Evaluation of Differences in Patellar Height After Patellar Stabilization Procedures Not Intended to Address Patella Alta: A Multicenter Study.

Background: Recent studies have reported conflicting results as to whether isolated medial patellofemoral ligament reconstruction (MPFLr) leads to decreased patellar height. Purpose: To investigate if patellar stabilization surgery not intended to address patella alta influences patellar height. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective chart review was conducted, and patients who underwent MPFLr, medializing tibial tuberosity osteotomy (TTO), and/or trochleoplasty between 2016 and 2020 were included. The Caton-Deschamps index (CDI) was calculated from radiographs obtained preoperatively, 2 weeks postoperatively, and 3 months postoperatively. The preoperative CDI value was compared with the 2-week postoperative and 3-month postoperative values according to stabilization procedure (isolated MPFLr, isolated TTO, MPFLr + TTO, MPFLr + trochleoplasty, and MPFLr + trochleoplasty + TTO) using the paired t test. Analyses of the 1-bundle versus 2-bundle MPFLr technique and the presence of lateral retinacular release or lateral retinacular lengthening were conducted on the isolated MPFLr and combined MPFLr + TTO cohorts. Results: A total of 356 knees were included. Statistically significant pre- to postoperative decreases in CDI were seen in all stabilization procedures analyzed (P≤ .017 for all). Within the isolated MPFLr cohort, this significant decrease was seen at 2 weeks postoperatively with the 2-bundle technique (ΔCDI = -0.09; P < .001) but not with the 1-bundle technique (ΔCDI = -0.01; P = .621). Conclusion: The different surgical techniques analyzed in the current study affected patellar height, even when a distalizing TTO was not performed. The decrease was dependent on surgical technique, with a 2-bundle MPFLr leading to a statistically significant decrease and a 1-bundle MPFLr effecting no change.

Incidence of Early Adverse Events After Tibial Tubercle Osteotomy.

Background: Tibial tubercle osteotomy (TTO) is a commonly utilized surgical procedure for the treatment of patellofemoral instability. Although midterm and long-term outcomes are known, perioperative complications have not been consistently reported. Purpose: To identify the incidence and predictors of adverse events in the first 90-day perioperative period after TTO. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing primary TTO between January 1, 2010, and December 31, 2019, were included. Readmissions in the first 90 days after surgery were collected, and data were collected for the following variables: age, sex, smoking status, body mass index, laterality, preoperative diagnosis, presence of trochlear dysplasia, tourniquet use, TTO procedure, tibial tubercle distalization, trochleoplasty, chondral procedure, number of screws, and use of an epidural catheter. Predictors of readmission for any reason were identified using multivariable logistic regression analysis. Results: A total of 345 TTO procedures were included in the final analysis. The incidence of readmissions for any reason was 20.6% (71/345). The most common reason for readmission was postoperative pain (26/345 [7.5%]), followed by wound complications (19/345 [5.5%]) and epidural catheter-related complications (overall: 16/345 [4.6%]; specific: 16/167 [9.6%]. The incidence of major complications was 2.0% (7/345). The number of patients with each major complication was as follows: 1 for deep vein thrombosis, 2 for pulmonary embolism, 1 for septic arthritis, 1 for tibial tubercle fracture, and 2 for loss of fixation. Female sex and smoking were associated with readmission for pain. Conclusion: The incidence of major complications after TTO was very low (2.0%), but 20.6% of cases required readmission, primarily for an indwelling epidural catheter (3.5%) and postoperative pain (7.5%). Concomitant soft tissue procedures and the number of screws were associated with readmission after TTO. Utilizing individualized postoperative pain management and preoperative discussions about expected pain may help to avoid readmission for pain after TTO.

Do Patellar Tendon Repairs Have Better Outcomes than Quadriceps Tendon Repairs? A Prospective Cohort Analysis.

