Treatment of Shoulder Osteoarthritis With Intact Rotator Cuff and Severe Glenoid Retroversion.

The American Academy of Orthopaedic Surgeons has developed an Appropriate Use Criteria (AUC) for Treatment of Shoulder Osteoarthritis with Intact Rotator Cuff and Severe Glenoid Retroversion. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to determine the appropriateness of various treatments of shoulder osteoarthritis with intact rotator cuff and severe glenoid retroversion. The AUC for Treatment of Shoulder Osteoarthritis with Intact Rotator Cuff and Severe Glenoid Retroversion were derived by identifying scenarios evident during the clinical decision-making process on this topic. These scenarios relied on definitions and general assumptions, mutually agreed upon by the writing panel during scenario development. These definitions and assumptions were necessary to provide consistency in the interpretation of the clinical scenarios among experts rating the scenarios and readers using the final criteria. Writing panel members of this AUC developed patient scenarios using these guiding principles: comprehensive (covers a wide range of patients), mutually exclusive (no overlap between patient scenarios/indications), homogeneous (final ratings should result in equal application in each of the patient scenarios), and manageable (number of total rating items [ie, number of patient scenarios × number of treatments] should be practical for the rating panel). The target number of total rating items was <1,500. This means that not all patient indications and treatments can be assessed using AUC. A total of 240 patient scenarios and five treatments were developed by the writing panel, a group of clinicians who are specialists in this AUC topic. Next, a separate, multidisciplinary, rating panel (made up of specialists and non-specialists) rated the appropriateness of treatment of each patient scenario using a nine-point scale to designate a treatment as "appropriate" (median rating, 7 to 9), "may be appropriate" (median rating, 4 to 6), or "rarely appropriate" (median rating, 1 to 3).

Resident Perceptions of Virtual Reality Versus Dry Lab Simulation for Advanced Shoulder Arthroscopy Resident Training.

INTRODUCTION: Surgical training using simulation can fill gaps in traditional surgical residency learning. We hypothesize that arthroscopy training conducted on a virtual reality simulator will be preferred by orthopaedic surgery residents over a traditional dry lab simulation model. METHODS: 38 orthopaedic surgery residents at a single U.S. residency program were randomized to train for a shoulder arthroscopy procedure using either a virtual reality simulator or a table-top dry lab simulator. Training and learning preferences were then asked of the resident participants. RESULTS: Junior residents were likely to report training preference for the virtual reality simulator compared to senior residents [15/24 (62.5%) v. 8/14 (57.1%); P = .043]. Simulator preference was not influenced by subspecialty interest, prior arthroscopy experience, or simulator experience. Virtual reality simulation was associated with positive attitude towards arthroscopy and high chance of reporting learning gains on general arthroscopic understanding. Senior residents were 4.7 times more likely than juniors to report learning gains via staff discussion pre- and post-operatively. A majority of residents [34/38 (89.5%)] reported, however, wanting more simulation for training surgical skills. CONCLUSION: Simulation is a desired and potentially valuable adjunct to training orthopaedic residents in arthroscopy. Training needs do evolve; and junior arthroscopists may benefit more from virtual reality platforms for general skills. Senior residents preferred dry lab simulation, possibly because it allowed for handling of actual instruments and implants.

The Military Orthopedics Tracking Injuries and Outcomes Network: A Solution for Improving Musculoskeletal Care in the Military Health System.

INTRODUCTION: Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense's Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care. MATERIALS AND METHODS: MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management. RESULTS: This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report. CONCLUSIONS: MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency's Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population.

BACKGROUND: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages. PURPOSE: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis. RESULTS: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0). CONCLUSION: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Shoulder Arthroscopy Simulator Training Improves Surgical Procedure Performance: A Controlled Laboratory Study.

