Randomized Controlled Trials Comparing Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autografts in Anterior Cruciate Ligament Reconstruction Surgery Are Statistically Fragile: A Systematic Review.

PURPOSE: To assess the statistical fragility of recently published randomized controlled trials (RCTs) comparing the use of hamstring tendon autograft with bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction. METHODS: The PubMed, Embase, and MEDLINE databases were queried for RCTs published since 2010 comparing autograft type (bone-patellar tendon-bone vs hamstring tendon) in ACL reconstruction surgery. The fragility index (FI) and reverse FI (rFI) were determined for significant and nonsignificant outcomes, respectively, as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) and reverse FQ, representing fragility as a proportion of the study population, were calculated by dividing the FI and rFI, respectively, by the sample size. RESULTS: We identified 19 RCTs reporting 55 total dichotomous outcomes. The median FI of the 55 total outcomes was 5 (interquartile range [IQR], 4-7), meaning a median of 5 outcome event reversals would alter the outcomes' significance. Five outcomes were reported as statistically significant with a median FI of 4 (IQR, 2-6), meaning a median of 4 outcome event reversals would change outcomes to be nonsignificant. Fifty outcomes were reported as nonsignificant with a median rFI of 5 (IQR, 4-7), meaning a median of 5 outcome event reversals would change outcomes to be significant. The FQ and reverse FQ for significant and nonsignificant outcomes were 0.025 (IQR, 0.018-0.045) and 0.082 (IQR, 0.041-0.106), respectively. For 61.8% of outcomes, patients lost to follow-up exceeded the corresponding FI or rFI. CONCLUSIONS: There is substantial statistical fragility in recent RCTs on autograft choice in ACL reconstruction surgery given that altering a few outcome events is sufficient to reverse study findings. For over half of outcomes, maintaining patients lost to follow-up may have been sufficient to reverse study conclusions. CLINICAL RELEVANCE: We recommend co-reporting FIs and P values to provide a more comprehensive representation of a study's conclusions when conducting an RCT.

Fragile Statistical Findings in Randomized Controlled Trials Evaluating Autograft Versus Allograft Use in Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To analyze the statistical stability of randomized controlled trials (RCTs) evaluating the surgical management of autografts versus allografts in the anterior cruciate ligament reconstruction (ACLR) literature and calculate the fragility index (FI) and fragility quotient and explore a subgroup analysis by calculating the proportion of outcome events where the FI was less than the number of patients lost to follow-up. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic search in the PubMed and Cochrane databases to identify RCTs published between 2000 and 2022 that investigated the use of autografts versus allografts in ACLR literature and reported dichotomous data. The fragility index of each dichotomous variable was calculated through the reversal of a single outcome event until significance was reversed. The fragility quotient was calculated by dividing each fragility index by the study sample size. The interquartile range also was calculated. RESULTS: Of the 4407 articles screened, 23 met the search criteria, with 11 RCTs evaluating ALCR using autografts and allografts included for analysis. Two hundred and 18 outcome events with 32 significant (P < .05) outcomes and 186 nonsignificant (P ≥ .05) outcomes were identified. The overall fragility index and fragility quotient for all 218 outcomes were 6 subjects (interquartile range 5-8) and 0.058 (interquartile range 0.039-0.077). Fragility analysis of statistically significant outcomes and nonsignificant outcomes had a fragility index of 3.5 (interquartile range 1-5.5) and 6 (interquartile range 5-8), respectively. All of the studies reported a loss to follow-up where 45.5% (5) reported a loss to follow-up greater or equal to 6. CONCLUSIONS: The RCTs in the ACLR peer-reviewed literature evaluating autograft versus allograft use are vulnerable to a small number of outcome event reversals and exemplify significant statistical fragility in statistically significant findings. LEVEL OF EVIDENCE: Level I, systematic review of Level I studies.

