Association Among Surgeon Volume, Surgical Approach, and Uterine Size for Hysterectomy for Benign Indications.

OBJECTIVE: To assess the relationship between surgeon volume and surgical approach for patients undergoing hysterectomy for benign indications among uteri of varying sizes. METHODS: This was a retrospective cohort study of patients who underwent hysterectomy for benign indications from 2012 to 2021 within the Michigan Surgical Quality Collaborative registry. For each hysterectomy, the relative annual volume of the performing surgeon was assessed by calculating the proportion of hysterectomy cases contributed by the surgeon each calendar year relative to the total number of hysterectomies in the registry for that year. Hysterectomies were stratified into tertiles: those performed by low-volume surgeons, intermediate-volume surgeons, and high-volume surgeons. Uterine size was represented by the uterine specimen weight and categorized to facilitate clinical interpretation. Multivariable logistic regression models were developed incorporating interaction terms for surgeon volume and uterine size to explore potential effect modification. RESULTS: A total of 54,150 hysterectomies were included. Hysterectomies performed by intermediate- and high-volume surgeons were more likely to be performed through a minimally invasive approach compared with those performed by low-volume surgeons (intermediate-volume: adjusted odds ratio [aOR] 1.68, 95% CI, 1.47-1.92; high-volume: aOR 2.14, 95% CI, 1.87-2.46). Moreover, this likelihood increased with increasing uterine weight. For uteri weighing between 1,000 g and 1,999 g, the odds of minimally invasive approach was significantly higher among intermediate-volume surgeons (aOR 3.38, 95% CI, 2.04-5.12) and high-volume (aOR 9.26, 95% CI, 5.64-15.2) surgeons, compared with low-volume surgeons. After including an interaction term for uterine weight and surgeon volume, we identified effect modification of surgeon volume on the relationship between uterine size and choice of minimally invasive surgery. CONCLUSION: For uteri up to 3,000 g in weight, hysterectomies performed by high-volume surgeons have a higher likelihood of being performed through a minimally invasive approach compared with those performed by low-volume surgeons.

Pelvic myofascial pain is associated with restriction of sexual activity in women with pelvic pain: a cross-sectional study.

Background Dyspareunia and restriction of sexual activity are often reported by patients with chronic pelvic pain, but less is known about which conditions or factors contribute most to these symptoms. Methods This is a cross-sectional study of consecutive new patients who presented to a chronic pelvic pain and endometriosis referral clinic between January 2013 and December 2015. Patients completed a detailed questionnaire prior to their first visit and underwent a comprehensive standardised pelvic examination at their first visit. Patients were grouped according to description of sexual activity as 'normal activity without pain', 'normal activity but painful', 'severely restricted by pain', or 'absent due to pain.' Primary outcome was restriction of sexual activity due to pain. Multinomial logistic regression was performed with 'normal activity without pain' group as reference category and adjusted for age, depression, history of endometriosis, and pelvic myofascial pain. Results Over half of the 187 patients with chronic pelvic pain described severely restricted (n =75, 40.1%) or absent (n =21, 11.2%) sexual activity due to pain. Pelvic myofascial pain was highly prevalent in this population and pelvic myofascial tenderness score was associated with higher odds of sexual activity that was severely restricted by pain (OR 1.05, 95% CI 1.01-1.09, P =0.006) or absent due to pain (OR 1.09, 95% CI 1.04-1.13, P Conclusion Dyspareunia and sexual dysfunction are highly prevalent among patients with chronic pelvic pain, and pelvic myofascial pain is strongly associated with restriction of sexual activity due to pain.

Root Repair Has Superior Radiological and Clinical Outcomes Than Partial Meniscectomy and Nonoperative Treatment in the Management of Meniscus Root Tears: A Systematic Review.