Patellar tendon (PT) and quadriceps tendon (QT) ruptures represent significant injuries and warrant surgical intervention in most patients. Outcome data are predominantly retrospective analyses with low sample sizes. There are also minimal data comparing QT and PT repairs and the variables impacting patient outcomes. The level of evidence of the study is level II (prognosis). From the prospective OME cohort, 189 PT or QT repairs were performed between February 2015 and October 2019. Of these, 178 were successfully enrolled (94.2%) with 1-year follow-up on 141 (79.2%). Baseline demographic data included age, sex, race, BMI, years of education, smoking status, and baseline VR-12 MCS score. Surgical and follow-up data included surgeon volume, fixation technique, baseline, and 1-year Knee Injury and Osteoarthritis Outcome Score-Pain (KOOS-Pain), Knee Injury and Osteoarthritis Outcome Score-Physical Function (KOOS-PS), and 1-year Patient Acceptable Symptom State (PASS) scores and complications. Multivariable regression analysis was utilized to identify prognosis and significant risk factors for outcomes-specifically, whether KOOS-Pain or KOOS-PS were different between QT versus PT repairs. There were 59 patients in the PT cohort and 82 patients in QT cohort. Baseline demographic data demonstrated that PT cohort was younger (45.1 vs. 59.5 years, p <0.001), included significantly fewer patients of White race (51.7 vs. 80.0%, p = 0.001), lesser number of years of education (13.9 vs. 15.2 years, p = 0.020), a higher percentage of "high" surgeon volume (72.9% vs. 43.9%, p = 0.001) and 25.4% of PT repairs had supplemental fixation (QT had zero, p <0.001). Multivariable analysis identified gender (female-worse, p = 0.001), years of education (higher-better, p = 0.02), and baseline KOOS-Pain score (higher-better, p <0.001) as the risk factors that significantly predicted KOOS-Pain score. The risk factors that significantly predicted KOOS-PS were gender (female worse, p = 0.033), race (non-White-worse, p <0.001), baseline VR-12 MCS score (higher-better, p <0.001), and baseline KOOS-PS score (higher better, p = 0.029). KOOS-Pain and KOOS-PS scores improved after both QT and PT repairs. Patient reported pain and function at 1 year were similar between PT and QT repairs after adjusting for known risk factors. Multivariable analysis identified female gender and low baseline KOOS scores as predictors for worse outcomes.

Evaluation of Health Care Disparities in Patients With Anterior Cruciate Ligament Injury: Does Race and Insurance Matter?

Background: It is unknown whether race- or insurance-based disparities in health care exist regarding baseline knee pain, knee function, complete meniscal tear, or articular cartilage damage in patients who undergo anterior cruciate ligament reconstruction (ACLR). Hypothesis: Black patients and patients with Medicaid evaluated for ACLR would have worse baseline knee pain, worse knee function, and greater odds of having a complete meniscal tear. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A cohort of patients (N = 1463; 81% White, 14% Black, 5% Other race; median age, 22 years) who underwent ACLR between February 2015 and December 2018 was selected from an institutional database. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, KOOS Function subscale, and intraoperatively assessed complete meniscal tear (tear that extended through both the superior and the inferior meniscal surfaces) were determined via multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS). Results: The 3 factors most strongly associated with worse KOOS Pain and KOOS Function were lower VR-12 MCS score, increased BMI, and increased age. Except for age, the other two factors had an unequal distribution between Black and White patients. Univariate analysis demonstrated equal baseline median KOOS Pain scores (Black, 72.2; White, 72.2) and KOOS Function scores (Black, 68.2; White, 68.2). After adjusting for confounding variables, there was no significant difference between Black and White patients in KOOS Pain, KOOS Function, or complete meniscal tears. Insurance status was not a significant predictor of KOOS Pain, KOOS Function, or complete meniscal tear. Conclusion: There were clinically significant differences between Black and White patients evaluated for ACLR. After accounting for confounding factors, no difference was observed between Black and White patients in knee pain, knee function, or complete meniscal tear. Insurance was not a clinically significant predictor of knee pain, knee function, or complete meniscal tear.

Posteromedial Tibial Bone Bruise After Anterior Cruciate Ligament Injury: An MRI Study of Bone Bruise Patterns in 208 Patients.

Background: Bone bruise patterns after anterior cruciate ligament (ACL) rupture may predict the presence of intra-articular pathology and help explain the mechanism of injury. Lateral femoral condyle (LFC) and lateral tibial plateau (LTP) bone bruises are pathognomic to ACL rupture. There is a lack of information regarding medial tibial plateau (MTP) and medial femoral condyle (MFC) bone bruises. Purpose: To summarize the prevalence and location of MTP bone bruises with acute ACL rupture and to determine the predictors of MTP bone bruises. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Inclusion criteria were patients who underwent ACL reconstruction between February 2015 and November 2017, magnetic resonance imaging (MRI) within 90 days of injury, and participation in the database. Exclusion criteria included previous ipsilateral surgery, multiligamentous injuries, and incomplete imaging. Due to the large number of cases remaining (n = 600), 150 patients were selected randomly from each year included in the study, for a total of 300 patients. Two readers independently reviewed injury MRI scans using the Costa-Paz bone bruise grading system. Logistic regression was used to identify factors associated with MTP bone bruises. Results: Included were 208 patients (mean age, 23.8 years; mean body mass index, 25.6). The mechanism of injury was noncontact in 59% of injuries, with over half from soccer, basketball, and football. The median time from injury to MRI scan was 12 days. Of the 208 patients, 98% (203/208) had a bone bruise, 79% (164/208) had an MTP bone bruise, and 83% (172/208) had bruises in both medial and lateral compartments. The most common pattern, representing 46.6% of patients (97/208), was a bruise in all 4 locations (MFC, LFC, MTP, and LTP). Of the 164 MTP bruises, 160 (98%) involved the posterior third of the plateau, and 161 were grade 1. The presence of an MFC bruise was the only independent risk factor for an MTP bruise (odds ratio, 3.71). The resulting nomogram demonstrated MFC bruise, sport, and mechanism of injury were the most important predictors of an MTP bruise. Conclusion: MTP bruise after acute ACL rupture was as prevalent as lateral bruises. The presence of a posterior MTP bruise suggested anterior tibial translation at the time of injury and could portend more medial compartment pathology at the time of injury than previously recognized.

