Inter-rater Reliability of the Classification of the J-Sign Is Inadequate Among Experts.

OBJECTIVE: The purpose of this study was to determine the inter-rater and intra-rater reliability of the symmetry, classification, and underlying pathoanatomy associated with the J-sign in patients with recurrent lateral patellofemoral instability. STUDY DESIGN: Blinded, inter-rater reliability study. SETTING: N/A. PARTICIPANTS: Thirty patellofemoral joint experts. INTERVENTIONS: Thirty clinicians independently assessed 30 video recordings of patients with recurrent lateral patellofemoral instability performing the J-sign test. MAIN OUTCOME MEASURES: Raters documented J-sign symmetry and graded it according to the quadrant and Donell classifications. Raters indicated the most significant underlying pathoanatomy and presence of sagittal plane maltracking. Intra-rater reliability was assessed by 4 raters repeating the assessments. Mean pairwise simple and/or weighted Cohen's kappa were performed to measure inter-rater and intra-rater reliability, as well as calculation of percent agreement. RESULTS: J-sign symmetry demonstrated fair inter-rater reliability (k = 0.26), whereas intra-rater reliability was moderate (k = 0.48). Inter-rater reliability for the quadrant and Donell classifications indicated moderate agreement, k = 0.51 and k = 0.49, respectively, whereas intra-rater reliability was k = 0.79 and k = 0.72, indicating substantial agreement. Inter-rater reliability of the foremost underlying pathoanatomy produced only slight agreement (k = 0.20); however, intra-rater reliability was substantial (k = 0.68). Sagittal plane maltracking demonstrated slight inter-rater agreement (k = 0.23) but substantial intra-rater agreement (k = 0.64). CONCLUSIONS: The symmetry, classification, and underlying pathoanatomy of the J-sign demonstrated fair to moderate inter-rater reliability and moderate to substantial intra-rater reliability among expert reviewers using video recordings of patients with recurrent lateral patellofemoral instability. These findings suggest individual raters have a consistent standard for assessing the J-sign, but that these standards are not reliable between assessors. LEVEL OF EVIDENCE: III.

Patella alta is reduced following MPFL reconstruction but has no effect on quality-of-life outcomes in patients with patellofemoral instability.

PURPOSE: The primary purpose of this study was to determine if isolated medial patellofemoral ligament (MPFL) reconstruction for lateral patellofemoral instability altered the patellar height ratio. Secondary purposes were to use disease-specific quality-of-life scores to determine if MPFL reconstruction is as successful in patients with patella alta, compared to those without; and whether the change in the patellar height ratio after MPFL reconstruction is influenced by demographic and clinical factors. METHODS: Demographic and clinical data were collected pre-operatively on 283 patients with recurrent patellofemoral instability. Pre-operative and 6-month post-operative true-lateral radiographs were assessed to determine the patellar height ratio using the Caton-Deschamps index. A Caton-Deschamps index ≥ 1.2 was defined as patella alta. Paired t tests evaluated the effect of MPFL reconstruction on the Caton-Deschamps index. Using a two-sample t test, pre- and 24-month post-operative Banff Patellofemoral Instability Instrument (BPII) scores were assessed for differences in clinical outcomes between patients with and without patella alta. Pearson (for continuous variables) and Spearman rank correlations (for binary/ordinal variables) were calculated to determine the relationship between the patellar height ratio, demographic and pathoanatomic risk factors, and pre- and post-operative BPII scores. RESULTS: Pre- and post-operative true-lateral radiographs were admissible for 229/283 patients (81%) following isolated MPFL reconstruction. A statistically significant difference in the Caton-Deschamps index was evident from pre- to post-operative for the entire cohort (p < 0.001). The mean decrease in ratio was 0.03, and the effect size was 0.27, classified as small. Pre-operatively 52/229 patients (22.7%) demonstrated a Caton-Deschamps index ≥ 1.2, mean = 1.27 (SD = 0.08); post-operatively 21/229 patients (9.2%) demonstrated patella alta, mean = 1.18, (SD = 0.10), p < 0.001 (two-tailed). The mean decrease in the Caton-Deschamps index for patients with pre-operative patella alta was 0.10; the effect size was 0.82, classified as large. Pearson r correlation of patella alta to the pre- and post-operative BPII scores demonstrated no statistically significant relationship. CONCLUSION: This study has demonstrated that treatment of lateral patellofemoral instability with an isolated MPFL reconstruction results in a statistically significant decrease in patellar height ratio, with the effect size being greatest in patients with higher pre-operative Caton-Deschamps indices. In patients that presented with patella alta, normalization of the patellar height ratio occurred in 31/52 (59.6%) of the cases. Pre-operative patella alta was not associated with a statistically significant difference in disease-specific BPII outcome scores at any time point. Given these findings, the utility and results of tibial tubercle distalization in patients with patella alta should be a focus of further research. Level of evidence IV.