PURPOSE: To compile and analyze structural and clinical outcomes after meniscus root tear treatment as currently described in the literature. METHODS: A review was conducted to identify studies published since 2011 on efficacy of repair, meniscectomy, and nonoperative management in the treatment of meniscus root tears. Patient cohorts were grouped into treatment categories, with medial and lateral root tears analyzed separately; data were collected on patient demographics, structural outcomes including joint space width, degree of medial meniscal extrusion, progression to total knee arthroplasty, and patient-reported outcome measures. Risk of bias was assessed using the MINORS (methodological index for non-randomized studies) criteria. Heterogeneity was measured using the I-statistic, and outcomes were summarized using forest plots without pooled means. RESULTS: The 56 included studies comprised a total of 3,191 patients. Mean age among the included studies ranged from 24.6 to 65.6 years, whereas mean follow-up ranged from 12 to 125.9 months. Heterogeneity analysis identified significant differences between studies. Change in joint space width ranged from -2.4 to -0.6 mm (i.e., decreased space) after meniscectomy (n = 186) and -0.9 to -0.1 mm after root repair (n = 209); change in medial meniscal extrusion ranged from -0.6 to 6.5 mm after root repair (n = 521) and 0.2 to 4.2 mm after meniscectomy (n = 66); and event rate for total knee arthroplasty ranged from 0.00 to 0.22 after root repair (n = 205), 0.35 to 0.60 after meniscectomy (n = 53), and 0.27 to 0.35 after nonoperative treatment (n = 93). Root repair produced the greatest numerical increase in International Knee Documentation Committee and Lysholm scores of the 3 treatment arms. In addition, root repair improvements in Knee Injury and Osteoarthritis Outcome Score Pain (range: 22-32), Sports and Recreational Activities (range: 23-36), Quality of Life (range: 22-42), and Symptoms subscales (range: 10-19), in studies with low risk of bias. CONCLUSIONS: The literature reporting on the treatment of meniscus root tears is heterogenous and largely limited to Level III and IV studies. Current evidence suggests root repair may be the most effective treatment strategy in lessening joint space narrowing of the knee and producing improvements in patient-reported outcomes. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Surgical Repair of Hypermobile Lateral Meniscus Secondary to Popliteomeniscal Fascicle Tears Improves Pain and Mechanical Symptoms.

Purpose: To describe the clinical and radiographic features associated with isolated hypermobile lateral meniscus (HLM), and report patient outcomes following surgically repaired isolated HLM. Methods: All patients diagnosed with HLM from 2000 to 2020 at a single academic institution were identified and reviewed. Patients were excluded if they had concomitant ligament injury or lacked 2-year follow-up. Preoperative and postoperative visual analog scale (VAS) pain scores were determined from clinical notes. Statistical analysis was performed in JMP, and statistical significance was determined with use of a paired t-test. Results: Eighteen knees in 17 patients met inclusion criteria. Mean patient age was 24.1 (range: 6-61) years. Mean follow-up was 73 months (25-151 months). All 18 knees reported pain at presentation; 94% (17/18) had mechanical symptoms. All 18 knees had preoperative MRIs, but only 1 (5.6%) knee was correctly diagnosed by a musculoskeletal trained radiologist. Most repairs were performed with an all-inside technique (61%, 11/18). VAS score improved significantly from 7.2 ± 2.9 preoperatively to 0.7 ± 1.9 postoperatively, with average improvement of VAS score of 6.5 (P < .001). Only one (5.6%) knee required revision meniscal surgery. Conclusion: Hypermobile lateral meniscus patients commonly see multiple providers, fail to have their HLM diagnosed on MRI, and undergo various treatments prior to a successful diagnosis. Localized lateral joint line pain, mechanical symptoms, and absence of distinct meniscus tear on MRI are the most frequent clinical presentations. Surgery with meniscus repair is a reliable solution to improve pain and mechanical symptoms. Level of Evidence: Level IV, therapeutic case series.

Artificial Intelligence Can Define and Predict the "Optimal Observed Outcome" After Anterior Shoulder Instability Surgery: An Analysis of 200 Patients With 11-Year Mean Follow-Up.

Purpose: The purpose of this study was to use unsupervised machine learning clustering to define the "optimal observed outcome" after surgery for anterior shoulder instability (ASI) and to identify predictors for achieving it. Methods: Medical records, images, and operative reports were reviewed for patients <40 years old undergoing surgery for ASI. Four unsupervised machine learning clustering algorithms partitioned subjects into "optimal observed outcome" or "suboptimal outcome" based on combinations of actually observed outcomes. Demographic, clinical, and treatment variables were compared between groups using descriptive statistics and Kaplan-Meier survival curves. Variables were assessed for prognostic value through multivariate stepwise logistic regression. Results: Two hundred patients with a mean follow-up of 11 years were included. Of these, 146 (64%) obtained the "optimal observed outcome," characterized by decreased: postoperative pain (23% vs 52%; P < 0.001), recurrent instability (12% vs 41%; P < 0.001), revision surgery (10% vs 24%; P = 0.015), osteoarthritis (OA) (5% vs 19%; P = 0.005), and restricted motion (161° vs 168°; P = 0.001). Forty-one percent of patients had a "perfect outcome," defined as ideal performance across all outcomes. Time from initial instability to presentation (odds ratio [OR] = 0.96; 95% confidence interval [CI], 0.92-0.98; P = 0.006) and habitual/voluntary instability (OR = 0.17; 95% CI, 0.04-0.77; P = 0.020) were negative predictors of achieving the "optimal observed outcome." A predilection toward subluxations rather than dislocations before surgery (OR = 1.30; 95% CI, 1.02-1.65; P = 0.030) was a positive predictor. Type of surgery performed was not a significant predictor. Conclusion: After surgery for ASI, 64% of patients achieved the "optimal observed outcome" defined as minimal postoperative pain, no recurrent instability or OA, low revision surgery rates, and increased range of motion, of whom only 41% achieved a "perfect outcome." Positive predictors were shorter time to presentation and predilection toward preoperative subluxations over dislocations. Level of Evidence: Retrospective cohort, level IV.

