Primary Intraosseous Spindle Cell Rhabdomyosarcoma: A Case Report in an Unusual Location.

Spindle cell/sclerosing rhabdomyosarcoma is an infrequent subtype of rhabdomyosarcoma according to the World Health Organization Classification of Soft Tissue and Bone Tumours, which includes a novel category of intraosseous spindle-cell rhabdomyosarcomas (ISCRMS) with EWSR1:: or FUS::TFCP2 fusions. We report a case of ISCRMS with EWSR1::TFCP2 fusion presenting in the femur mimicking osteosarcoma in this unusual primary location. We present an 18-year-old male with relapsed widely metastatic sarcoma, morphologically identical to osteosarcoma responding poorly to chemotherapy, initially presenting in the distal femur. Sections showed a high-grade malignant neoplasm with sheets of epithelioid and spindled cells without obvious rhabdomyoblastic differentiation morphologically containing focal areas resembling new bone/osteoid formation. Molecular sequencing identified t(12;22) EWSR1::TFCP2. The tumor cells were diffusely positive for pancytokeratin, MyoD1, and ALK by retrospective immunohistochemistry. Desmin and SATB2 were focally positive. Myogenin was negative, and INI-1 expression was retained. ISCRMS commonly involves craniofacial and pelvic bones, but rarely originates in long bones, as in this case. Initially, osteosarcoma was the primary diagnostic consideration based on distal long bone location, patient age, and evidence of osteoid formation. Distinction between the two entities may be nearly impossible on morphologic grounds alone, which presents a diagnostic pitfall without molecular or extensive immunoprofiling data.

The birth of pediatric urology in the United States: From pioneers to subcertification.

INTRODUCTION: Pediatric urology is a subspecialty of urology that emerged from a culture in which children with urological disorders were cared for by general urologists and general pediatric surgeons. The development of pediatric urology as a subspecialty was years in the making, highlighted by individuals who recognized that children with urological conditions were not just "small adults," but required special experience and training. Subspecialization was initiated by persistent visionaries who recognized the need for a trained cadre of experts to provide better care for children. It took the coordinated effort of all subgroups and leaderships in pediatric urology to push these efforts over the goal line. The focus of this review is to highlight certain individuals who played major roles in this vision and to document the efforts of many to coordinate the pathways to sub-specialization. METHODS: The careers of Meredith F. Campbell and Frank B. Bicknell were researched to identify their rationale and roles in developing pediatric urology as a distinct medical specialty in the United States. In addition, the minutes of the meetings of the Pediatric Urology Advisory Council (PUAC) with the American Board of Urology (ABU) were reviewed. The origins of the Society for Pediatric Urology (SPU) and the American Academy of Pediatrics Section of Urology (AAP-SOU) were researched. The contributions of each to the certification of pediatric urology as a distinct subspecialty was delineated. RESULTS: Campbell was Chair of Urology at the New York University (NYU) School of Medicine and wrote prolifically about pediatric urology. He published one of the first practical textbooks in pediatric urology, almost completely self-written, in 1937. Bicknell, a general urologist in Michigan on the faculty at Wayne State University School of Medicine, led the initiative to create the Society for Pediatric Urology (SPU) that first met at the 1951 annual American Urological Association (AUA) meeting in Chicago and included nine attendees. Subsequently, John Lattimer (College of Physicians and Surgeons at Columbia University) organized a well-attended meeting of urologists interested in pediatrics at the 1964 annual AAP meeting in New York City. This led to the formation of the AAP Section on Urology. Integral to the justification for the development of a subspecialty was evidence of a published corpus of content. In addition to published textbooks devoted exclusively to pediatric urology, this was further fulfilled by the AAP Section on Urology Pediatric Supplement to the Journal of Urology, first published in 1986, and later with the Journal of Pediatric Urology in 2005. The SPU and the AAP Section on Urology came together to form the Pediatric Urology Advisory Council (PUAC) in 2000, which worked with the ABU to create subspecialty certification in pediatric urology with an independent exam, first administered in 2008 to 176 applicants. CONCLUSION: The metaphor "We have stood on the shoulders of giants" is apt for pediatric urology: Meredith Campbell, Frank Bicknell, David Innes Williams (Hospital for Sick Children, London), and J. Herbert Johnston (Alder Hay Hospital, Liverpool) come to mind among the first generation of pediatric urology pioneers, and others among their colleagues also had significant impact. Clearly this is a story of persistence and attention to detail on the part of those giants and those who followed. Pediatric urology became a distinct discipline after the SPU and AAP-SOU came together to create a robust cohort of pediatric urologists who through education and negotiation were able to help the ABU and the American Board of Medical Specialties (ABMS) recognize that subspecialization would lead to better care for children with urologic disorders. This benchmark set a high bar for future subspecialization in urology and other fields.