BACKGROUND: Previous simulation studies evaluated either dry lab (DL) or virtual reality (VR) simulation, correlating simulator training with the performance of arthroscopic tasks. However, these studies did not compare simulation training with specific surgical procedures. PURPOSE/HYPOTHESIS: To determine the effectiveness of a shoulder arthroscopy simulator program in improving performance during arthroscopic anterior labral repair. It was hypothesized that both DL and VR simulation methods would improve procedure performance; however, VR simulation would be more effective based on the validated Arthroscopic Surgery Skill Evaluation Tool (ASSET) Global Rating Scale. STUDY DESIGN: Controlled laboratory study. METHODS: Enrolled in the study were 38 orthopaedic residents at a single institution, postgraduate years (PGYs) 1 to 5. Each resident completed a pretest shoulder stabilization procedure on a cadaveric model and was then randomized into 1 of 2 groups: VR or DL simulation. Participants then underwent a 4-week arthroscopy simulation program and completed a posttest. Sports medicine-trained orthopaedic surgeons graded the participants on completeness of the surgical repair at the time of the procedure, and a single, blinded orthopaedic surgeon, using the ASSET Global Rating Scale, graded participants' arthroscopy skills. The procedure step and ASSET grades were compared between simulator groups and between PGYs using paired t tests. RESULTS: There was no significant difference between the groups in pretest performance in either the procedural steps or ASSET scores. Overall procedural step scores improved after combining both types of simulator training (P = .0424) but not in the individual simulation groups. The ASSET scores improved across both DL (P = .0045) and VR (P = .0003), with no significant difference between the groups. CONCLUSION: A 4-week simulation program can improve arthroscopic skills and performance during a specific surgical procedure. This study provides additional evidence regarding the benefits of simulator training in orthopaedic surgery for both novice and experienced arthroscopic surgeons. There was no statistically significant difference between the VR and DL models, which disproved the authors' hypothesis that the VR simulator would be the more effective simulation tool. CLINICAL RELEVANCE: There may be a role for simulator training in the teaching of arthroscopic skills and learning of specific surgical procedures.

Generating the American Shoulder and Elbow Surgeons Score Using Multivariable Predictive Models and Computer Adaptive Testing to Reduce Survey Burden.

BACKGROUND: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. PURPOSE: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. RESULTS: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. CONCLUSION: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

Current Practice Patterns in Anterior Cruciate Ligament Reconstruction Among Fellowship-Trained Military Orthopaedic Surgeons.

PURPOSE: To evaluate current practice patterns in anterior cruciate ligament reconstruction (ACLR) surgery among fellowship-trained military surgeons. METHODS: The MOTION database is a prospectively collected dataset of intraoperative variables across the Military Health System. This database was queried using Current Procedural Terminology code 29888 for ACLR among active-duty service members between October 2016 and December 2019. The intraoperative data pertaining to ACLR involving both isolated primary ACLRs and primary ACLRs combined with meniscal or chondral injuries were extracted with patient age, sex, and rank. RESULTS: Two hundred sixty-six primary ACLRs performed by 21 fellowship-trained orthopaedic surgeons at 9 MTFs were identified. The mean age of patients undergoing ACLR was 27.2 ± 7.7 years. Bone-patellar tendon-bone autograft was the most commonly used graft source (137 of 266 [51.5%] cases.) Meniscal injuries were treated with an isolated debridement in 53 of 156 (34.0%) tears, whereas meniscal repair was performed in 86 of 156 (55.1%) tears. Concomitant chondral pathology was noted in 43 of 266 cases (16.2%) and most commonly addressed with chondroplasty (25 of 49 [51.0%] chondral lesions). CONCLUSIONS: Bone-patellar tendon-bone autograft was the most commonly used graft type in ACLR among fellowship-trained surgeons treating active-duty service members. Concomitant meniscal pathology was encountered at rates comparable with what has been previously reported, and meniscal repair was favored over meniscal debridement in more than 50% cases. LEVEL OF EVIDENCE: Level IV: Therapeutic case series.

Assessment of Disability Related to Femoroacetabular Impingement Syndrome by Use of the Patient-Reported Outcome Measure Information System (PROMIS) and Objective Measures of Physical Performance.

