Variation in Reported Learning Outcomes and Measurement Instruments in Hip Arthroscopy Simulation Training: A Systematic Review.

PURPOSE: To systematically review the current literature on the effectiveness of hip arthroscopy simulation training and to determine the consistency of reporting and validation of simulation used in hip arthroscopy. METHODS: Three databases (PubMed, EMBase, and CINAHL) were screened using PRISMA guidelines in January 2022 for published literature on virtual simulation in hip arthroscopy. Studies reporting on the use of hip arthroscopy simulation training in orthopedic surgical trainees were included and assessed for quality and risk of bias using MINORS criteria. The number of participants, participant education level, experience, simulator type, validation type, method of assessment, and simulation outcomes were extracted from included studies. RESULTS: Of the 286 articles screened, 11 met inclusion criteria for review evaluating 323 orthopedic trainees with a mean of 29.36 participants per study published between 2012 and 2021, most commonly in the United Kingdom (55%). The four most reported surgical skills evaluated were visualization and probing tasks (82%), mean time to perform the task (73%), number of cartilage and soft tissue collisions (73%), and number of hand movements (73%). The most described measurement instruments included a simulation built-in scoring system (55%), Arthroscopic Surgical Skill Evaluation Tool (ASSET) Global Rating Scale (GRS) (27%), and motion analysis system (18%). Construct validity was the most reported overall type of validity (82%), followed by face validity (36%), transfer validity (18%) and content validity (18%). Construct validity was also the most reported validity for the simulator and measurement instrument (55% and 89%, respectively). CONCLUSIONS: There is significant variation in reported learning outcomes and measurement instruments for evaluating the effectiveness of hip arthroscopic-based education. This study highlights that simulation training may be an effective tool for evaluation of hip arthroscopy skills. LEVEL OF EVIDENCE: Level III, systematic review of level I to III studies.

Does central sensitization correlate with two-year postoperative functional outcome scores following hip arthroscopy?

Background: Central sensitization (CS) involves amplified central nervous system (CNS) signaling and several biochemical changes which lead to pain hypersensitivity. Data on the effects of CS are limited in orthopaedics and has been associated with reported levels of postoperative pain after hip arthroscopy. Methods: Patients over the age of 18 who underwent hip arthroscopy with preoperative as well as 2-year postoperative functional outcome scores were identified through the Multicenter Arthroscopic Study of the Hip (MASH) database. Patient demographics, procedure information, as well as patient reported outcome measures (PROMs) were collected along with CS index scores. Results: 34 patients met inclusion criteria for our study. Preop MCS and iHOT as well as Postop MCS, showed moderate to strong negative correlations with CSI scores (-0.607, -0.573, and -0.756, respectively). VAS, PCS and MSC scores were significantly different preoperatively to postoperatively, ensuring alleviation of pain after hip arthroscopy. Subgroup analysis by stratifying CSI scores into 1 SD below the mean, within 1 SD of the mean, and above 1 SD showed significant differences across all 3 groups for preoperative MCS (p < 0.001), postoperative MCS (p = 0.001), and PSEQ2 (p = 0.015). Postoperative VAS pain approached significance but did not meet criteria of p < 0.05 (p = 0.062). Conclusion: Increased postoperative CSI scores directly correlated with decreased preoperative and postoperative MCS scores and worse preoperative resilience. Recognizing the influence of CS on pain perception and resilience on coping with adversity in the recovery period may guide orthopaedic surgeons in developing comprehensive treatment plans to continue to improve surgical outcomes in hip arthroscopy. Level of evidence: IV.

Patients With Low Resilience Scores Have Significantly Worse Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction Than Patients With Normal or High Resilience Scores.