The Variability of MCID, SCB, PASS, and MOI Thresholds for PROMs in the Reverse Total Shoulder Arthroplasty Literature: A Systematic Review.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) is a common procedure utilized to address degenerative pathologies of the glenohumeral joint and rotator cuff. Increased reliance on patient-reported outcome measures (PROMs) has placed emphasis on the utilization of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), patient acceptable symptom state (PASS), and maximal outcome improvement (MOI) thresholds to assess the clinical efficacy of RTSA. In this study, we systematically reviewed the MCID, SCB, PASS, and MOI thresholds reported for PROMs following RTSA. METHODS: PubMed, Embase, MEDLINE, Cochrane Library, and Google Scholar were queried for articles from Jan. 1, 2000-Aug. 31, 2023 reporting MCID, SCB, PASS, or MOI values for PROMs following RTSA. Patient demographic data, study characteristics, MCID/SCB/PASS/MOI thresholds, and threshold calculation methods were extracted. RESULTS: 141 articles were screened with 39 ultimately included, comprising 11,984 total patients that underwent RTSA. 34 (87%) studies reported MCID thresholds, 20 (51%) reported SCB, 5 (13%) reported PASS, and 2 (5%) reported MOI. 25/39 (64%) studies referenced a previous study when reporting MCID, SCB, PASS, or MOI values, 11 (28%) used an anchor-based method to calculate threshold values, 1 (3%) used a distribution-based method, and 2 (5%) used both anchor and distribution methods. There were 19 newly calculated MCID (11), SCB (5), PASS (1), and MOI (2) thresholds. For five of the six most utilized PROMs (ASES, SST, Constant, UCLA, SPADI), the range of reported MCID values exceeded 50% of the most common threshold. For three of the six, the range of SCB values exceeded 25% of the most common threshold. CONCLUSION: There is substantial variability in the MCID and SCB threshold values reported in the RTSA literature. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and MOI thresholds for RTSA may allow for improved assessment of PROMs.

The fragility of statistical findings in the reverse total shoulder arthroplasty literature: a systematic review of randomized controlled trials.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has seen increasing utilization as an effective intervention for a wide variety of shoulder pathologies. The scope and indications for growth are often driven by findings from randomized controlled trials (RCTs) guiding surgical decision-making for RTSA. In this study, we utilized the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to assess the robustness of outcomes reported in RCTs in the RTSA literature. METHODS: PubMed, Embase, and MEDLINE were queried for RCTs (Jan. 1, 2010-Mar. 31, 2023) in the RTSA literature reporting dichotomous outcomes. The FI and rFI were defined as the number of outcome reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI by the sample size of each study. Subgroup analysis was performed based on outcome category. RESULTS: One hundred seventy-six RCTs were screened with 18 studies included. The median FI across 59 total outcomes was 4 (interquartile range [IQR]: 3-5) with an associated FQ of 0.051 (IQR: 0.029-0.065). Thirteen outcomes were statistically significant with a median FI of 3 (IQR: 1-4) and FQ of 0.033 (IQR: 0.012-0.066). Forty-six outcomes were nonsignificant with a median rFI of 4 (IQR: 3-5) and FQ of 0.055 (IQR: 0.032-0.065). The most fragile outcome category was revision/reoperations with a median FI of 2.50 (IQR: 1.00-3.25), followed by clinical score/outcome (median FI: 3.00), complications (median FI: 4.00), "other" (median FI: 4.00), and radiographic findings (median FI: 5.00). Notably, the number of patients lost to follow-up was greater than or equal to the FI for 59% of outcomes. CONCLUSION: The statistical findings in RTSA RCTs are fragile and should be interpreted with caution. Reversal of only a few outcomes, or maintaining postoperative follow-up, may be sufficient to alter significance of study findings. We recommend standardized reporting of P values with FI and FQ metrics to allow clinicians to effectively assess the robustness of study findings.

Statistical Outcomes Guiding Periprosthetic Joint Infection Prevention and Revision Are Fragile: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Dichotomous outcomes are frequently reported in orthopaedic research and have substantial clinical implications. This study utilizes the fragility index (FI) and fragility quotient (FQ) metrics to determine the statistical stability of outcomes reported in total joint arthroplasty randomized controlled trials (RCTs) relating to periprosthetic joint infection (PJI). METHODS: The RCTs that reported dichotomous data related to PJI published between January 1, 2010, and December 31, 2022, were evaluated. The FI and reverse FI (RFI) were defined as the number of outcome event reversals required to reverse the significance of significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI or RFI by the respective sample size. There were 108 RCTs screened, and 17 studies included for analysis. RESULTS: A total of 58 outcome events were identified, with a median FI of 4 (interquartile range [IQR] 2 to 5) and associated FQ of 0.0417 (IQR 0.0145 to 0.0602). The 13 statistically significant outcomes had a median FI of 1 (IQR 1 to 2) and FQ of 0.00935 (IQR 0.00629 to 0.01410). The 45 nonsignificant outcomes had a median RFI of 4 (IQR 3 to 5) and FQ of 0.05 (IQR 0.0361 to 0.0723). The number of patients lost to follow-up was greater than or equal to the FI in 46.6% of outcomes. CONCLUSIONS: Statistical outcomes in RCTs analyzing PJI are fragile and may lack statistical integrity. We recommend a comprehensive fragility analysis, with the reporting of FI and FQ metrics, to aid in the interpretation of outcomes in the total joint arthroplasty literature.