Evaluation of Preoperative Variables that Improve the Predictive Accuracy of the Risk Assessment and Prediction Tool in Primary Total Hip Arthroplasty.

INTRODUCTION: Discharge disposition after total joint arthroplasty may be predictable. Previous literature has attempted to improve upon models such as the Risk Assessment and Prediction Tool (RAPT) in an effort to optimize postoperative planning. The purpose of this study was to determine whether preoperative laboratory values and other previously unstudied demographic factors could improve the predictive accuracy of the RAPT. METHODS: All patients included had RAPT scores in addition to the following preoperative laboratory values: red blood cell count, albumin, and vitamin D. All values were recorded within 90 days of surgery. Demographic variables including marital status, American Society of Anesthesiologists (ASA) scores, body mass index, Charlson Comorbidity Index, and depression were also evaluated. Binary logistic regression was used to determine the significance of each factor in association with discharge disposition. RESULTS: Univariate logistic regression found significant associations between discharge disposition and all original RAPT factors as well as nonmarried patients (P < 0.001), ASA class 3 to 4 (P < 0.001), body mass index >30 kg/m2 (P = 0.065), red blood cell count <4 million/mm3 (P < 0.001), albumin <3.5 g/dL (P < 0.001), Charlson Comorbidity Index (P < 0.001), and a history of depression (P < 0.001). All notable univariate models were used to create a multivariate model with an overall predictive accuracy of 90.1%. CONCLUSIONS: The addition of preoperative laboratory values and additional demographic data to the RAPT may improve its PA. Orthopaedic surgeons could benefit from incorporating these values as part of their discharge planning in THA. Machine learning may be able to identify other factors to make the model even more predictive.

Superior Pain Reduction with Anteromedialization Tibial Tubercle Osteotomy Versus Non-Operative Management for Patellofemoral Osteoarthritis.

PURPOSE: The purpose of this study was to compare the clinical outcomes of patients with patellofemoral osteoar-thritis (PFOA) treated non-operatively with those treated operatively with an unloading anteromedialization tibial tubercle osteotomy (TTO). METHODS: A retrospective chart review was performed to identify patients with isolated PFOA who were either managed non-operatively or surgically with a TTO and who had a minimum follow-up of 2 years. Patients were surveyed with the visual analog scale (VAS) for pain, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), Anterior Knee Pain scale (Kujala), and Tegner Activity scale. Statistical analysis included two-sample t-testing, one-way ANOVA, and bivariate analysis. RESULTS: The clinical outcomes of 49 non-operatively managed patients (mean age: 52.7 ± 11.3 years; mean follow-up: 1.7 ± 1.0 years) and 35 operatively managed patients (mean age: 31.8 ± 9.4 years; mean follow-up: 3.5 ± 1.7 years) were assessed. The mean VAS improved sig-nificantly in both groups [6.12 to 4.22 (non-operative), p < 0.0001; 6.94 to 2.45 (TTO); p < 0.0001], with operatively treated patients having significantly lower postoperative pain than non-operatively managed patients at the time of final follow-up [2.45 (TTO) vs. 4.22 (non-operative), p < 0.001]. The mean KOOS-JR score was significantly greater in the operative group at time of final follow-up [78.7 ± 11.6 (TTO) vs. 71.7 ± 17.8 (non-operative), p = 0.035]. There was no significant difference in Kujala or Tegner scores between the treatment groups. Additionally, there was no sig-nificant relationship between the number of intra-articular injections, duration of NSAID use, and number of physical therapy sessions on clinical outcomes in the non-operatively treated group (p > 0.05). CONCLUSIONS: An unloading anteromedialization TTO provides significantly better pain relief and restoration of function compared to non-operative management in the treatment of symptomatic PFOA.

Return to athletics after total knee arthroplasty: a survey study of 784 recreational athletes across 12 sports.

