Early MicroRNA and Metabolite Changes Post-ACL Reconstruction Surgery.

OBJECTIVES: Anterior cruciate ligament (ACL) reconstruction after injury does not prevent post-traumatic osteoarthritis (PTOA). Circulating microRNA (miRNA) and metabolite changes emerging shortly after ACL injury and reconstruction remain insufficiently defined, potentially harbouring early cues contributing to PTOA evolution. Moreover, their differential expression between females and males also may influence PTOA's natural trajectory. This study aims to determine alterations in plasma miRNA and metabolite levels in the early stages following ACL reconstruction and between females and males. METHODS: A cohort of 43 ACL reconstruction patients was examined. Plasma was obtained at baseline, 2-weeks, and 6-weeks post-surgery (129 biospecimens in total). High throughput miRNA sequencing and metabolomics were conducted. Differentially expressed miRNAs and metabolites were identified using negative binomial and linear regression models, respectively. Associations between miRNAs and metabolites were explored using time and sex as co-variants, (pre- versus 2- and 6-weeks post-surgery). Using computational biology, miRNA-metabolite-gene interaction and pathway analyses were performed. RESULTS: Levels of 46 miRNAs were increased at 2-weeks post-surgery compared to pre-surgery (baseline) using miRNA sequencing. Levels of 13 metabolites were significantly increased while levels of 6 metabolites were significantly decreased at 2-weeks compared to baseline using metabolomics. Hsa-miR-145-5p levels were increased in female subjects at both 2-weeks (log2-fold-change 0.71, 95%CI 0.22,1.20) and 6-weeks (log2-fold-change 0.75, 95%CI 0.07,1.43) post-surgery compared to males. In addition, hsa-miR-497-5p showed increased levels in females at 2-weeks (log2-fold-change 0.77, 95%CI 0.06,1.48) and hsa-miR-143-5p at 6-weeks (log2-fold-change 0.83, 95%CI 0.07,1.59). Five metabolites were decreased at 2-weeks post-surgery in females compared to males: L-leucine (-1.44, 95%CI -1.75,-1.13), g-guanidinobutyrate (-1.27, 95%CI 1.54,-0.99), creatinine (-1.17, 95%CI -1.44,-0.90), 2-methylbutyrylcarnitine (-1.76, 95%CI -2.17,-1.35), and leu-pro (-1.13, 95%CI -1.44,-0.83). MiRNA-metabolite-gene interaction analysis revealed key signalling pathways based on post-surgical time-point and in females versus males. CONCLUSION: MiRNA and metabolite profiles were modified by time and by sex early after ACL reconstruction surgery, which could influence surgical response and ultimately risk of developing PTOA.

Anterior Cruciate Ligament Patellar Tendon Autograft Fixation at 0° Versus 30° Results in Improved Activity Scores and a Greater Proportion of Patients Achieving the Minimal Clinical Important Difference For Knee Injury and Osteoarthritis Outcome Score Pain: A Randomized Controlled Trial.

PURPOSE: The aim of the current study was to determine the effect of the knee flexion angle (KFA) during tibial anterior cruciate ligament (ACL) graft fixation on patient-reported outcomes, graft stability, extension loss, and reoperation after anatomic single-bundle ACL reconstruction. METHODS: All 169 included patients (mean age 28.5 years, 65% male) were treated with anatomic single-bundle ACL reconstruction using patellar tendon autograft and were randomized to tibial fixation of the ACL graft at either 0° (n = 85) or 30° (n = 84). The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) 2 years after surgery. Secondary outcomes were the Marx Activity Scale (MAS), the rate of reoperation, and physical examination findings at 1 year, including KT-1000 and side-to-side differences in knee extension. RESULTS: The follow-up rate was 82% (n = 139) for the primary outcome. Graft failure rate at 2 years was 1% (n = 2, 1 per group). ACL tibial graft fixation at 0° or 30° did not have a significant effect on KOOS scores at 2 years after ACLR. Patients whose graft was fixed at a knee flexion angle of 0° had greater scores on the MAS (mean 9.6 95% confidence interval [CI] 8.5 to 10.6, versus 8.0, 95% CI 6.9 to 9.1; P = .04), and a greater proportion achieved the minimal clinical important difference (MCID) for the KOOS pain subdomain (94% versus 81%; P = .04). There was no significant difference in knee extension loss, KT-1000 measurements, or reoperation between the 2 groups. CONCLUSION: In the setting of anatomic single-bundle ACLR using patellar tendon autograft and anteromedial portal femoral drilling, there was no difference in KOOS scores between patients fixed at 0° and 30°. Patient fixed in full extension did demonstrate higher activity scores at 2 years after surgery and a greater likelihood of achieving the MCID for KOOS pain. LEVEL OF EVIDENCE: II, prospective randomized trial.

Editorial Commentary: Injections for Knee Osteoarthritis: Doc, You Gotta Help Me!

