Most Anterior Cruciate Ligament Injuries in Professional Athletes Occur Without Contact to the Injured Knee: A Systematic Review of Video Analysis Studies.

PURPOSE: To systematically review studies using video analyses to evaluate anterior cruciate ligament (ACL) injury mechanisms in athletes during sport to better understand risk factors and the potential for injury prevention. METHODS: A literature search was conducted in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines statement using SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials from database inception through June 2023. Inclusion criteria included studies reporting on ACL injury mechanisms occurring in athletes based on video analysis. Athlete demographics, injury mechanisms, position of the lower extremity, and activity at the time of injury were recorded. RESULTS: A total of 13 studies, consisting of 542 athletes, met inclusion criteria. Most athletes competed at the professional level (91%, n = 495/542), with 79% (n = 422/536) of athletes being male. The most common sports were soccer (33%, n = 178/542) and American football (26%, n = 140/542). The most common injury mechanism was noncontact in 42.9% (n = 230/536) of athletes, followed by indirect contact (32.6%, n = 175/536) and direct contact (22.4%, n = 120/536). The most common position of injury was with a planted foot (91.7%, n = 110/120), full or near-full knee extension (84.4%, n = 49/58), and axial loading (81.3%, n = 87/107). Injuries commonly involved a deceleration/shift in momentum (50.4%, n = 123/244) or pivoting maneuver (36.1%, n = 77/213). At the time of injury, the knee commonly fell into valgus (76.8%, n = 225/293) with associated internal (53.5%, n = 46/86) or external tibiofemoral rotation (57.7%, n = 101/175). CONCLUSIONS: Most ACL injuries, when evaluated by video analysis, involve professional athletes participating in soccer and American football. The most common injury mechanism occurred without contact with the knee in extension during a deceleration or momentum shift, with resultant valgus and rotational force across the knee. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Is Biomechanically Equivalent to Reconstruction and Clinically Demonstrates Excellent Outcomes: A Systematic Review.

PURPOSE: To systematically review (1) biomechanical properties of augmented elbow ulnar collateral ligament (UCL) repair compared with reconstruction and (2) clinical efficacy and complication rates of UCL repair with and without augmentation. METHODS: A systematic review was completed August 15, 2023, identifying articles that (1) biomechanically compared suture augmented UCL repair and reconstruction and (2) clinically evaluated medial elbow UCL repairs. Search terms included: "UCL repair" OR "internal brace" OR "suture augmentation" AND "UCL reconstruction." For inclusion, biomechanical studies compared augmented repair with reconstruction; clinical studies required clinical outcomes with minimum 6-month follow-up. Biomechanical data included torsional stiffness, gap formation, peak torque, and failure torque. Clinical data included return to previous level of play, time to return, functional outcomes, and complications. RESULTS: In total, 8 biomechanical and 9 clinical studies were included (5 with and 4 without augmentation). In most biomechanical studies, augmented repairs demonstrated less gap formation, with equivalent torsional stiffness, failure load, and peak torque compared with reconstruction. Clinical outcomes in 104 patients without augmentation demonstrated return to previous level of 50% to 94% for nonprofessional athletes and 29% for professional baseball pitchers. Suture augmented repairs in 554 patients demonstrated return to previous level from 92% to 96%, at 3.8 to 7.4 months, with Kerlan Jobe Orthopaedic Clinic scores of 86 to 95. The overall complication rate for augmented UCL repair was 8.7%; most commonly ulnar neuropraxia (6%). CONCLUSIONS: Biomechanically, UCL repair with augmentation provided less gapping with equivalent torsional stiffness and failure compared with reconstruction. Clinically, augmented UCL repair demonstrated excellent return to previous level of play and Kerlan Jobe Orthopaedic Clinic scores with modest complications and time to return. Augmented UCL repair is biomechanically equivalent to reconstruction and may be a viable alternative to reconstruction in indicated athletes. CLINICAL RELEVANCE: UCL repair with suture augmentation is biomechanically equivalent to reconstruction and clinically demonstrates excellent outcomes.

Elbow Ulnar Collateral Ligament Tears in 2023: Evaluation and Management.

