Testing Digital Methods of Patient-Reported Outcomes Data Collection: Prospective Cluster Randomized Trial to Test SMS Text Messaging and Mobile Surveys.

BACKGROUND: Health care delivery continues to evolve, with an effort being made to create patient-centered care models using patient-reported outcomes (PROs) data. Collecting PROs has remained challenging and an expanding landscape of digital health offers a variety of methods to engage patients. OBJECTIVE: The aim of this study is to prospectively investigate two common methods of remote PRO data collection. The study sought to compare response and engagement rates for bidirectional SMS text messaging and mobile surveys following orthopedic surgery. METHODS: The study was a prospective, block randomized trial of adults undergoing elective orthopedic procedures over 6 weeks. The primary objective was to determine if the method of digital patient engagement would impact response and completion rates. The primary outcome was response rate and total completion of PRO questionnaires. RESULTS: A total of 127 participants were block randomized into receiving a mobile survey (n=63) delivered as a hyperlink or responding to the same questions through an automated bidirectional SMS text messaging system (n=64). Gender, age, number of comorbidities, and opioid prescriptions were similar across messaging arms. Patients receiving the mobile survey were more likely to have had a knee-related surgery (n=50, 83.3% vs n=40, 62.5%; P=.02) but less likely to have had an invasive procedure (n=26, 41.3% vs n=39, 60.9%; P=.03). Overall engagement over the immediate postoperative period was similar. Prolonged engagement for patients taking opioids past postoperative day 4 was higher in the mobile survey arm at day 7 (18/19, 94.7% vs 9/16, 56.3%). Patients with more invasive procedures showed a trend toward being responsive at day 4 as compared to not responding (n=41, 59.4% vs n=24, 41.4%; P=.05). CONCLUSIONS: As mobile patient engagement becomes more common in health care, testing the various options to engage patients to gather data is crucial to inform future care and research. We found that bidirectional SMS text messaging and mobile surveys were comparable in response and engagement rates; however, mobile surveys may trend toward higher response rates over longer periods of time. TRIAL REGISTRATION: ClinicalTrials.gov NCT03532256; https://clinicaltrials.gov/ct2/show/NCT03532256.

Traumatic Hip Dislocation in an NCAA DI Football Player with Occult Sequelae: A Case Report.

BACKGROUND AND PURPOSE: American football generates the most sports-related injuries in the United States, with tackling as the leading injury mechanism. Overall injury rate at the collegiate level has been reported as 8.61 per 1,000 athlete exposures (AEs) - twice the rate of high school levels; competition injury rates are reported as high as 36.94/1000 AEs. Traumatic hip dislocation is an uncommon injury typically arising from high-energy axial impact with only 2-5.5% occurring during sports activities. CASE DESCRIPTION: A 22-year-old NCAA Division I football defensive back who experienced extreme left hip pain following contact with another player with his hip flexed during a game was diagnosed with a type 1 posterior hip dislocation, a grade 1 medial collateral ligament sprain with concomitant posterior thigh and hip muscle strains. Key impairments were limited left lower extremity motor performance, range of motion deficits, left hip pain, and diminished function and weight-bearing ability. OUTCOMES: The athlete reintegrated into typical defensive back off-season training approximately four to five months post injury without restrictions, however presented with new anterior hip pain seven months post injury revealing occult sequelae requiring surgical intervention. He was able to return to full play the following football season. DISCUSSION: This case report describes the successful return to sport of a Division I football player who sustained a traumatic posterior hip dislocation and complicated course including surgical intervention secondary to associated sequelae. LEVEL OF EVIDENCE: 5.

Implementation of an Injury Prevention Program in NCAA Division I Athletics Reduces Injury-Related Health Care Costs.

