Search

Unlabelled: The Bernese periacetabular osteotomy is commonly used to treat symptomatic acetabular dysplasia. Although periacetabular osteotomy is becoming a more common surgical intervention to relieve pain and improve function, the strength of clinical evidence to support this procedure for these goals is not well defined in the literature. We therefore performed a systematic review of the literature to define the level of evidence for periacetabular osteotomy, to determine deformity correction, clinical results, and to determine complications associated with the procedure. Thirteen studies met our inclusion criteria. Eleven studies were Level IV, one was Level III, and one was Level II. Radiographic deformity correction was consistent and improvement in hip function was noted in all studies. Most studies did not correlate radiographic and clinic outcomes. Clinical failures were commonly associated with moderate to severe preoperative osteoarthritis and conversion to THA was reported in 0% to 17% of cases. Major complications were noted in 6% to 37% of the procedures. These data indicate periacetabular osteotomy provides pain relief and improved hip function in most patients over short- to midterm followup. The current evidence is primarily Level IV.Level Of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

BACKGROUND: The risk of tear of the intact anterior cruciate ligament in the contralateral knee after anterior cruciate ligament reconstruction of the opposite knee and the incidence of rupturing the anterior cruciate ligament graft during the first 2 years after surgery have not been extensively studied in a prospective manner. Clinicians have hypothesized that the opposite normal knee is at equal or increased risk compared with the risk of anterior cruciate ligament graft rupture in the operated knee. HYPOTHESIS: The risk of anterior cruciate ligament graft rupture and contralateral normal knee anterior cruciate ligament rupture at 2-year follow-up is equal. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The Multicenter Orthopaedic Outcome Network (MOON) database of a prospective longitudinal cohort of anterior cruciate ligament reconstructions was used to determine the number of anterior cruciate ligament graft ruptures and tears of the intact anterior cruciate ligament in the contralateral knee at 2-year follow-up. Two-year follow-up consisted of a phone interview and review of operative reports. RESULTS: Two-year data were obtained for 235 of 273 patients (86%). There were 14 ligament disruptions. Of these, 7 were tears of the intact anterior cruciate ligament in the contralateral knee (3.0%) and 7 were anterior cruciate ligament graft failures (3.0%). CONCLUSION: The contralateral normal knee anterior cruciate ligament is at a similar risk of anterior cruciate ligament tear (3.0%) as the anterior cruciate ligament graft after primary anterior cruciate ligament reconstruction (3.0%). [ABSTRACT FROM AUTHOR]

BACKGROUND: Six classification systems have been proposed for describing rotator cuff tears designed to help understand their natural history and make treatment decisions. PURPOSE: To assess the interobserver variation for these classification systems and identify the method with the best interobserver agreement. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Six rotator cuff tear classification systems were identified in a literature search. The components of these systems included partial-thickness rotator cuff tears and classification by size, shape, configuration, number of tendons involved, and by extent, topography, and nature of the biceps. Twelve fellowship-trained orthopaedic surgeons who each perform at least 30 rotator cuff repairs per year reviewed arthroscopy videos from 30 patients with a random assortment of rotator cuff tears and classified them by the 6 classification systems. Interobserver variation was determined by a kappa analysis. RESULTS: Interobserver agreement was high when distinguishing between full-thickness and partial-thickness tears (0.95, kappa = 0.85). The investigators agreed on the side (articular vs bursal) of involvement for partial-thickness tears (observed agreement 0.92, kappa = 0.85) but could not agree when classifying the depth of the partial-thickness tear (observed agreement 0.49, kappa = 0.19). The best agreement for full-thickness tears was seen when the tear was classified by topography (degree of retraction) in the frontal plane (observed agreement 0.70, kappa = 0.54). CONCLUSION: With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. Researchers should consider describing full-thickness rotator cuff tears by topography (degree of retraction) in the frontal plane. [ABSTRACT FROM AUTHOR]

Human sperm function was compared in co-culture with monolayers of oviduct epithelial cells (OEC) from three species, human, macaque and bovine. For all species, freeze-thawed and passaged OEC from females in the periovulatory phase were used. OEC cultured on an extra-cellular matrix (Matrigel) formed a monolayer which supported human sperm attachment to OEC from all three species. Spermatozoa in co-culture with OEC from all three species showed prolonged survival and improved motility characteristics over those cultured in medium alone. This paper describes an efficient, repeatable co-culture system for human spermatozoa which supports sperm attachment to OEC and subsequently improves sperm function over that seen in control medium cultures. Because the improved sperm function in co-culture did not differ significantly between human and bovine OEC for those attributes studied, it is proposed that bovine OEC could be used as an alternative to human OEC in certain human sperm co-culture studies. Follicular phase bovine OEC from reproductively normal donors are far more accessible than their human counterparts, thus making this co-culture system more widely available for the study of human spermatozoa-female tract interactions. [ABSTRACT FROM PUBLISHER]

BACKGROUND: The meniscal flounce sign is a fold in the free, nonanchored inner edge of the medial meniscus that can be noted during routine arthroscopy of the knee. HYPOTHESIS: The meniscal flounce sign can be a significant indicator of the presence or absence of medial meniscus injury. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 4. METHODS: One hundred sixty-eight patients were prospectively evaluated at the time of the arthroscopy for the presence or absence of the arthroscopic meniscal flounce sign. These results were then correlated with the presence of medial meniscus tears. RESULTS: The presence of the meniscal flounce sign has a positive predictive value of a normal meniscus of 0.97 (63/65). The absence of the meniscal flounce sign has a positive predictive value of an abnormal meniscus of 0.98 (101/103). Specificity is 98%, and sensitivity is 97%. CONCLUSION: The absence of the arthroscopic meniscal flounce sign is a sensitive and specific predictor of the presence of medial meniscus tears that should alert the surgeon to probe carefully for an occult medial meniscus tear. [ABSTRACT FROM AUTHOR]

Objective: The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears., Methods: This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis., Results: A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m 2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear., Conclusions: Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients., Level of Evidence: III., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Humeral avulsion of the glenohumeral ligament (HAGL) lesions are an uncommon cause of anterior glenohumeral instability and may occur in isolation or combination with other pathologies. As HAGL lesions are difficult to detect via magnetic resonance imaging (MRI) and arthroscopy, they can remain unrecognized and result in continued glenohumeral instability., Purpose: To compare patients with anterior shoulder instability from a large multicenter cohort with and without a diagnosis of a HAGL lesion and identify preoperative physical examination findings, patient-reported outcomes, imaging findings, and surgical management trends associated with HAGL lesions., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Patients with anterior glenohumeral instability who underwent surgical management between 2012 and 2020 at 11 orthopaedic centers were enrolled. Patients with HAGL lesions identified intraoperatively were compared with patients without HAGL lesions. Preoperative characteristics, physical examinations, imaging findings, intraoperative findings, and surgical procedures were collected. The Student t test, Kruskal-Wallis H test, Fisher exact test, and chi-square test were used to compare groups., Results: A total of 21 HAGL lesions were identified in 915 (2.3%) patients; approximately one-third (28.6%) of all lesions were visualized intraoperatively but not identified on preoperative MRI. Baseline characteristics did not differ between study cohorts. Compared with non-HAGL patients, HAGL patients were less likely to have a Hill-Sachs lesion (54.7% vs 28.6%; P = .03) or an anterior labral tear (87.2% vs 66.7%; P = .01) on preoperative MRI and demonstrated increased external rotation when their affected arm was positioned at 90° of abduction (85° vs 90°; P = .03). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization surgery (odds ratio, 74.6 [95% CI, 25.2-221.1]; P < .001)., Conclusion: Approximately one-third of HAGL lesions were missed on preoperative MRI. HAGL patients were less likely to exhibit preoperative imaging findings associated with anterior shoulder instability, such as Hill-Sachs lesions or anterior labral pathology. These patients underwent open procedures more frequently than patients without HAGL lesions., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This research was supported by the National Institutes of Health and Orthopaedic Research and Education Foundation. See the Supplemental Material for all author disclosures. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Objective: Meniscal tear in persons aged ≥45 years is typically managed with physical therapy (PT), and arthroscopic partial meniscectomy (APM) is offered to those who do not respond. Prior studies suggest APM may be associated with greater progression of radiographic changes., Methods: We assessed changes between baseline and 60 months in the Kellgren-Lawrence (KL) grade and OARSI radiographic score (including subscores for joint space narrowing and osteophytes) in subjects aged 45-85 years enrolled into a seven-center randomized trial comparing outcomes of APM with PT for meniscal tear, osteoarthritis changes, and knee pain. The primary analysis classified subjects according to treatment received. To balance APM and PT groups, we developed a propensity score and used inverse probability weighting (IPW). We imputed a 60-month change in the OARSI score for subjects who underwent total knee replacement (TKR). In a sensitivity analysis, we classified subjects by randomization group., Results: We analyzed data from 142 subjects (100 APM, 42 PT). The mean ± SD weighted baseline OARSI radiographic score was 3.8 ± 3.5 in the APM group and 4.0 ± 4.9 in the PT group. OARSI scores increased by a mean of 4.1 (95% confidence interval [95% CI] 3.5-4.7) in the APM group and 2.4 (95% CI 1.7-3.2) in the PT group (P < 0.001) due to changes in the osteophyte component. We did not observe statistically significant differences in the KL grade. Sensitivity analyses yielded similar findings to the primary analysis., Conclusion: Subjects treated with APM had greater progression in the OARSI score because of osteophyte progression but not in the KL grade. The clinical implications of these findings require investigation., (© 2023 American College of Rheumatology.)

