Satisfactory Clinical Outcomes and Continuance of Sports After Hip Arthroscopic Labral Repair in Young Competitive Athletes at Minimum 8.5-Year Follow-Up.

PURPOSE: To evaluate long-term patient-reported outcomes and achievement rates of patient acceptable symptomatic state (PASS) in young athletes undergoing hip arthroscopy, and to report long-term sports continuance and reoperation. METHODS: Inclusion criteria consisted of age <24 years at surgery, femoroacetabular impingement undergoing primary hip arthroscopy with labral repair, and participation in sport with intent to return to sport after surgery. The enrollment period was from April 2009 to June 2014. Modified Harris Hip Scores (mHHS), Hip Outcome Score (HOS), HOS Activities of Daily Living (HOS-ADL), and HOS Sport (HOS-Sport) were collected preoperatively, 2 years' postoperatively, and final follow-up. Patients were evaluated for PASS achievement, reoperation, and sports participation. RESULTS: Forty-two hips in 37 patients (11 male, 26 female, age: 17.7 ± 2.1 years, range 13.6-23.0, body mass index 22.8 ± 2.9, range 17.6-33.7) met inclusion criteria and were followed for 10.0 ± 1.3 years (range 8.5-13.0) postoperatively. Mean mHHS, HOS-ADL and HOS-Sports outcome scores at minimum 8.5 years were 82.2 ± 12.9, 89.6 ± 10.9, and 81.8 ± 16.4, respectively, with significant (P < .001) postoperative improvements. Thirty survey respondents (83%) met PASS for mHHS, 27 (75%) for HOS-ADL, and 24 (67%) for HOS-Sports. At minimum 8.5-year follow-up, only 9 of 37 (24%) cited their hip as the reason for stopping sport. Of the remaining patients, 17 of 28 (61%), continued playing their initial sport. There was no difference in patient-reported outcomes between patients who endorsed sports continuance and patients who did not report sports continuance and did not cite their hip as a reason (P ≥ .229). At final follow-up, 4 hips (10%) had undergone subsequent surgical intervention at a mean of 4.8 ± 3.3 years (range 1.0-8.4) postoperatively. CONCLUSIONS: Durable mid-term outcomes and satisfactory PASS achievement rates are observed in young amateur athletes undergoing primary hip arthroscopy. At minimum 8.5-year follow up, approximately 1 in 4 patients discontinue their sports due to hip related reasons. LEVEL OF EVIDENCE: Level IV, case-series.

High incidence of medial meniscus root/radial tears and extrusion in 253 patients with subchondral insufficiency fractures of the knee.

PURPOSE: The demographic and radiological risk factors of subchondral insufficiency fractures of the knee (SIFK) continue to be a subject of debate. The purpose of this study was to associate patient-specific factors with SIFK in a large cohort of patients. METHODS: Inclusion criteria consisted of patients with SIFK as verified on magnetic resonance imaging (MRI). All radiographs and MRIs were reviewed to assess characteristics such as meniscus tear presence and type, subchondral oedema presence and location, location of SIFK, mechanical limb alignment, osteoarthritis as assessed by Kellgren-Lawrence grade and ligamentous injury. A total of 253 patients (253 knees) were included, with 171 being female. The average body mass index (BMI) was 32.1 ± 7.0 kg/m2. RESULTS: SIFK was more common in patients with medial meniscus tears (77.1%, 195/253) rather than tears of the lateral meniscus (14.6%, 37/253) (p < 0.001). Medial meniscus root and radial tears of the posterior horn were present in 71.1% (180/253) of patients. Ninety-one percent (164/180) of medial meniscus posterior root and radial tears had an extrusion ≥3.0 mm. Eighty-one percent (119/147) of patients with SIFK on the medial femoral condyle and 86.8% (105/121) of patients with SIFK on the medial tibial plateau had a medial meniscus tear. Varus knees had a significantly increased rate of SIFK on the medial femoral condyle in comparison to valgus knees (p = 0.016). CONCLUSION: In this large cohort of patients with SIFK, there was a high association with medial meniscus root and radial tears of the posterior horn, meniscus extrusion ≥3.0 mm as well as higher age, female gender and higher BMI. Additionally, there was a particularly strong association of medial compartment SIFK with medial meniscus tears. As SIFK is frequently undiagnosed, identifying patient-specific demographic and radiological risk factors will help achieve a prompt diagnosis. LEVEL OF EVIDENCE: Level IV.

Blood Flow Restriction Therapy for 2 Weeks Prior to Anterior Cruciate Ligament Reconstruction Did Not Impact Quadriceps Strength Compared to Standard Therapy.