BACKGROUND: The estimated cost per year of injuries in collegiate athletics has been reported to be billions of dollars in the United States. Injury prevention programs are often assessed only by their ability to reduce injuries, and there is little evidence of any potential reduction in associated health care costs. PURPOSE: To investigate changes in injury-related health care costs at a National Collegiate Athletic Association (NCAA) Division I university after the implementation of an injury prevention program. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were 12 sports teams that used the injury prevention program (user group) and 16 teams that did not implement the program (nonuser group). The injury surveillance and prevention system (Sparta Science) utilized a commercially available force-plate system to assess kinematic variables, flag high-risk athletes, and guide individual conditioning programs. Data were obtained from 3 academic years before (2012-2014) and 2 academic years after (2015-2016) implementation of the Sparta Science system. The number of injuries and associated health care costs (surgery, clinic visits, imaging, and physical therapy) were compared between users and nonusers. RESULTS: Total average annual injuries did not change significantly between users and nonusers after implementation of the program; however, users demonstrated a 23% reduction in clinic visits as compared with a 14% increase for nonusers (P = .049). Users demonstrated a 13% reduction in associated health care encounters, compared with a 13% increase for nonusers (P = .032). Overall health care costs changed significantly for both groups, with an observed 19% decrease ($2,456,154 to $1,978,799) for users and an 8% increase ($1,177,542 to $1,270,846) for nonusers (P < .01 for both). Costs related to associated health care encounters also decreased by 20% for users as compared with a 39% increase for nonusers (P = .027). CONCLUSION: This study demonstrated the ability to significantly reduce injury-related health care costs in NCAA Division I athletes via a comprehensive injury surveillance and prevention program utilizing force-plate technology. Given the substantial and appropriate focus on value of care delivery across the US health care system, we recommend the continued study of sports injury surveillance and prevention programs for reducing injury-related health care costs.

The Comma Sign: The Coracohumeral Ligament and Superior Glenohumeral Ligament Exhibit Similar Quantitative Characteristics With Terminal Confluence at the Subscapularis Insertion.

PURPOSE: The purpose of this morphologic cadaveric study was to quantitatively define the composition of the previously described comma tissue along with its relation to the subscapularis tendon insertion. METHODS: Fresh frozen cadaveric shoulder specimens were included for analysis. The coracohumeral ligament (CHL) was exposed at its origin along the base of the coracoid process and freed laterally along its course to the lesser tuberosity adjacent to the bicipital groove. The superior glenohumeral ligament (SGHL) was identified and traced along its course deep to the CHL within the rotator interval with insertion onto the superior aspect of the lesser tuberosity. The midpoint diameters of the SGHL and CHL and their composite insertional diameters on the subscapularis tendon insertion and lesser tuberosity were measured with digital calipers. The mean diameter was determined from 3 measurements taken of each ligament. RESULTS: Eight specimens were included. With the use of digital calipers, the mean midpoint diameters of the SGHL and CHL were identified as 5.99 mm (range, 5.25-6.91 mm) and 5.13 mm (range, 4.28-5.72 mm), respectively. The composite insertional diameter of the SGHL and CHL on both the lesser tuberosity and humeral insertion of the subscapularis tendon was 9.93 mm (range, 6.69-12.05 mm). At its insertion, the SGHL and CHL comprised 54% and 46% of the comma tissue, respectively. Additionally, all specimens were identified as showing a confluence of the SGHL and CHL composite insertion with the subscapularis tendon at the point of its humeral head insertion. CONCLUSIONS: The comma tissue is a pivotal structure for the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of the midpoint diameter, insertional diameter, and composite distribution of the CHL and SGHL provided by this morphologic cadaveric analysis may aid surgeons in their efforts to restore the native anatomy. CLINICAL RELEVANCE: Subscapularis tendon tears have often been under-addressed during rotator cuff repair. The comma tissue has been described as an anatomic structure that can aid in the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of this important arthroscopic landmark may aid surgeons in their efforts to restore the native anatomy.

Arthroscopic Diagnosis of Occult Posterolateral Meniscocapsular Separations: Another Hidden Lesion.

PURPOSE: The purpose of this study was to describe the surgical findings and clinical outcomes in a series of patients with occult posterolateral meniscocapsular separations diagnosed arthroscopically after a negative magnetic resonance imaging (MRI) scan. METHODS: A retrospective analysis of prospectively collected data of consecutive patients who underwent surgical arthroscopy with repair of an occult posterolateral meniscocapsular separation by 2 fellowship-trained orthopaedic sports medicine surgeons at a single institution was performed. All lesions were identified arthroscopically in the posterolateral aspect of the lateral compartment as a distinct pathologic separation between the posterolateral capsule and adjacent meniscal tissue with increased excursion on probing. Clinical examination notes, MRI scans, and operative reports were reviewed. Patient-reported outcome measures were assessed via patient questionnaire. RESULTS: A total of 6 patients were included for analysis. MRI evaluation of the lateral meniscus was unrevealing in 4 patients, suggesting a possible tear of the body of the lateral meniscus in one patient and demonstrating a parameniscal cyst abutting the anterior root of the lateral meniscus in another patient. Arthroscopic examination revealed meniscocapsular separations of the posterolateral meniscus in all 6 knees, with 2 knees demonstrating concomitant bucket-handle meniscus tears. Patient-reported outcomes were determined for 67% of study patients. The average reported International Knee Documentation Committee score was 63.8, the average Knee Outcome Survey Activities of Daily Living Scale score was reported as 63, the 12-Item Short Form Survey (SF-12) Physical score averaged 46.8 with an average SF-12 Mental score of 59.9. CONCLUSIONS: The diagnosis of occult posterolateral meniscocapsular separations (MCS) could be missed on advanced imaging, such as MRI, so arthroscopic diagnosis may be required. This study indicates that arthroscopic diagnosis and repair of occult posterolateral MCS results in good functional and clinical outcomes. LEVEL OF EVIDENCE: IV, therapeutic case series.