The ulnar collateral ligament, also called the medial collateral ligament of the elbow, is the primary stabilizer against valgus loads. This ligament can be traumatically torn, such as in an elbow dislocation, or can tear through attritional damage with overhead sports. Although baseball pitching is the most common contributor, these injuries also occur with volleyball, gymnastics, and javelin throwing. Patients most commonly report a history of medial elbow pain with associated loss of command, control, and throw velocity. The ulnar nerve lies directly superficial to the posterior band of the ulnar collateral ligament and ulnar neuritis is commonly associated with ulnar collateral ligament pathology. Nonsurgical treatment, including rest from activity, flexor-pronator strengthening, and possible platelet-rich plasma injections, can be considered for partial-thickness tears. Surgical treatment can be considered for patients in whom nonsurgical treatment fails and full-thickness tears. Historically, surgical treatment involved reconstruction of the ligament with a tendon graft. Ipsilateral palmaris longus autograft has been the most commonly used graft, but contralateral palmaris, autograft hamstring tendons, and allograft tendon have also been used. This procedure has a high rate of return to play and a low complication rate, but most athletes require 12 to 18 months to fully return. More recently, repair of the ligament, with the addition of a biologic ingrowth ligament augmentation suture, has demonstrated similarly high rates of return to play and low complication rates, with a full return to play in 6 months.

Magnetic Resonance Imaging Assessment of Cartilage Appearance Following Marrow Stimulation of Osteochondritis Dissecans of the Humeral Capitellum.

PURPOSE: Osteochondritis dissecans (OCD) of the capitellum is often treated by marrow stimulation techniques with good long-term outcomes. Magnetic resonance imaging (MRI) can be used to characterize the healing of cartilage repair tissue. However, no formal system exists for assessment of cartilage healing after marrow stimulation in capitellar OCD. The aims of this study were to describe the postoperative MRI appearance of capitellar repair cartilage after debridement and marrow stimulation for capitellar OCD and assess differences between symptomatic and asymptomatic patients. METHODS: This was a retrospective study of patients with capitellar OCD who underwent arthroscopic debridement and marrow stimulation and had a postoperative MRI to assess healing. The classification system developed by Marlovits and colleagues (Magnetic Resonance Observation of Cartilage Repair Tissue) was used to quantitatively profile the cartilage repair tissue in comparison to adjacent "normal" cartilage. Study participants completed an online survey to correlate outcomes with cartilage appearance. RESULTS: Eleven patients who underwent MRI for routine evaluation (asymptomatic), and 18 who underwent MRI for symptoms were identified. Overall, 59% of defects were completely filled, and in 83%, the cartilage surface had ulcerations or fibrillations. The cartilage variables were similar between symptomatic and asymptomatic patients. Capitellar subchondral bone edema was observed on the MRI of every patient who underwent a reoperation and was present in only 62% of those who did not. Clinical scores did not correlate with MRI cartilage findings, but the small sample size limited conclusions regarding clinical outcomes related to postoperative cartilage features seen on MRI. CONCLUSIONS: This detailed assessment of cartilage appearance by MRI after marrow stimulation for capitellar OCD demonstrated that incomplete cartilage fill was common in both symptomatic and asymptomatic patients. Those requiring a second surgery were more likely to demonstrate subchondral bone edema. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Reliability of ulnar collateral ligament findings in magnetic resonance imaging.

BACKGROUND: Ulnar collateral ligament (UCL) tears are common in baseball players. Although magnetic resonance imaging (MRI) is the most used imaging modality for UCL injuries, the inter-rater reliability of MRI analyzing specific characteristics of UCL pathology has not been defined. The purpose of this study was to define the inter-rater reliability of MRI for evaluating UCL characteristics. METHODS: Three surgeons analyzed 45 noncontrast MRIs: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with intraoperatively confirmed full-thickness tears. Findings evaluated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcifications, and partial- or full-thickness tearing) and location of the pathology (proximal, midsubstance, or distal). Fleiss' κ coefficients were used to assess interobserver reliability. RESULTS: There were high rates of agreement for midsubstance (κ: 0.50) and distal (κ: 0.69) ligament edema and proximal osseous edema (κ: 0.48). There were low rates of agreement for proximal ligament edema (κ: 0.08), ligament thickening (κ: -0.02 to 0.20), and proximal to midsubstance calcifications (κ: -0.04 to 0.10). Midsubstance (κ: 0.55) and distal full-thickness tears (κ: 0.63) demonstrated higher agreement than proximal (κ: 0.29). Proximal partial-thickness tears (κ: 0.45) had higher agreement than midsubstance (κ: -0.02) or distal (κ: -0.02). CONCLUSIONS: In our study, there was high inter-rater reliability regarding proximal osseous edema, midsubstance, and distal ligament edema and full-thickness tears. There was no agreement for midsubstance and distal partial-thickness UCL tears, but fair agreement for proximal tears. UCL tissue characteristics including ligament thickening and calcifications demonstrated low agreement. Challenges remain in effectively evaluating UCL tissue characteristics on noncontrast MRIs.

