Very Few ACGME-accredited Orthopaedic Surgery Residency Programs Have Web-accessible Leave Policies Dedicated to Parental Leave for Residents, Despite ACGME Requirements.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires that all graduate medical education (GME) programs provide at least 6 paid weeks off for medical, parental, and caregiver leave to residents. However, it is unclear whether all orthopaedic residency programs have adapted to making specific parental leave policies web-accessible since the ACGME's mandate in 2022. This gap in policy knowledge leaves both prospective and current residents in the dark when it comes to choosing residency programs, and knowing what leave benefits they are entitled to when having children during training via birth, surrogacy, adoption, or legal guardianship. QUESTIONS/PURPOSES: (1) What percentage of ACGME-accredited orthopaedic surgery residency programs provide accessible parental leave policies on their program's website, their GME website, and through direct contact with their program's administration? (2) What percentage of programs offer specific parental leave policies, generic leave policies, or defer to the Family and Medical Leave Act (FMLA)? METHODS: As indicated in the American Medical Association's 2022 Freida Specialty Guide, 207 ACGME-accredited orthopaedic residency programs were listed. After further evaluation using previous literature's exclusion criteria, 37 programs were excluded based on osteopathic graduate rates. In all, 170 ACGME-accredited allopathic orthopaedic surgery residency programs were identified and included in this study. Three independent reviewers assessed each program website for the presence of an accessible parental leave policy. Each reviewer accessed the program's public webpage initially, and if no parental leave policy was available, they searched the institution's GME webpage. If no policy was found online, the program administrator was contacted directly via email and phone. Available leave policies were further classified into five categories by reviewers: parental leave, generic leave, deferred to FMLA, combination of parental and FMLA, and combination of parental and generic leave. RESULTS: Our results demonstrated that 6% (10 of 170) of orthopaedic residency programs had policy information available on their program's main orthopaedic web page. Fifty nine-percent (101 of 170) of orthopaedic residency programs had a clearly stated policy on their institution's GME website. The remaining 35% (59 of 170) had no information on their public website and required direct communication with program administration to obtain policy information. After directly contacting program administration, 12% (21 of 170) of programs responded to researchers request with a PDF explicitly outlining their policy. Twenty-two percent (38 of 170) of programs did not have an accessible policy available. Of the programs that had available policies, a total of 53% (70 of 132) of programs were categorized as offering explicit parental leave policies, 9% (12 of 132) were categorized as offering general leave policies, and 27% (36 of 132) deferred to FMLA. Seven percent (9 of 132) offered combined parental leave policies with FMLA, and 4% (5 of 132) offered combined general leave policies with FMLA. CONCLUSION: Although most ACGME-accredited allopathic orthopaedic surgery residency programs met the ACGME requirement of written parental leave policies in 2023, a small minority of programs have clear, accessible parental leave policies provided on their webpage. CLINICAL RELEVANCE: Parental leave policies should be easily accessible to prospective and current trainees and should clearly state compensation and length of leave. Ensuring orthopaedic surgery residency programs provide accessible and transparent parental leave policies is important for maintaining diversity in prospective applicants and supporting the work-life balance of current residents.

Preoperative Low Resilience Is Associated With Female Patients, Whereas High Resilience Is Associated With Improved Mental Health Scores During Anterior Cruciate Ligament Reconstruction.