Patient-Reported Opioid Consumption and Pain Intensity After Common Orthopedic and Urologic Surgical Procedures With Use of an Automated Text Messaging System.

Importance: Surgeons must balance management of acute postoperative pain with opioid stewardship. Patient-centered methods that immediately evaluate pain and opioid consumption can be used to guide prescribing and shared decision-making. Objective: To assess the difference between the number of opioid tablets prescribed and the self-reported number of tablets taken as well as self-reported pain intensity and ability to manage pain after orthopedic and urologic procedures with use of an automated text messaging system. Design, Setting, and Participants: This quality improvement study was conducted at a large, urban academic health care system in Pennsylvania. Adult patients (aged ≥18 years) who underwent orthopedic and urologic procedures and received postoperative prescriptions for opioids were included. Data were collected prospectively using automated text messaging until postoperative day 28, from May 1 to December 31, 2019. Main Outcomes and Measures: The primary outcome was the difference between the number of opioid tablets prescribed and the patient-reported number of tablets taken (in oxycodone 5-mg tablet equivalents). Secondary outcomes were self-reported pain intensity (on a scale of 0-10, with 10 being the highest level of pain) and ability to manage pain (on a scale of 0-10, with 10 representing very able to control pain) after orthopedic and urologic procedures. Results: Of the 919 study participants, 742 (80.7%) underwent orthopedic procedures and 177 (19.2%) underwent urologic procedures. Among those who underwent orthopedic procedures, 384 (51.8%) were women, 491 (66.7%) were White, and the median age was 48 years (interquartile range [IQR], 32-61 years); 514 (69.8%) had an outpatient procedure. Among those who underwent urologic procedures, 145 (84.8%) were men, 138 (80.7%) were White, and the median age was 56 years (IQR, 40-67 years); 106 (62%) had an outpatient procedure. The mean (SD) pain score on day 4 after orthopedic procedures was 4.72 (2.54), with a mean (SD) change by day 21 of -0.40 (1.91). The mean (SD) ability to manage pain score on day 4 was 7.32 (2.59), with a mean (SD) change of -0.80 (2.72) by day 21. The mean (SD) pain score on day 4 after urologic procedures was 3.48 (2.43), with a mean (SD) change by day 21 of -1.50 (2.12). The mean (SD) ability to manage pain score on day 4 was 7.34 (2.81), with a mean (SD) change of 0.80 (1.75) by day 14. The median quantity of opioids prescribed for patients who underwent orthopedic procedures was high compared with self-reported consumption (20 tablets [IQR, 15-30 tablets] vs 6 tablets used [IQR, 0-14 tablets]), similar to findings for patients who underwent urologic procedures (7 tablets [IQR, 5-10 tablets] vs 1 tablet used [IQR, 0-4 tablets]). Over the study period, 9452 of 15 581 total tablets prescribed (60.7%) were unused. A total of 589 patients (64.1%) used less than half of the amount prescribed, and 256 patients (27.8%) did not use any opioids (179 [24.1%] who underwent orthopedic procedures and 77 [43.5%] who underwent urologic procedures). Conclusions and Relevance: In this quality improvement study of adult patients reporting use of opioids after common orthopedic and urologic surgical procedures through a text messaging system, the quantities of opioids prescribed and the quantity consumed differed. Patient-reported data collected through text messaging may support clinicians in tailoring prescriptions and guide shared decision-making to limit excess quantities of prescribed opioids.

A Rare Incident of Intraarticular Fibromatosis of the Knee: A Case Report.

CASE: Our patient is a 34-year-old male aHthlete who presented for consultation after left knee discomfort and pressure for greater than 2 years. Advanced imaging revealed a nonspecific intraarticular suprapatellar lesion with subsequent ultrasound-guided core biopsy demonstrating a spindle cell proliferation consistent with superficial fibromatosis. Thus, the patient underwent an open en bloc surgical resection by a fellowship-trained orthopaedic oncologist. CONCLUSION: As the first reported case of intraarticular fibromatosis of the knee, this case highlights the importance of a thoughtful approach to the management of nonspecific intraarticular lesions through a comprehensive and collaborative strategy to decrease patient morbidity and optimize outcomes.