Validity, Responsiveness, and Reliability of the ACL-QOL in an Adolescent Population.

BACKGROUND: The anterior cruciate ligament quality of life (ACL-QOL) score is a disease-specific patient-reported outcome measure that assesses patients with ACL deficient and reconstructed knees. The ACL-QOL has demonstrated validity, responsiveness, and reliability in adult populations but has yet to be specifically evaluated in adolescent patients. The purpose of this study was to assess the validity, responsiveness, and reliability of the ACL-QOL in an adolescent population. METHODS: Between 2010 and 2015, questionnaires from 294 consecutive adolescent patients consented for an ACL reconstruction were collected from an orthopaedic sport medicine clinic. The ACL-QOL was administered preoperatively, and at 6, 12, and 24 months following primary ACL reconstruction. To assess content validity, the Cronbach α and floor and ceiling effects were measured. Question reading level was measured with an online tool (https://readable.com/). Responsiveness was assessed with a 1-way analysis of variance to compare the preoperative and postoperative time periods. A test-retest strategy with completion of the ACL-QOL twice within 3 weeks was used to assess reliability using an intraclass correlation coefficient (ICC 2,k) and the SEM. RESULTS: The ACL-QOL demonstrated high content validity with a Cronbach αbetween 0.93 and 0.97, with no evidence of floor or ceiling effects at any study time point. The mean readability grade level was calculated to be 6.9, along with a readability score of 68. The ACL-QOL scores revealed a statistically significant improvement over time (P<0.001) with a Cohen d of 0.56, indicating a large effect size. Test-retest reliability revealed an ICC (2,k) of 0.997 (95% confidence interval=0.992-0.999). CONCLUSIONS: The ACL-QOL demonstrated content validity, responsiveness to change, and reliability in an adolescent ACL reconstruction population. The readability of the ACL-QOL is acceptable for adolescents with an ACL injury. The ACL-QOL is a valid, responsive, and reliable patient-reported outcome measure that can be used in an adolescent population with ACL deficiency or following ACL reconstruction. LEVEL OF EVIDENCE: Level III.

Validity and Reliability of the Banff Patellofemoral Instability Instrument 2.0 in an Adolescent Population.

BACKGROUND: Lateral patellofemoral instability is a relatively common problem in the adolescent population. Subjective and objective patient outcomes are commonly used to evaluate treatment success or failure. The Banff Patellofemoral Instability Instrument (BPII) and Paediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Form are patient-reported outcome measures that have been used with an adolescent population previously. The BPII 2.0 is a shortened version of the BPII and has not been validated in an adolescent population. The purpose of the current study was to validate the BPII 2.0 with an adolescent population. METHODS: This was a multicenter study where patients were recruited from 3 tertiary orthopaedic surgery clinics. A convenience sample (n=140 adolescent patients) with a confirmed diagnosis of lateral patellofemoral instability and who had failed conservative treatment was referred to one of the 3 orthopaedic surgeons. All patients completed the BPII 2.0 and Pedi-IKDC before their clinic appointment. Cronbach's alpha and floor/ceiling effects were used to determine the content validity of both instruments. Patients were also interviewed to ask questions about the BPII 2.0 comprehension and importance of items. One clinic site sent out the BPII 2.0 to 30 additional patients twice in 2 weeks to measure the test-retest reliability (intraclass correlation coefficient 2,k). A Pearson r correlation coefficient was used to determine the relationship between the BPII 2.0 and the Pedi-IKDC and criterion validity. RESULTS: Cronbach's alpha values were 0.95 and 0.76 for the BPII 2.0 and Pedi-IKDC, respectively. There was no evidence of floor or ceiling effects for either the BPII 2.0 or the Pedi-IKDC. The Pearson r correlation coefficient between the BPII 2.0 and IKDC baseline scores taken at the initial consultation was 0.65 (P<0.001; 95% confidence interval, 0.94-0.97). The intraclass correlation coefficient (2,k) for the test-retest subsample (n=30) was 0.94. Patient interviews revealed that they thought the BPII 2.0 questions were both important and comprehensible. CONCLUSIONS: The BPII 2.0 is a valid, reliable, and disease-specific patient-reported outcome measure that can be used with an adolescent population with lateral patellofemoral instability. The BPII 2.0 has demonstrated criterion validity through its moderately strong correlation to the Pedi-IKDC for adolescents.