PURPOSE: To evaluate the efficacy of a 2-week home-based blood flow restriction (BFR) prehabiliation program on quadriceps strength and patient-reported outcomes prior to anterior cruciate ligament (ACL) reconstruction. METHODS: Patients presenting with an ACL tear were randomized into two groups, BFR and control, at their initial clinic visit. Quadriceps strength was measured using a handheld dynamometer in order to calculate peak force, average force, and time to peak force during seated leg extension at the initial clinic visit and repeated on the day of surgery. All patients were provided education on standardized exercises to be performed 5 days per week for 2 weeks between the initial clinic visit and date of surgery. The BFR group was instructed to perform these exercises with a pneumatic cuff set to 80% of limb occlusion pressure placed over the proximal thigh. Patient-Reported Outcome Measurement System Physical Function (PROMIS-PF), knee range of motion, and quadriceps circumference were gathered at the initial clinic visit and day of surgery, and patients were monitored for adverse effects. RESULTS: A total 45 patients met inclusion criteria and elected to participate. There were 23 patients randomized to the BFR group and 22 patients randomized into the control group. No significant differences were noted between the BFR and control groups in any demographic characteristics (48% vs 64% male [P = .271] and average age 26.5 ± 12.0 vs 27.0 ± 11.0 [P = .879] in BFR and control, respectively). During the initial clinic visit, there were no significant differences in quadriceps circumference, peak quadriceps force generation, time to peak force, average force, pain, and PROMIS scales (P > .05 for all). Following completion of a 2-week home prehabilitation protocol, all patients indeterminant of cohort demonstrated decreased strength loss in the operative leg compared to the nonoperative leg (P < .05 for both) However, there were no significant differences in any strength or outcome measures between the BFR and control groups (P > .05 for all). There were no complications experienced in either group, and both were compliant with the home-based prehabilitation program. CONCLUSIONS: A 2-week standardized prehabilitation protocol preceding ACL reconstruction resulted in a significant improvement in personal quadriceps peak force measurements, both with and without the use of BFR. No difference in quadriceps circumference, strength, or patient reported outcomes were found between the BFR and the control group. The home-based BFR prehabiliation protocol was found to be feasible, accessible, and well tolerated by patients. LEVEL OF EVIDENCE: Level II, randomized controlled trial with small effect size.

Platelet-Rich Plasma and Marrow Venting May Serve as Cost-Effective Augmentation Techniques for Isolated Meniscal Repair: A Decision-Analytical Markov Model-Based Analysis.

PURPOSE: To evaluate the cost-effectiveness of 3 isolated meniscal repair (IMR) treatment strategies: platelet-rich plasma (PRP)-augmented IMR, IMR with a marrow venting procedure (MVP), and IMR without biological augmentation. METHODS: A Markov model was developed to evaluate the baseline case: a young adult patient meeting the indications for IMR. Health utility values, failure rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing IMR at an outpatient surgery center. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). RESULTS: Total costs of IMR with an MVP were $8,250; PRP-augmented IMR, $12,031; and IMR without PRP or an MVP, $13,326. PRP-augmented IMR resulted in an additional 2.16 QALYs, whereas IMR with an MVP produced slightly fewer QALYs, at 2.13. Non-augmented repair produced a modeled gain of 2.02 QALYs. The ICER comparing PRP-augmented IMR versus MVP-augmented IMR was $161,742/QALY, which fell well above the $50,000 willingness-to-pay threshold. CONCLUSIONS: IMR with biological augmentation (MVP or PRP) resulted in a higher number of QALYs and lower costs than non-augmented IMR, suggesting that biological augmentation is cost-effective. Total costs of IMR with an MVP were significantly lower than those of PRP-augmented IMR, whereas the number of additional QALYs produced by PRP-augmented IMR was only slightly higher than that produced by IMR with an MVP. As a result, neither treatment dominated over the other. However, because the ICER of PRP-augmented IMR fell well above the $50,000 willingness-to-pay threshold, IMR with an MVP was determined to be the overall cost-effective treatment strategy in the setting of young adult patients with isolated meniscal tears. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Improves Outcomes and Clinical Benefit Achievement Rates at Short-Term Follow-Up: A Multicenter Analysis.

PURPOSE: To report minimum 2-year follow-up patient-reported outcome scores (PROs) and rates of achieving the minimal clinically important difference (MCID), the patient-acceptable symptomatic state (PASS), and the maximal outcome improvement (MOI) on adolescents following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Second, to determine risk factors for revision surgery. METHODS: Prospectively collected data from two high-volume hip arthroscopy centers were retrospectively reviewed on adolescents (≤19 years old) who underwent primary hip arthroscopy between November 2008 and February 2019. Adolescents with a minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scale (VAS) for pain were included regardless of their growth plate status. Exclusion criteria were Tönnis grade >1, lateral center edge-angle <18°, and previous ipsilateral hip surgery or conditions. Preoperative and postoperative radiographic data, MCID, PASS, MOI, secondary surgeries, and complications were reported. A multivariable survival analysis for risk factors for secondary surgery was conducted. RESULTS: A total of 287 hips (249 patients) were included (74.9% females). The mean values for age, body mass index, and follow-up were 16.3 ± 1.3 years, 22.3 ± 3.5, and 26.6 ± 9.4 months, respectively. Further, 88.9% underwent labral repair, 81.5% femoroplasty, and 85.4% capsular closure. Improvement for all PROs was reported (P < .001) with high patient satisfaction (8.8 ± 1.5). Achievement for the MCID was 71.7%, 83.0%, 68.1%, and 79.5% for the mHHS, NAHS, HOS-SSS, and iHOT-12, respectively. Achievement for the PASS was 68.3% for the mHHS and 73.2% for the NAHS. The MOI for mHHS, NAHS, and VAS was 58.3%, 77.0%, and 59.6%, respectively. Rates of revision hip arthroscopy, cam recurrence, and heterotopic ossification were 5.8%, 1.7%, and 5.5%, respectively. Acetabular retroversion was found to be a risk factor for revision surgery (P = .03). CONCLUSION: The results of this multi-center study demonstrated that adolescents who underwent primary hip arthroscopy for FAIS reported significant improvement in all PROs, with satisfactory achievement rates for the MCID, PASS, MOI, and high patient satisfaction at a minimum 2-year follow-up. LEVEL OF EVIDENCE: IV, retrospective multicenter study.