Purpose: To evaluate the relationship between patient resilience and patient-reported outcome measures (PROMS) after primary anterior cruciate ligament (ACL) reconstruction. Methods: Patients who underwent an ACL reconstruction by a single surgeon between January 2012 and June 2020 were identified by an institutional query using Current Procedural Terminology codes. Patients were included if they (1) underwent a primary ACL reconstruction and (2) had a minimum of 2 years' follow-up. Data were retrospectively collected regarding demographics, surgical details, visual analog scale (VAS) scores, and 12-item short form survey (SF-12) scores. Resilience scores were obtained via the Brief Resilience Scale questionnaire. Stratification into low (LR), normal (NR), and high resilience (HR) was based on standard deviation from mean Brief Resilience Scale score to determine differences in PROMS between groups. Results: One-hundred eighty-seven patients were identified by the institutional query. Of the 187 patients, 180 met inclusion criteria. Seven patients underwent revision ACL reconstruction and were excluded from the study. One-hundred three patients (57.2%) completed the postoperative questionnaire and were included. Patients in the NR group and HR group had significantly greater postoperative SF-12 scores (P < .001) and lower postoperative VAS pain scores (P < .001) when compared with those of the LR group. This trend was again shown with breakdown of the SF-12 into physical and mental aspects, each of which were significantly greater in either the NR group or HR group when compared with the LR group (P < .001). Overall, 97.9% and 99.0% of patients had changes in their SF-12 total and VAS pain scores respectively that exceeded the minimal clinically important difference for the cohort. Conclusions: Patients with lower resilience scores have worse PROMs and increased pain than patients with greater resilience at a minimum of 2-year follow-up after ACL reconstruction. Level of Evidence: Level IV, prognostic case series.

Associating Outcomes After Hip Arthroscopy With Patient Resilience.

Background: Higher patient resilience has been shown to be associated with improved patient-reported outcome measures (PROMs) at 6 months after hip arthroscopy. Purpose: To examine the relationship between patient resilience and PROMs at minimum 2 years after hip arthroscopy. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were 89 patients (mean age, 36.9 years; mean follow-up, 4.6 years). Patient demographics, surgical details, and preoperative International Hip Outcome Tool-12 (iHOT-12) and visual analog scale (VAS) pain scores were collected retrospectively. Postoperative variables were collected via a survey and included the Brief Resilience Scale (BRS), Patient Activation Measure-13 (PAM-13), Pain Self-efficacy Questionnaire-2 (PSEQ-2), VAS satisfaction, and postoperative iHOT-12, and VAS pain scores. Based on the number of standard deviations from the mean BRS score, patients were stratified as having low resilience (LR; n = 18), normal resilience (NR; n = 48), and high resilience (HR; n = 23). Differences in PROMs were compared between the groups, and a multivariate regression analysis was performed to assess the relationship between pre- to postoperative change (Δ) in PROMs and patient resilience. Results: There were significantly more smokers in the LR group compared with the NR and HR groups (P = .033). Compared with the NR and HR groups, patients in the LR group had significantly more labral repairs (P = .006), significantly worse postoperative iHOT-12, VAS pain, VAS satisfaction, PAM-13, and PSEQ-2 scores (P < .001 for all), and significantly lower ΔVAS pain and ΔiHOT-12 scores (P = .01 and .032, respectively). Regression analysis showed significant associations between ΔVAS pain and NR (ß = -22.50 [95% CI, -38.81 to -6.19]; P = .008) as well as HR (ß = -28.31 [95% CI, -46.96 to -9.67; P = .004) and between ΔiHOT-12 and NR (ß = 18.94 [95% CI, 6.33 to 31.55]; P = .004) as well as HR (ß = 20.63 [95% CI, 6.21 to 35.05]; P = .006). Male sex was a significant predictor of ΔiHOT-12 (ß = -15.05 [95% CI, -25.42 to -4.69]; P = .006). Conclusion: The study results indicate that lower postoperative resilience scores were associated with significantly worse PROM scores, including pain and satisfaction, at 2 years after hip arthroscopy.

Trends in Anterior Cruciate Ligament Injury and Recovery in Professional Snowboarders: The Extreme Sport of Snowboardcross.