Injections for the pain caused by knee osteoarthritis have been the focus of significant research for the last few decades. Systematic reviews and meta-analyses suggest that platelet-rich plasma (PRP) can provide up to 12 months of pain relief in these patients, superior to both cortisone and hyaluronic acid. There is also some evidence for a synergistic effect when combining both PRP and hyaluronic acid. Bone marrow aspirate concentrate (BMAC) has significantly greater levels of interleukin-1ra than PRP, as well as a small concentration of mesenchymal stromal cells. However, BMAC is yet unproven in its efficacy, and obtaining BMAC is not as simple as taking blood. Research into the use of expanded autologous and allogenic mesenchymal stem cells continues and shows future promise. For today, PRP remains the gold standard for the treatment of pain associated with knee osteoarthritis.

Editorial Commentary: Patients Who Achieve a Minimal Clinically Important Difference (Feel Better) Early After Hip Arthroscopy Have the Highest Rates of Long-Term Satisfaction.

Analyzing patient-reported outcomes using the lens of the minimal clinical important difference (MCID) and patient acceptable symptomatic state allows surgeons to assess patient recovery at the individual level and make necessary changes to management if necessary. When patients with femoroacetabular impingement achieve MCID 6 months after arthroscopic treatment, they achieve patient acceptable symptomatic state 2 years postoperatively 88% of the time. The findings highlight the importance of the postoperative recovery trajectory and illustrate a quantitative way to study the progress of individual patients along their care journey.

Preoperative Magnetic Resonance Imaging Accurately Detects the Arthroscopic Comma Sign in Subscapularis Tears.

PURPOSE: To assess the accuracy and reliability of routine preoperative magnetic resonance imaging (MRI) in the detection of the comma sign compared with the gold standard of arthroscopic findings. METHODS AND MATERIALS: Preoperative MRI exams in consecutive patients undergoing arthroscopic subscapularis tendon repair, over a 5-year time frame, were retrospectively reviewed for full-thickness tears of the subscapularis and supraspinatus tendons, fatty atrophy of the subscapularis and supraspinatus muscles, and status of the long head of the biceps tendon. Each case was also evaluated for presence or absence of a comma sign on MRI. Surgical findings served as the diagnostic standard of reference in determination of a comma sign. RESULTS: The study cohort included 45 male and 10 female patients (mean age, 56; range, 32-80 years). A comma sign was present at arthroscopy in 19 patients (34.5%). Interclass and intrarater correlation showed 100% agreement in preoperative assessment of a comma sign on MRI. MRI showed an overall accuracy of 83.6% in diagnosis of a comma sign (sensitivity, 63.2%; specificity, 94.4%; positive predictive value, 85.7%; negative predictive value, 82.9%; positive likelihood ratio, 11.37; negative likelihood ratio, 0.39). No statistically significant association was observed between an arthroscopic comma sign and patient demographics or MRI findings of full-thickness rotator cuff tears, muscle fatty atrophy, or long head of the biceps tendon pathology. CONCLUSIONS: MR imaging illustrates excellent reliability and good specificity and accuracy in detection of the arthroscopic comma sign in the setting of subscapularis tendon tearing. Detection of a comma sign on MRI may be important preoperative planning information in the arthroscopic management of patients with subscapularis tendon tears. LEVEL OF EVIDENCE: Level IV, retrospective diagnostic study.

A Comparison of Quadriceps Tendon Autograft With Bone-Patellar Tendon-Bone Autograft and Hamstring Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Quantitative Synthesis.

OBJECTIVE: There is growing enthusiasm for the increased use of quadriceps tendon (QT) autograft for primary anterior cruciate ligament reconstruction (ACLR). The purpose of this analysis was to synthesize and quantitatively assess the available evidence comparing QT autograft with hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts, regarding functional outcomes, knee stability, anterior knee pain, and revision rates. DATA SOURCES: A search in MEDLINE, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials for eligible studies up to May 2018 was conducted. Two reviewers selected studies based on inclusion criteria and assessed methodological quality. Outcomes analyzed were anterior knee pain, graft failure rates, knee stability, functional outcomes, and adverse events. Pooled analyses were performed for continuous and dichotomous variables where appropriate. MAIN RESULTS: Ten studies (1 randomized trial and 9 nonrandomized cohorts) met our inclusion criteria, which included 1398 patients. The analysis showed no statistical difference in anterior knee pain when comparing QT and HT autografts, but a significant difference between QT and BPTB autografts [odds ratio, 0.15 (95% confidence interval, 0.08-0.27); P < 0.001]. There were no differences between all 3 autografts in revision rates, knee stability, and patient-reported functional outcomes. CONCLUSIONS: Quadriceps tendon autograft is a suitable graft alternative for primary ACLR, as it achieves good clinical outcomes with a low incidence of anterior knee pain. Given the limited quality of the included studies, there is a need for a well-designed multicenter randomized control trial comparing QT autograft with other primary ACL autografts to confirm our findings. LEVEL OF EVIDENCE: Level IV systematic review.