Background: Failure rates up to 14% have been reported after arthroscopic posterior capsulolabral repair. It is unknown if revision arthroscopic posterior capsulolabral stabilization has inferior restoration of stability and return to sport when compared with primary repair. Optimal management of failed posterior capsulolabral stabilization is unknown., Purpose: To report outcomes of revision posterior capsulolabral repair and factors that contribute to failure and to determine optimal management of failed posterior stabilization procedures., Study Design: Systematic review; Level of evidence, 4., Methods: A computerized search of the PubMed, EMBASE, and Web of Science databases and manual screening of selected article reference lists were performed in January 2022. Randomized controlled trial, cohort, case-control, and case series studies reporting clinical outcomes of revision arthroscopic posterior capsulolabral repair were eligible. Patient characteristics, indications for revision, intraoperative findings, surgical techniques, and patient-reported outcomes were recorded. Owing to heterogeneity of reported outcomes, data were summarized and presented without pooled statistics., Results: Only 3 of the 990 identified studies met inclusion criteria. The included studies encompassed 26 revision arthroscopic posterior capsulolabral repairs, with follow-up ranging from 2.3 to 5.3 years. The failed index procedure was arthroscopic capsulolabral repair with suture anchors (n = 22) or posterior thermal capsulorrhaphy (n = 4). The primary indications for revision were recurrent instability and pain. Six patients experienced recurrent instability after revision. Patient satisfaction ranged from 15% to 25%., Conclusion: This systematic review of 3 studies demonstrated that the incidence of persistent pain and recurrent instability after revision arthroscopic posterior shoulder stabilization is common, and despite slight improvement in patient-reported outcomes, many patients are dissatisfied with their clinical outcomes. Revision arthroscopic posterior shoulder stabilization appears to have a significant failure rate, and there is need for additional prospective studies to help determine the best intervention for these patients., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.B. has received grant support from DJO, education payments from Arthrex and Smith & Nephew, and hospitality payments from Stryker. R.W.W. has received royalties from Responsive Arthroscopy. J.D. has received education payments from Supreme Orthopedic Systems and nonconsulting fees from Arthrex. L.L. has received grant support from DJO and education payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: Meniscal tear in older adults often accompanies knee osteoarthritis and is commonly treated with arthroscopic partial meniscectomy (APM) when patients have persistent pain after a trial of physical therapy. Cross-sectional evidence suggests that synovitis is associated with baseline pain in this patient population, but little is known about the relationship between synovitis and postoperative recovery or progression of knee osteoarthritis., Purpose/hypothesis: Intra-articular extended-release triamcinolone may reduce inflammation and thereby improve outcomes and slow disease progression. This article presents the rationale behind the Corticosteroid Meniscectomy Trial (CoMeT) and describes its study design and implementation strategies., Study Design: Randomized controlled trial., Methods: CoMeT is a 2-arm, 3-center, randomized placebo-controlled trial designed to establish the clinical efficacy of extended-release triamcinolone administered via intra-articular injection immediately after APM. The primary outcome is change in Knee injury and Osteoarthritis Outcome Score Pain subscore at 3-month follow-up. Synovial biopsy, joint fluid aspirate, and urine and blood sample analyses will examine the associations between various objective measures of baseline inflammation and pre- and postoperative outcome measures and clinical responses to triamcinolone intervention. Quantitative 3-T magnetic resonance imaging will evaluate cartilage and meniscal composition and 3-dimensional bone shape to detect early joint degeneration., Results: We discuss methodologic innovations and challenges., Conclusion: To our knowledge, this is the first randomized double-blind clinical trial that will analyze the effect of extended-release triamcinolone acetonide on pain, magnetic resonance imaging measures of structural change and effusion/synovitis, soluble biomarkers, and synovial tissue transcriptomics after APM., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: All study-related activities are supported by the Arthritis Foundation, with the exception that Pacira BioSciences will provide the necessary doses of extended-release triamcinolone (Zilretta) to all 3 study sites and will support collection and analysis of biospecimens. C.S.W. has received consulting fees from Siemens Medical. K.P.S. has received consulting fees and honoraria from Flexion Therapeutics. R.W.W. has received royalties from Responsive Arthroscopy. M.H.J. has received consulting fees from Regeneron. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Objectives: Physically-demanding occupations may increase rotator cuff disease (RCD) risk and need for surgery. We linked a job-exposure matrix (JEM) to the UK Biobank cohort study to measure physical occupational exposures and estimate associations with RCD surgery., Methods: Jobs and UK Standard Occupational Classification (SOC) codes were recorded during the UK Biobank verbal interview. Lifetime job histories were captured through a web-based survey. UK SOC codes were linked to a JEM based on the US O*NET database. O*NET-based scores [static strength, dynamic strength, general physical activities, handling/moving objects (range=1-7), time spent using hands, whole body vibration, and cramped/awkward positions (range=1-5)] were assigned to jobs. RCD surgeries were identified through linked national hospital inpatient records. Multivariable Cox regression was used to calculate hazard ratios (HR) as estimates of associations with RCD surgery. Among those with lifetime job histories, associations were estimated for duration of time with greatest exposure (top quartile of exposure)., Results: Of 277 808 people reporting jobs, 1997 (0.7%) had an inpatient RCD surgery. After adjusting for age, sex, race, education, area deprivation, and body mass index, all O*NET variables considered were associated with RCD surgery (HR per point increase range=1.10-1.45, all P<0.005). A total of 100 929 people reported lifetime job histories, in which greater exposures were significantly associated with RCD surgery after >10 years of work (eg, HR for 11-20 versus 0 years with static strength score ≥4 = 2.06, 95% confidence interval 1.39-3.04)., Conclusions: Workplace physical demands are an important risk factor for RCD surgery, particularly for workers with more than a decade of exposure.

Objective: Patients with meniscal tears reporting meniscal symptoms such as catching or locking have traditionally undergone arthroscopy. The present study was undertaken to investigate whether patients with meniscal tears who report meniscal symptoms have greater improvement with arthroscopic partial meniscectomy (APM) than physical therapy (PT)., Methods: We used data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial, which randomized participants with knee osteoarthritis (OA) and meniscal tear to APM or PT. The frequency of each meniscal symptom (clicking, catching, popping, intermittent locking, giving way, swelling) was measured at baseline and 6 months. We used linear regression models to determine whether the difference in improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score at 6 months between patients treated with APM versus PT was modified by the presence of each meniscal symptom. We also determined the percentage of participants with resolution of meniscal symptoms by treatment group., Results: We included 287 participants. The presence (versus absence) of any of the meniscal symptoms did not modify the improvement in KOOS pain score between APM versus PT by >0.5 SD (all P interaction >0.05). APM led to greater resolution of intermittent locking and clicking than PT (locking 70% versus 46%, clicking 41% versus 25%). No difference in resolution of the other meniscal symptoms was observed., Conclusion: Meniscal symptoms were not associated with improved pain relief. Although symptoms of clicking and intermittent locking had a greater reduction in the APM group, the presence of meniscal symptoms in isolation should not inform clinical decisions surrounding APM versus PT in patients with meniscal tear and knee OA., (© 2021 American College of Rheumatology.)