Machine Learning Model Identifies Preoperative Opioid Use, Male Sex, and Elevated Body Mass Index as Predictive Factors for Prolonged Opioid Consumption Following Arthroscopic Meniscal Surgery.

PURPOSE: To develop a predictive machine learning model to identify prognostic factors for continued opioid prescriptions after arthroscopic meniscus surgery. METHODS: Patients undergoing arthroscopic meniscal surgery, such as meniscus debridement, repair, or revision at a single institution from 2013 to 2017 were retrospectively followed up to 1 year postoperatively. Procedural details were recorded, including concomitant procedures, primary versus revision, and whether a partial debridement or a repair was performed. Intraoperative arthritis severity was measured using the Outerbridge Classification. The number of opioid prescriptions in each month was recorded. Primary analysis used was the multivariate Cox-Regression model. We then created a naïve Bayesian model, a machine learning classifier that uses Bayes' theorem with an assumption of independence between variables. RESULTS: A total of 581 patients were reviewed. Postoperative opioid refills occurred in 98 patients (16.9%). Multivariate logistic modeling was used; independent risk factors for opioid refills included male sex, larger body mass index, and chronic preoperative opioid use, while meniscus resection demonstrated decreased likelihood of refills. Concomitant procedures, revision procedures, and presence of arthritis graded by the Outerbridge classification were not significant predictors of postoperative opioid refills. The naïve Bayesian model for extended postoperative opioid use demonstrated good fit with our cohort with an area under the curve of 0.79, sensitivity of 94.5%, positive predictive value (PPV) of 83%, and a detection rate of 78.2%. The two most important features in the model were preoperative opioid use and male sex. CONCLUSION: After arthroscopic meniscus surgery, preoperative opioid consumption and male sex were the most significant predictors for sustained opioid use beyond 1 month postoperatively. Intraoperative arthritis was not an independent risk factor for continued refills. A machine learning algorithm performed with high accuracy, although with a high false positive rate, to function as a screening tool to identify patients filling additional narcotic prescriptions after surgery. LEVEL OF EVIDENCE: III, retrospective comparative study.

Understanding risk for early dislocation resulting in reoperation within 90 days of reverse total shoulder arthroplasty: extreme rare event detection through cost-sensitive machine learning.

BACKGROUND: Reliable prediction of postoperative dislocation after reverse total shoulder arthroplasty (RSA) would inform patient counseling as well as surgical and postoperative decision making. Understanding interactions between multiple risk factors is important to identify those patients most at risk of this rare but costly complication. To better understand these interactions, a game theory-based approach was undertaken to develop machine learning models capable of predicting dislocation-related 90-day readmission following RSA. MATERIAL & METHODS: A retrospective review of the Nationwide Readmissions Database was performed to identify patients who underwent RSA between 2016 and 2018 with a subsequent readmission for prosthetic dislocation. Of the 74,697 index procedures included in the data set, 740 (1%) experienced a dislocation resulting in hospital readmission within 90 days. Five machine learning algorithms were evaluated for their ability to predict dislocation leading to hospital readmission within 90 days of RSA. Shapley additive explanation (SHAP) values were calculated for the top-performing models to quantify the importance of features and understand variable interaction effects, with hierarchical clustering used to identify cohorts of patients with similar risk factor combinations. RESULTS: Of the 5 models evaluated, the extreme gradient boosting algorithm was the most reliable in predicting dislocation (C statistic = 0.71, F2 score = 0.07, recall = 0.84, Brier score = 0.21). SHAP value analysis revealed multifactorial explanations for dislocation risk, with presence of a preoperative humerus fracture; disposition involving discharge or transfer to a skilled nursing facility, intermediate care facility, or other nonroutine facility; and Medicaid as the expected primary payer resulting in strong, positive, and unidirectional effects on increasing dislocation risk. In contrast, factors such as comorbidity burden, index procedure complexity and duration, age, sex, and presence or absence of preoperative glenohumeral osteoarthritis displayed bidirectional influences on risk, indicating potential protective effects for these variables and opportunities for risk mitigation. Hierarchical clustering using SHAP values identified patients with similar risk factor combinations. CONCLUSION: Machine learning can reliably predict patients at risk for postoperative dislocation resulting in hospital readmission within 90 days of RSA. Although individual risk for dislocation varies significantly based on unique combinations of patient characteristics, SHAP analysis revealed a particularly at-risk cohort consisting of young, male patients with high comorbidity burdens who are indicated for RSA after a humerus fracture. These patients may require additional modifications in postoperative activity, physical therapy, and counseling on risk-reducing measures to prevent early dislocation after RSA.

