Sustainability studies in orthopaedic surgery: The carbon footprint of anterior cruciate ligament reconstruction depends on graft choice.

PURPOSE: Environmental sustainability in medicine is a growing concern. Determining the carbon footprint of medical procedures may aid in selecting a less impactful technique moving forward. The purpose of this study was to understand the environmental impact of different anterior cruciate ligament reconstruction techniques, for which there is no consensus in terms of optimal graft. METHODS: A life cycle analysis of different anterior cruciate ligament reconstruction techniques was performed. These included quadrupled semitendinosus graft, bone-patellar tendon-bone graft, iliotibial band augmented with gracilis graft, doubled semitendinosus and doubled gracilis graft, and quadriceps tendon graft. All procedures were systematically paired with a lateral extra-articular procedure. The study was conducted in a specialised centre using surgeon preference cards, with the help of a dedicated organisation for calculation according to the ISO 14044 standard. The primary outcome measure was the carbon footprint of each of the five techniques. Secondary outcomes included other environmental impact indicators, including human carcinogenic toxicity and mineral resource scarcity, among others, based on the ReCiPe 2016 midpoint guideline. The analysis had three scopes, each encompassing varying numbers of processes: graft implantation, full procedure, and entire environmental impact, from medical prescription to patient discharge. Results were reported as percentage increases compared to the graft technique with the lowest environmental impact. RESULTS: It was demonstrated that the surgical procedure itself accounted for <40% of the life cycle, with arthroscopy being 88% of surgery's GHG emissions, and scrubbing and draping contributing 39% to the carbon footprint. The iliotibial band augmented with gracilis tendon technique had the lowest carbon footprint (0.199 Kg Co2 eq), and the least impact in most categories at all scopes of the life cycle analysis. Using this technique as a reference, in terms of graft implantation, it was determined that extensor mechanism grafts had the highest carbon footprint (300% higher than the reference). Greater scopes showed a similar trend, with percentage differences decreasing significantly, reaching 1-3% when considering the entire environmental impact for most categories. Nevertheless, among the aforementioned factors of the ReCiPe 2016 guidelines, the semitendinosus graft paried with a lateral extra-articular procedure displayed greater difference in human carcinogenic toxicity and mineral resource scarcity (6% and 10% respectively) compared to the reference. The individual processes with the highest impact were also highlighted. CONCLUSIONS: In the institution where the study was conducted, the studied iliotibial band graft option was found to have the lowest environmental impact. Such analyses of standardised procedures can be replicated in individual institutions in order to determine their environmental impact. Identification of procedures with comparable results and differing environmental consequences may influence the future decision-making process. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Mapping competency in public health training - experience of the Europubhealth consortium.

BACKGROUND: Public health education aims at producing a competent workforce. The WHO-ASPHER framework proposes a set of relevant public health competencies organised in 10 sections (e.g. science practice, leadership, law policies and ethics etc). As part of the Europubhealth (EPH) consortium, eight universities collaborate for the delivery of a 2-year international public health master course. The training pathway includes a first "foundation" year, with a choice of four options (components), and a second "specialisation" year with a choice of seven components. In 2020, EPH consortium decided to use the WHO-ASPHER framework in order to map the competencies addressed and the level of proficiency targeted by each component of its master course. METHODS: An 84-item questionnaire covering the whole WHO-ASPHER framework was sent to the 11 EPH component coordinators, asking them to rate the proficiency levels targeted at the end of their courses. Answers from each coordinator were summarised by calculating mean proficiency levels for each of the 10 competency sections. We used Bland & Altman plots to explore heterogeneity of answers and then calculated transformed scores to account for rating heterogeneity. We use tabulation and a heat map to explore patterns of proficiency levels across components. RESULTS: There were differences in overall proficiency levels between years with, as expected, higher scores in year two. Year one components reached medium to high proficiency scores for the sections "science practice", "health promotion" and "communication" with scores ranging from 2.6 to 3 (on a 1-low to 4-high scale). When compared with year one on a heat-map, year two components displayed more contrasted profiles, typically aiming for high proficiency level (i.e. scores above 3.5) on 3 out of the 10 sections of competencies. Except for the "collaborations and partnership" section, the training pathways offered by the EPH master course seem to offer opportunities for a high proficiency level in all domains of competencies. CONCLUSIONS: The mapping proved a useful exercise to identify strengths and complementarities among the EPH consortium. The results suggest that the EPH master course is coherent and offers students opportunities to gain proficiency in most competencies relevant to public health practice.