Introduction  An anterior cruciate ligament (ACL) tear is a devastating injury for athletes that is predominantly low energy and non-contact in nature. ACL tears are one of the most well-researched injuries in sports, however, scant research has been done on competitive snowboarders. Boardercross is a relatively new sport introduced to the Winter Olympics in 2006. Initially, it entailed four snowboarders racing head-to-head down a course of obstacles in a race to the finish, with the top two riders advancing to the next rounds. It has since expanded to six racers traveling up to 60 mph and jumps up to 100 feet in length in a head-to-head race to the finish. This extreme sport puts its athletes at risk for serious injury, requiring investigation. Purpose Investigate the prevalence of ACL tears in the extreme sport of boardercross, evaluate sport-specific factors that may put athletes at higher risk, and report return to sport data. Methods An expedited IRB approval was obtained. A survey was distributed to athletes via e-mail to national/regional coaches of countries with competitive boardercross teams. Professional coaches distributed the survey and secondarily distributed it to athletes. Results Sixty-six competitive snowboardcross athletes responded to the email surveys 48.5% of respondents had torn their ACL at least once in their career. Of the female respondents, 55.6% suffered at least one ACL tear, and 43.6% of male respondents suffered at least one ACL tear. 31.2% suffered more than one ACL tear during their career. Of those who tore their ACL, 91.3% (p <0.001) tore their front leg. 100.0% of the respondent athletes returned to sport post-ACL reconstruction. Conclusion Professional boardercross racers are at a higher risk of tearing their ACL than other winter sport athletes, including alpine skiers. A predominance of ACL injuries occurred on the front leg during landing from an aerial maneuver. All respondent athletes returned to the sport after injury, with approximately half returning within six months. Although no statistical significance was achieved, the data provided trends on risk factors related to ACL injuries among snowboardcross athletes.

Arthroscopic Rotator Cuff Repair Technique Using a Bio-Composite Scaffold for Tissue Augmentation.

The use of biologics and rotator cuff augmentation have seen significant growth in interest to combat complications of rotator cuff retear after arthroscopic rotator cuff repair. Bio-inductive implants are used to induce new tissue formation; however, they lack structural strength at the time of implantation. Conversely, dermal allografts are used to provide structural strength at implantation, but they do not allow for sufficient tissue incorporation and carry inherent risks of allograft tissue. The BioBrace™ (Biorez, New Haven, CT) is a bio-inductive scaffold composed of highly porous type I collagen and bio-resorbable poly (l-lactide) microfilaments developed to combat the latter drawbacks. The unique bio-composite properties provide the ability to combine the benefits of bio-induction and strength into a single implant. We propose a successful, reproducible technique for the implantation of BioBrace for rotator cuff augmentation.

Postoperative Multimodal Pain Management and Opioid Consumption in Arthroscopy Clinical Trials: A Systematic Review.

Purpose: To provide an updated review of multimodal pain management in arthroscopic surgery by evaluating pain and opioid consumption after shoulder, knee, and hip arthroscopy. Methods: A comprehensive literature search was performed to identify randomized controlled trials (RCTs) investigating multimodal pain management after shoulder, knee, and hip arthroscopy. Articles were identified from January 2011 through December 2020 using various databases. As the primary outcome variables of this study, differences in postoperative pain and opioid consumption volumes were summarized from all reported postoperative time points. Results: 37 shoulder, 28 knee, and 8 hip arthroscopy RCTs were included in the study. The most frequent bias present in the included RCTs was incomplete outcome data (58%), while group allocation concealment was the least frequent bias (15%). Qualitative analysis of rotator cuff repair (n = 12), anterior cruciate ligament reconstruction (n = 11), meniscectomy (n = 5), femoroacetabular impingement (n = 2), oral medications (n = 8), postoperative interventions (n = 10), and nonpharmacological interventions (n = 6) was performed. Conclusions: Many multimodal pain management protocols offer improved pain control and decreased opioid consumption after arthroscopic surgery. On the basis of the current literature, the evidence supports an interscalene nerve block with a dexamethasone-dexmedetomidine combination for rotator cuff repair, a proximal continuous adductor canal block for anterior cruciate ligament reconstruction, and local infiltration analgesia (e.g., periacetabular injection with 20 mL of .5% bupivacaine) for hip arthroscopy. When evaluating oral medication, the evidence supports 150 mg Pregabalin for shoulder arthroscopy, 400 mg Celecoxib for knee arthroscopy, and 200 mg Celecoxib for hip arthroscopy, all taken preoperatively. There is promising evidence for the use of various nonpharmacological modalities, specifically preoperative opioid education for rotator cuff repair patients; however, more clinical trials that evaluate nonpharmacological interventions should be performed. Level of Evidence: Level II, systematic review of Level I and II studies.