Conventional Follow-up Versus Mobile Application Home Monitoring for Postoperative Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial.

PURPOSE: To determine whether a mobile app can reduce the need for in-person visits and examine the resulting societal cost differences between mobile and conventional follow-up for postoperative anterior cruciate ligament (ACL) reconstruction patients. METHODS: Study design was a single-center, 2-arm parallel group randomized controlled trial. All patients undergoing ACL reconstruction aged 16 to 70 years were screened for inclusion in the study. Competent use of a mobile device and ability to communicate in English was required. Patients were randomly assigned to receive follow-up via a mobile app or conventional appointments. Analysis was intention-to-treat. The primary outcome was the number of in-person visits to any health care professional during the first 6 postoperative weeks. Secondary outcomes included analysis of costs incurred by the health care system and personal patient costs related to both methods of follow-up. Patient-reported satisfaction and convenience scores, rates of complications, and clinical outcomes were also analyzed. RESULTS: Sixty patients were analyzed. Participants in the app group attended a mean of 0.36 in-person visits versus 2.44 in-person visits in the conventional group (95% confidence interval 0.08-0.28; P < .0001). On average, patients in the app group spent $211 (Canadian dollars) less than the conventional group over 6 weeks (P < .0001) on personal costs related to follow-up. Health care system costs were also significantly less in the app group ($157.5 vs CAD $202.2; P < .0001). There was no difference between groups in patient satisfaction, convenience, complication rates, or clinical outcome measures. CONCLUSIONS: Mobile follow-up can eliminate a significant number of in-person visits during the first 6 postoperative weeks in patients undergoing ACL reconstruction with cost savings to both the patient and health care system. This method should be considered for dissemination among similar orthopaedic procedures during early postoperative care. LEVEL OF EVIDENCE: I: Prospective randomized controlled trial.

Operative Versus Nonoperative Treatment of Femoroacetabular Impingement Syndrome: A Meta-analysis of Short-Term Outcomes.

PURPOSE: To compare the outcomes of patients with femoroacetabular impingement (FAI) syndrome treated with hip arthroscopy versus those treated with physical therapy alone. METHODS: The PubMed, Embase, and Cochrane Library databases were searched from inception to February 15, 2019. All randomized controlled trials (RCTs) that compared operative versus nonoperative treatment in the management of FAI for a minimum 6-month follow-up period were included. The primary outcome was the International Hip Outcome Tool 33. The CLEAR NPT (Checklist to Evaluate a Report of a Nonpharmacological Trial) was used to evaluate the methodologic quality of included studies. RESULTS: Three RCTs (Level I) were included with a total of 650 patients (323 randomized to surgery and 327 randomized to physical therapy), follow-rate of 90% (583 patients, 295 operative and 288 nonoperative), and average of 11.5 months' follow-up. Regarding participation, 222 of 350 patients (63%) in the FAIT (Femoroacetabular Impingement Trial) study, 348 of 648 (54%) in the FASHIoN (Full UK RCT of Arthroscopic Surgery for Hip Impingement Versus Best Conservative Care) study, and 80 of 104 (77%) in the study by Mansell et al. agreed to participate. The mean age was 35 years, and 51.5% of patients were male patients. All 3 RCTs represented high methodologic quality and a low risk of bias. The frequency-weighted mean follow-up period was 10 months. A meta-analysis of the 3 randomized trials showed that patients treated with operative management had improved preoperative-to-postoperative change scores on the International Hip Outcome Tool 33 compared with the nonoperative group (standardized mean difference, 3.46; 95% confidence interval, 0.07-6.86; P < .05). One study reported on the achievement of clinically relevant outcomes at the individual level, with 51% of the operative group and 32% of the nonoperative group achieving the minimal clinically important difference and with 48% and 19%, respectively, achieving the patient acceptable symptomatic state for the Hip Outcome Score-Activities of Daily Living. CONCLUSIONS: The results of this meta-analysis show that patients with FAI syndrome treated with hip arthroscopy have statistically superior hip-related outcomes in the short term compared with those treated with physical therapy alone. LEVEL OF EVIDENCE: Level I, meta-analysis of Level I RCTs.