Impact of recommendations on sodium valproate prescription among women with epilepsy: An interrupted time-series study.

BACKGROUND: The European Medicines Agency (EMA) has developed risk minimization measures (RMMs) to reduce the use of the teratogenic drug, sodium valproate (VPA). The objective was to assess the impact of these RMMs among females with epilepsy in France. METHODS: We used data from the French National Health Insurance Database (SNDS), including 114,936 females aged under 50, with a reimbursement claim for an antiepileptic drug from January 2011 to December 2017, and identified as people with epilepsy. We used a controlled interrupted time series stratifying on age: girls (0-14 years old) and women of childbearing age (15-49 years), and with 129,917 males as controls. RESULTS: VPA prevalent use among girls and women of childbearing age with epilepsy decreased significantly after the issue of the RMMs (trend changes of, respectively, -5 and -4 users per 1000 females at-risk per quarter in comparison to the control group). We did not detect any significant change in VPA incident use. CONCLUSIONS: VPA use decreased over the study period among females with epilepsy but there were still 317 women and 206 girls started on VPA therapy VPA in 2017 (8 per 1000 at-risk and 18 per 1000, respectively). This suggests that either the measures should be strengthened or that the lowest level of VPA use has been reached. In this context, the introduction of a new RMM (in 2018) needs to be evaluated.

Gender difference of geographic distribution of the stroke incidence affected by socioeconomic, clinical and urban-rural factors: an ecological study based on data from the Brest stroke registry in France.

BACKGROUND: Mapping the spatial distribution of disease occurrence is a strategy to identify contextual factors that could be useful for public health policies. The purpose of this ecological study was to examine to which extent the socioeconomic deprivation and the urbanization level can explain gender difference of geographic distribution in stroke incidence in Pays de Brest, France between 2008 and 2013. METHODS: Stroke cases aged 60 years or more were extracted from the Brest stroke registry and combined at the census block level. Contextual socioeconomic, demographic, and geographic variables at the census block level come from the 2013 national census. We used spatial and non-spatial regression models to study the geographic correlation between socioeconomic deprivation, degree or urbanization and stroke incidence. We generated maps using spatial geographically weighted models, after longitude and latitude smoothing and adjustment for covariates. RESULTS: Stroke incidence was comparable in women and men (6.26 ± 3.5 vs 6.91 ± 3.3 per 1000 inhabitants-year, respectively). Results showed different patterns of the distribution of stroke risk and its association with deprivation or urbanisation across gender. For women, stroke incidence was spatially homogeneous over the entire study area, but was associated with deprivation level in urban census blocks: age adjusted risk ratio of high versus low deprivation = 1.24, [95%CI 1.04-1.46]. For men, three geographic clusters were identified. One located in the northern rural and deprived census blocks with a 9-14% increase in the risk of stroke. Two others clusters located in the south-eastern (mostly urban part) and south-western (suburban and rural part) with low deprivation level and associated with higher risk of stroke incidence between (3 and 8%) and (8.5 and 19%) respectively. There were no differences in profile of cardiovascular risk factors, stroke type and stroke severity between clusters, or when comparing clusters cases to the rest of the study population. CONCLUSIONS: Understanding whether and how neighborhood and patient's characteristics influence stroke risk may be useful for both epidemiological research and healthcare service planning.

Correction to: Vancomycin-soaked autografts during ACL reconstruction reduce the risk of post-operative infection without affecting return to sport or knee function.

The article Vancomycin­soaked autografts during ACL reconstruction reduce the risk of post­operative infection without affecting return to sport or knee function, written by Yoann Bohu.

Vancomycin-soaked autografts during ACL reconstruction reduce the risk of post-operative infection without affecting return to sport or knee function.