Availability of Consumer Prices for Arthroscopic Meniscus Surgery.

The purpose is to examine the availability of consumer pricing information for arthroscopic meniscal surgery in the United States. Secondary objectives were comparing the price of meniscal repair to meniscectomy and regional pricing differences. Orthopaedic sports medicine clinics were sorted by state and randomly selected from American Orthopaedic Society for Sports Medicine's online directory. Following standardized script, each clinic was called a maximum of three times to obtain pricing information for meniscal surgery. A total of 1,008 distinct orthopaedic sport medicine practices were contacted. Six (6%) clinics were able to provide complete bundle pricing, and 183 (18.2%) clinics were able to provide physician-only fees for either meniscectomy or meniscal repair. Physician-only fees and bundle pricing were significantly less for meniscal repairs as compared to meniscectomies. There were no geographic regional differences in pricing for physician-only fees. There is a paucity of information regarding price transparency for arthroscopic meniscal surgery. (Journal of Surgical Orthopaedic Advances 32(2):083-087, 2023).

Multimodal Nonopioid Pain Protocol Provides Better or Equivalent Pain Control Compared to Opioid Analgesia Following Arthroscopic Rotator Cuff Surgery: A Prospective Randomized Controlled Trial.

PURPOSE: To evaluate the efficacy of a multimodal nonopioid analgesic protocol in controlling postoperative pain compared to opioids following a primary arthroscopic rotator cuff repair. METHODS: Seventy consecutive patients undergoing a primary rotator cuff repair were assessed for eligibility. An observer-blinded prospective randomized controlled trial was designed in accordance with the Consolidated Standards of Reporting Trials 2010 (CONSORT) statement. The two arms of the study included a multimodal nonopioid pain regimen for the experimental group, and a standard of care narcotics for the control group. The primary outcome was visual analog scale (VAS) pain scores for the first 10 postoperative days. Secondary outcomes included PROMIS-PI (Patient-Reported Outcomes Measurement Information System-Pain Interference) scale, patient satisfaction, and adverse drug events. RESULTS: Thirty patients declined to participate or were excluded, and 40 patients were included in the final analysis. A total of 23 patients were in the traditional group, and 17 patients were in the nonopioid group. Control patients on opioid pain management reported a significantly higher VAS pain score on postoperative day 1 (opioid: 5.7 ± 2, nonopioid: 3.7 ± 2.2; P = .011) and postoperative day 4 (opioid: 4.4 ± 2.7, nonopioid: 2.4 ± 2.2; P = .023). No significant difference was seen on any other postoperative day. When mixed measured models were used to control for confounding factors, the nonopioid group demonstrated significantly lower VAS and PROMIS-PI scores (P < .01) at every time point. Patients in the traditional analgesia group reported significantly more days with constipation (P = .003) and days with upset stomach (P = .020) than those in the nonopioid group. CONCUSSION: The present study found that a multimodal nonopioid pain protocol provided equivalent or better pain control compared to traditional opioid analgesics in patients undergoing primary arthroscopic rotator cuff repair. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort. All patients reported satisfaction with their pain management. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

The Nonoperative Instability Severity Index Score: Is It Predictive in a Larger Shoulder Instability Population at Long-Term Follow-Up?

PURPOSE: To evaluate the effect of the Nonoperative Instability Severity Index Score (NISIS) criteria on an established US-geographic population-based cohort of patients with anterior shoulder instability. METHODS: An established geographically based medical record system was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient demographics and instability characteristics. Patient-specific risk factors were individually incorporated into the 10-point NISIS criteria: age (>15 years), bone loss, type of instability (dislocation vs subluxation), type of sport (collision vs noncollision), male sex, and dominant arm involvement. High risk was considered a score of ≥7 points and low risk as <7 points. Failure was defined as either progression to surgery or recurrent instability diagnosed by a consulting physician at any point after initial consultation. RESULTS: The study population consisted of 405 patients with a mean follow-up time of 9.6 ± 5.9 years. Failure was defined as recurrent instability or progression to surgery, and the overall failure rate was 52.8% (214/405). The rate of recurrent instability after initial consultation was 34.6% (140/405), and the rate of conversion to surgery was 37.8% (153/405). A total of 264 (65.2%) patients were considered low risk (NISIS < 7), and 141 (34.8%) patients were considered high risk (NISIS ≥ 7). Patients in the high-risk group were more likely to fail nonoperative management than those in the low-risk group (60.3% vs 48.9%; P = .028). CONCLUSIONS: The NISIS has been proposed as a potentially useful tool in clinical decision-making regarding the appropriate use of nonoperative treatment in scholastic athletes. When applied to an established US-geographic population-based cohort consisting of competitive and recreational athletes under the age of 40 with longer-term follow-up, the NISIS high-risk cutoff was able to predict overall failure with 60.3% accuracy. LEVEL OF EVIDENCE: III, retrospective observation trial.

