Application of Machine Learning Algorithms to Predict Clinically Meaningful Improvement After Arthroscopic Anterior Cruciate Ligament Reconstruction

Background:

Understanding specific risk profiles for each patient and their propensity to experience clinically meaningful improvement after anterior cruciate ligament reconstruction (ACLR) is important for preoperative patient counseling and management of expectations.

Purpose:

To develop machine learning algorithms to predict achievement of the minimal clinically important difference (MCID) on the International Knee Documentation Committee (IKDC) score at a minimum 2-year follow-up after ACLR.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

An ACLR registry of patients from 27 fellowship-trained sports medicine surgeons at a large academic institution was retrospectively analyzed. Thirty-six variables were tested for predictive value. The study population was randomly partitioned into training and independent testing sets using a 70:30 split. Six machine learning algorithms (stochastic gradient boosting, random forest, neural network, support vector machine, adaptive gradient boosting, and elastic-net penalized logistic regression [ENPLR]) were trained using 10-fold cross-validation 3 times and internally validated on the independent set of patients. Algorithm performance was assessed using discrimination, calibration, Brier score, and decision-curve analysis.

Results:

A total of 442 patients, of whom 39 (8.8%) did not achieve the MCID, were included. The 5 most predictive features of achieving the MCID were body mass index ≤27.4, grade 0 medial collateral ligament examination (compared with other grades), intratunnel femoral tunnel fixation (compared with suspensory), no history of previous contralateral knee surgery, and achieving full knee extension preoperatively. The ENPLR algorithm had the best relative performance (C-statistic, 0.82; calibration intercept, 0.10; calibration slope, 1.15; Brier score, 0.068), demonstrating excellent predictive ability in the study’s data set.

Conclusion:

Machine learning, specifically the ENPLR algorithm, demonstrated good performance for predicting a patient’s propensity to achieve the MCID for the IKDC score after ACLR based on preoperative and intraoperative factors. The femoral tunnel fixation method was the only significant intraoperative variable. Range of motion and medial collateral ligament integrity were found to be important physical examination parameters. Increased body mass index and prior contralateral surgery were also significantly predictive of outcome.

Patient-Reported Outcomes and Factors Associated with Achieving the Minimal Clinically Important Difference After ACL Reconstruction: Results at a Mean 7.7-Year Follow-up

Background

Analyzing outcomes and the minimal clinically important difference (MCID) after anterior cruciate ligament reconstruction (ACLR) is of increased interest in the orthopaedic literature. The purposes of this study were to report outcomes after ACLR at medium to long-term follow-up, identify the threshold preoperative outcome values that would be predictive of achieving the MCID postoperatively, and analyze outcome maintenance at medium to long-term follow-up after ACLR.

Methods

Active athletes who underwent ACLR were identified in an institutional ACL registry. Patient-reported outcome measures (PROMs) were administered preoperatively and at the 2-year and >5-year postoperative follow-up; measures included the International Knee Documentation Committee (IKDC) form, the 12-item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS), and Lysholm scale. We calculated the MCID from baseline to each of the 2 follow-up periods (2-year and mean 7.7-year). Logistic regression was performed to investigate factors associated with achievement of the MCID.

Results

A total of 142 patients (mean follow-up, 7.7 years [range, 6.6 to 9.1 years]) underwent ACLR. The mean age and body mass index at the time of surgery were 27.2 ± 13.0 years and 23.2 ± 3.0 kg/m2, respectively. Final postoperative outcome scores improved significantly from baseline for the IKDC (50.9 ± 14.7 to 87.9 ± 11.2), SF-12 PCS (41.6 ± 8.9 to 55.6 ± 3.2), and Lysholm scale (62.2 ± 17.6 to 90.5 ± 10.3) (p < 0.0001), while the SF-12 MCS did not improve significantly (54.2 ± 8.0 to 54.4 ± 6.0) (p = 0.763). Between 2- and >5-year follow-up, the SF-12 PCS showed significant improvement (54.6 ± 4.5 to 55.6 ± 3.2; p = 0.036), while no change was noted in the IKDC (87.6 ± 11.1 to 87.9 ± 11.2), SF-12 MCS (55.5 ± 5.3 to 54.4 ± 6.0), and Lysholm scale (89.8 ± 10.6 to 90.5 ± 10.3) (p ≥ 0.09). At the time of final follow-up, the MCID was achieved by 94.7% of patients for the IKDC, 80.8% for the Lysholm, 79.0% for the SF-12 PCS, and 28.2% for the SF-12 MCS. At 2-year follow-up, 95.3% of patients were either "very" or "somewhat" satisfied with their surgery, compared with 88.6% at the time of final follow-up.

Conclusions

We found a high level of maintained function following ACLR. The IKDC, SF-12 PCS, and Lysholm scores improved significantly after ACLR at the time of final follow-up and were not significantly different between follow-up periods. Approximately 95% and 89% of patients reported being satisfied with the outcome of surgery at the 2-year and final follow-up, respectively.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors Predictive of Prolonged Postoperative Narcotic Usage Following Orthopaedic Surgery

BACKGROUND

The purpose of this comprehensive review was to investigate risk factors associated with prolonged opioid use after orthopaedic procedures. A comprehensive review of the opioid literature may help to better guide preoperative management of expectations as well as opioid-prescribing practices.

METHODS

A systematic review of all studies pertaining to opioid use in relation to orthopaedic procedures was conducted using the MEDLINE, Embase, and CINAHL databases. Data from studies reporting on postoperative opioid use at various time points were collected. Opioid use and risk of prolonged opioid use were subcategorized by subspecialty, and aggregate data for each category were calculated.

RESULTS

There were a total of 1,445 eligible studies, of which 45 met inclusion criteria. Subspecialties included joint arthroplasty, spine, trauma, sports, and hand surgery. A total of 458,993 patients were included, including 353,330 (77%) prolonged postoperative opioid users and 105,663 (23%) non-opioid users. Factors associated with prolonged postoperative opioid use among all evaluated studies included body mass index (BMI) of ≥40 kg/m (relative risk [RR], 1.06 to 2.32), prior substance abuse (RR, 1.08 to 3.59), prior use of other medications (RR, 1.01 to 1.46), psychiatric comorbidities (RR, 1.08 to 1.54), and chronic pain conditions including chronic back pain (RR, 1.01 to 10.90), fibromyalgia (RR, 1.01 to 2.30), and migraines (RR, 1.01 to 5.11). Age cohorts associated with a decreased risk of prolonged postoperative opioid use were those ≥31 years of age for hand procedures (RR, 0.47 to 0.94), ≥50 years of age for total hip arthroplasty (RR, 0.70 to 0.80), and ≥70 years of age for total knee arthroplasty (RR, 0.40 to 0.80). Age cohorts associated with an increased risk of prolonged postoperative opioid use were those ≥50 years of age for sports procedures (RR, 1.11 to 2.57) or total shoulder arthroplasty (RR, 1.26 to 1.40) and those ≥70 years of age for spine procedures (RR, 1.61). Identified risk factors for postoperative use were similar across subspecialties.

