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» Shoulder instability is a complex problem with a high rate of recurrence in athletes. Treatment of a first-time subluxation or dislocation event is controversial and depends on patient-specific factors as well as the identified pathology. » Athletic trainers and physical therapists are an integral part of the treatment team of an in-season athlete who has experienced a shoulder instability event. Through comprehensive physiological assessments, these providers can effectively suggest modifications to the patient's training regimen as well as an appropriate rehabilitation program. » Surgical intervention for shoulder stabilization should use an individualized approach for technique and timing. » A team-based approach is necessary to optimize the care of this high-demand, high-risk population.

Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes than primary ACL reconstruction. The reasons remain varied and not completely understood. METHODS: Patients undergoing revision ACL reconstruction were prospectively enrolled. Data collected included baseline demographics, surgical technique and pathological condition, prescribed rehabilitation instructions, and a series of validated patient-reported outcome instruments. Patients were followed for 2 years and asked to complete a set of outcome instruments identical to those completed at baseline. Subsequent surgical procedures on the ipsilateral knee were recorded. Regression analysis was used to control for age, sex, activity level, baseline outcome scores, and the above-mentioned rehabilitation-related variables in order to assess the factors affecting clinical outcomes 2 years after revision ACL reconstruction. RESULTS: A total of 843 patients met the inclusion criteria and were successfully enrolled, and 82% (695) were followed for 2 years. Two rehabilitation-related factors were found to influence outcome. First, patients who were prescribed an ACL brace for their return to sports had a significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) for sports and recreational activities at 2 years (odds ratio [OR] =1.50, 95% confidence interval [CI] = 1.07 to 2.11; p = 0.019). Second, patients prescribed an ACL brace for the postoperative rehabilitation period were 2.3 times more likely to have subsequent surgery by 2 years (OR = 2.26, 95% CI = 1.11 to 4.60; p = 0.024). The odds of a graft rerupture were not affected by any type of brace wear. CONCLUSIONS: Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years. Weight-bearing and motion can be initiated immediately postoperatively. Bracing during the early postoperative period is not helpful. Use of a functional brace early in the postoperative period was associated with an increased risk of a reoperation. Use of a functional brace for a return to sports improved the KOOS on the sports/recreation subscale. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed as an extensive question bank with multiple health domains that could be utilized for computerized adaptive testing (CAT). In the present study, we investigated the use of the PROMIS Physical Function CAT (PROMIS PF CAT) in an otherwise healthy population scheduled to undergo surgery for meniscal injury with the hypotheses that (1) the PROMIS PF CAT would correlate strongly with patient-reported outcome instruments that measure physical function and would not correlate strongly with those that measure other health domains, (2) there would be no ceiling effects, and (3) the test burden would be significantly less than that of the traditional measures. METHODS Patients scheduled to undergo meniscal surgery completed the PROMIS PF CAT, Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale, Short Form-36 (SF-36), and EuroQol-5 Dimension (EQ-5D) questionnaires. Correlations were defined as high (≥0.7), high-moderate (0.61 to 0.69), moderate (0.4 to 0.6), moderate-weak (0.31 to 0.39), or weak (≤0.3). If ≥15% respondents to a patient-reported outcome measure obtained the highest or lowest possible score, the instrument was determined to have a significant ceiling or floor effect. RESULTS A total of 107 participants were analyzed. The PROMIS PF CAT had a high correlation with the SF-36 Physical Functioning (PF) (r = 0.82, p < 0.01) and KOOS Sport (r = 0.76, p < 0.01) scores; a high-moderate correlation with the KOOS Quality-of-Life (QOL) (r = 0.63, p < 0.01) and EQ-5D (r = 0.62, p < 0.01) instruments; and a moderate correlation with the SF-36 Pain (r = 0.60, p < 0.01), KOOS Symptoms (r = 0.57, p < 0.01), KOOS Activities of Daily Living (ADL) (r = 0.60, p < 0.01), and KOOS Pain (r = 0.60, p < 0.01) scores. The majority (89%) of the patients completed the PROMIS PF CAT after answering only 4 items. The PROMIS PF CAT had no floor or ceiling effects, with 0% of the participants achieving the lowest and highest score, respectively. CONCLUSIONS The PROMIS PF CAT correlates strongly with currently used patient-reported outcome measures of physical function and demonstrates no ceiling effects for patients with meniscal injury requiring surgery. It may be a reasonable alternative to more burdensome patient-reported outcome measures.