BACKGROUND: Postoperative return to recreational activity is a common concern among the increasingly active total knee arthroplasty (TKA) patient population, though there is a paucity of research characterizing sport-specific return and function. This study aimed to assess participation level, postoperative return to activity, sport function, and limitations for recreational athletes undergoing TKA. METHODS: A survey of recreational sports participation among primary, elective TKA patients from a single academic center between June 2011 and January 2022 was conducted. Of the 10,777 surveys administered, responses were received from 1,063 (9.9%) patients, among whom 784 indicated being active in cycling (273 [34.8%]), running (33 [4.2%]), jogging (68 [8.7%]), swimming (228 [29.1%]), tennis (63 [8.0%]), skiing (55 [7.0%]), or high-impact team sports (64 [8.2%]) between two years preoperatively and time of survey administration, and were included for analyses. RESULTS: Cycling (62.3% at two years preoperatively vs. 59.0% at latest follow-up) and swimming (62.7% at two years preoperatively vs. 63.6% at latest follow-up) demonstrated the most favorable participation rate changes, while running (84.0% at two years preoperatively vs. 48.5% at latest follow-up) and skiing (72.7% at two years preoperatively vs. 45.5% at latest follow-up) demonstrated the least favorable participation rate changes. The majority of respondents were "satisfied" or "very satisfied" with their return across all sports, though dissatisfaction was highest among runners and joggers. For cycling, running, jogging, and swimming, respondents most commonly reported no change in speed or distance capacity, though among these cyclists reported the highest rates of improved speed and distance. The majority of returning skiers reported improved balance, form, and ability to put on skis. CONCLUSION: Return to sport is feasible following TKA with high satisfaction. Swimming and cycling represent manageable postoperative activities with high return-rates, while runners and joggers face increased difficulty returning to equal or better activity levels. Patients should receive individualized, sports-specific counseling regarding their expected postoperative course based on their goals of treatment.

Preoperative Symptom Severity Predicts 5-Year Hip Arthroscopy Outcomes.

PURPOSE: Thisstudy sought to assessthe prognostic effect of preoperative symptom severity on hip arthroscopy outcomes for femoroacetabular impingement syndrome (FAI). METHODS: Patients undergoing hip arthroscopy between September 2012 and July 2014 for FAI with a minimum of 5-year clinical outcomes were compiled. Patient reported outcomes (PROs) including modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) were collected. High and low preoperative function (PF) subgroups were created using baseline population median mHHS (43.3) as a threshold with PROs below the median score indicating low preoperative function and vice versa for scores above the median. Kaplan-Meier analysis, Cox proportional modeling, analysis of variance (ANOVA), and linear regressions were used for analysis. RESULTS: One hundred five of 131 eligible patients(80.2% inclusion; age: 42.6 ± 1.4 years; body mass index: 25.3 ± 0.4 kg/m2 ) met the study criteria. The 5-year survival-torevision rate (85% versus 61%, p = 0.013) and survivalto-arthroplasty rate (95% vs. 82%, p = 0.022) were greater in the high versus low PF group. ANOVA demonstrated the high versus low PF group had higher baseline (mHHS: 52.7 ± 1.4 vs. 36.1 ± 1.1, p < 0.001; NAHS: 57.4 ± 1.6 vs. 39.3 ± 1.2, p < 0.001) and 1-year (mHHS: 91.9 ± 1.8 vs. 79.5 ± 2.7, p < 0.001; NAHS: 91.7 ± 1.6 vs. 80.8 ± 2.5, p < 0.001) outcomes. High versus low PF achieved higher Minimal Clinically Important Difference (77% vs. 57%, p = 0.026) at 5-years. High versus low PF achieved higher Patient Acceptable Symptomatic State rates at 1 year (79% vs. 47%, p < 0.001) and 5 years (66% vs. 45%, p = 0.032). Linear regression demonstrated body mass index (mHHS: p = 0.002; NAHS: p = 0.005), pincer resection (mHHS: p = 0.046), and preoperative symptom severity (mHHS: p = 0.001; NAHS: p = 0.002) to be predictors of 5-year change in PROs. CONCLUSION: Preoperative symptom severity is a reliable prognostic indicator of clinical survival rates and PROs after hip arthroscopy for FAI. Subjects with high PF are likely to have increased longevity of the index procedure while maintaining excellent PASS and MCID rates mid-term as opposed to those with low PF.

Tunnel Widening Following All-Inside Anterior Cruciate Ligament Reconstruction Varies Depending on Soft Tissue Graft Type.