PURPOSE: To evaluate the relationship between resilience, as measured by the Brief Resilience Scale (BRS), and patient-reported outcome measures (PROMs) after primary anterior cruciate ligament reconstruction (ACLR). METHODS: A cohort of 72 patients undergoing primary ACLR were followed for a minimum of 2 years. Preoperative BRS scores were collected, and patients were categorized into low resilience (LR), normal resilience (NR), and high resilience (HR). PROMs including the visual analog scale (VAS), measuring overall pain level from 0 to 10, the Veterans Rand (VR) 12-Item Health Survey Physical Component and Mental Components, Knee Injury and Osteoarthritis Outcomes Score, and Marx Activity Rating Scale were collected preoperatively as well as up to 2 years postoperatively and compared among the various resilience groups. RESULTS: BRS scores were significantly associated with VAS, VR 12-Item Health Survey Mental Component, and KOOS outcome scores. There was a significant difference among all 3 resilience groups (P = .0382) in change of VAS score from baseline to 2 years postoperatively, with a mean difference of 2.5 points, 1.1 points, and 0.7 points for LR, NR, and HR groups, respectively. There was a significant association of greater VR 12-Item Health Survey Mental Component scores, with greater resilience scores preoperatively (P < .0001) and at both 1 (P = .0034) and 2 years (P = .0235) postoperatively. Greater resilience scores were associated with greater KOOS scores at 1 year postoperatively (P = .0270). Female patients were more likely to fall into the LR group (80%). CONCLUSIONS: In this cohort of patients undergoing ACLR, low resilience is positively associated with greater improvement in pain, and female patients tend to fall more into the LR group. At 1 year postoperatively, greater resilience scores were positively associated with greater aggregated KOOS scores. At 1 and 2 years postoperatively, greater resilience was positively associated with improved VR-12M scores. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Increased patient resilience scores are related to positive postoperative outcomes in rotator cuff repairs.

HYPOTHESIS: We sought to determine whether patients' preoperative resilience scores predict postoperative outcomes in arthroscopic rotator cuff repair surgery. METHODS: Patients were prospectively enrolled and underwent data collection preoperatively and at 3, 6, 12, and 24 months postoperatively. Data collected included demographic characteristics and the Brief Resilience Scale (BRS) score, visual analog scale score, Veterans RAND 12-Item Health Survey scores (mental component [VR-12M] and physical component [VR-12P]), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Single Assessment Numeric Evaluation score, and Simple Shoulder Test (SST) score. RESULTS: In total, 131 patients had complete 1- or 2-year postoperative outcome measures. Female patients comprised 56.5% of our sample, and the average age was 57.6 years. Between the low, normal, and high resilience groups, there were significant differences in the VR-12M scores at 0, 12, and 24 months postoperatively (P < .01 for all). The VR-12P scores at 12 months were 44.2, 47.4, and 49.8 in the low, normal, and high resilience groups, respectively, showing a trend upward, but this failed to reach the level of significance (P = .08). The SST scores of the low, normal, and high resilience groups at 12 months were 69.1, 79.9, and 85.1, respectively, again showing a trend upward, but this failed to reach the level of significance (P = .07). The SST scores at 0 and 24 months did not differ between groups. There were no significant differences in American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores at 0, 12, or 24 months postoperatively. We found a significant positive correlation between the BRS score and SST score at 12 months (R = 0.18), VR-12M score at 12 months (R = 0.38), VR-12M score at 24 months (R = 0.31), and VR-12P score at 12 months (R = 0.21). CONCLUSIONS: Our study provides evidence that BRS scores in patients undergoing arthroscopic rotator cuff repair are related to postoperative outcomes, measured through the VR-12M and SST scores at 2-year follow-up.

Grinding, Clicking, and Pivot Pain Resolve in Most Patients After Knee Arthroscopy.

PURPOSE: To determine whether knee arthroscopy alleviates the symptom constellation of knee grinding/clicking, catching/locking, and pivot pain. METHODS: One-year follow-up data from 584 consecutive subjects who underwent knee arthroscopy from August 2012 to December 2019 were collected prospectively. Subjects reported frequency of knee grinding/clicking, catching/locking, and/or pivot pain preoperatively and 1 and 2 years postoperatively. A single surgeon performed each procedure and documented all intraoperative pathology. We measured the postoperative resolution or persistence of these symptoms and used multivariable regression models to identify preoperative demographic and clinical variables that predicted symptom persistence. We also assessed changes in the Pain, Activities of Daily Living, and Quality of Life subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Postoperative symptom resolution was more likely for grinding/clicking (65.6%) and pivot pain (67.8%) than for catching/locking (44.1%). Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predicted persistence of 1 or more patient-reported knee symptoms. KOOS subscale scores consistently improved by at least one standard deviation. Individuals who had resolution of patient-reported knee symptoms exhibited roughly 2-fold improvements in KOOS Pain, ADL and Quality of Life scores compared with those whose symptoms persisted. Persistence of pivot pain was associated with the least improvement of the 3 KOOS subscales. CONCLUSIONS: Two in three patients with grinding/clicking or pivot pain experience symptom resolution after knee arthroscopy, although catching/locking is more likely to persist. Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predict symptom persistence after knee arthroscopy. LEVEL OF EVIDENCE: Therapeutic Level IV, retrospective cohort analysis of prospective data.

