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Background: Patients undergoing elective procedures often utilize online educational materials to familiarize themselves with the surgical procedure and expected postoperative recovery. While the Internet is easily accessible and ubiquitous today, the ability of patients to read, understand, and act on these materials is unknown. Purpose: To evaluate online resources about anterior cruciate ligament (ACL) surgery utilizing measures of readability, understandability, and actionability. Study Design: Cross-sectional study; Level of evidence, 4. Methods: Using the term “ACL surgery,” 2 independent searches were performed utilizing a public search engine ( Google.com ). Patient education materials were identified from the top 50 results. Audiovisual materials, news articles, materials intended for advertising or medical professionals, and materials unrelated to ACL surgery were excluded. Readability was quantified using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, Coleman-Liau Index, Automated Readability Index, and Gunning Fog Index. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) was utilized to assess the actionability and understandability of materials. For each online source, the relationship between its Google search rank (from first to last) and its readability, understandability, and actionability was calculated utilizing the Spearman rank correlation coefficient (ρS). Results: Overall, we identified 68 unique websites, of which 39 met inclusion criteria. The mean Flesch-Kincaid Grade Level was 10.08 ± 2.34, with no website scoring at or below the 6th-grade level. Mean understandability and actionability scores were 59.18 ± 10.86 (range, 33.64-79.17) and 34.41 ± 22.31 (range, 0.00-81.67), respectively. Only 5 (12.82%) and 1 (2.56%) resource scored above the 70% adequate PEMAT-P threshold mark for understandability and actionability, respectively. Readability (lowest P value = .103), understandability (ρS = –0.13; P = .441), and actionability (ρS = 0.28; P = .096) scores were not associated with Google rank. Conclusion: Patient education materials on ACL surgery scored poorly with respect to readability, understandability, and actionability. No online resource scored at the recommended reading level of the American Medical Association or National Institutes of Health. Only 5 resources scored above the proven threshold for understandability, and only 1 resource scored above it for actionability.

Background: Anterior cruciate ligament (ACL) tears are common in collegiate athletes. The rate of return to the preinjury level of sport activities after ACL reconstruction continues to evolve. Purpose/Hypothesis: The purpose was to determine the return-to-sport rate after ACL reconstruction in a cohort of National Collegiate Athletic Association Division I athletes in different sports. It was hypothesized that, with intensive supervision of rehabilitation, the return-to-sport rate would be optimal. Study Design: Case series; Level of evidence, 4. Methods: We retrospectively reviewed the records of 75 collegiate athletes from a single institution who had undergone unilateral or bilateral ACL reconstruction between 2001 and 2013 and participated in an extensive supervised rehabilitation program. Prospectively collected athlete data as well as data about preinjury exposure, associated lesions, surgical technique, time lost to injury, number of games missed, time to return to full sport activity or retire, and subsequent surgical procedures were extracted from the medical and athletic trainer records. Results: The 75 patients (40 male, 35 female; mean age, 20.1 years) underwent 81 reconstruction procedures (73 primary, 8 revision). The mean follow-up was 19.3 months. The overall return-to-sport rate was 92%. After reconstruction, 9 athletes (12%) retired from collegiate sports, but 3 of them returned to sport activities after graduation. Overall, 8 athletes (11%) experienced an ACL graft retear. Conclusion: The return-to-sport rate in our National Collegiate Athletic Association Division I athletes compared favorably with that reported in other studies in the literature. The strict follow-up by the surgeon, together with the high-profile, almost daily technical and psychological support given mainly by the athletic trainers during the recovery period, may have contributed to preparing the athletes for a competitive rate of return to sport at their preinjury level.

Objectives: The prevalence of preoperative psychiatric comorbidities and substance abuse disorders among patients undergoing common sports medicine operative procedures has yet to be delineated. This study investigated the prevalence and influence of preoperative psychiatric comorbidities on costs following ten common orthopaedic sports medicine procedures. Methods: The Humana Inc. administrative claims database was accessed using the PearlDiver research program to identify patients undergoing ten common Sports Medicine interventions (Starman et al,, JBJS, 2010) (Table 1): ACL reconstruction; PCL reconstruction; MCL repair/reconstruction; achilles reconstruction; rotator cuff repair; meniscal repair/reconstruction; hip arthroscopy; arthroscopic shoulder labral repair; patellofemoral instability; and shoulder instability repair from 2007-2017q1. Patients were stratified by preoperative diagnoses (Table 2) of depression, anxiety, bipolar disorder, or schizophrenia. Cohorts included patients with ≥1 psychiatric comorbidity [Psychiatric] vs. those without psychiatric comorbidities [No Psychiatric]. Patients were assessed for diagnosed substance-abuse disorders, including alcohol use disorder, opioid use disorder, or tobacco use disorder. Temporal trends from 2007-2016 [rate of ≥1 psychiatric co-morbidity] were assessed per 100,000 persons utilizing linear regression and ANOVA regression analyses. Differences in costs across groups were assessed utilizing MannWhitney tests using the R statistical tool housed within the PearlDiver research program. Results: The prevalence of ≥1 psychiatric co-morbidity [Psychiatric] in the whole database was 10.31% versus 21.21% amongst those patients undergoing one of the ten common orthopaedic interventions. Rotator cuff repair (28%), meniscus repair (24.58%), and hip arthroscopy with concomitant labral repair (26.27%) had the highest prevalence of patients with ≥1 psychiatric co-morbidity diagnosed preoperatively. The presence of ≥1 psychiatric co-morbidities diagnosed preoperatively versus those without psychiatric co-morbidities was associated with increased per capita patient costs (all p0.05, Table 5-6; Figure 1) from 2007-2016. Conclusion: The prevalence of preoperatively diagnosed psychiatric comorbidities among patients undergoing orthopaedic sports medicine procedures (21.21%) is alarmingly high and nearly two times higher than baseline rates reported in the database. The presence of psychiatric comorbidities preoperatively was associated with increased costs for all investigated orthopaedic sports medicine procedures, warranting further investigation. 1Quality and Content of Internet-Based Information for Ten Common Orthopaedic Sports Medicine Diagnoses. Starman, J.S., Gettys, F.K., Capo, J.A., Fleischli, J.E., Norton, H.J. and Karunakar, M.A. JBJS. (92)1612-1618. 2010. [Figure: see text][Figure: see text][Figure: see text][Figure: see text]

Objectives: Labral tears are often described by either their location (superior, anterior, or posterior) or their size, commonly defined as degrees of labral involvement from 0° to 360°. Large tears are thought to include 270° or more of the labrum, which has been reported to include 3.3% to 6.5% of those undergoing shoulder instability surgery for labral pathology. Demographic or injury characteristics of those with large labral tears (>270°) has not been defined in the literature. The purpose of this study was to identify factors predictive of a large labral tear at the time of shoulder instability surgery. Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Those with an isolated SLAP (superior labrum anterior to posterior) tear or a concomitant rotator cuff tear requiring repair were excluded. Demographic data, injury history, preoperative patient-reported outcome scores (PROs), imaging and intraoperative findings, and surgical procedures performed were recorded. The treating surgeon reported the size and location of labral pathology visualized at the time of surgery. Patients with greater than a 270° tear were defined as having a large labral tear. For categorical demographic variables, a chi-square test or Fisher’s Exact test was used, as appropriate based on cell counts. For continuous demographic variables, a two-sample t-test was performed. In order to build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm (Lambert et al. 2018) was used to add significant interaction effects iteratively until no more significant two-way interactions could be added to the model. Results: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort with an average age of 24.7 years old (12 – 66 years old). The incidence of large tears was 4.6% with the average tear size being 141.9°, or 39.4%. Males accounted for significantly more of the large tears seen in the cohort (94.7%, p = 0.01). Racquet sports (p = 0.002), swimming (p = 0.02), softball (p = 0.05), skiing (p = 0.04), and golf (p = 0.04) were all found to be predictive of large labral tears as was a higher Western Ontario Shoulder Instability (WOSI) score (p = 0.01) (Table 1). Patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (p = 0.007). Age, race, history of dislocation, injury during sport, or previous shoulder surgery were not associated with having a larger tear. Conclusion: Patients with large labral tears are a small, but not insignificant, subset of patients undergoing shoulder instability surgery. Multiple factors were identified as being associated with large labral tears at the time of surgery including male sex, pre-operative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. Surgeons treating patients with these risk factors should be prepared to encounter a large labral tear at the time of surgery. Further studies will evaluate the outcomes of this patient population. Table 1. Comparison of patient demographics and sport history between shoulder instability patients with large labral tears (>270°). Small Tears (270°) P N 1178 (95.4%) 57 (4.6%) - Sex (F, M (%F)) 219,959 (81.4% M) 3, 54 (94.7% M) 0.01 Age 24.69.0 265.9.7 0.13 Injury During Sport 836 (71.0%) 42 (73.7%) 0.74 Racquet Sport 46 (3.9%) 7 (12.3%) 0.002 Swimming 205 (17.4%) 17 (29.8%) 0.02 Softball 114 (9.7%) 10 (17.5%) 0.05 Skiing 206 (17.5%) 16 (28.1%) 0.04 Golf 225 (19.0%) 17 (19.8%) 0.04

