Pathoanatomy of Shoulder Instability in Collegiate Female Athletes.

BACKGROUND: Shoulder instability has been well described in young men; however, few studies have specifically evaluated the pathoanatomy and unique spectrum of injuries in women with shoulder instability. PURPOSE: To describe the pathoanatomy of operative shoulder instability in a collegiate female cohort. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors performed a retrospective analysis of a consecutive series of female students at a National Collegiate Athletic Association Division I military service academy treated operatively for shoulder instability by a single surgeon between September 2008 and September 2014. Preoperative data collected included patient age, sport, mechanism of injury, number and frequency of dislocations, direction of instability, and co-occurring surgical abnormalities at the time of arthroscopy. Outcome variables included recurrent instability after surgery and need for revision. RESULTS: Thirty-six female student athletes with an average age of 20 years (range, 18-22 years) were included. The majority of instability events were traumatic in nature (69%), and 61% of the total events were subluxations. Rugby was the most common sport for experiencing instability (7 patients), followed by obstacle course training (6 patients). Thirty-two patients (89%) reported multiple instability events, averaging 4 per shoulder. The primary direction of instability was anterior in 26, combined anterior and posterior in 7, and 3 met criteria for multidirectional instability. At the time of surgery, 26 patients (72%) had a Bankart tear, 9 (25%) had a posterior labral tear, and 5 (14%) had superior labrum anterior to posterior tears. Nine patients (25%) were found to have humeral avulsion of the glenohumeral ligament (HAGL) lesions, 7 (19%) had partial-thickness articular-sided rotator cuff tears, and only 1 patient (3%) had evidence of true attritional glenoid bone loss. Hill-Sachs lesions were found in 16 patients (44%). Recurrent instability occurred in 9 patients (25%) following arthroscopic stabilization, and revision surgery was performed in 6 (17%). CONCLUSION: Shoulder instability in female athletes presents commonly as multiple subluxation events. While soft tissue Bankart lesions were found in numbers equal to those in previous studies include both sexes, bony Bankart lesions were less common in women. Finally, the presence of combined anterior and posterior labral tears and HAGLs in women was more common than previously reported.

Primary and Posttraumatic Knee Osteoarthritis in the Military.

Osteoarthritis is a particularly burdensome and career-limiting condition for military service members. The daily demands of military service place the service members at a baseline increased risk of developing primary OA as well as increased risk of acute knee injuries that further predispose to developing posttraumatic OA. There are multiple treatment options available for primary and posttraumatic OA from osteotomy to arthroplasty.

Change in KOOS and WOMAC Scores in a Young Athletic Population With and Without Anterior Cruciate Ligament Injury.

BACKGROUND: Several studies have examined changes in patient-reported outcome measures (PROMs) after anterior cruciate ligament (ACL) injury, but no studies to date have prospectively evaluated changes from preinjury baseline through injury and follow-up among ACL-injured patients compared to the baseline and follow-up changes of uninjured patients. PURPOSE: To examine changes in PROMs over time from preinjury baseline to at least 2 years after ACL reconstruction and to compare these changes with those of an uninjured control group having similar physical activity requirements. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The authors conducted a prospective cohort study with a nested case-control analysis at a US service academy. All incoming first year students were recruited to participate in this study. Consenting participants completed a baseline questionnaire that included the KOOS (Knee injury and Osteoarthritis Outcome Score), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), and MARS (Marx Activity Rating Scale). Participants who sustained a subsequent ACL injury completed assessments at the time of surgery and at 6, 12, and 24 months after surgery. Healthy participants were recruited to repeat the baseline assessments within 1 year of graduation. Inter- and intragroup differences at these time points were evaluated with dependent and independent t tests, respectively. We also compared these results with established minimum clinically important difference (MCID) values. RESULTS: Of 1268 first year students entering the academy, 1005 with no previous injuries consented to participate in this study (82% male, mean ± SD age 19 ± 1 years). Of those enrolled, 30 suffered an ACL injury and met the inclusion criteria for this study. Ninety uninjured control students who met the inclusion criteria completed follow-up assessments. There were statistically significant differences across all KOOS and WOMAC subscales between ACL-injured group and uninjured group at the time of the final follow-up assessment. Four KOOS subscales (Pain, Symptoms, Sports and Recreation Function, and Knee-Related Quality of Life) and the WOMAC Stiffness subscale demonstrated >8-point differences between groups, which exceeded the established MCID for these instruments. There were no significant differences between the ACL-injured group and uninjured groups noted for the MARS ( P = .635). At the time of final follow-up, the ACL-injured group also reported significant deficits on the WOMAC Stiffness subscale ( P = .032), the MARS ( P = .030), and all KOOS subscales, with the exception of Functional Activities of Daily Living, as compared with their preinjury baseline scores. These deficits exceeded the established MCID values for 3 KOOS subscales and the MARS. CONCLUSION: Patients with ACL injuries reported significant deficits on PROMs at least 2 years after surgical reconstruction in relation to preinjury baseline scores and an uninjured control group. Many of these deficits exceeded established MCID values.

