Editorial Commentary: Knee Cartilage Restoration Does Not Greatly Improve Clinical Outcomes After High Tibial Osteotomy-In the Short Term.

The treatment of osteoarthritis of the knee (OAK) is a complex matter with significant global, economic, and societal implications. Globally, OAK is currently estimated to affect more than 650 million individuals. In the United States alone, the cost of OAK treatments on the medical system was more than $140 billion in 2013. Because of the increased incidence of OAK as our population grows older, this topic is increasingly more pertinent to our research efforts to determine which treatments are most effective. Many of the treatments focus on cartilage restoration procedures looking to rebuild our knees back to their previous state. OAK is often accompanied with varus malalignment as a concomitant pathology necessitating high tibial osteotomy (HTO) to correct the deformity and provide a beneficial environment for the cartilage restoration to flourish. Cartilage restoration procedures include implanted chondrocytes, particulated juvenile cartilage, osteoarticular allografts, and novel modalities such as costal hyaline allograft. The addition of these restoration procedures is thought to enhance the results of HTO and provide longer duration of effects. Unfortunately, most studies have failed to show improved clinical outcomes in the short term, leading us to wonder whether longer term studies will show improved efficacy or are we just missing the bigger picture.

Recurrent Instability and Surgery Are Common After Nonoperative Treatment of Posterior Glenohumeral Instability in NCAA Division I FBS Football Players.

BACKGROUND: In-season return to play after anterior glenohumeral instability is associated with high rates of recurrent instability and the need for surgical stabilization. We are not aware of previous studies that have investigated in-season return to play after posterior glenohumeral instability; furthermore, as posterior shoulder instability in collision athletes occurs frequently, understanding the expected outcome of in-season athletes may improve the ability of physicians to provide athletes with a better understanding of the expected outcome of their injury and their ability to return to sport. QUESTIONS/PURPOSES: (1) What proportion of athletes returned to play during the season after posterior instability in collegiate football players? (2) How much time did athletes lose to injury, what proportion of athletes opted to undergo surgery, and what proportion of athletes experienced recurrent instability after a posterior instability episode during a collegiate football season? METHODS: A multicenter, prospective, observational study of National Collegiate Athletic Association (NCAA) Division 1 Football Bowl Subdivision athletes was performed at three US Military Service Academies. Ten athletes who sustained a posterior instability event during the regular football season and who pursued a course of nonoperative treatment were identified and prospectively observed through the subsequent season. All athletes in the observed cohort attempted an initial course of nonoperative treatment during the season. All athletes sustained subluxation events initially identified through history and physical examination at the time of injury. None of the athletes sustained a dislocation event requiring a manual reduction. Intraarticular pathology consisting of posterior labral pathology was further subsequently identified in all subjects via MRI arthrogram. Return to play was the primary outcome of interest. Time lost to injury, surgical intervention, and subsequent instability were secondary outcomes. RESULTS: Of the 10 athletes who opted for a trial of initial nonoperative management, seven athletes were able to return to play during the same season. Although these seven athletes returned within 1 week of their injury (median of 1 day), 5 of 7 athletes sustained recurrent subluxation events with a median (range) of four subluxation events per athlete (0 to 8) during the remainder of the season. Seven athletes were treated surgically after the completion of their season, four of whom returned to football. CONCLUSION: This study suggests that although collegiate football players are able to return to in-season sport after a posterior glenohumeral instability event, they will likely sustain multiple recurrent instability events and undergo surgery after the season is completed. The results of this study can help guide in-season management of posterior shoulder instability by allowing more appropriate postinjury counseling and decision making through the identification of those athletes who may require additional attention from medical staff during the season and possible modifications to training regimens to minimize long-term disability. Further prospective studies involving a larger cohort over several seasons should be performed through collaborative studies across the NCAA that better assess function and injury risk factors before beginning collegiate athletics. This would better characterize the natural history and associated functional limitations that athletes may encounter during their collegiate careers. LEVEL OF EVIDENCE: Level IV, prognostic study.

Return to Sport After Nonoperative Management of Medial Ulnar Collateral Ligament Injuries About the Elbow in Non-throwing Athletes.