What are the indications for medial ulnar collateral ligament surgery in baseball players? An MRI case-based study.

BACKGROUND: Ulnar collateral ligament (UCL) tears are common in baseball players. When nonoperative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs. reconstruction. METHODS: Twenty-six orthopedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, midsubstance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95% CI) helped identify significant predictors for both queries. RESULTS: The odds of recommending surgical treatment compared to nonoperative treatment were 2.4× more likely for a proximal partial-thickness tear, 3.2× for distal partial-thickness tear, 5.1× for distal full-thickness tear, and 7.0× for proximal full-thickness tear (P < .001). Significant indications for repair included distal partial (OR = 1.6, 95% CI 1.0, 2.1, P < .001) and full-thickness tears (OR = 1.7, 95% CI 1.1, 2.3, P < .001). Repair was 3× less likely recommended for midsubstance full-thickness tears (OR = 3.0, 95% CI -5.0, -1.0, P = .004). Ultrasound stress testing was requested in 78% of partial tears. CONCLUSIONS: Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial-thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete midsubstance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes.

Return to play following nonsurgical management of superior labrum anterior-posterior tears: a systematic review.

BACKGROUND: Superior labrum anterior-posterior (SLAP) tears are common shoulder injuries, especially in overhead athletes. Often, initial management of these injuries is nonsurgical with focused rehabilitation. The purpose of this review was to evaluate the outcomes of nonsurgical management of SLAP tears in athletes. METHODS: A systematic review was performed for articles published before March 2021 using key search terms pertaining to clinical studies evaluating the nonsurgical treatment of SLAP tears in adult patients published in English-language literature. Abstracts and manuscripts were independently reviewed by 2 co-authors to determine eligibility. Return-to-play rate and return-to-prior-athletic-performance rate were determined by combining results across studies. RESULTS: Five articles met the inclusion criteria. There were 244 total athletes (162 elite or higher-level athletes). The mean ages ranged from 20.3 to 38.0 years. Type II SLAP tears were most common; baseball, softball, and weightlifting were the most common sports involved. The return-to-play rate was 53.7% in all athletes and 52.5% in elite or higher-level athletes. In athletes who were able to complete their nonoperative rehabilitation program, the return-to-play rate was 78% in all athletes and 76.6% in elite or higher-level athletes. The overall rate of return to prior performance was 42.6%, which increased to 72% for those athletes who were able to complete their rehabilitation. Patients who discontinued the rehabilitation protocol in favor of surgery had an average of 8 physical therapy sessions compared with 20 sessions for patients with successful nonoperative treatment. The timing of return to play was generally less than 6 months in studies that reported it. Patient-reported outcomes, including the American Shoulder and Elbow Surgeons score and visual analog scale, all improved significantly after nonsurgical treatment. Factors associated with failure of nonsurgical management included older age, participation in overhead sports (especially baseball pitchers), traumatic injury, positive compression rotation test, concomitant rotator cuff injury, longer baseball career, longer symptomatic period, and the presence of a Bennett spur. CONCLUSIONS: Overall, nonoperative treatment of SLAP tears in athletes can be successful, especially in the subset of patients who are able to complete their rehabilitation program before attempting a return to play. Although nonoperative treatment should be considered the first line of treatment for most SLAP tears, there are some factors that may be associated with failure of conservative treatment; therefore, further high level, prospective studies would be beneficial to identify those athletes most likely to respond favorably to nonoperative treatment.