PURPOSE: To compare return to sport and knee function 1 year after anterior cruciate ligament (ACL) reconstruction using autografts with and without vancomycin presoaking. METHODS: A case-control study based on a retrospective analysis of prospective data included athletes over the age of 16 operated from 2012 to 2018 for ACL reconstruction. There were two groups of patients due to a change in treatment protocols: Group 1 « without vancomycin ¼ before November 2016 and Group 2 « with vancomycin¼ after this date. In Group 2, the graft was soaked in a vancomycin solution for 10 min and then fixed into the bone tunnels. The primary evaluation criterion was the return to sport 1 year after surgery. The secondary criteria were various knee scores. The number of patients needed to perform a non-inferiority study was calculated. RESULTS: 1674 patients fulfilled the selection criteria, 1184 in Group 1 and 490 in Group 2. The series included 1112 men and 562 women, mean age 30 ± 9.7 years, 68 professional athletes, 674 competitive athletes and 932 recreational athletes. While seven patients presented with post-operative septic arthritis in Group 1, this complication was not found in Group 2. No significant difference was identified in the return to running between the two groups 1 year after surgery (75.9% vs. 76.1%, n.s.). Significantly more of the patients in Group 2 returned to their preinjury sport (p = 0.04). Knee function was comparable between the groups. CONCLUSION: Vancomycin-soaked grafts during ACL reconstruction reduce the risk of post-operative infection of the knee without affecting the return to sport or knee function. LEVEL OF EVIDENCE: III. TRIAL REGISTRATION: https://clinicaltrials.gov/ , ClinicalTrials.gov Identifier: NCT02511158.

Determinants of Case Fatality After Hospitalization for Stroke in France 2010 to 2015.

Background and Purpose- The aims of this study were to (1) describe early and late case fatality rates after stroke in France, (2) evaluate whether their determinants differed, and (3) analyze time trends between 2010 and 2015. Methods- Data were extracted from the Système National des données de santé database. Patients hospitalized for stroke each year from 2010 to 2015, aged ≥18 years, and affiliated to the general insurance scheme were selected. Cox regressions were used to separately analyze determinants of 30-day and 31- to 365-day case fatality rates for each stroke type (ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage). Results- In 2015, of the 73 124 persons hospitalized for stroke, 26.8% died in the following year, with the majority of deaths occurring within the first 30 days (56.9%). Nonadmission to a stroke unit, older age, and having comorbidities were all associated with a poorer 30-day and 31- to 365-day prognosis. Female sex was associated with a lower 31- to 365-day case fatality rate for all patients with stroke. Living in an area with a high deprivation index was associated with both higher 30-day and 31- to 365-day case fatality rates for all stroke types. Between 2010 and 2015, significant decreases in both 30-day and 31- to 365-day case fatality rates for ischemic patients were observed. Conclusions- Case fatality rates after stroke remained high in 2015 in France, despite major improvements in stroke care and organization. Improvement in stroke awareness and preparedness, particularly in the most deprived areas, together with better follow-up after the acute phase are urgently needed.

Stroke Incidence and Case Fatality According to Rural or Urban Residence: Results From the French Brest Stroke Registry.

Background and Purpose- Recent findings suggest that in the United States, stroke incidence is higher in rural than in urban areas. Similar analyses in other high-income countries are scarce with conflicting results. In 2008, the Brest Stroke Registry was started in western France, an area that includes about 366 000 individuals living in various urban and rural settings. Methods- All new patients with stroke included in the Brest Stroke Registry from 2008 to 2013 were classified as residing in town centers, suburbs, isolated towns, or rural areas. Poisson regression was used to analyze stroke incidence and 30-day case fatality variations in the 4 different residence categories. Models with case fatality as outcome were adjusted for age, stroke type, and stroke severity. Results- In total, 3854 incident stroke cases (n=2039 women, 53%) were identified during the study period. Demographic and socio-economic characteristics and primary healthcare access indicators were significantly different among the 4 residence categories. Patterns of risk factors, stroke type, and severity were comparable among residence categories in both sexes. Age-standardized stroke rates varied from 2.90 per thousand (95% CI, 2.59-3.21) in suburbs to 3.35 (95% CI, 2.98-3.73) in rural areas for men, and from 2.14 (95% CI, 2.00-2.28) in town centers to 2.34 (95% CI, 2.12-2.57) in suburbs for women. Regression models suggested that among men, stroke incidence was significantly lower in suburbs than in town centers (incidence rate ratio =0.87; 95% CI, 0.77-0.99). Case fatality risk was comparable across urban categories but lower in rural patients (relative risk versus town centers: 0.76; 95% CI, 0.60-0.96). Conclusions- Stroke incidence was comparable, and the 30-day case fatality only slightly varied in the 4 residence categories despite widely different socio-demographic features covered by the Brest Stroke Registry.

