Decision Making of the In-season Athlete with Anterior Shoulder Instability.

In-season management of anterior shoulder instability in athletes is a complex problem. Athletes often wish to play through their current season, though recurrent instability rates are high, particularly in contact sports. Athletes are generally considered safe to return to play when they are relatively pain-free, and their strength and range of motion match the uninjured extremity. If an athlete is unable to progress toward recovering strength and range of motion, surgical management is an option, though this is often a season-ending decision.

Health Literacy in Shoulder Arthroscopy: A Quantitative Assessment of the Understandability and Readability of Online Patient Education Material.

Background: The National Institutes of Health (NIH) and American Medical Association (AMA) recommend that online health information be written at a maximum 6th grade reading level. The aim was to evaluate online resources regarding shoulder arthroscopy utilizing measures of readability, understandability, and actionability, using syntax reading grade level and the Patient Education Materials Assessment Tool (PEMAT-P). Methods: An online Google™ search utilizing "shoulder arthroscopy" was performed. From the top 50 results, websites directed at educating patients were included. News and scientific articles, audiovisual materials, industry websites, and unrelated materials were excluded. Readability was calculated using objective algorithms: Flesch-Kincaid Grade-Level (FKGL), Simple Measure of Gobbledygook (SMOG) grade, Coleman-Liau Index (CLI), and Gunning-Fog Index (GFI). The PEMAT-P was used to assess understandability and actionability, with a 70% score threshold. Scores were compared across academic institutions, private practices, and commercial health publishers. The correlation between search rank and readability, understandability, and actionability was calculated. Results: Two independent searches yielded 53 websites, with 44 (83.02%) meeting inclusion criteria. No mean readability score performed below a 10th grade reading level. Only one website scored at or below 6th grade reading level. Mean understandability and actionability scores were 63.02%±12.09 and 29.77%±20.63, neither of which met the PEMAT threshold. Twelve (27.27%) websites met the understandability threshold, while none met the actionability threshold. Institution categories scored similarly in understandability (61.71%, 62.68%, 63.67%) among academic, private practice, and commercial health publishers respectively (p=0.9536). No readability or PEMAT score correlated with search rank. Conclusion: Online shoulder arthroscopy patient education materials score poorly in readability, understandability, and actionability. One website scored at the NIH and AMA recommended reading level, and 27.27% of websites scored above the 70% PEMAT score for understandability. None met the actionability threshold. Future efforts should improve online resources to optimize patient education and facilitate informed decision-making. Level of Evidence: IV.

Postoperative Bracing after Medial Patellofemoral Ligament Reconstruction.

It is unclear if bracing is necessary after isolated medial patellofemoral ligament reconstruction (MPFLr) for recurrent patellar instability. We hypothesize that patients who did not use a brace will have similar outcomes to those who were braced postoperatively. A retrospective review of patients who underwent isolated MPFLr from January 2015 to September 2020 at a single institution was performed. Those with less than 6 weeks of follow-up were excluded. The braced group was provided a hinged-knee brace postoperatively until the return of quadriceps function, which was determined by the treating physical therapist (brace, "B"; no brace, "NB"). Time to straight leg raise (SLR) without lag, recurrent instability, and total re-operations were determined. Univariate analysis and logistic regression were used to evaluate outcomes (statistical significance, p < 0.05). Overall, 229 isolated MPFLr were included (B: 165 knees, 146 patients; NB: 64 knees, 58 patients). Baseline demographics were similar (all p > 0.05). Median time to SLR without lag was shorter in the NB group (41 days [interquartile range [IQR]: 20-47] vs. 44 days [IQR: 35.5-88.3], p = 0.01), while return to sport times were equivalent (B: 155 days [IQR: 127.3-193.8] vs. NB: 145 days [IQR: 124-162], p = 0.31). Recurrent instability rates were not significantly different (B: 12 knees [7.27%] vs. NB: 1 knee [1.56%], p = 0.09), but the re-operation rate was higher in the brace group (20 knees [12.1%] vs. 0 [0%], p = 0.001). Regression analysis identified brace use (odds ratio [OR]: 19.63, 95% confidence interval [CI]: 1.43-269.40, p = 0.026) and female patients (OR: 2.79, 95% CI: 1.01-7.34, p = 0.049) to be associated with needing reoperation. Recurrent instability rates and return to sport times were similar between patients who did or did not use a hinged knee brace after isolated MPFLr. Re-operation rates were higher in the braced group. Retrospective Comparative Study, Level III.