Objectives: The current opioid epidemic in the United States is a significant cause of increasing morbidity and mortality. The purpose of this study was to determine rate of opioid use before and after arthroscopic meniscal surgery, and assess patient factors associated with prolonged opioid use following primary arthroscopic meniscal surgery. Methods: Patients undergoing primary arthroscopic meniscal surgery procedures from 2007-2016 were retrospectively accessed from the Humana Inc. administrative claims database. Patients were categorized as patients who filled opioid prescriptions within 3 months (OU), within 1 month (A-OU), between 1 to 3 months (C-OU), and never filled opioid prescriptions (N-OU) before surgery. Rates of opioid use were evaluated preoperatively and longitudinally tracked for OU and N-OU cohorts. Prolonged opioid use was defined as continued opioid prescription filling at ≥3 months after surgery. Multiple logistic regression analysis was used to control for various patient characteristics and identify factors associated with opioid use at 12 months after surgery, with significance defined as PResults: There were 107,717 patients (54% female) that underwent arthroscopic meniscal surgery during the study period, of which 46.1% (n=49,630) were N-OU. One year after surgery, opioid fill rate was significantly higher in the OU group compared to the N-OU group with a relative risk of 6.98 (21.1% vs 3.02%; 95% CI: 6.61-7.36; pConclusion: Preoperative opioid use is a significant risk factor for opioid use at 12 months following surgery. Diabetes mellitus, hypertension, chronic obstructive pulmonary disease, smoking status, and psychiatric diagnosis were independent risk factors for opioid use 1-year following surgery.

Background: Patients who have undergone shoulder instability surgery are often allowed to return to sports, work, and high-level activity based largely on a time-based criterion of 6 months postoperatively. However, some believe that advancing activity after surgery should be dependent on the return of strength and range of motion (ROM). Hypothesis: There will be a significant loss of strength or ROM at 6 months after arthroscopic Bankart repair with remplissage compared with Bankart repair alone. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 38 patients in a prospective multicenter study underwent arthroscopic Bankart repair with remplissage (33 males, 5 females; mean age, 27.0 ± 10.2 years; 82% with ≥2 dislocation events in the past year). Strength and ROM were assessed preoperatively and at 6 months after surgery. Results were compared with 104 matched patients who had undergone Bankart repair without remplissage, although all had radiographic evidence of a Hill-Sachs defect. Results: At 6 months, there were no patients in the remplissage group with anterior apprehension on physical examination. However, 26% had a ≥20° external rotation (ER) deficit with the elbow at the side, 42% had a ≥20° ER deficit with the elbow at 90° of abduction, and 5% had persistent weakness. Compared with matched patients who underwent only arthroscopic Bankart repair, the remplissage group had greater humeral bone loss and had a greater likelihood of a ≥20° ER deficit with the elbow at 90° of abduction ( P = .004). Risk factors for a ≥20° ER deficit with the elbow at 90° of abduction were preoperative stiffness in the same plane ( P = .02), while risk factors for a ≥20° ER deficit with the elbow at the side were increased number of inferior quadrant glenoid anchors ( P = .003), increased patient age ( P = .02), and preoperative side-to-side deficits in ER ( P = .04). The only risk factor for postoperative ER weakness was preoperative ER weakness ( P = .04), with no association with remplissage ( P = .26). Conclusion: Arthroscopic Bankart repair with remplissage did not result in significant strength deficits but increased the risk of ER stiffness in abduction compared with Bankart repair without remplissage at short-term follow-up.

Background: Lower socioeconomic status (SES) is associated with worse patient-reported outcome (PRO) after orthopaedic procedures. In patients with anterior cruciate ligament (ACL) reconstruction, evaluating SES by use of traditional measures such as years of education or occupation is problematic because this group has a large proportion of younger patients. We hypothesized that lower education level and lower values for SES would predict worse PRO at 2 years after ACL reconstruction and that the effect of education level would vary with patient age. Purpose: To compare the performance of multivariable models that use traditional measures of SES with models that use an index of neighborhood SES derived from United States (US) Census data. Study Design: Cohort study; Level of evidence, 3. Methods: A cohort of 675 patients (45% female; median age, 20 years), were prospectively enrolled and evaluated 2 years after ACL reconstruction with questionnaires including the International Knee Documentation Committee (IKDC) questionnaire, the Knee injury and Osteoarthritis Outcome Score (KOOS), and the Marx activity rating scale (Marx). In addition, a new variable was generated for this study, the SES index, which used geocoding performed retrospectively to identify the census tract of residence for each participant at the time of enrollment and extract neighborhood SES measures from the 2000 US Census Descriptive Statistics. Multivariable models were constructed that included traditional measures of SES as well as the SES index, and the quality of models was compared through use of the likelihood ratio test. Results: Lower SES index was associated with worse PRO for all measures. Models that included the SES index explained more variability than models with traditional SES. In addition, a statistically significant variation was found regarding the impact of education on PRO based on patient age for the IKDC score, the Marx scale, and 4 of the 5 KOOS subscales. Conclusion: This study demonstrates that lower neighborhood SES is associated with worse PRO after ACL reconstruction and that age and education have a significant interaction in this patient population. Future studies in patients who have undergone ACL reconstruction should attempt to account for neighborhood SES when adjusting for confounding factors; further, targeting patients from areas with lower neighborhood SES with special interventions may offer an opportunity to improve their outcomes.

Objectives: The Latarjet procedure is the becoming increasingly popular for the treatment of young athletes with recurrent instability. Earlier return to play protocols have been trialed with the thought that one is primarily waiting on bone healing. However, the impact of post-operative range of motion (ROM) and strength must be considered as well. Return to play has traditionally been accepted at 6 months post-operatively, but it is unknown what percentage of athletes achieve full strength and range of motion at that point. The purpose of this study was to 1) To evaluate rates of return of full strength and range of motion at 6 months after Latarjet, and 2) determine whether rates of results vary by percent bone loss, subscapularis split versus tenotomy, or athlete status (contact or overhead). Methods: Ten participating sites throughout the United States enrolled patients in a multicenter prospective cohort study. Sixty-five athletes met inclusion criteria (mean age 24.5 SD 8.2; 59 male, 6 female) and underwent Latarjet procedure for anterior instability (19/65 (29%) primary operation, 46/65 (71%) had a prior failed anterior stabilization). All participated in either contact sports (83%) and/or overhead sports (37%). Regarding anterior glenoid bone loss, 10% had Results: 45% of patients failed to meet one or more return to play criteria: 9% failed for persistent weakness and 39% for ≥ 20 degree side to side loss of motion. All patients with loss of motion had ≥ 20 degree external rotation (ER) deficits either with elbow at side (88%) or at 90 degrees abduction (44%). There was no difference in achieving RTP criteria at 6 months between subscapularis split versus tenotomy either for strength (p=0.89) or range of motion (p=0.53). Contact athletes had a 53% RTP rate while overhead athletes had a 67% passage rate (p=0.17). Pre-operative weakness was not significantly predictive of post-operative weakness (p=0.13), and pre-operative external rotation was not predictive of post-operative ER deficits (p=0.16). Percent bone loss was not predictive of side-to side post-operative ROM deficits or weakness (p>0.20 all planes of motion). No other predictors for failure to meet RTP criteria at 6 months were identified. Conclusion: A large percentage of athletes do not have full return of strength and range of motion at 6 months following Latarjet procedure. Further consideration may be warranted prior to releasing these athletes to contact sports.