CONCLUSIONS

We provide a comprehensive review of the various preoperative and postoperative risk factors associated with prolonged opioid use after elective and nonelective orthopaedic procedures. Increased BMI, prior substance abuse, psychiatric comorbidities, and chronic pain conditions were most commonly associated with prolonged postoperative opioid use. Careful consideration of elective surgical intervention for painful conditions and perioperative identification of risk factors within each patient's biopsychosocial context will be essential for future modulation of physician opioid-prescribing patterns.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To determine which interventions optimize clinical outcomes in adhesive capsulitis by performing a network meta-analysis of randomized controlled trials.

METHODS

A systematic review was conducted of all clinical trials on adhesive capsulitis published since 2008. Patient cohorts were grouped into treatment categories; data collected included range of motion (ROM) and patient-reported outcome measures (PROMs). Interventions were compared across groups by means of arm-based Bayesian network meta-analysis in a random-effects model.

RESULTS

Sixty-six studies comprising 4042 shoulders (57.6% female patients, age 54.8 ± 3.2 years [mean ± standard deviation]) were included. The most commonly studied interventions were physical therapy (PT) or shoulder injections. Network meta-analysis demonstrated that arthroscopic surgical capsular release was the most effective treatment in increasing ROM. This effect was apparent in forward flexion (effect difference [ED] versus placebo, 44°, 95% confidence interval [CI] 31° to 58°), abduction (ED 58°, 45° to 71°), internal rotation (ED 34°, 24° to 44°), and external rotation (ED 59°, 37° to 80°). Interventions most effective for pain relief included PT supplemented with either medical therapy (ED -4.50, -9.80 to 2.80) or ultrasound therapy (ED -5.10, -5.10 to -1.40). Interventions most effective for improvement of functional status included PT, manipulation under anesthesia (MUA), intra-articular or subacromial steroid injection, surgical capsular release, and supplementation of PT with alternative therapy.

CONCLUSIONS

No one treatment emerged superior in regard to ROM, pain symptoms, and functional status. Surgery (after failure of conservative treatment) ranked highest across all ROM domains. Treatments that ranked highest for treatment of pain included PT supplemented with either medical therapy or ultrasound. Finally, treatments that ranked highest for improvements in functional status included MUA, PT with medical therapy, surgical intervention, PT with ultrasound, PT with injection, and injection alone.

LEVEL OF EVIDENCE

II, systematic review and network meta-analysis of level I and II studies.

Current Orthopaedic Health Economic Literature: Quality Is High but Ethical and Societal Perspectives Are Lacking

PURPOSE

To evaluate the quality of orthopaedic cost-effectiveness analyses (CEAs) in accordance with the 2016 recommendations by the Second Panel on Cost-Effectiveness in Health and Medicine.

METHODS

A systematic review of all CEAs from September 2017 to September 2019 in the 10 highest impact orthopaedic surgery journals was performed. Quality scoring used the Quality of Health Economic Studies (QHES) instrument and the Second Panel checklist. QHES scores ≥80 were considered high quality and <50 poor quality. Mann-Whitney U and independent samples Kruskal-Wallis tests compared individual and multiple groups, respectively. Linear regression analysis was performed to correlate QHES score, checklist item fulfillment, and impact factor.

RESULTS

The 10 highest impact orthopaedic journals published 6,323 articles with 35 (0.55%) meeting inclusion criteria. Total joint arthroplasty (TJA) and sports medicine articles comprised 65.7% of included studies. Overall mean QHES score was 89.0 ± 7.6, with 82.8% considered high quality. Mean proportion of Second Panel checklist items fulfilled was 82.1% ± 13.3%, but no studies performed an impact inventory accounting for consequences within and outside the health care sector or discussed ethical implications. Mean QHES score and satisfied checklist items were significantly different by journal (P = .025 and P = .01, respectively). In addition, there was a moderate positive correlation between QHES score and impact factor (r = 0.446, P = .007). TJA CEAs satisfied a higher number of checklist items compared with spine surgery CEAs.

CONCLUSIONS

Recent orthopaedic CEAs have generally been high quality according to updated Second Panel guidelines but consistently miss checklist items relating to societal impact and ethics. TJA and sports medicine continue to be the most frequently studied orthopaedic subspecialties in health economics, and the breadth of orthopaedic procedures analyzed by CEAs has improved.

STUDY DESIGN

Level IV, systematic review.

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up

PURPOSE

To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.

METHODS

A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated.

RESULTS

There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated.

CONCLUSIONS

AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction.

LEVEL OF EVIDENCE

IV (Case Series).

Adductor injuries in the National Basketball Association: an analysis of return to play and player performance from 2010 to 2019

Objectives: 1) To evaluate return to play (RTP) timing in National Basketball Association (NBA) athletes following adductor injuries, and 2) to evaluate the effect of adductor injuries on player performance, game availability, and career longevity following RTP. Methods: Adductor injuries in NBA athletes from the 2009-2010 to 2018-2019 seasons were identified utilizing publicly available records via previously validated methodology. RTP time was calculated, and player performance and game availability were compared pre- vs. post-injury. Additionally, an injury-free control group matched for age, BMI, position, and experience was assembled to allow for comparisons in performance, availability, and career length. Results: In total, 79 adductor injuries across 65 NBA athletes were identified. The average injured player was 28.3 ± 4.0 years of age, and had 6.5 ± 4.2 seasons of NBA experience. Guards were injured more frequently than forwards or centers (49% vs 25% vs 25%, respectively). All players were able to RTP following first-time adductor injury after missing an average of 7.7 ± 9.8 games (median [IQR]: 4 [1-9]) and 16.9 ± 20.4 days (median [IQR]: 9 [3.5-20]). Twelve players (18.5%) suffered an adductor re-injury at a mean latency of 509.5 ± 503.9 days. Adductor injuries did not result in significant changes in any major statistical category (points, assists, rebounds, steals, blocks, turnovers, field goal percentage), player efficiency rating (PER), minutes/game, games/season, or a number of all-star selections (all P > 0.05) following RTP. Additionally, when compared to matched controls, no difference was found in pre- to post-injury change of PER, games/season, or minutes/game (all P > 0.05). Career longevity was not significantly different between groups (P = 0.44). Conclusion: Following adductor injury, NBA players returned to gameplay after missing an average of 16 to 17 days, or 7 to 8 games. Adductor injury did not affect player performance, nor game availability or career longevity.

