Do Outcomes Differ After Proximal Hamstring Repair for Patients Receiving Workers' Compensation?

Background: Patients with workers' compensation (WC) insurance claims are often shown to experience inferior patient-reported outcomes (PROs) after an orthopaedic surgical intervention compared with patients without WC claims. Purpose: To compare the postoperative PROs of patients with WC claims (WC patients) versus those without WC claims (non-WC patients) after proximal hamstring repair (PHR). Study Design: Cohort study; Level of evidence, 3. Methods: WC patients who underwent PHR between November 2011 and to September 2020 were propensity score matched at a 1:2 ratio to non-WC patients according to age, sex, and body mass index. Comorbidity data were collected as well as minimum 1-year postoperative PRO scores for the Lower Extremity Functional Scale (LEFS), the Hip Outcome Score (HOS), and the 12-Item Short From Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS). The type of work was characterized according to national WC insurance guidelines as light (maximum 20 lbs [9.1 kg]), medium (maximum 50 lbs [22.7 kg]), or heavy (≥50 lbs) [>/=22.7 kg]. Results: A total of 30 patients (10 WC and 20 non-WC) were included. The work type and baseline demographic characteristics of patients did not differ between groups. There were no significant between-group differences in postoperative PRO scores as measured by the LEFS (P = .488), HOS (P = .233), or SF-12 PCS (P = .521). However, the WC cohort showed inferior SF-12 MCS scores compared with the non-WC group (49.28 ± 9.97 vs 54.26 ± 9.69, respectively; P = .032). The WC status was also associated with an increased time needed for patients to return to full-duty work capacity (21 ± 9 vs 9 ± 8 weeks; P = .005). Conclusion: Our findings suggest that WC and non-WC patients who undergo PHR have comparable outcomes. Differences in SF-12 MCS scores and return to work time for full-duty capacity warrant further investigation.

Opioid Consumption Patterns and Prolonged Opioid Use Among Opioid-Naïve Ankle Fracture Patients.

INTRODUCTION: Previous literature has demonstrated an association between acute opioid exposure and the risk of long-term opioid use. Here, the investigators assess immediate postoperative opioid consumption patterns as well as the incidence of prolonged opioid use among opioid-naïve patients following ankle fracture surgery. METHODS: Included patients underwent outpatient open reduction and internal fixation of an ankle or tibial plafond fracture over a 1-year period. At patients' first postoperative visit, opioid pills were counted and standardized to the equivalent number of 5-mg oxycodone pills. Prolonged use was defined as filling a prescription for a controlled substance more than 90 days after the index procedure, tracked by the New Jersey Prescription Drug Monitoring Program up to 1 year postoperatively. RESULTS: At the first postoperative visit, 173 patients consumed a median of 24 out of 40 pills prescribed. The initial utilization rate was 60%, and 2736 pills were left unused. In all, 32 (18.7%) patients required a narcotic prescription 90 days after the index procedure. Patients with a self-reported history of depression (P = .11) or diabetes (P = .07) demonstrated marginal correlation with prolonged narcotic use. CONCLUSION: Our study demonstrated that, on average, patients utilize significantly fewer opioid pills than prescribed and that many patient demographics are not significant predictors of continued long-term use following outpatient ankle fracture surgery. Large variations in consumption rates make it difficult for physicians to accurately prescribe and predict prolonged narcotic use. LEVEL OF EVIDENCE: Level III.

Relationship of Subtalar Joint Range of Motion to Ankle Injuries in NBA G League and Collegiate Basketball Players.

