Establishing Maximal Medical Improvement After Arthroscopic Rotator Cuff Repair.

BACKGROUND: As health care transitions from a pay-for-service to a pay-for-performance infrastructure, the value of orthopaedic care must be defined accurately. Significant efforts have been made in defining quality and cost in arthroplasty; however, there remains a lag in ambulatory orthopaedic care. PURPOSE: Two-year follow-up has been a general requirement for reporting outcomes after rotator cuff repair. However, this time requirement has not been established scientifically and is of increasing importance in the era of value-based health care. Given that arthroscopic rotator cuff repair is a common ambulatory orthopaedic procedure, the purpose of this study was to establish a time frame for maximal medical improvement (the state when improvement has stabilized) after arthroscopic rotator cuff repair. STUDY DESIGN: Systematic review. METHODS: A systematic review of the literature was conducted, identifying studies reporting sequential patient-reported outcomes up to a minimum of 2 years after arthroscopic rotator cuff repair. The primary clinical outcome was patient-reported outcomes at 3-month, 6-month, 1-year, and 2-year follow-up. Secondary clinical outcomes included range of motion, strength, retears, and complications. Clinically significant improvement was determined between various time intervals by use of the minimal clinically important difference. RESULTS: The review included 19 studies including 1370 patients who underwent rotator cuff repair. Clinically significant improvement in patient-reported outcomes was seen up to 1 year after rotator cuff repair, but no clinical significance was noted from 1 year to 2 years. The majority of improvement in strength and range of motion was seen up to 6 months, but no clinically meaningful improvement was seen thereafter. All reported complications and the majority of retears occurred within 6 months after rotator cuff repair. CONCLUSION: After rotator cuff repair, a clinically significant improvement in patient-reported outcomes, range of motion, and strength was seen up to 1 year after surgery, but not beyond this. This information is important not only to establish appropriate patient expectations but also to determine a time frame for outcome collection after surgery to better define value in orthopaedic care.

Publication Rates of Podium Versus Poster Presentations at the Arthroscopy Association of North America Meetings 2008-2012.

PURPOSE: To analyze the publication rate of poster and podium presentations at Arthroscopy Association of North America (AANA) annual meetings from 2008 to 2012. METHODS: An online search using PubMed and Google Scholar for all published manuscripts associated with abstracts presented from 2008 to 2012 AANA annual meetings was performed. Abstracts were classified by presentation type (poster vs podium), and the journal and publication date were recorded for all published abstracts. Descriptive statistics, logistic regression, and Fisher's exact tests were performed, with P < .05 considered significant. RESULTS: A total of 1,508 abstracts were submitted to AANA annual meetings from 2008 to 2012, with 976 abstracts accepted for presentation (65% overall acceptance rate). There were 328 podium (22% acceptance rate) and 648 poster (43% acceptance rate) presentations. Of the 976 accepted abstracts, 479 (49%) were published within 3 years in peer-reviewed journals. The overall publication rates for podium and poster presentations were 59% (n = 193) and 44% (n = 286), respectively. Podium presentations were significantly more likely to be published within 3 years compared with poster presentations (P < .0001; odds ratio 1.8095, confidence interval 1.3826-2.3682). There were no differences in time to publication between podium and poster presentations (1.3 ± 1.2 vs 1.1 ± 1.3 years, P = .0633). Over the 5-year study period, the overall abstract acceptance rate (P < .0001) and the rate of abstracts accepted for poster presentation (P < .0001) increased significantly over time, whereas there was no increase in the rate of abstracts accepted for podium presentation (P = .5638). The most common journals of publication were Arthroscopy (n = 157, 32.7%) followed by American Journal of Sports Medicine (n = 93, 19.4%). CONCLUSIONS: The overall publication rate of abstracts presented at AANA annual meetings is 49%, with podium presentations 1.8 times more likely to be published than poster presentations. The overall abstract acceptance rate and the rate of abstracts accepted for poster presentation increased significantly over time, whereas there was no significant increase in the rate of abstracts accepted for podium presentation. CLINICAL RELEVANCE: The publication rates of abstracts presented at the AANA annual meetings demonstrate the meetings' impact and importance to the advancement of the scientific literature.

Publication rates of podium presentations at the American Shoulder and Elbow Surgeons annual open versus closed meetings 2008 to 2012.