Generalized joint hypermobility does not influence clinical outcomes following isolated MPFL reconstruction for patellofemoral instability.

PURPOSE: Generalized joint hypermobility (GJH) has frequently been described as a risk factor for patellofemoral instability; however, only a few primary research studies have demonstrated any evidence of a relationship. The primary purpose of this study was to determine if isolated proximal soft tissue stabilization for patellofemoral instability is as successful in patients with GJH compared those without, as measured by disease-specific quality-of-life (QOL), symptom scores and functional outcomes. The secondary purpose was to determine if clinical and patient-reported outcomes were influenced by patient demographic factors in the presence of joint hypermobility. METHODS: Between 2009 and 2014, data were collected on 174/193 knees (92% follow-up) following an isolated medial patellofemoral ligament reconstruction (MPFL-R). Patients with a Beighton score of 4 or greater were classified as positive for GJH, and any score of 3 or less was classified as negative. Pre- and post-operative Banff Patella Instability Instrument (BPII) scores were compared using a two-sample t test to determine the influence of GJH on QOL. The relationship between the Beighton score, and demographic and clinical factors was explored using correlational analysis. Functional testing including balance and single-leg hop testing was conducted 1 and 2 years post-operatively. Limb symmetry and mean limb-to-limb performance differences were calculated. RESULTS: In this cohort of isolated MPFL reconstructions, 55.1% had a positive Beighton score. There were seven surgical failures (3.6%). There was no evidence of a relationship between a positive Beighton score and pre-operative BPII scores, post-operative BPII scores or post-operative symptom scores. GJH did not correlate significantly with any post-operative functional testing measures. A positive Beighton score was inversely related to patient age and more prevalent in females. CONCLUSIONS: This study determined that the presence of GJH did not influence disease-specific quality of life, physical symptom score or functional outcomes following MPFL reconstruction. LEVEL OF EVIDENCE: III.

Validity, Reliability, and Responsiveness of the Banff Patellar Instability Instrument (BPII) in a Adolescent Population.

BACKGROUND: Health-related quality of life measures for the adolescent patellar instability population are limited. The Banff Patella Instability Instrument (BPII) is a disease-specific health-related quality of life that has been tested on a mixed adult and adolescent population but has not been exclusively tested with an adolescent population. The purpose of this study was to determine the validity, reliability, and responsiveness of the BPII within an adolescent population. METHODS: Content validation was tested with 3 measures: floor and ceiling effects; the Cronbach alpha; readability grade level. Reliability was measured with an intraclass correlation coefficient (2, k) and the SEM. Responsiveness was measured using a 1-way analysis of variance comparing preoperative BPII scores to postoperative BPII scores at 6, 12, and 24 months. Eta squared was calculated to measure effect size. RESULTS: The BPII demonstrated no floor or ceiling effects. The Cronbach alpha for the BPII ranged from 0.97 to 0.98 for the preoperative and postoperative time periods. The readability index was a mean grade level of 8.9. Test-retest reliability assessment demonstrated an intraclass correlation coefficient (2, k) of 0.99 indicating strong reliability. The SEM was 1.3. There was a statistically significant difference in BPII scores for the 4 different time interval measures (F3, 176=50.04; P<0.001). Eta squared was 0.46 demonstrating a moderate to large effect. CONCLUSIONS: The BPII demonstrated validity, reliability, and responsiveness in an adolescent population. Furthermore, it has demonstrated an appropriate cognitive reading grade level of 8.9, commensurate with the mean age (16.08 y) of the population tested. LEVEL OF EVIDENCE: Level III.

Validity, Reliability, and Responsiveness of the Anterior Cruciate Ligament Quality of Life Measure: A Continuation of Its Overall Validation.

OBJECTIVE: The purpose is to provide more validity, reliability, and responsiveness testing of the anterior cruciate ligament-quality of life instrument (ACL-QOL), particularly in light of consensus-based standards for the selection of health status measurement instruments (COSMIN) guidelines. DESIGN: Prospective case series. SETTING: An orthopedic surgical practice for consultation. PATIENTS: A convenience sample of 579 ACL-deficient patients. INTERVENTION: Anterior cruciate ligament reconstructive surgery. MAIN OUTCOME MEASURES: Patients completed the ACL-QOL at initial visit and underwent reconstructive surgery. Patients were followed at 6, 12, and 24 months using the ACL-QOL to determine its validity and responsiveness. Cronbach's alpha was used to determine the unidimensionality of the ACL-QOL. A subset of patients took the ACL-QOL twice in a test-retest reliability analysis (intraclass correlation coefficient or ICC 2,k). Another subset of 24-month postsurgical patients measured the success of their surgery using a 7-point global rating scale of improvement as an anchor-based method of responsiveness. RESULTS: Cronbach's alpha coefficients = 0.93, 0.95, 0.96, and 0.98 at 6, 12, and 24 months, respectively. Intraclass correlation coefficient = 0.60, SEM = 6.16, and confidence interval of 12.1 (CI 95%). Responsiveness was measured by comparing the 4 serial time periods. Patients improved significantly at each time period (P < 0.05, ETA squared 0.61). A 24-month ACL-QOL was significantly correlated (P > 0.05) to being "significantly better" or "somewhat better." CONCLUSIONS: The results of this study added more validity, reliability, and responsiveness for the ACL-QOL. The ACL-QOL has completed 8 of 9 COSMIN criteria.