BACKGROUND: This study sought to determine whether range of motion (ROM) of the ankle and subtalar joint complex (STJ) is correlated with ankle injuries in National Basketball Association (NBA) G-league and collegiate basketball players to identify an at-risk population that may benefit from participation in an ankle injury prevention program. METHODS: This prospective cohort study encompassed 103 player-seasons (68 collegiate, 35 NBA G-League). Patient demographics, passive ankle and STJ range of motion measurements, anterior drawer, and talar tilt tests were collected at preseason physicals along with plain radiographs. Subtalar eversion and inversion measurements were added to assess the Combination Motion (CM) of the STJ and subtracted to calculate the Subtalar Difference (SD). We defined the ratio of CM to SD as Subtalar Mobility Index (SMI=CM/SD). RESULTS: Twenty-one ankle injuries occurred with 10 405 player exposures yielding an incidence of 2.11/1000 exposures, resulting in 113 days of missed playing time. No direct measures of ankle, subtalar, or combined motion were associated with risk of injury, rejecting our original hypothesis that increased STJ ROM would predispose to ankle injuries. However, we did find that athletes with CM >16 degrees in combination with either SD <6 degrees (P = .025) or SMI >3.75 (P = .032) were nearly 3 times more likely to have an ankle injury (3.14 vs 2.97, respectively). CONCLUSION: Using the predictive subtalar mobility thresholds found in this study may help identify at-risk players that may benefit from targeted ankle injury prevention programs. LEVEL OF EVIDENCE: Level II, prospective cohort study.

A novel comorbidity risk score for predicting postoperative 30-day complications in total shoulder arthroplasty and elucidation of potential racial disparities.

Background: Efficient and effective preoperative identification of those patients with elevated risk may allow for more cost-effective interventions, accurate bundled payment adjustments, and overall improved patient care. Few comorbidity indices have provided clinical utility and adequate discriminative ability in the setting of complications after shoulder arthroplasty (SA). Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for anatomic and/or reverse SA procedures between 2010 and 2019. A subset of comorbidities were utilized including end-stage renal disease, history of hypertension, chronic obstructive pulmonary disease, functional status, history of bleeding disorder, and disseminated cancer. Results: A total of 25,927 patients with an average age of 69.2 (standard deviation ±9.5) years were included in the study. Patients with a comorbidity risk score (CRS) at or above 2 were indicated to have at least a 29.6% 30-day postoperative complication rate after undergoing total shoulder arthroplasty, significantly higher than the described average of approximately 15%. The area under receiver operator curve for the novel CRS scoring system was 0.595, indicating fair discriminative ability to predict 30-day postoperative complications after SA. This illustrates a discriminative ability similar to that of the American Society of Anesthesiologists classification (0.584, confidence interval [CI] 0.578-0.589), modified Charlson Comorbidity Index (0.567, CI 0.561-0.573), and modified Frailty Index (0.534, CI 0.529-0.539), each of which are common comorbidity indices used for the National Surgical Quality Improvement Program database. The average CRS for the population was 0.8537 (CI 0.8011-0.8150; P < .05) while that for the Black demographic was 1.08 (CI 1.03-1.13; P < .001). Our results suggest that if the disparity in CRS among races was corrected, the average complication rate would be decreased by 2.0%. Discussion and Conclusion: A higher CRS score resulted in higher rates of 30-day postoperative complications following SA. Black patients had a higher average CRS than all other races illustrating a racial disparity in comorbidity risk. Although the average complication rate of each race would still be unequal, this could mitigate some of the racial disparities observed and decrease the overall 30-day complication rate in SA. With the rise of bundled payments further increasing the need to preoperatively identify patients at high risk for costly complications, the CRS is based on easily identified, relevant comorbidities that may be an advantageous tool to identify patients at increased risk of complications following SA.

A validated algorithm using current literature to judge the appropriateness of anatomic total shoulder arthroplasty utilizing the RAND/UCLA appropriateness method.