Development of a certification examination for orthopedic sports medicine fellows

Background: The purpose of this study was to develop a multifaceted examination to assess the competence of fellows following completion of a sports medicine fellowship. Methods: Orthopedic sports medicine fellows over 2 academic years were invited to participate in the study. Clinical skills were evaluated with objective structured clinical examinations, multiple-choice question examinations, an in-training evaluation report and a surgical logbook. Fellows' performance of 3 technical procedures was assessed both intraoperatively and on cadavers: anterior cruciate ligament reconstruction (ACLR), arthroscopic rotator cuff repair (RCR) and arthroscopic shoulder Bankart repair. Technical procedural skills were assessed using previously validated task-specific checklists and the Arthroscopic Surgical Skill Evaluation Tool (ASSET) global rating scale. Results: Over 2 years, 12 fellows were assessed. The Cronbach α for the technical assessments was greater than 0.8, and the interrater reliability for the cadaveric assessments was greater than 0.78, indicating satisfactory reliability. When assessed in the operating room, all fellows were determined to have achieved a minimal level of competence in the 3 surgical procedures, with the exception of 1 fellow who was not able achieve competence in ACLR. When their performance on cadaveric specimens was assessed, 2 of 12 (17%) fellows were not able to demonstrate a minimal level of competence in ACLR, 2 of 10 (20%) were not able to demonstrate a minimal level of competence for RCR and 3 of 10 (30%) were not able to demonstrate a minimal level of competence for Bankart repair. Conclusion: There was a disparity between fellows' performance in the operating room and their performance in the high-fidelity cadaveric setting, suggesting that technical performance in the operating room may not be the most appropriate measure for assessment of fellows' competence.

Contexte: Le but de cette étude était de concevoir un examen à plusieurs volets pour évaluer la compétence des moniteurs cliniques à la fin de leur formation en médecine sportive. Méthodes: Après leur formation de 2 ans pour devenir orthopédistes en médecine sportive, les moniteurs cliniques ont été invités à participer à l'étude. Leurs habiletés cliniques ont été évaluées au moyen d'examens cliniques objectifs structurés, de questionnaires à choix multiple, d'un rapport d'évaluation en cours de formation et d'un journal de bord chirurgical. Leur habileté à réaliser 3 techniques chirurgicales différentes a été évaluée au bloc opératoire et sur des cadavres : reconstruction du ligament croisé antérieur (RLCA), réparation arthroscopique de la coiffe des rotateurs (RACR) et intervention de Bankart sous endoscopie pour l'épaule. Les habiletés techniques ont été évaluées au moyen de listes de vérification spécifiques aux tâches validées et au moyen de l'outil d'évaluation globale ASSET (Arthroscopic Surgical Skill Evaluation). Résultats: Sur une période de 2 ans, 12 moniteurs ont été évalués. Le coefficient α de Cronbach pour les évaluations techniques a été supérieur à 0,8, et la fiabilité inter-examinateurs pour l'évaluation des interventions sur des cadavres a été supérieure à 0,78, soit une fiabilité jugée satisfaisante. Lors de l'évaluation au bloc opératoire, on a jugé que tous les moniteurs détenaient le niveau minimum de compétences pour exécuter les 3 techniques chirurgicales, à l'exception d'un seul qui n'a pas atteint le niveau de compétence pour la RLCA. À l'évaluation de leurs compétences pour les interventions sur des cadavres, 2 sur 12 (17 %) n'ont pas atteint le niveau minimum de compétence pour la RLCA, 2 sur 10 (20 %) pour la RACR et 3 sur 10 (30 %) pour l'intervention de Bankart. Conclusion: On a noté une disparité dans la compétence des moniteurs entre le bloc opératoire et le contexte cadavérique haute fidélité, ce qui donne à penser que le rendement technique au bloc opératoire pourrait ne pas être le moyen le plus approprié d'évaluer la compétence des moniteurs cliniques.

Opioid- and Motor-sparing with Proximal, Mid-, and Distal Locations for Adductor Canal Block in Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial.

BACKGROUND: The ideal location for single-injection adductor canal block that maximizes analgesia while minimizing quadriceps weakness after painful knee surgery is unclear. This triple-blind trial compares ultrasound-guided adductor canal block injection locations with the femoral artery positioned medial (proximal adductor canal), inferior (mid-adductor canal), and lateral (distal adductor canal) to the sartorius muscle to determine the location that optimizes postoperative analgesia and motor function. The hypothesis was that distal adductor block has (1) a superior opioid-sparing effect and (2) preserved quadriceps strength, compared with proximal and mid-locations for anterior cruciate ligament reconstruction. METHODS: For the study, 108 patients were randomized to proximal, mid-, or distal adductor canal injection locations for adductor canal block. Cumulative 24-h oral morphine equivalent consumption and percentage quadriceps strength decrease (maximum voluntary isometric contraction) at 30 min postinjection were coprimary outcomes. The time to first analgesic request, pain scores, postoperative nausea/vomiting at least once within the first 24 h, and block-related complications at 2 weeks were also evaluated. RESULTS: All patients completed the study. Contrary to the hypothesis, proximal adductor canal block decreased 24-h morphine consumption to a mean ± SD of 34.3 ± 19.1 mg, (P < 0.0001) compared to 64.0 ± 33.6 and 65.7 ± 22.9 mg for the mid- and distal locations, respectively, with differences [95% CI] of 29.7 mg [17.2, 42.2] and 31.4 mg [21.5, 41.3], respectively, mostly in the postanesthesia care unit. Quadriceps strength was similar, with 16.7%:13.4%:15.3% decreases for proximal:mid:distal adductor canal blocks. The nausea/vomiting risk was also lower with proximal adductor canal block (10 of 34, 29.4%) compared to distal location (23 of 36, 63.9%; P = 0.005). The time to first analgesic request was longer, and postoperative pain was improved up to 6 h for proximal adductor canal block, compared to mid- and distal locations. CONCLUSIONS: A proximal adductor canal injection location decreases opioid consumption and opioid-related side effects without compromising quadriceps strength compared to mid- and distal locations for adductor canal block in patients undergoing anterior cruciate ligament reconstruction.