Objective: To estimate the risk of magnetic resonance imaging (MRI)-based structural changes in knee osteoarthritis (OA) among individuals with meniscal tear and knee OA, using MRIs obtained at baseline and 18 and 60 months after randomization in a randomized controlled trial of arthroscopic partial meniscectomy (APM) versus physical therapy (PT)., Methods: We used data from the Meniscal Tear in Osteoarthritis Research (METEOR) trial. MRIs were read using the MRI OA Knee Score (MOAKS). We used linear mixed-effects models to examine the association between treatment group and continuous MOAKS summary scores, and Poisson regression to assess categorical changes in knee joint structure. Analyses assessed changes in OA between baseline and month 18 and between months 18 and 60. We performed both intention-to-treat and as-treated analyses., Results: The analytic sample included 302 participants. For both treatment groups, more OA changes were seen during the early interval than during the later interval. ITT analysis revealed that, between baseline and month 18, APM was significantly associated with an increased risk of having a worsening cartilage surface area score, involving both any worsening across all knee joint subregions (risk ratio [RR] 1.35 [95% confidence interval (95% CI) 1.14, 1.61]) and the number of subregions damaged (RR 1.44 [95% CI 1.13, 1.85]) having a worsening effusion-synovitis score (RR 2.62 [95% CI 1.32, 5.21]), and having ≥1 additional subregion with osteophytes (RR 1.24 [95% CI 1.02, 1.50]). Significant associations were detected between months 18 and 60 only for having any subregion with a worsening osteophyte score (RR 1.28 [95% CI 1.04, 1.58])., Conclusion: These findings suggest that the association between APM and MRI-based structural changes in knee OA is most apparent during the initial 18 months after surgery. The reason for attenuation of this association over longer follow-up merits further investigation., (© 2022 American College of Rheumatology.)

Background: The anterior cruciate ligament (ACL) is crucial for knee proprioception and postural stability. While ACL reconstruction (ACLR) and rehabilitation improve postural stability, the timing in improvement of dynamic postural stability after ACLR remains relatively unknown., Purpose: To evaluate changes in dynamic postural stability after ACLR out to 24 months postoperatively., Study Design: Case series; Level of evidence, 4., Methods: Patients undergoing ACLR were prospectively enrolled, and dynamic postural stability was assessed within 2 days before surgery, at 3-month intervals postoperatively to 18 months, then at 24 months. Measurements were made on a multidirectional platform tracking the patient's center of mass based on pelvic motion. The amount of time the patient was able to stay on the platform was recorded, and a dynamic motion analysis score, reflecting the patient's ability to maintain one's center of mass, was generated overall and in 6 independent planes of motion., Results: A total of 44 patients with a mean age of 19.7 ± 6.2 years completed the study protocol. Overall mean dynamic postural stability improved significantly at 3, 6, 9, and 12 months after surgery, with continued improvement out to 24 months. Notable improvements occurred in medial/lateral and anterior/posterior stability from baseline to 6 months postoperatively, while internal/external rotation and flexion/extension stability declined initially after surgery from baseline to 3 months postoperatively before stabilizing to the end of the study period., Conclusion: Overall dynamic postural stability significantly improved up to 12 months after ACLR. Improvement in postural stability occurred primarily in the medial/lateral and anterior/posterior planes of motion, with initial decreases in the flexion/extension and internal/external rotational planes of motion., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.H.B. has received education payments from Arthrex, Breg, Elite Orthopedics, and Smith & Nephew; consulting fees from Sanofi; and speaking fees from Arthrex. K.A.S. has received education payments from Elite Orthopedics. D.M.K. has received grant support from Arthrex and education payments from DJO, Elite Orthopedics, Medwest, and Smith & Nephew. M.J.M. has received education payments from Arthrex and Elite Orthopedics/Apollo Orthopedics and consulting fees from Heron Therapeutics and Pacira Pharmaceuticals. R.W.W. has received royalties from Responsive Arthroscopy. M.V.S. has received consulting fees from Arthrex and Flexion Therapeutics and speaking fees from Elite Orthopedics. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

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)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Research reported in this publication was partially supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award No. R01AR053684 (to K.P.S.) and under award No. K23AR066133, which supported a portion of M.H.J.’s professional effort. Contents of this article are solely the responsibility of the authors and do not necessarily represent official views of the National Institutes of Health. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) computer-adaptive testing (CAT) has been shown to be a valid and reliable means of assessing patient-reported outcomes. However, normal scores and distributions for a subset of a healthy young athletic population have not been established., Purpose: To establish normative PROMIS scores for the domains of Physical Function (PF-CAT), Mobility (M-CAT), Upper Extremity Function (UE-CAT), and Pain Interference (PI-CAT) and determine the frequency of floor and ceiling effects in a population of healthy collegiate athletes., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Healthy collegiate athletes (18-23 years of age) were prospectively enrolled to complete the 4 PROMIS CAT domains. Additionally, the athletes provided information regarding their age, sex, and sport(s). Mean scores (±SD) and identification of ceiling or floor effects were calculated. Ceiling and floor effects were considered significant if >15% of the participants obtained the highest or lowest possible score on a domain., Results: A total of 194 healthy athletes (mean age, 19.1 years) were included in the study: 118 (60.8%) men and 76 (39.2%) women. Mean scores were 62.9 ± 6.7 for PF-CAT, 58.2 ± 4.1 for M-CAT, 57.4 ± 5.8 for UE-CAT, and 43.2 ± 6.2 for PI-CAT. Distributions of scores for M-CAT and UE-CAT indicated strong ceiling effects by 77.3% and 66.0% of the participants, respectively. In healthy athletes, the PF-CAT differed most from the expected population-based mean score (50), with the mean being >1 SD above (62.9), without a ceiling effect observed. There were no significant sex- or age-based differences on any of the PROMIS domain scores., Conclusion: Healthy collegiate athletes scored nearly 1 SD from population-based means for all of the domains tested. M-CAT and UE-CAT demonstrated ceiling effects in more than two-thirds of healthy athletes, which may limit their utility in this population. The PF-CAT did not demonstrate floor or ceiling effects and demonstrated differences in a young adult athletic population from the population mean. The mean PF-CAT score of 62.9 can represent a target for return of function in injured athletes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: D.B. has received educational support from Smith & Nephew and Arthrex. R.W.W. is a paid consultant for Responsive Arthroscopy. M.J.M. has received consulting fees from Arthrex and Heron Therapeutics and educational support from Elite Orthopedics. J.J.N. has received consulting fees from Smith & Nephew, Ceterix, and Responsive Arthroscopy and research funding from Smith & Nephew, Stryker, and Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Background: Letters of recommendation (LOR) are an important component of trainee advancement and assessment. Examination of word use in LOR has demonstrated significant differences in how letter writers describe female and male applicants. Given the emphasis on increasing both gender and racial diversity among orthopaedic surgeons, we aimed to study gender and racial differences in LOR for applicants to orthopaedic surgery residencies., Methods: All applications submitted to a single, academic orthopaedic residency program in 2018 were included. Self-identified gender and race were recorded. The LOR were analyzed via a text analysis software program using previously described categories of communal, agentic, grindstone, ability, and standout words. We examined the relative frequency of word use in letters for (1) male and female applicants and (2) white and underrepresented in orthopaedics (UiO) applicants, with the subgroup analysis based on whether standardized (using the American Orthopaedic Association template) or traditional (narrative) LOR were used., Results: Two thousand six hundred twenty-five LOR were submitted for 730 applicants (79% men). Fifty-nine percent of applicants were self-identified as white, and 34% were self-identified as UiO. In traditional LOR, standout words (odds ratio [OR] 1.07; p = 0.01) were more likely to be used in letters for women compared with men, with no difference in any other word-use category. In standardized LOR, there were no gender-based differences in any word category. In traditional LOR, grindstone words (OR = 0.96; p = 0.02) were more likely to be used in letters for UiO than white applicants, whereas standout words (OR = 1.05; p = 0.04) were more likely to be used in letters for white candidates. In standardized LOR, there were no race-based differences in any word category use., Conclusions: Small differences were found in the categories of words used to describe male and female candidates and white and UiO candidates. These differences were not present in the standardized LOR compared with traditional LOR. It is possible that the use of standardized LOR may reduce gender- and race-based bias in the narrative assessment of applicants., (Copyright © 2020 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Objective: The present study was undertaken to evaluate changes in knee magnetic resonance imaging (MRI) findings over the course of 18 months in subjects with osteoarthritic change and meniscal tear treated with arthroscopic partial meniscectomy (APM) or nonoperatively with physical therapy (PT)., Methods: We used 18-month follow-up data from the Meniscal Tear in Osteoarthritis Research Trial. MRI results were read with reference to the MRI Osteoarthritis Knee Score. We focused on 18-month change in bone marrow lesions (BMLs), cartilage thickness, cartilage surface area, osteophyte size, effusion-synovitis, and Hoffa-synovitis. We used multinomial logistic regression to assess associations between MRI-based changes in each feature and treatment type., Results: A total of 351 subjects were randomized, and 225 had both baseline and 18-month MRI results. In both treatment groups, patients experienced substantial changes in several MRI-based markers. In 60% of the APM group, versus 33% of the PT group, cartilage surface area damage advanced in ≥2 subregions (adjusted odds ratio 4.2 [95% confidence interval 2.0-9.0). Patients who underwent APM also had greater advancement in scores for osteophytes and effusion-synovitis. We did not find significant associations between treatment type and change in cartilage thickness, BMLs, or Hoffa-synovitis., Conclusion: This cohort of patients with meniscal tear and osteoarthritis showed marked advancement in MRI-based features over 18 months. Patients treated with APM showed more advancement in some features compared to those treated nonoperatively. The clinical relevance of these early findings is unknown and requires further study., (© 2019, American College of Rheumatology.)