PURPOSE: Bone tunnel widening (TW) is a well-described complication after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to evaluate radiographic bone TW and clinical outcomes in patients with ACLR performed with suspensory fixation on both the femoral and tibial tunnels using different soft tissue grafts. METHODS: Patients who underwent primary ACLR with a soft tissue graft (hamstring autograft or allograft or quadriceps autograft) using an all-inside technique were included for analysis. Anterior cruciate ligament tunnel width was measured postoperatively on anteroposterior and lateral plain radiographs at a minimum of 12 months of follow-up. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) subjective knee form as well as assessing patient records for complication data. RESULTS: Fifty patients (15 quadriceps autografts, 24 hamstring autografts, 11 hamstring allografts) were included in this study. The quadriceps autograft cohort was the youngest, (16.6 ± 2.8 years), followed by the hamstring autograft cohort (27.7 ± 9.0 years), and the hamstring allograft cohort (48.2 ± 9.4 years; p < 0.001) for all comparisons. Quadriceps autografts experienced less tibial tunnel-widening (0.6 ± 0.6 mm) than hamstring autografts (2.0 ± 1.1 mm; p = 0.011), which, in turn, experienced less widening than hamstring allografts (3.9 ± 2.3 mm; p < 0.001). Quadriceps autografts also experienced less femoral tunnel widening (0.3 ± 0.6 mm) than hamstring autografts (2.1 ± 1.2 mm; p < 0.001) which, in turn, experienced less tunnel-widening than hamstring allografts (4.0 ± 2.1; p < 0.001). At follow-up, mean IKDC for hamstring autografts, quadriceps autografts, and hamstring allografts were 79.9 ± 17.9, 88.5 ± 7.1, and 77.7 ± 20.4, respectively (p = 0.243). There was no statistically significant difference between groups with respect to postoperative complications; p = 0.874. CONCLUSIONS: Anterior cruciate ligament reconstruction with quadriceps autograft resulted in the least tunnel widening compared to hamstring autograft and allograft when using an all-inside suspensory fixation device. Both autograft groups resulted in less widening than the allograft group. Despite the greatest increased radiographic tunnel widening in the allograft group, there was no significant difference in clinical outcomes or knee laxity.

Pain-management protocol aimed at reducing opioids following total knee arthroplasty does not negatively impact patient satisfaction.

BACKGROUND: Prior research has demonstrated that the prescription of opioid medications may be associated with the desire to treat pain in order to achieve favorable patient satisfaction. The purpose of the current study was to investigate the effect of decreased opioid prescribing following total knee arthroplasty (TKA) on survey-administered patient satisfaction scores. METHOD: This study is a retrospective review of prospectively collected survey data for patients who underwent primary elective TKA for the treatment of osteoarthritis (OA) between September 2014 and June 2019. All patients included had completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey information. Patients were stratified into two cohorts based on whether their surgery took place prior to or subsequent to the implementation of an institutional-wide opioid-sparing regimen. RESULTS: Of the 613 patients included, 488 (80%) were in the pre-protocol cohort and 125 (20%) in the post-protocol cohort. Rate of opioid refills (33.6% to 11.2%; p < 0.001) as well as length of stay (LOS, 2.40 ± 1.05 to 2.13 ± 1.13 days; p = 0.014) decreased significantly after protocol change while rate of current smokers increased significantly (4.1% to 10.4%; p = 0.011). No significant difference was observed in "top box" percentages for satisfaction with pain control (Pre: 70.5% vs Post: 72.8%; p = 0.775). CONCLUSIONS: Protocols calling for reduced prescription of opioids following TKA resulted in significantly lower rates of opioid refills, and were associated with significantly shorter LOS, while causing no statistically significant deleterious changes in patient satisfaction, as measured by HCAPS survey. LOE: III. CLINICAL RELEVANCE: This study suggests that HCAPS scores are not negatively impacted by a reduction in postoperative opioid analgesics.

Clinical Outcomes After Concomitant Hip Arthroscopy and Iliotibial Band Lengthening With Trochanteric Bursectomy Compared to a Matched Cohort.