Background: Injuries to the posterolateral corner (PLC) may occur concurrently with anterior cruciate ligament (ACL) injury. Purpose/Hypothesis: This study evaluated the outcomes of patients who underwent operative management of PLC injuries concurrently with ACL reconstruction in a prospective multicenter cohort. We hypothesized that there would be no differences in outcomes between patients who were treated with PLC repair and PLC reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing ACL reconstruction were enrolled into a prospective longitudinal multicenter cohort between 2002 and 2008. Those with complete 6-year follow-up data (patient-reported outcomes and subsequent surgery information) were identified. Excluded from the study were patients with posterior cruciate ligament injuries. Patients who underwent PLC repair were compared with those who underwent PLC reconstruction with regard to interval from injury to surgery, need for revision surgery, and long-term outcomes at 6 years. Results: During the identified time frame, 3026 identified patients underwent primary ACL reconstruction; 34 (1.1%) also underwent concurrent PLC surgery (15 repairs, 19 reconstructions [18 allografts, 1 autograft]). With the numbers available, we did not detect significant differences between groups regarding the rate of meniscal or chondral injuries. Median time to PLC reconstruction was 121 days as compared with 19 days for concurrent ACL reconstruction and PLC repair ( P = .01). There were no between-group differences in Marx activity scores prior to surgery ( P = .4). At 6-year follow-up, there were no between-group differences in Knee injury and Osteoarthritis Outcome Score ( P = .36-.83) or International Knee Documentation Committee score ( P = .84); however, patients treated with PLC reconstructions had lower Marx activity scores (4.1 vs 9.4; P = .02). There was 1 ACL revision in the PLC reconstruction group, and 1 of the PLC repairs was revised to a reconstruction during the follow-up period. Conclusion: Good outcomes were achieved at 6-year follow-up with both repair and reconstruction of PLC injuries treated concurrently with ACL reconstruction. The PLC reconstruction group had lower activity levels 6 years after surgery. The present data suggest that, for appropriately selected patients undergoing acute surgical treatment of combined ACL and PLC injuries, PCL repair can achieve good long-term outcomes.

Objectives: To compare knotless versus traditional glenoid anchors as well as use of all-suture versus non-all suture anchor material in early outcomes after arthroscopic shoulder stabilization. We hypothesize there is no difference in outcomes between anchor type or material. Methods: Patients who were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group instability database completed a series of patient reported outcomes (PROs) pre and post-operatively at 2 years. At the time of surgery, physicians documented technique utilized and materials employed. The incidence of subsequent shoulder surgeries, re-dislocations or subluxations, and return to sport (RTS) were obtained. Patients were stratified by anchor type (knotless [KL] versus knotted [KT]) and then by anchor material (all-suture [AS] versus non-all suture [NS]). Bivariate analyses were performed to compare outcomes between groups, including the Wilcoxon signed-rank test and chi-square test. Results: A total of 447 patients who underwent primary arthroscopic shoulder stabilization were evaluated, with 112 patients in the KL group (90.2% male) and 335 in the KT group (82.4% male; p > .05). Then there were 70 patients in the AS group (74.3% male) and 377 in the NS group (86.2% male; p = .01). The KT group (24.6 ± 8.9 years) was significantly older than the KL group (21.3 ±7.8 years; p = .0003) while the AS group (26.8 ±9.1 years) was significantly older than the NS group (23.2 ±8.6 years; p = .003). Significantly more patients in the KL group (87.5%) underwent surgery in the beach chair (BC) position than the KT group (45.4%; p < .0001) and significantly more patients in the NS group (59.9%) underwent surgery in the BC position than the AS group (34.3%; p < .0001). The primary direction of instability was anterior, with 78.6% in the KL group, 71.3% in the KT group, 82.9% in the AS group and 71.4% in the NS group. The number of contact athletes was similar in each group, with 75.0% in the KL group, 66.0% in the KT group, 70.0% in the AS group, and 67.9% in the NS group. Significantly more anchors were used in the KL group (4.2 ± 1.6) compared to the KT group (3.9 ± 1.8; p = .003) and significantly more anchors were used in the AS group (5.3 ± 2.4) compared to the NS group (3.7 ± 1.4; p < .0001). Significantly more patients had a redislocation in the KL group (11.6%) compared to the KT group (5.7%; p = .03), and significantly more patients had a redislocation in the NS group (8.2%) compared to the AS group (1.4%; p = .04). There were no significant differences in improvement of any PROs, incidence of RTS, subsequent shoulder surgeries or subluxations between anchor type or material groups. Conclusion: Compared to traditional knotted glenoid anchors, patients undergoing arthroscopic shoulder stabilization with knotless anchors can expect to experience similar clinical outcomes. However, use of knotless anchors may be a significant risk factor for subsequent dislocation 2 years after arthroscopic shoulder stabilization surgery, which may be related to patients’ age. Moreover, use of all-suture based anchors may be associated with lower rates of subsequent dislocation which may be attributed to the size of their footprint and the apparent inclination of surgeons using these to utilize more anchors per labral repair, thus increasing points of labral fixation. Continued investigation of potential confounding variables is necessary to identify the direct effect of anchor type and material on patient outcomes.

Background: Ulnar collateral ligament (UCL) reconstruction, distal biceps tendon repair, and elbow arthroscopic surgery are common elbow procedures performed in active patients. Hypothesis: We hypothesized (1) good to excellent correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and traditional orthopaedic upper extremity patient-reported outcome (PRO) measures; (2) that PROMIS instruments would demonstrate ceiling effects; and (3) that the PROMIS physical function computer adaptive test (PF CAT) would demonstrate a low question burden compared with other PRO instruments. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 76 patients undergoing UCL repair/reconstruction, distal biceps tendon repair, or elbow arthroscopic surgery filled out the Short Form–36 Health Survey (SF-36) Physical Function subscale, EuroQol–5 Dimensions (EQ-5D) questionnaire, PROMIS PF CAT, and PROMIS upper extremity item bank (UE). Excellent correlation between PROs was defined as ≥.70. Results: The PROMIS PF CAT had excellent correlation with the SF-36 ( r = 0.74; P < .0001), Disabilities of the Arm, Shoulder and Hand (DASH) survey ( r = –0.76; P < .0001), and PROMIS UE ( r = 0.73; P < .0001). The PROMIS UE demonstrated excellent correlation with the SF-36 ( r = 0.73; P < .0001) and DASH survey ( r = –0.81; P < .0001). The PROMIS UE had ceiling effects in 33% of patients. The SF-36 showed ceiling effects in 20% of patients. On average, patients answered 5.1 ± 2.2 questions on the PROMIS PF CAT. Conclusion: The PROMIS PF CAT and PROMIS UE are valid in patients undergoing distal biceps tendon repair, elbow arthroscopic surgery, and UCL repair. The PROMIS UE demonstrated high ceiling effects in younger, higher functioning patients and should be used with caution in this group. A further evaluation and modification of the PROMIS UE in younger, high-functioning patients are warranted. Finally, the PROMIS PF CAT exhibited a low question burden relative to traditional PRO instruments without the loss of reliability.

Background:When meniscal repair is performed during anterior cruciate ligament (ACL) reconstruction (ACLR), the effect of ACL graft type on meniscal repair outcomes is unclear.Hypothesis:The authors hypothesized that meniscal repairs would fail at the lowest rate when concomitant ACLR was performed with bone--patellar tendon--bone (BTB) autograft.Study Design:Cohort study; Level of evidence, 3.Methods:Patients who underwent meniscal repair at primary ACLR were identified from a longitudinal, prospective cohort. Meniscal repair failures, defined as any subsequent surgical procedure addressing the meniscus, were identified. A logistic regression model was built to assess the association of graft type, patient-specific factors, baseline Marx activity rating score, and meniscal repair location (medial or lateral) with repair failure at 6-year follow-up.Results:A total of 646 patients were included. Grafts used included BTB autograft (55.7%), soft tissue autograft (33.9%), and various allografts (10.4%). We identified 101 patients (15.6%) with a documented meniscal repair failure. Failure occurred in 74 of 420 (17.6%) isolated medial meniscal repairs, 15 of 187 (8%) isolated lateral meniscal repairs, and 12 of 39 (30.7%) of combined medial and lateral meniscal repairs. Meniscal repair failure occurred in 13.9% of patients with BTB autografts, 17.4% of patients with soft tissue autografts, and 19.4% of patients with allografts. The odds of failure within 6 years of index surgery were increased more than 2-fold with allograft versus BTB autograft (odds ratio = 2.34 [95% confidence interval, 1.12-4.92]; P = .02). There was a trend toward increased meniscal repair failures with soft tissue versus BTB autografts (odds ratio = 1.41 [95% confidence interval, 0.87-2.30]; P = .17). The odds of failure were 68% higher with medial versus lateral repairs ( P < .001). There was a significant relationship between baseline Marx activity level and the risk of subsequent meniscal repair failure; patients with either very low (0-1 points) or very high (15-16 points) baseline activity levels were at the highest risk ( P = .004).Conclusion:Meniscal repair location (medial vs lateral) and baseline activity level were the main drivers of meniscal repair outcomes. Graft type was ranked third, demonstrating that meniscal repairs performed with allograft were 2.3 times more likely to fail compared with BTB autograft. There was no significant difference in failure rates between BTB versus soft tissue autografts.Registration:NCT00463099 (ClinicalTrials.gov identifier).