Obesity and sex influence fatty infiltration of the rotator cuff: the Rotator Cuff Outcomes Workgroup (ROW) and Multicenter Orthopaedic Outcomes Network (MOON) cohorts.

BACKGROUND: Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited. METHODS: We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates. RESULTS: A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men. CONCLUSIONS: Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients.

Male Sex, Western Ontario Shoulder Instability Index Score, and Sport as Predictors of Large Labral Tears of the Shoulder: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

PURPOSE: To identify factors predictive of a large labral tear at the time of shoulder instability surgery. METHODS: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. RESULTS: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). CONCLUSIONS: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. LEVEL OF EVIDENCE: I, prognostic study.

Magnetic Resonance Imaging in Osteochondritis Dissecans of the Humeral Capitellum: Preoperative Assessment of Lesion Size and Lateral Wall Integrity.

PURPOSE: Magnetic resonance imaging (MRI) is a helpful tool in the evaluation of osteochondritis dissecans (OCD) of the humeral capitellum. The relationship between MRI appearance and clinically relevant intraoperative findings is incompletely understood. The goal of this study was to evaluate capitellar OCD lesions via preoperative MRI and to determine its accuracy in predicting lesion characteristics including lesion size and capitellar lateral wall integrity. METHODS: Patients surgically treated for capitellar OCD between January 2010 and June 2018 were reviewed. Preoperative MRI images were assessed by a musculoskeletal radiologist with documentation of lesion size, location, violation of the lateral wall, and stage, in accordance with previously established criteria. These data were compared with intraoperative findings. Involvement of the lateral wall of the capitellum was defined using 2 methods: (1) subchondral edema or articular cartilage disruption in the lateral third of the capitellum (lateral third method) or (2) disruption of the proximal-distal subchondral line along the lateral border of the capitellum descending vertically before the subchondral bone turns horizontally to form the radiocapitellar articulation (capitellar lateral wall sign method). Diagnostic test characteristics were compared for both methods. RESULTS: We reviewed the preoperative MRIs of 33 elbows with capitellar OCD and found no significant difference in mean lesion size between preoperative MRI (1.12 cm2) and intraoperative measurement (1.08 cm2). For detection of lateral wall integrity, preoperative MRI evaluation using the capitellar lateral wall sign method had an accuracy of 93%, sensitivity of 80%, specificity of 96%, positive predictive value of 80%, and negative predictive value of 96%. CONCLUSIONS: Preoperative MRI is a valid predictor of lesion size. The capitellar lateral wall sign method is highly accurate in the identification of lateral wall involvement, which may influence preoperative planning. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Early Improvement in Patient-Reported Outcome Scores After Operative Treatment of Osteochondritis Dissecans of the Humeral Capitellum.

PURPOSE: Outcome measures that lack sensitivity for the detection of clinical changes early after surgery for capitellar osteochondritis dissecans (OCD) make it difficult to determine the optimal treatment for these defects. We sought to evaluate the early responsiveness of patient-reported outcomes measurement information system (PROMIS) scores in a cohort of patients operatively treated for capitellar OCD. METHODS: Four PROMIS questionnaires (mobility, upper extremity [UE], pain interference, and peer relations) were electronically administered to patients treated for capitellar OCD at a single tertiary academic medical center between January 1, 2015, and July 1, 2018. The questionnaires were administered at the initial preoperative outpatient clinic visit as well as at the 2-week, 6-week, and final return-to-play (RTP) visits. RESULTS: Twenty-nine patients (31 elbows, mean age 12.9 years) with available preoperative and postoperative PROMIS data were included. The mean final follow-up period was 26 weeks. Compared with that before surgery, there was a significant improvement in the mobility, pain interference, and UE scores at 6 weeks following surgery. The scores improved most significantly by 6 weeks, reached a relative plateau, and remained significantly improved through the RTP visit thereafter. Patients with preoperative, intra-articular loose bodies scored significantly better than those without them during the 6-week and RTP visits. Patients with lesions >1 cm2, compared with those with lesions ≤1 cm2, demonstrated greater improvement in the UE scores during the RTP visit. CONCLUSIONS: In patients undergoing operative treatment for capitellar OCD, a significant improvement in the PROMIS domains of mobility, pain interference, and UE can be expected early in the postoperative period, with majority of patients reaching their greatest improvement in scores by 6 weeks following surgery. CLINICAL RELEVANCE: This is important information for preoperative counseling. In addition, this information is helpful in confirming that PROMIS scores are responsive in the detection of changes in outcomes during the early postoperative period in this population.