Background: The operative treatment of Achilles tendon ruptures has been associated with lower rerupture rates and better function but also a risk of surgery-related complications compared with nonoperative treatment, which may provide improved outcomes with accelerated rehabilitation protocols. However, economic decision analyses integrating the updated costs of both treatment options are limited in the literature., Purpose: To compare the cost-effectiveness of operative and nonoperative treatment of acute Achilles tendon tears., Study Design: Economic and decision analysis; Level of evidence, 2., Methods: An economic decision model was built to assess the cost-utility ratio (CUR) of open primary repair versus nonoperative treatment for acute Achilles tendon ruptures, based on direct costs from the practices of sports medicine and foot and ankle surgeons at a single tertiary academic center, with published outcome probabilities and patient utility data. Multiway sensitivity analyses were performed to reflect the range of data., Results: Nonoperative treatment was more cost-effective in the average scenario (nonoperative CUR, US$520; operative CUR, US$1995), but crossover occurred during the sensitivity analysis (nonoperative CUR range, US$224-US$2079; operative CUR range, US$789-US$8380). Operative treatment cost an extra average marginal CUR of US$1475 compared with nonoperative treatment, assuming uneventful healing in both treatment arms. The sensitivity analysis demonstrated a decreased marginal CUR of operative treatment when the outcome utility was maximized, and rerupture rates were minimized compared with nonoperative treatment., Conclusion: Nonoperative treatment was more cost-effective in average scenarios. Crossover indicated that open primary repair would be favorable for maximized outcome utility, such as that for young athletes or heavy laborers. The treatment decision for acute Achilles tendon ruptures should be individualized. These pilot results provide inferences for further longitudinal analyses incorporating future clinical evidence., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: L.B. has received educational support from Elite Orthopaedics and hospitality payments from Arthrex and Smith & Nephew. J.J. has received educational support from Arthrex, consulting fees from Tornier and Wright Medical, speaking fees from Arthrex, royalties from Tornier and Wright Medical, and hospitality payments from Stryker. M.J.M. has received educational support from Arthrex, Breg, and Elite Orthopaedics; consulting fees from Arthrex, Heron Therapeutics, Pacira, and Schwartz Biomedical; and speaking fees from Arthrex. J.M. has received educational support from Elite Orthopaedics, consulting fees from Wright Medical, and speaking fees from Arthrex and Wright Medical. M.V.S. has received educational support from Elite Orthopaedics, consulting fees from Arthrex and Flexion Therapeutics, and speaking fees from Arthrex. R.W.W. has received royalties from Responsive Arthroscopy. R.H.B. has received educational support from Arthrex and Elite Orthopaedics; consulting fees from Arthrex, ISTO Technologies, and Sanofi-Aventis; and speaking fees from Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Background: Understanding predictors of pain is critical, as recent literature shows that comorbid back pain is an independent risk factor for worse functional and patient-reported outcomes (PROs) as well as increased opioid dependence after total joint arthroplasty., Purpose/hypothesis: The purpose of this study was to evaluate whether comorbid back pain would be predictive of pain or self-reported instability symptoms at the time of stabilization surgery. We hypothesized that comorbid back pain will correlate with increased pain at the time of surgery as well as with worse scores on shoulder-related PRO measures., Study Design: Cross-sectional study; Level of evidence, 3., Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients consented to participate in pre- and intraoperative data collection. Demographic characteristics, injury history, preoperative PRO scores, and radiologic and intraoperative findings were recorded for patients undergoing surgical shoulder stabilization. Patients were also asked, whether they had any back pain., Results: The study cohort consisted of 1001 patients (81% male; mean age, 24.1 years). Patients with comorbid back pain (158 patients; 15.8%) were significantly older (28.1 vs 23.4 years; P < .001) and were more likely to be female (25.3% vs 17.4%; P = .02) but did not differ in terms of either preoperative imaging or intraoperative findings. Patients with self-reported back pain had significantly worse preoperative pain and shoulder-related PRO scores (American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index) ( P < .001), more frequent depression (22.2% vs 8.3%; P < .001), poorer mental health status (worse scores for the RAND 36-Item Health Survey Mental Component Score, Iowa Quick Screen, and Personality Assessment Screener) ( P < .01), and worse preoperative expectations ( P < .01)., Conclusion: Despite having similar physical findings, patients with comorbid back pain had more severe preoperative pain and self-reported symptoms of instability as well as more frequent depression and lower mental health scores. The combination of disproportionate shoulder pain, comorbid back pain and mental health conditions, and inferior preoperative expectations may affect not only the patient's preoperative state but also postoperative pain control and/or postoperative outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported, in part, by research grants from the Orthopaedic Research & Education Fund. B.R.W. is a paid board member of United HealthCare and a paid consultant for ConMed Linvatec and SportsMed Innovate. B.R.W.’s institution has received educational support from ConMed, Smith & Nephew, Arthrex, and Wardlow Enterprises. K.M.B. has received consulting fees from Wright Medical, speaking fees from Wright Medical and Arthrex, and royalties from Lippincott Williams & Wilkins. J.T.B. has received consulting fees from Encore Medical, Smith & Nephew, and DJO Global; speaking fees from Smith & Nephew; and royalties from Shukla Medical. R.H.B. has received educational support from Arthrex and Elite Orthopedics, speaking fees from Arthrex and Smith & Nephew, and consulting fees from ISTO Technologies and Sanofi-Aventis. B.T.F. has received hospitality payments from Zimmer Biomet. J.A.G. has received educational support from Pinnacle, hospitality payments from Aesculap Biologics and Smith & Nephew, and consulting fees from Ossur and JRF Ortho. G.L.J. is a board member for the Musculoskeletal Transplant Foundation and has received educational support from CDC Medical. J.E.K. is a paid editor for the Journal of Shoulder and Elbow Surgery. C.B.M. has received speaking fees from Zimmer Biomet and consulting fees from Zimmer Biomet, Medacta, Stryker, Tornier, Wright Medical, and Linvatec. R.G.M. is a paid editor for the Journal of Bone and Joint Surgery and receives royalties from Springer and Demos Health. E.C.M. has received consulting fees from Zimmer Biomet; research support from Smith & Nephew, Arthrex, and DePuy; and royalties from Zimmer Biomet and Elsevier. B.S.M. has received consulting fees from Arthrex. A.J.S. has received educational support from Gemini Medical and Arthrex, honoraria from Encore Medical, and consulting fees from Medacta. M.V.S. has received educational support from Elite Orthopedics and consulting fees from Arthrex and Flexion Therapeutics. R.W.W. has received royalties from Wolters Kluwer–Lippincott Williams & Wilkins and is a team physician for the St. Louis Blues Hockey Club. A.L.Z. has received consulting fees from Stryker. C.M.H. has received research support from Zimmer Biomet, speaking fees from Pacira Pharmaceuticals, and hospitality payments from Arthrex and Tornier., (© The Author(s) 2020.)

