Intraobserver and Interobserver Reliability of the Snyder and Expanded SLAP Classification System: A Video Study.

Background: Superior labral anterior and posterior (SLAP) tears are a common finding in overhead athletes. The original classification system produced by Snyder in 1990 contained 4 types of SLAP tears and was later expanded to 10 types. The classification has been challenging because of inconsistencies between surgeons making diagnoses and treatments based on the diagnosis. Furthermore, patient factors-such as age and sports played-affect the treatment algorithms, even across similarly classified SLAP tears. Purpose: To (1) assess the interobserver and intraobserver reliability of the Snyder and expanded SLAP (ESLAP) classification systems and (2) determine the consistency of treatment for a given SLAP tear depending on different clinical scenarios. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 20 arthroscopic surgical videos and magnetic resonance imaging scans of patients with SLAP tears were sent to 20 orthopaedic sports medicine surgeons at various stages of training. Surgeons were asked to identify the type of SLAP tear using the Snyder and ESLAP classifications. Surgeons were then asked to determine the treatment for a SLAP tear using 4 clinical scenarios: (1) in the throwing arm of an 18-year-old pitcher; (2) in the dominant arm of an 18-year-old overhead athlete; (3) a 35-year-old overhead athlete; (4) or a 50-year-old overhead athlete. Responses were recorded, and the cases were shuffled and sent back 6 weeks after the initial responses. Results were then analyzed using the Fleiss kappa coefficient (κ) to determine interobserver and intraobserver degrees of agreement. Results: There was moderate intraobserver reliability in both the Snyder and ESLAP classifications (κ = 0.52) and fair interobserver reliability for both classification systems (Snyder, κ = 0.31; ESLAP, κ = 0.30; P < .0001) among all surgeons. Additionally, there was only fair agreement (κ = 0.30; P < .0001) for the treatment modalities chosen by the reviewers for each case. Conclusion: This study demonstrated that SLAP tears remain a challenging problem for orthopaedic surgeons in diagnostics and treatment plans. Therefore, care should be taken in the preoperative discussion with the patient to consider all the possible treatment options because this may affect the postoperative recovery period and patient expectations.

Trends in Laboratory-Confirmed SARS-CoV-2 Reinfections and Associated Hospitalizations and Deaths Among Adults Aged ≥18 Years - 18 U.S. Jurisdictions, September 2021-December 2022.

Although reinfections with SARS-CoV-2 have occurred in the United States with increasing frequency, U.S. epidemiologic trends in reinfections and associated severe outcomes have not been characterized. Weekly counts of SARS-CoV-2 reinfections, total infections, and associated hospitalizations and deaths reported by 18 U.S. jurisdictions during September 5, 2021-December 31, 2022, were analyzed overall, by age group, and by five periods of SARS-CoV-2 variant predominance (Delta and Omicron [BA.1, BA.2, BA.4/BA.5, and BQ.1/BQ.1.1]). Among reported reinfections, weekly trends in the median intervals between infections and frequencies of predominant variants during previous infections were calculated. As a percentage of all infections, reinfections increased substantially from the Delta (2.7%) to the Omicron BQ.1/BQ.1.1 (28.8%) periods; during the same periods, increases in the percentages of reinfections among COVID-19-associated hospitalizations (from 1.9% [Delta] to 17.0% [Omicron BQ.1/BQ.1.1]) and deaths (from 1.2% [Delta] to 12.3% [Omicron BQ.1/BQ.1.1]) were also substantial. Percentages of all COVID-19 cases, hospitalizations, and deaths that were reinfections were consistently higher across variant periods among adults aged 18-49 years compared with those among adults aged ≥50 years. The median interval between infections ranged from 269 to 411 days by week, with a steep decline at the start of the BA.4/BA.5 period, when >50% of reinfections occurred among persons previously infected during the Alpha variant period or later. To prevent severe COVID-19 outcomes, including those following reinfection, CDC recommends staying up to date with COVID-19 vaccination and receiving timely antiviral treatments, when eligible.

Adolescent BMI trajectory and associations with adult metabolic syndrome and offspring obesity.