Prediction of ACL Injuries from Vertical Jump Kinetics in Division 1 Collegiate Athletes.

BACKGROUND: The incidence of ACL injuries continues to rise secondary to an increase in sport participation. Evidence supports the use of force plate testing to quantify kinetics during rehabilitation after injury and recovery; however, there is limited current research regarding if jump kinetics can identify athletes who are at higher risk for injury. Altered kinetics could potentially lead to abnormal force dissipation and resultant injury. PURPOSE: The purpose of this investigation was to identify whether the force-time variables from vertical jumps could predict ACL injuries in collegiate athletes. STUDY DESIGN: Retrospective cohort. METHODS: Vertical jump testing is performed by all healthy varsity collegiate athletes at several intervals throughout the athletic year at a Division I institution using a commercially available force plate system with dedicated software. Athletes who sustained an ACL injury between 1/1/15 and 6/1/19 were identified (n=16) and compared to healthy athletes who participated in the same sports (n = 262). ACL injuries were considered for this study if they occurred no more than 10 weeks after a jump test. The outcome variables were load, explode, and drive, operationally defined as the average eccentric rate of force development, average relative concentric force, and concentric relative impulse, respectively, which the system normalized to T scores. Mann-Whitney U tests were used to assess group differences for load, explode, drive, and the ratio between the variables. Logistic regression was used to determine if the battery of variables could predict whether or not an athlete would sustain an ACL injury. The p-value was set to 0.10 for the Mann-Whitney U tests, and 0.05 for the logistic regression. RESULTS: Significant differences between the ACL and healthy groups were seen for explode (p=0.08), drive (p=0.06), load:explode ratio (p=0.06), and explode:drive ratio (p=0.03). Explode and drive, when entered into the regression equation, showed the ability to predict injury, χ 2 = 6.8, df = 2, p=0.03. CONCLUSIONS: The vertical jump force plate variables were able to identify athletes who sustained an ACL injury within 66 days of testing. Athletes who sustained an ACL injury demonstrated altered kinetics and less ability to transmit forces during the vertical jump. LEVEL OF EVIDENCE: 3.

USE OF AN UPPER EXTREMITY FUNCTIONAL TESTING ALGORITHM TO DETERMINE RETURN TO PLAY READINESS IN COLLEGIATE FOOTBALL PLAYERS: A CASE SERIES.

BACKGROUND/PURPOSE: Return to play decision making for upper extremity injuries is challenging due to a lack of evidence-based protocols and testing. Current guidelines utilize tests and measures with minimal evidence on re-injury risks and prediction. The purpose of this case series is to highlight a functional testing algorithm for upper extremities injuries and the outcomes for the patients that followed it. STUDY DESIGN: Case series. CASE DESCRIPTIONS: Six subjects (18 - 21 years old) who underwent shoulder capsulolabral repair secondary to recurrent instability and/or unyielding pain are included. All subjects underwent a criterion-based rehabilitation program before being assessed with the authors' upper extremity functional testing algorithm. The upper extremity functional testing algorithm consists of measures of active range of motion (AROM), passive range of motion (PROM), peak isometric force, a fatigue testing battery, and the closed kinetic chain upper extremity stability test (CKCUEST) to assess readiness for return to sport. OUTCOMES: All athletes achieved > 90% symmetry on at least two out of three tests during a fatigue testing protocol and at least 25 touches on the CKCUEST. All of the athletes returned to unrestricted football the season following surgical intervention. None of the athletes sustained an additional glenohumeral subluxation, dislocation, or upper extremity injury requiring surgical intervention for the remainder of their athletic careers (six years). DISCUSSION: The presented cases help to illustrate the effectiveness of the upper extremity functional testing algorithm to assess return to sport readiness for male collegiate football athletes. The algorithm included testing of AROM/PROM and strength that is typically used, but also included the CKCUEST and fatigue testing to further challenge and assess the upper extremity prior to returning to sports. LEVEL OF EVIDENCE: 4.

REPEATABILITY OF SWAY MEASURES IN UPPER EXTREMITY WEIGHT-BEARING.