Majority of patients find sleep patterns return to normal 6 months following rotator cuff repair.

BACKGROUND AND HYPOTHESIS: Rotator cuff tears have a wide variability in presentation, with some causing pain and reduced function but others remaining completely asymptomatic. Sleep disturbances are a primary driver for patients with rotator cuff tears to see a physician, and one of the main goals of rotator cuff repair (RCR) surgery is to restore normal sleep patterns in these patients. The primary purpose of this study aimed to determine the percentage of patients undergoing RCR who report preoperative sleep disturbances. Second, this study sought to identify at what postoperative follow-up intervals patients stopped reporting sleep disturbances and how the percentages change over time. It was hypothesized that the majority of patients undergoing arthroscopic RCR would report preoperative and initial postoperative sleep disturbances and that 75% of patients would report resolution of sleep disturbances by 1 year postoperatively. METHODS: A total of 326 patients undergoing primary arthroscopic RCR were prospectively enrolled in this study. Validated patient-reported outcome measures were obtained preoperatively and postoperatively, including the visual analog pain scale score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, Simple Shoulder Test (SST) score, and Veterans RAND 12-Item Health Survey physical and mental component scores. RESULTS: According to question 2 of the SST, 291 patients (89%) reported preoperative sleep disturbances. Within the cohort of patients who reported resolution of sleep disturbances, 46% reported resolution by 3 months postoperatively; an additional 31%, by 6 months; a further 14%, by 12 months; and the final 8%, by 24 months. Age ≥ 65 years was significantly associated with increased reporting of resolution compared with age < 65 years. All patient-reported outcome measures, including the visual analog pain scale score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, SST score, and Veterans RAND 12-Item Health Survey (physical component) score, showed statistically significant improvements after surgery. CONCLUSIONS: Eighty-nine percent of patients reported preoperative sleep disturbances. Seventy-seven percent of patients reported resolution of sleep disturbances by 6 months postoperatively, and 81% of patients reported resolution of sleep disturbances by 2 years postoperatively.

All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus: Comparable 2-Year Outcomes in Male and Female Patients.

PURPOSE: To determine 2-year functional outcomes using an all-inside quadrupled semitendinosus anterior cruciate ligament (ACL) reconstruction technique in male and female patients. METHODS: A total of 100 patients who underwent quadrupled semitendinosus all-inside hamstring ACL reconstruction by a single surgeon were enrolled. Patient-reported outcome scores collected preoperatively and postoperatively included visual analog scale, Veterans Rand 12-Item Health Survey (VR-12; Physical and Mental), Marx Activity Scale, Knee Injury and Osteoarthritis Outcome Scores (KOOS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: A total of 100 ACL reconstructions comprising 62 female, and 38 male patients were included in this study. Mean graft diameter was 9.4 mm in female and 9.8 mm in male patients (range, 9-11). Outcome scores demonstrated improvement from preoperative to 2-year postoperative respectively: visual analog scale pain 3.18, 1.07, VR-12 physical 36.35, 52.64, VR-12 mental 53.96, 54.65, KOOS pain 59.17, 89.03, KOOS symptoms 52.64, 80.79, KOOS Activities of Daily Living 69.38, 95.4, KOOS Sport 28.97, 81.25, KOOS Quality of Life 27.54, 71.56, WOMAC Pain 71.56, 92.65, WOMAC Stiffness 60.55, 84.13, and WOMAC Function 69.38, 95.4. Marx activity score decreased from baseline (10.98) to 2 years' postoperatively (8.75). At 2 years, patient expectations were met or exceeded with regards to pain (94%), motion and strength (91%), normal function of daily living (95%), and return to sport (79%). CONCLUSIONS: Anatomic all-inside quadrupled semitendinosus ACL reconstruction improves functional outcomes similarly to previous studies between baseline and clinical follow-up at 1-year and 2-years postoperatively and is comparable in both male and female patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Resilience as a Predictor of Patient Satisfaction With Nonopioid Pain Management and Patient-Reported Outcome Measures After Knee Arthroscopy.