Psychosocial predictors of change in sexual activity and sexual function after hysterectomy in women with pelvic pain.

BACKGROUND: Potential impact on sexual function is an often-cited concern for many patients considering hysterectomy. The existing literature indicates that sexual function remains stable to slightly improved for most patients who undergo hysterectomy, but most studies demonstrate a small subset of patients in whom sexual function declines after surgery. Unfortunately, there is a lack of clarity as to surgical, clinical, and psychosocial factors that may influence the likelihood of sexual activity after surgery or the magnitude and direction of change in sexual function. Although psychosocial factors are strongly associated with overall female sexual function, there is minimal data exploring the potential impact of these factors on the change in sexual function after hysterectomy. OBJECTIVE: This study aimed to evaluate the relationship between baseline psychosocial factors and both sexual activity and sexual function at 6 months after hysterectomy. STUDY DESIGN: Patients undergoing hysterectomy for benign, non-obstetric indications were prospectively recruited as part of an observational cohort study evaluating presurgical predictors of posthysterectomy outcomes on pain, quality of life, and sexual function. The Female Sexual Function Index was administered before hysterectomy and 6 months after surgery. Presurgical psychosocial assessments included validated self-reported measures of depression, resilience, relationship satisfaction, emotional support, and social participation. RESULTS: Complete data was available for 193 patients, of whom 149 (77.2%) reported sexual activity at 6 months after hysterectomy. In the binary logistic regression model examining sexual activity at 6 months, older age was associated with a lower likelihood of sexual activity (odds ratio, 0.91; 95% confidence interval, 0.85-0.96; P=.002). Higher relationship satisfaction before surgery was associated with a greater likelihood of sexual activity at 6 months (odds ratio, 1.09; 95% confidence interval, 1.02-1.16; P=.008). As expected, preoperative sexual activity was associated with a greater likelihood of postoperative sexual activity (odds ratio, 9.78; 95% confidence interval, 3.95-24.19, P<.001). Analyses using Female Sexual Function Index scores were limited to patients who were sexually active at both time points (n=132 [68.4%]). The total Female Sexual Function Index score did not change significantly from baseline to 6 months, but there were statistically significant changes in several individual domains of sexual function. Patients reported significant improvement in desire (P=.012), arousal (P=.023), and pain (P<.001) domains. However, significant decreases were reported in orgasm (P<.001) and satisfaction (P<.001) domains. The proportion of patients who met the criteria for sexual dysfunction was quite high (>60%) at both time points, but there was not a statistically significant change in the proportion from baseline to 6 months. In the multivariate linear regression model, there was no relationship between change in sexual function score and any of the variables examined, including age, endometriosis history, pelvic pain severity, or psychosocial measures. CONCLUSION: In this cohort of patients with pelvic pain undergoing hysterectomy for benign indications, both sexual activity and sexual function remained fairly stable after hysterectomy. Higher relationship satisfaction, younger age, and preoperative sexual activity were associated with a greater probability of sexual activity at 6 months after surgery. Psychosocial factors, such as depression, relationship satisfaction, and emotional support, and history of endometriosis were not related to change in sexual function among patients who were sexually active both before hysterectomy and at 6 months after surgery.

Management of Partial-Thickness Tears of the Distal Bicep Tendon: Evaluation of 111 Patients With 10-Year Follow-up.