BACKGROUND: Analysis of upper extremity weight bearing ability is important for athletes as some function largely in a closed chain capacity (e.g., wrestling, football, gymnastics); also, all require closed chain upper extremity function during strength and conditioning. Additionally, in a rehabilitation setting, closed chain upper extremity functional testing is often used as a return to play criterion. Lower extremity sway measures (biomechanical and clinical) have been published widely and have established reliability and validity; however, the reliability of upper extremity sway biomechanical measures has not been investigated to date. HYPOTHESIS/PURPOSE: The purpose of this study was to determine the repeatability of a variety of force plate measurements during an upper extremity task in an athletic population. It was hypothesized that variables measuring upper extremity sway in a closed kinetic chain position would have excellent reliability. STUDY DESIGN: Cross-sectional. METHODS: All data were collected using a force plate system with commercially available software. Four hundred and ninety healthy Division I athletes were tested for both their dominant and non-dominant upper extremity at one of two testing sessions. Subjects were instructed to stay as still as possible while maintaining a full plank position with one upper extremity on the force plate and the contralateral upper extremity behind their back. Two, 20-second trials were performed for each extremity. Variables measured included average sway velocity (ASV), sway velocity in medial-lateral (SVML) and anterior-posterior (SVAP) directions, sway velocity at 1st and 2nd time intervals for AP (VAP1 and 2) and ML (VML1 and 2) directions, and sway frequency in the AP direction for 1st and 2nd time intervals (FreAP1 and 2). Intraclass correlation coefficients (ICC(2,1)) and their 95% confident intervals were calculated for all force plate variables for 980 limbs. RESULTS: No difference was seen between left and right extremities for any measure (p > 0.05). ICC's ranged from 0.61-0.90 for all variables, indicating moderate to excellent reliability for all variables. CONCLUSION: Upper extremity sway biomechanical variables using a force plate system have moderate to excellent reliability. These results are important prior to validation and clinical utilization of these measures including baseline testing, return to play guidelines, and injury prevention parameters. LEVEL OF EVIDENCE: 3.

State-level variation in opioid prescribing after knee arthroscopy among the opioid-naïve in the USA: 2015-2019.

OBJECTIVE: It has been established that most patients prescribed opioids after minor surgery have tablets left over, better understanding the variation in opioid prescribing and variation in dosage of the prescription could guide efforts to reduce prescribing. This study describes the state-level variation in opioid prescribing after a knee arthroscopy among opioid-naïve patients. DESIGN: Retrospective cohort study. SETTING: Commercial insurance claims data. PARTICIPANTS: 98 623 individual across the USA with commercial insurance who were opioid-naïve and had a knee arthroscopy between 2015 and 2019. EXPOSURE: Patients who filled an opioid prescription within 3 days of a knee arthroscopy. OUTCOME MEASURES: Opioid prescriptions were measured as a pharmacy claim for filling an opioid within 3 days of a knee arthroscopy. We measured the patient and state-level opioid prescribing rate, tablet count, morphine milligram equivalent dose per prescription and risk-adjusted predicted opioid quantity. RESULTS: Overall, 72% of patients filled an opioid prescription with a median tablet count of 40 and median morphine milligram equivalent of 250. Patients with an invasive procedure (27.9% vs 22.4%; p<0.001), higher education level (p<0.001) and fewer comorbidities (0.9 vs 1.2, p<0.001) had higher rates of opioid prescribing. The prescribing rate in the highest state, Nebraska (85%), was double the prescribing rate in the lowest state, South Dakota (40%). Comparing the casemix adjusted expected prescribing rate to the observed prescribing rate displayed that 18 states had observed prescribing rates that were higher than their expected prescribing rates. CONCLUSION: Wide variation in the likelihood of receiving a prescription, depending on state of residence, was observed. The dosages prescribed were high and have been associated with transition to long-term use. These findings suggest that there is substantial opportunity for the development of guidelines to reduce variability in opioid prescribing for this common ambulatory procedure.

Profile of upper extremity strength and function in division 1 collegiate athletes.

OBJECTIVES: To profile shoulder strength and functional test scores in collegiate athletes across various sports. DESIGN: Cross-sectional. SETTING: Pre-participation physical screens for varsity athletes at a Division I university. PARTICIPANTS: 476 healthy Division 1 collegiate athletes (270 males; 27 varsity sports). MAIN OUTCOME MEASURES: Two trials of each 1. Isometric peak force (PF) using hand-held dynamometry for shoulder internal rotation (IR), external rotation (ER), and forward elevation (FE) in kg; 2. Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), quantified by number of touches. RESULTS: PF values (mean(SD), dominant/non-dominant) for females were: IR = 8.7(2.6)/8.7(6.2); ER = 8.2(2.5)/7.9(2.5); FE = 8.0(2.5)/8.0(2.7); CKCUEST scores were 21.8(3.9). PF values for males were: IR = 12.0(3.8)/11.9(3.6); ER = 10.7(3.4)/10.7(3.5); FE = 10.7(3.5)/10.4 (3.5); CKCUEST scores were 26.0(4.1) touches. CONCLUSIONS: Normative values should be used as an athlete's baseline for the CKCUEST. This may help target athletes who are at a higher risk of upper extremity injury and help with goals or return to sport readiness during the rehabilitation process.