PURPOSE: This study sought to determine the clinical outcomes of patients that underwent hip arthroscopy for femoroacetabular impingement (FAI) and concomitant arthroscopic iliotibial (IT) band lengthening with trochan- teric bursectomy (TB group) as well as a matched cohort of patients undergoing hip arthroscopy for isolated FAI symptoms (NTB group) from baseline to a minimum of 2-year follow-up. METHODS: Patients who were diagnosed with FAI and symptomatic trochanteric bursitis and who failed con- servative measures and underwent hip arthroscopy and arthroscopic IT band lengthening with trochanteric bur- sectomy were identified. These patients were matched by age, sex, and body mass index (BMI) to a group of patients who underwent surgery for FAI without trochanteric bur- sitis symptoms. Patients were separated into two groups: iliotibial band lengthening with trochanteric bursectomy (TB) and non-trochanteric bursectomy (NTB). The patient reported outcomes (PROs) recorded were the modified Har- ris Hip Score (mHHS) and Non-Arthritic Hips Score (NAHS), which were obtained with a minimum of 2-years follow-up. RESULTS: Each cohort was composed of 22 patients. The TB cohort was composed of 19 females (86%) with a re- ported mean age of 49.3 ± 11.6 years. The NTB cohort was composed of 19 females (86%) with a reported mean age of 49.0 ± 11.7 years. Both cohorts showed significant improve- ment from baseline in the mHHS and NAHS. There was no significant difference in the mHHS and NAHS between the two groups. There was no significant difference between TB and NTB groups with respect to achieving minimal clinically important difference (MCID), [19 (86%) vs. 20 (91%), p > 0.99] or patient acceptable symptom state (PASS), [13 (59%) vs. 14 (64%), p = 0.76]. CONCLUSIONS: There was no difference in PROs of patients with FAI and trochanteric bursitis who underwent hip ar- throscopy with concomitant arthroscopic IT band lengthen- ing with trochanteric bursectomy compared to patients with isolated FAI who underwent hip arthroscopy.

The Efficacy of Tranexamic Acid for the Treatment of Traumatic Hip Fractures: A Network Meta-Analysis.

OBJECTIVES: To compare the efficacy of different dosages of intravenous (IV) tranexamic acid (TXA) in the treatment of traumatic hip fractures against that of the control group of no TXA. DATA SOURCES: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to perform a network meta-analysis on the use of TXA for the treatment of hip fractures. The study team used Ovid MEDLINE, Cochrane Reviews, Scopus, Embase, and Web of Science databases to perform the search. Studies that were published in English between the years 2010 and 2020 were selected. STUDY SELECTION/DATA EXTRACTION: For inclusion in this study, selected articles were required to be randomized controlled trials with at least 1 control group that had no antifibrinolytic intervention to serve as a control, and IV formulations of TXA were used as part of the treatment group. Furthermore, all study participants must have undergone surgical intervention for traumatic hip fractures. Studies that did not immediately meet criteria for inclusion were saved for a review by the full investigating team and were included based on consensus. DATA SYNTHESIS: All statistical analyses conducted for this study were performed using R software (R Foundation for Statistical Computing, Vienna, Austria). Network meta-analyses were conducted with a frequentist approach with a random-effects model using the netmeta package version 0.9-6 in R. The frequentist equivalent to surface under the cumulative ranking probabilities, termed " P score," was used to rank different treatments. CONCLUSION: The use of TXA in the surgical management of traumatic hip fractures reduces the number of transfusions and perioperative blood loss, with minimal to no increased incidence of thrombotic events when compared with those in controls. When comparing formulations, no route of administration is clearly superior in reducing perioperative blood loss. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Non-English Speakers and Socioeconomic Minorities are Significantly Less Likely to Complete Patient-Reported Outcome Measures for Total Hip and Knee Arthroplasty: Analysis of 16,119 Cases.

BACKGROUND: The Comprehensive Care for Joint Replacement requires patient-reported outcome measure (PROM) completion for total knee/hip arthroplasty (TKA/THA) patients. A 90% completion rate to avoid penalties was planned for 2023 but has been delayed. Our analysis compares TKA/THA PROM completion and results across demographics. We hypothesized that minority groups would be less likely to complete PROMs. METHODS: A retrospective review was performed from 2018 to 2021 of 16,119 patients who underwent primary elective TKA or THA at a single institution. Pairwise chi-squared tests, t-tests, analysis of variance, and multiple logistic regression analyses were used to compare PROM completion rates and scores across demographics and surgery type (TKA/THA). RESULTS: Comparing patients who had (N = 7,664) and did not have (N = 8,455) documented PROMs, completion rates were significantly lower in patients who were women, Black, Hispanic, less educated, used Medicaid insurance, lived in lower income neighborhoods, spoke non-English languages, required an interpreter, and underwent TKA versus THA. After regression analyses, odds ratios for PROM completion remained significantly lower in non-English speakers, Hispanic and Medicaid patients, lower income groups, and patients undergoing TKA. For the 31.8% of patients who completed both preoperative/postoperative PROMs, women, Black, and non-English speaking patients had significantly lower PROM scores for most measures preoperatively and postoperatively despite similar or better improvements after surgery. CONCLUSION: Patients undergoing TKA and non-English speaking, ethnic, and socioeconomic minorities are less likely to complete PROMs. Strategies to create, validate, and collect PROMs for these populations are needed to avoid exacerbation of healthcare disparities.