Factors Associated With Pain and Function Before Medial Patellofemoral Ligament Reconstruction.

Background: Medial patellofemoral ligament (MPFL) reconstruction is performed to treat recurrent patellar instability. Measurement of joint pain and function at the time of surgery has been demonstrated to be a predictor of the final outcomes in many surgical procedures. Purpose/Hypothesis: The purpose of this study was to evaluate the relationship between baseline patient characteristics, mental health, and intraoperative findings and patient-reported knee pain and function at the time of MPFL reconstruction. We hypothesized that patient characteristics and associated pathology would be associated with the degree of pain and dysfunction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were skeletally mature patients who underwent unilateral open MPFL reconstruction between 2015 and 2020 at a single institution. Baseline descriptive information was collected, and the following outcome measures were administered preoperatively: the Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS) and the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain, Physical Function Short Form (PS), and Quality of Life (QoL) subscales. Intraoperative findings were collected in a standardized format. Patient characteristics, preoperative variables, intraoperative findings, and VR-12 MCS were used as risk factors, and multivariate analysis was conducted to assess for relationships with the KOOS subscale scores. Results: In total, 201 patients with patella dislocations were included in this analysis. Intraoperatively, 122 patients (60.7%) had either normal cartilage or grade 1 or 2 cartilage injury, 79 patients (39.3%) had grade 3 or 4 cartilage injury, 35 patients (17.4%) had a loose body, and 3 patients (1.49%) had evidence of synovitis. Younger age (P = .012), male sex (P < .001), never having smoked (P = .029), and lower baseline VR-MCS (P < .001) were significantly associated with higher baseline KOOS Pain scores. Older age (P = .035), female sex (P = .003), higher body mass index (P = .005), and lower baseline VR-12 MCS (P < .001) were significantly associated with higher baseline KOOS PS scores. Younger age (P = .003), male sex (P < .001), lower baseline VR-12 MCS (P < .001), and no dysplasia (P = .023) were significantly associated with higher baseline KOOS QoL scores. Conclusion: Patient age, sex, and baseline VR-12 MCS were associated with all 3 baseline KOOS subscale scores, whereas intraoperative findings outside of trochlear dysplasia were not associated with any of the KOOS subscale scores.

Are There Racial Disparities in Knee Symptoms and Articular Cartilage Damage in Patients Presenting for Arthroscopic Partial Meniscectomy?

The purpose of the present study was to examine whether Black patients presenting for arthroscopic partial meniscectomy (APM) have worse baseline knee pain, worse knee function, and greater articular cartilage damage than White patients. Methods: A cohort of 3,086 patients (84% of whom were White; 13%, Black; and 3%, other race, with a median age of 53 years) who underwent APM were enrolled. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with the preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) for pain (KOOS-pain) and the KOOS-Physical Function Short Form (KOOS-function) and the intraoperative assessment of cartilage damage (highest modified Outerbridge grading) were determined by multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Summary (VR-12 MCS) score. Results: The 3 factors most strongly associated with worse KOOS-pain and KOOS-function were a lower VR-12 MCS score, increased BMI, and increased age. The 3 factors most strongly associated with higher-grade articular cartilage damage were increased age, increased BMI, and meniscal tear location. All of these factors had an unequal distribution between Black and White patients. After adjusting for confounding variables, the KOOS-pain score for Black patients was a mean of 2.6 points lower than that for White patients regardless of insurance status; the KOOS-function score for Black patients with commercial insurance was a mean of 2.4 points lower than that for White patients with commercial insurance but was not lower than that for Black patients on Medicare. Compared with commercially insured White patients, commercially insured Black patients had 1.4-fold greater odds of having higher-grade articular damage, and no difference in risk was detected among Medicare-insured Black patients. Conclusions: There are clinically important differences in the distribution of risk factors between Black and White patients presenting for APM regarding several factors associated with worse knee pain, knee function, and greater articular cartilage damage. When controlling for these confounding factors, a significant, but not clinically relevant, racial disparity remained with respect to knee pain, knee function, and cartilage damage. Two of the 3 major risk factors for all 3 included age and BMI. The third factor for knee pain and function was mental health, and the location of a meniscal tear was the third factor for articular cartilage damage. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Opioid Use After Simple Arthroscopic Knee Surgery.