Comparison of core neuromuscular control and lower extremity postural stability in athletes with and without shoulder injuries.

BACKGROUND: The kinetic chain theory is widely used as a rationale for the inclusion of core stability training in athletes. Core stability (muscle capacity and neuromuscular control) impairments may result in less than optimal performance and abnormal force dissipation to the shoulder complex that could lead to shoulder injuries. However, a paucity of literature exists to support this relationship, and no previous studies have investigated the relationship between isolated core neuromuscular control and shoulder injuries. Additionally, lower extremity postural stability has been associated with athletic function and may also be associated with shoulder injuries. The purpose of this study was to compare biomechanical measures of isolated core neuromuscular control and lower extremity postural stability between athletes with and without non-traumatic shoulder injuries. METHODS: Eighty athletes (55 males, age: 21.2 ± 3.3 years, 40 with a current shoulder injury) completed biomechanical measures of isolated core neuromuscular control and lower extremity postural stability. Athletes were matched by age, gender, body mass index, and sport type. MANOVAs were used to assess differences between measures of core neuromuscular control and lower extremity postural stability between groups. FINDINGS: There were no statistically significant differences between athletes with and without shoulder injuries for the static core neuromuscular control measures, F(4,75) = 0.45, P = 0.78, η2 = 0.02; dynamic core neuromuscular control measures, F(4,75) = 0.81, P = 0.52, η2 = 0.04; or lower extremity postural stability measures, F(8,61) = 0.85, P = 0.56, η2 = 0.10. INTERPRETATION: Although core stability is widely incorporated in rehabilitation of athletes with shoulder injuries, athletes with current non-traumatic shoulder injuries may not present with impairments in core neuromuscular control or lower extremity postural stability.

Cape-like Anomalous Confluence of the Long Head of the Biceps and Rotator Cuff in the Presence of a SLAP Tear: A Case Report.

CASE: A 25-year-old woman sustained an acute tear of her superior anterior-posterior labrum with arthroscopic identification of an anomalous origin of the long head of the biceps arising exclusively from the supraspinatus tendon with no attachment to the supraglenoid tubercle or superior labrum. CONCLUSION: This is the first report of a symptomatic superior labrum anterior-posterior tear in a patient with a rare anatomic confluence of the long head of the biceps to the supraspinatus. We recommend addressing the labral pathology with utilization of a standard technique because satisfactory results can be realized with isolated labral fixation to the glenoid, despite the absence of an attached biceps tendon.

Surgeon Agreement on the Presence of Pathologic Anterior Instability on Shoulder Imaging Studies.

BACKGROUND: In the setting of anterior shoulder instability, it is important to assess the reliability of orthopaedic surgeons to diagnose pathologic characteristics on the 2 most common imaging modalities used in clinical practice: standard plain radiographs and magnetic resonance imaging (MRI). PURPOSE: To assess the intra- and interrater reliability of diagnosing pathologic characteristics associated with anterior shoulder instability using standard plain radiographs and MRI. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Patient charts at a single academic institution were reviewed for anterior shoulder instability injuries. The study included 40 sets of images (20 radiograph sets, 20 MRI series). The images, along with standardized evaluation forms, were distributed to 22 shoulder/sports medicine fellowship-trained orthopaedic surgeons over 2 points in time. Kappa values for inter- and intrarater reliability were calculated. RESULTS: The overall response rate was 91%. For shoulder radiographs, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.49), estimate of glenoid lesion surface area (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.35), and estimate of Hill-Sachs surface area (κ = 0.50). Intrarater agreement was moderate for radiographs (κ = 0.48-0.57). For shoulder MRI, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.44), glenoid lesion surface area (κ = 0.35), Hill-Sachs lesion (κ = 0.33), Hill-Sachs surface area (κ = 0.28), humeral head edema (κ = 0.41), and presence of a capsulolabral injury (κ = 0.36). Fair agreement was found for specific type of capsulolabral injury (κ = 0.21). Intrarater agreement for shoulder MRI was moderate for the presence of glenoid lesion (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.52), estimate of Hill-Sachs surface area (κ = 0.50), humeral head edema (κ = 0.51), and presence of a capsulolabral injury (κ = 0.53), and agreement was substantial for glenoid lesion surface area (κ = 0.63). Intrarater agreement was fair for determining the specific type of capsulolabral injury (κ = 0.38). CONCLUSION: Fair to moderate agreement by surgeons was found when evaluating imaging studies for anterior shoulder instability. Agreement was similar for identifying pathologic characteristics on radiographs and MRI. There was a trend toward better agreement for the presence of glenoid-sided injury. The lowest agreement was observed for specific capsulolabral injuries.