OBJECTIVE: This study examined the association of adolescent BMI trajectory with adult metabolic syndrome (MetSyn) and with intergenerational obesity. METHODS: This study used data from the National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study (1987-1997). Data from the 20-year follow-up (2016-2019) study were included from the original participants (N = 624) and their children (N = 645). Adolescent BMI trajectories were identified using latent trajectory modeling. Mediation analysis using logistic regression models was performed to estimate confounder-adjusted odds ratios (OR) and 95% CI between adolescent BMI trajectory and adult MetSyn. Using similar methods, the association between BMI trajectory and offspring obesity was examined. RESULTS: Latent trajectory modeling identified four patterns: "weight loss then gain" (N = 62); "persistently normal" (N = 374); "persistently high BMI" (N = 127); and "weight gain then loss" (N = 61). Women who had a persistently high BMI trajectory had twice the odds of having children who met the definition for obesity compared with the persistently normal group, adjusting for adult BMI (OR: 2.76; 95% CI: 1.39-5.46). None of the trajectory groups was associated with adult MetSyn compared with the persistently normal group. CONCLUSIONS: Intermittent adolescent obesity may not confer MetSyn risk during adulthood. However, maternal adolescent BMI trajectories that are persistently high may increase the odds of intergenerational obesity among offspring.

Risky business: A mixed methods study of decision-making regarding COVID-19 risk at a public university in the United States.

Introduction: Until vaccines became available in late 2020, our ability to prevent the spread of COVID-19 within countries depended largely on voluntary adherence to mitigation measures. However, individual decision-making regarding acceptable COVID-19 risk is complex. To better understand decision-making regarding COVID-19 risk, we conducted a qualitative substudy within a larger Berkeley COVID-19 Safe Campus Initiative (BCSCI) during the summer of 2020, and completed a mixed-methods analysis of factors influencing decision-making. Materials and methods: We interviewed 20 participants who tested positive for SARS-CoV-2 and 10 who remained negative, and analyzed quantitative survey data from 3,324 BCSCI participants. The BCSCI study enrolled university-affiliated people living in the local area during summer of 2020, collected data on behaviors and attitudes toward COVID-19, and conducted SARS-CoV-2 testing at baseline and endline. Results: At baseline, 1362 students (57.5%) and 285 non-students (35.1%) said it had been somewhat or very difficult to comply with COVID-19-related mandates. Most-cited reasons were the need to go out for food/essentials, difficulty of being away from family/friends, and loneliness. Eight interviewees explicitly noted they made decisions partially because of others who may be at high risk. We did not find significant differences between the behaviors of students and non-students. Discussion: Despite prevailing attitudes about irresponsibility of college students during the COVID-19 pandemic, students in our study demonstrated a commitment to making rational choices about risk behavior, not unlike non-students around them. Decision-making was driven by perceived susceptibility to severe disease, need for social interaction, and concern about risk to others. A harm reduction public health approach may be beneficial.

Anticipated and Experienced Stigma After Testing Positive for SARS-CoV-2: A Qualitative Study.

INTRODUCTION: Stigma has inhibited public health practitioners' influence during the COVID-19 pandemic. We explore the experienced and anticipated stigma of people affiliated with a large university in the United States, using the Health Stigma and Discrimination Framework. METHODS: We conducted a qualitative secondary substudy of 20 people who tested SARS-CoV-2 positive and 10 who tested negative in the summer of 2020, selected from a study of 3,324 university students and employees. FINDINGS: No participants reported anticipated stigmatization prior to testing positive. However, eight of 20 participants recounted stigma marking (being marked by COVID-19 diagnosis or membership in a "high-risk" group) or manifestations of stigma after testing positive, including feelings of guilt or shame, and concerns about being judged as selfish or irresponsible. Three described being denied services or social interactions as a result of having had COVID-19, long after their infectiousness ended. Participants noted that clear public health messaging must be paired with detailed scientific information, rather than leaving people to resort to non-experts to understand the science. DISCUSSION: Public health messaging designed to mitigate spread of SARS-CoV-2 and protect the community may perpetuate stigma and exacerbate inequities. As a result, people may avoid testing or treatment, mistrust public health messaging, or even use risk-increasing behavior as coping mechanisms. IMPLICATIONS FOR PRACTICE: Intentional use of language that promotes equity and deters discrimination must be high priority for any COVID-19-related public health messaging. Partnership with community leaders to co-create programs and disseminate messaging is a critical strategy for reducing stigma, especially for historically mistreated groups.

The moving valgus stress test produces more ulnar collateral ligament change in length during extension than during flexion: a biomechanical study.