Autologous Interleukin 1 Receptor Antagonist Blood-Derived Products for Knee Osteoarthritis: A Systematic Review.

PURPOSE: To systematically review the available clinical data regarding the use of autologous IL-1 receptor antagonist blood products (AILBPs) and their validity as an alternative intra-articular (IA) therapy for symptomatic knee osteoarthritis (OA). METHODS: The PubMed, MEDLINE, Embase, and Cochrane Library databases were searched from inception to June 2018. All randomized controlled trials (RCTs) and noncomparative studies that evaluated the clinical efficacy of AILBPs (i.e., autologous protein solution and autologous conditioned serum) for knee OA were included. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index. The secondary outcomes measured were the Knee Injury and Osteoarthritis Outcome Score, visual analog scale score, Short Form 36 (SF-36) score, radiographic scores, and adverse events, which were qualitatively analyzed. RESULTS: We included 8 studies, comprising 3 RCTs (Level II) and 5 noncomparative studies (Level IV), with a total of 592 patients (mean age, 56.4 years; 49.7% male patients). The RCTs represented high methodologic quality, whereas the noncomparative studies represented moderate to good quality. With AILBPs, 2 of 4 studies (50%) showed improvements in the Knee Injury and Osteoarthritis Outcome Score symptom and sport subscales, 5 of 7 studies (71%) achieved improvements in the Western Ontario and McMaster Universities Osteoarthritis Index score, and 4 of 5 studies (80%) attained improvements in the visual analog scale pain score from baseline to final follow-up. Most adverse events associated with AILBPs were mild to moderate in severity and were primarily localized to the injection site. CONCLUSIONS: Limited evidence substantiates that AILBPs are a safe and tolerable IA injection therapy that may improve pain parameters and functionality for mild to moderate knee OA patients and may be an effective adjunct for those unresponsive to traditional IA therapies. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Bone marrow stimulation decreases retear rates after primary arthroscopic rotator cuff repair: a systematic review and meta-analysis.

BACKGROUND: Despite the optimization of biomechanical and patient factors in the setting of rotator cuff repair (RCR), postoperative retear rates remain high in many series reported in the literature. Preclinical studies have suggested bone marrow stimulation (BMS) at the rotator cuff footprint may reduce the rate of retear after RCR. The objective of this meta-analysis was to analyze the clinical evidence investigating the effect of arthroscopic RCR, with and without BMS, on rotator cuff healing and functional outcomes. METHODS: PubMed, MEDLINE, Embase, and the Cochrane Library were searched through December 2017. Two reviewers selected studies based on the inclusion criteria and assessed methodologic quality. Pooled analyses were performed for continuous and binomial variables where appropriate. RESULTS: Four studies (365 patients), including 2 Level I randomized controlled trials and 2 Level III retrospective comparative cohort studies were included. There was no statistical difference in the Disabilities of the Arm, Shoulder and Hand score, University of California Los Angeles Shoulder Rating Scale score, or the Constant score between the BMS and conventional repair groups. The pooled retear rates were 18.4% (28 of 152) and 31.8% (56 of 176) for patients treated with and without BMS, respectively. The pooled analysis of rotator cuff retear rates from the 4 studies (328 patients) showed a statistically significant difference favoring BMS over conventional repair (odds ratio, 0.42; 95% confidence interval, 0.25-0.73; P = .002; I2 = 0%). CONCLUSION: BMS reduces the retear rate after RCR but shows no difference in functional outcomes compared with conventional repair. This study provides evidence for the use of BMS as a potential cost-effective biological approach toward improving rotator cuff healing.

Does Platelet-Rich Plasma Lead to Earlier Return to Sport When Compared With Conservative Treatment in Acute Muscle Injuries? A Systematic Review and Meta-analysis.