BACKGROUND: The National Institutes of Health (NIH)-sponsored Patient-Reported Outcomes Measurement System (PROMIS) has been described as a valuable tool for characterizing outcomes among patients with specific musculoskeletal conditions. Additionally, previously proposed objective measures of physical performance among patients with nonarthritic hip abnormalities are costly and not practically incorporated into routine clinical practice. PURPOSE: (1) To determine the ability of the PROMIS to differentiate between patients with femoroacetabular impingement (FAI) and asymptomatic controls, (2) to determine the effect of FAI on subjects' completion of timed physical performance measures, and (3) to determine whether associations exist between established patient-reported outcome (PRO) measures and subjects' completion of physical performance measures. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Twenty-two asymptomatic controls (CON group) and 20 patients with FAI completed multiple activities to assess physical ability: self-selected walking velocity (SSWV), timed stair ascent (TSA), four-square step test (FSST), and sit-to-stand five times test (STS5). All subjects also underwent a battery of PRO questionnaires: Visual Analog Scale for Pain (VAS), Modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-33), Hip Disability and Osteoarthritis Outcome Score (HOOS), and PROMIS. Descriptive analyses were performed and comparisons between groups were made by use of paired t tests with Bonferroni-Holm correction. Spearman's rank correlation coefficients were used to determine associations between physical performance measures and PRO. The magnitude of differences between groups for each measured variable was calculated by use of Cohen's d. RESULTS: Significant differences between CON and FAI groups were observed for all hip-specific PRO measures (CON vs FAI for all; HOOS 99.2 vs 42.8, P < .001, iHOT-33 99.0 vs 26.6, P < .001, mHHS 99.6 vs 62.2, P < .001). Similarly, PROMIS scores were significantly different between groups for 8 of 9 tested domains. Patients with FAI demonstrated significant decrements in performance of all tested physical measures compared with asymptomatic controls (CON vs FAI, SSWV: 1.51 vs 1.32 m/s, P = .002; TSA: 3.05 vs 5.92 s, P = .017; FSST: 4.83 vs 8.89 s, P = .006; STS5: CON 5.53 vs FAI 10.75 s, P = .005.) Deficits in activities involving hip flexion-TSA, STS5-were strongly associated ( r < -0.7, P < .001) with increased reports of disability. CONCLUSION: FAI has a negative effect on patient-reported and objectively measured function. Hip-specific and general measures such as PROMIS, FSST, TSA, and STS5 are responsive to FAI-associated debility and may be used to objectively assess surgical or rehabilitative outcomes.

The epidemiology of medial collateral ligament sprains in young athletes.

BACKGROUND: A medial collateral ligament (MCL) knee sprain is a prevalent injury in athletic populations that may result in significant time lost to injury. Remarkably little is known of the epidemiology of this injury. PURPOSE: To define the incidence of MCL tears and to determine the demographic and athletic risk factors. STUDY DESIGN: Descriptive epidemiological study. METHODS: A longitudinal cohort study was performed to examine the epidemiology of isolated MCL sprains at the United States Military Academy (USMA) between 2005 and 2009. Charts and radiographic studies were reviewed by an independent orthopaedic surgeon to identify all new isolated MCL sprains resulting in time lost to sport and activity that occurred within the study period. Incidence rates (IRs) with 95% confidence intervals (CIs) were calculated per 1000 person-years at risk and by sex, sport, and level of competition. The IR per 1000 athlete-exposures (AEs) was also determined. Incidence rate ratios (IRRs) and respective 95% CIs were calculated between male and female students, intercollegiate and intramural athletes, and male and female intercollegiate athletes involved in selected sports. Chi-square and Poisson regression analyses were used to examine the relationship between the variables of interest and the incidence of MCL sprains, with statistical significance set at P < .05. RESULTS: A total of 128 cadets sustained isolated MCL injuries during 17,606 student person-years from 2005 to 2009. This resulted in an IR of approximately 7.3 per 1000 person-years. Of the 128 injuries, 114 were in male athletes (89%) and 14 were in female athletes (11%). Male cadets had a 44% higher IR than did female cadets (7.60 vs 5.36, respectively), although this was not significant (P = .212). Of 5820 at-risk intercollegiate athletes, 59 (53 male, 6 female) sustained an isolated MCL sprain during 528,523 (407,475 male, 121,048 female) AEs for an overall IR of 10.14 per 1000 person-years and 0.11 per 1000 AEs. The IRR of MCL sprains of men compared with women involved in intercollegiate athletics was 2.87 (95% CI, 1.24-8.18) per 1000 person-years and 2.62 (95% CI, 1.13-7.47) per 1000 AEs. Of 21,805 at-risk intramural athletes, with quarterly participation, 16 (all male) sustained isolated MCL injuries during 225,683 AEs for an overall IR of 0.07 per 1000 AEs. The IRs of MCL injuries of intercollegiate and intramural athletes did not differ significantly. In intercollegiate sports, wrestling (0.57), judo (0.36), hockey (0.34), and rugby (men's, 0.22; women's, 0.23) had the highest IRs per 1000 AEs. When examining men's intercollegiate athletics, the IRRs of wrestling (13.41; 95% CI, 1.80-595.27) and hockey (8.12; 95% CI, 0.91-384.16) were significantly higher compared with that of lacrosse. Among women's intercollegiate sports as well as intramural sports, there were no significant differences in IRs. A median of 16 days was lost to injury, with 2407 total days lost for all injuries. Grade 1 MCL injuries lost a median of 13.5 days, while higher grade injuries lost a median of 29 days. CONCLUSION: Medial collateral ligament injuries are relatively common in athletic cohorts. The most injurious sports are contact sports such as wrestling, hockey, judo, and rugby. Male athletes are at a greater risk than female athletes. Intercollegiate athletes are at a greater risk than intramural athletes. The average amount of time lost per injury was 23.2 days, with greater time lost with higher grade sprains than grade 1 sprains.

