Clinically Depressed Patients Having Anterior Cruciate Ligament Reconstruction Show Improved but Inferior Rate of Achieving Minimum Clinically Important Difference for Patient-Reported Outcomes Measurement Information System Compared With Situationally Depressed or Nondepressed Patients.

PURPOSE: To determine whether the preoperative diagnosis of depression predicted worse postoperative outcomes, including physical therapy (PT) compliance, return-to-sport, and patient-reported outcomes using the Patient-Reported Outcomes Measurement Information System (PROMIS) after anterior cruciate ligament (ACL) reconstruction. METHODS: A multisurgeon series of consecutive patients who had undergone ACL reconstruction with minimum 2-year follow-up were included. Chart review was conducted to determine depression diagnosis status, demographic data, rehabilitation PT compliance, return to sports, and patient-reported outcome data using PROMIS. Patients who met the PROMIS threshold for mild depression but did not carry a clinical diagnosis of depression were classified as "situationally depressed." RESULTS: Ninety-five of 115 consecutive patients (81%) met inclusion criteria with an average follow-up of 34 ± 1.9 months. Fourteen patients (15%) had a preoperative diagnosis of depression, whereas 21 (22%) were considered situationally depressed. Clinically depressed patients had a greater rate of PT noncompliance (33.2% ± 17.6% vs 21.9% ± 12.6%; P = .02) and a lower postoperative PROMIS Physical Function (50.8 ± 7.7 vs 57.8 ± 11.0; P = .03 compared with patients without depression. Situationally depressed patients had lower preoperative physical function (35.4 vs 42.5; P = .04) with no differences in postoperative outcomes scores compared to the non-depressed cohort.19/21 (90.5%) of situationally depressed patients had postoperative resolution of their depressive symptoms. CONCLUSIONS: Situationally depressed patients without a clinical diagnosis of depression can expect significant improvements in both pain and function, as well as a resolution of their depressed mood based on PROMIS scores as they progress through recovery after ACL reconstruction. Clinically depressed patients also experience significant improvements; however, their rate of achieving the minimum clinically important difference for PROMIS outcomes may be less than their nondepressed or situationally depressed counterparts. LEVEL OF EVIDENCE: III, prognostic comparative trial.

What Regions of the Distal Clavicle Have the Greatest Bone Mineral Density and Cortical Thickness? A Cadaveric Study.

BACKGROUND: Osteosynthesis of distal clavicle fractures can be challenging because of comminution, poor bone quality, and deforming forces at the fracture site. A better understanding of regional differences in the bone structure of the distal clavicle is critical to refine fracture fixation strategies, but the variations in BMD and cortical thickness throughout the distal clavicle have not been previously described. PURPOSE: /questions (1) Which distal clavicular regions have the greatest BMD? (2) Which distal clavicular regions have the greatest cortical thickness values? METHODS: Ten distal clavicle specimens were dissected from cadaveric shoulders. Eight specimens were female and two were male, with a mean (range) age of 63 years (59 to 67). The specimens were selected to match known epidemiology, as distal clavicular fractures occur more commonly in older patients with osteoporotic bone, and clavicular fractures in older patients are more common in females than males. The clavicles were then imaged using quantitative micro-CT to create 3-D images. The BMD and cortical thickness were calculated for 10 regions of interest in each specimen. These regions were selected to represent locations where distal clavicular fractures commonly occur and locations of likely bony comminution. Findings were compared between different regions using repeated measures ANOVA with Geiser-Greenhouse correction, followed by Bonferroni method multiple comparison testing. Effect size was also calculated to estimate the magnitude of difference between regions. RESULTS: The four most medial regions of the distal clavicle contained the greatest BMD (anterior intertubercle space 887 ± 31 mgHA/cc, posterior intertubercle space 879 ± 26 mgHA/cc, anterior conoid tubercle 900 ± 21 mgHA/cc, posterior conoid tubercle 896 ± 27 mgHA/cc), while the four most lateral regions contained the least BMD (anterior lateral distal clavicle 804 ± 32 mgHA/cc, posterior lateral distal clavicle 800 ± 38 mgHA/cc, anterior medial distal clavicle 815 ± 27 mgHA/cc, posterior medial distal clavicle 795 ± 26 mgHA/cc). All four most medial regions had greater BMD than the four most lateral regions, with p < 0.001 for all comparisons. For the BMD ANOVA, η was determined to be 0.81, representing a large effect size. The four most medial regions of the distal clavicle also had the greatest cortical thickness (anterior intertubercle space 0.7 ± 0.2 mm, posterior intertubercle space 0.7 ± 0.3 mm, anterior conoid tubercle 0.9 ± 0.2 mm, posterior conoid tubercle 0.7 ± 0.2 mm), while the four most lateral regions had the smallest cortical thickness (anterior lateral distal clavicle 0.2 ± 0.1 mm, posterior lateral distal clavicle 0.2 ± 0.1 mm, anterior medial distal clavicle 0.3 ± 0.1 mm, posterior medial distal clavicle 0.2 ± 0.1 mm). All four most medial regions had greater cortical thickness than the four most lateral regions, with p < 0.001 for all comparisons. For the cortical thickness ANOVA, η was determined to be 0.80, representing a large effect size. No differences in BMDs and cortical thicknesses were found between anterior and posterior regions of interest in any given area. CONCLUSIONS: In the distal clavicle, BMD and cortical thickness are greatest in the conoid tubercle and intertubercle space. When compared with clavicular regions lateral to the trapezoid tubercle, the BMD and cortical thickness of the conoid tubercle and intertubercle space were increased, with a large magnitude of difference. CLINICAL RELEVANCE: Distal clavicular fractures are prone to comminution and modern treatment strategies have centered on the use of locking plate technology and/or suspensory fixation between the coracoid and the clavicle. However, screw pullout or cortical button pull through are known complications of locking plate and suspensory fixation, respectively. Therefore, it seems intuitive that implant placement during internal fixation of distal clavicle fractures should take advantage of the best-available bone. Although osteosynthesis was not directly studied, our study suggests that the best screw purchase in the distal clavicle is available in the areas of the conoid tubercle and intertubercle space, as these areas had the best bone quality. Targeting these areas during implant fixation would likely reduce implant failure and strengthen fixation. Future studies should build on our findings to determine if osteosynthesis of distal clavicular fractures with targeted screw purchase or cortical button placement in the conoid tubercle and intertubercle space increase fixation strength and decreases construct failure. Furthermore, our findings provide consideration for novel distal clavicular locking plate designs with modified screw trajectories or refined surgical techniques with suspensory fixation implants to reliably capture these areas of greatest bone quality.