United States Under-19 Rugby-7s: Incidence and Nature of Match Injuries During a 5-year Epidemiological Study

Background

There is a lack of injury data for the new Olympic sport of Rugby-7s, particularly for involved youth.

Objective

To determine injury rates and characteristics for players participating in U.S. Rugby-7s U19 (under 19 years of age) tournaments.

Methods

Injury data were collected, using the Rugby Injury Survey & Evaluation report methodology, at 24 U.S. Rugby-7 s U19 tournaments over 30 tournament days (2010–2014). Tournament medical-attention injuries and time-loss injuries (days absent before return to training/competition including post tournament) were recorded.

Results

During the 2101 playing hours (3072 males, aged 17.2 ± 1.5 years; 732 females, 16.6 ± 1.3 years of age), there were 173 tournament injuries with an overall injury incidence of 82.4/1000 player-match-hours (ph) (CI 70.5–95.6). Acute injuries (79.5/1000 ph) occurred during tackling (56.2/1000 ph) and involved joints/ligaments (32.8/1000 ph) of lower extremities (31.9/1000 ph). Head and neck injuries, including concussions, were common (males 21.9/1000 ph; females 22.0/1000 ph). Medical-attention injury incidences (49.5/1000 ph; n = 104; 95% CI 40.5–60.0) were higher than time loss (32.8/1000 ph; n = 69; 95% CI 25.5–41.6). Overall, injury incidences found no difference between sex (RR 0.78; p = 0.369). Time-loss injuries resulted in an average of 35.5 d to return to sport.

Discussion

This study is the first to report match injury incidences for U19 participants in Rugby-7s. Overall, match injury incidence among U.S. U19 Rugby-7s tournaments was similar compared to adult U.S. community Rugby-7s. Recurrent injury risk was notable in this population. Community injury surveillance studies are essential to understand risk from participation in amateur sports. Knowledge of these injury patterns in U19 Rugby-7s will help identify areas to direct resources to enable growth of Rugby-7s in youths and emerging countries being exposed to Rugby-7 s. Age-based injury frequency and patterns in rugby and its various formats are needed for the development of evidence-based, sport-specific, and population-specific injury prevention initiatives.

Conclusions

The match injury incidence of U19 participants in U.S. Rugby-7s was similar to the incidence among adult participants. Recurrent match injury risk was high at 23%. There were no significant differences in injury incidences between males and females. The first three matches of a tournament day result in the most injuries.

Adverse Impact of Corticosteroid Injection on Rotator Cuff Tendon Health and Repair: A Systematic Review

PURPOSE

To assess adverse effects of preoperative corticosteroid injections (CSIs) in patients with rotator cuff disease, especially before rotator cuff repair (RCR).

METHODS

A systematic review of the MEDLINE database was performed according to guidelines from the Preferred Reporting Item for Systematic Reviews and Meta-Analyses for all studies reporting on adverse clinical effects of CSIs on rotator cuff tendon.

RESULTS

A total of 8 articles were identified that report on adverse outcomes and risks associated with corticosteroid injections in the setting of rotator cuff tendinosis. Among these included articles, a single CSI for rotator cuff tendinosis was associated with increased risk of revision rotator cuff repair (odds ratio [OR]: range 1.3 [1.1-1.7] to 2.8 [2.2-3.4]) when administered up to a year before surgery and postoperative infections (OR: 2.1 [1.5-2.7]) when administered within a month before RCR. The risk of adverse outcomes after rotator cuff repair are greatest if a CSI is administered within 6 months of surgery (OR: 1.8 [1.3-2.6]) or if ≥2 injections are given within a year of surgery (OR: range 2.1 [1.8-2.5] to 3.3 [2.7-4.0]).

CONCLUSION

Several recent clinical trials have demonstrated that CSIs are correlated with increased risk of revision surgery after RCR in a temporal and dose dependent matter. Caution should be taken when deciding to inject a patient, and this treatment should be withheld if an RCR is to be performed within the following 6 months.

LEVEL OF EVIDENCE

IV, systematic review of Level III and IV studies.

How Much Do Psychological Factors Affect Lack of Return to Play After Anterior Cruciate Ligament Reconstruction? A Systematic Review

Background:

Variables affecting return to sport after anterior cruciate ligament reconstruction (ACLR) are multifactorial. The nonphysical factors germane to successful return to play (RTP) are being increasingly recognized.

Purpose:

To (1) evaluate the available evidence base for psychological factors relating to RTP after ACLR, (2) identify psychological factors affecting RTP after ACLR, and (3) understand currently available metrics used to assess psychological RTP readiness.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A review of the MEDLINE database was performed for studies reporting RTP after ACLR. Studies reporting on the psychological determinants of RTP were included. Demographic, methodological, and psychometric properties of the included studies were extracted. Weighted analysis was performed after patients were pooled across included studies.

Results:

Of 999 studies identified in the initial search, 28 (2.8%) studies, comprising 2918 patients, were included; 19 studies (n = 2175 patients) reported RTP rates. The mean time for RTP was 17.2 months. There was a 63.4% rate of RTP, and 36.6% of patients returning to sport were not able to perform at their prior level of play. Of the 795 patients who did not achieve RTP, 514 (64.7%) cited a psychological reason for not returning. Fear of reinjury was the most common reason (n = 394; 76.7%); other psychological factors included lack of confidence in the treated knee (n = 76; 14.8%), depression (n = 29; 5.6%), and lack of interest/motivation (n = 13; 2.5%). The Tampa Scale for Kinesiophobia, the Hospital Anxiety and Depression Scale, the ACL–Return to Sport after Injury scale, and the Knee Self-Efficacy Scale were reported measures for assessing the influence of psychology on RTP.

Conclusion:

Psychological factors play an important role in RTP after ACLR. Among studies evaluating the impact of psychology on RTP, there was a delay in returning as well as lower RTP rates compared with the previously reported normative literature. Fear of reinjury was the most commonly reported impediment to RTP. The psychosocial measures identified in this review may have a role in RTP protocols for assessing mental resiliency; however, their roles need to be further investigated and validated in patients who have undergone ACLR.

Outcome of isolated posterior cruciate ligament reconstruction at mean 6.3-year follow up: a consecutive case series

OBJECTIVES

There is a paucity of reporting on surgical outcomes of isolated posterior cruciate ligament reconstruction (PCLR). We hypothesize that isolated PCL injuries failing nonoperative treatment achieve good outcomes and are able to return to sport following PCLR.