HYPOTHESIS AND BACKGROUND: Injuries to the elbow medial ulnar collateral ligament (mUCL) pose a diagnostic challenge, with the moving valgus stress test (MVST) currently accepted as the gold-standard clinical test. This study sought to biomechanically evaluate the change in length of the ulnar collateral ligament (UCL) during flexion-extension using a null hypothesis that the mUCL will not experience a greater change in length with movement than with static loading. METHODS: Seven fresh-frozen human cadaveric elbows were tested with static and dynamic valgus stress. We measured (1) ligament length with a multi-camera optical system, (2) elbow flexion with an incremental encoder, and (3) valgus deviation with an electronic inclinometer. With a force applied to the wrist to simulate a clinical stress examination, the elbow was flexed and extended in a physiological elbow simulator to mimic the flexion and extension of the MVST. RESULTS: The simulated MVST produced more elongation of the UCL compared with static stress testing (P < .001). Ninety degrees of flexion produced the highest mean change, and the anterior and posterior bands demonstrated different length change characteristics. Comparison of dynamic flexion and extension showed a statistically significant difference in change in length: The mUCL reached the greatest change during extension, with the greatest changes during extension near 90° of flexion. DISCUSSION AND CONCLUSION: The MVST produces significantly more elongation of the mUCL than either a static test or a moving test in flexion. This study provides biomechanical evidence of the validity of the MVST as a superior examination technique for injuries to the UCL.

Therapeutic trials of biologics in primary biliary cholangitis: An open label study of abatacept and review of the literature.

Primary biliary cholangitis (PBC) is a classic autoimmune disease in which humoral, cytotoxic, and innate immune responses have been implicated with the specific targeting of a mitochondrial antigen. The mainstay of treatment remains the bile acid ursodeoxycholic acid (UDCA). Corticosteroids may have some benefits, but to date, clinical trials of biologics targeting B cells and IL-12/23 have not shown any efficacy. Because activated T cells target the intrahepatic bile ducts in PBC and pre-clinical models suggested that blocking CD80/CD86 with CTLA-4 Ig might have therapeutic benefit in PBC, we performed an open-label trial to determine if CTLA-4 Ig (abatacept) is safe and potentially efficacious in PBC patients with an incomplete response to UDCA. PBC patients with an alkaline phosphatase (ALP) > 1.67 × the upper limit of normal after 6 months on UDCA treatment or who were intolerant of UDCA received abatacept 125 mg s.q. weekly for 24 weeks. The co-primary endpoint was ALP normalization or a >40% reduction from baseline. Among 16 subjects enrolled and who received at least 1 dose of abatacept, 1 (6.3%) met the co-primary endpoint. Absolute and percent changes in ALP [median (95% CI)] were +2.8 U/L (-90.9-96.6) and -0.28% (-21.1-15.5), respectively. No significant changes were observed in ALP, ALT, total bilirubin, albumin, immunoglobulins, or liver stiffness. Abatacept treatment decreased several non-terminally differentiated CD4+ but not CD8+ T cell populations, including decreases in CD4+ CCR5+ (p = 0.02) and CD4+ PD1+ (p = 0.03) lymphocytes. In contrast there were increases in CD4+ CCR7+ lymphocytes (p = 0.034). Treatment emergent adverse events occurred in 4 subjects. Abatacept was well tolerated in this population of PBC patients but like other biologics in PBC was ineffective in achieving biochemical responses associated with improved clinical outcomes.

An Algorithm for Diagnosing and Treating Primary and Recurrent Patellar Instability.

Major anatomic risk factors for recurrent patellar instability include trochlear dysplasia, patella alta, a lateralized tibial tuberosity, and medial patellofemoral ligament insufficiency. Acute first-time patellar dislocation may be treated nonoperatively in the absence of osteochondral injury. Recurrent patellar instability often requires medial patellofemoral ligament reconstruction, with osseous procedures reserved for patients with substantial underlying anatomic abnormalities. Surgical treatment of patellar instability is complex and should be individualized to address the needs of each patient.

Hybrid Repair of Large Crescent Rotator Cuff Tears Using a Modified SpeedBridge and Double-Pulley Technique.

An ideal rotator cuff repair maximizes the tendon-bone interface and has adequate biomechanical strength that can withstand a high level of demand. Arthroscopic transosseous-equivalent rotator cuff repairs have become popular and have been shown to be superior to many other methods of fixation. We present an alternative method of repair for large crescent rotator cuff tears that combines 2 well-known methods of fixation: modified SpeedBridge (Arthrex, Naples, FL) and double-pulley techniques. These 2 repair constructs were combined to provide the greatest amount of compression across the footprint while also providing rigid fixation. Ultimately, this can provide an optimal environment for healing in otherwise significant injuries.