Background: There is a paucity of research on the management of partial-thickness tears of the distal bicep tendon, and even less is known about the long-term outcomes of this condition. Purpose: To identify patients with partial-thickness distal bicep tendon tears and determine (1) patient characteristics and treatment strategies, (2) long-term outcomes, and (3) any identifiable risk factors for progression to surgery or complete tear. Study Design: Case-control study; Level of evidence, 3. Methods: A fellowship-trained musculoskeletal radiologist identified patients diagnosed with a partial-thickness distal bicep tendon tear on magnetic resonance imaging between 1996 and 2016. Medical records were reviewed to confirm the diagnosis and record study details. Multivariate logistic regression models were created using baseline characteristics, injury details, and physical examination findings to predict operative intervention. Results: In total, 111 patients met inclusion criteria (54 treated operatively, 57 treated nonoperatively), with 53% of tears in the nondominant arm and a mean follow-up time after surgery of 9.7 ± 6.5 years. Only 5% of patients progressed to full-thickness tears during the study period, at a mean of 35 months after the initial diagnosis. Patients who were nonoperatively treated were less likely to miss time from work (12% vs 61%; P < .001) and missed fewer days (30 vs 97 days; P < .016) than those treated surgically. Multivariate regression analyses demonstrated increased risk of progression to surgery with older age at initial consult (unit odds ratio [OR], 1.1), tenderness to palpation (OR, 7.5), and supination weakness (OR, 24.8). Supination weakness at initial consult was a statistically significant predictor for surgical intervention (OR, 24.8; P = .001). Conclusion: Clinical outcomes were favorable for patients regardless of treatment strategy. Approximately 50% of patients were treated surgically; patients with supination weakness were 24 times more likely to undergo surgery than those without. Progression to full-thickness tear was a relatively uncommon reason for surgical intervention, with only 5% of patients progressing to full-thickness tears during the study period and the majority occurring within 3 months of initial diagnosis.

Predicting the Risk of Posttraumatic Osteoarthritis After Primary Anterior Cruciate Ligament Reconstruction: A Machine Learning Time-to-Event Analysis.

BACKGROUND: There is a significant long-term risk of posttraumatic osteoarthritis (PTOA) after anterior cruciate ligament reconstruction (ACLR). Elucidating the risk factors and successfully identifying at-risk patients is challenging. PURPOSE/HYPOTHESIS: The purpose of this study was to produce machine learning survival models that can identify (1) patients at risk of symptomatic PTOA and (2) patients who are at risk of undergoing total knee arthroplasty (TKA) after ACLR. It was hypothesized that these models would outperform traditional Kaplan-Meier estimators. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A geographic database was used to identify patients undergoing ACLR between 1990 and 2016 with a minimum 7.5-year follow-up. Models were used to analyze various factors to predict the rate and time to (1) symptomatic osteoarthritis and (2) TKA using random survival forest (RSF) algorithms. Performance was measured using out-of-bag (OOB) c-statistic, calibration, and Brier score. The predictive performances of the RSF models were compared with Kaplan-Meier estimators. Model interpretability was enhanced utilizing global variable importance and partial dependence curves. RESULTS: A total of 974 patients with ACLR and a minimum follow-up of 7.5 years were included; among these, 215 (22.1%) developed symptomatic osteoarthritis, and 25 (2.6%) progressed to TKA. The RSF algorithms achieved acceptable good to excellent predictive performance for symptomatic arthritis (OOB c-statistic, 0.75; Brier score, 0.128) and progression to TKA (OOB c-statistic, 0.89; Brier score, 0.026), respectively. Significant predictors of symptomatic PTOA included increased pain scores, older age, increased body mass index, increased time to ACLR, total number of arthroscopic surgeries before the diagnosis of arthritis, positive pivot-shift test after reconstruction, concomitant chondral injury, secondary meniscal tear, early (<250 days) or delayed (>500 days) return to sports or activity, and use of allograft. Significant predictors for TKA included older age, increased pain scores, total number of arthroscopic surgeries, high-demand activity/occupation, hypermobility, higher body mass index, systemic inflammatory disease, increased time to surgery, early (<250 days) or delayed (>500 days) return to sports or activity, and midsubstance tears. The Brier score over time revealed that RSF models outperformed traditional Kaplan-Meier estimators. CONCLUSION: Machine learning survival models were used to reliably identify patients at risk of developing symptomatic PTOA, and these models consistently outperformed traditional Kaplan-Meier estimators. Strong predictors for the development of PTOA after ACLR included increased pain scores at injury and postoperative visit, older age at injury, total number of arthroscopic procedures, positive postoperative pivot-shift test, and secondary meniscal tear.

Osteochondritis Dissecans of the Capitellum of the Elbow: Improved Outcomes in Surgically Treated Versus Nonoperatively Treated Patients at Long-Term Follow-up.