Multimodal Nonopioid Pain Protocol Provides Equivalent Pain Versus Opioid Control Following Meniscus Surgery: A Prospective Randomized Controlled Trial.

PURPOSE: To assess the effectiveness of a nonopioid pain regimen in controlling postoperative pain as compared with a traditional opioid pain control following primary meniscectomy or meniscal repair. METHODS: Ninety-nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the Consolidated Standards of Reporting Trials 2010 statement. The 2 arms of the study included a multimodal nonopioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for the first 10 days postoperatively. Secondary outcomes included patient-reported outcomes, complications, and patient satisfaction. Randomization was achieved using a random-number generator. Patients were not blinded. Data collection was done by a blinded observer. RESULTS: Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen and 31 randomized to the nonopioid regimen. Patients receiving the nonopioid regimen demonstrated noninferior visual analog scale scores compared with patients who received opioid pain medication (P > .05). No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, P = .724) or postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, P = .064) Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form scores. No difference was found in recorded side effects between both groups at any given time point: constipation, nausea, diarrhea, upset stomach, and drowsiness (P > .05). CONCLUSIONS: This study found that a multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

Career Longevity and Performance After Shoulder Instability in National Football League Athletes.

PURPOSE: To investigate the career longevity, game utilization, and performance of National Football League (NFL) athletes after glenohumeral instability events treated operatively versus nonoperatively. METHODS: Using public resources, we identified NFL players who sustained a shoulder instability event from September 2000 to February 2019. Players with prior shoulder instability, without NFL experience before injury, or who did not return to play (RTP) after injury were excluded. Demographic information, utilization (games and seasons), and season approximate value (SAV) statistics were recorded 1 year prior to injury and 3 years after RTP. Statistical analysis compared utilization and the SAV after RTP for athletes managed operatively versus nonoperatively. RESULTS: We identified 97 NFL players who sustained their first instability event while playing in the NFL, 91 of whom returned to play (93.8%). Quarterbacks were significantly more likely to undergo immediate surgical management compared with players in other positions (P = .023). The final analysis included 58 players managed operatively and 33 managed nonoperatively by the end of the index season. Players treated operatively played in significantly more seasons after RTP during their remaining careers (4.1 ± 2.7 seasons vs 2.8 ± 2.5 seasons, P = .015). There were no differences in games played or started, offensive or defensive snap count percentage, or performance (SAV) before and after injury when compared between cohorts (P > .05). After surgical stabilization, time to RTP (36.62 ± 10.32 weeks vs 5.43 ± 12.33 weeks, P < .05) and time interval before recurrent instability (105.7 ± 100.1 weeks vs 24.7 ± 40.6 weeks, P < .001) were significantly longer than with nonoperative treatment. Additionally, the operative cohort experienced less recurrent instability (27% vs 50%, P = .035). CONCLUSIONS: Athletes who RTP in the NFL after a shoulder instability injury do so with a similar workload and performance irrespective of surgical or nonsurgical management. Whereas nonoperative treatment is associated with faster RTP, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Preoperative Patient-Centric Predictors of Postoperative Outcomes in Patients Undergoing Arthroscopic Meniscectomy.

PURPOSE: To determine the minimal clinically important difference (MCID) using Patient-Reported Outcome Measurement Information System (PROMIS) computer-adaptive testing assessments in patients undergoing arthroscopic partial meniscectomy. The secondary purpose was to identify which preoperative patient factors are associated with MCID achievement. METHODS: Three PROMIS computer-adaptive testing assessments (Physical Function [PF], Pain Interference [PI], and Depression [D]) were administered to all patients presenting to 1 of 2 board-certified, sports medicine orthopaedic surgeons. Patients with Current Procedural Terminology codes of 29880 or 29881 were chart reviewed for a host clinical and demographic factors. PROMIS scores were assessed for improvement and patient characteristics were assessed for influence on any improvement. MCID was calculated according to the distribution methodology and receiver operating characteristics were used to assess preoperative scores predictive ability. RESULTS: In total, 166 patients met inclusion criteria (58 exclusions). Postoperative PROMIS-PF (45.6), PROMIS-PI (54.6), and PROMIS-D (44.1) significantly improved at least 3 months after surgery when compared with baseline (P = .002). MCID values for PROMIS-PF, PROMIS-PI, and PROMIS-D were 3.5, 3.3, and 4.4, respectively. Individuals with PROMIS-PF scores below 34.9 yielded an 82% probability of achieving MCID, while PROMIS-PI scores above 67.5 yielded an 86% probability of achieving MCID and a cutoff of 58.9 for PROMIS-D yielded a 60% probability of achieving MCID, with 90% specificity. CONCLUSIONS: PROMIS scores, obtained preoperatively, were shown to be valid predictors of postoperative clinical improvement in patients undergoing meniscectomy. Our findings suggest that patients with physical function scores of 34.9 or less have an increased probability of reaching a minimal clinically important difference. Similarly, patients with pain interference scores of 67.5 and above have increased probability of reaching MCID for pain interference. These cutoffs may be used by physicians to aid in the counseling of patients considering arthroscopic meniscectomy. LEVEL OF EVIDENCE: IV, Case Series.