There is a paucity of literature published on management of acute medial ulnar collateral ligament injuries in the non-throwing athlete and when these athletes may expect to safely return to sport. Non-overhead throwing athletes that sustained medial ulnar collateral ligament (MUCL) injuries treated conservatively with brace immobilization and therapy can successfully return to sport in a relatively short duration. A radiographic query of Magnetic Resonance Images (MRIs) was performed to identify patients sustaining elbow MUCL injury. Only those participating as intercollegiate athletes were included. Medical charts and documents were reviewed to determine time away from sport and rehabilitation protocol. A total of 17 patient-athletes were identified as having sustained MUCL injuries that met inclusion criteria. There was a 100% return to sport rate, averaging 5 weeks from date of injury. Non-overhead throwing athletes competing at the intercollegiate level who sustained acute MUCL injury were effectively treated nonoperatively. (Journal of Surgical Orthopaedic Advances 30(3):136-139, 2021).

The Effect of Increased Intraocular Pressure During Steep Trendelenburg Positioning in Robotic Prostatectomy and Hysterectomy on Structural and Functional Ocular Parameters.

BACKGROUND: Robotic prostatectomy and robotic hysterectomy require steep Trendelenburg positioning. Many authors documented significant increases in intraocular pressure (IOP) during steep Trendelenburg. However, the long-term biological effect of a significant increase in IOP on the structural and functional ocular system is unknown. This study examines the effect of a significant increase in IOP on the visual acuity, retinal nerve fiber layer thickness (RNFLT), and ganglion cell complex (GCC) thickness in 52 patients without preexisting ocular disease of both genders before and 3 months after their procedures. METHODS: This was a prospective cohort study. The total number of patients included was 56, then 3 females and 1 male case were excluded, totaling 28 robotic hysterectomies and 24 robotic prostatectomies were performed. Patients underwent complete eye examination before the procedure and 3 months after, measuring the main outcome of RNFLT and the secondary outcomes of GCC thickness, foveal threshold (FT), mean deviation (MD), and pattern standard deviation (PSD). These outcomes were analyzed using linear mixed-effects models. On the day of surgery, we examined the IOP after induction of anesthesia, at the end of steep Trendelenburg, and in the recovery room. RESULTS: There were significant differences in IOP values at the end of steep Trendelenburg versus after induction and 45-60 minutes post-awakening (P < .001 for both groups). No difference between IOP 45 and 60 minutes post-awakening and IOP after induction was observed in either group. The highest IOPs occurred at the end of the steep Trendelenburg time point for both groups. The mean duration of steep Trendelenburg in robotic prostatectomy was 184.6 minutes (standard deviation [SD] = 30.8), while the mean duration in robotic hysterectomy was 123.0 minutes (SD = 29.8). All ophthalmologic examinations were normal preoperatively and 3 months postoperatively. The ocular parameters in the retina and optic disk did not differ significantly before surgery and 3 months after. CONCLUSIONS: There is a significant increase in IOP during steep Trendelenburg positioning. There was no significant difference in the ocular parameters examined 3 months after the procedure in this cohort.

The Evolving Role of the Orthopaedic Surgeon in Combat Zones and Austere Deployed Locations Since the 2012 Troop Drawdown.

The purpose of this study was to evaluate the operative experience of orthopaedic surgeons in the various deployment locations since 2012. We also evaluated the implications of humanitarian surgical care and the impact of deployment on an orthopaedic practice. An emailed survey was sent to orthopaedic surgeons deployed after 2012. The survey was 48 questions. Most cases in Iraq, Afghanistan and Syria were emergent traumas. In other locations, however, most cases were elective/non-emergent cases. Of surgeons surveyed, 44% performed less than 10 cases during their deployment, and 50% considered humanitarian surgery part of their mission. Six weeks was needed to prepare for deployment, and 4.4 weeks to re-build a practice. Disparity exists in surgical case volume and types of cases performed by orthopaedic surgeons that is dependent on deployed location. This dichotomy in operative experience places surgeons deployed to such locations at risk of losing surgical skills. (Journal of Surgical Orthopaedic Advances 29(3):182-186, 2020).

Incidence of Anterolateral Ligament Tears in the Anterior Cruciate Ligament-Deficient Knee: A Magnetic Resonance Imaging Analysis.