Reconstruction of the Superior Glenoid Labrum With Biceps Tendon Autograft: A Cadaveric Biomechanical Study.

PURPOSE: To describe 2 superior labral reconstruction techniques using long head of the biceps (LHB) autograft and to investigate the ability of the 2 reconstruction techniques to restore superior restraint to the glenohumeral joint compared with superior labrum-deficient models. METHODS: In this biomechanical study, 10 cadaveric shoulders were cycled on a servohydraulic machine while the force required to cause superior subluxation was recorded. Each specimen was cycled under 4 conditions: intact labrum, SLAP tear, posterior (9- to 12-o'clock position) labral reconstruction using LHB autograft (superior labral reconstruction 1 [SLR1]), and 180° (9- to 3-o'clock position) labral reconstruction using LHB autograft (superior labral reconstruction 2 [SLR2]). RESULTS: The mean peak force required to cause superior subluxation in the intact labrum was 32.75 N versus 19.75 N in the SLAP tear (P = .0120). SLR1 required a mean peak force of 31.23 N versus 44.09 N for SLR2 (P = .0175). SLR1 required 94.96% of the force needed in the intact labrum to cause subluxation, whereas SLR2 required 140.6%. SLR1 and SLR2 required 34.21% higher (P = .0074) and 79.84% higher (P = .0033) forces, respectively, to generate subluxation compared with the SLAP tear state. CONCLUSIONS: Both proposed superior labral reconstruction techniques increased the force needed for humeral head superior migration in the setting of a labral tear. SLR1 (posterior labral reconstruction) closely matched the constraint of an intact labrum, whereas SLR2 (180° labral reconstruction) provided greater superior constraint than an intact labrum. CLINICAL RELEVANCE: The natural history of irreparable rotator cuff tears results in superior glenohumeral escape and eventual arthrosis. The superior glenoid labrum is an important contributor to superior glenohumeral constraint and is often degenerated in this setting. Clinical application of the 2 described superior labral reconstruction techniques may improve glenohumeral superior stability in patients with rotator cuff disease and superior labral deficiency.

Computer Modeling Analysis of the Talar Dome as a Graft for the Humeral Head.