Rapid Adoption of Telemedicine Increases Opioid Prescribing in Orthopedic Surgery.

Background: The COVID-19 pandemic led to health care practitioners utilizing new technologies to deliver health care, including telemedicine. The purpose of this study was to examine the effect of rapidly proliferative use of video visits on opioid prescribing to orthopedic patients at a large academic health system that had existing procedure-specific opioid prescribing guidelines. Methods: This IRB-exempt study examined 651 opioid prescriptions written to patients who had video (visual and audio), telephone (audio only), or in-person encounters at our institution from March 1 to June 1, 2020 and compared them with 963 prescriptions written during the same months in 2019. Prescriptions were converted into daily milligram morphine equivalents (MMEs) to facilitate direct comparison. Chi-square testing was used to compare categorical data, whereas analysis of variance and Mann-Whitney tests were used to compare numerical data between groups. Statistical significance was set at <0.05. Results: Six hundred fifty-one of 1,614 prescriptions analyzed (40.3%) occurred during the pandemic. Patients prescribed opioids during video visits were prescribed 53.3 ± 37 MME, significantly higher than in-person (p = 0.002) or audio visits (p < 0.001) before or during the pandemic. Prepandemic, significantly higher MME were prescribed for in-person versus audio only visits (41.6 ± 89 vs. 30.2 ± 28 MME; p = 0.026); during the pandemic, there was no difference between these groups (p = 0.91). Significantly higher MME were prescribed by Nurse Practitioners and Physician Associates versus MD or DO prescribers for both time periods (51.3 ± 109 vs. 27.9 ± 42 MME; p < 0.001; 42.9 ± 70 vs. 28.2 ± 42 MME; p < 0.001). Conclusion: During crisis and with new technology, we should be vigilant about prescribing of opioid analgesics. Despite well-established protocols, patients received significantly higher MME through video than for other encounter types, including in-person encounters. In addition, significantly higher MME were prescribed by mid-level prescribers compared with DOs or MDs. Institutions should ensure these prescribers are involved during creation of opioid prescribing protocols after orthopedic surgery.

The Minimal Clinically Important Difference: A Review of Clinical Significance.

BACKGROUND: The minimal clinically important difference (MCID) is a term synonymous with orthopaedic clinical research over the past decade. The term represents the smallest change in a patient-reported outcome measure that is of genuine clinical value to patients. It has been derived in a myriad of ways in existing orthopaedic literature. PURPOSE: To describe the various modalities for deriving the MCID. STUDY DESIGN: Narrative review; Level of evidence, 4. METHODS: The definitions of common MCID determinations were first identified. These were then evaluated by their clinical and statistical merits and limitations. RESULTS: There are 3 primary ways for determining the MCID: anchor-based analysis, distribution-based analysis, and sensitivity- and specificity-based analysis. Each has unique strengths and weaknesses with respect to its ability to evaluate the patient's clinical status change from baseline to posttreatment. Anchor-based analyses are inherently tied to clinical status yet lack standardization. Distribution-based analyses are the opposite, with strong foundations in statistics, yet they fail to adequately address the clinical status change. Sensitivity and specificity analyses offer a compromise of the other methodologies but still rely on a somewhat arbitrarily defined global transition question. CONCLUSION: This current concepts review demonstrates the need for (1) better standardization in the establishment of MCIDs for orthopaedic patient-reported outcome measures and (2) better study design-namely, until a universally accepted MCID derivation exists, studies attempting to derive the MCID should utilize the anchor-based within-cohort design based on Food and Drug Administration recommendations. Ideally, large studies reporting the MCID as an outcome will also derive the value for their populations. It is important to consider that there may be reasonable replacements for current derivations of the MCID. As such, future research should consider an alternative threshold score with a more universal method of derivation.