Purpose: To (1) report the long-term outcomes associated with both operative and nonoperative management of capitellar osteochondritis dissecans (OCD), (2) identify factors associated with failure of nonoperative management, and (3) determine whether delay in surgery affects final outcomes. Methods: All patients who received a diagnosis of capitellar OCD from 1995-2020 within a geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. The cohort was divided into 3 groups: (1) nonoperative management, (2) early surgery, and (3) delayed surgery. Delayed surgery (surgery ≥6 months after symptom onset) was considered failure of nonoperative management. Results: Fifty elbows with a mean follow-up period of 10.5 years (median, 10.3 years; range, 1-25 years) were studied. Of these, 7 (14%) were definitively treated nonoperatively, 16 (32%) underwent delayed surgery after at least 6 months of failed nonoperative treatment, and 27 (54%) underwent early surgical intervention. When compared with nonoperative management, surgical management resulted in superior Mayo Elbow Performance Index pain scores (40.1 vs 33, P = .04), fewer mechanical symptoms (9% vs 50%, P < .01), and better elbow flexion (141° vs 131°, P = .01) at long-term follow-up. Older patients trended toward increased failure of nonoperative management (P = .06). The presence of an intra-articular loose body predicted failure of nonoperative management (P = .01; odds ratio, 13). Plain radiography and magnetic resonance imaging had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes after early versus delayed surgical management were not observed. Conclusions: Nonoperative management of capitellar OCD failed 70% of the time. Elbows that did not undergo surgery had slightly more symptoms and decreased functional outcomes compared with those treated surgically. The greatest predictors of failure of nonoperative treatment were older age and presence of a loose body; however, an initial trial of nonoperative treatment did not adversely impact the success of future surgery. Level of Evidence: Level III, retrospective cohort study.

Grooveplasty Compared With Trochleoplasty for the Treatment of Trochlear Dysplasia in the Setting of Patellar Instability.

Purpose: To compare the clinical efficacy in the resolution of patellar instability, patient-reported outcomes (PROs), and complication and reoperation rates between patients who underwent grooveplasty (proximal trochleoplasty) and patients who underwent trochleoplasty as part of a combined patellofemoral stabilization procedure. Methods: A retrospective chart review was performed to identify a cohort of patients who underwent grooveplasty and a cohort who underwent trochleoplasty at the time of patellar stabilization. Complications, reoperations, and PRO scores (Tegner, Kujala, and International Knee Documentation Committee scores) were collected at final follow-up. The Kruskal-Wallis test and Fisher exact test were performed when appropriate, and P < .05 was considered significant. Results: Overall, 17 grooveplasty patients (18 knees) and 15 trochleoplasty patients (15 knees) were included. Seventy-nine percent of patients were female, and the average follow-up period was 3.9 years. The mean age at first dislocation was 11.8 years overall; most patients (65%) had more than 10 lifetime instability events and 76% of patients underwent prior knee-stabilizing procedures. Trochlear dysplasia (Dejour classification) was similar between cohorts. Patients who underwent grooveplasty had a higher activity level (P = .007) and a higher degree of patellar facet chondromalacia (P = .008) at baseline. At final follow-up, no patients had recurrent symptomatic instability after grooveplasty compared with 5 patients in the trochleoplasty cohort (P = .013). There were no differences in postoperative International Knee Documentation Committee scores (P = .870), Kujala scores (P = .059), or Tegner scores (P = .052). Additionally, there were no differences in complication rates (17% in grooveplasty cohort vs 13% in trochleoplasty cohort, P > .999) or reoperation rates (22% vs 13%, P = .665). Conclusions: Proximal trochlear reshaping and removal of the supratrochlear spur (grooveplasty) in patients with severe trochlear dysplasia may offer an alternative strategy to complete trochleoplasty for the treatment of trochlear dysplasia in complex cases of patellofemoral instability. Grooveplasty patients showed less recurrent instability and similar PROs and reoperation rates compared with trochleoplasty patients. Level of Evidence: Level III, retrospective comparative study.

Children and Restraints Study in Emergency Ambulance Transport: An Observational Study and Analysis of Current Pediatric Ambulance Transport Practices.