National Trends in Patients Hospitalized for Stroke and Stroke Mortality in France, 2008 to 2014.

BACKGROUND AND PURPOSE: Stroke is the leading cause of death in women and the third leading cause in men in France. In young adults (ie, <65 years old), an increase in the incidence of ischemic stroke was observed at a local scale between 1985 and 2011. After the implementation of the 2010 to 2014 National Stroke Action Plan, this study investigates national trends in patients hospitalized by stroke subtypes, in-hospital mortality, and stroke mortality between 2008 and 2014. METHODS: Hospitalization data were extracted from the French national hospital discharge databases and mortality data from the French national medical causes of death database. Time trends were tested using a Poisson regression model. RESULTS: From 2008 to 2014, the age-standardized rates of patients hospitalized for ischemic stroke increased by 14.3% in patients <65 years old and decreased by 1.5% in those aged ≥65 years. The rate of patients hospitalized for hemorrhagic stroke was stable (+2.0%), irrespective of age and sex. The proportion of patients hospitalized in stroke units substantially increased. In-hospital mortality decreased by 17.1% in patients with ischemic stroke. From 2008 to 2013, stroke mortality decreased, except for women between 45 and 64 years old and for people aged ≥85 years. CONCLUSIONS: An increase in cardiovascular risk factors and improved stroke management may explain the increase in the rates of patients hospitalized for ischemic stroke. The decrease observed for in-hospital stroke mortality may be because of recent improvements in acute-phase management.

Combined reconstruction of the anterior cruciate ligament associated with anterolateral tenodesis effectively controls the acceleration of the tibia during the pivot shift.

PURPOSE: The pivot shift test is quantified subjectively during assessment of patients presenting with suspected Anterior Cruciate Ligament (ACL) tears and has a low interobserver reproducibility. The Kinematic Rapid Assessment (KiRA) is a triaxial accelerometer that makes it possible to non-invasively quantify tibial acceleration during the pivot shift test. Abolishing pivot shift is considered to be a key element in surgical reconstruction but is incomplete in 25-38% of patients. METHODS: Patients were included prospectively. Inclusion criteria were patients requiring ACL reconstruction associated with at least one of the following factors corresponding to the patient who have a high risk of rupture either by their sports activity, a failure case, or the notion of important rotational laxity: the patient practiced a competitive pivot-contact sport, revision ACL reconstruction (besides STG (semitendinosus-gracilis graft) repair), subjective explosive rotational laxity, Segond fracture, and TELOS value of >10 mm. Standardized pre- and postoperative pivot shift tests were immediately performed under anesthesia in both knees. RESULTS: Forty-three patients were included. Mean preoperative variations in tibial acceleration in the healthy and injured knees were 1.2 ± 0.1 and 2.7 ± 0.3 m/s2, respectively, p < 0.01. A statistically significant decrease in immediate postoperative mean variations in acceleration in the injured knee occurred: 1.5 ± 0.3 m/s2, p < 0.01. There was no longer any statistical difference between postoperative contralateral healthy knees and operated knees (n.s). CONCLUSIONS: Combined ACL reconstruction associated with anterolateral tenodesis suppress acute pathologic tibial acceleration in the pivot shift. LEVEL OF EVIDENCE: III.

Do socioeconomic disparities in stroke and its consequences decrease in older age?