METHODS

A retrospective analysis was performed to identify patients with isolated PCL injuries that underwent reconstruction between 2001 and 2014. Patients with multi-ligamentous injury or another concomitant knee pathology were excluded. Medical records were reviewed for demographic, clinical and operative data. Patients were contacted for administration of a telephone-based questionnaire which included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form, Lysholm-Tegner scales, Marx activity scale (MAS), return to sport status, and patient satisfaction instruments.

RESULTS

A total of 15 isolated PCL reconstructions in 14 patients with a mean age of 27.5 years (range 17-43) met the study inclusion criteria; mean follow up was 6.3 years (range 1.4-15.2). Pre-operatively, the primary complaint was knee instability in all patients; on physical examination, lack of a firm end point during posterior drawer testing was found in 93% (14/15) of the knees. In total, 12 of 15 knees underwent transtibial, single-bundle PCLR and three of 15 underwent tibial inlay, double bundle PCLR. Graft types included: quadriceps autograft (7/15), Achilles allograft (6/15), and hamstring autograft (2/15). There were no graft failures in our patient cohort. At most recent follow up the mean scores respectively on the IKDC form, Lysholm-Tegner scales and MAS were (standard deviation): 77.3 (16.5), 83.1 (17.9), 6.13 (2.6), and 7.1 (6.0). All fourteen patients were athletes prior to their injury and 79% (11/14) returned to sport and overall patient satisfaction was 9.2/10.

CONCLUSIONS

Isolated PCLR provides good outcomes at mean medium-term follow up with restoration of function, high rate of return to sport and overall patient satisfaction.

Electrodiagnostic evidence of suprascapular nerve recovery after decompression

INTRODUCTION

The purpose of this study was to determine whether surgical arthroscopic decompression or ultrasound-guided aspiration of a paralabral cyst would result in suprascapular nerve recovery from axonal regeneration based on electrodiagnostic testing.

METHODS

Nine patients with preoperative electromyography (EMG) evidence of suprascapular neuropathy due to paralabral cysts at the suprascapular or spinoglenoid notch were prospectively studied. Eight patients underwent arthroscopic surgical decompression, and 1 patient underwent ultrasound-guided aspiration. Postoperative EMG was performed in all patients to evaluate nerve regeneration.

RESULTS

Three (33%) patients had cysts at the suprascapular notch, whereas 6 (67%) patients had cysts at the spinoglenoid notch. All patients showed complete electrophysiological recovery after decompression.

DISCUSSION

Decompression of paralabral cysts at the suprascapular or spinoglenoid notch resulted in postoperative EMG evidence of nerve recovery. Long-term studies with a greater number of patients are required to elucidate time to recovery. Muscle Nerve 59:247-249, 2019.

Contingent Valuation Studies in Orthopaedic Surgery: A Health Economic Review

BACKGROUND

A greater emphasis on providing high-value orthopaedic interventions has resulted in increased health economic reporting. The contingent-valuation method (CVM) is used to determine consumer valuation of the benefits provided by healthcare interventions. CVM is an important value-based health economic tool that is underutilized in orthopaedic surgery.

QUESTIONS/PURPOSES

The purpose of this study was to (1) identify previously published CVM studies in the orthopaedic literature, (2) assess the methodologies used for CVM research, and (3) understand how CVM has been used in the orthopaedic cost-benefit analysis framework.

METHODS

A systematic review of the literature using the MEDLINE database was performed to compile CVM studies. Search terms incorporated the phrase willingness to pay (WTP) or willingness to accept (WTA) in combination with orthopaedic clinical key terms. Study methodology was appraised using previously defined empirical and conceptual criteria for CVM studies.

RESULTS

Of the 160 studies retrieved, 22 (13.8%) met our inclusion criteria. The economics of joint arthroplasty (n = 6, 27.3%) and non-operative osteoarthritis care (n = 4, 18.2%) were the most common topics. Most studies used CVM for pricing and/or demand forecasting (n = 16, 72.7%); very few studies used CVM for program evaluation (n = 6). WTP was used in all included studies, and one study used both WTP and WTA. Otherwise, there was little consistency among included studies in terms of CVM methodology. Open-ended questioning was used by only ten studies (45.5%), a significant number of studies did not perform a sensitivity analysis (n = 9, 40.9%), and none of the studies accounted for the risk preference of subjects. Only two of the included studies applied CVM within a cost-benefit analysis framework.

CONCLUSION

CVM is not commonly reported in orthopaedic surgery and is seldom used in the context of cost-benefit analysis. There is wide variability in the methods used to perform CVM. We propose that CVM is an appropriate and underappreciated method for understanding the value of orthopaedic interventions. Increased attention should be paid to consumer valuations for orthopaedic interventions.

The Quality of Online Resources Available to Patients Interested in Knee Biologic Therapies Is Poor

BACKGROUND

As the use of biologic therapies for the management of knee pathology continues to expand, it is more likely that patients will turn to the Internet to gather information on this topic. Given the lack of scientific consensus on the use of biologics, care providers must understand what information is available online.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate the quality of websites that patients may use to educate themselves on knee biologics.

METHODS

Websites were identified using search terms relevant to multiple biologic therapies available for knee pathology. Websites were scored based on an author-derived grading rubric, with a total of 25 possible points relating to the role of knee biologics in the diagnosis, evaluation, and treatment of knee pathology. Websites were categorized based on the source (e.g., physician-operated website vs. industry-related website). Reading level was assessed with the Flesch-Kincaid readability test.

RESULTS

The initial search yielded 375 results, with 96 websites meeting final inclusion criteria. Mean website score was poor, at 6.01 of the 25 possible points (24.0%). Physician websites were the most common, with 60% of the articles identified. Industry-related websites scored the lowest (mean, 3.2 ± 0.97) while hospital-related websites scored the highest (mean, 8.3 ± 2.93). Overall, websites published from hospitals or orthopedic professional societies had significantly higher scores than other websites. The search term "knee PRP" yielded higher-quality results than "knee platelet rich plasma." Similarly, "knee BMAC" led to better results than "knee bone marrow aspirate concentrate." The average reading level was 11.4.

CONCLUSION

Many online resources are available for patients seeking information about knee biologic therapies, but the quality of websites identified was very poor. Patients should be counseled that the information available online for knee biologic therapy is unreliable. Surgeons should play an increased role in providing resources to patients and educating them on biologic options.

Race and Insurance Status Are Associated With Surgical Management of Isolated Meniscus Tears

PURPOSE

The purpose of this study was to perform a population-level analysis to evaluate the effect of socioeconomic markers on the use of meniscus surgery in patients with meniscus tears.