BACKGROUND: Evidence-based prescribing guidelines are lacking for opioids after most orthopaedic surgical procedures. HYPOTHESIS: Opioids are commonly overprescribed after simple knee arthroscopy. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A cohort of 174 patients who underwent simple arthroscopic knee surgery were prospectively evaluated using data from the Outcome Management and Evaluation database. All patients received 10 combined hydrocodone 5 mg and acetaminophen 325 mg pills postoperatively. Patients were excluded if they (1) had revision surgery, (2) had concomitant complex surgery (eg, ligament surgery, osteotomy), (3) had current opioid use, (4) had open surgery for removal of hardware, (5) or had bilateral knee surgery. Total opioid consumption was reported at the first postoperative visit, and a distribution was created based on patient response. Based on the distribution, patients were separated into low (0-2 pills) versus high (3 or more pills) opioid consumption groups for evaluating risk factors for opioid use. The risk factors included were age, body mass index, smoking status, education level, baseline pain (Knee injury and Osteoarthritis Outcome Score pain subscale [KOOS Pain]), and baseline mental health (Veterans RAND 12-Item Health Survey Mental Component Score), as well as intraoperative findings such as synovial characteristics and extent of osteoarthritis in the multivariate model. RESULTS: Total opioid consumption ranged from 0 to 19 pills. The median pill count was 2 (25th; 75th interquartile range, 0; 4). Of total patients, 59% were categorized as having low opioid consumption, and the remaining 41% were in the high opioid consumption group. Only 23 patients (13.2%) took 6 or more pills. Preoperative pain as measured by KOOS Pain score was a significant predictor of high opioid consumption postoperatively (odds ratio, 0.97; 95% CI, 0.95-0.99; P = .003). CONCLUSION: The clinically relevant conclusion is that opioids are overprescribed after simple arthroscopic knee surgery. Based on distribution, the authors recommend that 4 pills be prescribed after simple arthroscopic knee surgery. After accounting for confounding variables, preoperative pain was associated with higher postoperative opioid consumption.

Evaluation of Differences Between Non-Hispanic White and African American Patients With Sports Medicine-Related Hip Disabilities.

BACKGROUND: Racial disparities within the field of orthopaedics are well-documented in the spinal surgery, knee arthroplasty, and hip arthroplasty literature. Not much is known about racial differences in patients with sports medicine-related hip disabilities. PURPOSE: To investigate whether differences exist between African American and non-Hispanic White (White) patients evaluated for hip disabilities. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a multicenter retrospective cohort study of 905 patients who were evaluated over a 1-year period for hip-related orthopaedic concerns. Patient demographic data, disability characteristics, and hip radiographic findings were obtained from electronic medical records. We also obtained data on whether patients were offered physical therapy, magnetic resonance imaging (MRI), and/or surgery. Comparisons by race and insurance status were evaluated using univariate and multivariate analyses. RESULTS: African Americans comprised a significantly lower proportion of the patients evaluated for hip-related disabilities compared with Whites (6.5% vs 93.5%; P < .001). A significantly smaller proportion of African Americans with hip disabilities was recommended for surgery than White patients (35.6% vs 54.6%; P = .007). Cam deformities were more common in White vs African American patients (39.7% vs 23.7%; P = .021), as were labral tears (54.1% vs 35.6%; P = .009). Logistic regression demonstrated that neither race nor insurance status were significant determinants in surgery recommendations. Conversely, race was a determinant of whether an MRI was performed, as White patients were 2.74 times more likely to have this procedure. There were no differences with respect to obtaining an MRI between private and Medicaid insurance. CONCLUSION: Compared with White patients, there were differences in both the proportion of African Americans evaluated for hip-related disabilities and the proportion receiving a surgery recommendation. African Americans with sports medicine-related hip issues were also less likely to obtain an MRI. With regard to observed pathology, African American patients were less likely to have cam deformities and labral tears than White patients.

Patient-Reported Outcomes After a Modified Albee Procedure.