New Paradigms in the Throwing Shoulder: Pathophysiology and Examination.

There continues to be a high incidence of shoulder injuries in throwing athletes, with sometimes disappointing return-to-play outcomes, creating an increased need to understand the pathophysiology of the injury and to better characterize the injury during the clinical examination. Current concepts suggest that the disabled throwing shoulder is a useful construct to develop a more comprehensive view of the complex local and distant musculoskeletal alterations that can be seen associated with the clinical symptoms. The pathophysiology can be seen as a cascade to injury, in which proximal or distal deficits in motion, strength, and strength balance can affect force production, joint position, and joint loads throughout the kinetic chain. Local imbalances between force production and load can create anatomic injury or create distant imbalances that create the injury. The evaluation then becomes a more comprehensive one, necessitating a look at all areas of the kinetic chain and evaluation of them in the context of the requirements on the structures during each of the phases of the throwing motion. Specific testing for core stability, scapular stability and motion, and local muscle strength, strength balance, and flexibility needs to be performed, as well as tests for tissue injury.

COMPARISON OF CORE STABILITY AND BALANCE IN ATHLETES WITH AND WITHOUT SHOULDER INJURIES.

BACKGROUND: Relationships between core stability and lower extremity injuries have been described in the literature; however, evidence of the relationship between upper extremity injuries and core stability and balance is limited. HYPOTHESIS/PURPOSE: The purpose of this study was to compare clinical measures of core stability and balance between athletes with and without non-traumatic shoulder injuries. STUDY DESIGN: Cross sectional. METHODS: Eighty athletes (54 males, age: 21.2 + 3.3 years) participated in this study. Forty athletes with a current shoulder injury were matched to healthy athletes by age, gender, BMI, and sport. Athletes completed clinical core stability tests including flexor and extensor endurance tests, double leg lower test (°) and balance tests including single leg stance under eyes open and eyes closed conditions, and the Y-balance test. MANOVAs were used to assess group differences. RESULTS: No statistically significant differences existed between athletes with and without shoulder injuries for clinical tests of core stability, F(1,78)=0.97, p=0.41; η2 = 0.04. No statistically significant differences existed between injured athletes with and without shoulder injuries for static and dynamic balance measures, F(1,78)=0.86, p=0.53; η2 = 0.07. CONCLUSIONS: Although core stability is widely incorporated in rehabilitation of athletes with shoulder injuries, performance on these clinical tests did not differ in the group of athletes assessed in this study. LEVEL OF EVIDENCE: 3.

Descriptive Epidemiology of the MOON Shoulder Instability Cohort.

BACKGROUND: Shoulder instability is a common diagnosis among patients undergoing shoulder surgery. PURPOSE: To perform a descriptive analysis of patients undergoing surgery for shoulder instability through a large multicenter consortium. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients undergoing surgery for shoulder instability who were enrolled in the MOON Shoulder Instability Study were included. Baseline demographics included age, sex, body mass index, and race. Baseline patient-reported outcomes (PROs) included the American Shoulder and Elbow Surgeons (ASES) score, Shoulder Activity Score, Western Ontario Shoulder Instability Index (WOSI), 36-Item Health Survey (RAND-36), and Single Assessment Numeric Evaluation (SANE). The preoperative physician examination included active range of motion (ROM) and strength testing. Preoperative imaging assessments with plain radiography, magnetic resonance imaging (MRI), and computed tomography were also included and analyzed. RESULTS: Twenty-six surgeons had enrolled 863 patients (709 male, 154 female) across 10 clinical sites. The mean age for the cohort was 24 years (range, 12-63 years). Male patients represented 82% of the cohort. The primary direction of instability was anterior for both male (74%) and female (73%) patients. Football (24%) and basketball (13%) were the most common sports in which the primary shoulder injury occurred. No clinically significant differences were found in preoperative ROM between the affected and unaffected sides for any measurement taken. Preoperative MRI scans were obtained in 798 patients (92%). An anterior labral tear was the most common injury found on preoperative MRI, seen in 66% of patients, followed by a Hill-Sachs lesion in 41%. Poor PRO scores were recorded preoperatively (mean: ASES, 72.4; WOSI, 43.3; SANE, 46.6). CONCLUSION: The MOON Shoulder Instability Study has enrolled the largest cohort of patients undergoing shoulder stabilization to date. Anterior instability is most common among shoulder instability patients, and most patients undergoing shoulder stabilization are in their early 20s or younger. The results of this study provide important epidemiological information for patients undergoing shoulder stabilization surgery.