METHODS

We queried all hospital-based clinic visits from 2011 to 2014 in the Statewide Planning and Research Cooperative System database, which also contains all New York inpatient/outpatient visits. Patients with known prior knee surgery, meniscus tear before 2011, or other ligament injuries were excluded. The primary outcome was a meniscus procedure (meniscectomy or meniscus repair). Survival analysis was used to calculate the rate of meniscus surgery within 6 months. A multivariate model identified patient factors (age, sex, race, and payer) associated with surgical intervention.

RESULTS

There were 32,012 patients identified who met the inclusion criteria. The rate of meniscus procedure within 6 months of diagnosis was 49.6%. Meniscectomy was performed in 98.8% of cases compared with 1.2% for meniscus repair. Rates of meniscus procedures were higher in patients who were older, male, and white, as well as those first diagnosed by a surgeon. The highest rates of meniscus procedures were in those with private, worker's compensation, or other insurance types. Multivariable analysis showed that female sex, non-white race, and public or self-pay insurance were independently associated with lower rates of meniscus surgery.

CONCLUSIONS

These results suggest both insurance-based and race-based disparities regarding surgical treatment. Additionally, the strongest variable for surgical management was a meniscus tear being first diagnosed by a surgeon.

LEVEL OF EVIDENCE

Level of Evidence IV, retrospective case-control study.

Preoperative Short Form Health Survey Score Is Predictive of Return to Play and Minimal Clinically Important Difference at a Minimum 2-Year Follow-up After Anterior Cruciate Ligament Reconstruction

BACKGROUND

There is increased interest in understanding the preoperative determinants of postoperative outcomes. Return to play (RTP) and the patient-reported minimal clinically important difference (MCID) are useful measures of postoperative outcomes after anterior cruciate ligament reconstruction (ACLR).

PURPOSE

To define the MCID after ACLR and to investigate the role of preoperative outcome scores for predicting the MCID and RTP after ACLR.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

There were 294 active athletes enrolled as part of an institutional ACL registry with a minimum 2-year follow-up who were eligible for inclusion. A questionnaire was administered to elicit factors associated with RTP. Patient demographic and clinical data as well as patient-reported outcome measures were captured as part of the registry. Outcome measures included the International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm scale, and 12-Item Short Form Health Survey (SF-12) physical component summary (PCS) and mental component summary (MCS). Preoperative outcome score thresholds predictive of RTP were determined using a receiver operating characteristic (ROC) with area under the curve (AUC) analysis. The MCID was calculated using a distribution-based method. Multivariable logistic models were fitted to identify predictors for achieving the MCID and RTP.

RESULTS

At a mean (±SD) follow-up of 3.7 ± 0.7 years, 231 patients were included from a total 294 eligible patients. The mean age and body mass index were 26.7 ± 12.5 years and 23.7 ± 3.2 kg/m², respectively. Of the 231 patients, 201 (87.0%) returned to play at a mean time of 10.1 months. Two-year postoperative scores on all measures were significantly increased from preoperative scores (IKDC: 50.1 ± 15.6 to 87.4 ± 10.7; Lysholm: 61.2 ± 18.1 to 89.5 ± 10.4; SF-12 PCS: 41.5 ± 9.0 to 54.7 ± 4.6; SF-12 MCS: 53.6 ± 8.1 to 55.7 ± 5.7; P < .001 for all). The corresponding MCID values were 9.0 (IKDC), 10.0 (Lysholm), 5.1 (SF-12 PCS), and 4.3 (SF-12 MCS). Preoperative score thresholds predictive of RTP were the following: IKDC, 60.9; Lysholm, 57.0; SF-12 PCS, 42.3; and SF-12 MCS, 48.3. These thresholds were not independently predictive but achieved significance as part of the multivariable analysis. In the multivariable analysis for RTP, preoperative SF-12 PCS scores above 42.3 (odds ratio [OR], 2.73; 95% CI, 1.09-7.62) and SF-12 MCS scores above 48.3 (OR, 4.41; 95% CI, 1.80-10.98) were predictive for achieving RTP; an ACL allograft (OR, 0.26; 95% CI, 0.06-1.00) was negatively predictive of RTP. In the multivariable analysis for the MCID, patients with higher preoperative scores were less likely to achieve the MCID ( P < .0001); however, a higher preoperative SF-12 MCS score was predictive of achieving the MCID on the IKDC form (OR, 1.27; 95% CI, 1.11-1.52) and Lysholm scale (OR, 1.08; 95% CI, 1.00-1.16). Medial meniscal injuries, older age, and white race were also associated with a decreased likelihood for achieving the MCID.

CONCLUSION

Preoperative SF-12 MCS and PCS scores were predictive of RTP after ACLR; patients scoring above 42.3 on the SF-12 PCS and 48.3 on the SF-12 MCS were more likely to achieve RTP. Additionally, we defined the MCID after ACLR and found that higher SF-12 MCS scores were predictive of achieving the MCID on knee-specific questionnaires.

Return to play and performance after anterior cruciate ligament reconstruction in the National Basketball Association: surgeon case series and literature review

OBJECTIVES

To investigate return to play (RTP) and functional performance after anterior cruciate ligament reconstruction (ACLR) in National Basketball Association (NBA) players and to perform a systematic review of the literature to understand RTP after ACLR in professional basketball.

METHODS

NBA players undergoing ACLR between 2008 and 2014 by two surgeons were identified. RTP and performance were assessed based on a review of publically available statistics. A systematic review of the literature was performed using the MEDLINE database. Inclusion criteria were: English language, ACL surgery outcome, professional basketball and RTP outcome. We reviewed studies for RTP rates and RTP performance.

RESULTS

Our study included 12 professional basketball players with NBA level experience. Eleven of the 12 players returned to their prior level of play. Eight of the 9 (88.9%) players actively playing in the NBA returned to play in the NBA at a mean 9.8 months. Among players returning to NBA play, during RTP season 1, mean per game statistics decreased for the following: minutes, points, rebounds, assists, steals, blocks, turnovers and personal fouls - none of these changes reached statistical significance. Player efficiency ratings significantly declined from pre-injury (12.5) to the first RTP season (7.6) (p = 0.05). By RTP season 2, player performance metrics approximated pre-injury levels and were not significantly different. Six studies met inclusion criteria; reported RTP rates ranged from 78-86%. Identified studies similarly found a decline in functional performance after RTP.

CONCLUSION

There is a high rate (89%) of return to NBA play for NBA players undergoing ACLR. After RTP, however, there is a quantitative decline in initial season 1 RTP statistics with a significant decrease in player efficiency rating. By RTP season 2, performance metrics demonstrated an improvement compared to RTP season 1 but did not reach pre-injury functional performance, though performance metrics are not significantly different between pre-injury and RTP season 2.