PURPOSE: To study the degree of surface congruency between the talar dome and humeral head, to determine the size of graft harvestable from the talar dome, and to determine if there are surrogate markers that correspond to a higher degree of surface congruency. METHODS: Computer models of 7 nonmatched humeral heads and 7 talar domes were generated by digital segmentation of magnetic resonance (MR) images. Modeled defect regions of each humeral head were then aligned with medial and lateral surfaces of each talar dome using software to maximally limit surface mismatch. Modeled defect sizes ranging from 24 × 10 mm to 30 × 10 mm were tested. Congruence match of <1 mm separation was then measured. RESULTS: The average surface match between randomly selected talar domes to humeral head surfaces was 87.2% when 1 mm was selected as the maximal acceptable congruence difference. Congruence match was not affected by graft size or laterality of talar dome as source of graft. Matching radius of curvature of talar dome to humeral head and height of donor to recipient correlated with improved congruence match. Under best match conditions, a maximal congruence match of 95.2% was achieved. CONCLUSIONS: The present study indicates that the talar dome can be a potential source of osteochondral allograft for Hill-Sachs lesions with a maximal defect size of 30 × 10 mm for a single graft. Larger graft sizes resulted in decreased success of actual graft harvest as a result of dimensional constraints of the talar dome. Additional studies are required to determine the biomechanical compatibility of this graft. CLINICAL RELEVANCE: The talar dome has a high degree of surface congruency in comparison with the humeral head though the maximal graft size harvestable limits its clinical applicability.

Assessing Diagnostic Arthroscopy Performance in the Operating Room Using the Arthroscopic Surgery Skill Evaluation Tool (ASSET).

PURPOSE: To determine the validity and reliability of using the Arthroscopic Surgery Skill Evaluation Tool (ASSET) to assess arthroscopic skill in the operating room. METHODS: Eight orthopaedic residents, 1 sports medicine fellow, and 3 sports medicine faculty members recorded the diagnostic portion of 3 shoulder and 3 knee procedures in the operating room. Two blinded raters used the ASSET to assess each recorded procedure video. Criterion for a passing score on a procedure was attaining a 3 or greater in all 8 domains assessed. RESULTS: In total 70 videos (36 shoulder, 34 knee) were evaluated by each rater. The attending/fellow group was assigned significantly higher mean ASSET scores compared with resident groups for both procedures (P = .01). The attending/fellow group also had the highest passing percentage (95.8%). Raters were in agreement for total ASSET scores assigned to both diagnostic arthroscopy of the shoulder (intraclass correlation coefficient [ICC] = 0.84) and knee (ICC = 0.81). Agreement on individual ASSET domains was moderate (ICC = 0.61 to 0.80) for all domains except safety and difficulty of procedure. Raters concurred on the pass-fail evaluation in 62 of 70 (88.6%) of procedures evaluated. CONCLUSIONS: Using the ASSET to assess surgical skills in the operating room is feasible, reliable, and valid. CLINICAL RELEVANCE: When combined with previously published results using the ASSET, the ASSET may provide a validated and reliable method for evaluating arthroscopic surgical skills in the surgical simulation lab and operating room.

Effects of varying locations for biceps tendon tenotomy and superior labral integrity on shoulder stability in a cadaveric concavity-compression model.

PURPOSE: The purpose of this study was to examine the location of biceps tenotomy and the integrity of the superior labrum as they relate to superior glenohumeral joint stability in a cadaveric concavity-compression model. METHODS: Eight cadaveric glenoid labrums were mounted individually onto a load cell with the corresponding humerus fixed to the loading arm in the hanging-arm position. All surrounding soft tissue was removed except the labrum and proximal stump of the long head of the biceps (LHB) tendon, simulating a biceps tenotomy. A compressive load of 22 N was applied across the glenohumeral joint. The humerus was then translated superiorly until it subluxated over the glenoid labrum. The force resisting superior translation was characterized for each of 50 cycles. Each specimen was tested under the following conditions: (1) with a 4 cm biceps stump after tenotomy, (2) with a 0 cm biceps stump, (3) after full detachment of the superior labrum, and (4) after repair of the labrum. RESULTS: Biceps tenotomy performed at the biceps-labral junction resulted in an average decrease in force required to superiorly subluxate the humeral head by 8.6% (P = .01) when compared with leaving 4 cm of biceps stump. Resection of the entire superior labrum resulted in a future decrease to 15.2% (P < .001) from baseline. Repair of the labrum resulted in restoration of stability with a mean of 101.1% (P = .82) and was not statistically different from baseline. The kinematics of the glenohumeral joint was affected by labral repair, with an earlier upslope on the force-to-displacement curve and alteration in the total energy required to cause subluxation of the humeral head noted. CONCLUSIONS: In this study, location of the biceps tenotomy and integrity of the superior labrum affected glenohumeral stability during axial loading in the hanging-arm position. Repair of the labrum restored stability for superior subluxation but also changed the kinematics of the subluxation event. CLINICAL RELEVANCE: Preservation of superior labrum after biceps tenotomy provides increased resistive force to superior translation in a unidirectional biomechanical model.