PURPOSE: The purpose of this study was to evaluate the Brief Resilience Score (BRS) as a predictor for patient satisfaction with nonopioid pain management and patient-reported outcome measures (PROMs) after arthroscopic partial meniscectomy or chondroplasty. METHODS: One hundred seventy-five patients undergoing arthroscopic partial meniscectomy and/or chondroplasty were recruited from a single clinic and were preoperatively stratified into low-to-normal resilience or high resilience groups as measured by the BRS. Satisfaction with nonopioid pain control was assessed at a 2-week follow-up visit using the Hospital Consumer Assessment of Healthcare Provider and Systems questionnaire, and various PROMs were measured at 3 and 6 months postoperatively. Statistical analysis was performed to assess for differences in satisfaction with pain control or PROMs between resilience groups. RESULTS: Analysis revealed no statistically significant differences between the low-to-normal resilience group and the high resilience group with regard to satisfaction with nonopioid pain control or PROMs assessed at 3- or 6-month follow-ups. Outcome measures [visual analog scale pain, Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain, KOOS Activities of Daily Living, KOOS Quality of Life, Single Assessment Numerical Evaluation (SANE) Knee, and Veterans Rand 12-Item Health Survey Physical and Mental Component Scores] all followed expected trajectories after surgery, without a statistically significant difference between resilience groups. CONCLUSION: This study provides evidence that preoperative resilience score, as measured by the BRS, does not correlate with postoperative patient-reported functional outcome or satisfaction with a nonopioid pain regimen after knee arthroscopy. LEVEL OF EVIDENCE: II.

Low energy availability, menstrual dysfunction, and impaired bone health: A survey of elite para athletes.

INTRODUCTION: The Female Athlete Triad (Triad) is a syndrome describing three interrelated conditions: low energy availability (LEA), menstrual dysfunction, and low bone mineral density (BMD). Relative Energy Deficiency in Sport (RED-S) expands the Triad to include multiple physiologic consequences of LEA in both sexes. The purpose of this study is to determine the prevalence of factors associated with the Triad/RED-S in an elite para athlete population. METHODS: Athletes were U.S. elite para athletes training to qualify for the 2016 or the 2018 Paralympic Games. Participants completed an online questionnaire characterizing nutrition, menstrual status (in females), bone health, and awareness of the Triad/RED-S. RESULTS: The athletes were 260 elite para athletes (150 male, 110 female). While few reported prior eating disorder (3.1%), 32.4% had elevated Eating Disorder Examination Questionnaire (EDE-Q) pathologic behavior subscale scores. Most athletes (95 male, 65 female) were attempting to change their body composition or weight to improve performance. Forty-four percent of premenopausal females had oligomenorrhea/amenorrhea. Bone stress injury was reported in 9.2% of athletes; of these, 54.5% (n = 12) had low BMD. Less than 10% of athletes reported awareness of the Triad/RED-S. CONCLUSIONS: Factors associated with the Triad/RED-S are present in an elite para athlete population, regardless of sex or sport type. Awareness of the Triad/RED-S in para athletes is low. The consequences of LEA in para athlete populations are poorly understood. However, the high prevalence of factors observed suggests value in advancing screening tools and education efforts to optimize health in this population.

Patient Satisfaction With Nonopioid Pain Management Following Arthroscopic Partial Meniscectomy and/or Chondroplasty.