Background: Multiple studies have shown that patients are susceptible to posttraumatic osteoarthritis (PTOA) after an anterior cruciate ligament (ACL) injury, even with ACL reconstruction (ACLR). Prospective studies using multivariable analysis to identify risk factors for PTOA are lacking., Purpose/hypothesis: This study aimed to identify baseline predictors of radiographic PTOA after ACLR at an early time point. We hypothesized that meniscal injuries and cartilage lesions would be associated with worse radiographic PTOA using the Osteoarthritis Research Society International (OARSI) atlas criteria., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 421 patients who underwent ACLR returned on-site for standardized posteroanterior semiflexed knee radiography at a minimum of 2 years after surgery. The mean age was 19.8 years, with 51.3% female patients. At baseline, data on demographics, graft type, meniscal status/treatment, and cartilage status were collected. OARSI atlas criteria were used to grade all knee radiographs. Multivariable ordinal regression models identified baseline predictors of radiographic OARSI grades at follow-up., Results: Older age (odds ratio [OR], 1.06) and higher body mass index (OR, 1.05) were statistically significantly associated with a higher OARSI grade in the medial compartment. Patients who underwent meniscal repair and partial meniscectomy had statistically significantly higher OARSI grades in the medial compartment (meniscal repair OR, 1.92; meniscectomy OR, 2.11) and in the lateral compartment (meniscal repair OR, 1.96; meniscectomy OR, 2.97). Graft type, cartilage lesions, sex, and Marx activity rating scale score had no significant association with the OARSI grade., Conclusion: Older patients with a higher body mass index who have an ACL tear with a concurrent meniscal tear requiring partial meniscectomy or meniscal repair should be advised of their increased risk of developing radiographic PTOA. Alternatively, patients with an ACL tear with an articular cartilage lesion can be reassured that they are not at an increased risk of developing early radiographic knee PTOA at 2 to 3 years after ACLR., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Research reported in this publication was partially supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number R01AR053684 (K.P.S.) and under award number K23AR066133 (which supported a portion of M.H.J.’s professional effort). The content is solely the responsibility of the authors and does not necessarily represent official views of the National Institutes of Health. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. One or more of the authors has declared the following potential conflict of interest or source of funding: M.H.J. is on the scientific advisory board for Samumed. R.H.B. has received educational support from Elite Orthopedics; speaking fees from Smith & Nephew; research support from Zimmer; and consulting fees from Arthrex, ISTO, and Sanofi-Aventis. C.L.C.’s relative is an employee of Smith & Nephew. W.R.D. has received consulting fees from Linvatec and hospitality payments from Wright Medical. D.C.F. is a paid consultant for Linvatec, Vericel, MTF/Conmed, Smith & Nephew, DePuy, Moximed, and Zimmer; has received educational support from MTF/Conmed and Smith & Nephew; serves on the advisory panel for Vericel, MTF/Conmed, Histogenics, and Moximed; and has received hospitality payments from Wright Medical. B.C.F. receives a stipend for serving as an associate editor for The American Journal of Sports Medicine, has received hospitality payments from Smith & Nephew and consulting fees from New York R&D Center for Translational Medicine and Therapeutics, and is cofounder of Miach Orthopaedics. C.C.K. has received research support from DJO; educational support from CDC Medical, DePuy, and Smith & Nephew; consulting fees from Smith & Nephew and Zimmer Biomet; and nonconsulting payments from Arthrex. M.K. has received hospitality payments from Zimmer Biomet. T.S.L. has received educational support from Arthrex and Smith & Nephew and nonconsulting payments from Smith & Nephew. R.A.M. has received research support from Zimmer and educational support from Arthrex, CDC Medical, DonJoy, and Smith & Nephew. M.J.M. has received educational support from Apollo Surgical and Elite Orthopedics and consulting fees from Arthrex, Breg, Heron Therapeutics, Pacira, and Schwartz Biomedical. R.D.P. has received hospitality payments from the Musculoskeletal Transplant Foundation and Smith & Nephew and royalties from Zimmer Biomet. M.V.S. has received educational support from Arthrex and Elite Orthopedics, speaking fees from Arthrex and Elite Orthopedics, and consulting fees from Flexion Therapeutics and ISTO. C.W. has received consulting fees from Aastrom Biosciences, and his spouse owns stock in Pfizer and General Electric. R.W.W. receives royalties from Wolters Kluwer–Lippincott Williams & Wilkins. K.P.S. has received research support from DonJoy and Smith & Nephew; consulting fees from the National Football League, Cytori, and Mitek; and hospitality payments from DePuy and Biosense Webster. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

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., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: T.J.M. has received educational support from DJO, Smith & Nephew, and Stryker. K.A.M. has received educational support from Alliqua Biomedical and Arthrex; honoraria from Alliqua Biomedical; consulting fees from Arthrex, Stryker, and Zimmer Biomet; speaking fees from Alliqua Biomedical and Arthrex; and hospitality payments from Amniox Medical, Apollo Surgical Group, and Wright Medical. C.M.H. has received research support from Rotation Medical, Tornier, Wright Medical, and Zimmer Biomet; nonconsulting payments from Pacira Pharmaceuticals; and hospitality payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