BACKGROUND: Currently, appropriateness criteria evaluating when to perform total shoulder arthroplasty (TSA) is lacking. In the absence of society guidelines and limited quality evidence, the RAND/University California in Los Angeles (UCLA) method provides a suitable alternative to evaluate appropriateness and assist in clinical decision making. Given the rise in utilization, appropriateness criteria for TSA have the potential to be an extremely powerful tool for improving quality of care and controlling costs. Thus, the goal of this study was to test explicit criteria to assess the appropriateness of TSA decision making using the RAND/UCLA appropriateness method. METHODS: A review of recent scientific literature to gather available evidence about the use, effectiveness, efficiency, and the risks involved in surgical intervention was performed by a shoulder/elbow fellowship trained physician. Based on pertinent variables including age, rotator cuff status, previous surgical management, mobility, symptomatology, and imaging classifications, 186 clinical scenarios were created. Appropriateness criteria for TSA were developed using a modified Delphi method with a panel consisting of American Shoulder and Elbow Surgeons (ASES) members. A second panel of ASES members rated the same scenarios, with reliability testing performed to compare groups. RESULTS: Panel members reached agreement in 40 (64%) indications. TSA was appropriate in 15 (24%) of indications. For patients with severe symptomatology, TSA was often appropriate for patients aged <75 years and inconclusive or inappropriate for patients aged >75 years. Among patients aged <65 years, TSA varied between appropriate and inconclusive, often dependent on Walch classification. For patients with moderate symptomatology, TSA was inappropriate or inconclusive for patients aged <65 or >75 years. When compared to the second panel's results, moderate agreement was obtained with a weighted kappa statistic of 0.56. CONCLUSIONS: Using the RAND/UCLA method, ASES members created an appropriateness decision tree for pertinent patient variables. This presents the data in a manner that streamlines the clinical decision-making process and allows for rapid and more reliable determination of appropriateness for practitioners. The decision tree is based on a combination of clinical experience from high-volume ASES-member surgeons and a comprehensive review of current evidence. This tool can be used as part of a broader set of factors, including individual patient characteristics, prior studies, and expert opinion, to inform clinical decision making, improve quality of care, and control costs.

Investigating a Potential Limit to Access to Care: Preoperative Cutoff Values for Body Mass Index for Shoulder Arthroplasty.

INTRODUCTION: The primary purpose of this study was to determine the number of patients who would be denied a complication-free total shoulder arthroplasty (TSA) based on implementation of body mass index (BMI) eligibility cutoffs. METHODS: The National Surgical Quality Improvement Program database was queried to identify all patients who underwent primary TSA. Patient demographics and 30-day postoperative complications were compared according to BMI stratification using the Pearson chi-square test and binary logistic regression analysis adjusted for age and modified Charlson comorbidity index. A BMI eligibility criterion of ≥40 kg/m2 was used to calculate the positive predictive value (PPV) to assess the number of complication-free TSAs that would be denied to avoid a complication in a single patient. RESULTS: A total of 23,284 patients who underwent TSA met inclusion criteria. The overall complication rate was 7.2%. Using a BMI cutoff of ≥40 kg/m2 would yield a PPV of 7% for all Major Complications. This means that 14 complication-free procedures would be denied to avoid a Major Complication. In addition, BMI ≥40 kg/m2 served as an independent risk factor for acute renal failure, pulmonary embolism, ventilator use >48 hours, and readmission. The PPV for these clinically significant complications using BMI ≥40 kg/m2 as a cutoff was 4.9%. This translates into 20 patients being denied a complication-free procedure to avoid a single clinically significant medical complication. If this policy was enforced on the 2,426 patients who exceeded BMI ≥40 kg/m2 in this study, nearly 2,307 patients would be denied the potential benefit of surgery to prevent 119 complications. CONCLUSION: The use of eligibility criteria for primary TSA or RSA based solely on BMI threshold values presents a potential limitation in access to care to these patients who otherwise would have a complication-free procedure. LEVEL OF EVIDENCE: Level III, prognostic, retrospective cohort study.

Primary reverse total shoulder arthroplasty performed for glenohumeral arthritis: does glenoid morphology matter?