Performance of Patient-Reported Outcomes Measurement Information System (PROMIS) scores compared with legacy metrics in evaluating outcomes after surgical treatment for osteochondritis dissecans of the humeral capitellum.

BACKGROUND: Patient-Reported Outcomes Measurement Information System (PROMIS) scores have not previously been used to measure long-term outcomes in operatively treated capitellar osteochondritis dissecans (OCD) patients. The aims of our study were to (1) assess patients' long-term outcomes using PROMIS scores, (2) compare the performance of PROMIS with other validated elbow legacy metrics, and (3) evaluate ceiling and floor effects in these outcome measures in patients undergoing surgical treatment for capitellar OCD. METHODS: We evaluated demographic characteristics, procedure details, preoperative PROMIS scores, and associated sports information in surgically treated pediatric capitellar OCD patients. An online survey was sent to the study participants, including the Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow score, the quick Disabilities of the Arm, Shoulder and Hand questionnaire, and the Liverpool Elbow Score patient-answered questionnaire, as well as the Mobility, Pain Interference, and Upper Extremity questionnaires from the PROMIS pediatrics bank. Correlations were evaluated between outcome measures. Ceiling and floor effects were evaluated for each outcome measure. RESULTS: Completed surveys were obtained for 57 patients (59 elbows). The mean patient age at surgery was 14 years (range, 10-18 years). The mean follow-up time was 6 years (standard deviation, 5 years; range, 1-18 years). The mean PROMIS Mobility score improved from 41.2 preoperatively to 55.2 postoperatively (P < .001). The mean Pain Interference score decreased from 46.9 preoperatively to 38 postoperatively (P < .001). The mean Upper Extremity score improved from 42.7 preoperatively to 53.2 postoperatively (P < .001). Significant correlations were observed between all legacy metrics and postoperative PROMIS scores (|r| > 0.54, P < .001). Ceiling or floor effects were seen in all legacy metrics and PROMIS scores. The KJOC score was least affected by ceiling or floor effects. CONCLUSION: There is a strong correlation between PROMIS scores and legacy measures evaluating outcomes after surgical management of capitellar OCD. However, large ceiling and floor effects were present in all measures, likely owing to the favorable clinical results. The KJOC score was limited the least by ceiling and floor effects.

Decreased Postural Control in Patients Undergoing Anterior Cruciate Ligament Reconstruction Compared to Healthy Controls.

CONTEXT: Patients with anterior cruciate ligament (ACL) tears are likely to have deficient dynamic postural stability compared with healthy sex- and age-matched controls. OBJECTIVES: To test the hypothesis that patients undergoing ACL reconstruction have decreased dynamic postural stability compared with matched healthy controls. DESIGN: Prospective case-control study. SETTING: Orthopedic sports medicine and physical therapy clinics. PATIENTS OR OTHER PARTICIPANTS: Patients aged 20 years and younger with an ACL tear scheduled for reconstruction were enrolled prospectively. Controls were recruited from local high schools and colleges via flyers. INTERVENTIONS: Patients underwent double-stance dynamic postural stability testing prior to surgery, recording time to failure and dynamic motion analysis (DMA) scores. Patients were then matched with healthy controls. MAIN OUTCOME MEASURES: Demographics, time to failure, and DMA scores were compared between groups. RESULTS: A total of 19 females and 12 males with ACL tears were matched with controls. Individuals with ACL tears were more active (Marx activity score: 15.7 [1.0] vs 10.8 [4.9], P < .001); had shorter times until test failure (84.4 [15.8] vs 99.5 [14.5] s, P < .001); and had higher (worse) DMA scores (627 [147] vs 481 [132], P < .001), indicating less dynamic postural stability. Six patients with ACL deficiency (1 male and 5 females) demonstrated lower (better) DMA scores than their controls, and another 7 (4 males and 3 females) were within 20% of controls. CONCLUSIONS: Patients undergoing ACL reconstruction had worse global dynamic postural stability compared with well-matched controls. This may represent the effect of the ACL injury or preexisting deficits that contributed to the injury itself. These differences should be studied further to evaluate their relevance to ACL injury risk, rehabilitation, and return to play.