BACKGROUND: Trochlear dysplasia (TD) is a recognized condition that can become a risk factor for patellofemoral instability. A modified Albee osteotomy procedure using a trapezoidal-shaped wedge to elevate the lateral wall of the trochlea can be used with the goal of preventing further dislocation. However, outcomes studies are lacking, and scores on patient-reported outcome measures (PROMs) are largely unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to identify PROM scores for the Kujala Anterior Knee Pain Scale (AKPS), International Knee Documentation Committee (IKDC), Activity Rating System (ARS), and 100-point pain visual analog scale (VAS) for patients having undergone the modified Albee osteotomy. The hypothesis was that patients will have acceptable pain and function at mid- to long-term follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 1999 to 2017, a total of 46 consecutive patients (49 knees) underwent a modified Albee procedure by a single surgeon at a single health care system. These 46 patients were contacted and asked to complete the AKPS, IKDC, ARS, and pain VAS. Additional demographic information was obtained via chart review. Frequencies and rates for categorical variables and means and standard deviations for continuous variables of the demographics and PROM scores were calculated. RESULTS: PROM scores were obtained in 28 (30 knees; 61%) of the 46 patients. At minimum follow-up of 82 months, the mean scores were 78.5 ± 18.2 for AKPS, 61.2 ± 11.4 for IKDC, 5.2 ± 5.3 for ARS, and 24.4 ± 28.7 for VAS pain. Notably, only 1 of the 28 patients reported a patellofemoral dislocation since surgery, and this was an isolated incident without further instability. CONCLUSION: A modified Albee trochlear osteotomy can be a successful adjunctive procedure to prevent recurrent patellar dislocations in patients with mild TD. However, owing to the loss of one-third of patient follow-up scores and the absence of baseline function scores in this study, the procedure deserves further investigation as a way to address a particularly difficult dilemma for a select subset of patients with patellofemoral instability.

Do Narcotic Use, Physical Therapy Location, or Payer Type Predict Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction?

BACKGROUND: Opioid use and public insurance have been correlated with worse outcomes in a number of orthopaedic surgeries. These factors have not been investigated with anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS: To evaluate if narcotic use, physical therapy location, and insurance type are predictors of patient-reported outcomes after ACLR. It was hypothesized that at 1 year postsurgically, increased postoperative narcotic use would be associated with worse outcomes, physical therapy obtained within the authors' integrated health care system would lead to better outcomes, and public insurance would lead to worse outcomes and athletic activity. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: All patients undergoing unilateral, primary ACLR between January 2015 and February 2016 at a large health system were enrolled in a standard-of-care prospective cohort. Knee injury and Osteoarthritis Score (KOOS) and the Hospital for Special Surgery Pediatric-Functional Activity Brief Scale (HSS Pedi-FABS) were collected before surgery and at 1 year postoperatively. Concomitant knee pathology was assessed arthroscopically and electronically captured. Patient records were analyzed to determine physical therapy location, insurance status, and narcotic use. Multivariable regression analyses were used to identify significant predictors of the KOOS and HSS Pedi-FABS score. RESULTS: A total of 258 patients were included in the analysis (mean age, 25.8; 51.2% women). In multivariable regression analysis, narcotic use, physical therapy location, and insurance type were not independent predictors of any KOOS subscales. Public insurance was associated with a lower HSS Pedi-FABS score (-4.551, P = .047) in multivariable analysis. Narcotic use or physical therapy location was not associated with the HSS Pedi-FABS score. CONCLUSION: Increased narcotic use surrounding surgery, physical therapy location within the authors' health care system, and public versus private insurance were not associated with disease-specific KOOS subscale scores. Patients with public insurance had worse HSS Pedi-FABS activity scores compared with patients with private insurance, but neither narcotic use nor physical therapy location was associated with activity scores. Physical therapy location did not influence outcomes, suggesting that patients be given a choice in the location they received physical therapy (as long as a standardized protocol is followed) to maximize compliance.

The Evaluation of Trochlear Osseous Morphology: An Epidemiologic Study.

BACKGROUND: The femoral trochlea is considered the most significant osseous factor affecting stability in the patellofemoral joint. The true prevalence of trochlear dysplasia in the general population is largely unknown. PURPOSE/HYPOTHESIS: To investigate the prevalence of trochlear dysplasia in the general population. Our hypothesis was that, while trochlear dysplasia is not uncommon, there is a low prevalence of severe dysplasia in the general population. STUDY DESIGN: Descriptive epidemiology study. METHODS: Five observers were asked to evaluate 692 skeletally mature femoral specimens from 359 skeletons for trochlear dysplasia at 2 time points. We further subclassified the dysplastic trochlea in 62 femora with the highest rated degree of dysplasia. RESULTS: Sex (P = .11) and race (P = .2) had no effect on the severity of dysplasia. Interobserver reliability was excellent (0.906 and 0.904), and intraobserver reliability was good to excellent (0.686 to 0.808). The percentages of trochlea graded as normal, mildly dysplastic, moderately dysplastic, and severely dysplastic were 61.5%, 21.4%, 12.7%, and 4.4%, respectively, in the first evaluation, and 58.5%, 23.7%, 12.7%, and 5.1% in the second evaluation. Of the 62 trochlea with the highest scores for dysplasia, 36 had trochlear dysplasia without a supratrochlear spur, 8 had trochlear dysplasia with medial femoral condyle hypoplasia, and 18 had trochlear dysplasia with a supratrochlear spur. CONCLUSION: Observers with differing degrees of clinical experience had similar opinions on the degree of trochlear dysplasia. Also, our cohort showed that moderate to severe dysplasia is not uncommon, as it is present in approximately 17% of knees in our cohort. Our findings also suggest that clinicians are speaking the same language when identifying and describing trochlear dysplasia on gross inspection.