PURPOSE: To compare the time to return to sport and reinjury rate after platelet-rich plasma (PRP) injection versus control therapy (i.e., physiotherapy or placebo injection) in patients with acute grade I or II muscle strains. METHODS: All eligible studies comparing PRP against a control in the treatment of acute (≤7 days) grade I or II muscle strains were identified. The primary outcome was time to return to play. The secondary outcome was the rate of reinjury at a minimum of 6 months of follow-up. Subgroup analysis was performed to examine the efficacy of PRP in hamstring muscle strains alone. The checklist to evaluate a report of a nonpharmacologic trial (CLEAR-NPT) was used to assess the quality of studies. RESULTS: Five randomized controlled trials including a total of 268 patients with grade I and II acute muscle injuries were eligible for review. The pooled results revealed a significantly earlier return to sport for the PRP group when compared with the control group (mean difference, -5.57 days [95% confidence interval, -9.57 to -1.58]; P = .006). Subgroup analysis showed no difference in time to return to sport when comparing PRP and control therapy in grade I and II hamstring muscle strains alone (P = .19). No significant difference was noted in the rate of reinjury between the 2 groups (P = .50) at a minimum of 6 months of follow-up. CONCLUSIONS: Evidence from the current literature, although limited, suggests that the use of PRP may result in an earlier return to sport among patients with acute grade I or II muscle strains without significantly increasing the risk of reinjury at 6 months of follow-up. However, no difference in time to return to sport was revealed when specifically evaluating those with a grade I or II hamstring muscle strain. LEVEL OF EVIDENCE: Level II, meta-analysis of level I and II studies.

Reliability and Validity of the Arthroscopic International Cartilage Repair Society Classification System: Correlation With Histological Assessment of Depth.

PURPOSE: To determine the interobserver reliability of the International Cartilage Repair Society (ICRS) grading system of chondral lesions in cadavers, to determine the intraobserver reliability of the ICRS grading system comparing arthroscopy and video assessment, and to compare the arthroscopic ICRS grading system with histological grading of lesion depth. METHODS: Eighteen lesions in 5 cadaveric knee specimens were arthroscopically graded by 7 fellowship-trained arthroscopic surgeons using the ICRS classification system. The arthroscopic video of each lesion was sent to the surgeons 6 weeks later for repeat grading and determination of intraobserver reliability. Lesions were biopsied, and the depth of the cartilage lesion was assessed. Reliability was calculated using intraclass correlations. RESULTS: The interobserver reliability was 0.67 (95% confidence interval, 0.5-0.89) for the arthroscopic grading, and the intraobserver reliability with the video grading was 0.8 (95% confidence interval, 0.67-0.9). A high correlation was seen between the arthroscopic grading of depth and the histological grading of depth (0.91); on average, surgeons graded lesions using arthroscopy a mean of 0.37 (range, 0-0.86) deeper than the histological grade. CONCLUSIONS: The arthroscopic ICRS classification system has good interobserver and intraobserver reliability. A high correlation with histological assessment of depth provides evidence of validity for this classification system. CLINICAL RELEVANCE: As cartilage lesions are treated on the basis of the arthroscopic ICRS classification, it is important to ascertain the reliability and validity of this method.

Performance Assessment of Arthroscopic Rotator Cuff Repair and Labral Repair in a Dry Shoulder Simulator.

PURPOSE: To evaluate the use of dry models to assess performance of arthroscopic rotator cuff repair (RCR) and labral repair (LR). METHODS: Residents, fellows, and sports medicine staff performed an arthroscopic RCR and LR on a dry model. Any prior RCR and LR experience was noted. Staff surgeons assessed participants by use of task-specific checklists, the Arthroscopic Surgical Skill Evaluation Tool (ASSET), and a final overall global rating. All procedures were video recorded and were scored by a fellow blinded to the year of training of each participant. RESULTS: A total of 51 participants and 46 participants performed arthroscopic RCR and LR, respectively, on dry models. The internal consistency or reliability (Cronbach α) using the total ASSET score for the RCR and LR was high (>0.9). One-way analysis of variance for the total ASSET score showed a difference between participants based on year of training (P < .001) for both procedures. The inter-rater reliability for the ASSET score was excellent (>0.9) for both procedures. A good correlation was seen between the ASSET score and the year of training, as well as the previous number of sports rotations. CONCLUSIONS: The results of this study show evidence of construct validity when using dry models to assess performance of arthroscopic RCR and LR by residents. CLINICAL RELEVANCE: The results of this study support the use of arthroscopic simulation in the training of residents and fellows learning arthroscopic shoulder surgery.

Accuracy of infraspinatus isometric testing in predicting tear size and tendon reparability: comparison with imaging and arthroscopy.