Injury Profile of American Women's Rugby-7s

PURPOSE

The objective of this study is to determine incidence (injuries/1000 playing hours (ph)), severity (days of absence), and cause of match injuries in US women's Rugby-7s.

METHODS

We performed a prospective epidemiological study (2010-2013) of injury of 3876 under-19 to elite/national female Rugby-7s players (nonelite = 3324, elite = 552) on 323 teams (nonelite = 277, elite = 46), applying methodology and injury definitions compliant with the international consensus statement on rugby research. Injuries occurred in USA Rugby-sanctioned tournament series: USA Rugby Local Area (2010), Territorial Union (2011-2013), National and All-Star Sevens Series, and USA Sevens Invitational (2011-2012) and Collegiate Rugby Championships (2012).

RESULTS

One hundred and twenty time-loss injuries were encountered (elite, n = 15; 13%) with an injury rate of 46.3 injuries/1000 ph. Injury rates in nonelite were 49.3/1000 ph, and in national level (elite) candidates, 32.6/1000 ph (RR = 1.5, P = 0.130). Mean days missed found elite level players at 74.9 d per injury, whereas nonelite at 41.8 d (P = 0.090). Acute injuries were significant (95%, RR = 1.9, P < 0.001), resulting in immediate removal from the pitch (56%, P < 0.001). The main mechanism of injury occurred when tackling players (73%, P < 0.001). The most common type of injury seen were ligament sprains (37%, 13.9/1000 ph), involving the lower extremity (45%, 20.5/1000 ph). The most common body parts injured were the knee and head/face (16%, 7.3/1000 ph).

CONCLUSIONS

Time-loss injuries occurred with frequency in the US women's Rugby-7s tournaments. Overall injury rates in US women are lower than those in international elite men and women's Rugby-7s. The head and neck area in our female players was injured at greater rates (16%) than in international male Rugby-7s (5%). Injury prevention in US women's Rugby-7s must focus on injuries of the knee, head, and neck. Understanding risk factors will allow safe return-to-play decisions and formulate injury prevention protocols.

Return to Play and Patient Satisfaction After ACL Reconstruction: Study with Minimum 2-Year Follow-up

BACKGROUND

Return to play and patient satisfaction after anterior cruciate ligament reconstruction (ACLR) have been inconsistently studied. The purposes of this study were to (1) investigate rates and predictors of return to play after ACLR, (2) evaluate patient satisfaction after ACLR, and (3) analyze the relationship between return to play and satisfaction with the result of ACLR.

METHODS

Eligible patients were active athletes included in an institutional ACL registry who had undergone ACLR and had been followed for a minimum of 2 years. A questionnaire was administered to elicit information regarding factors associated with return to play, sports performance, reinjury, and overall patient satisfaction. The Wilcoxon-Mann-Whitney U test was used to compare return to play with patient satisfaction. Multivariable logistic regression was used to identify demographic, sports, and clinical factors associated with return to play.

RESULTS

Two hundred and thirty-two patients with a mean age of 26.7 years (standard deviation [SD] = 12.5 years) who had been followed for a mean of 3.7 years were enrolled. Of 231 patients who responded to the return-to-play question, 201 (87.0%) had returned to play, at a mean of 10.1 months; of 175 athletes eligible to return to their prior level of competition, 89.1% had done so. Overall satisfaction was high: 85.4% were very satisfied with the outcome and 98.1% stated that they would have surgery again. Patients were more likely to respond "very satisfied" if they had returned to play (p < 0.001). Use of a patellar tendon autograft (odds ratio [OR] = 5.63, 95% confidence interval [CI] = 1.32 to 25.76) increased the chance of returning to play whereas playing soccer (OR = 0.23, 95% CI = 0.08 to 0.66) or lacrosse (OR = 0.24, 95% CI = 0.06 to 0.99) preoperatively decreased the likelihood of returning to play.

CONCLUSIONS

The rates of return to play and patient satisfaction are high after ACLR in active athletes. The use of patellar tendon autograft increased the likelihood of returning to play whereas preinjury participation in soccer and lacrosse decreased these odds. Additionally, patients who returned to play were more likely to be very satisfied with the result of the ACLR.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

How are we measuring clinically important outcome for operative treatments in sports medicine?

OBJECTIVES

Minimal clinically important difference (MCID) and other measures of minimum clinical importance are increasingly recognized as important clinical considerations for evaluating the efficacy of an intervention. As our interpretation of clinical outcome evolves beyond statistical significance, psychometric properties such as MCID will be increasingly important to various stakeholders in the orthopaedic community. The purpose of this study was to: 1) describe the state of clinically important outcome reporting and 2) describe the methods used to derive these psychometric values for sports medicine patients undergoing operative treatments.

METHODS

A review of the MEDLINE database was performed. Studies primarily deriving and reporting clinically important outcome measures for operative interventions in sports medicine were included. Demographic, methodological and psychometric properties of included studies were extracted. Level of Evidence and the Newcastle Ottawa Scale (NOS) were used to assess study quality. Statistical analysis was primarily descriptive.

RESULTS

Fifteen studies met inclusion criteria; 10 of the 15 studies were Level II evidence and mean NOS score was 5.3/9. Minimal detectable change (MDC) was the most commonly derived measure of clinical importance, calculated in 53.3% of studies, followed by MCID, calculated in 40.0% of studies. A combination of distribution and anchor-based methods was the most commonly used method to determine clinical importance (N = 7, 46.7%) followed by distribution only (N = 5, 33.3%). Predictors of clinically important change were reported in four studies and were most commonly related to pre-operative functional score.

CONCLUSIONS

MDC and the MCID are the most commonly reported measures of clinically important outcome after operative treatment in sports medicine. A combination of both distribution and anchor-based methods is commonly used to derive these values. More attention should be paid to reporting outcomes that are clinically important and developing guidelines for reporting clinical meaningful outcome.

Unused Opioid Pills After Outpatient Shoulder Surgeries Given Current Perioperative Prescribing Habits

BACKGROUND

In the past 16 years, the number of prescription opioids sold in the United States, as well as deaths from prescription opioids, has nearly quadrupled. However, the overall amount of pain reported by patients has not changed significantly. Specific information about opioid prescriptions in the perioperative period is lacking. Of the studies that have been published, investigators have shown that the majority of patients have unused postoperative opioid pills. Moreover, patients appear to lack information about disposal of unused opioid pills.

PURPOSE

To compare the number of pills prescribed versus the numbers left unused after outpatient shoulder surgeries at an orthopaedic surgery institution.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

In this prospective, observational study, 100 patients (age >18 years) undergoing outpatient shoulder surgery (rotator cuff repair, labral repair, stabilization/Bankart repair, debridement) were enrolled. Follow-ups were conducted via surveys on postoperative days (PODs) 7, 14, 28, and 90. The primary outcome was the number of unused pills from the originally prescribed medication.