BACKGROUND: Overall decreased socioeconomic status (SES) has been linked to increased stroke incidence and mortality. Questions remain regarding whether these relationships persist into older age and apply to stroke sequelae. It is also unknown whether the influence of SES on absolute risk-the metric of most importance for population health-differs by age. METHODS: A nationally representative cross-sectional survey conducted in 2009 in France involved 26 000 participants, 1653 of whom declared previous stroke. We identified stroke with sequelae and stroke with dependency. SES was characterized as low, medium or high education. We compared the prevalence of stroke outcome across education within age groups (40-59, 60-79 and 80+). RESULTS: Prevalence of stroke was 23.8 per thousand. 65.1% of patients had sequelae and 19.6% were dependent. Variations in the prevalence of stroke and of stroke sequelae were statistically significant only in the youngest generations. A significant education gradient for stroke with dependency was apparent in all three generations, although the prevalence ratio (PR) was highest in the 40-59 (low to high education PR = 8.4, P < 10-3) compared with that in the 80+ (PR = 2.5; P < 10-3); conversely, the absolute difference was of much greater magnitude in the oldest vs. youngest generation (prevalence differences, respectively, 22.8 vs. 1.3 per thousand). CONCLUSIONS: SES disparities in the older age group were significant and large in absolute terms when considering more severe outcomes such as stroke dependency. These findings question the ability of universal health care systems to answer equitably the need of the aging population.

Mortality following stroke during and after acute care according to neighbourhood deprivation: a disease registry study.

BACKGROUND: Neighbourhood deprivation has been shown to be inversely associated with mortality 1 month after stroke. Whether this disadvantage begins while patients are still receiving acute care is unclear. We aimed to study mortality after stroke specifically in the period while patients are under acute care and the ensuing period when they are discharged to home or other care settings. METHODS: Our sample includes 1760 incident strokes (mean age 75, 48% men, 86% ischaemic) identified between 1998 and 2010 by the population-based stroke registry of Dijon (France). We used Cox regression to study all-cause mortality up to 90 days after stroke occurrence. RESULTS: Overall, 284 (16.1%) patients died during the 90 days following stroke. Prior to stroke, risk factors prevalence (eg, high blood pressure and diabetes) and acute care management did not vary across deprivation levels. There was no association between deprivation and mortality while patients were in acute care (HR comparing the highest to the lowest tertiles of deprivation: 1.01, 95% CI 0.71 to 1.43). After discharge, however, age and gender adjusted mortality gradually increased with deprivation (HR 2.08, 95% CI 1.07 to 4.02). This association was not modified when stroke type and severity were accounted for. CONCLUSIONS: The gradient of higher poststroke mortality with increasing neighbourhood deprivation was noticeable only after acute hospital discharge. Quality of postacute care and social support are potential determinants of these variations.

[Teaching quantitative methods in public health: the EHESP experience]. / Enseignement des méthodes quantitatives en santé publique: l'expérience de l'EHESP.

Many scientific disciplines, including epidemiology and biostatistics, are used in the field of public health. These quantitative sciences are fundamental tools necessary for the practice of future professionals. What then should be the minimum quantitative sciences training, common to all future public health professionals? By comparing the teaching models developed in Columbia University and those in the National School of Public Health in France, the authors recognize the need to adapt teaching to the specific competencies required for each profession. They insist that all public health professionals, whatever their future career, should be familiar with quantitative methods in order to ensure that decision-making is based on a reflective and critical use of quantitative analysis.

Comparison of the retear rate 2years after ACL reconstruction with the Tape Locking Screw short graft system and the STG technique: A case control study with propensity score matching.