Elbow Torque Is Reduced in Asymptomatic College Pitchers With Elbow Laxity: A Dynamic Ultrasound Study.

PURPOSE: To determine the relation between medial elbow torque, as measured by wearable sensor technology, and adaptations of the medial elbow structures on dynamic ultrasound imaging in asymptomatic collegiate pitchers. METHODS: Thirty-four pitchers from National Collegiate Athletic Association Division II universities were eligible for preseason testing. The exclusion criteria included age younger than 18 years, history of surgery, non-pitcher, or current restrictions. Pitchers were fitted with a wearable sensor sleeve that recorded elbow torque, arm slot, arm speed, and arm rotation. Pitchers threw 5 fastballs in a standardized manner off the mound at game-speed effort. They also underwent dynamic ultrasound imaging of the elbow by a musculoskeletal sonographer, with standardized valgus loading. Images were deidentified, and measurements of the ulnar collateral ligament (UCL) and ulnohumeral joint space (UHJS), to assess elbow laxity, were performed by a musculoskeletal radiologist. RESULTS: The final analysis included 28 pitchers with an average age of 20.1 years (standard deviation, 1.3 years; range, 18-23 years) and playing experience of 15.3 years (standard deviation, 1.8 years; range, 11-19 years). The dominant UCL thickness (P < .001), loaded UHJS (P = .039), and delta UHJS (P < .001) were significantly greater than the nondominant measurements. An inverse correlation was found between loaded UHJS and medial elbow torque (r = -0.4, P < .001). Additionally, every 1-mm increase in UHJS significantly reduced medial elbow torque by 2.27 Nm (P = .032) and arm slot by 8.8° (P = .019) and increased arm rotation by 5.3° (P = .043). Pitchers with a loaded UHJS of 4.4 mm or greater and delta UHJS of 1.25 mm or greater had significantly reduced medial elbow torque (P < .001). Pitchers with a UCL thickness of 1.65 mm or greater had significantly increased medial elbow torque (47.4 Nm vs 44.8 Nm, P = .006). CONCLUSIONS: Pitchers with increased dynamic elbow laxity were found to experience reduced medial elbow torque while pitching. Additionally, pitchers with greater UCL thickness on ultrasound were found to experience increased medial elbow torque while pitching. This study's findings suggest a relation between anatomic adaptations found on ultrasound of the pitching elbow and medial elbow torque. LEVEL OF EVIDENCE: Level II, prospective cohort study.

The Patient Acceptable Symptomatic State in Primary Anterior Cruciate Ligament Reconstruction: Predictors of Achievement.

PURPOSE: To identify thresholds for patient acceptable symptomatic state (PASS) achievement in a cohort of primary anterior cruciate ligament reconstruction (ACLR) recipients, and to identify factors predictive of PASS achievement. METHODS: A prospective clinical registry was queried for primary ACLR patients from January 2014 to April 2017 with serial patient-reported outcome measure (PROM) completion at 6, 12, and 24 months. Exclusion criteria included significant concomitant procedures. Knee-based PROMs included the International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores. PASS threshold values were calculated using receiver operating characteristic (ROC) curves with area under the curve (AUC) analysis. A stepwise multivariate regression identified preoperative and operative predictors of PASS achievement. RESULTS: A total of 144 primary ACLR patients (30.86 ± 12.78 years, body mass index 25.51 ± 4.64, 41.0% male) were included in the analysis. PASS threshold values were established using ROC curve analysis, all of which exceeded 0.7 on AUC analysis (0.742 to 0.911). Factors impacting odds of PASS achievement in the ACLR cohort included preoperative exercises (odds ratio [OR] 2.95 to 4.74, P = .003 to .038), worker's compensation status (OR 0.25 to 0.28, P = .014 to .033), preoperative scores (OR 1.03 to 1.07, P = .005 to <.001), iliotibial band tenodesis (OR 11.08, P = .010), and anteromedial approach (OR 18.03 to 37.05, P < .001). CONCLUSION: Factors predictive of PASS achievement in recipients of primary ACLR include functional status (e.g., preoperative exercise, preoperative KOOS Sport/Recreation score), worker's compensation status, technique (e.g., anteromedial) and preoperative PROMs. The results of our study are important in better informing shared decision-making models and improving evidence-based guidelines to optimize patient outcomes.

Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials.