The Fragility of Statistical Findings in Cervical Disc Arthroplasty: a Systematic Review of Randomized Controlled Trials.

PURPOSE: This study employs both the fragility index (FI) and fragility quotient (FQ) to assess the level of robustness in the cervical disc arthroplasty (CDA) literature. We hypothesize that dichotomous outcomes involving CDA would exhibit statistical vulnerability. METHODS: A PubMed search was conducted to evaluate dichotomous data for randomized controlled trials (RCTs) in CDA literature from 2000 to 2023. The FI of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The FQ was calculated by dividing each fragility index by the study sample size. The interquartile range (IQR) was also calculated for the FI and FQ. RESULTS: Of the 1561 articles screened, 111 met the search criteria, with 35 RCTs evaluating CDA included for analysis. Six hundred and ninety-three outcome events with 130 significant (P < 0.05) outcomes and 563 nonsignificant (P ≥ 0.05) outcomes were identified. The overall FI and FQ for all 693 outcomes were 5 (IQR 3-7) and 0.019 (IQR 0.011-0.043). Fragility analysis of statistically significant outcomes and nonsignificant outcomes both revealed an FI of 5. All of the studies reported loss to follow-up (LTF) data where 65.7% (23) did not report or reported an LTF greater or equal to 5. CONCLUSIONS: The literature regarding CDA RCTs lacks statistical robustness and may misrepresent the conclusions with the sole use of the P value. By implementing the FI and FQ along with the P value, we believe the interpretation and contextualization of the clinical data surrounding CDA will be better understood.

The Statistical Fragility of Orbital Fractures: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: The P value has often been used as a tool to determine the statistical significance and evaluate the statistical robustness of study findings in orthopedic literature. The purpose of this study is to apply both the fragility index (FI) and the fragility quotient (FQ) to evaluate the degree of statistical fragility in orbital fracture literature. We hypothesized that the dichotomous outcomes within the orbital fracture literature will be vulnerable to a small number of outcome event reversals and will be statistically fragile. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors identified all dichotomous data for randomized controlled trials (RCTs) in orbital fracture literature and performed a PubMed search from 2000 to 2022. The FI of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The FQ was calculated by dividing each FI by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ. RESULTS: Of the 3,329 studies screened, 28 met the criteria with 10 RCTs evaluating orbital fractures included for analysis. A total of 58 outcome events with 22 significant (P < .05) outcomes and 36 nonsignificant (P ≥ .05) outcomes were identified. The overall FI and FQ for all 58 outcomes was 5 (IQR: 4 to 5) and 0.140 (IQR: 0.075 to 0.250), respectively. Fragility analysis of statistical significant outcomes and nonsignificant outcomes had an FI of 3.5 with no IQR and 5 (IQR 4-5), respectively. All of the studies reported a loss to follow-up data, where 20% (2) was greater than the overall FI of 5. CONCLUSION: The orbital fracture literature provides treatment guidance by relying on statistical significant results from RCTs. However, the RCTs in the orbital fracture peer-reviewed literature may not be statistically stable as previously thought. The sole reliance of the P value may depict misleading results. Thus, we recommend standardizing the reporting of the P value, FI, and FQ in the orbital fracture literature to aid readers in reliably drawing conclusions based on fragility outcome measures impacting clinical decision-making.