Assessment of demographic and pathoanatomic risk factors in recurrent patellofemoral instability.

PURPOSE: The WARPS/STAID classification employs clinical assessment of presenting features and anatomic characteristics to identify two distinct subsets of patients within the patellofemoral instability population. The purpose of this study was to further define the specific demographics and the prevalence of risky pathoanatomies in patients classified as either WARPS or STAID presenting with recurrent patellofemoral instability. A secondary purpose was to further validate the WARPS/STAID classification with the Banff Patella Instability Instrument (BPII), the Marx activity scale and the Patellar Instability Severity Score (ISS). METHODS: A convenience sample of 50 patients with recurrent patellofemoral instability, including 25 WARPS and 25 STAID subtype patients, were assessed. Clinical data were collected including assessment of demographic risk factors (sex, BMI, bilaterality of symptoms, affected limb side and age at first dislocation) and pathoanatomic risk factors (TT-TG distance, patella height, patellar tilt, grade of trochlear dysplasia, Beighton score and rotational abnormalities of the tibia or femur). Patients completed the BPII and the Marx activity scale. The ISS was calculated from the clinical assessment data. Patients were stratified into the WARPS or STAID subtypes for comparative analysis. An independent t test was used to compare demographics, the pathoanatomic risk factors and subjective measures between the groups. Convergent validity was tested with a Pearson r correlation coefficient between the WARPS/STAID and ISS scores. RESULTS: Demographic risk factors statistically associated with a WARPS subtype included female sex, age at first dislocation and bilaterality. Pathoanatomic risk factors statistically associated with a WARPS subtype included trochlear dysplasia, TT-TG distance, generalized ligamentous laxity, patellar tilt and rotational abnormalities. The independent t test revealed a significant difference between the ISS scores: WARPS subtype (M = 4.4, SD = 1.1) and STAID subtype (M = 2.5, SD = 1.5); t(48) = 5.2, p < 0.001. The relationship between the WARPS/STAID and the ISS scores, measured using a Pearson r correlation coefficient, demonstrated a strong relationship: r = -0.61, n = 50, p < 0.001. CONCLUSIONS: This study has demonstrated statistically significant evidence that certain demographics and pathoanatomies are more prevalent in each of the WARPS and STAID patellofemoral instability subtypes. There was no difference in quality-of-life or activity level between the subtypes. The WARPS/STAID score demonstrated convergent validity to the ISS and divergent validity to the BPII score and the Marx activity scale. This study has further validated both the WARPS/STAID classification and the ISS of patients that present with recurrent patellofemoral instability. LEVEL OF EVIDENCE: III.

Introduction of a classification system for patients with patellofemoral instability (WARPS and STAID).

PURPOSE: The primary purpose of this paper is to introduce the WARPS/STAID classification system for patellofemoral instability. The secondary purpose is to establish the validity and reliability of the WARPS/STAID classification system. METHODS: Patients (n = 31) with a confirmed diagnosis of patellofemoral instability underwent a thorough knee history and physical examination with 3 raters. The raters graded each component of the WARPS/STAID classification system on a visual analogue scale (VAS). A single Global VAS WARPS/STAID score was graded after all other components of the classification system were completed. Intraclass correlation coefficient (ICC 2, 3) was calculated for each metric of the classification scale and for the Global score. Concurrent validity was assessed by correlating the WARPS/STAID score with the Kujala score. Subjects were assigned to one of three categories (WARPS, STAID, or mixed characteristics) according to the Total WARPS/STAID score to determine the level of agreement between the three raters. RESULTS: Intraclass correlation coefficient (ICC 2, 3) of the WARPS/STAID classification continuum ranged between 0.73 and 0.91 for the individual metrics of the classification. The ICC (2, 3) for the Global WARPS/STAID score was 0.75. The mean Kujala score (m = 61, SD 18) was significantly correlated with the total WARPS/STAID score (r = 0.387, p < 0.05). The majority of subjects were assigned to either the WARPS or STAID categories. CONCLUSION: This study introduced the WARPS/STAID classification system and established both validity and reliability in subjects with patellofemoral instability. LEVEL OF EVIDENCE: II.