PURPOSE: To evaluate the efficacy of nonopioid pain medication related to patient satisfaction with postoperative pain and identify potential risk factors for decreased patient satisfaction with nonopioid pain medications. METHODS: This was a prospective study conducted between January 2017 and April 2018 at a single institution. A power analysis was performed a priori, which determined an appropriate cohort size of 163 patients. Inclusion criteria were all patients older than age 18 who were undergoing a knee arthroscopy for a partial meniscectomy and/or chondroplasty. Patients were prescribed maximum-strength ibuprofen or acetaminophen and completed a preoperative and 2-week postoperative questionnaire to assess satisfaction with pain management. RESULTS: Among the 163 patients enrolled in the study, the average age was 48.7 years (range 21-73 years); 74 (45%) were male and 89 (55%) were female. Overall, 81.6% (95% confidence interval 75.7% to 87.5%, P < .001) of patients reported satisfactory postoperative pain control without the use of opioids. Patients with a history of opioid use were found to be less likely to report adequate satisfaction with pain control than were patients who had no prior history of opioid use (relative risk 0.65, 95% confidence interval 0.38-1.12, P = .031). CONCLUSIONS: Based on the findings of this study, 82% of patients who undergo arthroscopic partial meniscectomy and/or chondroplasty can achieve satisfactory pain control with nonopioid pain management. LEVEL OF EVIDENCE: Prospective comparative study: Level II.

Predicting Quadrupled Graft Length and Diameter Using Single-Strand Tendon Dimensions in All-Inside Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine whether single-strand semitendinosus autograft or allograft dimensions can reliably predict quadrupled graft diameter and length. METHODS: Intraoperative semitendinosus graft measurements were recorded for consecutive all-inside anterior cruciate ligament (ACL) reconstructions from 2013 to 2016 and retrospectively reviewed. Intraoperative single-strand tendon length and width and the corresponding quadrupled graft length and diameter were recorded. Pearson correlation coefficients were used to assess the linear association between single-strand width and quadrupled diameter, as well as between single-strand length and quadrupled length. Linear regression models were used to predict quadrupled values. To test the accuracy of the predicted quadrupled values, dimensions from an additional series of 30 all-inside ACL reconstructions were reviewed. RESULTS: Seventy-three ACL reconstruction procedures were reviewed. We excluded 12 grafts because gracilis and semitendinosus constructs were used. Thus 61 semitendinosus quadrupled grafts (30 autografts and 31 allografts) were included. Single-strand width was associated with quadrupled diameter (P = .012), and single-strand length was associated with quadrupled graft length (P < .001). CONCLUSIONS: Quadrupled hamstring graft length and diameter may be accurately predicted based on length and width of the semitendinosus tendon used for all-inside, single-bundle ACL reconstruction. The ability to predict quadrupled graft dimensions can guide the surgeon in intraoperative decision making and ensure the desired ACL graft dimensions are achieved, thereby minimizing the risk of ACL reconstruction failure. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Insulin-Like Growth Factor II (IGF-II) Inhibits IL-1ß-Induced Cartilage Matrix Loss and Promotes Cartilage Integrity in Experimental Osteoarthritis.

Osteoarthritis (OA) is a widespread chronic joint disease characterized by articular cartilage destruction and accompanied by pain and disability. In this study, we found that the expression of Insulin-like Growth Factor II (IGF-II) was reduced in articular cartilage in human OA patients as well as in the murine experimental OA model of destabilization of the medial meniscus (DMM). In primary human articular chondrocytes, ectopic expression of lentiviral IGF-II inhibited pro-inflammatory cytokine IL-1ß-induced NF-κB activation as well as catabolic gene expression. Interestingly, IGF-II did not significantly alter the phosphorylation states of ERK1/2 or Akt, which are kinases typically activated by IGF-I. Instead, it induced the activity of phospholipase C (PLC) and a PLC inhibitor blocked the inhibitory activity of IGF-II against IL-1ß, suggesting that this activity is mediated through PLC. Furthermore, IGF-II increased cartilage matrix levels and decreased MMP13 protein expression in explanted human OA cartilage cultures in vitro. In the in vivo DMM model, intraarticular injection of lentiviral IGF-II led to enhanced cartilage matrix levels and decreased MMP13 protein expression, as well as reduced osteophyte formation and subchondral bone sclerosis. Therefore, our results suggest that IGF-II can promote cartilage integrity and halt knee joint destruction in OA.