Efforts to Improve Diversity, Equality, and Inclusion in Sports Medicine via Community Engagement Initiatives Within American Cities Divided by Racial, Social, and Economic Factors.

Although the twenty-first century has seen major advances in evidence-based medicine to improve health, athletic performance, and injury prevention, our inability to implement these best practices across underserved American communities has limited the impact of these breakthroughs in sports medicine. Rochester, NY is stereotypical of American communities in which an economically challenged racially diverse urban center with grossly underperforming public schools is surrounded by adequately resourced predominantly Caucasian state-of-the-art education systems. As these great disparities perpetuate and further degrade our society in the absence of interventions, the need for community engagement initiatives is self-evident.

Arthroscopic subacromial decompression improved outcomes in situationally depressed patients compared to clinically depressed or nondepressed patients.

Background: The purpose of this study is to evaluate patient reported outcomes after arthroscopic extensive débridement of the shoulder with subacromial decompression (SAD) for subacromial impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) system and evaluate if depression (Dep) (clinical or situational) impacts patients achieving a Minimal Clinically Important Difference (MCID). Methods: Preoperative PROMIS Physical function (PF), Mood, and Dep scores were obtained at the closest date prior to arthroscopic rotator cuff repair and postoperative scores were collected at every clinical visit thereafter. Final PROMIS score used for data analysis was determined by the patients final PROMIS value between 90 to 180 days. Clinical Dep was determined by patients having a formal diagnosis of "Depression or Major Depressive Disorder" at the time of their surgery. Situationally depressed patients, those without a formal diagnosis yet exhibited symptomatic depressive symptoms, were classified by having a PROMIS-Dep cutoff scores larger than 52.5. Results: A total of 136 patients were included for final statistical analysis. 13 patients had a clinical but not situational diagnosis of Dep, 86 patients were identified who had no instance of clinical or situational Dep (nondepressed). 35 patients were situationally depressed. All three cohorts demonstrated a significant improvement in postoperative PROMIS Dep, PI, and PF score relative to their preoperative value (P = .001). Situationally depressed patients achieved greater delta PROMIS-Dep compared to patients with major depressive disorder. Depressed patients had a higher chance of achieving MCID for PROMIS-Dep compared to nondepressed patients (P = .01). Logistic regression analysis demonstrated that underlying Dep did not alter the odds of obtaining MCID compared to nondepressed patients. Nonsmoking patients had significantly greater odds of achieving MCID for PF (P = .02). Discussion: Patients improved after undergoing SAD regardless of underlying Dep or depressive symptoms. Depressed patients exhibited greater change in PROMIS scores compared to nondepressed patients. Smoking remains a risk factor for postoperative outcomes in patients undergoing SAD for subacromial impingement. Identifying and counseling patients with underlying depressive symptoms without a formal major depressive disorder diagnosis may lead to improved outcomes. These findings may help guide clinicians in deciding who would benefit the most from this procedure.

Impact of Sports Participation on Achievement of Clinically Relevant Outcomes 2 Years After ACL Reconstruction.

Background: Clinically relevant threshold values associated with patient-reported outcome measures after orthopaedic procedures such as anterior cruciate ligament reconstruction (ACLR) are important for relating these scores to meaningful postoperative improvement. Purpose/Hypothesis: The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) for the Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) after ACLR. It was hypothesized that preoperative sport participation would have an impact on PASS achievement. Study Design: Case series; Level of evidence, 4. Methods: Included were consecutive patients who underwent primary assisted ACLR between January 4 and August 1, 2016. Patients were administered the PROMIS-CAT Physical Function (PF) and Pain Interference domains preoperatively and at a minimum 2 years postoperatively, with external anchor questions used to determine the PASS. Receiver operating characteristic (ROC) curves were constructed for the entire study population as well as separately for athletes and nonathletes to determine PROMIS PASS thresholds for each population. A previously published PROMIS-PF minimal clinically important difference was used to evaluate postoperative improvement. A post hoc multivariate nominal logistic multivariate analysis was constructed to assess the effects of preoperative patient characteristics on the likelihood of attaining both the minimal clinically important difference and PASS. Results: In total, 112 patients were included in the study, with 79 (71%) having recreational or higher levels of athletic participation. The PASS for the study population was 56.0 (area under the ROC curve, 0.86) and was unaffected by baseline PROMIS-PF scores but was affected by preoperative athletic participation (56.0 for athletes, 49.0 for nonathletes). A post hoc analysis found 57 patients (51%) achieved the PASS for the PROMIS-PF (cutoff, 56.0), but when the athlete and nonathlete thresholds were applied to their respective patient groups, 66% of athletes and 64% of nonathletes achieved the PASS postoperatively. The multivariate analysis found that sport participation (odds ratio, 6.2; P = .001) but not age, sex, body mass index, or preoperative PROMIS affected the likelihood of achieving the PASS on the PROMIS-PF. Conclusion: Preoperative athletic participation significantly affected the ability to achieve PASS.