A Scoping Review of Injuries in Amateur and Professional Men's Ice Hockey.

Background: Orthopaedic injuries are common in ice hockey at all levels and can result in physical and psychological adverse effects on these athletes. Purpose: Primarily, to summarize published data on orthopaedic hockey injuries at the junior through professional level. Secondarily, to characterize the literature based on anatomic site injured, return-to-play rates, cause/mechanism of injury, time lost, and treatments used. Study Design: Scoping review; Level of evidence, 4. Methods: PubMed, EMBASE, Cochrane library, and SCOPUS were searched using the terms "hockey" and "injuries" using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and 4163 studies involving orthopaedic injuries were identified. Our inclusion criteria consisted of accessible full-text articles that evaluated orthopaedic injuries in men's ice hockey athletes of all levels. We excluded case reports and articles evaluating women's ice hockey injuries, as well as those evaluating nonorthopaedic injuries, such as concussions; traumatic brain injuries; and facial, dental, and vascular injuries, among others. Studies were divided based on level of play and anatomic site of injury. Level of evidence, year published, country of corresponding author, method of data collection, incidence of injury per athlete-exposure, and time lost were extracted from each article. Results: A total of 92 articles met the inclusion criteria and were performed between 1975 and 2020, with the majority published between 2015 and 2020. These were divided into 8 anatomic sites: nonanatomic-specific (37%), intra-articular hip (20.7%), shoulder (9.8%), knee (8.7%), trunk/pelvis (7.6%), spine (7.6%), foot/ankle (6.5%), and hand/wrist (2.2%). Of these studies, 71% were level 4 evidence. Data were obtained mostly via surveillance programs and searches of publicly available information (eg, injury reports, player profiles, and press releases). Conclusion: This scoping review provides men's hockey players and physicians taking care of elite ice hockey athletes of all levels with a single source of the most current literature regarding orthopaedic injuries. Most research focused on nonanatomic-specific injuries, intra-articular hip injuries, knee injuries, and shoulder injuries, with the majority having level 4 evidence.

Comparing Intramedullary Nailing Versus Locked Plating in the Treatment of Native Distal Femur Fractures: Is One Superior to the Other?

INTRODUCTION: Distal femur fractures make up < 1% of all fractures and 3-6% of all femur fractures. In the literature, both intramedullary nailing (IMN) and locked plating (LP) have shown favorable results, but there is no consensus on a gold standard. The purpose of this systematic review is to compare outcomes of native distal femur fractures treated via IMN versus LP in an effort to determine if one is superior to the other. METHODS: Systematic review of MEDLINE, EMBASE, and Cochrane Library databases was conducted according to PRISMA guidelines. Only articles published within the last ten years were included. Evidence and study quality were evaluated with the MQOE and Oxford Criteria. RESULTS: Forty-six articles were included in the review. Fractures treated with IMN were found to have a 93.9% union rate, an average time to union of 19.2 weeks, an average arc of motion of 105.1 degrees, with an average of 14.4 degrees of malalignment. Fractures treated with LP were found to have a 90.2% union rate, an average time to union of 20.5 weeks, an average arc of motion of 104 degrees, with an average of 12.6 degrees of malalignment. CONCLUSION: Compiled data comparisons revealed no differences in union rate, malalignment, time to union, average arc of motion, or complication rates requiring a return to the operating room. Until higher level randomized data is available, either IMN or LP are acceptable methods of treatment for native distal femur fractures.

Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery.

¼: Acetaminophen is an effective addition to a multimodal pain regimen; however, evidence to support intravenous versus oral administration requires further evaluation. ¼: While nonsteroidal anti-inflammatory drugs are a valuable addition to a multimodal pain strategy, concerns regarding their effect on healing after certain procedures (i.e., rotator cuff repair) in select patients may preclude their use. ¼: The use of perioperative gabapentinoids have varied results for pain control, and additional research is warranted to support their use after certain shoulder procedures. ¼: Opioid-prescribing should be limited and reserved for severe postoperative pain. When prescribed, opioids should be taken at the lowest possible dose and for the shortest period. ¼: Centrally acting analgesics such as tramadol have been shown to be as effective as opioids and have a lower risk of complications. ¼: Nerve blocks are an excellent addition to multimodal pain management strategies. Longer-lasting formulations of perioperative single-shot injections and indwelling catheters may reduce rebound pain.