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., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Research reported in this publication was partially supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award numbers K23AR066133 (to M.H.J.) and R01AR053684 (to K.P.S.). The content is solely the responsibility of the authors and does not necessarily represent official views of the National Institutes of Health. K.P.S. has received consulting fees from Cytori and hospitality payments from DePuy. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Objective: To compare the transcriptome of articular cartilage from knees with meniscus tears to knees with end-stage osteoarthritis (OA)., Design: Articular cartilage was collected from the non-weight bearing medial intercondylar notch of knees undergoing arthroscopic partial meniscectomy (APM; N = 10, 49.7 ± 10.8 years, 50% females) for isolated medial meniscus tears and knees undergoing total knee arthroplasty (TKA; N = 10, 66.0 ± 7.6 years, 70% females) due to end-stage OA. Ribonucleic acid (RNA) preparation was subjected to SurePrint G3 human 8 × 60K RNA microarrays to probe differentially expressed transcripts followed by computational exploration of underlying biological processes. Real-time polymerase chain reaction amplification was performed on selected transcripts to validate microarray data., Results: We observed that 81 transcripts were significantly differentially expressed (45 elevated, 36 repressed) between APM and TKA samples (≥ 2 fold) at a false discovery rate of ≤ 0.05. Among these, CFD, CSN1S1, TSPAN11, CSF1R and CD14 were elevated in the TKA group, while CHI3L2, HILPDA, COL3A1, COL27A1 and FGF2 were highly expressed in APM group. A few long intergenic non-coding RNAs (lincRNAs), small nuclear RNAs (snoRNAs) and antisense RNAs were also differentially expressed between the two groups. Transcripts up-regulated in TKA cartilage were enriched for protein localization and activation, chemical stimulus, immune response, and toll-like receptor signaling pathway. Transcripts up-regulated in APM cartilage were enriched for mesenchymal cell apoptosis, epithelial morphogenesis, canonical glycolysis, extracellular matrix organization, cartilage development, and glucose catabolic process., Conclusions: This study suggests that APM and TKA cartilage express distinct sets of OA transcripts. The gene profile in cartilage from TKA knees represents an end-stage OA whereas in APM knees it is clearly earlier in the degenerative process., (Copyright © 2019 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background: Patient preference information has become increasingly more important in clinical decision making., Purpose: To assess patient preferences when making treatment decisions in the shoulder to determine which features are more important according to patient age, race, activity level, and sex., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Study participants aged ≥18 years were surveyed as to their preferences regarding surgical treatment for shoulder and proximal biceps abnormalities. Survey features included time to return to unrestricted activities, time to return to work, size and appearance of scars, the potential for persistent pain in the upper arm or shoulder, fatigue in the biceps with repetitive lifting, potential for muscle cramping, and deformity in the proximal biceps. Participants also completed a validated shoulder activity scale, and demographic data regarding age, race, and sex were collected., Results: A total of 349 participants (166 female, 183 male) with a mean age of 45 years (range, 18-81 years) completed the survey. Overall, time to return to unrestricted activities and residual pain were considered very important to the majority of the respondents, while the size and appearance of surgical scars were of little importance. Prior shoulder pain (ρ = -0.17; P = .01) and prior shoulder surgery (ρ = -0.16; P = .03) correlated to concern about time to return to unrestricted activities. Younger age (ρ = -0.11; P = .04) and a higher level of education (ρ = 0.14; P = .03) correlated with greater concern for time to return to work. Women and African Americans were more concerned about the size and appearance of surgical scars (ρ = -0.28; P < .0001 and ρ = -0.20; P = .0002, respectively) and biceps deformity. Respondents with a higher activity level (ρ = 0.20; P = .0002) and men (ρ = 0.11; P = .04) were more concerned about fatigue., Conclusion: Concerns about residual pain, time to return to unrestricted activities, and time away from work are important to patients when considering the treatment for shoulder lesions. Patient preferences are associated with age, sex, race, and shoulder activity level. These features should be considered when discussing treatment options for shoulder and proximal biceps tendon disorders., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Support for the statistical analysis by K.S.-M. was provided by the Washington University Institute of Clinical and Translational Sciences (grant UL1TR000448) from the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH). M.V.S. is a paid speaker/presenter for Arthrex and Elite Orthopedics and is a consultant for Flexion Therapeutics and ISTO Technologies. M.J.M. has received educational support from Breg and Arthrex, is a paid speaker/presenter for Apollo Surgical, and is a consultant for Pacira Pharmaceuticals. R.W.W. has grants/grants pending from the NIH and receives publishing royalties from Wolters Kluwer–Lippincott Williams & Wilkins. R.H.B. is a consultant for Sanofi, Arthrex, and ISTO Technologies; is a paid speaker/presenter for Arthrex and Smith & Nephew; and has grants/grants pending from Zimmer. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Objective: To assess the impact of osteoarthritis (OA) on the meniscus by comparing transcripts and biological processes in the meniscus between patients with and without OA., Design: RNA microarrays were used to identify transcripts differentially expressed (DE) in meniscus obtained from 12 OA and 12 non-OA patients. The non-OA specimens were obtained at the time of arthroscopic partial meniscectomy. Real-time PCR was performed on selected transcripts. Biological processes and gene-networking was examined computationally. Transcriptome signatures were mapped with 37 OA-related transcripts to evaluate how meniscus gene expression relates to that of OA cartilage., Results: We identified 168 transcripts significantly DE between OA (75 elevated, 93 repressed) and non-OA samples (≥1.5-fold). Among these, CSN1S1, COL10A1, WIF1, and SPARCL1 were the most prominent transcripts elevated in OA meniscus, POSTN and VEGFA were most highly repressed in OA meniscus. Transcripts elevated in OA meniscus represented response to external stimuli, cell migration and cell localization while those repressed in OA meniscus represented histone deacetylase activity (related to epigenetics) and skeletal development. Numerous long non-coding RNAs (lncRNAs) were DE between the two groups. When segregated by OA-related transcripts, two distinct clustering patterns appeared: OA meniscus appeared to be more inflammatory while non-OA meniscus exhibited a "repair" phenotype., Conclusions: Numerous transcripts with potential relevance to the pathogenesis of OA are DE in OA and non-OA meniscus. These data suggest an involvement of epigenetically regulated histone deacetylation in meniscus tears as well as expression of lncRNAs. Patient clustering based on transcripts related to OA in articular cartilage confirmed distinct phenotypes between injured (non-OA) and OA meniscus., (Copyright © 2017. Published by Elsevier Ltd.)

Background: Football puts athletes at risk for knee injuries such meniscus and anterior cruciate ligament (ACL) tears, which are associated with the development of osteoarthritis (OA). Previous knee surgery, player position, and body mass index (BMI) may be associated with knee OA., Hypothesis: In elite football players undergoing knee magnetic resonance imaging at the National Football League's Invitational Combine, the prevalence of knee OA is associated with previous knee surgery and BMI., Study Design: Retrospective cohort., Level of Evidence: Level 4., Methods: A retrospective review was performed of all participants of the National Football League Combine from 2005 to 2009 who underwent magnetic resonance imaging of the knee because of prior knee injury, surgery, or knee-related symptoms or concerning examination findings. Imaging studies were reviewed for evidence of OA. History of previous knee surgery-including ACL reconstruction, meniscal procedures, and articular cartilage surgery-and position were recorded for each athlete. BMI was calculated based on height and weight., Results: There was a higher prevalence of OA in knees with a history of previous knee surgery (23% vs 4.0%, P < 0.001). The prevalence of knee OA was 4.0% in those without previous knee surgery, 11% in those with a history of meniscus repair, 24% of those with a history of ACL reconstruction, and 27% of those with a history of partial meniscectomy. Among knees with a previous ACL reconstruction, the rate of OA doubled in tibiofemoral compartments in which meniscal surgery was performed. BMI >30 kg/m 2 was also associated with a higher risk of OA ( P = 0.007) but player position was not associated with knee OA., Conclusions: Previous knee surgery, particularly ACL reconstruction and partial meniscectomy, and elevated BMI are associated with knee OA in elite football players. Future research should investigate ways to minimize the risk of OA after knee surgery in these athletes., Clinical Relevance: Treatment of knee injuries in football athletes should consider chondroprotection, including meniscal preservation and cartilage repair, when possible.

Background: Fast-pitch softball is one of the fastest growing sports, but there is little research regarding pitcher fatigue. Currently, there are no pitch limits or game counts., Questions/purposes: To study the effect of fatigue on youth fast-pitch softball pitchers during a high school season, we hypothesized increased games pitched during the season would correlate with increased player-reported pain and fatigue and decreased with upper extremity strength and range of motion (ROM)., Methods: This prospective cross-sectional study evaluated pre- and postgame shoulder and elbow strength, ROM, pain, and fatigue in 17 high school fast-pitch softball pitchers. These measures were recorded at two games, one at the beginning and one at the end of the season. Pitch count and number of games pitched during the season were recorded. We compared pre- and postgame measurements and measurements made at the beginning and end of the season., Results: Supraspinatus, forward flexion strength, and external rotation strength in abduction decreased significantly postgame compared to pregame. Pregame pain and fatigue increased with a greater number of games pitched during the season. Forward flexion, supraspinatus, and external rotation strength decreased with increasing number of games pitched during the season., Conclusions: Fast-pitch softball pitchers experience increased pain and fatigue during a single game and over the entire season. The increase in fatigue may predispose the player to injury. Further studies are needed to understand the relationship of pain and fatigue with predisposition to injury.