AIM: The purpose of this study was to analyze the publication rate for abstracts presented at podium presentations from the American Shoulder and Elbow Surgeons (ASES) annual open and closed meetings from 2008 to 2012. MATERIALS AND METHODS: Abstracts accepted as podium presentations for the open and closed meetings from 2008 through 2012 were followed. A search was performed using Google Scholar and PubMed for all published manuscripts. This analysis looks at abstracts categorized based on annual meeting (open versus closed) and by meeting year (2008-2012). Data including publication journal, publication date, and level of evidence were recorded. Descriptive statistics, t-tests, and odds ratios were performed with p < 0.05 significance. RESULTS: A total of 365 abstracts were accepted to the open and closed annual meetings from 2008 to 2012, with 49% and 51% presented in open and closed forums. A total of 222 (61%) were published within 3-years in peer-reviewed journals. No difference existed in 3-year publication rate between open and closed podium presentation meetings (112/178, 63% open; 110/187, 59% closed; p = 0.4229); however, presentations at closed meetings were more likely to be published after 3-years compared to open meetings (2/178, 2% open; 15/187, 12% closed; p = 0.002). Most common journal of publication was the Journal of Shoulder and Elbow Surgery (JSES) (50%). CONCLUSIONS: Podium abstracts presented at the open and closed annual meetings have publication rates of 63% and 59% with overall combined publication rates of 61% from 2008 to 2012. The high publication rate and high impact of publications speak to the exemplary educational value of ASES annual meetings.

Growth Abnormalities Following Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient: A Systematic Review.

PURPOSE: To identify all reported cases of growth disturbances after anterior cruciate ligament (ACL) reconstruction in patients with open growth plates and analyze trends with respect to different surgical techniques, graft choices, and methods of fixation. METHODS: A systematic literature review was conducted using the MEDLINE, EMBASE, and SCOPUS databases with the following term: "((anterior cruciate ligament OR ACL) AND ((((immature) OR growth plates) OR physes) OR pediatric))." Only studies that evaluated ACL reconstruction in patients with open growth plates and reported angular malformations or limb length discrepancy were included. Data were extracted, including patient characteristics, surgical technique, and postoperative growth disturbance. RESULTS: Twenty-one studies containing 39 patients with growth abnormalities were included in the review. Mean chronological age was 13 years, and 89% of patients were male. Overall, there were 16 cases of angular malformations and 29 cases of limb length discrepancy. The most common angular malformation was genu valgum (81%, n = 13; mean of 6.5°). The most common surgical technique on the tibia and femur was transphyseal (54%, and 77% respectively), and the most common graft used was hamstring autograft (58%). Among patients with limb length discrepancy, overgrowth was most common (62%, n = 18; mean of 13 mm). Interestingly, we observed that 50% of patients with overgrowth underwent a physeal-sparing technique, whereas 64% of patients with shortening underwent a transphyseal technique. CONCLUSIONS: At present, there are 21 studies reporting 39 patients with growth abnormalities in the current literature, of which 29 cases were of limb length discrepancy and 16 of angular malformation. Of the 29 cases of limb length discrepancy, limb overgrowth accounted for 62% of cases. Perhaps most interestingly, physeal-sparing techniques were performed in 25% of the cases of angular malformation and 47% cases of limb length discrepancy, despite the commonly held belief that this technique mitigates the risks of ACL reconstruction by not violating the growth plate. According to this study, it is clear that growth abnormalities after ACL reconstruction in the skeletally immature patient are underreported, and our current understanding of the etiology of these abnormalities is limited. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Infant Brain Extraction in T1-Weighted MR Images Using BET and Refinement Using LCDG and MGRF Models.

In this paper, we propose a novel framework for the automated extraction of the brain from T1-weighted MR images. The proposed approach is primarily based on the integration of a stochastic model [a two-level Markov-Gibbs random field (MGRF)] that serves to learn the visual appearance of the brain texture, and a geometric model (the brain isosurfaces) that preserves the brain geometry during the extraction process. The proposed framework consists of three main steps: 1) Following bias correction of the brain, a new three-dimensional (3-D) MGRF having a 26-pairwise interaction model is applied to enhance the homogeneity of MR images and preserve the 3-D edges between different brain tissues. 2) The nonbrain tissue found in the MR images is initially removed using the brain extraction tool (BET), and then the brain is parceled to nested isosurfaces using a fast marching level set method. 3) Finally, a classification step is applied in order to accurately remove the remaining parts of the skull without distorting the brain geometry. The classification of each voxel found on the isosurfaces is made based on the first- and second-order visual appearance features. The first-order visual appearance is estimated using a linear combination of discrete Gaussians (LCDG) to model the intensity distribution of the brain signals. The second-order visual appearance is constructed using an MGRF model with analytically estimated parameters. The fusion of the LCDG and MGRF, along with their analytical estimation, allows the approach to be fast and accurate for use in clinical applications. The proposed approach was tested on in vivo data using 300 infant 3-D MR brain scans, which were qualitatively validated by an MR expert. In addition, it was quantitatively validated using 30 datasets based on three metrics: the Dice coefficient, the 95% modified Hausdorff distance, and absolute brain volume difference. Results showed the capability of the proposed approach, outperforming four widely used BETs: BET, BET2, brain surface extractor, and infant brain extraction and analysis toolbox. Experiments conducted also proved that the proposed framework can be generalized to adult brain extraction as well.