BACKGROUND: Indications for reverse total shoulder arthroplasty (RTSA) have expanded to include primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. Limited evidence exists on RTSA in patients with primary GHOA and no posterior glenoid wear (Walch A1, A2, and B1 morphologies). The purpose of this retrospective cohort study was to determine if glenoid morphology is associated with clinical outcomes in patients undergoing RTSA for primary GHOA. METHODS: A retrospective review of prospectively collected data was performed in patients undergoing primary RTSA for GHOA with a minimum of 2-year clinical follow-up. Preoperative computed tomography and magnetic resonance imaging were used to categorize glenoid morphology as described by the modified Walch classification. Pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) pain scores, and range of motion (ROM) measurements were compared across Walch glenoid subtypes. The percentage of patients that reached previously established clinically significant thresholds for minimal clinically important difference (MCID) and substantial clinical benefit (SCB) was also comparatively assessed. Multivariable analysis was used to evaluate the association between glenoid morphology and postoperative ASES score while controlling for potentially confounding variables. RESULTS: Of the 247 consecutive patients, 197 were available at a minimum 2-year follow-up (80%). Significant improvements were seen in ASES, VAS pain, SANE, and ROM from baseline to final postoperative follow-up in the combined patient cohort (all P < .001). Most (98.0%) patients reached MCID, and 90.9% of patients reached SCB for ASES threshold. No significant differences were found among Walch subtypes in terms of preoperative to postoperative improvement in ASES (P = .39), SANE (P = .4), VAS pain (P = .49), forward elevation (P = .77), external rotation (P = .45), or internal rotation (P= 0.1). The only significant difference in postoperative outcomes between Walch glenoid subtypes was higher postoperative ASES scores among type B3 glenoids compared with type A1 glenoids (P = .03) on univariate analysis. However, no individual Walch glenoid subtype was associated with lower postoperative ASES scores on multivariable analysis (P > .05). CONCLUSION: Primary RTSA provides excellent short-term outcomes in patients with glenohumeral arthritis with intact rotator cuff, regardless of the degree of preoperative glenoid deformity. Surgeons can use these data to support the use of RTSA for glenohumeral arthritis in a more standardized way.

Clinical Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Primary Glenohumeral Osteoarthritis Compared With Rotator Cuff Tear Arthropathy: Does Preoperative Diagnosis Make a Difference?

INTRODUCTION: The primary purpose of this study was to evaluate the clinical outcomes of patients who underwent reverse total shoulder arthroplasty performed for primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff compared with rotator cuff tear arthropathy (CTA). METHODS: This was a retrospective review of prospectively collected data including consecutive patients who underwent primary reverse total shoulder arthroplasty for GHOA or CTA with a minimum of 2-year follow-up. Baseline patient demographics and clinical outcomes including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation, and visual analog scale for pain were collected. Univariate and multivariate regression analyses were performed to evaluate the effect of preoperative diagnosis on clinical outcomes. RESULTS: Patients with a preoperative diagnosis of GHOA demonstrated significantly better postoperative active forward elevation (138.6° versus 127.3°; P < 0.01), external rotation (54.2° versus 43.8°; P < 0.01), and change in internal rotation (Δ 2.1 points versus Δ 1.2 points; P < 0.01). Patients with GHOA demonstrated significantly better postoperative ASES (86.8 versus 76.6; P < 0.01), Single Assessment Numerical Evaluation (89.7 versus 78.5; P < 0.01), and visual analog scale scores (0.63 versus 1.2; P < 0.01). Minimal clinically important difference for ASES score was achieved by 97.5% of patients with GHOA compared with 86.7% of patients with CTA (P < 0.01), whereas substantial clinical benefit was achieved by 90.4% of patients with GHOA and 71.7% of patients with CTA (P < 0.01). After a multivariate linear regression analysis, postoperative ASES scores were independently associated with previous ipsilateral shoulder surgery (P = 0.042), preoperative ASES score (P = 0.01), and primary diagnosis of GHOA (P < 0.01). CONCLUSION: RTSA performed in patients with GHOA and an intact rotator cuff is associated with improved functional and clinical outcomes compared with those patients treated for CTA. LEVEL OF EVIDENCE: Level III Therapeutic Study.

Surgical Technique for Superior Capsule Reconstruction With 6-mm Acellular Dermal Allograft and Knotless Glenoid Anchors.