The Success of Hip Arthroscopy in an Active Duty Population.

PURPOSE: To examine the outcomes of arthroscopic treatment of the hip in a young, active military population. Specifically, the ability to return to duty was the prime indicator of success. In addition, an objective evaluation of various demographic and surgery-related variables was performed to identify predictors for success or failure of treatment in this military population. METHODS: A retrospective chart review was undertaken to ascertain the results of hip arthroscopy at a single academic military medical center. A total of 206 patients underwent 223 hip arthroscopies during a 13-year period (2000-2013). Of these, 159 patients met the inclusion criteria, which included active duty military service and at least 12-month follow-up. Veterans Affairs Beneficiaries, active duty dependents, and those with less than 12 months of follow-up were excluded. Surgeries were performed by 1 of 5 fellowship-trained orthopaedic surgeons. Data were collected from the Armed Forces Health Longitudinal Technology Application, Electronic profiling system, and Physical Evaluation Board. RESULTS: A total of 159 patients were available for the study, 102 males and 57 females. The average age of the patients overall was 30.9 ± 8.3 years (range, 18-52 years). Junior enlisted, which is considered entry level, made up 64.2% of the subjects. The most common diagnosis was femoroacetabular impingement, and the most common procedure performed was acetabuloplasty. Twenty-two percent of patients underwent evaluation by the medical retention board after hip arthroscopy and were separated from military service. Seventy-eight percent of soldiers were maintained on active duty after hip arthroscopy. The overall complication rate was 15.7%, with a major complication rate of 1.25% defined as femoral neck fracture, abdominal compartment syndrome, osteonecrosis, deep vein thrombosis and/or pulmonary embolus, and septic arthritis. Univariate analysis of risk factors showed the presence of a complication to be a significant predictor for failure to return to active duty (odds ratio [OR] 4.04, P = .0035) as was senior noncommissioned officer rank (OR 0.20, P = .0347). Multivariate analysis showed only the presence of a complication to be a significant predictor for failure to return to active duty (OR 3.71, P = .0083). CONCLUSIONS: Hip arthroscopy in a military population is effective in treating multiple causes and retaining soldiers on active duty status. Complications of any kind from surgery or postoperatively are significant predictors of medical separation and may warrant earlier initiation of a medical evaluation board. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Risk factors for complications and in-hospital mortality following hip fractures: a study using the National Trauma Data Bank.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To describe the impact of patient demographics, injury-specific factors, and medical co-morbidities on outcomes after hip fracture using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB). METHODS: The 2008 NSP-NTDB was queried to identify patients sustaining hip fractures. Patient demographics, co-morbidities, injury-specific factors, and outcomes (including mortality and complications) were recorded and a national estimate model was developed. Unadjusted differences for risk factors were evaluated using t test/Wald Chi square analyses. Weighted logistic regression and sensitivity analyses were performed to control for all factors in the model. RESULTS: The weighted sample contained 44,419 incidents of hip fracture. The average age was 72.7. Sixty-two percent of the population was female and 80 % was white. The mortality rate was 4.5 % and 12.5 % sustained at least one complication. Seventeen percent of patients who sustained at least one complication died. Dialysis, presenting in shock, cardiac disease, male sex, and ISS were significant predictors of mortality, while dialysis, obesity, cardiac disease, diabetes, and a procedure delay of ≥2 days influenced complications. The major potential modifiable risk factor appears to be time to procedure, which had a significant impact on complications. CONCLUSIONS: This is the first study to postulate predictors of morbidity and mortality following hip fracture in a US national model. While many co-morbidities appear to be influential in predicting outcome, some of the more significant factors include the presence of shock, dialysis, obesity, and time to surgery. LEVEL OF EVIDENCE: Prognostic study, Level II.