Prevention and Management of Post-operative Complications Following ACL Reconstruction.

PURPOSE OF REVIEW: The goal of this paper is to review the current management and prevention of post-operative complications after anterior cruciate ligament (ACL) reconstruction. Trends in rehabilitation techniques will be presented, in addition to suggestions for interventions and expected milestones in ACL reconstruction recovery. RECENT FINDINGS: ACL reconstruction protocols have evolved to more of a criterion-based progression rather than a tissue-healing time frame. Given the evolution of ACL surgical reconstruction techniques and rehabilitation protocols, the risk of post-operative complications can arise both early and late in the recovery process. This paper will discuss the role of preventative measures as it applies to the post-operative patient with ACL reconstruction. Short-term complications following ACL reconstruction include infection and deficits to knee motion and strength, whereas long-term complications include secondary ACL injury to either the involved or contralateral knee and lack of ability to return to high-level sports following this procedure. Future research should continue to address the multifactorial causes of secondary ACL injury and limited ability of patients to return to high level activities.

T1ρ Magnetic Resonance Imaging to Assess Cartilage Damage After Primary Shoulder Dislocation.

BACKGROUND: Patients who suffer anterior shoulder dislocations are at higher risk of developing glenohumeral arthropathy, but little is known about the initial cartilage damage after a primary shoulder dislocation. T1ρ is a magnetic resonance imaging (MRI) technique that allows quantification of cartilage proteoglycan content and can detect physiologic changes in articular cartilage. PURPOSE: This study aimed to establish baseline T1ρ MRI values for glenoid and humeral head cartilage, determine whether T1ρ MRI can detect glenohumeral cartilage damage after traumatic primary shoulder dislocation, and assess for patterns in cartilage damage in anterior shoulder dislocation. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Nine male patients (mean age, 32.0 years; range, 20-59 years) who sustained first-time anterior shoulder dislocations underwent 3T T1ρ MRI. Five healthy controls (mean age, 27.4 years; range, 24-30 years) without prior dislocation or glenohumeral arthritis also underwent 3T T1ρ MRI. The T1ρ relaxation constant was determined for the entire glenoid and humeral head for patients with a dislocation and for healthy controls. The glenoid and humeral head were divided into 9 zones, and T1ρ values were determined for each zone in dislocated and control shoulders to identify patterns in cartilage damage in dislocated shoulders. RESULTS: Average overall T1ρ values for humeral head cartilage in dislocated shoulders were significantly greater than in controls (41.7 ± 3.9 ms vs 38.4 ± 0.6 ms, respectively; P = .03). However, average overall T1ρ values for glenoid cartilage were not significantly different in dislocated shoulders compared with controls (44.0 ± 3.3 ms vs 44.6 ± 2.4 ms, respectively; P = .40), suggesting worse damage to humeral head cartilage. T1ρ values in the posterior-middle humeral head were higher in patients with a dislocation compared with controls (41.5 ± 3.8 ms vs 38.2 ± 2.2 ms, respectively; P = .021) and trended toward significance in the posterior-superior and middle-superior zones (35.2 ± 4.9 ms vs 31.3 ± 1.0 ms and 33.7 ± 5.0 ms vs 30.5 ± 1.3 ms, respectively; P = .056). These 3 humeral head zones are where Hill-Sachs lesions predominate. T1ρ values in the anterior-inferior glenoid zone trended toward significance in patients with a dislocation compared with controls (47.4 ± 5.0 ms vs 43.5 ± 3.5 ms, respectively; P = .073). CONCLUSION: Humeral head cartilage sustained greater damage than glenoid cartilage in primary dislocation. T1ρ values were higher in glenohumeral zones associated with Bankart and Hill-Sachs lesions. Widespread initial cartilage damage may predispose patients to glenohumeral arthropathy.