Biomechanical comparison of docking ulnar collateral ligament reconstruction with and without an internal brace.

BACKGROUND: Current ulnar collateral ligament (UCL) reconstruction techniques are substantially less stiff and demonstrate lower load to failure compared with the native UCL. UCL repair with the addition of an internal brace has demonstrated superior biomechanical performance compared with docking UCL reconstruction, but internal bracing has not yet been used in UCL reconstruction. HYPOTHESIS/PURPOSE: To evaluate the time-zero biomechanical performance of a UCL docking technique reconstruction with and without an internal brace compared with native UCL properties. METHODS: Twelve matched pairs of cadaveric elbows were dissected and fixed at 90° for biomechanical testing. A cyclic valgus torque protocol was used to test the anterior band of the UCL in native specimens. After native specimens were failed, palmaris grafts were used for a docking reconstruction with or without internal brace and were subjected to the same valgus torque test protocol. Torsional stiffness, ultimate failure torque, and ulnohumeral gapping were determined. RESULTS: Stiffness in UCL reconstructions using a standard docking technique (3.0 ± 0.4 N m/deg) were significantly less stiff (P < .001) than native UCL (4.0 ± 0.8 N m/deg), whereas reconstructions using an internal brace (3.6 ± 0.6 N m/deg) were not different (P = .120) compared with native. Ultimate failure torque for standard docking (18.3 ± 4.1 N m) was significantly lower (P < .001) than native UCL (36.9 ± 10.1 N m), whereas the internal brace samples (35.3 ± 9.8 N m) were not different (P = .772) than native. CONCLUSION: UCL reconstruction with an internal brace augmentation provides superior stiffness and time-zero failure strength when compared with the standard docking technique.

Patient Reported Outcomes Measurement Information System Scores Are Responsive to Early Changes in Patient Outcomes Following Arthroscopic Partial Meniscectomy.

PURPOSE: The purpose of this study was to test the hypothesis that Patient Reported Outcomes Measurement Information System (PROMIS) computer-adaptive testing (CAT) physical function and pain interference scores can detect early variations in postoperative outcomes following arthroscopic partial meniscectomy and to determine whether age, sex, body mass index, mechanical symptoms, duration of symptoms, and the severity of chondrosis affect these scores. METHODS: Seventy-five patients who had undergone a partial meniscectomy between September 2015 and March 2016 and had both preoperative and postoperative PROMIS-CAT data for physical function, pain interference, and depression were included. Demographic, clinical, and surgical data including the presence of intraoperative chondral lesions were collected for statistical analysis to assess for factors that led to differences in PROMIS-CAT outcomes. RESULTS: Preoperatively, patients had decreased physical function and increased pain interference in excess of 1 standard deviation from the general population with mean PROMIS scores of 38.5 and 63.5, respectively. At the 6-week postoperative visit, patients had significant improvements in both physical function and pain interference with mean scores of 43.4 (P < .001, SE = 0.75) and 55.5 (P < .001, SE = 0.83). Female patients had less improvement in PROMIS physical function (P = .03) and depression (P = .02) scores postoperatively compared with male patients. Patients with high-grade articular cartilage lesions had less improvement in physical function (P = .014) and pain interference (P = .010) at 6 weeks postoperative compared with patients with low grade or no chondral lesion. CONCLUSIONS: PROMIS-CAT provides responsive outcome measures to early postoperative changes in physical function and pain following arthroscopic partial meniscectomy and has prognostic value in patient outcomes 6 weeks after procedure. LEVEL OF EVIDENCE: Level IV case series.

Surgery versus physical therapy for a meniscal tear and osteoarthritis.