OBJECTIVES: The aims of this study were to identify the pediatric transport methods used by Emergency Medical Services (EMS) personnel in our area and to highlight the need for federal standards to unify prehospital transport of children. METHODS: Children and Restraints Study in Emergency Ambulance Transport is a retrospective observational study of EMS arrivals to an academic pediatric emergency department for 1 year. Review of existing security footage from the ambulance entrance focused on the appropriateness of the selected restraints and the correctness of their application. A total of 3034 encounters were adequate for review and were matched to an emergency department encounter. Weight and age were identified from the chart. Patient weight was used in conjunction with video review to assess for the appropriateness of restraint selection. RESULTS: A total of 53.5% (1622) of patients were transported using a weight appropriate device or restraint system. In 77.1% of all cases (2339), the devices or restraint systems were applied incorrectly. The best results were observed for commercial pediatric restraint devices (54.5% secured appropriately) and for convertible car seats (55.5%). Ambulance cot was used alone in 69.35% of all transports despite it being the appropriate choice in just 18.2% of transports. CONCLUSIONS: Our findings confirmed that most pediatric patients transported by EMS are not appropriately secured and are at increased injury in a crash and potentially during normal vehicle operation. Opportunity exists for regulators, industry, and leaders in EMS and pediatrics to develop fiscally and operationally prudent techniques and devices to improve the safety of children in ambulances.

Association Between Nociplastic Pain and Pain Severity and Impact in Women With Chronic Pelvic Pain.

Exploring the relationship between nociplastic pain and the severity and impact of pelvic pain symptoms could lend insight into the heterogeneous symptom presentation and treatment response that complicates management of chronic pelvic pain. In this prospective cross-sectional study, we sought to evaluate relationships between degree of nociplastic pain, measured by the Fibromyalgia (FM) Survey Score, and multiple aspects of the chronic pelvic pain (CPP) experience, including severity, frequency, tenderness during pelvic myofascial exam, interference with daily life, and high-impact pain. The study included 303 women who presented to a tertiary referral clinic for chronic pelvic pain and endometriosis. Multiple measures of pelvic pain, including pain severity, frequency, interference, pelvic myofascial pain, and high-impact pain were examined in General Linear Models with FM Survey Score as the primary predictor of interest in models controlling for endometriosis, surgical history, use of opioids, body mass index, and patient age. Higher level of nociplastic pain was associated with greater pelvic pain severity, frequency, interference, and pelvic myofascial pain (all P < .05). For all models, degree of nociplastic pain was more strongly associated with pain outcomes than the presence of endometriosis, and use of opioids was the only stronger predictor of worse pain outcomes. The likelihood of high impact pain increased 7% for each additional point on the FM Survey Score. Degree of nociplastic pain was robustly associated with severity, frequency, and impact of pelvic pain, and was independent of the presence of endometriosis, history of surgical procedures for pelvic pain, age, and BMI. Trial registration: not applicable PERSPECTIVE: This article evaluates the impact of nociplastic pain on symptoms and functional status in chronic pelvic pain. These findings raise the possibility that a simple screening tool for nociplastic pain might provide clinically actionable information without the need for deep neurobiological phenotyping and may inform development of personalized management strategies.

A Number of Modifiable and Nonmodifiable Factors Increase the Risk for Elbow Medial Ulnar Collateral Ligament Injury in Baseball Players: A Systematic Review.

PURPOSE: To analyze the current literature regarding risk factors associated with medial ulnar collateral ligament (MUCL) injury in baseball players and to serve as a robust source for identifying modifiable risk factors that once optimized, have the potential to reduce injury risk. METHODS: Comprehensive search of the available literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies were included if they evaluated risk factors for MUCL injuries in the elbow of baseball players. Risk of bias assessment was performed via Methodological Index for Non-randomized Studies (MINORS) scoring system. The Oxford Centre for Evidence-Based Medicine was used to determine level of evidence. Variables of interest; player age, position, shoulder motion, humeral retrotorsion, joint laxity, strength, balance, geography, velocity, pitch count, pitch types, throwing volumes, and throwing mechanics were recorded. RESULTS: Twenty-one studies were included in this systematic review. MINORS scores ranged from 75 to 87%, and variables demonstrated significant heterogeneity. Performance-based risk factors for MUCL injury included: increased pitch count (both annual and per game), higher percentage of fastballs thrown, smaller pitch repertoire, and/or a loss of pitching velocity. Biomechanical studies demonstrated the relationship between decreased shoulder range of motion (total ROM, ER, IR, and abduction), increased humeral retrotorsion, increased elbow valgus opening in the throwing arm, lower Y-Balance score, and increased lateral release position to increased MUCL injury. CONCLUSIONS: Risk factors for MUCL injury can generally be categorized into 4 primary groups: 1) various player demographics and characteristics, 2) throwing too hard (high velocity), 3) throwing too much (pitch count/volume), and 4) throwing with poor mechanics. In this systematic review, the most significant nonmodifiable risk factors for MUCL injuries included: increased glenohumeral retrotorsion and elbow valgus opening. The most consistent modifiable risk factors included: total shoulder range of motion, pitch count, pitch selection, Y balance score, and lateral release position. Pitch velocity was inconsistent in literature, but most studies found this as a risk for injury. These risk factors may serve as appropriate targets for future evidence-based injury mitigation strategies. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Advances in the Treatment of Rotator Cuff Tears: Management of Rotator Cuff Tears in the Athlete.