Health literacy in rotator cuff repair: a quantitative assessment of the understandability of online patient education material.

Background: The American Medical Association and National Institutes of Health recommend online health information be written at a 6th grade or lower reading level for clear understanding. While syntax reading grade level has previously been utilized, those analyses do not determine whether readers are processing key information (understandability) or identifying available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT-P) is a method to measure the understandability and actionability of online patient education materials. The purpose of this study was to evaluate online resources regarding rotator cuff repair utilizing measures of readability, understandability, and actionability. Methods: The search term "rotator cuff surgery" was used in two independent online searches to obtain the top 50 search results. The readability of included resources was quantified using valid objective algorithms: Flesch-Kincaid Grade-Level, Simple Measure of Gobbledygook grade, Coleman-Liau Index, and Gunning Fog Index. The PEMAT-P form was used to assess actionability and understandability. Results: A total of 49 unique websites were identified to meet our inclusion criteria and were included in our analysis. The mean Flesch-Kincaid Grade Level graded materials at a 10.6 (approximately a 10th grade reading level), with only two websites offering materials at a 6th grade reading level or below. The remaining readability studies graded the mean reading level at high school or greater, with the Gunning Fog Index scoring at a collegiate reading level. Mean understandability and actionability scores were 64.6% and 29.5%, respectively, falling below the 70% PEMAT score threshold for both scales. Fourteen (28.6%) websites were above the threshold for understandability, while no website (0%) scored above the 70% threshold for actionability. When comparing source categories, commercial health publishers provided websites that scored higher in understandability (P < .05), while private practice materials scored higher in actionability (P < .05). Resources published by academic institutions or organizations scored lower in both understandability and actionability than private practice and commercial health publishers (P < .05). No readability, understandability, or actionability score was significantly associated with search result rank. Conclusion: Overall, online patient education materials related to rotator cuff surgery scored poorly with respect to readability, understandability, and actionability. Only two (4.1%) of the patient education websites scored at the American Medical Association and National Institutes of Health recommended reading level. Fourteen (28.6%) scored above the 70% PEMAT score for understandability; however, no website met the threshold for actionability.

Physician-Patient Communication in the Orthopedic Clinic: Surgeon-Identified Challenges.

Background: Effective communication between the physician and the patient is crucial to quality healthcare. The orthopedic surgery clinic setting provides an environment for cultivating the physician-patient relationship, eliciting diagnostic data, and developing treatment strategies. However, little is known about the orthopedic surgeon perspective on communicating with patients. The purpose of the study was to identify patient communication and care issues faced in the orthopedic surgery clinic setting that physicians categorize as challenging. Methods: All surgeons in the department of orthopedics in a large tertiary care center were invited to respond to an online survey on common communication challenges. Physicians were asked to rate 13 challenges identified by the literature and opinion leaders using a four-point Likert scale ranging from "Not at all challenging" to "Extremely challenging". In addition, the survey included open ended questions regarding common challenges in communicating with patients and types of encounters, and thematic analysis was applied. Mean scores were calculated. Results: Nineteen orthopedic surgeons completed the survey and were included in the analysis. Orthopedic surgeons identified misaligned expectations for surgical intervention for a nonsurgical diagnosis as the most challenging encounter in the clinic (16/19). Managing postoperative patient expectations (14/19) and communicating with patients who were dissatisfied with their surgical outcome (13/19) were also commonly rated as particularly challenging. Open ended responses echoed these ratings and additional difficulty facilitating patient understanding of complex information as common communication challenges. Conclusion: Common challenges in the orthopedic clinic often surround managing patient expectations and providing effective explanations, particularly where physicians perceive a surgical intervention as inappropriate for addressing the patient complaint. Identifying these issues can guide training efforts to help orthopedic physicians in managing these and improving communication. These findings can also provide basis for collecting information about communication challenges from orthopedic surgeons across institutions. Level of Evidence: IV.

Total Hip Arthroplasty: Direct Anterior Approach Versus Posterior Approach in the First Year of Practice.