PURPOSE: Theoretically, short semitendinosus grafts result in less pain and morbidity while providing greater knee flexion strength and sparing the gracilis tendon. They often require the use of blind bone tunnels as well as fixation at both ends of the graft with suspensory cortical buttons. The "Tape Locking Screw" (TLS) system is another option. There are few studies comparing ACL reconstruction with a short graft using the 4-strand semitendinosus graft (ST4-TLS) technique with that of the semitendinosus-gracilis (STG) procedure. This study was designed: (1) to compare the retear rate following these two technics after 2years of follow-up, (2) to compare the clinical scores, complications and return to sport times between the two procedures Q1, Q2. HYPOTHESIS: Our hypothesis was that there would be no differences in retear rates between the two techniques. METHODS: This single center case control study included 290 patients who underwent STG reconstruction that were paired by propensity score matching to 299 patients who underwent ST4-TLS reconstruction. The main evaluation criterion was the retear rate 2years after surgery. Secondary criteria were the two-year postoperative complication rate, the time to return to sport, to pivot sports and to running, as well as the complication rates and clinical scores 6months, 1year and 2years after surgery. RESULTS: At the final follow-up, the overall retear rate in our series of ACL ligament reconstruction was 6.0% (36/596). There was no difference in retear rates between the groups 2years after ligament reconstruction [ST4-TLS: 6.7% (20/299) vs. STG: 5.4% (16/297); p=0.47]. The postoperative KOOS symptom score and the Tegner score were found to be better in the STG group at 1year (81 vs. 78, p=0.008) and 2years (5.64 vs. 5.10, p=0.016), respectively, representing the minimally clinically important difference (MCID) for the latter. No difference was found in the other clinical scores 6months, 1year or 2years after surgery. There was no significant difference in the return to sport [TLS: 93.0% (164/299) vs. STG: 93.0% (158/297) p=0.99] or the complication rate [TLS: 8.7% (26/299) vs. STG: 7.4% (22/297) p=0.89] between the groups. DISCUSSION: The ST4-TLS ACL ligament reconstruction technique was found to be as reliable as the standard STG procedure 2years after surgery for the retear rate and the return to sport, although the results of certain postoperative clinical scores seem to be lower. LEVEL OF EVIDENCE: III; case control study.

Validity and reproducibility of the ARL-RSI score to assess psychological readiness before returning to sport after lateral ankle sprain.

Purpose: Although multiple scales exist to evaluate psychological readiness before returning to sport post-lateral ankle sprain (LAS), no score has been validated specifically for LAS or chronic ankle instability. The main aim of the study is to evaluate the validity and reproducibility of the ankle ligament reconstruction-return to sport injury (ALR-RSI) scale in assessing psychological readiness after LAS and its ability to identify patients who can return to their preinjury level. Methods: A total of 64 patients (35 females and 29 males; 33.8 ± 13.2 years) who recently experienced an acute LAS were included in this study. All patients participated in a predictive validation component of the study and were assessed at 2 and 4 months following an LAS. The ALR-RSI was completed twice by 20 patients at a 7-day interval to evaluate the reliability of the score in patients suffering from LAS. Results: The ALR-RSI was significantly (p < 0.001) and positively correlated with the other scores. The correlation was strong with the Foot and Ankle Ability Measure Sports: r = 0.77; 95% confidence interval [CI]: 0.78-0.83) and moderate with the American Orthopaedic Foot and Ankle Society (r = 0.69; 95% CI: 0.60-0.78) and the Foot and Ankle Ability Measure Activities of Daily Living Scores (r = 0.63; 95% CI: 0.51-0.72). Two-month ALR-RSI scores had good ability for predicting nonreturners at 4 months (area under the curve = 0.76; 95% CI: 0.6-0.9; p = 0.005). A Youden index of 0.51 was observed at an ALR-RSI score of 46%, corresponding to a sensitivity of 67% and specificity of 83%. Test-retest reliability of the ALR-RSI was excellent, with an ICC of 0.98 (95% CI: 0.96-0.99), a standard error of measurement of 3.02% and a minimum detectable change of 8.37%. Conclusions: The results of the current study validated the ALR-RSI as an important questionnaire to assess psychological readiness to return to sport after LAS. Level of Evidence: Level II prospective cohort study.

Validation of the Parisian Hamstring Avulsion Score (PHAS) in the Evaluation and Follow-up of Patients Operated for Proximal Hamstring Avulsion.