Rotator Cuff Weakness Is Not a Risk Factor for First-Time Anterior Glenohumeral Instability.

BACKGROUND: Shoulder instability is a common problem in young athletes and can lead to pain and decreased ability to participate in high-level activities. Little is known about the modifiable risk factors for glenohumeral joint instability. HYPOTHESIS: Isometric shoulder strength at baseline would be a modifiable risk factor associated with subsequent first-time anterior instability events. STUDY DESIGN: Cohort study. METHODS: Study participants were freshmen entering the United States Military Academy in June 2006. All participants completed bilateral isometric strength evaluations with a hand-held dynamometer at baseline upon entry into the study. Variables measured included internal and external rotation at 0° (IR0, ER0) and internal and external rotation at 45° of abduction (IR45, ER45). All subjects were followed for subsequent glenohumeral joint instability events until graduation in May 2010. Independent t tests were used to analyze the data. RESULTS: Baseline strength data were available for 1316 shoulders with no prior history of instability, of which 26 went on to have an acute first-time anterior shoulder instability event while the individuals were at the academy. There were no significant differences in mean strength between shoulders that did not go on to develop instability (uninjured; n = 1290) and those that did develop anterior instability (injured; n = 26). The mean strength values in pounds of force for uninjured and injured shoulders, respectively, were as follows: IR0 (49.80 vs 49.29; P = .88), ER0 (35.58 vs 33.66; P = .27), IR45 (47.38 vs 46.93; P = .88), and ER45 (40.08 vs 38.98; P = .59). CONCLUSION: No association was found between isometric shoulder strength measures at baseline and subsequent first-time anterior glenohumeral joint instability within the high-risk athletic population studied in this prospective cohort.

Operation Enduring Freedom: trends in combat casualty care by forward surgical teams deployed to Afghanistan.

This study examined the clinical experience of a U.S. Army Forward Surgical Team (FST) deployed to Afghanistan in 2005 and compared the findings with those of 3 previously deployed FSTs. Medical records of all patients evaluated by the FST were abstracted for analysis. Demographically, the cohort (n = 614) was predominantly male (94%), with a median age of 24, and distributed according to the following: disease (8.6%), nonbattle injury (42%), and battle injury (49%). Combat casualties were mostly Afghan National Army or Police (56%) and U.S. military (21%). Predominant wounding instruments were small arms (34%), improvised explosive devices (33%), and rocket-propelled grenades (15%). Anatomical sites of battle injury were extremities (38%), external soft tissue (35%), and head/neck/torso (28%). Operative procedures for combat injury (n = 227) were primarily orthopedic (45%) or thoracic/abdominal (36%). Combat casualty statistics provide insight to trauma epidemiology, patterns, and trends vital for surgical management. Workload statistics guides the structuring, training, and employment of FSTs.