Use of Area Deprivation Index to Predict Minimal Clinically Important Difference for Patient Reported Outcomes Measurement Information System After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Socioeconomic disparities correlate with worse outcomes after arthroscopic rotator cuff repair. However, use of a surrogate to describe socioeconomic disadvantage has been a challenge. The Area Deprivation Index (ADI) is a tool that encompasses 17 socioeconomic variables into a single metric based on census location. HYPOTHESIS: Higher ADI would result in a worse minimal clinically important difference (MCID) for the Patient Reported Outcomes Measurement Information System (PROMIS) and have less improvement in range of motion (ROM) following arthroscopic rotator cuff repair (ARCR). STUDY DESIGN: Cohort study; Level of evidence, 3. METHOD: A retrospective review was performed for patients who underwent arthroscopic rotator cuff repair. Patients in the most socioeconomically disadvantaged quartile (ADIHigh) were compared with the least disadvantaged quartile (ADILow) in the ability to reach MCID. Demographic and surgical features were assessed for attainment of MCID. RESULTS: In total 1382 patients were identified who underwent ARCR, of which a total of 306 patients met final inclusion criteria. A higher percentage of patients within the ADIHigh cohort identified as "Black" or "other" race and had government-issued insurance compared with the ADILow cohort (P < .05). The ADIHigh cohort had significantly worse postoperative forward flexion compared with the ADILow cohort (145.0°± 32.5° vs 156.3°± 23.4°; P = .001) despite starting with comparable preoperative ROM (P = .17). Logistic regression showed that ADI was the only variable significant for predicting achievement of MCID for all 3 PROMIS domains, with the ADIHigh cohort having significantly worse odds of achieving MCID Physical Function (odds ratio [OR], 0.31; P = .001), Pain Interference (OR, 0.21; P = .001), and Depression (OR, 0.28; P = .001). Meanwhile, age, sex, body mass index, and smoking history were nonsignificant. Moreover, "other" for race and Medicare insurance were significant for achievement of MCID Depression but not Physical Function or Pain Interference. Finally, ADI was the main feature for predictive logistic regression modeling. CONCLUSION: ADI served as the only significant predictor for achieving MCID for all 3 PROMIS domains after arthroscopic rotator cuff repair. Patients who face high levels of socioeconomic disadvantage have lower rates of achieving MCID. In addition, patients with greater neighborhood disadvantage demonstrated significantly worse improvement in active forward flexion. Further investigation is required to understand the role of ADI on physical therapy compliance and to identify the barriers that prevent equitable postoperative care.

Effect of Insurance Reimbursement Status on Pre- and Postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Scores After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Previous studies reported inferior patient-reported outcomes (PROs) after arthroscopic rotator cuff repair for patients receiving workers' compensation (WC) relative to patients with commercial insurance. The extent to which alternative insurance reimbursement, including Medicaid and Medicare, influences outcomes after arthroscopic rotator cuff repair remains understudied. HYPOTHESIS: Compared with patients with commercial insurance reimbursement, patients with WC or government-issued reimbursement would report lower pre- and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scores, report higher pre- and postoperative PROMIS Depression (D) and Pain Interference (PI) scores, and experience smaller levels of improvement in all PROMIS domains with surgical intervention. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Demographic and surgical data were extracted from the medical record, and PROMIS domains were prospectively collected. Patients were divided into cohorts based on insurance reimbursement status. Differences between insurance-based cohorts for baseline variables, pre- and postoperative PROMIS scores, and change from baseline to final follow-up (delta) for PROMIS scores were evaluated using Kruskal-Wallis or chi-square tests. Mixed-effects linear regression models were performed to assess the influence of insurance while controlling for other variables. Survival analysis was performed to determine time to achieve minimal clinically important difference (MCID) for each PROMIS domain per cohort. RESULTS: 1252 patients underwent arthroscopic rotator cuff repair, met inclusion criteria, and completed PROMIS questionnaires. Statistically significant differences were noted in demographic variables including age (P < .001), sex (P < .001), ethnicity (P < .001), and body mass index (P < .001) between insurance-based cohorts. Unadjusted analysis revealed significantly higher PF scores and lower PI and D scores for the group with commercial insurance relative to those with Medicare, Medicaid, and WC at 6- and 12-month follow-up (P < .01 all comparisons), except for the Medicare versus commercial subcohort analysis for PI at 6 months (P = .28). These differences persisted for the Medicare, Medicaid, and WC groups (P < .03 all comparisons) after adjustment for confounding variables in linear regression. CONCLUSIONS: The baseline characteristics of patients undergoing arthroscopic rotator cuff repair differed based on insurance reimbursement. Patients with commercial insurance reported improved physical function, decreased pain interference, and improved mood (less depression) relative to patients with government-issued and WC insurance, with maximum improvement 6 to 12 months postoperatively. There were few significant differences between insurance groups in change of PROMIS scores from preoperative to postoperative intervals, indicating that differences in the baseline demographic and surgical characteristics of these groups accounted for differences in response to surgery.