A comparison of pain scores and medication use in patients undergoing single-bundle or double-bundle anterior cruciate ligament reconstruction.

BACKGROUND: No gold standard exists for the management of postoperative pain following anterior cruciate ligament reconstruction (ACLR). We compared the pain scores and medication use of patients undergoing single-bundle (SB) or double-bundle (DB) ACLR in the acute postoperative period. Pain and medication use was also analyzed for spinal versus general anesthesia approaches within both surgery types. METHODS: We assessed 2 separate cohorts of primary ACLR patients, SB and DB, for 14 days postoperatively. We used a standard logbook to record self-reported pain scores and medication use. Pain was assessed using a 100 mm visual analogue scale (VAS). Medications were divided into 3 categories: oral opioids, oral nonsteroidal anti-inflammatories and acetaminophen. RESULTS: A total of 88 patients undergoing SB and 41 undergoing DB ACLR were included in the study. We found no significant difference in VAS pain scores between the cohorts. Despite similar VAS pain scores, the DB cohort consumed significantly more opioid and analgesia medication (p = 0.011). Patients who underwent DB with spinal anesthesia experienced significantly less pain over the initial 14-day postoperative period than those who received general anesthesia (p < 0.001). CONCLUSION: Adequate pain relief was provided to all ACLR patients in the initial postoperative period. Patients in the DB cohort experienced more pain, as evidenced by the significant diffrence in consumption of opioids and acetaminophen, than the SB cohort. Patients who underwent spinal anesthesia experienced less pain in the acute postoperative period than those who received general anesthesia.

CONTEXTE: Il n'existe pas de norme établie pour la prise en charge de la douleur postopératoire après la reconstruction du ligament croisé antérieur (RLCA). Nous avons comparé les scores de douleur et le recours aux analgésiques chez des patients soumis à une RLCA simple faisceau (SF) ou double faisceau (DF) durant la période postopératoire immédiate. La douleur et l'utilisation des analgésiques ont aussi été analysées en rapport avec l'anesthésie utilisée, rachidienne ou générale, dans les 2 types de chirurgie. MÉTHODES: Nous avons évalué 2 cohortes distinctes de patients soumis à une RLCA primaire, SF et DF, pendant les 14 premiers jours postopératoires. Les patients ont consigné leurs scores de douleur et leur utilisation d'analgésiques dans des carnets de bord standard. La douleur était évaluée au moyen d'une échelle analogique visuelle (ÉAV) de 100 mm. Les analgésiques étaient regroupés sous 3 catégories, soit opiacés oraux, antiinflammatoires non stéroïdiens oraux et acétaminophène. RÉSULTATS: En tout, 88 patients soumis à une RLCA SF et 41 à une RLCA DF ont été inclus dans l'étude. Nous n'avons observé aucune différence significative quant au score de douleur à l'ÉAV entre les cohortes. Malgré des scores de douleur similaires à l'ÉAV, la cohorte soumise à l'intervention DF a utilisé significativement plus d'opiacés et autres analgésiques (p = 0.011). Comparativement aux patients sous anesthésie générale, les patients soumis à l'intervention DF sous anesthésie rachidienne ont éprouvé significativement moins de douleur au cours des 14 premiers jours postopératoires (p < 0.001). CONCLUSION: Tous les patients qui ont subi une RLCA ont obtenu un soulagement adéquat de leur douleur durant la période postopératoire initiale. Les patients de la cohorte DF ont éprouvé davantage de douleur, comme en témoigne la différence significative de consommation d'opiacés et d'acétaminophène comparativement à la cohorte SF. Les patients qui ont subi une anesthésie rachidienne ont éprouvé moins de douleur pendant la période postopératoire immédiate, comparativement aux patients sous anesthésie générale.

Being a woman and an orthopaedic surgeon-A primer on the challenges we face.

A higher number of women are graduating from medical schools than men, yet orthopedic surgery continues to register the lowest proportion of female surgeons and residents of the surgical specialties. This trend is observed not only in North America but also globally. The presence of a more diverse workforce has been shown to lead to improved patient outcomes, enhanced efficiencies, and overall wellness within healthcare systems and would be of benefit to the orthopedic surgery profession. This primer aims to provide surgeons and leaders with evidence-based insights into diversity, equity, and equality, as well as define barriers and potential solutions pertaining to women in orthopedic surgery.

Palpation and fluoroscopy are valid but unreliable for the assessment of femoral tunnel position after medial patellofemoral ligament reconstruction.