Unique biomechanical factors in the overhead and throwing athlete lead to a spectrum of rotator cuff pathology, usually with progressive lateralization of the supraspinatus footprint. Initial comprehensive nonoperative management is indicated for all athletes. Progression to arthroscopic debridement, repair of concomitant injuries, and possible rotator cuff repair with a transosseous equivalent technique are the current management strategies for athletes when nonoperative management fails.

Central arterial pressure and patient-specific model parameter estimation based on radial pressure measurements.

One-dimensional arterial flow simulations are suitable to estimate the aortic pressure from peripheral measurements in a patient-specific arterial network. This study introduces a reduction of the system parameters, and a novel calculation method to estimate the patient-specific set and the aortic curve based on radial applanation tonometry. Peripheral and aortic pressure curves were measured in patients, optimization were carried out. The aortic pressure curves were reproduced well, with an overestimation of the measured Systolic and Mean Blood Pressures on average by 0.6 and 0.5 mmHg respectively, and the Root Mean Square Difference of the curves was 3 mmHg on average.

Risk factors for secondary meniscus tears can be accurately predicted through machine learning, creating a resource for patient education and intervention.

PURPOSE: This study sought to develop and internally validate a machine learning model to identify risk factors and quantify overall risk of secondary meniscus injury in a longitudinal cohort after primary ACL reconstruction (ACLR). METHODS: Patients with new ACL injury between 1990 and 2016 with minimum 2-year follow-up were identified. Records were extensively reviewed to extract demographic, treatment, and diagnosis of new meniscus injury following ACLR. Four candidate machine learning algorithms were evaluated to predict secondary meniscus tears. Performance was assessed through discrimination using area under the receiver operating characteristics curve (AUROC), calibration, and decision curve analysis; interpretability was enhanced utilizing global variable importance plots and partial dependence curves. RESULTS: A total of 1187 patients underwent ACLR; 139 (11.7%) experienced a secondary meniscus tear at a mean time of 65 months post-op. The best performing model for predicting secondary meniscus tear was the random forest (AUROC = 0.790, 95% CI: 0.785-0.795; calibration intercept = 0.006, 95% CI: 0.005-0.007, calibration slope = 0.961 95% CI: 0.956-0.965, Brier's score = 0.10 95% CI: 0.09-0.12), and all four machine learning algorithms outperformed traditional logistic regression. The following risk factors were identified: shorter time to return to sport (RTS), lower VAS at injury, increased time from injury to surgery, older age at injury, and proximal ACL tear. CONCLUSION: Machine learning models outperformed traditional prediction models and identified multiple risk factors for secondary meniscus tears after ACLR. Following careful external validation, these models can be deployed to provide real-time quantifiable risk for counseling and timely intervention to help guide patient expectations and possibly improve clinical outcomes. LEVEL OF EVIDENCE: III.

Stimulated whole-blood cytokine/chemokine responses are associated with interstitial cystitis/bladder pain syndrome phenotypes and features of nociplastic pain: a multidisciplinary approach to the study of chronic pelvic pain research network study.