Academic Orthopaedics As a Driver of Gender Diversity in the Orthopaedic Workforce: A Review of 4,519 Orthopaedic Faculty Members.

BACKGROUND: The purpose of this study was to perform a cross-sectional analysis on the gender composition of practicing academic orthopaedic surgeons using three databases composed of clinical orthopaedic surgeons. METHODS: A comprehensive database of 4,519 clinically active academic orthopaedic surgeons was compiled for this study after the review of publicly available data. The complied data set was evaluated alongside orthopaedic databases obtained from the 2017 Association of American Medical Colleges (AAMC) Faculty Administrative Management Online User System and the 2016 American Academy of Orthopaedic Surgery (AAOS) Orthopaedic Practice in the US census representing the entire academy membership orthopaedic workforce. Gender status was obtained and compared between the three databases. RESULTS: Of the 4,519 clinically active academic orthopaedic surgeons analyzed, 435 (10%) were female compared with 19% for the AAMC faculty database and 7% for the AAOS members. Fourteen percent of women had achieved the rank of professor compared with 25% of the men (P < 0.001). AAMC faculty had a significantly higher percentages of female representation compared with both the clinical faculty (19% versus 10%; P < 0.001) and AAOS members (19% versus 7%; P < 0.001). CONCLUSION: Despite multiple initiatives designed to increase diversity, the 7% female representation in the orthopaedic workforce identified in this study remains markedly lower than other medical and surgical specialties. A higher percentage of women were associated with the AAMC orthopaedic faculty compared with clinically active female surgeons at these institutions. Academic orthopaedic surgeons had greater female representation than the general orthopaedic workforce, highlighting the importance of training institutions at promoting gender equity.

Use of Fitbit Data to Evaluate the Effects of an Athletic Performance and Injury Prevention Training Program on Daily Physical Levels in Underrepresented Minority Female High School Athletes: A Prospective Study.

A marginal number of adolescents meet the recommended guidelines of 60 minutes of moderate to vigorous daily physical activity, and even fewer underrepresented minority females achieve this metric as compared to their male and white counterparts. While potential interventions exist to address these low levels of activity, which is a known risk for acute injuries and chronic disease, there is lack of consensus on the devices used to measure the intensity of daily activity levels. Wearable activity trackers such as Fitbit™ have been utilized to quantify human motion and exercise intensity, but there is little precedence for these measures being assessed in adolescent wearers. Thus, our objective was to assess the feasibility of using Fitbit to assess daily physical activity levels in underrepresented minority adolescent females, who attend an economically challenged urban high school, over the course of a physical activity intervention. We also aimed to identify candidate Fitbit outcome measures for future prospective studies. A 10-week physical activity intervention was implemented in a cohort of 24 high school female athletes. From within this cohort, a sample of five students were provided Fitbit™ devices, from which we obtained data sets from three students. Activity on the days of the exercise intervention was measured and compared to activity on non-intervention days. Post-hoc assessments were performed based on individual heart rate reserves, the predefined levels set by the Inspire Fitbit™ device and the American College of Sports Medicine (ACSM) 2009 guidelines. The results showed that while compliance is challenging, wearable devices can be used to assess daily physical activity levels and intensities in underrepresented minority high school female athletes during an extended physical activity intervention. Of the Fitbit outcomes currently available, assessment of moderate-vigorous activity (min/day) appeared to be the best as a measure of global physical activity. Prospective research is now warranted to validate these thresholds, and to test novel interventions for their ability to transition inactive adolescents at risk of sports-related injuries and long-term chronic disease, into a more active lifestyle.

Arthroscopic Posterior Glenohumeral Capsular Augmentation With Gracilis Tendon Allograft.