Objectives: The purpose of the study was to investigate the association between preoperative opioid use and persistent postoperative use, and determine the impact of preoperative opioid use on patient reported outcomes (PROs) in patients undergoing patellofemoral stabilization surgery. Methods: A retrospective analysis of 60 patients after patellofemoral stabilization surgery with a minimum of 2-year follow-up was performed using a prospectively-collected patellar instability registry. Patients were categorized as opioid naïve (n=48) or preoperative opioid users (n=12). Postoperative opioid use was assessed for all patients at 2 and 6 weeks. Knee Injury and Osteoarthritis Outcome Score (KOOS) and Kujala questionnaires were administered at baseline, and 6 months and 2 years postoperatively. Results: Preoperative opioid use was identified as an independent risk factor for postoperative opioid use at 2- and 6-weeks following surgery (p=0.0023 and p

Background: The Patient-Reported Outcome Measurement Information System (PROMIS) was developed to improve patient-reported outcome measures (PROMs) and administration through a computer adaptive test (CAT). The PROMIS physical function-CAT (PF-CAT) has not been investigated in patients with patellofemoral instability (PFI). Purpose/Hypothesis: The purpose of this study was to evaluate the construct validity of the PROMIS PF-CAT with previously validated tools for measuring PROMs in patients with a diagnosis of PFI. We hypothesized that the PF-CAT will have the strongest correlations with other PROMs that evaluated PF as well as moderate correlations with PROMs that measured other health domains. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients enrolled in this study who underwent operative intervention for PFI completed the following evaluations preoperatively: PROMIS PF-CAT, 36-Item Short Form Health Survey (SF-36), Knee injury and Osteoarthritis Outcome Score (KOOS), EuroQol-5 dimensions (EQ-5D), and Kujala Anterior Knee Pain Scale (AKPS). Correlation coefficients and the percentage of patients achieving the highest and lowest possible outcome score of each instrument were calculated to assess floor and ceiling effects. Statistical significance was defined as P < .05. Results: In total, 91 participants (63.7% females; mean age, 20.1 ± 7.2 years) completed the questionnaires. PF-CAT had the lowest number of questions (4.3 ± 1.1). The strongest correlations were between the PF-CAT and SF-36 PF subscale ( r = 0.78; P < .01), AKPS ( r = 0.68; P < .01), and KOOS Activities of Daily Living subscale ( r = 0.68; P < .01). Correlation was moderate between the PF-CAT and the KOOS subscales of Sports/Recreation ( r = 0.58; P < .01), Quality of Life ( r = 0.53; P < .01), and Symptoms ( r = 0.47; P < .01). The PROMIS PF-CAT demonstrated no floor or ceiling effects. Conclusion: In patients with PFI, construct validity of the PROMIS PF-CAT was supported by strong correlations demonstrated between the PF-CAT and PROMs evaluating PF and moderate correlations with those assessing other health domains. Our results demonstrated a low respondent burden and no floor or ceiling effects associated with the PROMIS PF-CAT. The PROMIS PF-CAT may be considered a beneficial alternative to previously established PF PROMs for preoperative evaluation of patients with PFI.

Background: The glenohumeral joint combines large range of motion and insufficient bony stabilization, making it susceptible to instability and dislocations. Arthroscopic surgery is routinely used as a diagnostic tool and has been considered the gold standard for the diagnosis of shoulder lesions. However, several studies have demonstrated variability in intraobserver and interobserver agreement. Purpose: To evaluate interobserver and intraobserver agreement in the assessment of intra-articular lesions associated with shoulder instability among fellowship-trained shoulder surgeons. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 24 arthroscopic videos from patients treated for recurrent shoulder instability were shown to a group of 10 fellowship-trained shoulder surgeons who are members of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group. They were presented to the surgeons on 2 different occasions at least 2 months apart. They were asked to classify labral tears by their position, type, extension, other intra-articular abnormality, and preferred treatment. No patient history or physical examination data were provided. The primary outcome was the median overall percentage of agreement for the surgeons performing a video review, measured for each variable evaluated. Intraclass correlation coefficients were used to evaluate continuous variables, and kappa values were used for categorical items. Results: Interobserver agreement was good for anterior labral lesions; good for Hill-Sachs lesions; and moderate for lesions of the superior labrum, posterior labrum, anterior sublabral foramen, and position and extension of the tear. Intraobserver agreement was either good or very good for all variables evaluated, except for being poor for inferior labral lesions and moderate for lesions of the meniscoid superior labrum. Conclusion: Interobserver and intraobserver reliability for the arthroscopic assessment of labral tears in patients with recurrent shoulder instability were good to moderate for the majority of anatomic structures assessed. There was relatively good agreement between shoulder instability surgeons on assessing and documenting shoulder instability–associated abnormalities. These findings are important when interpreting collaborative clinical cohort studies with numerous surgeons involved in the research.

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) is designed to advance patient-reported outcome (PRO) instruments by utilizing question banks for major health domains. Purpose: To compare the responsiveness and construct validity of the PROMIS physical function computer adaptive test (PF CAT) with current PRO instruments for patients before and up to 2 years after anterior cruciate ligament (ACL) reconstruction. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Initially, 157 patients completed the PROMIS PF CAT, Short Form–36 Health Survey (SF-36 physical function [PF] and general health [GH]), Marx Activity Rating Scale (MARS), Knee injury and Osteoarthritis Outcome Score (KOOS activities of daily living [ADL], sport, and quality of life [QOL]), and EuroQol–5 dimensions questionnaire (EQ-5D) at 6 weeks, 6 months, and 2 years after ACL reconstruction. Correlations between instruments, ceiling and floor effects, effect sizes (Cohen d), and standardized response means to describe responsiveness were evaluated. Subgroup analyses compared participants with and without additional arthroscopic procedures using linear mixed models. Results: At baseline, 6 weeks, and 6 months, the PROMIS PF CAT showed excellent or excellent-good correlations with the SF-36 PF ( r = 0.75-0.80, P < .01), KOOS-ADL ( r = 0.63-0.70, P < .01), and KOOS-sport ( r = 0.32-0.69, P < .01); excellent-good correlation with the EQ-5D ( r = 0.60-0.71, P < .01); and good correlation with the KOOS-QOL ( r = 0.52-0.58, P < .01). As expected, there were poor correlations with the MARS ( r = 0.00-0.24, P < .01) and SF-36 GH ( r = 0.16-0.34, P < .01 ). At 2 years, the PROMIS PF CAT showed good to excellent correlations with all PRO instruments ( r = 0.42-0.72, P < .01), including the MARS ( r = 0.42, P < .01), indicating frequent return to preinjury function. The PROMIS PF CAT had the fewest ceiling or floor effects of all instruments tested, and patients answered, on average, 4 questions. There was no significant difference in baseline physical function scores between subgroups; at follow-up, all groups showed improvements in scores that were not statistically different. Conclusion: The PROMIS PF CAT is a valid tool to assess outcomes after ACL reconstruction up to 2 years after surgery, demonstrating the highest responsiveness to change with the fewest ceiling and floor effects and a low time burden among all instruments tested. The PROMIS PF CAT is a beneficial alternative for assessing physical function in adults before and after ACL reconstruction.