PURPOSE: The purpose of this study is to determine the incidence of anterolateral ligament (ALL) tears on magnetic resonance imaging (MRI) in patients diagnosed with anterior cruciate ligament (ACL) tears. Furthermore, this study sought to determine the inter- and intraobserver reliability in diagnosing an ALL tear. METHODS: The MRI radiologic database at a community military hospital was queried for ACL tears over the period of January 2011 to April 2015. During this time, 181 MRIs were identified as having ACL tears. The MRIs were then independently reviewed by an orthopaedic surgeon and a musculoskeletal (MSK) trained radiologist. Both reviewers, independently confirmed the ACL tears, and the ALL was noted to be either torn, intact, or not visualized on axial, sagittal, and coronal images. Four weeks later the same MRIs were then reviewed for the presence and location of an ALL tear to determine inter- and intraobserver reliability. RESULTS: The MSK radiologist found ALL tears on MRI in 28.2% of the cases, while the orthopaedic surgeon found ALL tears in 39.8% of the cases; 5.5% of the MRIs were characterized as having a nonvisualized ALL. The interobserver reliability was noted to have a kappa value of 0.333. The intraobserver reliability of the MSK radiologist and orthopaedic surgeon demonstrated a kappa value of 0.654 and 0.251, respectively. CONCLUSIONS: This study shows that the majority of patients with a known ACL tear on MRI do not have a tear of the ALL. Additionally, the interobserver reliability of surgeons and radiologist is fair. In this study, the MSK radiologist had higher intraobserver reliability when looking for an ALL tear. LEVEL OF EVIDENCE: Level IV, case control study.

Innovations and adaptations in trabeculectomy.

PURPOSE OF REVIEW: This article examines the current literature reporting updates on trabeculectomy techniques, complications, and cost-effectiveness. RECENT FINDINGS: Trabeculectomy continues to be the standard for glaucoma surgery when a low intraocular pressure is required. Recent publications describe technique modifications that successfully increase efficacy and lower complications. There is also an ongoing effort to define the role of trabeculectomy in the management of glaucoma from a cost and public health standpoint. SUMMARY: The current literature continues to support the use of trabeculectomy as a method of lowering intraocular pressure in glaucoma management. Efficacy has been improved by ongoing surgical innovation, and reported complication rates are lower than those previously noted. Trabeculectomy has a favorable cost-benefit profile when compared with medical therapy or other surgical techniques. In spite of these ongoing changes, trabeculectomy appears to be decreasing in frequency in favor of newer surgeries and medications.

Pan-American mDNA haplogroups in Chilean patients with Leber's hereditary optic neuropathy.

PURPOSE: The clinical impact of mDNA mutations on the development of Leber hereditary optic neuropathy (LHON) may be modulated by mitochondrial haplogroups, which vary across populations. The aim of this research was to determine the clinical spectrum and molecular characteristics, including the haplogroup, of 15 South American families with LHON. METHODS: This study was a prospective, observational study conducted between March 2006 and August 2012. All patients were referred to the Clinical Hospital of the University of Chile, where the clinical study was conducted. Molecular studies were conducted at the Biomedical Sciences Institute (ICBM) of the University of Chile. Fifteen index cases were identified with molecular analysis after initial neuroophthalmic examination at different centers throughout Chile. Clinical features of patients with LHON and maternal relatives of the 15 families (75 individuals: 26 affected and 49 healthy carriers) were evaluated. The primary mDNA mutations (m.3460G>A, m.11778G>A, or m.14484T>C) were determined with restriction fragment length polymorphism analysis in all individuals. Mitochondrial haplogroups were determined with direct sequencing of two hypervariable regions (HV1 and HV2) and compared with reference sequences. RESULTS: The m.11778G>A mutation was found in 59 subjects (78.7%), the m.14484T>C mutation was found in 12 subjects (16.0%), and the m.3460G>A mutation was found in four (5.3%) subjects. The average age of onset of symptoms in affected subjects was 22.2 years old (range 3 to 53 years); 21 (80.7%) were male, and five (19.3%) were female. Twelve families (80%) had Amerindian haplogroups: One family had the A2 haplogroup, four families had the B2i2 haplogroup, six families had the C1b haplogroup, and one family had the D1g haplogroup. CONCLUSIONS: In this limited sample size, the Amerindian haplogroup A2 was associated with delayed onset of disease in this population. Patients with haplogroup C retained better vision than the patients with other haplogroups in this population. Disease in subjects with haplogroup D appeared to be underrepresented compared to the population at large.