Recurrent shoulder instability complicated by capsular insufficiency due to underlying soft-tissue disorders or multiple prior failed surgical procedures poses a challenging surgical problem. Traditional capsulolabral soft-tissue reconstruction techniques are less effective in this setting, and bony procedures sacrifice normal anatomic relations. The described arthroscopic technique aims to prevent instability while maintaining range of motion through creation of a soft-tissue allograft "sling" augmenting the posterior glenohumeral capsule.

Do Patient Reported Outcome Measurement Information System (PROMIS) Scales Demonstrate Responsiveness as Well as Disease-Specific Scales in Patients Undergoing Knee Arthroscopy?

BACKGROUND: The Patient Reported Outcomes Information System (PROMIS) is an efficient metric able to detect changes in global health. PURPOSE: To assess the responsiveness, convergent validity, and clinically important difference (CID) of PROMIS compared with disease-specific scales after knee arthroscopy. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: A prospective institutional review board-approved study collected PROMIS Physical Function (PF), PROMIS Pain Interference (PI), International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) results in patients undergoing knee arthroscopy. The change from preoperative to longest follow-up was used in analyses performed to determine responsiveness, convergent validity, and minimal and moderate CID using the IKDC scale as the anchor. RESULTS: Of the 100 patients enrolled, 76 were included. Values of the effect size index (ESI) ranged from near 0 to 1.69 across time points and were comparable across scales. Correlations of the change in KOOS and PROMIS with IKDC ranged from r values of 0.61 to 0.79. The minimal CID for KOOS varied from 12.5 to 17.5. PROMIS PF and PI minimal CID were 3.3 and -3.2. KOOS moderate CID varied from 14.3 to 18.8. PROMIS PF and PI moderate CID were 5.0 and -5.8. CONCLUSION: The PROMIS PF and PI showed similar responsiveness and CID compared with disease-specific scales in patients after knee arthroscopy. PROMIS PI, PROMIS PF, and KOOS correlations with IKDC demonstrate that these scales are measuring a similar construct. The ESIs of PROMIS PF and PI were similar to those of KOOS and IKDC, suggesting similar responsiveness at 6 months or longer (ESI >1.0). Minimum and moderate CID values calculated for PROMIS PF and PI using IKDC as an anchor were sufficiently low to suggest clinical usefulness. CLINICAL RELEVANCE: PROMIS PF and PI can be accurately used to determine improvement or lack thereof with clinically important changes after knee arthroscopy.

Use of PROMIS and Functional Movement System (FMS) Testing to Evaluate the Effects of Athletic Performance and Injury Prevention Training in Female High School Athletes.

Two major health concerns with female high school athletes are: 1) psychosocial wellness, and 2) sports-related injuries. It is also known that these health concerns are much greater for minority students who attend high school in economically depressed cities. While it has been well-established that exercise is an effective intervention for these health concerns, there are no established outcome measures to quantitatively assess athletic performance and injury prevention training interventions in this population. Previously, we have demonstrated the utility of Patient-Reported Outcomes Measurement Information System (PROMIS) as a robust outcome measure following ACL reconstruction. Functional Movement Screening (FMS) has been used as a tool to determine injury risk in female collegiate athletes. Since these tools are broadly available, we completed a research study of urban underrepresented minority and suburban female high school athletes, to assess the feasibility and utility of these tools to measure changes in this population during 10-weeks of athletic training. No adverse events of the training or study were reported. A Kaplan-Meier assessment of the data revealed that there was high student retention throughout the 10 weeks. In addition, we found no difference in weekly attendance between the students that completed the intervention vs. the dropouts (while they were in the program), indicating that the students were highly motivated to attend when possible. While no significant differences were found for fatigue and physical function, the intervention significantly improved anxiety, peer relationships, pain interference, and trended towards significance for depression (p<0.05). In terms of physical performance, bench press, combined Pro Agility, and total FMS were all significantly improved (p<0.05). Surprisingly, there were 10 students (67%) in peril of sports- related injury (FM˂14) at the start of the intervention, and all but 1 (90%) eliminated this serious risk factor. Collectively, these results demonstrate the feasibility of PROMIS and FMS outcomes to assess the efficacy of physical training interventions, in underrepresented minority female high school students, which warrants investigation in a formal prospective study.

Allograft Use in Shoulder Surgery: Instability and Rotator Cuff.

Shoulder instability and rotator cuff pathology can provide a challenging problem, especially in the revision setting. Allograft use in primary or revision surgical intervention for shoulder instability and rotator cuff tear may be a valuable resource. This paper reviews allograft tissue use in shoulder surgery for instability and rotator cuff tear.