Purpose: Diabetes has been associated with adverse outcomes after various types of surgery. There are no previously published data regarding the effect of diabetes on outcomes from anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to test the hypotheses that diabetes is associated with worse clinical outcomes and a higher prevalence of subsequent surgeries after ACLR., Methods: Anterior cruciate ligament-deficient patients (n = 2198) undergoing unilateral ACLR from a multicenter prospective study were included. Patients who self-reported diabetes on the basis of comorbidity questions before surgery were identified from the database. They were compared with the remainder of the cohort who did not self-report diabetes. All patients were followed up for a minimum of 2 yr after their index surgery. A minimum 2-yr follow-up was attained on 1905/2198 (87%) via completed outcome questionnaires and 2096/2198 (95%) regarding subsequent surgery. The primary outcome measures were three validated outcome instruments. The secondary outcome measure was the incidence of additional surgery on the ipsilateral and contralateral knees., Results: Patients with diabetes had a significantly higher activity level at 2 yr (OR = 2.96; 95% CI, 1.30-6.77; P = 0.01), but otherwise slightly worse clinical outcomes, compared with patients without diabetes (OR range = 0.42-0.59). The prevalence of subsequent surgeries in patients with diabetes was not significantly different from the prevalence in patients without diabetes., Conclusions: Patients with diabetes maintain a higher activity level after ACLR despite slightly lower patient-reported outcome scores compared with patients without diabetes and do not have a higher rate of subsequent surgery.

Objectives: (i) To provide baseline knowledge of gene expression in macroscopically normal articular cartilage, (ii) to test the hypothesis that age, body-mass-index (BMI), and sex are associated with cartilage RNA transcriptome, and (iii) to predict individuals at potential risk for developing "pre-osteoarthritis" (OA) based on screening of genetic risk-alleles associated with OA and gene transcripts differentially expressed between normal and OA cartilage., Design: Healthy-appearing cartilage was obtained from the medial femoral notch of 12 knees with a meniscus tear undergoing arthroscopic partial meniscectomy. Cartilage had no radiographic, magnetic-resonance-imaging or arthroscopic evidence for degeneration. RNA was subjected to Affymetrix microarrays followed by validation of selected transcripts by microfluidic digital polymerase-chain-reaction. The underlying biological processes were explored computationally. Transcriptome-wide gene expression was probed for association with known OA genetic risk-alleles assembled from published literature and for comparison with gene transcripts differentially expressed between healthy and OA cartilage from other studies., Results: We generated a list of 27,641 gene transcripts in healthy cartilage. Several gene transcripts representing numerous biological processes were correlated with age and BMI and differentially expressed by sex. Based on disease-specific Ingenuity Pathways Analysis, gene transcripts associated with aging were enriched for bone/cartilage disease while the gene expression profile associated with BMI was enriched for growth-plate calcification and OA. When segregated by genetic risk-alleles, two clusters of study patients emerged, one cluster containing transcripts predicted by risk studies. When segregated by OA-associated gene transcripts, three clusters of study patients emerged, one of which is remarkably similar to gene expression pattern in OA., Conclusions: Our study provides a list of gene transcripts in healthy-appearing cartilage. Preliminary analysis into groupings based on OA risk-alleles and OA-associated gene transcripts reveals a subset of patients expressing OA transcripts. Prospective studies in larger cohorts are needed to assess whether these patterns are predictive for OA.

Background: There is a scarcity of literature evaluating injuries in youth fast-pitch softball players., Purpose: To perform a descriptive analysis of player-reported injuries in youth fast-pitch softball position players and pitchers during a single select-level season., Study Design: Prospective observation cohort study., Level of Evidence: Level 3., Methods: Ninety-eight athletes (48 pitchers, 50 position players) were followed for a single select fast-pitch softball season. Study participants completed web-based surveys every 3 weeks reporting injuries related to participation in fast-pitch softball. Injury was defined as pain causing cessation of participation in the current game or practice that prevents the player's return to that session or any pain that causes cessation of a player's customary participation on the day after the day of onset., Results: The median age of the study participants was 14 years (range, 9-18 years). There were 49 reported injuries in 98 athletes. The average age was 13 years for those not injured and 14 years for those who were injured (P < 0.02). There were 31 injuries that were not related to pitching: 19 occurred in position players and 12 occurred in pitchers; 70% of these injuries were to the lower extremity. The proportion of injuries not related to pitching was significantly greater than the proportion of injuries related to pitching (P < 0.02). Eighteen injuries among the 48 pitchers (38%) were directly attributed to pitching. Among the 18 pitching injuries, 11 (61%) involved the shoulder. The majority (78%) of injuries related to pitching occurred in the first 6 weeks of the season., Conclusion: There was a high incidence of injury in this prospective cohort of youth select-level fast-pitch softball players. Better off-season and preseason conditioning may be a key factor for reducing pitching injuries., Clinical Relevance: Recognition of injury patterns in fast-pitch softball players is critical to developing strategies to keep these athletes competing safely., (© 2015 The Author(s).)

Objective: The prevalence of radiographic osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) approaches 50%, yet the prevalence of significant knee pain is unknown. We applied three different models of Knee injury and Osteoarthritis Outcome Score (KOOS) thresholds for significant knee pain to an ACLR cohort to identify prevalence and risk factors., Design: Multicenter Orthopaedic Outcomes Network (MOON) prospective cohort patients with a unilateral primary ACLR and normal contralateral knee were assessed at 2 and 6 years. Independent variables included patient demographics, validated Patient Reported Outcomes (PRO; Marx activity score, KOOS), and surgical characteristics. Models included: (1) KOOS criteria for a painful knee = quality of life subscale <87.5 and ≥2 of: KOOSpain <86.1, KOOSsymptoms <85.7, KOOSADL <86.8, or KOOSsports/rec <85.0; (2) KOOSpain subscale score ≤72 (≥2 standard deviations below population mean); (3) 10-point KOOSpain drop from 2 to 6 years. Proportional odds models (alpha ≤ 0.05) were used., Results: 1761 patients of median age 23 years, median body mass index (BMI) 24.8 kg/m(2) and 56% male met inclusion, with 87% (1530/1761) and 86% (1506/1761) follow-up at 2 and 6 years, respectively. At 6 years, n = 592 (39%), n = 131 (9%) and n = 169 (12%) met criteria for models #1 through #3, respectively. The most consistent and strongest independent risk factor at both time-points was subsequent ipsilateral knee surgery. Low 2-year Marx activity score increased the odds of a painful knee at 6 years., Conclusions: Significant knee pain is prevalent after ACLR; with those who undergo subsequent ipsilateral surgery at greatest risk. The relationship between pain and structural OA warrants further study., (Copyright © 2015 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Sternoclavicular (SC) dislocation is a rare injury of the upper extremity. Treatment of posterior SC dislocation ranges from conservative (closed reduction) to operative (open reduction with or without surgical reconstruction of the SC joint). To date, we are unaware of any literature that exists pertaining to this injury or its treatment in elite athletes. The purpose of this case report is to describe a posterior SC joint dislocation in a professional American football player and to illustrate the issues associated with its diagnosis and treatment and the athlete's return to sports. To our knowledge, this case is the first reported in a professional athlete. He was treated successfully with closed reduction and returned to play within 5 weeks of injury.

Context: Anterior cruciate ligament (ACL) reconstruction rehabilitation has evolved over the past 20 years. This evolution has been driven by a variety of level 1 and level 2 studies., Evidence Acquisition: The MOON Group is a collection of orthopaedic surgeons who have developed a prospective longitudinal cohort of the ACL reconstruction patients. To standardize the management of these patients, we developed, in conjunction with our physical therapy committee, an evidence-based rehabilitation guideline., Study Design: Clinical review., Level of Evidence: Level 2., Results: This review was based on 2 systematic reviews of level 1 and level 2 studies. Recently, the guideline was updated by a new review. Continuous passive motion did not improve ultimate motion. Early weightbearing decreases patellofemoral pain. Postoperative rehabilitative bracing did not improve swelling, pain range of motion, or safety. Open chain quadriceps activity can begin at 6 weeks., Conclusion: High-level evidence exists to determine appropriate ACL rehabilitation guidelines. Utilizing this protocol follows the best available evidence.