Total shoulder arthroplasty (TSA) is an effective treatment for end-stage glenohumeral joint pathology with good long-term results. Previous descriptions of morbidity and blood transfusion in TSA are limited by preoperative risk factors and postoperative complications considered and single-center studies.The purpose of this study was to define in a group of patients undergoing TSA (1) the type and incidence of complications; (2) the frequency of and risk factors for both minor and major complications; and (3) the risk factors for bleeding resulting in transfusion.We retrospectively queried the National Surgical Quality Improvement Program database using Current Procedural Terminology billing codes and identified 1922 cases of TSA performed between 2006 and 2011. Postoperative outcomes were divided into one of four categories: any complication, major morbidity (systemic life-threatening event or a substantial threat to a vital organ) or mortality, minor morbidity (localized to the operative upper extremity or not posing a major systemic threat to the patient), or bleeding resulting in transfusion. Univariate and multivariate analyses were then used to identify risk factors for complications.There were a total of 155 complications (8% of the 1922 patients identified). The most common complication was bleeding resulting in transfusion (82 patients [4.26%]) followed by urinary tract infections (27 patients [1.40%]), return to the operating room (14 patients [0.73%]), pneumonia (10 patients [0.52%]), and peripheral nerve injury (nine patients [0.47%]). The incidence of major morbidity was 2% (44 patients), which included five patients (0.26%) who died; the incidence of any minor morbidity was 7% (136 patients). After controlling for likely confounding variables, we found steroid use (odds ratio [OR], 3; 95% confidence interval [CI], 2-6), hematocrit 38% (OR, 2; 95% CI, 1-3), American Society of Anesthesiologists (ASA) Class 4 (OR, 3; 95% CI, 1-7), and operating time 2 hours (OR, 2; 95% CI, 1-3) as independent predictors of complication and congestive heart failure (OR, 12; 95% CI, 1-106) as an independent risk factor for major morbidity or mortality. Hematocrit 38% (OR, 3; 95% CI, 2-6), resident involvement (OR, 3; 95% CI, 2-5), steroid use (OR, 3; 95% CI, 1-6), and ASA Class 3 versus 1 or 2 (OR, 2; 95% CI, 1-5) were independent risk factors for bleeding resulting in transfusion.Short-term morbidity after TSA is higher than previously reported. The prevalence of complications within 30 days of surgery and our outlined risk factors should guide surgeon-driven preoperative patient evaluation, management, and counseling. Surgeons who perform TSA should be aware operative time 2 hours is associated with increased complications. Patients with preoperative hematocrit 38%, history of steroid use, ASA Class 2, and patients with congestive heart failure should receive medical optimization before TSA.Level III, therapeutic study.

Acromioclavicular (AC) reconstruction surgery is per- formed to address high-grade AC separations. In the double-loop anatomic reconstruction, the coracoclavicular ligaments are recon- structed in an anatomic fashion similar to the technique described by Mazzocca and colleagues using a free tissue graft and tunnels through the clavicle. However, the double-loop technique passes a graft both through and around the clavicle using semitendinosus graft. This allows maximal use of the long hamstring graft. A preliminary case series of 7 patients (7 operations) is presented. Shoulder complications were observed in 0 patients who underwent double-loop anatomic acromioclavicular reconstruction. Temporary hamstring graft harvest site pain observed in 2 patients. The described technique is safe and potentially useful alternative method for AC reconstruction.

Cases The authors present 2 cases of chronic posterolateral rotatory instability (PLRI) of pediatric elbows successfully treated with lateral collateral ligament (LCL) reconstruction using semitendinosus tendon allograft, including the first documented case of LCL reconstruction in the setting of an Osborne-Cotterill lesion in a pediatric patient. Full resolution of PLRI was achieved, and the patients returned to preinjury full-contact sports at 5 months postoperatively. Conclusions Few studies have reported LCL reconstruction in the setting of chronic PLRI in pediatric patients. The purpose of this report is to aid in the diagnosis and treatment of elbow PLRI and to describe a surgical option for recurrent PLRI in pediatric patients.