Resilience in the Orthopaedic Patient.

➤: Resilience is a dynamic psychological construct that refers to the ability to adapt and improve when facing adversity or other stressors. ➤: Recent investigations in various orthopaedic subspecialties have demonstrated that resilience may contribute to favorable mental health and physical function after a surgical procedure. ➤: More research, using well-designed prospective studies, is necessary to better define the role that resilience and other factors play in the health and outcomes of patients with orthopaedic conditions. ➤: Orthopaedic surgeons can consider incorporating resilience assessments into their practices to aid in identifying patients who will do well with a surgical procedure and those who may benefit from specialized therapy to optimize their health and function.

Gastrocnemius Injuries in Professional Baseball Players: An Epidemiological Study.

BACKGROUND: Gastrocnemius injuries are a common lower extremity injury in elite baseball players. There are no current epidemiological studies focused on gastrocnemius injuries in professional baseball players that provide information on the timing, distribution, and characteristics of such injuries. HYPOTHESIS: Gastrocnemius injury in professional baseball players is a common injury that is influenced by factors such as age, player position, and time of season. STUDY DESIGN: Descriptive epidemiological study. METHODS: Based on Major League Baseball's (MLB's) Health and Injury Tracking System (HITS) database, gastrocnemius injuries that caused time out of play for MLB and Minor League Baseball (MiLB) players during the 2011-2016 seasons were identified. Player characteristics, including age, level of play, and position at time of injury, were collected. Injury-specific factors analyzed included date of injury, time of season, days missed, and activity leading to injury. RESULTS: A total of 402 gastrocnemius injuries (n = 145, MLB; n = 257, MiLB) occurred during the 2011-2016 seasons. MLB players were significantly older at the time of injury (30.1 years, MLB; 23.9 years, MiLB; P < .001). Base running (36.1%) was the most common activity causing the injury, followed by fielding (23.6%), with 50.3% of base-running injuries sustained on the way to first base. In MLB players, gastrocnemius injuries were most common in infielders (48.3%), followed by pitchers (27.6%) and then outfielders (17.9%), while for MiLB players the injuries were more evenly distributed (33.5%, 28.8%, and 30.7%, respectively). The frequency of injuries in MLB players dropped off after the start of the regular season, whereas MiLB players had a consistent injury rate throughout the year. CONCLUSION: Gastrocnemius injuries are a common cause of lower extremity injury in professional baseball players, resulting in significant time out of play. Base running, particularly to first base, was the most common activity during injury. Outfielders had the fewest injuries; however, they required the longest time to recover. This study provides the first investigation to date with the HITS database to examine the characteristics and distribution of gastrocnemius injuries in professional baseball players, offering insight into risk factors, injury prevention, and recovery expectations.

Sex-Specific Analysis at Two Time Points in Three High-Impact Orthopaedic Sports Medicine Journals.

PURPOSE: To determine how well the orthopaedic sports medicine literature reported sex-specific analysis (SSA) in 2011 and 2016. METHODS: The 3 highest-impact orthopaedic sports medicine subspecialty journals (American Journal of Sports Medicine; Arthroscopy; and Knee Surgery, Sports Traumatology, Arthroscopy) were selected for review. Two independent investigators reviewed all journal issues published during 2 different calendar years (2011 and 2016). All randomized controlled, prospective and retrospective group, and case-control studies were included. Studies were stratified into those that involved SSA, where sex was a variable in a multifactorial statistical model, and those that only reported sex as a demographic characteristic or used sex-matched groups without further analysis. RESULTS: A total of 960 studies evaluating 3,400,569 patients met criteria and were included in this review. Although 44.4% of the overall study population was female, only 293 (30.5%) studies included patient sex as variable in a multifactorial statistical model. The proportion of studies that performed SSA did not differ between 2011 (29.6%) and 2016 (31.1%; P = .607), although publications from American Journal of Sports Medicine were likely to report SSA (P < .05). Of the 293 studies that reported SSA, 91 (31%) demonstrated a significant difference in outcomes. The most commonly reported differences were in outcomes following anterior cruciate ligament, medial patellofemoral ligament, and posterior cruciate ligament reconstruction; autograft preparation; postoperative use of opiates following arthroscopy; and recovery after sports-related concussions. CONCLUSIONS: Although most sports medicine studies include approximately 50% female and 50% male patients, statistical analysis differentiating the 2 subsets is not routinely performed. Only 30.5% of all studies performed SSA, 31% of which reported a statistically significant difference in the data when comparing outcomes between male and female patients with the same treatment modalities. CLINICAL RELEVANCE: The current study demonstrates that the orthopaedic sports medicine subspecialty literature is lacking in reporting SSA, and that there has been minimal improvement over a 5-year time period. In addition, this study highlights the high percentage of significant findings within the studies that performed SSA and underscores the differences in sex-specific injury patterns and treatment outcomes.