BACKGROUND: No validated score is available for the prediction of return to sport (RTS) after proximal hamstring avulsion (PHA) surgery. PURPOSE: To validate a new assessment tool for patients after PHA surgery: the Parisian Hamstring Avulsion Score (PHAS). STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: All patients at our clinic who had surgery for PHA between January 2015 and March 2018 were included in this study. A suspected clinical diagnosis of PHA was confirmed by magnetic resonance imaging. PHA was repaired by surgical reinsertion with suture anchors. Minimum postoperative follow-up was 2 years, and the PHAS, University of California, Los Angeles (UCLA), score, and Tegner score were used. The PHAS is a patient-reported outcome measure, evaluating the effect of PHA injury with 9 items. It was validated by calculating its psychometric properties, and then correlation analysis was performed to determine the relationship between the PHAS, UCLA score, and Tegner score. Cutoff values for the prediction of RTS were determined. RESULTS: A prospective case series study was performed. A total of 156 patients were included. Median age (first quartile; third quartile) was 54.2 years (44.7 years; 61.3 years), and the mean ± SD time of the final follow-up was 69 ± 11.6 months. Two years after surgery, 66.7% (n = 104) of patients were able to RTS. A strong correlation was noted between all 3 scores at 1 year postoperatively. Overall internal consistency was high, with a Cronbach alpha coefficient of 0.86. The intraclass correlation coefficient was 0.96, showing excellent reliability. The minimal detectable change was 12.9. No patients reached the maximum score at 2 years. Analysis of the receiver operating characteristic curves of the 3 scores at postoperative 9 months in relation to the RTS at 1 and 2 years showed area under the curve values of >0.7, indicating significant discriminant capacity for the RTS. A PHAS cutoff value of 86 at 9 months for the prediction of RTS at postoperative 1 year had a sensitivity of 65.6% (95% CI, 53.7%-77.5%) and a specificity of 81.4% (95% CI, 69.8%-93%). CONCLUSION: PHAS is a valid and reliable tool for follow-up after PHA surgery. It also offers a simple way to predict RTS.

French Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Development and Validation.

Background: The 12-item Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale was developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR). A short (6-item) English version was also developed, which has shown to have good reliability and validity. Purpose/Hypothesis: We aimed to develop and validate a French version of the short ACL-RSI scale. We hypothesized that the same questions would remain in the selection as the English version and that the French version of the scale would have the same psychometric properties. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The full 12-item French ACL-RSI scale was administered to 1000 patients who had undergone ACLR surgery. Reliability (Cronbach alpha) and factor analysis of the full scale were determined. Item selection and elimination process was conducted to develop a short (6-item) version. The same methodology was used to develop the English short ACL-RSI scale. A minimal (3-item) version was also developed and assessed. Results: Internal consistency of the full version of the French ACL-RSI was found to be high (Cronbach alpha = .95), suggesting item redundancy. The short (6-item) version was also found to have high internal consistency (Cronbach alpha = .92) and was strongly correlated with the full version (r = 0.98). The minimal (3-item) version was also found to have high internal consistency, as well as a strong correlation with the full version (r = 0.94). Conclusion: The French version of the short (6-item) ACL-RSI scale was valid, discriminant, consistent, and reproducible. The minimal (3-item) version was also found to be useful and more efficient to collect the information provided by the full ACL-RSI in a French-speaking population.

Association of Patient-Surgeon and Patient-Physical Therapist Relationships With Return to Sports After ACL Reconstruction: The Untested Dimension in Outcome Assessments.

Background: The Quality of Patient-Surgeon Relationship (QPASREL) is an 11-item questionnaire developed and validated to assess the relationship between practitioners and patients on recovery and return to work after surgery. Purpose: To evaluate the association of patient-surgeon relationship (PSR) and patient-physical therapist relationship (PPR), as measured by QPASREL, with a patient's return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR). Study Design: Case-control study; Level of evidence, 3. Methods: This study targeted patients who underwent primary ACLR at a specialized sports surgery referral center between January and May 2021. Patients who had revision surgery, multiligamentous knee injury, and sedentary status were excluded from the study. Patients were grouped based on ability to RTS at the preinjury level 1 year postoperatively (RTS group and no-RTS group). The primary outcome was rate of RTS at 1 year postoperatively, and the primary dependent variables were the quality of PSR and PPR as measured by QPASREL scores at 6-month intervals. Secondary outcomes were the correlation and discriminative capacity of the QPASREL compared with the Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scores (collected at 6-month intervals). Results: The study included 243 patients. Patients in the RTS group exhibited a higher mean PPR QPASREL score (36.6 ± 5.1) compared with no-RTS patients (34.8 ± 5.2; P = .01) as well as a higher mean PSR score (35.7 ± 5.1) compared with no-RTS patients (33.8 ± 5.9; P = .01). Multivariate analysis showed that every 5-point increase in the QPASREL scores for PPR and PSR resulted in a 39% (odds ratio [OR] = 1.39; P = 0.014) and 35% (OR = 1.35, P = 0.021) increased odds of RTS, respectively. A weak yet positive correlation was found between QPASREL and ACL-RSI. The predictive capacity of the QPASREL (area under the curve [AUC] = 0.60 for PPR and 0.61 for PSR), although significant, was less powerful compared with that of the ACL-RSI (AUC = 0.73). Conclusion: The quality of the PPR and PSR, as measured by QPASREL scores, demonstrated a significant association with RTS rates at 1 year after ACLR. A weak yet positive correlation was found between QPASREL and ACL-RSI.