The effect of interference screw diameter on fixation of soft-tissue grafts in anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to evaluate the effect that interference screw diameter has on fixation strength of a soft-tissue anterior cruciate ligament (ACL) graft. METHODS: We prepared 32 fresh-frozen bovine tibiae with 9-mm ACL tibial tunnels. Accompanying 9-mm soft-tissue bovine Achilles grafts were also prepared. Bioabsorbable interference screws of increasing diameters were used for tibial fixation. There were 4 groups, consisting of 8-, 9-, 10-, and 11-mm screws for fixation of the 9-mm graft in the 9-mm tunnel. Tensile testing and cyclic loading from 50 to 250 N at 2 Hz for a total of 1,500 cycles were performed with a hydraulic biaxial materials testing machine. Graft slippage was measured with a video analysis technique with photo-reflective markers. At the end of cyclic testing, the grafts were loaded to failure, and the ultimate strength was recorded. RESULTS: All grafts failed at the tendon-bone-screw interface. The ultimate strength (+/- SD) was greatest for the 11-mm screw (624 +/- 133 N), with slightly decreased strength for the 10-mm (601 +/- 54 N), 9-mm (576 +/- 85 N), and 8-mm (532 +/- 185 N) screws. Graft slippage (+/- SD) was least for the 9-mm screw (2.65 +/- 2.38 mm). There were no statistically significant differences in ultimate strength and graft slippage between screws (P = .45 and P = .34, respectively). CONCLUSIONS: All interference screws tested provided adequate fixation strength. The results of this study show no statistical significance for ultimate strength or graft slippage with variable screw diameter. CLINICAL RELEVANCE: Aperture fixation with the interference screw technique provides adequate stability for soft-tissue grafts in ACL reconstruction. Although no statistical significance was found, there was a trend toward less graft-site motion when we used a screw diameter equal to tunnel size.

The effect of the angle of suture anchor insertion on fixation failure at the tendon-suture interface after rotator cuff repair: deadman's angle revisited.

PURPOSE: To evaluate what effect the angle of screw-in suture anchor insertion has on fixation stability at the suture-tendon interface. METHODS: Supraspinatus tendons from 7 matched pairs of human cadaveric shoulders were split, yielding 4 tendons per cadaver. An experimental rotator cuff tear was created and repaired, using a 5.0-mm diameter screw-in suture anchor. In a staggered, matched pair arrangement, the angle of anchor insertion was varied between 45 degrees (deadman's angle) and 90 degrees to the articular surface. Each repair underwent cyclic loading, and 2 failure points were defined: the first at 3 mm of repair site gap formation and the second at the point of complete failure. The number of cycles to failure was compared between the 2 groups. RESULTS: The mean number of cycles to 3-mm gap formation for anchors inserted at 90 degrees was 380. This was significantly higher than for repairs made with the 45 degrees angle of anchor insertion (mean, 297 cycles). Complete failure occurred at a significantly greater number of cycles with the 90 degrees anchors (mean, 443 cycles) compared with the 45 degrees anchors (mean, 334 cycles). CONCLUSIONS: Compared with anchors placed at the current standard of the deadman's angle of 45 degrees, suture anchors placed at 90 degrees to the junction of the greater tuberosity and the humeral head articular surface provided improved soft tissue fixation in an experimental rotator cuff model. CLINICAL RELEVANCE: The angle of suture anchor insertion into the greater tuberosity during rotator cuff repair has an effect on the soft tissue fixation at the tendon-suture interface.

Hybrid anterior cruciate ligament reconstruction: introduction of a new technique for anatomic anterior cruciate ligament reconstruction.

Recently, anatomic or double-bundle reconstruction of the anterior cruciate ligament (ACL) has been presented in an effort to more accurately restore the native anatomy. These techniques create 2 tunnels in both the femur and tibia to reproduce the bundles of the ACL. However, the increased number of tunnels, particularly on the femoral side, has raised some concerns among authors and surgeons. We describe a technique to reconstruct the 2 distinct bundles of the ACL by using a single femoral tunnel and 2 tibial tunnels, the "hybrid" ACL reconstruction. The femoral tunnel is drilled through an anteromedial arthroscopy portal, which allows placement in a more anatomic position. Fixation in the femur is achieved with a novel device that separates a soft-tissue graft into 2 independently functioning bundles. Once fixed in the femur, the anteromedial and posterolateral bundles of the graft are passed through respective tunnels at the anatomic footprint on the tibia. These bundles are independently tensioned, which creates a reconconstruction that is similar to the native ACL. The technique presented provides surgeons with an alternative to other double-bundle techniques involving 4 tunnels.