BACKGROUND: The purpose of this study was to examine the accuracy of external rotation in neutral (0° external position) and in shortened position (45° external position) in relation to rotator cuff tear size, tendon reparability, and other clinical, surgical, and imaging findings. METHODS: This was a prospective blinded diagnostic study of consecutive surgical candidates for rotator cuff repair using magnetic resonance imaging and arthroscopic surgery as the "gold standards." The area under a receiver operating characteristic (AUROC) curve was calculated for each position. RESULTS: Eighty-five patients (35 female [41%] and 50 male [59%]; age, 65 years [standard deviation = 10]) were included. Sixty patients (71%) had a minor tear (4 small, 56 moderate), and 25 patients (29%) had a major tear (17 large and 8 massive). Seventy patients (82%) had a full repair, and 15 (18%) patients underwent a partial repair. There were 26 (31%) associated full-thickness tears of the infraspinatus. The isometric strength testing in both positions had good to excellent accuracy (range, 0.80-0.90) for detecting reparability, tear retraction, infraspinatus atrophic changes observed by the clinician, and infraspinatus fatty infiltration on magnetic resonance images. The shortened position had an overall higher accuracy than the neutral position and was more clinically useful for detecting an infraspinatus full-thickness tear (AUROC = 0.84 vs 0.78) and rotator cuff tear size (AUROC = 0.80 vs. 0.75). CONCLUSIONS: The isometric external rotation is an accurate test in diagnosing different aspects of rotator cuff disease and specifically of the infraspinatus muscle. The isometric strength at the shortened position was a better predictor of clinical, surgical, and imaging findings.

IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus Block: A Randomized, Three-arm, Triple-masked, Placebo-controlled Trial.

BACKGROUND: Perineural and IV dexmedetomidine have each been suggested to prolong the duration of analgesia when administered in conjunction with peripheral nerve blocks. In the first randomized, triple-masked, placebo-controlled trial to date, the authors aimed to define and compare the efficacy of perineural and IV dexmedetomidine in prolonging the analgesic duration of single-injection interscalene brachial plexus block (ISB) for outpatient shoulder surgery. METHODS: Ninety-nine patients were randomized to receive ISB using 15 ml ropivacaine, 0.5%, with 0.5 µg/kg dexmedetomidine administered perineurally (DexP group), intravenously (DexIV group), or none (control group). The authors sequentially tested the joint hypothesis that dexmedetomidine prolongs the duration of analgesia and reduces the 24-h cumulative postoperative morphine consumption. Motor blockade, pain severity, hemodynamic variations, opioid-related side effects, postoperative neurologic symptoms, and patient satisfaction were also evaluated. RESULTS: Ninety-nine patients were analyzed. The duration of analgesia was 10.9 h (10.0 to 11.8 h) and 9.8 h (9.0 to 10.6 h) for the DexP and DexIV groups, respectively, compared with 6.7 h (5.6 to 7.8) for the control group (P < 0.001). Dexmedetomidine also reduced the 24-h cumulative morphine consumption to 63.9 mg (58.8 to 69.0 mg) and 66.2 mg (60.6 to 71.8 mg) for the DexP and DexIV groups, respectively, compared with 81.9 mg (75.0 to 88.9 mg) for the control group (P < 0.001). DexIV was noninferior to DexP for these outcomes. Both dexmedetomidine routes reduced the pain and opioid consumption up to 8 h postoperatively and did not prolong the duration of motor blockade. CONCLUSION: Both perineural and IV dexmedetomidine can effectively prolong the ISB analgesic duration and reduce the opioid consumption without prolonging motor blockade.

Cognitive and Psychomotor Entrustable Professional Activities: Can Simulators Help Assess Competency in Trainees?

BACKGROUND: An entrustable professional activity describes a professional task that postgraduate residents must master during their training. The use of simulation to assess performance of entrustable professional activities requires further investigation. QUESTIONS/PURPOSES: (1) Is simulation-based assessment of resident performance of entrustable professional activities reliable? (2) Is there evidence of important differences between Postgraduate Year (PGY)-1 and PGY-4 residents when performing simulated entrustable professional activities? METHODS: Three entrustable professional activities were chosen from a list of competencies: management of the patient for total knee arthroplasty (TKA); management of the patient with an intertrochanteric hip fracture; and management of the patient with an ankle fracture. Each assessment of entrustable professional activity was 40 minutes long with three components: preoperative management of a patient (history-taking, examination, image interpretation); performance of a technical procedure on a sawbones model; and postoperative management of a patient (postoperative orders, management of complications). Residents were assessed by six faculty members who used checklists based on a modified Delphi technique, an overall global rating scale as well as a previously validated global rating scale for the technical procedure component of each activity. Nine PGY-1 and nine PGY-4 residents participated in our simulated assessment. We assessed reliability by calculating the internal consistency of the mean global rating for each activity as well as the interrater reliability between the faculty assessment and blinded review of videotaped encounters. We sought evidence of a difference in performance between PGY-1 and PGY-4 residents on the overall global rating scale for each station of each entrustable professional activity. RESULTS: The reliability (Cronbach's α) for the hip fracture activity was 0.88, it was 0.89 for the ankle fracture activity, and it was 0.84 for the TKA activity. A strong correlation was seen between blinded observer video review and faculty scores (mean 0.87 [0.07], p < 0.001). For the hip fracture entrustable professional activity, the PGY-4 group had a higher mean global rating scale than the PGY-1 group for preoperative management (3.56 [0.5] versus 2.33 [0.5], p < 0.001), postoperative management (3.67 [0.5] versus 2.22 [0.7], p < 0.001), and technical procedures (3.11 [0.3] versus 3.67 [0.5], p = 0.015). For the TKA activity, the PGY-4 group scored higher for postoperative management (3.5 [0.8] versus 2.67 [0.5], p = 0.016) and technical procedures (3.22 [0.9] versus 2.22 [0.9], p = 0.04) than the PGY-1 group, but no difference for preoperative management with the numbers available (PGY-4, 3.44 [0.7] versus PGY-1 2.89 [0.8], p = 0.14). For the ankle fracture activity, the PGY-4 group scored higher for postoperative management (3.22 [0.8] versus 2.33 [0.7], p = 0.18) and technical procedures (3.22 [1.2] versus 2.0 [0.7], p = 0.018) than the PGY-1 groups, but no difference for preoperative management with the numbers available (PGY-4, 3.22 [0.8] versus PGY-1, 2.78 [0.7], p = 0.23). CONCLUSIONS: The results of our study show that simulated assessment of entrustable professional activities may be used to determine the ability of a resident to perform professional tasks that are critical components of medical training. In this manner, educators can ensure that competent performance of these skills in the simulated setting occurs before actual practice with patients in the clinical setting.