The effect of cataract extraction on intraocular pressure.

PURPOSE OF REVIEW: To examine the current literature covering the long-term effect of cataract extraction on intraocular pressure (IOP). RECENT FINDINGS: As a result of the high rate of cataract surgery, the impact on IOP continues to be the subject of multiple studies in different populations. Recent publications include those that distinguish patients with open angles from those with more narrow angles, as well as prospective analyses that address the impact of regression to the mean and other types of bias on the effect of postoperative IOP lowering. SUMMARY: There are sufficient data to suggest that cataract surgery provides a lowering effect on IOP in the long term. This effect appears to be proportional to preoperative IOP. Eyes with higher preoperative IOP have the greatest average lowering, whereas eyes with IOP in the lower range of statistically normal tend to have an IOP that is unchanged from baseline or even higher following cataract surgery. In patients with narrow angles, the IOP-lowering effect appears to also be proportional to the degree of anterior chamber deepening induced by cataract surgery.

Prevalence of self-reported early glaucoma eye drop bottle exhaustion and associated risk factors: a patient survey.

BACKGROUND: One barrier to patient adherence with chronic topical glaucoma treatment is an inadequate amount of medication available between prescription refills. We examined the self-reported prevalence of early exhaustion of glaucoma eye drops prior to a scheduled refill, and associated risk factors. METHODS: This cross-sectional survey was performed at a University-based clinical practice. Glaucoma patients at the University of Washington who were experienced with eye drop application and were on a steady regimen of self-administered glaucoma drops in both eyes took a survey at the time of clinic examination. The main outcome measure was self-reported early eye drop bottle exhaustion. RESULTS: 236 patients were eligible and chose to participate. In general, patients included were relatively healthy (mean 2.3 comorbid medical conditions). Sixty patients (25.4%) reported any problem with early exhaustion of eye drop bottles, and this was associated with visual acuity ≤ 20/70 in the better eye (P = .049). Twelve patients (5.1%) reported that they "often" (5-7 times per year), "usually" (8-11 times per year) or "always" ran out of eye drops prior to a scheduled refill. Patients affected by this higher level (≥ 5 times yearly) of eye drop bottle exhaustion were more likely to have poor visual acuity in their worse eye ≤ 20/70 (P = .015) and had significantly lower worse-eye logMAR (P = .043). CONCLUSIONS: Self-reported early glaucoma bottle exhaustion regularly affected 5% of patients in our population and 25% reported early exhaustion at least once; the main risk factor was poor vision in at least one eye. These results may not be generalizable to a broad patient population, or to those inexperienced with eye drop self-administration. However, this pilot study compels further evaluation and consideration of early eye drop bottle exhaustion in glaucoma patients.

Rotator cuff healing after continuous subacromial bupivacaine infusion: an in vivo rabbit study.

BACKGROUND: The objective of this study was to evaluate the effects of continuous subacromial bupivacaine infusion on supraspinatus muscle and rotator cuff tendon healing using gross, biomechanical, and histologic analyses. MATERIALS AND METHODS: Thirty-three New Zealand White rabbits underwent unilateral supraspinatus transection and rotator cuff repair (RCR). Rabbits were assigned to 1 of 3 groups: (1) RCR only, (2) RCR with continuous saline infusion for 48 hours, or (3) RCR with continuous 0.25% bupivacaine with epinephrine (1:200,000) infusion for 48 hours. Rabbits were euthanized postoperatively at 2 weeks (for histologic assessment) or 8 weeks (for biomechanical and histologic assessment). RESULTS: Tensile testing showed a significantly higher load to failure in intact tendons compared with repaired tendons (P < .01); however, no statistical differences were detected among RCR only, RCR saline, and RCR bupivacaine groups. Histologically, the enthesis of repaired tendons showed increased cellularity and disorganized collagen fibers compared with intact tendons, with no differences between treatment groups. Muscle histology demonstrated scattered degenerative muscle fibers at 2 weeks in RCR saline and RCR bupivacaine groups, but no degeneration was noted at 8 weeks. CONCLUSIONS: The healing supraspinatus tendons exposed to bupivacaine infusion showed similar histologic and biomechanical characteristics compared with untreated and saline-infused RCR groups. Muscle histology showed fiber damage at 2 weeks for the saline and bupivacaine-treated groups, with no apparent disruption at 8 weeks, suggesting a recovery process. Therefore, subacromial bupivacaine infusion in this rabbit rotator cuff model does not appear to impair muscle or tendon after acute injury and repair.