Background: The direct anterior approach (DAA) for total hip arthroplasty (THA) has been popularized as a less invasive technique, however outcomes within the first year of practice after fellowship have not been investigated. The primary aim was to determine differences in complications and outcomes between DAA and posterior approach (PA) in the first year of practice. The secondary aim was to determine if there was a learning curve factor in DAA and PA after fellowship training. Methods: THA cases performed by two surgeons during their first year of practice were reviewed. Overall, 181 THAs (91 DAA, 90 PA) in 168 patients, were performed. Intraoperative differences (blood loss, operative time), hospital stay, complications, reoperations, and revisions were compared. Results: Overall surgical complications were similar between DAA and PA (11% vs. 9%, p=0.64), but complication profiles were different: dislocation (1% vs. 4%, p=0.17), intraoperative femoral fracture (2% vs. 1%, p=0.32), postoperative periprosthetic fractures (2% vs. 3%, p=0.64). neuropraxia (3% vs. 0%, p=0.08). There was no difference in rate of reoperation (1% vs. 3%, p=0.31). There was a difference in rate of revision at final follow-up (0% vs. 6%, p=0.02). DAA consisted of longer operative time (111 vs. 99 minutes; p<0.001), however was only significant in the first 50 cases (p<0.001), while the subsequent cases were similar (p=0.31). There was no difference in the first 50 cases compared to the subsequent cases for either approach regarding blood loss, complications, reoperations, or revisions. Conclusion: DAA and PA for THA performed within the first year of practice exhibit similarly low complication rates, but complication profiles are different. In our series, PA did demonstrate a higher risk of revision at final follow-up. A learning curve is not unique to the DAA. Both DAA and PA THA exhibited a learning curve in the first 50 cases performed at the start of a surgeon's practice. Level of Evidence: III.

Can Patients Read, Understand, and Act on Online Resources for Anterior Cruciate Ligament Surgery?

Background: Patients undergoing elective procedures often utilize online educational materials to familiarize themselves with the surgical procedure and expected postoperative recovery. While the Internet is easily accessible and ubiquitous today, the ability of patients to read, understand, and act on these materials is unknown. Purpose: To evaluate online resources about anterior cruciate ligament (ACL) surgery utilizing measures of readability, understandability, and actionability. Study Design: Cross-sectional study; Level of evidence, 4. Methods: Using the term "ACL surgery," 2 independent searches were performed utilizing a public search engine (Google.com). Patient education materials were identified from the top 50 results. Audiovisual materials, news articles, materials intended for advertising or medical professionals, and materials unrelated to ACL surgery were excluded. Readability was quantified using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, Coleman-Liau Index, Automated Readability Index, and Gunning Fog Index. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) was utilized to assess the actionability and understandability of materials. For each online source, the relationship between its Google search rank (from first to last) and its readability, understandability, and actionability was calculated utilizing the Spearman rank correlation coefficient (ρS). Results: Overall, we identified 68 unique websites, of which 39 met inclusion criteria. The mean Flesch-Kincaid Grade Level was 10.08 ± 2.34, with no website scoring at or below the 6th-grade level. Mean understandability and actionability scores were 59.18 ± 10.86 (range, 33.64-79.17) and 34.41 ± 22.31 (range, 0.00-81.67), respectively. Only 5 (12.82%) and 1 (2.56%) resource scored above the 70% adequate PEMAT-P threshold mark for understandability and actionability, respectively. Readability (lowest P value = .103), understandability (ρS = -0.13; P = .441), and actionability (ρS = 0.28; P = .096) scores were not associated with Google rank. Conclusion: Patient education materials on ACL surgery scored poorly with respect to readability, understandability, and actionability. No online resource scored at the recommended reading level of the American Medical Association or National Institutes of Health. Only 5 resources scored above the proven threshold for understandability, and only 1 resource scored above it for actionability.

Male Gender and Competitive Athlete Status Are Associated With Better Outcomes Following Hip Arthroscopy In Patients With Global Acetabular Retroversion.