Postoperative Strength Differences at Short-Term Follow-up Vary Based on Autograft Harvest Site After Adolescent Transphyseal Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare the clinical and patient-reported outcomes of adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) versus hamstring tendon (HT) autograft. METHODS: This was a retrospective cohort study of adolescent patients aged 18 years or younger treated at a single tertiary care children's hospital who underwent primary transphyseal ACLR using QT or HT between January 2018 and December 2019. All patients had minimum 6-month follow-up. Outcomes included isokinetic strength testing, postoperative Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores, and complications; these were compared between the QT and HT cohorts. RESULTS: A total of 84 patients (44 HT and 40 QT patients) were included. The QT cohort had a higher proportion of male patients (62.5% vs 34.1%, P = .01). At 3 months, HT patients had a lower hamstring-quadriceps (H/Q) strength ratio (60.7 ± 11.0 vs 79.5 ± 18.6, P < .01) and lower Limb Symmetry Index in flexion (85.6 ± 16.1 vs 95.5 ± 15.7, P = .01) whereas QT patients had a lower Limb Symmetry Index in extension (67.3 ± 9.5 vs 77.4 ± 10.7, P < .01). The H/Q ratio at 6 months was lower in HT patients (59.4 ± 11.5 vs 66.2 ± 7.5, P < .01). Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores were not different at 3 months or latest follow-up. QT patients had more wound issues (20.0% vs 2.3%, P = .01). Patients receiving HT autograft had more ipsilateral knee injuries (18.2% vs 2.5%, P = .03), but there was no difference in graft failure for ACLR using HT versus QT (9.1% vs 2.5%, P = .36). CONCLUSIONS: There were no differences in patient-reported outcome measures between patients receiving QT autografts and those receiving HT autografts. Patients with QT grafts had more postoperative wound issues but a lower rate of ipsilateral knee complications (graft failure or meniscal tear). Differences in quadriceps and hamstring strength postoperatively compared with the contralateral limb were observed for adolescent ACLR patients receiving QT and HT autografts, respectively. This contributed to higher H/Q ratios seen at 3 and 6 months postoperatively for patients receiving QT autografts. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic study.

The fragility of statistical findings in distal biceps tendon repairs: a systematic review of randomized controlled trials.

BACKGROUND: The purpose of this present study was to perform a fragility analysis to assess the robustness of randomized controlled trials (RCTs) evaluating the distal biceps tendon repairs. We hypothesize that the dichotomous outcomes will be statistically fragile, and higher fragility will exist among statistically significant outcomes comparable to other orthopedic specialties. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), randomized controlled trials from 4 orthopedic journals indexed on PubMed from 2000 to 2022 reporting dichotomous measures relating to distal biceps tendon repairs were included. The fragility index (FI) of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The fragility quotient (FQ) was calculated by dividing each fragility index by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ. RESULTS: Of the 1038 articles screened, 7 RCTs containing 24 dichotomous outcomes were included for analysis. The fragility index and fragility quotient of all outcomes was 6.5 (IQR 4-9) and 0.077 (IQR 0.031-0.123), respectively. However, statistically significant outcomes had a fragility index and fragility quotient of 2 (IQR 2-7) and 0.036 (IQR 0.025-0.091), respectively. The average number of patients lost to follow-up was 2.7 patients, with 28.6% of the included studies reporting loss to follow-up (LTF) greater than or equal to 6.5. CONCLUSIONS: The literature surrounding distal biceps tendon repair may not be as stable as previously thought and presents a similar fragility index to other orthopedic subspecialties. We therefore recommend triple reporting the P value, fragility index, and fragility quotient to aid in the interpretation of clinical findings reported in biceps tendon repair literature.

The Fragility of Tourniquet Use in Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Physicians utilize P-values to interpret clinical trial data and guide patient-care decisions. Fragility analysis assesses the stability of statistical findings in relation to outcome event reversals. This study assessed the statistical fragility of recent randomized controlled trials (RCTs) investigating tourniquet use in total knee arthroplasty (TKA). METHODS: We queried PubMed, EMBASE, and MEDLINE for RCTs comparing outcomes in TKA based on tourniquet use. Fragility index (FI) and reverse fragility index (reverse FI) were calculated - for significant and nonsignificant outcomes, respectively - as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) was calculated by dividing the FI or reverse FI by the sample size. Median overall FI and FQ were calculated for all included outcomes, and sub-analyses were performed by reported significance. The literature search yielded 23 studies reporting 91 total dichotomous outcomes. RESULTS: Overall median FI was 4 with an interquartile range (IQR) of 3 to 6. Overall median FQ was 0.0476 (IQR 0.0291 to 0.0867). A total of 11 outcomes were statistically significant with a median FI and FQ of 2 (IQR 1.5 to 5) and 0.0200 (IQR 0.0148 to 0.0484), respectively. There were 80 outcomes that were nonsignificant with a median reverse FI of 4 (IQR 3 to 6). Loss to follow-up was greater than the median FI in 17.6% of outcomes. CONCLUSION: Altering a small number of outcomes is often sufficient to reverse findings in RCTs evaluating tourniquet use in TKA. We recommend including fragility analyses to increase reliability in the interpretation of study conclusions.

Improving Radiographic Fracture Recognition Performance and Efficiency Using Artificial Intelligence.