Strategies for prevention and management of ocular events occurring with mirvetuximab soravtansine.

Mirvetuximab soravtansine (MIRV) is a first-in-class antibody-drug conjugate (ADC) targeting folate receptor alpha (FRα) and is indicated for the treatment of adult patients with FRα-positive, platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer who have received 1 to 3 prior systemic treatment regimens. MIRV has demonstrated single-agent anticancer activity in clinical trials, with a differentiated safety profile comprising primarily low-grade, resolvable gastrointestinal and ocular adverse events (AEs). Pooled safety analysis of 464 MIRV-treated patients across 3 trials, including the phase 2 SORAYA study, found that 50% of patients had ≥1 ocular AEs of interest (AEIs) of blurred vision or keratopathy, the majority being grade ≤2. Grade 3 ocular AEIs occurred in 5% of patients, and 1 patient (0.2%) had a grade 4 event of keratopathy. All grade ≥2 AEIs of blurred vision and keratopathy resolved to grade 1 or 0 in patients with complete follow-up data. MIRV-associated ocular AEs were primarily characterized by resolvable changes to the corneal epithelium, with no cases of corneal ulcers or perforations. This reflects the distinctive, milder ocular safety profile for MIRV compared with that of other ADCs with ocular toxicities in clinical use. To maintain a generally low incidence of severe ocular AEs, patients should follow recommendations for maintaining ocular surface health, including daily use of lubricating eye drops and periodic use of corticosteroid eye drops, and should undergo an eye examination at baseline, at every other cycle for the first 8 cycles of treatment, and as clinically indicated. Dose modification guidelines should be followed to maximize patients' ability to remain on therapy. Close collaboration between all care team members, including oncologists and eye care professionals, will help patients benefit from this novel and promising anticancer agent. This review focuses on the etiology, rates, prevention, and management of MIRV-associated ocular events.

An institution-specific analysis of ACL reconstruction failure.

The purpose of this study was to determine the most common causes of failed anterior cruciate ligament reconstruction (ACLR) using modern reconstructive techniques at a single, high-volume institution. In addition, the clinical outcomes of patients undergoing revision ACLR will be reported. The surgical logs of four senior knee surgeons were retrospectively reviewed for all patients who had undergone ACLR between 2002 and 2009. Patients were excluded if they did not have both the primary and revision surgery on the same knee with the same surgeon. Out of 1944 ACL reconstructions, 28 patients (56 reconstructions) were included in the study. Radiographic studies, operative reports, KT-1000 scores, and chart notes were used to identify all potential factors that may have led to failure. All patients were invited to return for a follow-up examination and survey. Of the 28 patients, the mean age at the index and revision procedure was 22 +/- 11 (range, 12 to 50) and 24 +/- 11 (range, 14 to 57), respectively. In 20 cases, the cause of failure was determined to be acute trauma (sports, work, or accident); in 1 case, the cause was biologic failure; while in 7 cases, the cause was technical error. During the study period the surgeons performed a combined total of 1944 procedures, for an overall failure rate of 1.8%. Twenty patients (71%) were available for follow-up at a mean 30.2 +/- 17.7 months. The overall postrevision outcomes were good to excellent for a majority of patients, with an average Lysholm score of 84 +/- 15.5 and International Knee Documentation Committee score of 77.2 +/- 13.8. The pre- and postoperative KT-1000 scores were 12.1 +/- 2.8 and 6.7 +/- 2.8, respectively. The results from this study suggest that traumatic re-injury, and not surgical/surgeon error, is the most common cause of ACLR failure using anatomic reconstructive principles and strong fixation. In addition, good to excellent outcomes following revision ACLR can be expected in the majority of patients.

Fishing-related ocular trauma in the Pacific Northwest: hook, line and sinker.

Traumatic injuries are a worldwide major cause of blindness and ocular morbidity. We report a series of four cases of fishing-related ocular trauma from the Pacific Northwest demonstrating the varied presentation and visual consequences of these injuries, including open and closed globe injuries, retained foreign bodies and retinal and subretinal hemorrhage. More efforts are needed to increase awareness and use of preventative measures.