Osteoid Osteoma Masquerading as Cholelithiasis: A Case Report.

CASE: We present a case report of an 18-year-old woman who presented to a general surgeon with a several month history of intermittent right upper quadrant pain, strongly suggestive of symptomatic cholelithiasis and underwent a laparoscopic cholecystectomy. She was eventually found to have an osteoid osteoma (OO) of the right eighth rib. She was treated with radiofrequency ablation with complete resolution of symptoms 1 month after treatment. CONCLUSIONS: In cases where a patient's age and risk factors would make the diagnosis of cholelithiasis less likely, OO should be added to the differential diagnosis of symptomatic right upper quadrant pain.

Smartphone Data Capture Efficiently Augments Dictation for Knee Arthroscopic Surgery.

INTRODUCTION: The objectives of this study are (1) to develop a provider-friendly, evidence-based data capture system for lower-limb orthopaedic surgeries and (2) to assess the performance of the data capture system on the dimensions of agreement with operative note and implant log, consistency of data, and speed of provider input. METHODS: A multidisciplinary team developed a database and user interfaces for Android and iOS operating systems. Branching logic and discrete fields were created to streamline provider data input. One hundred patients were randomly selected from the first four months of data collection (February to June 2015). Patients were limited to those undergoing anterior cruciate ligament reconstruction, meniscal repair, partial meniscectomy, or a combination of these procedures. Duplicate data on these 100 patients were collected through chart review. These two data sets were compared. Cohen's kappa statistic was used to assess agreement. RESULTS: The database and smartphone data capture tool show almost perfect agreement (kappa > 0.81) for all data tested. In addition, data are more comprehensive with near-perfect provider completion (100% for all data tested). Furthermore, provider data entry is extremely efficient (median 151-second completion time). CONCLUSION: A well-designed database and user-friendly interface have greater potential for research utility, clinical efficiency, and, thus, cost-effectiveness when compared with standard voice-dictated operative notes. Widespread utilization of such tools can accelerate the pace and improve the quality of orthopaedic clinical research. LEVEL OF EVIDENCE: Level IV.

What Are the Predictors of Poor Patient-Reported Outcomes After Shoulder Instability Surgery?

BACKGROUND: Prospectively collected responses to Patient Acceptable Symptom State (PASS) questions after shoulder instability surgery are limited. Responses to these outcome measures are imperative to understanding their clinical utility. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate which factors predict unfavorable patient-reported outcomes after shoulder instability surgery, including "no" to the PASS question. We hypothesized that poor outcomes would be associated with male adolescents, bone loss, combined labral tears, and articular cartilage injuries. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients aged ≥13 years undergoing shoulder instability surgery were included in point-of-care data collection at a single institution across 12 surgeons between 2015 and 2017. Patients with anterior-inferior labral tears were included, and those with previous ipsilateral shoulder surgery were excluded. Demographics, American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, and surgical findings were obtained at baseline. ASES and SANE scores, PASS responses, and early revision surgery rates were obtained at a minimum of 1 year after the surgical intervention. Regression analyses were performed. RESULTS: A total of 234 patients met inclusion criteria, of which 176 completed follow-up responses (75.2%). Nonresponders had a younger age, greater frequency of glenoid bone loss, fewer combined tears, and more articular cartilage injuries (P < .05). Responders' mean age was 25.1 years, and 22.2% were female. Early revision surgery occurred in 3.4% of these patients, and 76.1% responded yes to the PASS question. A yes response correlated with a mean 25-point improvement in the ASES score and a 40-point improvement in the SANE score. On multivariate analysis, combined labral tears (anterior-inferior plus superior or posterior tears) were associated with greater odds of responding no to the PASS question, while both combined tears and injured capsules were associated with lower ASES and SANE scores (P < .05). Sex, bone loss, and grade 3 to 4 articular cartilage injuries were not associated with variations on any patient-reported outcome measure. CONCLUSION: Patients largely approved of their symptom state at ≥1 year after shoulder instability surgery. A response of yes to the PASS question was given by 76.1% of patients and was correlated with clinically and statistically significant improvements in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across patient-reported outcome measures, whereas sex, bone loss, and cartilage injuries were not.

Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs.