Frank B. Bicknell: Pioneer in Pediatric Urology and Founder of the American Urological Association History Forum.

OBJECTIVE: To explore and document the life and urologic contributions of Dr. Frank B. Bicknell. METHODS: We researched the life of Dr. Bicknell via his publications, archived documents from the Didusch Museum and through the description of his life and accomplishments by his colleagues including John K. Lattimer and Frank Hinman Jr. RESULTS: Frank B. Bicknell (1907-1999) attended the University of Michigan (1925-1928) and Universityof Michigan Medical School (1928-1932) prior to his internship and urology residency at the Receiving Hospital, Detroit, Michigan (1932-1936). He served in the Merchant Marine in the 1930s, sailing around the world. He was a major in World War II and served as Professor of Urology at Wayne State University. In 1951 Dr. Bicknell got together a small group of eight urologists interested in pediatric urology during the AUA Annual Meeting. Drs. Campbell, Barber, Johnson, Mertz, Hinman Jr., Spence and Lattimer all met in Dr. Bicknell's Chicago hotel room and would form The Society for Pediatric Urology. At the time, Dr. Bicknell's brother-in-law had just become president of the American Academy of Pediatrics (AAP). Dr. John Lattimer with the help of Dr. Bicknell's brother-in-law was able to get a room at the AAP meeting which he filled with 2500 people, thought to be the largest collection of urologists in one room at the time. The success of the session led the AAP to develop a Section of Urology and impressed upon the AUA the magnitude of interest in pediatric urology. This allowed pediatric urologists to secure an exclusive session on the day before the main AUA meeting which has persisted since that time.Dr. Bicknell founded the History Forum in 1966 and chaired this very popular event during its first decade. The forum now occupies an entire afternoon during the AUA annual meeting, with papers presented on historic urologic topics. The highlight of this assembly is the annual lecture on the history of medicine. In 2000, this oration was renamed the Frank Bicknell History of Urology Oration to honor the founder of the History Forum. CONCLUSION: Dr. Frank Bicknell was an early leader in pediatric urology and urologic history who helped found The Society of Pediatric Urology and the AUA History Forum.

Variability of MRI reporting in proximal hamstring avulsion injuries: Are musculoskeletal radiologists and orthopedic surgeons utilizing similar landmarks?

BACKGROUND: Magnetic resonance imaging (MRI) is an integral component of the treatment algorithm for proximal hamstring avulsion injuries. OBJECTIVE: The purpose of this study was to survey orthopedic surgeons and musculoskeletal radiologists on the reporting and analysis of proximal hamstring avulsions on MRI. METHODS: Two online surveys were developed to evaluate musculoskeletal radiologists' and orthopedic surgeons' perceptions of MRI-reporting for proximal hamstring avulsion injuries. Each survey was designed to provide information on physicians' best practices with respect to four primary questions (1) ischial tuberosity landmark determination (2) difficulties associated with measuring tendon retraction, (3) important ancillary findings, and (4) perceived clinical impact of measured retraction. Descriptive statistics were calculated for all categorical variables, which were reported as frequencies with percentages. Chi-squared test was utilized to compare rates of responses between surgeons and radiologists. Statistically significant differences were analyzed with post-hoc Fisher's exact tests; p < 0.05 considered statistically significant. RESULTS: 218-Musculoskeletal radiologists and 33-orthopedic surgeons responded to their respective surveys. There were statistically significant differences with responses to two of the questions asked in both surveys; (1) in cases of complete hamstring avulsion (avulsion of both the semimembranosus and conjoint tendon), which arrow represents the tendon gap measurement used for planning surgery? p = 0.028; (2) in cases of avulsion of only the conjoint tendon, which arrow represents the tendon gap measurement used for planning surgery? p = 0.013. Post-hoc testing demonstrated that for either partial or complete hamstring avulsions, more surgeons use the conjoint tendon origin to measure tendon retraction than radiologists (p < 0.05 for both). Significantly more radiologists use the semimembranosus origin to measure hamstring retraction for partial or complete hamstring tears (p < 0.05 for both). However, for each of these questions, both radiologists and surgeons most frequently stated that the conjoint tendon landmark should be used for surgical planning. CONCLUSION: Musculoskeletal radiologists and orthopedists frequently utilize the conjoint tendon origin as an anatomic landmark for measuring complete and partial proximal hamstring avulsion injuries; though, orthopedists are more likely to utilize this landmark. Additionally, the broad surface area of the ischial tuberosity may lead to variability in measurement. CLINICAL IMPACT: Standard landmarks at the ischial tuberosity and/or detailed descriptions of tendon retractions would improve communication between radiologists and surgeons for proximal hamstring avulsions.