Superior capsule reconstruction (SCR) creates a humeral head depressor in the setting of a massive, irreparable rotator cuff tear. Recently, a 6-mm-thick acellular dermal allograft (ACD) has been shown to be noninferior to the standard fascia lata autograft in recreating native shoulder biomechanics. This paper outlines a reproducible means by which to perform an arthroscopic SCR using a 6-mm ACD. A standard diagnostic arthroscopy first assesses the integrity of the subscapularis and infraspinatus tendons. The glenoid anchors are then placed. Accessory anterior and posterolateral portals are made as well as a lateral portal by which to shuttle the graft. Suture management is paramount. Ideally allograft preparation occurs on the back table simultaneously to maintain efficiency. Suture passage through premade holes in the graft, and when the sutures have passed through and been tensioned, the graft is shuttled into place and tied down with medial and lateral row anchors in SpeedBridge fashion. The thickness of ACD has been shown to influence the ability of the reconstructed superior capsule to perform its role as a humeral head depressor. This technique describes the use of a 6-mm-thick ACD to perform an arthroscopic SCR that minimizes both donor-site morbidity and operative time.

The Effect of State Legislation on Opioid Prescriptions Following Arthroscopic Rotator Cuff Repair.

New Jersey State Law, P.L. 2017 Chapter 28 22, C.24:21-15.2, passed in February 2017, is the most restrictive opioid legislation passed thus far in the United States. This study evaluated the effects of this legislation on the postoperative opioid prescriptions of patients undergoing arthroscopic rotator cuff repair (RCR). Opioid prescriptions were compared following arthroscopic RCR before and after implementation of the new law using the New Jersey Prescription Monitoring Program Aware Drug Database. A consecutive cohort of patients who underwent RCR during a 6-month period prior to the legislation was compared with a consecutive cohort of patients who underwent RCR during a 6-month period after the law went into effect. The primary outcome measure was prescribed postoperative milligram morphine equivalents (MME) and number of pills prescribed. There were 265 patients in the pre-law cohort and 198 patients in the post-law cohort. In the pre-law cohort, there was a median of 1250 MME (interquartile range [IQR], 900-1800 MME) and a median of 100 pills (IQR, 60-175 pills) prescribed postoperatively. In the post-law cohort, a median of 900 MME (IQR, 550-1050 MME) and a median of 60 pills (IQR, 60-90 pills) were prescribed postoperatively. A comparison of pre-law and post-law data for MME and number of pills prescribed was statistically significant (P<.001). The median opioid consumption MME and number of pills prescribed following RCR decreased significantly following the implementation of the New Jersey state law. Findings of this study indicate state regulations may play a role in reducing narcotic consumption following RCR. [Orthopedics. 2021;44(1):e80-e84.].

Scapular Dyskinesis and the Kinetic Chain: Recognizing Dysfunction and Treating Injury in the Tennis Athlete.

PURPOSE OF REVIEW: This article aims to provide a comprehensive understanding of the evaluation, diagnosis, and management of scapular dyskinesis and its impact on the kinetic chain in tennis athletes. RECENT FINDINGS: Optimal glenohumeral biomechanics are intimately associated with proper scapular motion and function. The tennis serve requires the scapula to act as a force transducer in the kinetic chain to convert potential energy generated in the lower extremities to kinetic energy in the upper extremity. Any aberration within this complex kinetic chain will result in force uncoupling and increases the potential for injury through compensatory mechanisms. Specifically, scapular dyskinesis has been associated with an increased risk of shoulder pain of up to 43% in overhead athletes. These pathologies include rotator cuff disease, subacromial and posterior impingement, labral injuries, and SLAP tears. Although the direct causality of these injuries remains controversial, multiple kinematic studies have demonstrated altered scapular positioning increasing the predilection for soft tissue pathology. The diagnosis of scapular dyskinesis is predicated upon a thorough history, physical examination, and observational analysis of key nodes in the kinetic chain during tennis activity. Conservative management remains the mainstay of treatment and consists of a graduated physical therapy regimen. Although shoulder pain in the overhead athletes is often multifactorial, early recognition and treatment of scapular dyskinesis generally carry a favorable prognosis and result in improved patient outcomes.