PURPOSE: To determine which interventions optimize clinical outcomes in adhesive capsulitis by performing a network meta-analysis of randomized controlled trials. METHODS: A systematic review was conducted of all clinical trials on adhesive capsulitis published since 2008. Patient cohorts were grouped into treatment categories; data collected included range of motion (ROM) and patient-reported outcome measures (PROMs). Interventions were compared across groups by means of arm-based Bayesian network meta-analysis in a random-effects model. RESULTS: Sixty-six studies comprising 4042 shoulders (57.6% female patients, age 54.8 ± 3.2 years [mean ± standard deviation]) were included. The most commonly studied interventions were physical therapy (PT) or shoulder injections. Network meta-analysis demonstrated that arthroscopic surgical capsular release was the most effective treatment in increasing ROM. This effect was apparent in forward flexion (effect difference [ED] versus placebo, 44°, 95% confidence interval [CI] 31° to 58°), abduction (ED 58°, 45° to 71°), internal rotation (ED 34°, 24° to 44°), and external rotation (ED 59°, 37° to 80°). Interventions most effective for pain relief included PT supplemented with either medical therapy (ED -4.50, -9.80 to 2.80) or ultrasound therapy (ED -5.10, -5.10 to -1.40). Interventions most effective for improvement of functional status included PT, manipulation under anesthesia (MUA), intra-articular or subacromial steroid injection, surgical capsular release, and supplementation of PT with alternative therapy. CONCLUSIONS: No one treatment emerged superior in regard to ROM, pain symptoms, and functional status. Surgery (after failure of conservative treatment) ranked highest across all ROM domains. Treatments that ranked highest for treatment of pain included PT supplemented with either medical therapy or ultrasound. Finally, treatments that ranked highest for improvements in functional status included MUA, PT with medical therapy, surgical intervention, PT with ultrasound, PT with injection, and injection alone. LEVEL OF EVIDENCE: II, systematic review and network meta-analysis of level I and II studies.

Multimodal nonopioid pain protocol provides equivalent pain control versus opioids following arthroscopic shoulder labral surgery: a prospective randomized controlled trial.

BACKGROUND: This study aimed to compare postoperative pain and patient satisfaction in patients undergoing primary arthroscopic labral surgery managed with either a nonopioid alternative pain regimen or a traditional opioid pain regimen. METHODS: Sixty consecutive patients undergoing primary arthroscopic shoulder labral surgery were assessed for participation. In accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement, a prospective randomized controlled trial was performed. The 2 arms of the study were a multimodal nonopioid analgesic protocol as the experimental group and a standard opioid regimen as the control group. The primary outcome was postoperative pain scores (on a visual analog scale [VAS]) for the first 10 days postoperatively. Secondary outcomes included patient satisfaction, patient-reported outcomes, and complications. Randomization was performed with a random number generator, and all data were collected by blinded observers. Patients were not blinded. RESULTS: Twelve patients did not meet the inclusion criteria or declined to participate. Thus, 48 patients were included in the final analysis: 24 in the nonopioid group and 24 in the opioid group. There was no significant difference in VAS or PROMIS (Patient-Reported Outcomes Measurement Information System) scores between patients in the 2 cohorts on any postoperative day (P > .05). When we controlled for confounding factors with repeated-measures mixed models, the nonopioid cohort reported significantly lower VAS and PROMIS (Patient-Reported Outcomes Measurement Information System) Pain Interference scores (P < .01) at all time points. No difference was found in reported adverse events (constipation, diarrhea, drowsiness, nausea, and upset stomach) between cohorts at any time point (P > .05). CONCLUSION: This study found that a multimodal nonopioid pain regimen provided, at the minimum, equivalent pain control, an equivalent adverse reaction profile, and equivalent patient satisfaction when compared with a standard opioid-based regimen following arthroscopic shoulder labral surgery.

The relationship between shoulder range of motion and elbow stress in college pitchers.

HYPOTHESIS: College pitchers with increased external rotation gain (ERG) produce increased medial elbow torque (elbow stress) whereas those with reduced total rotational range of motion (ROM) have reduced medial elbow torque during pitching. METHODS: Pitchers were recruited from 3 college baseball teams. Players with prior injury or on pitching restrictions because of pain were excluded. Players were evaluated within 2 weeks before their first game of the season. Pitchers completed an intake survey, and shoulder and arm measurements were taken. Pitchers were fitted with a baseball sleeve that included a sensor at the medial elbow. The sensor calculated elbow torque, arm speed, arm slot, and shoulder rotation for each pitch, while a radar gun measured peak ball velocity. After adequate warm-up, pitchers threw 5 fastballs in a standardized manner off the mound at game-speed effort. The primary outcome evaluated the relationship between shoulder ROM and medial elbow torque. Additional outcomes evaluated pitcher characteristics and demographic characteristics in the context of shoulder ROM. RESULTS: Twenty-eight pitchers were included in the preseason analysis. The average age and playing experience were 20.1 years (standard deviation [SD], 1.3 years) and 15.3 years (SD, 1.8 years), respectively, with 2.5 years (SD, 1.2 years) playing at collegiate level. The dominant shoulder showed decreased internal rotation and increased external rotation (ER) relative to the nondominant side (P < .001). The average glenohumeral internal rotation deficit and ERG were 11.3° (SD, 9.87°) and 5.71° (SD, 8.8°), respectively. ERG ≥ 5° was a significant predictor of elbow stress during pitching (47.4 Nm [SD, 0.7 Nm] vs. 45.1 Nm [SD, 0.6 Nm], P = .014). Univariate associations showed that each additional degree of ER resulted in increased elbow torque (ß estimate, 0.35 ± 0.06 Nm; P = .003). Conversely, decreased medial elbow torque was found in pitchers with reduced shoulder ROM (glenohumeral internal rotation deficit ≥ 20°: 43.5 Nm [SD, 1.1 Nm] vs. 46.6 Nm [SD, 0.5 Nm], P = .011; loss of total rotational ROM ≥ 5°: 43.6 Nm [SD, 1.1 Nm] vs. 46.6 Nm [SD, 0.5 Nm], P = .013) and in those with greater arm length (P < .05). CONCLUSIONS: College pitchers with increased ER produce greater medial elbow torque during the pitching movement. Each degree of increased ER was found to correlate with increased elbow torque and ball velocity. On the contrary, arm length and reduced shoulder ROM were associated with reduced medial elbow torque. This study suggests that increased ER in pitchers is associated with greater elbow stress during pitching.