Objectives: Anterior cruciate ligament reconstruction is a commonly performed orthopaedic procedure. PROMIS (Patient-Reported Outcome Measurement Information System) was developed by the National Institutes of Health in an effort to advance patient-reported outcome (PRO) instruments by developing question banks for major health domains. Our goal was to compare the responsiveness and construct validity of the PROMIS physical function (PF) computer adaptive test (CAT) with current PRO instruments utilized in patients who undergo anterior cruciate ligament reconstruction. Methods: A total of 174 patients ages 14-53 scheduled to undergo anterior cruciate ligament reconstruction were asked to complete PROMIS PF-CAT, Short Form-36 Health Survey (SF36-PF and -GH), Marx activity rating scale (Marx), Knee Injury and Osteoarthritis Score (KOOS-ADL, -Sport, -QOL), and the EuroQol five dimensions questionnaire (EQ5D) at their preoperative visit. These surveys were repeated at six weeks and six months after surgery. Correlations between PRO instruments was defined as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), and poor (0.2-0.3) using Spearman Correlation Coefficients. The effect size (Cohen d) and standardized response mean (SRM) were used to describe the responsiveness of each PRO at the 6 week and 6 month follow-up visits and were defined as small (0.2), medium (0.5) and large (0.8). Ceiling and floor effects were defined as present if ≥15% of participants scored the highest or lowest score on a PRO, respectively. Subgroup analyses were performed comparing change in PRO scores at follow-up between participants with and without additional arthroscopic procedures (meniscal debridement and/or repair, microfracture, or OATS vs ACL reconstruction only) using linear mixed models. Results: There were excellent and excellent-good correlations between the PROMIS PF-CAT and physical function PROs including the SF36-PF (r=0.75-0.80, p0.05) to poor correlation with Marx activity (r=0.24, pConclusion: Our results support the construct validity of the PROMIS PF-CAT in patients who undergo ACL reconstruction. Responsiveness to change was highest by 6 months postop and greater for the PROMIS PF-CAT than for other measures of physical function with no ceiling or floor effects and a low time-burden. Taken together, these findings suggest that the PROMIS PF-CAT is a beneficial alternative to measuring and tracking changes in physical function in adults undergoing ACL reconstruction.

Objectives: Surgeons and healthcare systems have received a call to action in an effort to curtail the current opioid epidemic in the United States. Postoperative opioid demand after anterior cruciate ligament reconstruction (ACLR) is not well understood. The purpose of this study was to (1) define the natural history of opioid demand after ACLR performed with and without concomitant procedures and to (2) evaluate preoperative opioid demand as a risk factor for postoperative opioid demand. Methods: Arthroscopic ACLRs performed in the Humana Inc. database between 2007-2014 were identified using CPT code 29888. Further categorization of procedures was performed by identifying patients who underwent ACLR with no other procedures, those who underwent ACLR with meniscus repair, those who underwent ACLR with menisectomy, and those who underwent ACLR with microfracture. Postoperative opioid demand was trended by month following surgery for 1 year. The effect of preoperative opioid demand on postoperative opioid demand was evaluated by comparing those who had filled preoperative opioid prescriptions with those who hadn′t. Patients were considered preoperative opioid users if they had filled an opioid prescription in the 3 months preceding surgery. Relative risk of postoperative opioid use was calculated and 95% confidence intervals (CI) were determined. Results: Over the course of the study period, 4,946 arthroscopic ACLRs were performed. Of these, 7.24% were still filling opioid prescriptions at 2-3 months after their procedure; 4.71% of patients were filling opioid prescriptions at 1 year after surgery. Patients undergoing ACLR with microfracture were at increased risk of filling narcotic prescriptions compared to the other procedure groups. At 4-5 months postoperatively, ACLR with microfracture had increased risk of filling narcotic prescriptions compared to ACLR alone 1.96 (CI=1.32-2.92), ACL with meniscus repair 2.38 (CI=1.46-3.88), and ACL with meniscectomy 1.51 (CI=1.03-2.23). Nearly 35% of patients (1,716/4,946) were taking opioid pain medications in the 3 months prior to ACLR. Those filling preoperative opioid prescriptions were 5.34 (CI=4.12-6.94) times more likely to be filling narcotic prescriptions at 2-3 months after ACL reconstruction. Those filling preoperative opioid prescriptions were 7.54 (CI=5.32-10.71) and 6.42 (CI=4.5-9.15) times more likely to be filling opioid prescriptions at 9 and 12 months respectively after ACLR. Conclusion: Opioid demand after ACLR drops significantly in the vast majority of patients by the 3rd postoperative month. Surprisingly, 35% of patients undergoing ACLR were found to be using opioid medications preoperatively and we identify preoperative opioid use to be a strong predictor of postoperative opioid demand with a 5 to 7 fold increased risk in this patient population. Surgeons can use this data when counseling patients on typical postoperative opioid demand. Surgeons and healthcare systems should be aware a large portion of patients undergoing ACLR are receiving preoperative opioid prescriptions which put these patients at increased risk for extended postoperative opioid demand. In the setting of preoperative care for patients who will undergo ACLR, healthcare providers should pursue non-opioid prescribing regimens in an effort to limit postoperative opioid demand.

Objectives: Injuries to the posterolateral corner (PLC) may occur concurrently with anterior cruciate ligament (ACL) injury. Restoration of stability to the lateral knee is important for both preventing posterolateral rotatory instability and protecting concurrently addressed cruciate reconstructions. There has been a growing trend towards PLC reconstruction in recent literature, however little is known about how these techniques relate to long-term patient outcomes. The purpose of the present study was to evaluate the outcomes of patients who underwent operative management of PLC injuries concurrently with ACL reconstruction in a prospective multicenter cohort. We hypothesized that there would be no differences in patient outcomes between patients who were treated with repair and reconstruction. Methods: Patients undergoing ACL reconstructions were enrolled into a prospective longitudinal multi-center cohort between 2002-2008. Patients with six-year follow-up data (repeat operations and patient reported outcomes) who underwent concurrent PLC reconstruction or repair at the time of ACL reconstruction were identified. Patients who underwent PLC repair were compared to those who underwent PLC reconstruction in regard to operative delay, need for revision surgery and long-term outcomes at 6-years. Results: Initially, 3028 patients were identified to have undergone primary ACL reconstruction during the identified time frame, with 34/3028 (1.1%) also undergoing PLC surgery: 15 repairs and 19 reconstructions (18 allografts, 1 autograft). There were no differences in the rate of meniscal or chondral injuries between groups. The median time to PLC reconstruction was 121 days compared to 19 days for concurrent ACL reconstruction and PLC repair (p=0.01). Mean preoperative scores were significantly lower in the repair group with respect to KOOS Pain (57.4 versus 74.3), KOOS ADL (62.3 versus 76.2), KOOS KRQOL (17.5 versus 30.9), and IKDC (29.1 versus 48.4, p=0.004). There were no differences between groups in Marx activity scores prior to surgery (p=0.4). At 6-year follow-up, there were no differences between groups with regard to KOOS (p=0.36-0.83) or IKDC scores (p=0.84), however patients treated with lateral reconstructions had lower Marx activity scores at 6-years (4.0 versus 9.4, p=0.02). There was one ACL revision in the PLC reconstruction group and one of the PLC repairs was revised to a reconstruction during the follow-up period. Conclusion: Good outcomes were achieved with both repair and reconstruction of PLC injuries treated concurrently with ACL reconstruction at 6-year follow-up. Patients treated with reconstruction had lower activity levels 6-years after surgery. Lower KOOS and IKDC scores at the time of surgery may be explained by the increased time interval between injury and surgery in the reconstruction group. One of the 15 lateral repairs required a later reconstruction. Contrary to recent reports, our data suggests that appropriately selected patients may be successfully treated with acute PLC repair with good long-term outcomes.

Objectives: Revision shoulder stabilization procedures present a unique set of challenges that should be recognized by the treating surgeon in order to improve the likelihood of success. The current study aims to compare patient factors, intraoperative findings, and patient reported outcome measures between patients undergoing primary versus revision shoulder stabilization surgery. Methods: The Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort was utilized to identify all patients undergoing primary and revision open or arthroscopic shoulder instability surgery. Patients with concomitant rotator cuff pathology requiring operative repair were excluded. Patient demographic characteristics, intraoperative findings, and patient reported outcome measures at the time of shoulder stabilization were compared between primary and revision shoulder instability surgery patients using univariate methods using chi-square or Fisher exact tests for categorical variables and Wilcoxon rank sum test for continuous variables. Results: Primary shoulder stabilization procedures were performed in 625 (87.0%) patients and revision stabilization procedures in 93 patients (13.0%). Patients undergoing revision surgery were older (25.9 vs. 23.5 years, pConclusion: Glenohumeral articular cartilage lesions are a common finding at the time of shoulder stabilization procedures and are particularly frequent in patients undergoing revision stabilization procedures. Surgeons routinely performing these procedures should be prepared to deal with the technical challenges associated with glenoid or humeral head bone loss. However, at the time of surgery, the presence of articular cartilage lesions did not appear to negatively influence patient reported outcomes. Future studies should investigate the influence of articular cartilage lesions at mid- and long-term follow-up in this cohort of patients.