Patient-Reported Outcomes After Arthroscopic Shoulder Surgery With Interscalene Brachial Plexus Nerve Block Using Liposomal Bupivacaine: A Prospective Observational Study.

BACKGROUND: Interscalene brachial plexus nerve blocks (ISBPNBs) are commonly used to mitigate postsurgical pain after shoulder surgery. MATERIALS AND METHODS: We performed a prospective observational study in 57 consecutive adult patients undergoing arthroscopic shoulder surgery with an ultrasound-guided ISBPNB using liposomal bupivacaine (LB; 133mg/10ml) mixed with 0.5% bupivacaine (10ml). All patients received prescriptions for 1000mg of oral acetaminophen and 10 5mg oxycodone tablets upon discharge. RESULTS: Post-discharge telephone surveys revealed that mean (standard deviation [SD]) patient-reported motor and sensory recovery times after surgery were 26.8 (3.2) and 34.0 (3.6) hours, respectively. The average (SD) visual analog scale pain score was 5.1 (3.1) at day two post-surgery. The estimated opioid utilization rate at day seven post-surgery was 21% of the prescribed opioid tablets. CONCLUSIONS: Our real-world observational findings suggest that multimodal postsurgical pain control using single-shot, ultrasound-guided ISBPNB with LB and postsurgical acetaminophen provides favorable pain control and limited need for postsurgical opioid rescue for seven days after shoulder surgery.

Prospective Evaluation of Utilization Patterns and Prescribing Guidelines of Opioid Consumption Following Orthopedic Foot and Ankle Surgery.

BACKGROUND: Overprescription of narcotic pain medication is a major culprit in the present opioid epidemic plaguing the United States. The current literature on lower extremity opioid usage has limitations and would benefit from additional study. The purpose of our study was to prospectively assess opioid consumption patterns following outpatient orthopedic foot and ankle procedures. METHODS: Patients undergoing outpatient orthopedic foot and ankle procedures who met inclusion criteria had the following prospective information collected: patient demographics, preoperative health history, patient-reported outcomes, anesthesia type, procedure type, opioid prescription and consumption details. The morphine equivalent dose was calculated for each prescription and then converted to the equivalent of a 5-mg oxycodone "pill." Univariable analyses were performed to identify variables with a statistically robust association with opioid consumption for inclusion in a multivariable linear regression. A stepwise backward regression was then performed to identify independent predictors of opioid consumption. Postoperative opioid utilization was reported for 988 patients (mean age: 49 years). RESULTS: Overall, patients consumed a median of 20 pills whereas the median number of pills prescribed was 40. This resulted in a utilization rate of 50% and 20 631 pills left unused. Independent factors associated with higher opioid consumption were anesthesia type ( P < .004), age <60 years ( P < .001), preoperative visual analog scale (VAS) pain report of >6 ( P = .008), and bony procedures ( P = .008); residual standard error 16.73 ( F7,844=14.3, P < .001). CONCLUSION: Our study found that patients who underwent orthopedic foot and ankle procedures were overprescribed narcotic medication by nearly twice the amount that was actually consumed. Although we identified 4 independent factors associated with opioid consumption, the large residual standard error suggests that there remains a substantial degree of unexplained variance of opioid consumption observed in the patient population. Physicians face a challenging task of setting appropriate protocols when balancing pain relief and generalizable guidelines. LEVEL OF EVIDENCE: Level II, prospective observational cohort study.

Predicting Failure of Nonoperative Treatment for Insertional Achilles Tendinosis.

Nonoperative treatment for midportion Achilles tendinosis is well defined by the literature. Multiple modalities are described for the management of insertional Achilles pathology, but no consensus exists regarding efficacy. Surgical intervention for insertional Achilles tendinosis (IAT) is successful greater than 80% of the time. Our objective was to risk stratify patients who would fail nonsurgical management of IAT and thus benefit progressing to surgery. We reviewed the records of 664 patients with IAT. The cohort was 53% male and 80% obese. Mean age was 53.7 years (standard deviation 14.7 years). Average duration of symptoms was 10.4 months (standard deviation 28 months). Of the parameters collected, 4 were found to correlate with failing nonoperative treatment: visual analog scale, limited ankle range of motion, previous corticosteroid injection, and presence of Achilles tendon enthesophyte. We found that as the number of risk factors increased so did the chance of failing nonoperative treatment. With all 4 parameters, chance of failing conservative treatment was only 55%. Thus, nonoperative management should be exhausted until surgery is the only remaining option. However, the presence of one of the aforementioned risk factors can aid a surgeon in the decision to pursue surgery in the appropriate clinical scenario. LEVELS OF EVIDENCE: Level IV: Retrospective Case series.