OBJECTIVES: The purpose of this study was to evaluate the validity and reliability of two techniques, palpation and fluoroscopy, for assessing medial patellofemoral ligament (MPFL) reconstruction femoral tunnel position accuracy. METHODS: Twenty-one fresh frozen cadaveric knees had an MPFL femoral tunnel drilled and filled with a metal screw. Tunnels were created in a nonstandard fashion to ensure the sample included a range of tunnel positions from poor to ideal. Six experienced sport medicine and arthroscopy surgeons evaluated the placement of the femoral tunnel by palpating the screw in relation to anatomic landmarks and by fluoroscopy related to Schöttle's Point. They evaluated 1) the accuracy of femoral tunnel placement, 2) the direction of tunnel error, and 3) the clinical acceptability of the tunnel position. Validity measures included sensitivity, specificity, and correlation to clinical acceptability, which were calculated for the palpation and fluoroscopic assessments. Reliability measures included interrater reliability (ICC 2,k) for femoral tunnel accuracy and percent agreement of the raters' tunnel direction assessment. RESULTS: The palpation method demonstrated a sensitivity of 0.79 and specificity of 0.84 for assessing the accuracy of femoral tunnel placement, while the fluoroscopic method showed a sensitivity of 0.83 and specificity of 0.92. Pearson correlation coefficients for clinical acceptability of tunnel position were high, with both techniques ranging from .589 to .854. Interrater reliability for the palpation and fluoroscopic techniques for assessment of tunnel accuracy were 0.31 and 0.55 (ICC 2,k), respectively. Assessment of the direction of tunnel error was good with the fluoroscopic technique slightly more accurate than palpation. CONCLUSION: This study demonstrated that both palpation and fluoroscopy are valid techniques for assessing femoral tunnel position after MPFL reconstruction. Despite demonstrating good validity, the accuracy of assessing tunnel position was unreliable in a group of six experienced knee surgeons. Further research into MPFL reconstruction femoral tunnel assessment techniques, including patient-specific reference standards, is warranted. LEVEL OF EVIDENCE: Level 2.

Orthopaedic sport medicine surgeons and fellows value immersive virtual reality for improving surgical training, procedural planning, and distance learning.

OBJECTIVES: Overall, the potential utility of immersive virtual reality (iVR) technology in orthopaedic surgery is promising. The attitudes of medical students and surgical trainees on virtual reality simulated surgical training have been overwhelmingly positive. However, further research and understanding of the attitudes of practicing orthopaedic surgeons and fellows are needed to appreciate its benefits for clinical practice. The purpose of this study was to establish the face validity of iVR technology by assessing the attitudes of Canadian orthopaedic surgeons on the value of iVR for surgical training, clinical practice, and distance learning. METHODS: Forty-three orthopaedic surgeons and fellows attended an iVR demonstration at an annual orthopaedic meeting. The view and audio from the lead headset were cast to a large screen so the audience could follow the procedure in real time. Immediately after the presentation, the audience members were asked to complete a paper questionnaire assessing their perceptions and attitudes toward iVR for use in orthopaedic learning, clinical practice and distance education and mentoring. RESULTS: iVR was perceived to be valuable for the field of orthopaedic surgery providing face validity for the technology. All 13 questions were rated with mean Likert scores of five or greater, indicating a positive observed value for all 13 questions. The respondents indicated that iVR had value (score of 5 or greater) in each questionnaire domain, with agreement ranging from 78 to 98% for teaching and learning, 66-97% for clinical practice, and 88-100% for distance education and mentoring questions. CONCLUSION: This study has demonstrated that a group of Canadian sport medicine orthopaedic surgeons and fellows had favourable attitudes toward, and perceived that iVR has value in, orthopaedic surgical training, clinical practice, and distance learning and mentorship. The potential for utilizing iVR technology for distance learning, mentorship and global education appears promising. LEVEL OF EVIDENCE: II.

Remnant-Sparing Anterior Cruciate Ligament Reconstruction Results in Similar Clinical, Functional, and Quality-of-Life Outcomes to Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction.