BACKGROUND: Shoulder pain and dysfunction are common indications for rotator cuff repair surgery, yet the factors that are associated with these symptoms are not fully understood. PURPOSE/HYPOTHESIS: This study aimed to investigate the associations of patient and disease-specific factors with baseline patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair. We hypothesized that tear size and mental health status, as assessed by the Veterans RAND 12-Item Health Survey mental component score (VR-12 MCS), would be associated with baseline total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscale scores. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We prospectively identified 12 patient factors and 12 disease-specific factors as possible statistical predictors for baseline PROMs in patients undergoing surgical repair of superior-posterior rotator cuff tears at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in baseline PSS and its subscale scores. RESULTS: A total of 1442 patients who had undergone surgery by 23 surgeons met inclusion criteria, with a baseline median total PSS of 38.5 (pain, 12; function, 24.2; satisfaction, 2). Adjusted R2 in multivariable models demonstrated that the 24 general patient and disease-specific factors accounted for 22% to 24% of the variability in total PSS and its pain and function subscale scores. Large/massive tear size was significantly associated with worse PSS total score and function score but not pain or satisfaction scores. Lower VR-12 MCS was significantly associated with worse total PSS and all 3 subscale scores. Among other factors significantly associated with baseline PROMs were sex, race, preoperative opioid use, years of education, employment status, acromion status, and adhesive capsulitis. Lower VR-12 MCS, preoperative opioid use, female sex, and black race were the factors most strongly associated with baseline PROMs. CONCLUSION: Large/massive tear size, lower VR-12 MCS, and several additional patient and disease-specific factors are associated with baseline PROMs in patients undergoing rotator cuff repair. Further studies are needed to investigate whether these factors will also predict poor postoperative PROMs.

Establishing Safe Extra-articular Parameters for Cortical Button Distal Fixation During Ulnar Collateral Ligament Reconstruction.

BACKGROUND: A variety of methods exist for fixation during ulnar collateral ligament (UCL) reconstruction on the ulna for the overhead throwing athlete. Current biomechanical evidence suggests that cortical button fixation may fail at a higher load and under more cycles than interference screw fixation alone, while also minimizing the risk of fracture. A safe angle for placement of this cortical button has not yet been determined. PURPOSE: To define a safe angle for cortical button deployment during UCL reconstruction to avoid violation of the proximal radioulnar joint (PRUJ). STUDY DESIGN: Descriptive laboratory study. METHODS: Measurements on 100 cadaveric ulna bones, 50 women and 50 men, were obtained referencing the entry point for ulnar fixation, which is 1 cm distal to the ulnar humeral joint line along the medial UCL ridge. Ulnar width at the entry point and distance to the PRUJ were obtained to calculate safe distal angulation, while distance from the entry point to the posterior ulnar crest ulnarly and distance from the PRUJ to the posterior ulnar crest radially were obtained to calculate safe posterior angulation. Ten bony measurements on the same group of specimens were performed by 3 authors to establish an interobserver reliability. Means, quartiles, and outliers were obtained for the calculated angles. Finally, recommended angles of entry were determined to be approximately 1 interquartile range above the upper limit. RESULTS: The mean distal angle of entry that was obtained was 11.32° (SD, ±4.80°; 95% CI, 10.37°-12.27°; P < .001). Three upper limit outliers were discovered: 24.20°, 23.4°, and 21.1°. The mean posterior angle of entry was 40.44° (SD, ±6.18°; 95% CI, 39.22°-41.67°; P < .001). There were no outliers for the posterior angle of entry. Interobserver reliabilities were strong for the 4 measurements. CONCLUSION: To be safely outside of the PRUJ utilizing a cortical button construct, we recommend 30° distal angulation and 60° posterior angulation for ulnar fixation during UCL reconstruction. Both parameters are 1 quartile above the highest calculated angle of entry. CLINICAL RELEVANCE: These data define safe parameters for distal fixation during UCL reconstruction and highlight a clear entry point for reference.

Clinical Utility of an MRI-Based Classification System for Operative Versus Nonoperative Management of Ulnar Collateral Ligament Tears: A 2-Year Follow-up Study.

BACKGROUND: A recently introduced classification system of medial ulnar collateral ligament (UCL) tears accounting for location and severity has demonstrated high interobserver and intraobserver reliability, but little is known about its clinical utility. PURPOSE: The primary purpose of this study was to assess the relationship of the magnetic resonance imaging (MRI)-based classification system in predicting which athletes had success with nonoperative versus operative treatment after completing a standardized rehabilitation program. A secondary objective included return to play (RTP) and return to prior performance (RPP) analyses of baseball players. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: After an a priori power analysis, 58 consecutive patients with UCL tears and a minimum of 2-year follow-up were retrospectively divided into 2 groups: those who successfully completed operative treatment and those who completed nonoperative treatment. The MRI-based classification stages accounting for UCL tear location and severity were compared between the nonoperative and operative groups. A subanalysis for baseball players, including RTP and RPP, was performed. RESULTS: A total of 58 patients (40 baseball players [34 pitchers]) met inclusion criteria. Of these patients 35 (32 baseball players [27 pitchers]) underwent surgery, and 23 (8 baseball players [7 pitchers]) underwent nonoperative management. No patients in the nonoperative arm crossed over to surgery after completing the rehabilitation program. Patients with distal tears (odds ratio, 48.0; P = .0004) and complete tears (odds ratio, 5.4; P = .004) were more likely to undergo surgery. Baseball players, regardless of position, were confounding determinants of operative management, although there was no difference in RTP and RPP between treatment arms. CONCLUSION: A 6-stage MRI-based classification system addressing UCL tear location and severity may help early decision making, as patients likely to fail nonoperative treatment have complete, distal tears, whereas those with proximal, partial tears may be more amenable to nonoperative management.