Background:In the setting of anterior shoulder instability, it is important to assess the reliability of orthopaedic surgeons to diagnose pathologic characteristics on the 2 most common imaging modalities used in clinical practice: standard plain radiographs and magnetic resonance imaging (MRI).Purpose:To assess the intra- and interrater reliability of diagnosing pathologic characteristics associated with anterior shoulder instability using standard plain radiographs and MRI.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:Patient charts at a single academic institution were reviewed for anterior shoulder instability injuries. The study included 40 sets of images (20 radiograph sets, 20 MRI series). The images, along with standardized evaluation forms, were distributed to 22 shoulder/sports medicine fellowship–trained orthopaedic surgeons over 2 points in time. Kappa values for inter- and intrarater reliability were calculated.Results:The overall response rate was 91%. For shoulder radiographs, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.49), estimate of glenoid lesion surface area (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.35), and estimate of Hill-Sachs surface area (κ = 0.50). Intrarater agreement was moderate for radiographs (κ = 0.48-0.57). For shoulder MRI, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.44), glenoid lesion surface area (κ = 0.35), Hill-Sachs lesion (κ = 0.33), Hill-Sachs surface area (κ = 0.28), humeral head edema (κ = 0.41), and presence of a capsulolabral injury (κ = 0.36). Fair agreement was found for specific type of capsulolabral injury (κ = 0.21). Intrarater agreement for shoulder MRI was moderate for the presence of glenoid lesion (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.52), estimate of Hill-Sachs surface area (κ = 0.50), humeral head edema (κ = 0.51), and presence of a capsulolabral injury (κ = 0.53), and agreement was substantial for glenoid lesion surface area (κ = 0.63). Intrarater agreement was fair for determining the specific type of capsulolabral injury (κ = 0.38).Conclusion:Fair to moderate agreement by surgeons was found when evaluating imaging studies for anterior shoulder instability. Agreement was similar for identifying pathologic characteristics on radiographs and MRI. There was a trend toward better agreement for the presence of glenoid-sided injury. The lowest agreement was observed for specific capsulolabral injuries.

Background: Use of the Patient-Reported Outcomes Measurement Information System (PROMIS) instrument has not yet been validated in patients undergoing operative treatment for patellofemoral malalignment and chondral disease. Purpose: To evaluate the PROMIS Physical Function Computer Adaptive Testing (PF CAT) instrument in a population of patients with patellofemoral malalignment and chondral disease relative to established patient-reported outcome (PRO) instruments. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Eligible patients were prospectively enrolled at the time of indication for surgery and completed 5 PRO instruments preoperatively: 36-Item Short Form Health Survey (SF-36); Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); Marx activity rating scale (Marx); EuroQol 5-dimension, 5-level instrument (EQ-5D-5L); and PROMIS PF CAT. Convergent and discriminant validity was assessed by measuring correlations between PROMIS PF CAT and other PRO instruments, including the Knee injury and Osteoarthritis Outcome Score (KOOS). Strength of correlation was measured by use of Spearman correlation coefficients. Results: In total, 37 patients (40 knees) were enrolled in the study. All knees underwent Fulkerson osteotomy and concomitant cartilage procedure (29 chondroplasty, 6 allograft, 5 microfracture). Mean patient age was 33.4 years, and 73% of knees were in female patients. Correlations ( r) between PROMIS PF CAT and knee PRO instruments were as follows: SF-36 PF ( r = 0.80; P < .01); KOOS Pain ( r = 0.74; P < .01); KOOS Symptoms ( r = 0.47; P < .01); KOOS Quality of Life ( r = 0.68; P < .01); KOOS Sports and Recreation ( r = 0.72; P < .01); KOOS Activities of Daily Living (ADL) ( r = 0.80; P < .01); WOMAC Function ( r = 0.80; P < .01); WOMAC Pain ( r = 0.72; P < .01); WOMAC Stiffness ( r = 0.38; P = .02); Marx ( r = 0.22; P = .31); and EQ-5D-5L ( r = 0.72; P < .01). Neither floor nor ceiling effects were observed in PROMIS PF CAT or KOOS ADL. Mean (±SD) question burden with PROMIS PF CAT was 5.6 ± 0.6 questions. Conclusion: In patients with patellofemoral malalignment and chondral disease, PROMIS PF CAT is an efficient and reliable PRO instrument to preoperatively assess patients across a spectrum of knee function without floor or ceiling effects.

Objectives: To determine whether a greater degree of translation measured under anesthesia during anterior shoulder stabilization surgery was associated with greater injury severity, more dislocations in the previous year, and a greater duration of injury. Methods: This study evaluated Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group shoulder instability participants who underwent anterior shoulder stabilization surgery between October 2012-September 2016. Surgeons measured shoulder mobility under anesthesia following a standardized protocol and graded translation as 0, 1+, 2+ or 3+. Using this measure, translation was defined as having a grade ≥2+. Labral tear length, duration of injury, and number of times dislocated in the previous year were compared between mobility groups using the Wilcoxon Rank Sum Test while categorical variables were compared between groups using the chi-square or exact test. Logistic regression was also used to model the relationship between mobility grade as an ordered variable and presence of >10% bone loss as well as HSL >20%. Age and BMI were compared between groups using t-tests. Results: A total of 679 participants (19% women) with an average age of 24.8±9.5years and BMI of 25.4±4.4 kg/m2were included in analyses. Mobility grade groups 10% bone loss (5.8% vs 9.8%) did not significantly differ between groups (all p>0.05). However, there was a greater proportion of HSL >20% in the ≥2 (3.2%) vs 10% bone loss (OR: 1.51, 95%CI: 1.01-2.27, p=0.046). Labral tear length was significantly greater in individuals who reported at least two dislocations in the previous year (median=144, 0-360°) vs less than two (126, 0-360°, p=0.02). Conclusion: Measures of translation during EUA in patients undergoing anterior shoulder stabilization surgery demonstrated higher likelihood of HSL and increased glenoid bone loss>10% as positive predictors of translation ≥2 intra-operatively. Self-reported number of dislocations and Beighton scores≥4 were also found to be correlated with increasing translation under EUA and may serve as a reliable clinical predictor of patients at risk for recurrent instability.

Background: Glenohumeral instability is common in athletes. There are an estimated 0.12 episodes of instability per 1000 sporting exposures. Instability can lead to time away from sport and an increased risk of shoulder arthritis. Purpose: To determine the prevalence, demographic data, anatomic features, and likelihood of surgery for the different types of instability as defined by the FEDS (frequency, etiology, direction, and severity) classification system for different sports. Study Design: Cohort study; Level of evidence, 3. Methods: Databases at 3 institutions (University of Iowa, Vanderbilt University, and University of Pennsylvania) were searched for International Classification of Diseases--Ninth Revision codes related to shoulder instability in 2010. Demographic data, symptoms, causes, imaging findings, and operative reports were obtained. Data were entered into a custom-designed REDCap online survey. Patients with subjective instability related to sporting activities were included for analysis. Results: A total of 184 athletes had glenohumeral instability; 20.1% were female. The mean age at the time of the first instability episode was 19.0 years for both male and female patients. The most common sports were football (29.3%), basketball (19.0%), and wrestling (9.8%). The most common type of instability based on the FEDS system was occasional, traumatic, anterior dislocation. Surgery was performed on 69.6% of athletes, and 14.1% had a recurrence of instability after surgery overall. Football had the highest rate of recurrence postoperatively at 23.8%. There was no difference in surgery rates between athletes with subluxations versus dislocations ( P = .8458). Surgery was significantly more likely in those with frequent dislocations ( P < .0001) and posterior instability ( P = .027). There was a 10.7% recurrence rate overall with conservative treatment. Conclusion: Glenohumeral instability most commonly occurs in contact sports, affects male more than female patients, and is most frequently in the anterior direction. Recurrent instability is most common in football players. Attention should be turned to the specific characteristics of each type of instability to determine the best treatment for each athlete.