Purpose: To compare a large cohort of patients who underwent remnant-sparing anterior cruciate ligament reconstruction (rACLR) with a matched group of patients who underwent anatomic single-bundle anterior cruciate ligament reconstruction (ACLR) with respect to clinical laxity, patient-reported outcomes, and functional testing. Methods: Patients who underwent rACLR between January 2010 and December 2015 were matched according to age, sex, body mass index, and graft type to patients who underwent ACLR. The primary outcome measure was the ACL Quality of Life (ACL-QOL) score at final follow-up of 24 months. Secondary outcomes included functional tests and clinical laxity measurements at 6, 12, and 24 months postoperatively. Concurrent intra-articular pathology at the time of surgery and postoperative complications were also recorded. Statistical analyses included the dependent t test and the Wilcoxon signed rank test. Results: A total of 210 rACLR patients were successfully matched to a corresponding cohort of 210 ACLR patients. There were no statistically significant differences in ACL Quality of Life (ACL-QOL) or functional testing results between the groups; however, scores in both groups showed a steady and statistically significant improvement over time. A statistically significant difference was noted with respect to the Lachman test findings, favoring the rACLR cohort (Z = -2.79, P = .005); no between-group difference was seen for the pivot-shift test (Z = -0.36, P = .72). The rACLR group had a significantly lower rate of concurrent meniscal and chondral injury. There was no difference in complications between the groups (Z = -0.49, P = .63). Conclusions: There was no difference in patient-reported or functional testing outcomes in patients undergoing remnant-sparing compared with anatomic single-bundle ACLR. There was, however, a significantly lower rate of positive Lachman test findings after rACLR. Furthermore, the rate of concurrent meniscal and chondral pathology was lower in the rACLR group. Level of Evidence: Level III, retrospective cohort study.

Sulcus-Deepening Trochleoplasty for High-Grade Trochlear Dysplasia: Demystifying the Procedure-a Review of the Current Literature.

PURPOSE OF REVIEW: The most common and biomechanically influential pathoanatomic risk factor for recurrent patellofemoral instability is trochlear dysplasia. Sulcus-deepening trochleoplasty is a procedure developed to address high-grade trochlear dysplasia in the setting of patellofemoral instability. The purpose of this paper is to outline the current classification and surgical management of trochlear dysplasia as well as to review the current literature on the clinical outcomes and complications of sulcus-deepening trochleoplasty. RECENT FINDINGS: This review outlines the most recent literature reporting evidence behind the decision-making to perform a trochleoplasty in the setting of patellofemoral instability and high-grade trochlear dysplasia. Critical parameters include grade of trochlear dysplasia, severity of symptoms, pertinent physical examination findings, surgical techniques, modifications for skeletally immature patients, and considerations for the revision setting. Historic studies have elicited concerns regarding high reported complication rates for trochleoplasty; however, recent studies consistently report good clinical outcomes and acceptable complication rates, similar to those of other patellar stabilizing procedures. The addition of a trochleoplasty in patients with high-grade dysplasia results in a lower re-dislocation rate, significant improvements in patient-reported outcome measures (PROMs) as well as high levels of patient satisfaction and return to sport. The use of sulcus-deepening trochleoplasty for the treatment of high-grade dysplasia and recurrent patellofemoral instability is a well-established technique with good outcomes and an acceptable complication profile. In patients with high-grade dysplasia, trochleoplasty results in lower re-dislocation rates, high patient satisfaction scores, and good clinical and functional outcomes. An understanding of trochleoplasty and its indications should be in the armamentarium of surgeons treating patellofemoral instability.

Rates of Burnout in Female Orthopaedic Surgeons Correlate with Barriers to Gender Equity.

BACKGROUND: The primary purpose of this study was to investigate the relationships between career burnout and the barriers to gender equity identified by Canadian female orthopaedic surgeons. A secondary purpose was to assess relationships between the demographic characteristics of the female surgeons and career burnout and job satisfaction. METHODS: An electronic survey was distributed to 330 Canadian female orthopaedic surgeons. Demographic variables including age, stage and years in practice, practice setting, and marital status were collated. The survey included the Gender Bias Scale (GBS) questionnaire and 2 questions each about career burnout and job satisfaction. The Pearson r correlation coefficient evaluated the relationships among the higher- and lower-order factors of the GBS, burnout, and job satisfaction. Spearman rank correlation coefficient assessed relationships among burnout, job satisfaction, and demographic variables. RESULTS: Survey responses were received from 218 (66.1%) of the 330 surgeons. A total of 110 surgeons (50.5%) agreed or strongly agreed that they felt career burnout (median score = 4). Burnout was positively correlated with the GBS higher-order factors of Male Privilege (r = 0.215, p < 0.01), Devaluation (r = 0.166, p < 0.05), and Disproportionate Constraints (r = 0.152, p < 0.05). Job satisfaction (median = 4) was reported by 168 surgeons (77.1%), and 66.1% were also satisfied or very satisfied with their role in the workplace (median = 4). Burnout was significantly negatively correlated with surgeon age and job satisfaction. CONCLUSIONS: Half of the female orthopaedic surgeons reported symptoms of career burnout. Significant relationships were evident between burnout and barriers to gender equity. Identification of the relationships between gender-equity barriers and burnout presents an opportunity to modify organizational systems to dismantle barriers and reduce this occupational syndrome. CLINICAL RELEVANCE: Given the relationships between gender inequity and career burnout in this study of female orthopaedic surgeons, actions to dismantle gender barriers and address systemic biases are necessary at all career stages to reduce burnout.