Options for Failed Rotator Cuff Repair.

Failed rotator cuff repairs can pose a clinical challenge to the treating orthopedic surgeon. There are many nonsurgical and surgical options available to address the failed rotator cuff repair. Surgical options include revising the primary repair, partial or nonanatomic repair, tendon transfer, biological augmentation or use of tissue-engineered grafts for reconstruction, or total joint arthroplasty (typically with a modern reverse total shoulder arthroplasty system). The treating surgeon must assess the patient's functional status, health status, and expectations in order to customize the appropriate treatment plan for addressing the failed rotator cuff repair. With the abundance of treatment options available, there is typically an adequate solution to help the patient regain function and experience less pain.

Safety of Overlapping Inpatient Orthopaedic Surgery: A Multicenter Study.

BACKGROUND: Although overlapping surgery is used to maximize efficiency, more empirical data are needed to guide patient safety. We conducted a retrospective cohort study to evaluate the safety of overlapping inpatient orthopaedic surgery, as judged by the occurrence of perioperative complications. METHODS: All inpatient orthopaedic surgical procedures performed at 5 academic institutions from January 1, 2015, to December 31, 2015, were included. Overlapping surgery was defined as 2 skin incisions open simultaneously for 1 surgeon. In comparing patients who underwent overlapping surgery with those who underwent non-overlapping surgery, the primary outcome was the occurrence of a perioperative complication within 30 days of the surgical procedure, and secondary outcomes included all-cause 30-day readmission, length of stay, and mortality. To determine if there was an association between overlapping surgery and a perioperative complication, we tested for non-inferiority of overlapping surgery, assuming a null hypothesis of an increased risk of 50%. We used an inverse probability of treatment weighted regression model adjusted for institution, procedure type, demographic characteristics (age, sex, race, comorbidities), admission type, admission severity of illness, and clustering by surgeon. RESULTS: Among 14,135 cases, the frequency of overlapping surgery was 40%. The frequencies of perioperative complications were 1% in the overlapping surgery group and 2% in the non-overlapping surgery group. The overlapping surgery group was non-inferior to the non-overlapping surgery group (odds ratio [OR], 0.61 [90% confidence interval (CI), 0.45 to 0.83]; p < 0.001), with reduced odds of perioperative complications (OR, 0.61 [95% CI, 0.43 to 0.88]; p = 0.009). For secondary outcomes, there was a significantly lower chance of all-cause 30-day readmission in the overlapping surgery group (OR, 0.67 [95% CI, 0.52 to 0.87]; p = 0.003) and shorter length of stay (e, 0.94 [95% CI, 0.89 to 0.99]; p = 0.012). There was no difference in mortality. CONCLUSIONS: Our results suggest that overlapping inpatient orthopaedic surgery does not introduce additional perioperative risk for the complications that we evaluated. The suitability of this practice should be determined by individual surgeons on a case-by-case basis with appropriate informed consent. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Pain-related Outcomes and Inflammatory Cytokine Response to Pain Following Insomnia Improvement in Adults With Knee Osteoarthritis.

OBJECTIVES: Clinical insomnia is known to affect pain, but mechanisms are unclear. Insomnia can dysregulate inflammatory pathway, and inflammation plays a mediating role in pain. It is unclear whether insomnia-related alterations in inflammation can be modified with insomnia improvement, and if such alterations parallel improvement in pain. The current study objective was to provide proof of concept for the role of insomnia in inflammation and pain by testing whether improving insomnia would reduce pain and related physical function, and, concurrently, modulate inflammatory responses. MATERIALS AND METHODS: Thirty adults with osteoarthritis knee pain and insomnia (Insomnia Severity Index >10) provided baseline measures of osteoarthritis and laboratory pain, and serial blood samples for inflammatory biomarkers, interleukin 6, and tumor necrosis factor α, before and after pain testing. To manipulate insomnia, participants were randomly assigned to a 6-week cognitive-behavioral therapy for insomnia (n=16); or wait-list control (n=14). At 8-weeks (time 2), all measures were repeated. To directly test insomnia improvement effects, participants were grouped by insomnia status at time 2 after confirming baseline equivalency on all outcomes. RESULTS: Compared with those maintaining insomnia at time 2 (Insomnia Severity Index ≥8; n=18), those whose insomnia improved at time 2 (n=12) had significantly improved physical functioning, decline in knee pain during transfer activities, and attenuated increase in interleukin 6 and less decrease in tumor necrosis factor α across the pain testing session. DISCUSSION: These findings suggest further exploration of inflammatory pathways linking clinical insomnia, and its improvement, to chronic pain.