Return to Work and Sport Following Tibial Tubercle Anteromedialization.

BACKGROUND: Tibial tubercle anteromedialization (AMZ) is a commonly performed procedure for patients with patellofemoral instability or patellofemoral osteochondral disease. While prior studies have demonstrated that this form of osteotomy produces generally good outcomes, the time needed for return to work and return to sport remains unclear. This study aimed to determine the mean length of time before return to work and the rate of return to sport following AMZ. PATIENTS AND METHODS: Patients who had undergone AMZ for either patellofemoral instability or isolated osteochon- dral defect with a minimum follow-up time of 1 year were identified. Patients less than 18 years of age were excluded. Patients were asked to complete a series of patient reported outcomes surveys including specific queries regarding their return to work and return to athletic activity. RESULTS: A total of 109 patients were included in this study. The majority were female (79 patients, 72.3%). The mean age was 30.74 ± 9.90 years at the time of surgery. The mean follow-up duration was 3.40 ± 1.97 years. Of the 109 patients, 104 (95.4%) had returned to work at the time of follow-up. Mean time to return to work was 2.96 ± 3.33 months (range: 0.25 to 24 months). Of the 90 patients who were involved in a sport or physical activity prior to injury, 64 patients (71.1%) had returned to sport at some level at the time of most recent follow-up. Of those who had returned to sport, mean time to return to sport was 9.21 ± 5.46 months (range: 1 to 24 months). CONCLUSIONS: At a minimum follow-up time of 1 year, patients who underwent AMZ were found to have a return to sport rate of 71% with a mean time of 9.21 months to return to athletic activity. Over 95% of AMZ patients had returned to work by 1 year after the procedure. Patients required an average of 3 months to return to work, although those with physically demanding jobs required slightly more time. Data from the current study is useful in setting expectations for patients undergoing tibial tubercle anteromedialization for patellofemoral instability or patellofemoral osteochondral disease.

Age-Associated Functional Outcomes Following Hip Arthroscopy in Females Analysis with 5-Year Follow-Up.

PURPOSE: The purpose of this study was to evaluate out- comes of hip arthroscopy for femoroacetabular impingement (FAI) in female patients at 5-year follow-up. The working hypothesis for this study was that increased age and body mass index (BMI) would be associated with poor outcomes. METHODS: This study included all female patients 14 years and older who underwent primary hip arthroscopy for FAI with 5-year patient-reported outcome scores. Patients were separated into three age-based cohorts (< 30 years old, 30 to 45 years old, and > 45 years old) for subsequent statistical analysis. This analysis included a comparison of patient demographic information, intraoperative pathology, and functional outcome scores (modified Harris Hip Score [mHHS] and nonarthritic hip score [NAHS]). Statistically significant values were utilized in a regression-based analy- sis to determine predictors of 5-year outcomes in female patients. A p-value of < 0.05 was considered to be statisti- cally significant. RESULTS: Overall, 97 patients met the inclusion criteria, and there was no significant difference in patient demo- graphics (other than age and BMI) or in intraoperative pathologies identified. There were no significant difference across the three groups for mHHS and NAHS at baseline (p > 0.05). At baseline, there were no statistically significant differences between groups for NAHS scores, however < 30-year-old and 30- to 45-year-old cohorts had superior final NAHS scores relative to the > 45-year-old cohort (p = 0.005). At 5-year follow-up, the NAHS scores were significantly better for patients under 30 and 30 to 45 year olds relative to patients over 45 (84.2 ± 15.1 vs. 86.7 ± 11.0 vs. 71.9 ± 26.8, respectively; p = 0.005). Overall, 88 patients (91%) met the minimal clinically important differ- ence (MCID), and 60 patients (62%) achieved the patient acceptable symptomatic state (PASS). Baseline mHHS and BMI were shown to be statistically significant predictors of achieving MCID at 5 years in multivariate analysis (p < 0.001). CONCLUSION: The results of this study suggest that women generally have good-to-excellent outcomes following hip ar- throscopy, although females older than 45 may have inferior outcomes relative to younger patients, and BMI and baseline mHHS may be utilized to predict long-term improvement.