Prognostic utility of an magnetic resonance imaging-based classification for operative versus nonoperative management of ulnar collateral ligament tears: one-year follow-up.

BACKGROUND: A recently introduced classification of medial ulnar collateral ligament (UCL) tears has demonstrated high interobserver and intraobserver reliability, but little is known about its prognostic utility. The purpose of this study was to assess the relationship of the magnetic resonance imaging (MRI)-based classification system and nonoperative vs. operative management. Secondary objectives included subanalysis of baseball players. METHODS: Eighty-five consecutive patients with UCL tears after a standardized treatment paradigm were categorized as operative vs. nonoperative. UCL tears of patients with a minimum of 1-year follow-up were retrospectively classified using the MRI-based classification system. Subanalyses for baseball players included return-to-play and return-to-prior performance. RESULTS: A total of 80 patients (62 baseball players, 54 pitchers) met inclusion criteria. A total of 51 patients underwent surgery, and 29 patients completed nonoperative management. In baseball players, 59% of the proximal tears were treated nonoperatively and 97% of the distal tears were treated operatively; 100% of the proximal partial-thickness tears and 100% of the distal complete tears were treated nonoperatively and operatively, respectively. Patients with distal (odds ratio: 48.4, P < .0001) and complete (odds ratio: 5.0, P = .004) tears were more likely to undergo surgery. Baseball players, regardless of position, were determinants of operative management, and there was no difference in return-to-play clearance and return-to-prior performance between the operative and nonoperative groups. CONCLUSION: A reliable 6-stage MRI-based classification addressing UCL tear grade and location may confer decision making between operative and nonoperative management. Complete and distal tears carry a markedly increased risk of failing nonoperative care compared with proximal, partial tears.

Prevalence and Epidemiology of Injuries Among Elite Cyclists in the Tour de France.

BACKGROUND: Cycling injuries are increasing, particularly among elite athletes during major events such as the Tour de France. Many athletes miss considerable time from sport and require surgical intervention. Little is known about the epidemiology of injuries to guide practice participation strategies, return-to-competition expectations, and injury prevention protocols. PURPOSE: To evaluate the injury epidemiology, operative incidence, and return-to-competition timeline among all elite cyclists participating in the 21-stage Tour de France race over a span of 8 years. STUDY DESIGN: Descriptive epidemiological study. METHODS: All injuries sustained during 1584 unique rides by cyclists participating in the Tour de France from 2010 to 2017 were evaluated. In the absence of an established Tour de France injury database, demographic, injury, surgical, and return-to-competition details from all athletes who withdrew because of a traumatic injury were retrospectively compiled using publicly available data, which were cross-referenced for validity. The inclusion criterion consisted of any cyclist who withdrew from the Tour de France because of an injury; cyclists who withdrew for noninjury reasons were excluded. Independent variables included injury demographics, missed days, and whether the injury required surgery. Injury prevalence, relative frequency distributions, and sample proportions were dependent metrics for this investigation. RESULTS: Among the 1584 cycling entries evaluated over the 8-year study period, there were 259 cyclists (16%) who withdrew (17 cyclists/year). A total of 138 withdrawals were caused by acute trauma, 49% of which were fractures (n = 67), which represented the most common reason for withdrawal. A total of 29 (43%) cyclists with fractures underwent surgery. The most commonly fractured bones were the clavicle (n = 21), followed by the wrist (n = 6), hand (n = 5), femur (n = 5), humerus (n = 5), and ribs (n = 5). Cyclists who underwent operative fracture fixation had a longer time between the injury and their next race compared with those who did not undergo surgery (77 vs 44 days, respectively; P = .065). CONCLUSION: The most common injury leading to withdrawal from the Tour de France over the study period was acute fracture, comprising 49% of all injuries. Almost half of the cyclists with fractures underwent surgery. The clavicle was the most commonly fractured bone. For cyclists who underwent operative treatment of their fractures, return to competition was more than 1 month longer than for those who did not. A prospective database is warranted to catalog injuries among these elite cyclists.