Equivalent union rates between intramedullary nail and locked plate fixation for distal femur periprosthetic fractures - a systematic review.

BACKGROUND: The incidence of periprosthetic fracture following total knee arthroplasty continues to rise as the number of knee arthroplasty procedures increases. Management of periprosthetic fractures can be complex, with locked compression plating (LCP) and intramedullary nailing (IMN) being the most commonly used treatment options. We performed a systematic review to report and compare the clinical and radiographic outcomes of patients treated with intramedullary nail fixation versus plate fixation for periprosthetic fractures of the distal femur. METHODS: Several databases were screened. Studies evaluating intramedullary nail fixation or locked plate fixation for distal femur periprosthetic fractures were included. Primary and secondary variables as mentioned below, when included, were analyzed and compared. RESULTS: One prospective comparative study, 9 retrospective comparative studies, and 28 retrospective case series with 1,188 patients were included in this review. No statistically significant differences were found between IMN and LCP when analyzing union rate or time to union. Plating demonstrated a statistically significant decrease in the overall complication rate and reoperation rate when compared with IMN (p<0.003). IMN demonstrated a slightly higher percentage of patients reaching full weight bearing status and a quicker time to full weight bearing (100% and 7.6 weeks) when compared to plating (94% and 15.8 weeks). A higher percentage of patients treated with IMN returned to preinjury activity when compared to those treated with plating (70.8% vs. 61.6%). CONCLUSIONS: Both intramedullary nail and locked plate fixation offer unique benefits in terms of clinical and radiographic outcomes for treatment of periprosthetic distal femur fractures after total knee arthroplasty. While the standard of care remains controversial, an increase in the recent literature has allowed for better clarification of the significant clinicoradiologic advantages and disadvantages of both popular treatment options.

Patient-Reported Outcomes After Arthroscopic Shoulder Surgery With Interscalene Brachial Plexus Nerve Block Using Liposomal Bupivacaine: A Prospective Observational Study.

BACKGROUND: Interscalene brachial plexus nerve blocks (ISBPNBs) are commonly used to mitigate postsurgical pain after shoulder surgery. MATERIALS AND METHODS: We performed a prospective observational study in 57 consecutive adult patients undergoing arthroscopic shoulder surgery with an ultrasound-guided ISBPNB using liposomal bupivacaine (LB; 133mg/10ml) mixed with 0.5% bupivacaine (10ml). All patients received prescriptions for 1000mg of oral acetaminophen and 10 5mg oxycodone tablets upon discharge. RESULTS: Post-discharge telephone surveys revealed that mean (standard deviation [SD]) patient-reported motor and sensory recovery times after surgery were 26.8 (3.2) and 34.0 (3.6) hours, respectively. The average (SD) visual analog scale pain score was 5.1 (3.1) at day two post-surgery. The estimated opioid utilization rate at day seven post-surgery was 21% of the prescribed opioid tablets. CONCLUSIONS: Our real-world observational findings suggest that multimodal postsurgical pain control using single-shot, ultrasound-guided ISBPNB with LB and postsurgical acetaminophen provides favorable pain control and limited need for postsurgical opioid rescue for seven days after shoulder surgery.