BACKGROUND: Whether arthroscopic partial meniscectomy for symptomatic patients with a meniscal tear and knee osteoarthritis results in better functional outcomes than nonoperative therapy is uncertain. METHODS: We conducted a multicenter, randomized, controlled trial involving symptomatic patients 45 years of age or older with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging. We randomly assigned 351 patients to surgery and postoperative physical therapy or to a standardized physical-therapy regimen (with the option to cross over to surgery at the discretion of the patient and surgeon). The patients were evaluated at 6 and 12 months. The primary outcome was the difference between the groups with respect to the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical-function score (ranging from 0 to 100, with higher scores indicating more severe symptoms) 6 months after randomization. RESULTS: In the intention-to-treat analysis, the mean improvement in the WOMAC score after 6 months was 20.9 points (95% confidence interval [CI], 17.9 to 23.9) in the surgical group and 18.5 (95% CI, 15.6 to 21.5) in the physical-therapy group (mean difference, 2.4 points; 95% CI, -1.8 to 6.5). At 6 months, 51 active participants in the study who were assigned to physical therapy alone (30%) had undergone surgery, and 9 patients assigned to surgery (6%) had not undergone surgery. The results at 12 months were similar to those at 6 months. The frequency of adverse events did not differ significantly between the groups. CONCLUSIONS: In the intention-to-treat analysis, we did not find significant differences between the study groups in functional improvement 6 months after randomization; however, 30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases; METEOR ClinicalTrials.gov number, NCT00597012.).

Shoulder Activity Level is Associated With Type of Employment and Income in the Normative Population Without Shoulder Disorders.

BACKGROUND: Socioeconomic variables influence various healthcare issues in different ways. The effect of socioeconomic variables on the shoulder has not been well studied. Because activity level, defined by how much a patient actually does, is an important patient outcome measure and prognostic factor for the shoulder, studying its association with occupation and income will advance our understanding of how these variables relate to shoulder disorders, treatments, and outcomes. QUESTIONS/PURPOSE: We asked: (1) Does shoulder activity score correlate with income level, stratified by gender? (2) Do different employment groups-heavy, moderate, light, student, retired-have different shoulder activity scores, as stratified by gender? (3) Is type of sports participation (contact or overhead) associated with income level, employment type, race, or household size? METHODS: A survey collected the Brophy and Marx shoulder activity score and demographic information, such as age, gender, race, income, type of employment, and household size from 1625 individuals 18 years and older with no current or previous shoulder pain or injury who are members of a research panel matched to the United States population by age, gender, household income and size, race/ethnicity, and geography. Men and women were analyzed separately. Activity level was controlled for age. RESULTS: Shoulder activity correlated with income level among men (R = 0.03; p < 0.001) and women (R = 0.06; p = 0.0002). For men, heavy employment had the highest Shoulder Activity Scale (SAS) level (12.1 ± 4.9), which was more than SAS levels in sedentary (9.1 ± 4.5; mean difference, 3.0; 95% CI, 2.5-3.6; p = 0.001), student (8.8 ± 5.1; mean difference, 3.3; 95% CI, 3.0-3.7; p = 0.007), retired (8.0 ± 4.6; mean difference, 4.1; 95% CI, 3.6-4.7; p = 0.0001), and not working (7.5 ± 5.3; mean difference, 4.6; 95% CI, 4.6-4.6; p < 0.001) categories; similarly, for women, heavy employment had the highest SAS level (12.0 ± 5.8). However, as there were few women working in heavy labor, the only significant difference in women was between moderate employment (8.8 ± 4.2) and sedentary employment (7.0 ± 4.1; mean difference, 1.8; 95% CI, 1.6-1.9; p = 0.0015). Participation in contact (19.9% vs 12.0%; p = 0.006) and overhead sports (25.2% vs 14.2%; p < 0.001) was greater among males with higher incomes. CONCLUSIONS: Shoulder activity level is related to the socioeconomic factors of income and type of employment. Heavy laborers have higher shoulder activity level, likely directly related to their work. Individuals with higher incomes also have higher shoulder activity level, probably attributable to recreation as evidenced by their greater participation in contact and overhead sports. Independent of the underlying cause, these patients probably are more likely to seek treatment for shoulder disorders and may be more challenging to treat because of their elevated activity level. Future research should focus on how elevated activity level in these populations affects their risk for shoulder disorders, and their use of and outcomes from treatment for these disorders. LEVEL OF EVIDENCE: Level IV, prognostic study.