Patient-Reported Outcomes Measurement Information System Physical Function Has a Lower Effect Size and is Less Responsive Than Legacy Hip Specific Patient Reported Outcome Measures Following Arthroscopic Hip Surgery.

PURPOSE: To compare the use and responsiveness of Patient Reported Outcomes Measurement Information System (PROMIS) to legacy patient-reported outcome measures (PROMs) in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at 6-month follow-up. METHODS: Data from patients who underwent primary hip arthroscopy with routine capsular closure between August 2018 and January 2019 for the treatment of FAIS were analyzed. Preoperative outcomes, 6-month postoperative outcomes, and demographics were recorded. Primary outcome measures included PROMIS Physical Function (PROMIS-PF), PROMIS Pain Interference (PROMIS-PI), and PROMIS Depression. The legacy PROMs included Hip Outcome Score Activities of Daily Living (HOS-ADL), Hip Outcome Score Sport Subscale (HOS-SS), and the international hip outcome tool 12 questions (iHOT-12). Floor and ceiling effects along with the responsiveness and Cohen's d effect size of each PROM tool were calculated. RESULTS: Ninety-six patients with an average age and body mass index of 32.4 ± 11.9 years and 25.9 ± 6.1 kg/m2, respectively, were included in the final analysis. All outcomes were significantly higher at 6 months compared with the preoperative level (P < .001) except for PROMIS Depression (P = .873). PROMIS-PF demonstrated excellent correlation with HOS-SS (r = 0.81; P < .001), very good correlation with HOS-ADL (r = 0.73; P < .001), and good correlation with iHOT-12 (r = 0.68; P < .001). No floor was observed for any measure. The effect size was large for all outcomes, except PROMIS Depression (d = 0.04), but largest for iHOT12 (d = 1.87) followed by HOS-ADL (d = 1.29). The iHOT-12 was more responsive than PROMIS-PI (relative efficiency [RE] = 3.95), PROMIS-PF (RE = 4.13), HOS-ADL (RE = 2.26), and HOS-SS (RE = 3.84). HOS-SS was similarly responsive to PROMIS-PI (RE=1.03) and PROMIS-PF (RE=1.08). However, PROMIS-PF was overall the least responsive. CONCLUSIONS: In patients at 6 months postoperatively from hip arthroscopy for FAIS, iHOT-12 was the most responsive and had the largest effect size. In contrast, PROMIS-PF had a lower effect size compared with legacy hip-specific PROMs. Additionally, PROMIS-PF did not correlate as well with iHOT-12 compared with HOS-SS. LEVEL OF EVIDENCE: Level IV, case series.

A Multimodal Protocol to Diminish Pain Following Common Orthopedic Sports Procedures: Can We Eliminate Postoperative Opioids?

PURPOSE: To determine whether postsurgical pain, measured by the visual analog scale (VAS), following common orthopaedic sports procedures could be managed effectively with a nonopioid multimodal analgesic protocol. METHODS: This prospective study evaluated a custom multimodal nonopioid pain protocol in patients undergoing common orthopaedic sports procedures by a single fellowship-trained orthopaedic sports surgeon from May 2018 to December 2018. Procedures included anterior cruciate ligament reconstruction, rotator cuff repair, arthroscopic partial meniscectomy, and labrum repair. The nonopioid pain protocol consisted of preoperative analgesics, intraoperative local infiltration analgesia, and a postoperative pain regimen. Patient pain was immediately reported after surgery and 1 week postoperatively using the VAS, whereas rescue opioids (oxycodone 5 mg) used were recorded using a prescription opioid journal. Statistical analysis of patient VAS scores, demographic correlations, and comparison between opioid rescue users versus nonusers was performed. RESULTS: A total of 141 patients were included. One week following surgery, patients reported a mean VAS level of 3.2 ± 2.3 and required on average 2.6 ± 3.6 breakthrough oxycodone pills (8.6 ± 12.0 morphine equivalents). Forty-five percent of patients did not require any breakthrough prescription opioids and reported satisfaction with pain management. Patients who required opioids were more likely to have a history of anxiety/depression (44.2% vs 23.8%, P = .012) and reported greater pain scores as compared with nonusers (3.94 ± 2.5 vs 2.41 ± 1.75, P = .016). The most common side effect of the pain protocol was feeling drowsy (23.5%). All patients were satisfied with their pain management postoperatively. CONCLUSIONS: A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures. Patients were found to have low levels of pain, require minimal rescue opioids, and had no severe side effects related to the protocol. These results suggest a nonopioid alternative to pain management following common orthopedic sports procedures. LEVEL OF EVIDENCE: Level IV, prospective case series.