Content Relevance of the Foot and Ankle Ability Measure in Patients With Achilles Tendon Diseases.

BACKGROUND: The Foot and Ankle Ability Measure (FAAM) is among the most widely utilized and best psychometrically supported lower extremity-specific patient-reported outcome measures. However, its content relevance has never been directly subjected to patient assessment. METHODS: This was an institutional review board-approved, prospective, cross-sectional study of 75 patients with Achilles tendon diseases who ranked the relevance of the FAAM's items and subscales as 1 = Not relevant, 2 = Somewhat relevant, or 3 = Very relevant. Substantial content relevance was indicated by a minimum mean item or subscale score of 2.0. Nonsurgical and surgical subgroups were compared. RESULTS: At the whole group level, the mean score was above 2.0 for each individual item and subscale. Subgroup analysis revealed that the mean relevance was above 2.0 for each of the items and subscales with the exception of the "Personal Care" item, which nonsurgical patients ranked significantly lower than did surgical patients (mean = 1.74 vs 2.23, P = .02). Additionally, this was part of a general trend across items with more 95% confidence intervals crossing below 2.0 in the nonsurgical data set (15 items, 52%) than the surgical data set (1 item, 3%). CONCLUSION: These data confirm that the FAAM has substantial content relevance to patients with Achilles tendon diseases. However, it is unclear why the surgical subgroup consistently ranked items higher than did the nonsurgical subgroup. Future work should address how a patient's content relevance perception is influenced by the relative effects of their Achilles disease type and their perceived level of disease-related functional impairment. LEVELS OF EVIDENCE: Diagnostic, Level III.

Office-Based Needle Arthroscopy: A Standardized Diagnostic Approach to the Knee.

Surgical knee arthroscopy is among the most commonly performed procedures in the United States. The decision to treat is often based on clinical examination and magnetic resonance imaging. Equivocal results frequently require patients to undergo surgical arthroscopy, exposing the patient to inherent risks and potential surgical complications. Office-based needle arthroscopy provides an alternative approach to visualizing intra-articular anatomy and pathology in real time. The purpose of this article is to provide a standardized diagnostic approach to needle arthroscopy of the knee.

Achilles Tendon Disorders.

Disorders of the Achilles tendon, the largest tendon in the human body, are common and occur in both active and sedentary persons. A thorough history and physical examination allow primary care physicians to make an accurate diagnosis and to initiate appropriate management. Mismanaged or neglected injuries markedly decrease a patient's quality of life. A growing body of related literature is the basis for current therapeutic regimens, which use a multimodal conservative approach, including osteopathic manipulative treatment. Although primary care physicians can manage most cases of Achilles tendon disorders, specialty care may be needed in certain instances. Procedural intervention should consider any comorbid conditions in addition to patients' lifestyle to help guide decision making. When appropriately managed, Achilles tendon disorders generally carry a favorable prognosis.

Diagnosis and management of plantar fasciitis.

Plantar fasciitis, a chronic degenerative process that causes medial plantar heel pain, is responsible for approximately 1 million physician visits each year. Individuals with plantar fasciitis experience pain that is most intense during their first few steps of the day or after prolonged standing. The authors provide an overview of the diagnosis and management of a common problem encountered in the primary care setting. Routine imaging is not initially recommended for the evaluation of plantar fasciitis but may be required to rule out other pathologic conditions. Overall, plantar fasciitis carries a good prognosis when patients use a combination of several conservative treatment modalities. Occasionally, referral to a specialist may be necessary.