Background: The emergence of specialty orthopaedic hospitals has generated widespread controversy, but little is known about the quality of care they deliver. Our objective was to compare the characteristics and outcomes of patients undergoing major joint replacement in specialty orthopaedic and general hospitals. Methods: We conducted a retrospective cohort study of 51,788 Medicare beneficiaries who underwent total hip replacement and 99,765 who underwent total knee replacement in thirty-eight specialty orthopaedic hospitals and 517 general hospitals between 1999 and 2003. We compared demographic data, rates of comorbid illness, and socioeconomic status of patients treated in specialty and general hospitals. Logistic regression was used to calculate the odds of an adverse outcome (death or selected surgical complications) after adjustment for patient characteristics and hospital procedural volume. Results: The demographic data and the ratio of primary to revision arthroplasties were similar, but patients who received care in specialty hospitals had less comorbidity and resided in more affluent zip codes than their counterparts in general hospitals in 2003. Specialty hospitals had significantly greater mean procedural volumes in 2003 than did general hospitals for both total hip replacement (thirty-three compared with twenty procedures; p = 0.05) and total knee replacement (seventy-five compared with forty procedures; p = 0.006). The unadjusted rate of adverse outcomes was lower in specialty hospitals than in general hospitals for total hip replacement (3.0% compared with 6.9%; p < 0.001) and total knee replacement (2.1% compared with 3.9%; p < 0.001). After adjusting for patient characteristics and procedural volume, the odds of adverse outcomes occurring were significantly lower for patients in specialty hospitals than for those in general hospitals for both primary joint replacement (odds ratio, 0.64; 95% confidence interval, 0.56 to 0.75; p < 0.001) and revision joint replacement (odds ratio, 0.49; 95% confidence interval, 0.36 to 0.66; p < 0.001). Conclusions: After adjustment for patient characteristics and hospital volume, the specialty orthopaedic hospitals had better patient outcomes, as measured by Medicare administrative data, than did the general hospitals. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Mechanical alignment has been overlooked as an important contributor to knee stability with respect to collateral ligament laxity. The detrimental effects of varus or valgus limb malalignment become more obvious when the restraining force is lost because of ligamentous injury especially on the medial or the lateral/posterolateral side. Even with repair or reconstruction of these injuries, with repetitive load, the ligament will eventually fail to restore its structure and strength, resulting in failure and secondary restraint laxity. We have found that realignment of the limb is the most important factor in restoring a functional limb. After realignment, joint laxity, if persistent, can be addressed successfully with ligamentous reconstruction. Diagnosis and treatment of limb malalignment cannot be ignored in the management of chronic ligamentous instabilities, especially those with prior failed reconstruction. Our approach to these difficult problems and the preferred techniques of osteotomies on both tibial and femoral sides are described.

Patients: Forty patients who were 18 to 70 years of age (mean age, 48.5 years; 67.5% women) had pain in the shoulder or lateral deltoid area that was exacerbated by overhead throwing activity; symptoms lasting.3 months; pain on palpation and/or decreased range of motion with shoulder flexion, abduction, or internal and external rotation; and rotator cuff tendinosis or partial tendon tear confirmed by magnetic resonance imaging. Exclusion criteria included full-thickness tear, other serious concomitant disease, hemoglobin level ,11 g/dL and platelet level ,150 · 10/mL, and corticosteroid injection in the past 6 weeks and/or nonsteroidal anti-inflammatory drug use in the past week. Patients also had to show at least 50% improvement in pain on the Neer impingement test after a subacromial injection of local anesthetic. All patients were included in the analysis.

The American-British-Canadian (ABC) Exchange Fellowship was conceived by Dr. Robert I. Harris of the University of Toronto. In 1947, Dr. Harris, President of the American Orthopaedic Association (AOA), was concerned that “because of World War II and the accompanying post-war difficulties, young orthopaedic surgeons of Great Britain would find it difficult, if not impossible, to visit orthopaedic centres in the United States and Canada.”1 With the partnership of the Presidents of the Canadian Orthopaedic Association (COA, Edouard Samson) and the British Orthopaedic Association (BOA, S.A.S. Malkin), Dr. Harris designed a tour of North America and attracted funds. In the spring of 1948, thirteen orthopaedic surgeons from Great Britain sailed to North America on the RMS Queen Elizabeth and toured as the first ABC fellows. The following year, a reciprocal tour with fifteen North American orthopaedic surgeons took place in the United Kingdom. During the ensuing four years, debate raged within the orthopaedic associations regarding the future of the ABC Exchange Fellowship. While detractors were a vocal minority, the prevailing force was the persistence of individuals such as British fellows Philip Newman, Derick Strange, Sir Reginald Watson-Jones (President of the BOA), and Sir Henry Osmond-Clarke, who collectively extolled the significance of a face-to-face academic and cultural exchange. The ABC Exchange Fellowship resumed in 1954 with British fellows traveling to North America. The legacy of the ABC tour has continued without interruption since that time. The Fellowship was further acclaimed in 1958 when the fellows were received at the White House by President Dwight D. Eisenhower, who emphasized the value and importance of face-to-face exchanges. In 1964, the Ruth B. Lilly Fellowship Fund was created and ensured the continuation of the Fellowship in perpetuity. South Africa joined the tour in 1983, followed by Australia and New Zealand in 1985. During the …