Background Missed fractures are a common cause of diagnostic discrepancy between initial radiographic interpretation and the final read by board-certified radiologists. Purpose To assess the effect of assistance by artificial intelligence (AI) on diagnostic performances of physicians for fractures on radiographs. Materials and Methods This retrospective diagnostic study used the multi-reader, multi-case methodology based on an external multicenter data set of 480 examinations with at least 60 examinations per body region (foot and ankle, knee and leg, hip and pelvis, hand and wrist, elbow and arm, shoulder and clavicle, rib cage, and thoracolumbar spine) between July 2020 and January 2021. Fracture prevalence was set at 50%. The ground truth was determined by two musculoskeletal radiologists, with discrepancies solved by a third. Twenty-four readers (radiologists, orthopedists, emergency physicians, physician assistants, rheumatologists, family physicians) were presented the whole validation data set (n = 480), with and without AI assistance, with a 1-month minimum washout period. The primary analysis had to demonstrate superiority of sensitivity per patient and the noninferiority of specificity per patient at -3% margin with AI aid. Stand-alone AI performance was also assessed using receiver operating characteristic curves. Results A total of 480 patients were included (mean age, 59 years ± 16 [standard deviation]; 327 women). The sensitivity per patient was 10.4% higher (95% CI: 6.9, 13.9; P < .001 for superiority) with AI aid (4331 of 5760 readings, 75.2%) than without AI (3732 of 5760 readings, 64.8%). The specificity per patient with AI aid (5504 of 5760 readings, 95.6%) was noninferior to that without AI aid (5217 of 5760 readings, 90.6%), with a difference of +5.0% (95% CI: +2.0, +8.0; P = .001 for noninferiority). AI shortened the average reading time by 6.3 seconds per examination (95% CI: -12.5, -0.1; P = .046). The sensitivity by patient gain was significant in all regions (+8.0% to +16.2%; P < .05) but shoulder and clavicle and spine (+4.2% and +2.6%; P = .12 and .52). Conclusion AI assistance improved the sensitivity and may even improve the specificity of fracture detection by radiologists and nonradiologists, without lengthening reading time. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Link and Pedoia in this issue.

Comorbidity scores reported in anatomic and reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: Due to the aging population, the number of reverse shoulder arthroplasty (RSA) and anatomic shoulder arthroplasty (TSA) continue to increase annually. Although outcome measures are frequently reported in literature for patients who undergo shoulder arthroplasty, no studies have analyzed reporting of patient comorbidities in this population. The purpose of this study was to evaluate reporting of comorbidity indices in shoulder arthroplasty literature and assess how this reporting may inform management and outcomes. METHODS: A database was compiled systematically using PubMed to identify articles pertaining to shoulder arthroplasty published between 2019 and 2021. The search terms, "reverse shoulder arthroplasty" and "anatomic shoulder arthroplasty," were used to identify clinical studies. Non-clinical (e.g., translational and basic science) and review articles were excluded. Included studies were then analyzed for reporting of comorbidity indices. RESULTS: A total of 199 articles were included in this review and reported comorbidities. Of these, 15.6% (31 of 199) pertained to TSA, while 84.4% (168 of 199) pertained to RSA. Within this review, 57.8% (115 of 199) articles utilized comorbidity scores, while 42.2% (84 of 199) reported only comorbid diagnoses. Among the scores utilized, the American Society of Anesthesiologists (ASA) physical status classification system was the most widely used among both the TSA (52.9%, 9 of 17) and the RSA studies (58.2%, 57 of 98). Additional scores within the RSA literature included the Charlson Comorbidity Index (CCI) (35.3%, 6 of 17), the Charlson Comorbidity Index by Deyo et al. (J Clin Epidemiol. 45(6):613-9, 1992) (CCI-Deyo; 5.9%, 1 of 17), the Modified Charlson Comorbidity Index (modified-CCI) (5.9%, 1 of 17), the Elixhauser et al. (Med Care. 36(1):8-27, 1998) Comorbidity Measure (ECM) (11.8%, 2 of 17), and the Modified Frailty Index (mFI) (5.9%, 1 of 17). With the TSA literature, the additional comorbidity scores included the CCI (30.6%, 30 of 98), the CCI-Deyo (6.1%, 6 of 98), the modified-CCI (1.0%, 1 of 98), the ECM (8.2%, 8 of 98), the Factor-5 modified Frailty Index (mFI-5) (1.0%, 1 of 98), and the mFI (1.0%, 1 of 98). CONCLUSION: The reporting of comorbidity indices is an important factor when considering patient outcomes and complications reported in shoulder arthroplasty literature. Although the reporting of these scores appears to be more prevalent in current literature, there is no standard or consistency in terms of which scores are reported. Given this diversity in comorbidity scores, further research is necessary to develop a single standardized score to properly analyze the effect of comorbidities on shoulder arthroplasty patient outcomes.