Background:The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to capture patient-reported outcomes (PROs) in an efficient manner. Few studies have assessed this instrument postoperatively.Purpose:To compare the PROMIS Physical Function computer adaptive test (PROMIS PF CAT) and Upper Extremity (PROMIS UE) item bank to other previously validated PRO instruments and to evaluate ceiling and floor effects and construct validity responsiveness in patients who underwent operative interventions for shoulder instability.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A total of 72 patients who underwent operative interventions for shoulder instability completed the American Shoulder and Elbow Surgeons (ASES) assessment form, Marx shoulder activity scale (Marx), 36-Item Short Form Health Survey physical function (SF-36 PF) and general health (SF-36 GH), Western Ontario Shoulder Instability Index (WOSI), PROMIS PF CAT, and PROMIS UE before surgery and then at 6 weeks and 6 months postoperatively. Correlation coefficients were calculated among these tools. The effect size of change was also calculated for each tool at each time point. A total of 91 patients who had also undergone surgery for shoulder instability completed these PRO instruments 2 years postoperatively. The percentage of patients hitting the ceiling and floor effects of each of the PRO instruments was calculated at all time points.Results:The PROMIS PF CAT demonstrated excellent-good correlation with the SF-36 PF at all postoperative time points (0.61 at 6 weeks, 0.68 at 6 months, and 0.64 at 2 years; P < .01 for all). The PROMIS UE showed excellent correlation with the ASES at 6 weeks postoperatively (0.73, P < .01). Both the PROMIS PF CAT and PROMIS UE demonstrated the ability to detect change after surgical interventions with a medium to large effect size. The PROMIS UE demonstrated a ceiling effect at 6 months (68.1%) and 2 years (67.0%) postoperatively. The PROMIS PF CAT demonstrated no ceiling effect at any time point.Conclusion:The PROMIS PF CAT demonstrated good to excellent correlation with other previously validated PRO instruments that assess physical function in patients with shoulder instability postoperatively. The PROMIS UE demonstrated good correlation with other PRO tools but had a significant ceiling effect and is not recommended for this patient population. Both tools demonstrated an ability to detect change after surgical interventions with a good effect size.

Objectives: Previous investigations have shown decreased utilization and outcomes based on racial status in total knee arthroplasty (TKA) and total shoulder arthroplasty (TSA) cohorts; however, the impact of racial status in patients undergoing shoulder stabilization is poorly understood. The purpose of the current study was to compare how minority status affects surgical timing as well as pre- and intraoperative findings in patients undergoing operative treatment of shoulder instability. Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, 1010 patients consented to participate in pre- and intraoperative data collection. Demographic characteristics, injury history, preoperative patient-reported outcome scores (PROs), and radiologic and intraoperative findings were then compared between Caucasian and minority patients undergoing surgical shoulder stabilization. In addition, the Economic Innovation Group’s 2017 Distressed Communities Index (DCI) was recorded for each patient’s home zip code. DCI Scores are based on percentages of adults without a high school education, percentage living under the poverty line, unemployment rates, and the overall housing and business climate in a given area. DCI Scores range from 0 to 100, with higher scores indicative of greater economic distress, and DCI Scores ≥ 80 are considered to be highly distressed regions. Continuous variables were compared between groups using two-tailed independent t-tests and categorical variables were compared using chi-square tests. Results: Of the 1010 patients, 988 patients (97.8%) had complete preoperative and intraoperative data. The cohort was largely Caucasian (851, 86.1%), with 137 minority patients, including 71 African American, 49 Asian, 13 Native American, and 4 Hawaiian or Pacific Islander. DCI scores were significantly worse for minority patients than Caucasians (39.4 vs. 28.1, pConclusion: Racial minorities were found to have more preoperative dislocations, higher rates of articular cartilage lesions, and worse preoperative expectations. DCI scores were lower in the racial minority group; however, this was not found to be an independent predictor of pre- and/or intraoperative findings. These findings identify a need to identify barriers in an action to reduce racial disparities in the treatment of shoulder instability.

Objectives: Our goal was to compare clinical, functional and radiographic outcomes of posterolateral knee injuries treated with repair versus reconstruction. In addition, we compared varus stress radiographs of these patients with controls. Methods: A retrospective chart review was performed to identify patients that underwent posterolateral knee reconstruction or repair from January 1, 2000 to March 1, 2012. Patients were asked to return for a clinical exam and varus stress radiographs, as well as fill out IKDC and Lysholm knee scales. Patients that could not return to clinic were assessed via phone interviews. Chart reviews were performed on patients that could not be contacted.Further, we compared varus stress radiographs of 20 control knees, with no history of knee trauma, to both posterolateral knee repair and reconstruction groups. Results: We identified 61 knees in 60 patients who underwent posterolateral knee reconstruction or repair. 26 knees in 25 patients (17 reconstructions and 9 repairs) were evaluated at mean of 41.86 months postoperatively (range: 6-108). Average IKDC scores for reconstruction and repair were 68.23 and 71.30, respectively. Average Lysholm scores for these groups were 83.11 for reconstructions and 83.30 for repairs. There were no statistically significant differences in IKDC or Lysholm scores between the repair and reconstruction groups. Average varus gapping with the knee at zero degrees was 8.21 and 8.84 millimeters (mm) for reconstructions and repairs, respectively. Average varus gapping at 20 degrees knee flexion was 11.25 mm for reconstructions and 10.34 mm for repairs. No statistically significant differences were observed in varus gapping between the two groups. Control knee measurements, 20 knees in 20 different controls, showed average varus gapping of 5.27 mm at zero degrees and 6.55 mm at 20 degrees knee flexion. There was a statistically significant difference in varus gapping when comparing the operatively treated knees to the control group. On review of all 61 knees, there were five failures: three failed reconstructions, two failed repairs. The other complication included one small wound dehiscence in the reconstruction group that resolved without intervention. Conclusion: Unlike previous studies, we did not find statistical differences in our posterolateral knee patients treated with reconstruction versus repair. We did find statistically significant differences in varus gapping, at both 0 and 20 degrees of knee flexion, between control knees and the operatively treated groups. However, this did not correlate to poor clinical outcomes in either group..

Objectives: Complete disruptions of the medial collateral ligament (MCL) are rare, but do occur with anterior cruciate ligament (ACL) tears. Complete ACL/MCL injuries may be managed with ACL reconstruction and either conservative or operative treatment of the MCL. MCL tear location has also been associated with outcome. We hypothesized that outcomes would be best with acute surgery and worse with proximal MCL tears.We also hypothesized that operative management of MCL injuries would not influence outcome. Methods: Patients enrolled in a multicenter prospective longitudinal cohort who underwent unilateral primary ACL reconstruction between 2002-2008 and who had 2-year follow-up were evaluated. Patients with concomitant grade III MCL injuries treated either operatively or non-operatively were identified. Concurrent injuries (to meniscus or articular cartilage) and subsequent surgeries were documented. Comparisons of surgical chronicity (before and after 30 days from injury) and MCL tear location (femoral or tibial) were performed. Patient reported outcomes (KOOS, IKDC and Marx activity scores) were measured at the time of ACL reconstruction and at 2-year follow-up. Results: Initially, 3028 patients were identified to have undergone primary ACL reconstruction in the cohort during the identified time frame, with 2586 patients completing 2-year follow-up (85%). Complete MCL tears were documented in 1.1% (27/2586) of the cohort: 16 operatively managed patients and 11 conservatively treated MCLs during ACL reconstruction. Concurrent articular pathology was similar between groups. Clinically important differences were seen in baseline KOOS (all subscales) and IKDC scores, with lower scores seen in patients who underwent operative MCL treatment. Reoperation for arthrofibrosis was higher after operative repair of the MCL (19%) versus nonoperative treatment (9%). At 2 years the non-operative MCL cohort maintained significantly better KOOS Sports Rec (88.2 versus 74.4), KOOS QOL (81.3 versus 68.4), and IKDC (87.6 versus 76.0) scores compared to the MCL surgery group. Marx activity scores were equal between groups at the time of study enrollment, however patients who underwent operative MCL management had lower activity scores at 2 years (6.5 versus 10.7). Tibial-sided MCL injuries were associated with worse baseline outcomes compared with femoral-sided MCL injuries in terms of KOOS ADL, Sports Rec, and QOL subscales, but these differences were resolved by 2 years. Surgical chronicity did not influence 2-year outcome. Conclusion: Complete and combined ACL/MCL injuries are rare. Both operative and nonoperative management of MCL tears in our cohort demonstrated clinical improvements between study enrollment and 2-year follow-up. MCL surgery during ACL reconstruction was associated with more frequent stiffness, worse patient-reported outcomes and lower activity at 2 years. There may be a subset of patients with severe combined ACL and medial knee injuries that may benefit from operative management, however, that patient population has yet to be defined.