RESULTS

For all procedure types, the median (Q1, Q3) number of prescribed pills was 60 (40, 80). On POD 90, patients reported a median (Q1, Q3) of 13 (0, 32) unused pills; patients who underwent rotator cuff repairs had the lowest number of pills remaining (median [Q1, Q3], 0 [0, 16]), whereas patients who had stabilization/Bankart repairs had the highest number of unused pills (median [Q1, Q3], 37 [29, 50]). Patient satisfaction with pain management ranged from an average of 70% to 90%. Only 25 patients received instructions or education about opioid disposal.

CONCLUSION

Most outpatient shoulder surgery patients who underwent certain operations were prescribed more opioid analgesics than they consumed. Patient education regarding the disposal of opioids was lacking.

Comparative Influence of Sport Type on Outcome After Anterior Cruciate Ligament Reconstruction at Minimum 2-Year Follow-up

PURPOSE

To investigate differences between sport types for patient-reported outcome after anterior cruciate ligament reconstruction (ACLR).

METHODS

Included patients were enrolled as part of a prospective institutional ACL registry. Inclusion criteria were preoperative self-identification as a competitive athlete, maximum score on the preoperative Marx Activity Scale, and minimum 2-year follow-up. Demographic, intraoperative, and outcome data were extracted from the registry. Outcome tools administered as part of the registry included International Knee Documentation Committee (IKDC), Lysholm-Tegner Scales, Marx Activity Scale (MAS), and 12-Item Short Form Health Survey (SF-12).

RESULTS

A total of 294 patients with a mean age of 25.5 years (standard deviation 12.1) met the study inclusion criteria; mean follow-up was 3.7 years. Included sports categories were soccer (n = 92; 31.3%), skiing (n = 67; 22.8%), basketball (n = 56; 19.1%), lacrosse (n = 38; 12.9%), football (n = 29; 9.9%), and Tennis (n = 12; 4.1%). At baseline, compared with other sports, lacrosse players have higher outcome scores while skiers had lower scores. At 2-year follow-up, however, across all outcome tools, football players demonstrated significantly higher outcome scores than all other athletes (IKDC, 93.2, P = .001; Lysholm, 93.2, P = .03; MAS, 13.1, P = .03; SF-12 Mental Component Summary, 57.9, P = .0002). Conversely, at 2-year follow-up, soccer players demonstrated a significantly lower Lysholm (86.7, P = .02) and a trend toward lower IKDC (85.6, P = .09) scores.

CONCLUSIONS

Patient-reported outcomes after ACLR among active athletes are comparable. Football players demonstrate quantitatively higher outcome scores whereas soccer players have lower scores. However, these outcome score differences may not be clinically significant and may be subject to confounding variables. Continued attention should be paid to understanding sport-specific outcome after ACLR.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

How Are We Measuring Patient Satisfaction After Anterior Cruciate Ligament Reconstruction?

BACKGROUND

Reconstruction of the anterior cruciate ligament (ACL) is one of the most common orthopaedic operations in the United States. The long-term impact of ACL reconstruction is controversial, however, as longer term data have failed to demonstrate that ACL reconstruction helps alter the natural history of early onset osteoarthritis that occurs after ACL injury. There is significant interest in evaluating the value of ACL reconstruction surgeries.

PURPOSE

To examine the quality of patient satisfaction reporting after ACL reconstruction surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the MEDLINE database was performed using the PubMed interface. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as well as the PRISMA checklist were employed. The initial search yielded 267 studies. The inclusion criteria were: English language, US patient population, clinical outcome study of ACL reconstruction surgery, and reporting of patient satisfaction included in the study. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

A total of 22 studies met the inclusion criteria. These studies comprised a total of 1984 patients with a mean age of 31.9 years at the time of surgery and a mean follow-up period of 59.3 months. The majority of studies were evidence level 4 (n = 18; 81.8%), had a mean Newcastle-Ottawa scale score of 5.5, and were published before 2006 (n = 17; 77.3%); 5 studies (22.7%) failed to clearly describe their method for determining patient satisfaction. The most commonly used method for assessing satisfaction was a 0 to 10 satisfaction scale (n = 11; 50.0%). Among studies using a 0 to 10 scale, mean satisfaction ranged from 7.4 to 10.0. Patient-reported outcome and objective functional measures for ACL stability and knee function were positively correlated with patient satisfaction. Degenerative knee change was negatively correlated with satisfaction.

CONCLUSION

The level of evidence for studies reporting patient satisfaction is low, and the methodologies for reporting patient satisfaction are variable. Additionally, within the past decade there has been a significant decline in the inclusion of this outcome measure within published ACL studies. As sports surgeons are increasingly called on to demonstrate the value of operative procedures, attention should be paid to understanding and reporting patient satisfaction.

Clinical Outcomes After Suture Anchor Repair of Recalcitrant Medial Epicondylitis

This study evaluated clinical and patient-reported outcomes and return to sport after surgical treatment of medial epicondylitis with suture anchor fixation. Consecutive patients were evaluated after undergoing debridement and suture anchor repair of the flexor-pronator mass for the treatment of medial epicondylitis. Demographic variables, a short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Oxford Elbow Score (OES), and 10-point pain and satisfaction scales were collected. Ability and time to return to sport after surgery were evaluated, and the relationship between predictor variables and both elbow function and return to sport was investigated. Median age at the time of surgery was 55 years (range, 29-65 years), with median follow-up of 40 months (range, 12-67 months). Median QuickDASH score and OES at final follow-up were 2.3 (range, 0-38.6) and 45 (range, 22-48), respectively. Most patients returned to premorbid sporting activities at a median of 4.5 months (range, 2.5-12 months), whereas 4 patients (14%) reported significant limitations at final follow-up. Older age at the time of surgery was predictive of better QuickDASH score and OES (P=.05 and P=.02, respectively). Patients who underwent surgery after a shorter duration of symptoms had better outcomes, but the difference did not reach statistical significance (QuickDASH, P=.09; OES, P=.10). Surgical treatment of recalcitrant medial epicondylitis with suture anchor fixation offers good pain relief and patient satisfaction, with little residual disability. Older age at the time of surgery predicts a better outcome.

Anterior Cruciate Ligament Reconstruction With Autologous Hamstring: Can Preoperative Magnetic Resonance Imaging Accurately Predict Graft Diameter?

Background:

Recent clinical investigations have identified inadequate autograft hamstring graft diameter (<8 mm) to be predictive of failure after reconstruction of the anterior cruciate ligament (ACL).