A comparison of the lateral decubitus and beach-chair positions for shoulder surgery: advantages and complications.

Arthroscopic or open shoulder surgery can be performed using the lateral decubitus or beach-chair position. Advantages of the lateral decubitus position include better visualization and instrument access for certain procedures and decreased risk for cerebral hypoperfusion. Complications associated with this position include traction injuries, resulting in neurapraxia, thromboembolic events, difficulty with airway management, and the potential need to convert to an anterior open approach. One advantage of the beach-chair position is easier setup from a supine to upright position, which allows the surgeon the option to convert to an open procedure if necessary. Although rare, patients in this position may experience cerebral hypoperfusion and complications that range from cranial nerve injury to infarction. Other complications related to this position include cervical traction neurapraxia, blindness, and cardiac and embolic events. The surgeon must be cognizant of the complications associated with both positions and take extra care in the initial patient setup and coordination with the anesthesiologist to minimize the risk of complications and morbidity.

Barbed versus traditional sutures: closure time, cost, and wound related outcomes in total joint arthroplasty.

The purpose of this study was to compare barbed sutures to traditional sutures in three domains: time, cost, and wound related outcomes in total knee arthroplasty (TKA) and total hip arthroplasty (THA). A total of 34 patients were enrolled in a prospective randomized controlled trial to assess time to wound closure and cost. In addition, a retrospective chart review of an additional 100 patients was conducted to further assess wound-related outcomes. On average, barbed sutures decreased time to wound closure by 9.72 min (P<0.05) after controlling for length of incision, patient's BMI and number of physicians closing. Further, using barbed sutures saved an average of $549.59 per case. However, increased frequency and severity of wound complications were associated with barbed sutures.

Total joint arthroplasty surgery: does day of surgery matter?

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.

Preoperative Predictors of Arthroscopic Partial Meniscectomy Outcomes: The APM Index Score.

BACKGROUND: Preoperative risk factors contributing to poor outcomes after arthroscopic partial meniscectomy (APM) have not yet been consolidated and codified into an index scoring system used to predict APM success. PURPOSE: To create an index score using available preoperative factors to predict the likelihood of favorable postoperative outcomes after APM. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A consecutive cohort of patients undergoing primary APM were enrolled in this study. Patients completed pre- and postoperative patient-reported outcome measure (PROM) questionnaires that included the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain, Veterans RAND 12-Item Health Survey (VR-12 Physical and Mental), and Marx Activity Rating Scale (MARS). Multivariable logistic regression models were performed to evaluate independent predictors of KOOS Pain, Symptoms, and Activities of Daily Living scores and achievement of the minimal clinically important difference (MCID) and substantial clinical benefit (SCB). The authors assigned points to each variable proportional to its odds ratio, rounded to the nearest integer, to generate the index score. RESULTS: In total, 468 patients (mean age, 49 years [SD, 10.4 years; range, 19-81 years]) were included in this study. In the univariate analysis, shorter symptom duration, lower Kellgren-Lawrence (KL) grade, lower preoperative KOOS Pain value, and lower VR-12 Physical score were associated with a higher likelihood of clinical improvement at 1 year. In the multivariable model for clinical improvement with MCID, symptom duration (<3 months: OR, 3.00 [95% CI, 1.45-6.19]; 3-6 months: OR, 2.03 [95% CI, 1.10-3.72], compared with >6 months), KL grade (grade 0: OR, 3.54 [95% CI, 1.66-7.54]; grade 1: OR, 3.04 [95% CI, 1.48-6.26]; grade 2: OR, 2.31 [95% CI, 1.02-5.27], compared with grade 3), and preoperative KOOS Pain value (score <45: OR, 3.00 [95% CI, 1.57-5.76]; score of 45-60: OR, 2.80 [95% CI, 1.47-5.35], compared with score >60) were independent significant predictors for clinical improvement. The scoring algorithm demonstrated that a higher total score predicted a higher likelihood of achieving the MCID: 0 = 40%, 1 = 68%, 2 = 80%, 3 = 89%, and 4 = 96%. CONCLUSION: Using this model, the authors developed an index score that, using preoperative factors, can help identify which patients will achieve clinical improvement after APM. Longer symptom duration and higher KL grade were associated with a decreased likelihood of clinical improvement as measured by KOOS Pain at 1 year postoperatively.