Experiences of Canadian Female Orthopaedic Surgeons in the Workplace: Defining the Barriers to Gender Equity.

BACKGROUND: Only 13.6% of orthopaedic surgeons in Canada are women, even though there is nothing inherent to the practice of orthopaedic surgery that favors men over women. Clearly, there is a need to identify, define, and measure the barriers faced by women in orthopaedic surgery. METHODS: An electronic survey was distributed to 330 female-identifying Canadian orthopaedic surgeons and trainees and included the validated Gender Bias Scale (GBS) and questions about career burnout. The barriers for women in Canadian orthopaedics were identified using the GBS. The relationships between the GBS and burnout were investigated. Open-text questions explored the barriers perceived by female orthopaedic surgeons. RESULTS: The survey was completed by 220 female orthopaedic surgeons and trainees (66.7%). Five barriers to gender equity were identified from the GBS: Constrained Communication, Unequal Standards, Male Culture, Lack of Mentoring, and Workplace Harassment. Career burnout correlated with the GBS domains of Male Privilege (r = 0.215; p < 0.01), Disproportionate Constraints (r = 0.152; p < 0.05), and Devaluation (r = 0.166; p < 0.05). Five main themes emerged from the open-text responses, of which 4 linked closely to the barriers identified in the GBS. Work-life integration was also identified qualitatively as a theme, most notably the difficulty of balancing disproportionate parental and childcare responsibilities alongside career aspirations. CONCLUSIONS: In this study, 5 barriers to workplace equity for Canadian female orthopaedic surgeons were identified using the validated GBS and substantiated with qualitative assessment using a mixed-methods approach. Awareness of these barriers is a necessary step toward dismantling them and changing the prevailing culture to be fair and equitable for all. CLINICAL RELEVANCE: A just and equitable orthopaedic profession is imperative to have healthy and thriving surgeons who are able to provide optimal patient care.

Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. PURPOSE/HYPOTHESIS: The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. RESULTS: Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. CONCLUSION: The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.

Performance of 5-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction in the STABILITY Study: A Subgroup Analysis.

BACKGROUND: Anterior cruciate ligament (ACL) reconstructions (ACLRs) with graft diameters <8mm have been shown to have higher revision rates. The 5-strand (5S) hamstring autograft configuration is a proposed option to increase graft diameter. PURPOSE: To investigate the differences in clinical outcomes between 4-strand (4S) and 5S hamstring autografts for ACLR in patients who underwent ACLR alone or concomitantly with a lateral extra-articular tenodesis (LET) procedure. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Data from the STABILITY study were analyzed to compare a subgroup of patients undergoing ACLR alone or with a concomitant LET procedure (ACLR + LET) with a minimum graft diameter of 8mm that had either a 4S or 5S hamstring autograft configuration. The primary outcome was clinical failure, a composite of rotatory laxity and/or graft failure. The secondary outcome measures consisted of 2 patient-reported outcome scores (PROs)-namely, the ACL Quality of Life Questionnaire (ACL-QoL) and the International Knee Documentation Committee (IKDC) score at 24 months postoperatively. RESULTS: Of the 618 patients randomized in the STABILITY study, 399 (228 male; 57%) fit the inclusion criteria for this study. Of these, 191 and 208 patients underwent 4S and 5S configurations of hamstring ACLR, respectively, with a minimum graft diameter of 8mm. Both groups had similar characteristics other than differences in anthropometric factors-namely, sex, height, and weight, and Beighton scores. The primary outcomes revealed no difference between the 2 groups in rotatory stability (odds ratio [OR], 1.19; 95% CI, 0.77-1.84; P = .42) or graft failure (OR, 1.13; 95% CI, 0.51-2.50; P = .76). There was no significant difference between the groups in Lachman (P = .46) and pivot-shift (P = .53) test results at 24 months postoperatively. The secondary outcomes revealed no differences in the ACL-QoL (P = .67) and IKDC (P = .83) scores between the 2 subgroups. CONCLUSION: At the 24-month follow-up, there were no significant differences in clinical failure rates and PROs in an analysis of patients with 4S and 5S hamstring autografts of ≥8mm diameter for ACLR or ACLR + LET. The 5S hamstring graft configuration is a viable option to produce larger-diameter ACL grafts.