Outcomes and failure rates after revision meniscal repair: a systematic review and meta-analysis.

PURPOSE: The purpose of this meta-analysis is to determine the outcomes and failure rates for revision meniscus repairs in patients with re-tears after primary repair failure. METHODS: A literature search was conducted using PubMed and Embase with the terms "Meniscus," "Meniscal," "Revised," and "Revision." The search strategy was based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) protocol and included four articles (79 patients). The search criteria were limited to studies reporting outcomes and failure rates. The exclusion criteria included languages other than English, biomechanical studies, letters to editors, non-full text, review articles, meta-analysis, and case reports. RESULTS: Four comparative studies with 79 patients (53 males, 26 females) with a mean age of 23.9 ± 6.4 years treated with a revision meniscus repair were included in the final analysis. Within this analysis, we found a failure rate of 25.3% (20 of 79 patients). Of these failed repairs, 30.95% (13 of 42) were of the medial meniscus, and 18.9% (7 of 37) were of the lateral meniscus. In the four articles, the postoperative Tegner sports activity score was found to be 6.1 ± 1.6 (range, 2 to 10). The post-operative Lysholm score was reported in three articles (45 patients). At a mean follow-up of 58.3 ± 23.9 months, the mean post-operative Lysholm score was 89.1 ± 7.6 (range, 38 to 100). The Coleman score for the included articles ranged between 52 and 59. CONCLUSION: This analysis found that revision meniscus repairs in patients with re-tears after primary repair failure result in clinical outcomes similar to that of primary repairs.

Sports-related concussions in high school females: an epidemiologic analysis of twenty-year national trends.

The epidemiology of sports-related concussions (SRCs) and closed head injuries (CHIs) in high school females remains undefined at the national level, especially for unorganized sports and recreational activities. This study examines 1,176,092 national weighted estimates of SRCs or CHIs in female patients 14-18 years of age presenting to United States (US) emergency departments (EDs) between 2000 and 2019 in the National Electronic Injury Surveillance System (NEISS). The national weighted estimate of female patients in our study increased significantly (p < 0.001) between 2000 (9,835; 95% Confidence Interval [CI] 7,105-12,566) and 2019 (31,751; CI 26,392-37,110). The top five ranked sports and recreational activities most commonly associated with concussions and CHIs in female patients 14-18 years of age were: soccer (20.6%; CI 17.6%-23.6%); basketball (18.5%; CI 16.9%-20.1%); cheerleading (10.4%; CI 8.9%-11.9%); softball (10.1%; CI 9.0%-11.3%); volleyball (6.5%; CI 5.7%-7.2%). Simple univariate regression models showed that an increase of 10,000 annual female participants across all high school sports and recreational activities was associated with 308.7 (SE = 20.8, p < 0.001, R2 = 0.92) additional annual SRCs and CHIs presenting to US EDs. The promotion of concussion awareness and educational programs may help minimize SRCs and CHIs.

Editorial Commentary: The Epic Saga of the Anterior Cruciate Ligament and Anterolateral Complex of the Knee-Loyal Sidekick May Provide Protection Without Constraint.

There is a vast amount of conflicting literature evaluating the anatomic, biomechanical, and clinical outcomes of combined anterior cruciate ligament (ACL) and anterolateral complex injury. This has become-and remains-one of the most controversial topics in the ACL-deficient knee literature, thus requiring further inquiry with clear and systematic approaches to biomechanical analysis, indications, graft selection, surgical technique, and clinical outcome evaluation. The considerable variety of procedures to address anterolateral rotatory instability in the setting of ACL deficiency described in the literature strongly suggests the lack of a reliable and reproducible technique. Anterolateral complex reconstruction may provide protection to the ACL-reconstructed knee without detrimental overconstraint.

Opioid Prescribing Patterns of Orthopedic Surgery Residents After Open Reduction Internal Fixation of Distal Radius Fractures.