The Military Orthopedics Tracking Injuries and Outcomes Network: A Solution for Improving Musculoskeletal Care in the Military Health System.

INTRODUCTION: Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense's Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care. MATERIALS AND METHODS: MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management. RESULTS: This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report. CONCLUSIONS: MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency's Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

Biceps tenodesis with interference screw fixation: a biomechanical comparison of screw length and diameter.

PURPOSE: To evaluate the effect of screw length and diameter on the mechanical properties of biceps tenodesis (BT) with an interference screw in 2 different locations (proximal and distal). METHODS: We randomized 42 fresh-frozen human cadaveric shoulders (mean age, 65 ± 8 years) into 6 groups (n = 7): arthroscopic proximal BT using 7 × 15-, 7 × 25-, 8 × 15-, or 8 × 25-mm interference screws or distal subpectoral BT with 7 × 15- or 8 × 15-mm interference screws. Each repaired specimen was mounted onto a materials testing machine, preloaded to 5 N for 2 minutes, cycled from 5 to 70 N for 500 cycles (1 Hz), and loaded to failure (1 mm/s). Displacement during cyclical loading, pullout stiffness, and ultimate load to failure were computed, and the mechanism of failure was noted. RESULTS: All failures occurred at the tendon-screw interface. There was no statistically significant difference in ultimate displacement among all groups in the ultimate load to failure, displacement at peak load, and stiffness. CONCLUSIONS: There is no difference in ultimate load to failure, displacement at peak load, and stiffness of BT with regard to screw length or diameter at both proximal and distal tenodesis locations. These data would support use of a smaller-diameter and shorter implant for BT both proximally and distally. CLINICAL RELEVANCE: The results may serve as a guide to the orthopaedic surgeon performing proximal BT in selecting the appropriate interference screw. When possible, we recommend using the smallest screw size available to minimize risk of stress fracture at the tenodesis site.

Managing the Return to Football During the COVID-19 Pandemic: A Survey of the Head Team Physicians of the Football Bowl Subdivision Programs.

BACKGROUND: COVID-19 is a severe respiratory virus that spreads via person-to-person contact through respiratory droplets. Since being declared a pandemic in early March 2020, the World Health Organization had yet to release guidelines regarding the return of college or professional sports for the 2020-2021 season. PURPOSE: To survey the head orthopedic surgeons and primary care team physicians for the National Collegiate Athletic Association (NCAA) Football Bowl Subdivision (FBS) football teams so as to gauge the management of common COVID-19 issues for the fall 2020 college football season. STUDY DESIGN: Cross-sectional study. METHODS: The head team orthopaedic surgeons and primary care physicians for all 130 FBS football teams were surveyed regarding their opinions on the management of college football during the COVID-19 pandemic. A total of 30 questions regarding testing, return-to-play protocol, isolating athletes, and other management issues were posed via email survey sent on June 5, 2020. RESULTS: Of the 210 team physicians surveyed, 103 (49%) completed the questionnaire. Overall, 36.9% of respondents felt that it was unsafe for college athletes to return to playing football during fall 2020. While the majority of football programs (96.1%) were testing athletes for COVID-19 as they returned to campus, only 78.6% of programs required athletes to undergo a mandatory quarantine period before resuming involvement in athletic department activities. Of the programs that were quarantining their players upon return to campus, 20% did so for 1 week, 20% for 2 weeks, and 32.9% quarantined their athletes until they had a negative COVID-19 test. CONCLUSION: While US Centers for Disease Control and Prevention guidelines evolve and geographic regions experience a range of COVID-19 infections, determining a universal strategy for return to socialization and participation in sports remains a challenge. The current study highlighted areas of consensus and strong agreement, but the results also demonstrated a need for clarity and consistency in operations, leadership, and guidance for medical professionals in multiple areas as they attempt to safely mitigate risk for college football players amid the COVID-19 pandemic.

Generating the American Shoulder and Elbow Surgeons Score Using Multivariable Predictive Models and Computer Adaptive Testing to Reduce Survey Burden.

BACKGROUND: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. PURPOSE: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. RESULTS: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. CONCLUSION: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population.

BACKGROUND: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages. PURPOSE: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis. RESULTS: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0). CONCLUSION: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.