidence grade relevant to sports medicine surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Attia AK, Robertson GAJ, McKinley J, d’Hooghe PP, Maffulli N. Surgical management of Jones fractures in athletes: orthobiologic augmentation: a systematic review and meta-analysis of 718 fractures. Am J Sports Med. 2022 May 25:3635465221094014. The use of orthobiologics in primary fixation of Jones fractures in athletes was recently reviewed in a systematic review and meta-analysis of 718 fractures. The inclusion of orthobiologic augmentation resulted in higher fracture union rates, with equivalent rates of, and time to, return to play. These findings should be further evaluated with high-quality research to establish indications for augmentation with orthobiologics. The use of orthobiologics