Purpose/Hypothesis:

The objective of this study was to determine the utility of preoperative magnetic resonance imaging (MRI) variables of the hamstring tendons for the prediction of graft diameter at the time of surgery. The hypothesis was that cross-sectional area (CSA) of the hamstring tendon measured on MRI could accurately predict graft diameter, and threshold measurements could be established to predict graft diameter at the time of surgery.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

A total of 84 consecutive skeletally mature patients prospectively enrolled in our ACL reconstruction patient registry were identified for study purposes. Patients were included if they underwent an MRI of the affected knee at our institution prior to ACL reconstruction with hamstring (HT) autograft. Graft preparation was performed via a standard quadrupled hamstring technique after harvesting both the gracilis and semitendinosus (4-GST). The smallest diameter end of the HT autograft was then utilized for measurement analysis. Total CSA was calculated for both hamstring tendons using the “region of interest tool” on the corresponding proton density–weighted axial image of the knee at the widest condylar dimension. Three independent reviewers measured the MRI scans so that intra- and interrater reliability of the measurements could be determined. A trend analysis was then undertaken to establish correlations between the MRI CSA and graft diameter. Predictive analysis was then performed to establish threshold MRI measurement values for specific graft diameters and determine whether any patient-specific factors would affect graft diameter (age, sex, and body mass index).

Results:

Mean patient age at the time of surgery was 36 years (range, 11-57 years). Intra- and interrater reliability measurements achieved near-perfect agreement for CSA measurements, with intraclass correlation coefficients (ICCs) of 0.994 and 0.932, respectively. Trend analysis demonstrated that increasing CSA correlated well with increasing overall diameter of the graft (P < .001). Receiver operating characteristic (ROC) curves were generated to evaluate threshold CSA measurements for various graft diameters. Maximum sensitivity values of 21.64, 25.25, and 28.256 mm² were established for the respective graft diameters of 8, 9, and 10 mm in the 4-GST group. Independent patient factors of younger age, shorter stature, and female sex were significantly associated with graft diameter (P = .019, .034, and .028, respectively).

Conclusion:

Preoperative MRI can be used to accurately predict quadrupled hamstring autograft diameter at the time of surgery. A total cross-sectional area of >22 mm² can reliably provide a graft diameter of >8 mm at the time of surgery.

An Algorithmic Approach to the Management of Recurrent Lateral Patellar Dislocation

High-level evidence supports nonoperative treatment for first-time lateral acute patellar dislocations. Surgical intervention is often indicated for recurrent dislocations. Recurrent instability is often multifactorial and can be the result of a combination of coronal limb malalignment, patella alta, malrotation secondary to internal femoral or external tibial torsion, a dysplastic trochlea, or disrupted and weakened medial soft tissue, including the medial patellofemoral ligament (MPFL) and the vastus medialis obliquus. MPFL reconstruction requires precise graft placement for restoration of anatomy and minimal graft tension. MPFL reconstruction is safe to perform in skeletally immature patients and in revision surgical settings. Distal realignment procedures should be implemented in recurrent instability associated with patella alta, increased tibial tubercle-trochlear groove distances, and lateral and distal patellar chondrosis. Groove-deepening trochleoplasty for Dejour type-B and type-D dysplasia or a lateral elevation or proximal recession trochleoplasty for Dejour type-C dysplasia may be a component of the treatment algorithm; however, clinical outcome data are lacking. In addition, trochleoplasty is technically challenging and has a risk of substantial complications.

Patterns of strain and the determination of the safe arc of motion after subscapularis repair--A biomechanical study

This study characterizes the strain patterns and safe arcs for passive range of motion (ROM) in the superior and inferior subscapularis tendon in seven cadaveric shoulders, mounted for controlled ROM, after deltopectoral approach to the glenohumeral joint, including tenotomy of the subscapularis tendon 1 cm medial to its insertion on the lesser tuberosity. The tenotomy was repaired with end-to-end suture in neutral rotation. Strain patterns were measured during passive ROM in external rotation (ER), ER with 30° abduction (ER+30), abduction, and forward flexion in the scapular plane (SP) before and after surgery. Percentages were calculated from 35 trials corresponding to five trials of each motion across seven specimens. With ER of 0-30°, 89% of trials of superior subscapularis tendon and 100% of trials of inferior subscapularis tendon achieved strains >3%, with very similar patterns noted in ER+30. In abduction of 0-90°, 5.8% of trials of superior and 85.3% of trials of inferior tendon achieved >3% strain. With passive ROM in SP, 26.5% of trials reached 3% strain in superior tendon compared to 100% in inferior tendon. Strain patterns in abduction and SP differed significantly (p < 0.001). Selective tenotomy and repair of the superior subscapularis tendon with open reparative or reconstructive shoulder procedures, when feasible, may be favorable for protected early passive ROM and rehabilitation postoperatively.

Concussive Injuries in Rugby 7s: An American Experience and Current Review

PURPOSE

There is a comparative lack of concussion incidence data on the new Olympic sport Rugby 7s. This study aimed to determine the incidence (number of concussions per 1000 playing hours [ph]), mean and median severity (days absence), and cause of concussive injuries.

METHODS

This is a prospective epidemiology study, amateur to elite/national candidate, male (9768) and female (3876) players in USA Rugby sanctioned tournaments, compliant with the international consensus statement for studies in rugby union.

RESULTS

Concussions in US Rugby 7s were 7.7/1000 ph (n = 67). Women encountered concussions at 8.1/1000 ph, and men at 7.6/1000 ph (risk ratio [RR] = 1.10, P = 0.593). Elite/national-level players encountered concussions at higher rates (18.3/1000 ph) than lower levels (6.4/1000 ph; RR = 5.48, P < 0.001). Nonelite backs had higher concussive injury rates compared with forwards (7.7/1000 ph; 3.6/1000 ph; RR = 1.28, P = 0.024). Women missed 36.7 d absence from play, meanwhile men missed 27.9 d (P = 0.245). Retrospective history recall reflected previous concussive injuries occurred in 43% of the current study's cohort; of these, 57% encountered multiple concussions within 1 yr. The incidence of repetitive concussions was not statistically different between genders (RR = 1.09, P = 0.754). Most concussions occurred from tackles (63%) and collisions (24%) (P = 0.056).

CONCLUSIONS

Sports-related concussions occurred with frequency among US amateur Rugby 7s players. US Elite tournament players sustained concussions at much higher rates than international male Rugby 7s counterparts. A substantial portion of US players who sustained a concussion had previous concussion injuries. Given the high rate of concussion, including repetitive concussive injuries, US Rugby 7s may benefit from concussion prevention measures similar to other contact sports such as instruction on proper tackling techniques, in-game and postgame medical assessment, and a standardized return-to-play protocol.