Predictors of Early Return to Sport After Surgical Repair of Proximal Hamstring Complex Injuries in Professional Athletes: A Prospective Study.

BACKGROUND: Proximal hamstring complex injury (PHCI) is a common injury among professional athletes, particularly those participating in pivot contact sports. Previous studies have suggested that surgery can be effective in restoring function and allowing athletes to return to sport (RTS), but the factors influencing successful RTS have been less clear. PURPOSE: To assess RTS capabilities after surgical treatment of PHCI in professional athletes and to identify favorable predictors of RTS. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study (2002-2022) was conducted on professional athletes who underwent surgical treatment for PHCI at a sports surgery center. The primary outcome of the study was the RTS capability, evaluated based on the rate of athletes' return to their preinjury level of competition, time delay to RTS, and quality of RTS as measured using their level of performance and progression of scores on activity scales such as the Tegner Activity Scale (TAS) and University of California, Los Angeles (UCLA), scale. "Maintained performance" was defined as athletes returning to the same preinjury activity level (per the TAS and UCLA scale) and perceiving themselves to have maintained their performance. Secondary outcomes covered the potential RTS predictors and complication rate. The study distinguished 2 types of PHCI: proximal hamstring tendon avulsion injury (proximal rupture with empty footprint, or having a "positive dropped ice cream sign") and complete proximal hamstring free tendon rupture (PHTR; proximal rupture without empty footprint, or having a "negative dropped ice cream sign"). RESULTS: The study examined 64 professional athletes (mean age, 27.3 years; 82.8% male) undergoing surgery for PHCI. The RTS rate was 98.4%, with 78.1% of the athletes returning to their preinjury level of competition at 6.2 months (SD, 2.5 months). Twelve (19%) patients had returned to sport at an inferior level of competition, and 2 (3.1%) were unable to continue in their preinjury sport. Subgroup analysis revealed variation in RTS based on sport type, with the highest rate of return to preinjury performance found in athletes in handball and sports with splits (fencing, squash, and escalade; 100%) and soccer (95.2%). In the univariate analysis, male sex (hazard ratio [HR], 4.05; 95% CI, 1.45-11.3; P = .008), higher preinjury TAS score (HR, 1.27; 95% CI, 1.06-1.52; P = .011), injury involving the semimembranosus (HR, 4.84; 95% CI, 2.31-10.2; P < .001) or conjoint tendon (HR, 3.12; 95% CI, 1.55-6.25; P = .001), and PHTR (HR, 7.77; 95% CI, 3.54-17.0; P < .001) were significantly associated with a better postoperative level of competition. Multivariate analysis identified 3 favorable predictors of RTS with HRs of 2.91 (95% CI, 1.01-8.35; P = .047) for male sex, 3.86 (95% CI, 1.78-8.37; P < .001) for isolated semimembranosus injury, and 5.18 (95% CI, 2.24-12.0; P < .001) for PHTR. The complication rate was 4.7%. CONCLUSION: Favorable predictors of early RTS were male sex, isolated semimembranosus injury, and PHTR injuries. REGISTRATION: NCT02906865 (ClinicalTrials.gov identifier).