Background:Management of the medial collateral ligament (MCL) in the setting of a multiligamentous knee injury (MLKI) represents an area of great controversy.Purpose:Our study was designed to compare long-term patient-reported outcomes (PROs) after MCL repair versus reconstruction in the setting of a multiligamentous injury of the knee.Study Design:Cohort study; Level of evidence, 3.Methods:At a single institution, 68 patients were identified over a 10-year period as having MCL intervention in the setting of MLKI. Of these patients, 34 (50%) were successfully contacted via telephone to collect Lysholm and International Knee Documentation Committee (IKDC) scores. A retrospective chart review of these subjects was also conducted to identify patient and surgical factors affecting PROs.Results:At a mean 6-year follow-up (range, 2-11 years), the mean Lysholm score was 77.4 ± 23.1 and mean IKDC score was 72.6 ± 23.6. Univariate analyses identified time to surgery ( P = .005) and MCL reconstruction ( P = .001) as risk factors for Lysholm score ≤75. Univariate analyses identified patient age ( P = .049), time to surgery ( P = .018), and MCL reconstruction ( P = .004) as risk factors for IKDC score ≤75. On subsequent multivariate analysis, MCL reconstruction was found to be a predictor of Lysholm or IKDC score of ≤75.Conclusion:Patients undergoing MCL repair in the setting of MLKI generally had higher PROs than those undergoing reconstructions at a mean 6 years of follow-up. Further work is needed to elucidate patient and surgical factors that may influence subjective outcomes after multiligament knee injuries.

Objectives: Pre-operative and surgical factors related to early return to baseline function after anterior shoulder instability surgery are not clear. This study was designed to determine the pre-operative and operative factors affecting return to baseline function at 6 months following anterior shoulder instability surgery. Identifying these factors will help surgeons establish expectations for functional return post-operatively. Methods: The Multicenter Orthopaedic Outcomes Network (MOON) shoulder group enrolled patients undergoing surgery for shoulder instability from 16 sites throughout the United States. Initial demographic data and validated, patient-oriented outcomes questionnaires were collected along with the physicians documented initial physical exam, treatment, surgical findings and surgical techniques used at the time of surgery. At the 6-month follow up visit, range of motion (ROM) and strength measurement of the operative shoulder were collected and compared to pre-operative measurement. Return to baseline was defined as return to within -10° ROM and full strength at the 6 month physical exam. Continuous and categorical data were analyzed using student t-tests and chi-square tests, respectively. The Kruskal-Wallis/Wilcoxin tests were used to compare groups that were not normally distributed. Factors reaching significance in a univariate analysis were then applied in a multivariable model. Significance was set a pResults: A total of 338 patients with history of surgical intervention for anterior instability of the shoulder were identified. 278 patients had complete pre- and post-surgical range of motion and strength measurements. 138 (50%) patients (139 shoulders) returned to baseline and 133 (50%) patients did not return to baseline. Univariate analysis identified age (p=0.0013), Beighton score (p=0.0004), SF-36 general health (p=0.0017), WOSI (p=0.0250), and duration of symptoms (p=0.0046) as significant factors. When these factors were placed into a multivariate model, significant differences were identified in age (p=0.0316), SF-36 General health (p=0.0118), and Beighton score (p=0.0016). Conclusion: Older age, perception of general health and generalized joint laxity are associated with failure to return to baseline function at 6 months after anterior shoulder instability surgery. Duration of symptoms and number of dislocation events did not reach significance in the multivariate model, but trended toward likelihood of failure to return to baseline findings. Moreover, open vs. arthroscopic surgery and number of suture anchors were not significant, suggesting that pre-operative condition and not surgical factors predict return to baseline in the short-term.

Background:Capitellar osteochondritis dissecans (OCD) is commonly managed surgically in symptomatic adolesent throwers and gymnasts. Little is known about the impact that surgical technique has on return to sport.Purpose:To evaluate the clinical outcomes and return-to-sport rates after operative management of OCD lesions in adolescent athletes.Study Design:Systematic review; Level of evidence, 4.Methods:The PubMed, CINAHL, EMBASE, SPORTDiscus (EBSCO), and Cochrane Central Register of Controlled Trials databases were queried for studies evaluating outcomes and return to sport after surgical management of OCD of the capitellum. Two independent reviewers conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting patient outcomes with return-to-sport data and minimum 6-month follow-up were included in the review.Results:After review, 24 studies reporting outcomes in 492 patients (mean age ± SD, 14.3 ± 0.9 years) were analyzed. The overall return-to-sport rate was 86% at a mean 5.6 months. Return to the highest preoperative level of sport was most common after osteochondral autograft procedures (94%) compared with debridement and marrow stimulation procedures (71%) or OCD fixation surgery (64%). Elbow range of motion improved by 15.9° after surgery. The Timmerman-Andrews subjective and objective scores significantly improved after surgery. Complications were low (Conclusion:A high rate of return to sport was observed after operative management of capitellar OCD. Patients were more likely to return to their highest level of preoperative sport after OAT autograft compared with debridement or fixation. Significant improvements in elbow range of motion and patient outcomes are seen with low complication rates after OCD surgery.

Objectives: Meniscus tears frequently accompany acute anterior cruciate ligament ruptures. Management of meniscus tears is highly variable and includes repair, meniscectomy, and non-treatment of tears identified at the time of ACL reconstruction. The purpose of this study is to determine the rate of subsequent reoperation and clinical outcome of meniscal tears left in situ without treatment at the time of ACL reconstruction with a minimum follow-up of 6 years. Methods: Patients with meniscus tears left untreated at the time of primary ACL reconstruction were identified from a multicenter study group between 2002 and 2004 with minimum 6-year follow-up. Patient demographic variables, comorbidities, meniscus tear characteristics, and information on subsequent surgery were obtained. The primary endpoint of the study was need for reoperation for meniscal pathology. Univariate and multivariate analyses were used in order to determine patient demographic variables and meniscus tear characteristics that served as risk factors for reoperation. Results: There were 1440 primary ACL reconstructions performed during the timeframe of the study. There were 955 patients (66.3%) with concomitant meniscal tears identified. Of these, 143 (15.3%) had meniscal tears left in situ at the time of surgery. There were 11 patients (7.9%) who underwent reoperation for meniscal pathology within the same compartment as the meniscal tear left in situ (Table 1). Reoperation was performed more frequently for medial meniscus tears as compared to lateral meniscus tears (17.6% vs. 4.3%, p = 0.048). Medial meniscus tears and tears ≥10 mm in length were identified as risk factors for reoperation. Conclusion: Lateral and medial meniscus tears left in situ at the time of ACL reconstruction did not require reoperation at minimum 6-year follow-up in 95.7% and 82.4% of patients, respectively. Our results suggest that surgeons should consider alternative treatment for medial meniscus tears and tears ≥ 10 mm in length at the time of ACL reconstruction.

Background: Thromboembolism following shoulder arthroscopy is considered an uncommon complication, with fewer than 50 cases reported in the literature. Arthroscopy of the shoulder is one of the most commonly performed orthopaedic procedures, with low associated risks. Purpose: To identify potential risk factors for the development of venous thromboembolism (VTE) following shoulder arthroscopy and to determine the overall incidence of this complication. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective case-control review was performed of patients who developed symptomatic deep venous thrombosis (DVT) or pulmonary embolism (PE) following shoulder arthroscopy. Multiple surgeons from across North America were queried. For every case of DVT or PE identified, 2 control cases of shoulder arthroscopy were analyzed. The incidence of DVT/PE following shoulder arthroscopy was determined. A univariate analysis and a multivariate logistic regression model were conducted to identify any potential risk factors for the development of VTE following shoulder arthroscopy. Results: A total of 17 surgeons participated in this study and had performed a total of 15,033 cases of shoulder arthroscopy from September 2002 through August 2011. Eleven of the 17 participating surgeons had had a patient with a VTE complication during this time frame. The incidence of VTE in the 15,033 cases was 0.15%; 22 patients of the 15,033 patients had a DVT (n = 15) and/or PE (n = 8). Forty-four control cases were also analyzed. Univariate and multivariate analyses were performed. No significant risk factors were identified other than patient positioning. All cases and controls were positioned in the beach-chair position for surgery. Conclusion: The results of this study show that although rare, VTE occurs following shoulder arthroscopy at a rate of 0.15%. The variables analyzed in the cases of VTE compared with the control cases did not show any significant risk factors. All cases were positioned in the beach-chair position. Further analysis of future cases is warranted.