Effect of arthroscopic rotator cuff surgery in patients with preoperative restricted range of motion.

BACKGROUND: The purpose of this study was to examine the impact of rotator cuff (RC) decompression and/or repair on post-operative ROM in patients with pre-operative restricted passive motion who had undergone arthroscopic subacromial debridement and/or rotator cuff repair. Potential predictors of ROM recovery such as age, sex, mechanism of injury, type of surgery, presence of an endocrine illness and having an active Worker Compensation claim related to the shoulder were explored. METHODS: A retrospective analysis of prospectively collected data was performed. Pre-operative stiffness measured intra-operatively was defined as flexion of < =100° or external rotation of < =30° under anesthesia. Patients who received manipulation under anesthesia or required capsular release were excluded. RESULTS: Two hundred and eighteen patients met the criteria for having stiffness under anesthesia. Twenty six patients had stiffness in both directions, 19 patients had isolated restricted flexion and 173 had isolated restricted external rotation. At six months post-operatively, a statistically significant improvement was observed on average in all disability measures (P < 0.0001). The ROM improved on average in the restricted direction at 6 months (p < 0.0001). Older age had a negative impact on recovery of external rotation (F2,216 = -5.78, p = 0.02). Being a female, having a traumatic event, having a RC repair, or suffering from an endocrine illness such as diabetes, did not have a negative impact on recovery. Patients with an active work-related compensation claim showed an inferior recovery of flexion (F2,216 = -8.76, p = 0.003). CONCLUSION: Patients with RC pathology and concomitant stiffness showed significant improvement in ROM at six months following RC decompression or repair without the need for formal capsular releases or the performance of manipulation under anesthesia. Older patients and those with active Workers Compensation claim showed an inferior recovery in isolated directions.

The True Recurrence Rate and Factors Predicting Recurrent Instability After Nonsurgical Management of Traumatic Primary Anterior Shoulder Dislocation: A Systematic Review.

PURPOSE: To (1) define the cumulative recurrence rate after primary anterior shoulder dislocation in Level I and II comparative studies and (2) to pool risk ratios for common risk factors to provide a clinically practical hierarchy of modifiable and nonmodifiable risk factors for recurrence. METHODS: Level I and II prognostic studies were identified using the electronic databases CINAHL, Embase, and MEDLINE from inception to December 2014. Included studies (n = 15) had recurrent dislocation as the main outcome, and a minimum 2-year follow-up. The cumulative odds ratio of prognostic factors was calculated where appropriate. Bias was assessed in each study using the Quality in Prognosis Studies (QUIPS) tool. RESULTS: The reported rate of recurrence ranged from 19% to 88% (pooled overall = 21%; pooled Level I only = 47%). The pooled time to recurrence was 10.8 months (standard deviation 0.42). Male sex (n = 6 studies) conferred a 2.68 (1.66-4.31; P < .001) and patient age <20 years (n = 4 studies) conferred a 12.76 (5.77-28.2; P < .001; vs >20 years) increased odds of recurrence. An associated greater tuberosity fracture (n = 7 studies) decreased the odds of recurrence by 3.8 times (2.94-5.00; P < .001). The quality of evidence was moderate for age, low for sex, and very low for all other prognostic variables. CONCLUSIONS: The pooled rate of recurrence after primary anterior shoulder instability was found to be 21% among moderate- to high-quality prognostic studies. Male sex and younger age predicted a significantly higher risk of recurrent instability (approaching 80%), whereas concurrent fracture of the greater tuberosity significantly decreased the risk of subsequent recurrent dislocation. However, considering the quality of available evidence for these predictors, there remains a clear need for further high-quality prospective studies. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II prognostic studies.