Purpose: To evaluate outcomes of hip arthroscopy in patients with global acetabular retroversion and to identify correlations between sex, radiographic measurements, athlete status, and return to play with patient-reported outcomes (PROs). Methods: Retrospective study of patients with global acetabular retroversion who underwent arthroscopic femoroacetabular impingement (FAI) surgery was performed. Global acetabular retroversion was defined by 3 criteria: the crossover sign, ischial spine sign, and posterior wall sign on an anteroposterior (AP) pelvic radiograph. Radiographs were used to measure lateral center edge angle, alpha angle, and anterior and posterior wall indices. Femoral version was measured with 3-dimensional computed tomography. Demographics included age, gender, athlete status, return to play, and reoperation. PROs included modified Harris Hip Score, Hip Outcome Score (HOS), Hip Disability and Osteoarthritis Outcome Score, visual analog scale (VAS), and Veterans RAND-12. Spearman correlation determined correlation with perioperative PROs. Generalized estimating equation determined independent predictors. Significance was set at P = .05. Results: From 2013 to 2019, 149 patients (65.0% female) with 160 hips with FAI and global acetabular retroversion underwent hip arthroscopy. Follow-up averaged 29.6 months. All PROs demonstrated significant improvement with the exception of the Veterans RAND-12 Mental. Female patients scored significantly lower on most postoperative PROs and had greater VAS scores (P = .0002-0.0402). A greater proportion of male subjects met the minimum clinically important difference for the modified Harris Hip Score (88.00% vs 78.79%) Low femoral version correlated with greater HOS ADL, HOS Sport, and Hip Disability and Osteoarthritis Outcome Score Sport scores (P = .0077-0.0177). Athletes reported lower preoperative VAS scores, and higher perioperative scores in multiple PROs (P = .0004-0.0486). Nine hips (5.63%) underwent reoperation. Conclusions: Patients with global acetabular retroversion and FAI undergoing hip arthroscopy report good outcomes at short-term follow-up. Male subjects and athletes had superior outcomes compared to female subjects and nonathletes. Radiographic measurements did not correlate with outcomes with exception of low femoral version. Athletes reported lower preoperative pain scores and greater postoperative PROs than nonathletes. Level of Evidence: Level IV, therapeutic case series.

Structure, function, and defect tolerance with maturation of the radial tie fiber network in the knee meniscus.

The knee menisci are comprised of two orthogonal collagenous networks-circumferential and radial-that combine to enable efficient load bearing by the tissue in adults. Here, we assessed how the structural and functional characteristics of these networks developed over the course of skeletal maturation and determined the role of these fiber networks in defect tolerance with tissue injury. Imaging of the radial tie fiber (RTF) collagen structure in medial bovine menisci from fetal, juvenile, and adult specimens showed increasing heterogeneity, anisotropy, thickness, and density with skeletal development. The mechanical analysis showed that the tensile modulus in the radial direction did not change with skeletal development, though the resilience (in the radial direction) increased and the tolerance to defects in the circumferential direction decreased, in adult compared to fetal tissues. This loss of defect tolerance correlated with increased order in the RTF network in adult tissue. These data provide new insights into the role of the radial fiber network in meniscus function, will lead to improved clinical decision-making in the presence of a tear and may improve engineering efforts to reproduce this critical load-bearing structure in the knee.

Female Team Physician Representation in Professional and Collegiate Athletics.

BACKGROUND: Although a sex-based balance in US graduate medical education has been well-documented, a discrepancy remains in orthopaedic surgery. In orthopaedic sports medicine, the representation of women as team physicians has not previously been characterized. PURPOSE: To quantify the sex-related composition of team physicians of select National Collegiate Athletic Association (NCAA) Division I collegiate and professional teams. Additionally, the authors assess the sex-related composition of orthopaedic surgeon team physicians specifically and compare these proportions to the sex-related composition of orthopaedic surgeon membership of the American Orthopaedic Society for Sports Medicine (AOSSM). STUDY DESIGN: Cross-sectional study. METHODS: Publicly available sex-related data were collected for team physicians in select NCAA Division I collegiate conferences and professional sports organizations. Subspecialty characteristics and sex distribution were described by use of percentages. Chi-square tests were used to assess whether sex distributions of team physicians in collegiate and professional sports were (1) representative between the populations of female and male physicians compared with the general public and (2) representative of the sex-based composition of orthopaedic surgeons nationally. RESULTS: Women represented 12.7% (112/879) of all team physicians and 6.8% (30/443) of all orthopaedic surgeons (P < .0001). More than half (53.9%; 413/767) of male and 26.8% (30/112) of female team physicians were orthopaedic surgeons. In collegiate athletics, women comprised 18.1% of all team physicians and 7.7% of orthopaedic surgeon team physicians. In professional sports, women comprised 6.7% of all team physicians and 6.3% of orthopaedic surgeon team physicians, with the greatest proportion in the Women's National Basketball Association (31.3%). CONCLUSION: Women comprise a minority of team physicians in select NCAA Division I collegiate and professional sports organizations. When compared with the composition of AOSSM orthopaedic surgeon membership, expected female orthopaedic surgeon representation varies between conferences and leagues with little statistical significance. Although efforts have been made to increase sex-based diversity in orthopaedic surgery, results of this study suggest that barriers affecting female orthopaedic surgeons as team physicians should be identified and addressed.