Sports Medicine Considerations When Caring for the Transgender Athlete.

Orthopaedic surgeons and other orthopaedic care providers have expressed a desire to care for transgender patients but have a self-perceived knowledge deficit. Transgender athletes experience many psychosocial barriers to sport that are useful for clinicians to understand. Medical and surgical gender-affirming care can impact musculoskeletal physiology and pathophysiology. Transgender women (TW) have demonstrated an increased risk of insufficiency fractures and thromboembolism in patients receiving exogenous estrogen therapy. The impact of gender-affirming care on sex-based differences in athletic injuries is less well studied.

Resolution of Sleep Disturbance and Improved Functional Outcomes After Rotator Cuff Repair.

BACKGROUND: Most patients experience sleep disturbances before rotator cuff repair, with these symptoms largely improving postoperatively. However, the relationship between the resolution or persistence of sleep disturbance and patient-reported outcomes after rotator cuff repair remains unknown. PURPOSE: To compare outcomes after rotator cuff repair between patients who reported a preoperative sleep disturbance and those who did not. Outcomes at various time points after surgery were also assessed in relation to the persistence or resolution of sleep disturbance. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients undergoing primary arthroscopic rotator cuff repair at a tertiary academic center were prospectively enrolled in a registry database. Patient characteristics were obtained preoperatively and validated patient-reported outcome measures (PROMs) were obtained pre- and postoperatively, including the visual analog scale for pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Veterans RAND 12-Item Health Survey Physical and Mental components. Sleep disturbance was evaluated via responses to Simple Shoulder Test question 2. Patients with and without sleep disturbance were compared before and after surgery. RESULTS: In total, 293 patients were prospectively enrolled. A total of 262 (89.8%) patients reported a sleep disturbance preoperatively. Of these, 221 (84.4%) reported a resolution of sleep disturbance by 2 years postoperatively. After adjustment for age, workers' compensation status, and Cofield tear size, patients with a preoperative sleep disturbance reported significantly worse baseline PROMs, apart from the Veterans RAND 12-Item Health Survey Mental component, before surgery. However, postoperatively, these patients had greater improvement in PROMs, and no significant remaining differences were seen at follow-up between patients with and without preoperative sleep disturbance. Among patients who reported a preoperative sleep disturbance, those whose symptoms resolved postoperatively had superior PROM scores as well as significantly greater improvements from preoperative baseline values compared with patients with persistent sleep disturbances after surgery. CONCLUSION: Patients with preoperative sleep disturbances reported worse baseline functional scores before rotator cuff repair compared with patients without sleep disturbance. These disturbances largely resolved after surgery, with postoperative outcomes comparable with those of patients who reported no preoperative sleep concerns. Patients whose sleep disturbances resolved postoperatively also reported superior PROM scores compared with patients whose sleep disturbances persisted postoperatively.

Technique for All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus and Gracilis Autograft.

Anterior cruciate ligament (ACL) injuries are common to athletes and non-athletes alike. Whereas the literature has historically supported bone-patellar tendon-bone as the gold standard for active patients who elect to undergo ACL reconstruction, other studies have suggested that soft-tissue grafts do not increase the risk of rerupture. Because graft diameter has a direct effect on revision rates, we share a technique for all-inside ACL reconstruction using quadrupled semitendinosus and gracilis autograft that allows for a predictable, robust graft. Reproducible steps of graft harvesting, tunnel preparation, graft passage, and fixation are shared to achieve a robust anatomic reconstruction.