PURPOSE: In many academic medical centers, resident physicians typically write initial opioid prescriptions, but little is known about their prescribing practices. We hypothesized that lower resident postgraduate year, residency-training program, and noncompletion of an opioid prescribing training would be factors associated with increased opioid prescribing by orthopedic residents after open reduction and internal fixation of distal radius fractures. METHODS: A survey was administered to all 135 residents from 4 orthopedic residency programs in a state located in the northeastern United States between August 2017 and November 2017. Respondents were asked to indicate the initial analgesia (quantity and duration) they would prescribe for a younger and older, otherwise healthy, opiate-naïve female patient after open reduction and internal fixation of a distal radius fracture. We analyzed the quantity of initial opioids prescribed in morphine milligram equivalents (MME) and number of days supplied. Three different measures of overprescribing were assessed: prescribing over 150 MME, 225 MME, or 7 days of opioids. RESULTS: The response rate was 63% (85 of 135 residents). Of all respondents, 36.5% of residents reported completion of an opioid training in the past. In terms of overprescribing by duration, 19% of residents prescribed more than 7 days of opioids. For overprescribing by quantity, 36% to 59% (depending on patient age) of residents prescribed more than 20 tablets of 5 mg oxycodone (150 MME) and 16% to 25% (depending on patient age) prescribed more than 30 tablets of 5 mg oxycodone (225 MME). In comparison with junior residents, senior residents were more likely to prescribe over 225 MME. CONCLUSIONS: After open reduction and internal fixation of distal radius fractures, 19% of orthopedic surgery residents would prescribe more than 7 days of prescription opioids, which is beyond the state law maximum. In addition, we found that less than half of residents had participated in an opioid training program. Our results highlight the need for continued resident guidance when prescribing. Enrollment in opioid prescribing training programs that have been shown to decrease prescribed opioid quantities while still effectively managing patient pain is probably important. CLINICAL RELEVANCE: This study describes the opioid prescribing practices and prior training of orthopedic residents. It highlights an opportunity for increased involvement in educational programs on opioid prescribing that better align with published recommendations/guidelines.

The risk of nerve injury during anatomical and reverse total shoulder arthroplasty: an intraoperative neuromonitoring study.

BACKGROUND: This study compared the incidence and pattern of potential nerve injuries between reverse shoulder (RSA) and total shoulder arthroplasty (TSA) using intraoperative neuromonitoring. Our hypothesis was that RSA has a greater risk of nerve injury than TSA due to arm lengthening. METHODS: We reviewed 36 consecutive patients who underwent RSA (n = 12) or TSA (n = 24) with intraoperative neuromonitoring. The number of nerve alerts was recorded for each stage of surgery. Neurologic function was assessed preoperatively and postoperatively at routine follow-up visits. Predictive factors for increased intraoperative nerve alerts and clinically detectable neurologic deficits were determined. RESULTS: There were nearly 5 times as many postreduction nerve alerts per patient in the RSA cohort compared with the TSA cohort (2.17 vs. 0.46). There were 17 unresolved nerve alerts postoperatively, with only 2 clinically detectable nerve injuries, which fully resolved by 6 months postoperatively. A preoperative decrease in active forward flexion and the diagnosis of rotator cuff arthropathy were independent predictors of intraoperative nerve alerts. CONCLUSION: RSA has a higher incidence of intraoperative nerve alerts than TSA during the postreduction stage due to arm lengthening. Decreased preoperative active forward flexion and the diagnosis of rotator cuff arthropathy are predictors of more nerve alerts. The clinical utility of routine intraoperative nerve monitoring remains in question given the high level of nerve alerts and lack of persistent postoperative neurologic deficits.

Variability of MCID, SCB, and PASS Thresholds in Studies Assessing Patient-Reported Outcomes After Rotator Cuff Repair: A Systematic Review.

BACKGROUND: An increasing reliance on patient-reported outcomes has led to greater emphasis on minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) thresholds in assessing rotator cuff repairs. PURPOSE: To review the MCID, SCB, and PASS thresholds reported for patient-reported outcome measures (PROMs) after rotator cuff repair. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: The PubMed, Embase, Ovid, Cochrane, and Google Scholar databases were queried for full-text journal articles in English published between January 1, 2000, and May 31, 2022. Studies with MCID, SCB, and PASS thresholds reported for patients with rotator cuff repair and a minimum of 12 months of follow-up were included. Reported MCID, SCB, and PASS thresholds and associated calculation methods were extracted. RESULTS: There were 41 unique studies (6331 shoulders) that met the inclusion criteria. Of these, 37 (90%) reported MCID; 16 (39%), PASS; and 11 (27%), SCB values. The most common PROMs were the American Shoulder and Elbow Surgeons score and the Constant-Murley score. In total, 71% (29/41) of these studies referenced values in the literature, usually studies of patients undergoing rotator cuff repair (21/29). Twelve studies calculated MCID, SCB, or PASS thresholds using anchor-based approaches, whereas 6 studies also calculated thresholds using distribution-based methods. The use of MCID, SCB, and PASS in the rotator cuff repair literature is increasing, with half of the included studies published within the final 17 months of the studied period. CONCLUSION: Significant variability was seen in the reporting of MCID, SCB, and PASS threshold values after rotator cuff repair. Researchers should prioritize studies that report clinical outcome thresholds calculated using anchor-based methods and should critically review both the anchor question and its response choices. Standardization of MCID, SCB, and PASS values and calculation methods will allow for a more reliable assessment of PROMs in rotator cuff repair moving forward.