Understanding the Glenoid Avulsion of the Glenohumeral Ligaments as a Cause of Shoulder Instability: Surgical and Postsurgical Management.

In adolescents and young adults, instability is a common shoulder pathology with a myriad of coexisting soft tissue and bony lesions. When evaluating a patient for the cause of instability, care must be given to assess for the infrequent lesions, including glenoid avulsion of the glenohumeral ligaments. This case example illustrates key points in the diagnosis, surgical, and postsurgical management of this less common cause of anterior shoulder instability.

Casting and Splinting Management for Hand Injuries in the In-Season Contact Sport Athlete.

CONTEXT: Upper extremity injuries are extremely common in contact sports such as football, soccer, and lacrosse. The culture of competitive athletics provides an environment where hand injuries are frequently downplayed in an effort to prevent loss of game time. However, studies have shown that many sport-induced hand injuries do not actually require immediate surgical attention and can be safely treated through immobilization so that the athlete may complete the athletic season. In these cases, appropriate casting and splinting measures should be taken to ensure protection of the injured player and the other competitors without causing loss of game time. EVIDENCE ACQUISITION: Articles published between 1976 and 2015 were reviewed to capture historical and current views on the treatment of hand injuries in the in-season athlete. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: Although traditionally many sports-induced traumatic injuries to the hand held the potential to be season-ending injuries, experience has shown that in-season athletes do not necessarily need to lose game time to receive appropriate treatment. A thorough knowledge of converting everyday splints and casts into game day, sport-approved protective immobilization devices is key to safely allowing athletes with select injuries to play while injured. CONCLUSION: Protective techniques allow for maximum functionality during gameplay while safely and effectively protecting the injury from further trauma while bony healing takes place.

Bilateral, Atraumatic Proximal Tibiofibular Joint Instability Treated With Suspensory Button Fixation.

Proximal tibiofibular joint (PTFJ) instability is a rare cause of lateral-sided knee pain. The authors present a case of bilateral, symptomatic PTFJ instability with peroneal nerve dysfunction in an active 16-year-old female athlete. This was addressed with peroneal nerve decompression and PTFJ stabilization using a suspensory button fixation system. This provides an alternative treatment from historical methods such as PTFJ fusion or re-approximation of the joint with tendon through bone tunnels. The surgical technique, as well as potential treatment challenges, is described in detail. The purpose of this report is to highlight PTFJ instability as a cause of lateral-sided knee pain to avoid misdiagnosis and delay in appropriate treatment. This patient had significant improvement in pain and decreased neurologic symptoms after the stabilization and nerve decompression. She was able to return to high-level activity. [Orthopedics. 2017; 40(6):e1107-e1111.].

Large Animal Models of Meniscus Repair and Regeneration: A Systematic Review of the State of the Field.

Injury to the meniscus is common, but few viable strategies exist for its repair or regeneration. To address this, animal models have been developed to translate new treatment strategies toward the clinic. However, there is not yet a regulatory document guiding such studies. The purpose of this study was to carry out a systematic review of the literature on meniscus treatment methods and outcomes to define the state of the field. Public databases were queried by using search terms related to animal models and meniscus injury and/or repair over the years 1980-2015. Identified peer-reviewed manuscripts were screened by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. One of nine reviewers read each manuscript and scored them based on whether the publication described a series of predefined study descriptors and outcome measures. Additional data were extracted to identify common assays used. A total of 128 full-length peer-reviewed manuscripts were identified. The number of publications increased over the time frame analyzed, with 48% focused on augmented repair. Rabbit was, by far, the most prevalent species utilized (46%), with dog (21%) and sheep (20%) being the next most common. Analysis of study descriptors revealed that most studies appropriately documented details of the animal used, the surgical approach, and defect and implant characteristics (e.g., 63% of studies identified clearly the defect size). In terms of outcome parameters, most studies carried out macroscopic (85%), histologic (90%), and healing/integration (83%) analyses of the meniscus. However, many studies did not provide further analysis beyond these fundamental measures, and less than 40% reported on the adjacent cartilage and synovium, as well as joint function. There is intense interest in the field of meniscus repair. However, given the current lack of guidance documentation in this area, preclinical animal models are not performed in a standardized fashion. The development of a "Best Practices" document would increase reproducibility and external validity of experiments, while accelerating advancements in translational research. Advancement is of paramount importance given the high prevalence of meniscal injuries and the paucity of effective repair or regenerative strategies.