Resilience of Patients Undergoing Knee and Shoulder Arthroscopy Procedures.

INTRODUCTION: Resilience is a person's capacity to overcome adversity. The purpose was to determine what patient factors correlate with resilience using the Brief Resilience Score. We hypothesize that characteristics of female sex, younger age, Workers' Compensation status, and preoperative opioid use are predictors of a lower preoperative resilience score and that patients with positive psychosocial factors would have higher resilience scores. METHODS: Eight hundred nine patients undergoing knee or shoulder arthroscopy were preoperatively categorized into low, normal, and high-resilience groups. Preoperative patient-reported outcome measures (PROMs) and demographics were assessed. Statistical analyses evaluated differences in demographics and PROMs between resilience groups. RESULTS: Analysis disclosed notable differences between low, normal, and high-resilience groups regarding demographics and PROMs. High resilience was seen in older patients, male patients, and patients with positive psychosocial factors. Low resilience scores were discovered in Workers' Compensation patients and those with a history of preoperative opioid use. No difference in resilience scores was observed between smokers and nonsmokers. DISCUSSION: Preoperative resilience score is associated with age, sex, preoperative opioid use, Workers' Compensation status, and smoking status of patients undergoing knee or shoulder arthroscopy.

Biomechanical Comparison of 3 Adjustable-Loop Suspensory Devices for All-Inside ACL Reconstruction: A Time-Zero Full-Construct Model.

Background: Little is known about the stability of adjustable-loop devices (ALDs) for anterior cruciate ligament (ACL) reconstruction (ACLR). Purpose: To evaluate the stabilization behavior of 3 different types of ALDs for all-inside ACLR in a full-construct surgical technique-based manner. Study Design: Controlled laboratory study. Methods: The femoral and tibial devices of Ultrabutton (Smith & Nephew), Infinity (Conmed), and TightRope II (Arthrex) were applied to quadrupled bovine tendon grafts (n = 8 each) with tibial-sided traction applied (350 N) for graft tensioning in a simulated fully extended knee. Knotless femoral graft fixation was based on either a suture-locking device (SLD; Ultrabutton), button-locking device (BLD; Infinity), or dual-locking device (DLD; TightRope II). All constructs were progressively loaded (50 N/500 cycles) from 50 to 300 N for 3000 cycles (0.75 Hz), including complete unloading situations and pull to failure (50 mm/min). Construct elongation, stiffness, and ultimate load were analyzed. Results: BLD showed significantly greater initial elongation (-2.69 ± 0.15 mm) than DLD (-3.19 ± 0.21 mm; P < .001) but behaved similarly to SLD (-2.93 ± 0.23 mm). While DLD and SLD had the smallest initial elongation at the same significance level, they behaved opposite to each other with gradually increasing peak loading. At the end of testing, DLD had the lowest (-0.64 ± 0.32 mm) and SLD the highest (3.41 ± 1.01 mm) total elongation (P < .003 for both). SLD displayed significantly higher dynamic elongation (6.34 ± 0.23 mm) than BLD (3.21 ± 0.61 mm) and DLD (2.56 ± 0.31 mm) (P < .001 for both). The failure load of BLD (865.0 ± 183.8 N) was significantly lower (P < .026) compared with SLD and DLD (>1000 N). The predominant failure mode was suture rupture and tibial bone breakage with button subsidence (SLD, n = 4). No significant difference in stiffness between constructs was found. Conclusion: While DLD successfully restricted critical construct elongation, BLD partially and SLD completely exceeded the clinical failure threshold (>3 mm) of plastic elongation with loop lengthening during increasing cyclic peak loading with complete unloading. Higher failure loads of SLD and DLD implants (>1000 N) were achieved at similar construct stiffness to BLD. Clinical Relevance: A detailed biomechanical understanding of the stabilization potential is pertinent to the continued evolution of ALDs to improve clinical outcomes.