2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears.

BACKGROUND: The purpose of this study is to help define the indications for rotator cuff repair by identifying predictors of failure of nonoperative treatment. METHODS: A prospective, multicenter, cohort study design was used. All patients with full-thickness rotator cuff tears on magnetic resonance imaging were offered participation. Baseline data from this cohort were used to examine risk factors for failing a standard rehabilitation protocol. Patients who underwent surgery were defined as failing nonoperative treatment. A Cox proportional hazards model was fit to determinethe baseline factors that predicted failure. The dependent variable was time to surgery. The independent variables were tear severity and baseline patient factors: age, activity level, body mass index, sex, Single Assessment Numeric Evaluation score, visual analog scale score for pain, education, handedness, comorbidities, duration of symptoms, strength, employment, smoking status, and patient expectations. RESULTS: Of the 433 subjects in this study, 87 underwent surgery with 93% follow-up at 1 year and 88% follow-up at 2 years. The median age was 62 years, and 49% were female patients. Multivariate modeling, adjusted for the covariates listed previously, identified patient expectations regarding physical therapy (P < .0001) as the strongest predictor of surgery. Higher activity level (P = .011) and not smoking (P = .023) were also significant predictors of surgery. CONCLUSION: A patient's decision to undergo surgery is influenced more by low expectations regarding the effectiveness of physical therapy than by patient symptoms or anatomic features of the rotator cuff tear. As such, patient symptoms and anatomic features of the chronic rotator cuff tear may not be the best features to use when deciding on surgical intervention.

Understanding of Meniscus Injury and Expectations of Meniscus Surgery in Patients Presenting for Orthopaedic Care.

PURPOSE: The purpose of this study is to assess orthopaedic patient knowledge and perceptions about the meniscus, meniscal injury, and treatment to identify gaps in orthopaedic patients' understanding and to assess the outcomes most important to these patients. METHODS: A 41-question survey was designed to measure knowledge and perception of meniscal tears regarding anatomy, function, surgical indications, operative techniques, risks, overall benefits of repair or removal, and recovery times. Study participants aged between 18 and 60 years were recruited from an academic orthopaedic sports medicine clinic regardless of their present complaint. Patients aged younger than 18 years were excluded. RESULTS: We surveyed 253 individuals (132 men and 121 women), with a mean age of 38 years. Most respondents (62%) rated their knowledge about the meniscus as little or no knowledge. Participants answered between 49% and 50% of questions regardless of how they self-rated their knowledge base. There was no correlation between perceived knowledge and percent answered correctly or between level of knee injury/surgery exposure and percent answered correctly. Only 28% of respondents knew that partial meniscectomy is the most common type of surgical treatment for meniscal tears. The risk of osteoarthritis developing and the risk of further surgery were the major concerns regarding meniscus surgery. Those who had undergone a previous meniscus surgery performed better on factual questions regarding meniscus structure (P = .0006), function (P = .0001), mechanism of injury (P = .0001), and the need for surgery (P = .0001) than those who had not undergone previous meniscus surgery. CONCLUSIONS: Patients having undergone prior meniscus surgery have better knowledge of meniscus injury and treatment than those who have not had previous meniscus injury. Meniscus repair is believed to be the most common treatment rather than meniscectomy. The risk of needing additional surgery and the risk of arthritis developing after meniscus surgery are the main concerns among respondents.

The role of activity level in orthopaedics: an important prognostic and outcome variable.

A patient's activity level is increasingly recognized as an important factor that can influence orthopaedic outcomes. Validated, reliable activity measurement tools now exist for the shoulder, hip, knee, and ankle. These tools can be directly applied as outcome measures that determine whether interventions restored function. It is now evident that activity level is a powerful prognostic factor for outcomes in orthopaedic procedures such as anterior cruciate ligament reconstruction, articular cartilage repair, and total joint arthroplasty. Yet despite the recent increase in studies that have made use of quantitative, joint-specific activity scales, much room remains for further understanding of the exact role of activity level in the progression, treatment, and patient perception of musculoskeletal disorders, particularly in the shoulder and ankle, as well as in pediatric patients.