ABSTRACT: Interstitial cystitis/bladder pain syndrome (IC/BPS) is a common and debilitating disease with poor treatment outcomes. Studies from the multidisciplinary approach to the study of chronic pelvic pain research network established that IC/BPS patients with chronic overlapping pain conditions (COPCs) experience poorer quality of life and more severe symptoms, yet the neurobiological correlates of this subtype are largely unknown. We previously showed that ex vivo toll-like receptor 4 (TLR4) cytokine/chemokine release is associated with the presence of COPCs, as well as widespread pain and experimental pain sensitivity women with IC/BPS. Here, we attempt to confirm these findings in the multisite multidisciplinary approach to the study of chronic pelvic pain Symptom Patterns Study using TLR4-stimulated whole blood (female IC/BPS patients with COPC n = 99; without n = 36). Samples were collected in tubes preloaded with TLR4 agonist, incubated for 24 hours, and resulting supernatant assayed for 7 cytokines/chemokines. These were subject to a principal components analysis and the resulting components used as dependent variables in general linear models. Controlling for patient age, body mass index, and site of collection, we found that greater ex vivo TLR4-stimulated cytokine/chemokine release was associated with the presence of COPCs ( P < 0.01), extent of widespread pain ( P < 0.05), but not experimental pain sensitivity ( P > 0.05). However, a second component of anti-inflammatory, regulatory, and chemotactic activity was associated with reduced pain sensitivity ( P < 0.01). These results confirm that the IC/BPS + COPCs subtype show higher levels of ex vivo TLR4 cytokine/chemokine release and support a link between immune priming and nociplastic pain in IC/BPS.

Factors that Increase Elbow Stress in the Throwing Athlete: a Systematic Review of Biomechanical and Motion Analysis Studies of Baseball Pitching and Throwing.

PURPOSE OF REVIEW: Elbow pain poses a unique challenge in the throwing athlete. Due to the high levels of elbow stress during the throwing motion, elbow injuries are common in throwers of all ages. There are several postulated factors believed to contribute increased stress to the throwing elbow. A detailed review of the published biomechanical studies evaluating the stresses experienced by the throwing elbow is needed. Here, we review these biomechanical studies to extrapolate the contributing factors that increase stress, the modifications that may reduce such stress, and the post-injury rehabilitation that optimizes outcomes and reduces recurrence. RECENT FINDINGS: The biomechanical forces on the elbow have been further investigated delineated in recent work. Rotational malalignment of the shoulder, including both GIRD and decreased adduction, increases torque experienced by the elbow during pitching motions. Exact interactions between lower extremity, lumbopelvic or trunk rotation, and elbow forces during throwing remain uncertain with mixed results in recent literature. Pitch types may influence elbow stresses although delivery mechanism and distance thrown do not. Several biomechanical factors influence the stresses imparted on the throwing elbow. Throwing volume, proper throwing mechanics, and appropriate rehabilitation are likely to be to be the most influential on mitigating unnecessary stresses imparted to the elbow in the throwing athlete. A proper understanding of these factors may reduce the occurrence of these injuries in this population. Moreover, an understanding of proper rehabilitation following injury may ensure optimized results and reduce recurrence.

Comparison of Posterior Cruciate Ligament Reconstruction Using an All-Inside Technique With and Without Independent Suture Tape Reinforcement.

Background: Biomechanical studies support the use of suture tape reinforcement for limiting graft elongation and increasing strength in knee ligament reconstructions. Purpose: To compare posterior cruciate ligament (PCL) laxity, complication and reoperation rates, and patient-reported outcomes (PROs) after all-inside single-bundle PCL reconstruction (PCLR) with versus without independent suture tape reinforcement. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study of consecutive patients who underwent primary, all-inside allograft single-bundle PCLR with and without independent suture tape reinforcement at a single academic institution from 2012 to 2019. Medical records were reviewed for patient characteristics, additional injuries, and concomitant procedures. PRO scores (including the International Knee Documentation Committee [IKDC], Tegner activity scale, and Lysholm scores), bilateral comparison kneeling radiographs, and physical examination findings were collected at a minimum of 2 years postoperatively. Results: Included were 50 patients: 19 with suture tape reinforcement (mean age 30.6 ± 2.9 years) and 31 without suture tape reinforcement (control group; mean age 26.2 ± 1.6 years). One PCLR graft in the suture tape group failed. Posterior drawer examination revealed grade 1+ laxity in 4 of 19 (21%) of the suture tape cohort versus 6 of 31 (19%) of the control cohort (P > .999). Bilateral kneeling radiographs showed similar side-to-side differences in laxity between the groups (suture tape vs control: mean, 1.9 ± 0.4 vs 2.6 ± 0.6 mm; P = .361). There were no statistically significant differences between the groups in postoperative IKDC (suture tape vs control: 79.3 vs 79.6; P = .779), Lysholm (87.5 vs 84.3; P = .828), or Tegner activity (5.6 vs 5.7; P = .562) scores. Conclusion: All-inside single-bundle PCLR with and without independent suture tape reinforcement demonstrated low rates of graft failure, complications, and reoperations, with satisfactory PROs at a minimum 2-year follow-up. Radiographic posterior tibial translation was comparable between the 2 groups.