The Statistical Fragility of Marrow Stimulation for Cartilage Defects of the Knee: A Systematic Review of Randomized Controlled Trials.

OBJECTIVE: Marrow stimulation is used to address knee cartilage defects. In this study, we used the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to evaluate statistical fragility of outcomes reported in randomized controlled trials (RCTs) evaluating marrow stimulation. DESIGN: PubMed, Embase, and MEDLINE were queried for recent RCTs (January 1, 2010-September 5, 2023) assessing marrow stimulation for cartilage defects of the knee. The FI and rFI were calculated as the number of outcome event reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI by the study sample size. RESULTS: Across 155 total outcomes from 21 RCTs, the median FI was 3 (interquartile range [IQR], 2-5), with an associated median FQ of 0.067 (IQR, 0.033-0.010). Thirty-two outcomes were statistically significant, with a median FI of 2 (IQR, 1-3.25) and FQ of 0.050 (IQR, 0.025-0.069). Ten of the 32 (31.3%) outcomes reported as statistically significant had an FI of 1. In total, 123 outcomes were nonsignificant, with a median rFI of 3 (IQR, 2-5). Studies assessing stem cell augments were the most fragile, with a median FI of 2. In 55.5% of outcomes, the number of patients lost to follow-up was greater than or equal to the FI. CONCLUSION: Statistical findings in RCTs evaluating marrow stimulation for cartilage defects of the knee are statistically fragile. We recommend combined reporting of P-values with FI and FQ metrics to aid in the interpretation of clinical findings in comparative trials assessing cartilage restoration.

The Finger, Wrist, and Shoulder are the Most Commonly Injured Areas in Youth Volleyball Players but the Incidence of Injuries Decreased Overall Between 2012 and 2022.

Purpose: To analyze epidemiology, mechanisms, and diagnoses of upper extremity volleyball injuries in youth who present to United States emergency departments. Methods: Data from the National Electronic Injury Surveillance System were analyzed for upper extremity volleyball injuries in patients ≤18 years old from January 1, 2012, to December 31, 2022. Data were collected for body part, diagnosis, mechanism of injury, and disposition. Weighted national estimates were calculated using the hospitals' corresponding statistical sample weights. Linear regressions were used to analyze annual trends. χ2 tests were used to analyze categorical variables. Results: A weighted national estimate of 131,624 upper extremity volleyball-related injuries occurred in the study period. Average age was 13.9 ± 2.3 years. Female patients constituted 77.6% of patients; 99.3% of patients did not require admission. The most common body parts injured were fingers (43.0%), wrists (22.8%), and shoulders (12.2%). The most common identifiable mechanisms of injury were impacts with the floor (19.4%), impacts with the ball (14.7%), and spikes/serves (5.7%). Most common diagnoses were strains/sprains (42.6%) and fractures (19.5%). Most common locations of fracture were fingers (57.4% of all fractures), wrists (16.6%), and lower arms (12.4%). There was a decrease of 544 overall injuries per year (P = .03, 95% confidence interval [CI] -1031 to -58). Female players experienced more contusions/abrasions (16.0% vs 9.9%, P < .001) and strains/sprains (46.1% vs 30.4%, P < .001) compared with male players. Female patients had decreases of 513 overall injuries (P = .01, 95% CI -881 to -144), 349 strains/sprains (P = .002, 95% CI -530 to -168), 102 contusions/abrasions (P = .008, 95% CI 170 to -34), and 92 fractures per year (P = .03, 95% CI -175 to -10). Conclusions: Youth volleyball players are at risk of upper extremity injury, particularly involving the fingers, wrist, and shoulder. Despite increasing national participation in youth volleyball, there is a decreasing incidence of upper extremity injuries. Level of Evidence: Level IV, prognostic case series.