Background: The use of TKAs in young patients is increasing. Demographic characteristics and activity levels among this patient group may affect implant selection, performance, and survivorship. Patient age (≤ 55 years) and preoperative diagnosis have been used to define this patient group, with the presumption that these patients are more active than older patients with similar indications for TKA., Questions/purposes: We questioned whether (1) demographic features of young patients support high activity expectations after TKA, and (2) preoperative or postoperative functional activity measures support projections that young patients are active after TKA., Methods: We retrospectively compared demographic characteristics (gender, BMI, diagnosis) and functional activity profile (as determined by preoperative and postoperative UCLA activity score and functional subscores of The Knee Society and WOMAC instruments) for 150 patients 55 years old or younger (181 TKAs) and 262 patients who were between 65 to 75 years old (314 TKAs) at the time of surgery., Results: Younger patients having TKAs were significantly more likely than older patients to be female (74% versus 60%, p < 0.001) and to have diagnoses other than osteoarthritis (18% versus 3%, p < 0.001). BMI was significantly greater among younger female patients than among other age and gender combinations (35 kg/m(2) versus 31 kg/m(2), p < 0.001). Male patients had higher mean postoperative UCLA activity scores (5.5 versus 4.4, p < 0.001), Knee Society function subscores (80.2 versus 66.4, p < 0.001), and WOMAC function subscores (82.8 versus 74.2, p < 0.01) compared with female patients, but these were not different in older versus younger patients., Conclusions: Sustained high activity levels are not likely to be a principal cause of revision TKAs among younger patients when considering age and diagnosis alone. Determining the effect of activity on survivorship of prosthetic designs and techniques should be based on measured functional activity instead of using age and diagnosis as surrogates for activity., Level of Evidence: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Background: Although the reliability of determining acromial morphology has been examined, to date, there has not been an analysis of interobserver and intraobserver reliability on determining the presence and measuring the size of an acromial enthesophyte., Questions/purposes: The hypothesis of this study was that there will be poor intraobserver and interobserver reliability in the (1) determination of the presence of an acromial enthesophyte, (2) determination of the size of an acromial enthesophyte, and (3) determination of acromial morphology., Patients and Methods: Fifteen fellowship-trained orthopedic shoulder surgeons reviewed the radiographs of 15 patients at two different intervals. Measurement of acromial enthesophytes was performed using two techniques: (1) enthesophyte length and (2) enthesophyte-humeral distance. Acromial morphology was also determined. Interobserver and intraobserver agreement was determined using intraclass correlation and kappa statistical methods., Results: The interobserver reliability was fair to moderate and the intraobserver reliability moderate for determining the presence of an acromial enthesophyte. The measurement of the enthesophyte length showed poor interobserver and intraobserver reliability. The measurement of the enthesophyte-humeral distance showed poor interobserver reliability and moderate intraobserver reliability. The interobserver and intraobserver reliability in determining acromial morphology was found to be moderate and good, respectively., Conclusions: There is fair to moderate reliability among fellowship-trained shoulder surgeons in determining the presence of an acromial enthesophyte. However, there is poor reliability among observers in measuring the size of the enthesophyte. This study suggests that the enthesophyte-humeral distance may be more reliable than the enthesophyte length when measuring the size of the enthesophyte.

Objectives: To describe the spectrum of axillary artery pathology seen in high-performance overhead athletes and the outcomes of current treatment., Methods: A retrospective review of patients that had undergone management of axillary artery lesions in a specialized center for thoracic outlet syndrome (TOS). Treatment outcomes were assessed with respect to arterial pathology and operative management., Results: Nine male athletes were referred for arterial insufficiency in the dominant arm between January 2000 and August 2010, representing 1.6% of 572 patients treated for TOS (19% of 47 patients treated for arterial TOS). Seven were elite baseball pitchers (six professional, one collegiate), and two were professional baseball coaches with practice pitching responsibilities, with a mean age of 30.9 ± 2.9 years. Presenting symptoms included arm fatigue (five), finger numbness (four), cold hypersensitivity/Raynaud's (two), rest pain (one), and cutaneous fingertip embolism (one). Three patients underwent transcatheter thrombolysis prior to referral, including one with angioplasty and stenting. At angiography and surgical exploration 2.5 ± 0.8 weeks after symptom presentation (range, 1-8 weeks), six patients had occlusion of the distal axillary artery opposite the humeral head either at rest (three) or with arm elevation (three), one had axillary artery dissection with positional occlusion, and two had thrombosis of circumflex humeral artery aneurysms. Five patients had embolic arterial occlusions distal to the elbow. Treatment included segmental axillary artery repair with saphenous vein (n = 7; five interposition bypass grafts and two patch angioplasties), ligation/excision of circumflex humeral artery aneurysms (n = 2), and distal artery thrombectomy/thrombolysis (n = 2). Mean postoperative hospital stay was 3.8 ± 0.5 days, and the time until resumption of unrestricted overhead throwing was 10.8 ± 2.7 weeks. At a median follow-up of 15 months (range, 3-123 months), primary-assisted patency was 89%, and secondary patency was 100%. All nine patients had continued careers in professional baseball, although one retired during long-term follow-up., Conclusions: Repetitive positional compression of the axillary artery can cause a spectrum of pathology in the overhead athlete, including focal intimal hyperplasia, aneurysm formation, segmental dissection, and branch vessel aneurysms. Prompt recognition of these rare lesions is crucial given their propensity toward thrombosis and distal embolism, with positional arteriography necessary for diagnosis. Full functional recovery can usually be anticipated within several months of surgical treatment, consisting of mobilization and segmental reconstruction of the diseased axillary artery or ligation/excision of branch aneurysms, as well as concomitant management of distal thromboembolism., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: TKA is commonly performed to treat advanced inflammatory and degenerative knee arthritis. With increasing use in younger patients, it is important to define the best practices to enhance clinical performance and implant longevity., Questions/purposes: We systematically reviewed the literature to assess: (1) how TKAs perform in young patients; (2) whether the TKA is a durable procedure for young patients, and (3) what guidance the literature outlines for TKA in young patients., Methods: We searched the literature between 1950 and 2009 for all studies reporting on TKAs for patients younger than 55 years that documented clinical and radiographic assessments with a minimum 2-year followup. Thirteen studies, reporting on 908 TKAs performed for 671 patients, met these criteria., Results: Mean Knee Society clinical and functional scores increased by 47 and 37 points, respectively. Implant survivorship was reported between 90.6% and 99% during the first decade and between 85% and 96.5% during the second decade of followup. The literature does not direct specific techniques for TKA for young patients., Conclusions: TKA provides surgeon-measured clinical and functional improvements with a moderate increase in second-decade implant failures. Improvements in study design and reporting will be beneficial to guide decisions regarding implant selection and surgical technique., Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background: Radiographic evaluation of the hip is extremely important in the diagnosis and treatment decisionmaking process for pre-arthritic hip disease. Many different radiographic measurements have been described as indicators of underlying structural hip deformity. The purpose of this study was to determine the interobserver and intraobserver reliability of various musculoskeletal physicians in performing selected measurements of adult structural hip anatomy., Methods: A blinded review of 45 sets of radiographs from patients with developmental dysplasia, femoro-acetabular impingement, and normal anatomy was performed. Data points included the lateral center-edge angle (LCEA), vertical-center-anterior angle (VCA), head-neck offset ratio (UNO), alpha angle, Tönnis angle, Tönnis osteoarthritis grade and a radiographic diagnosis. One orthopaedic fellow, two orthopaedic residents, and two attending musculoskeletal physiatrists analyzed radiographs on two separate occasions. One sports medicine orthopaedic attending physician completed a single analysis of the image sets. Intraobserver and interobserver reliability was established using intra-class correlation coefficients (ICC) for continuous variables. Agreement regarding categorical variables was performed using the kappa coefficient, Results: Excellent intraobserver reliability was found for the following: LCEA (ICC = 0.88), VCA (0.88), Tönnis angle (0.83), HNO on the frog lateral (0.78), alpha angle on the frog lateral (0.76), HNO on the cross-table lateral (0.75), and angle alpha on the cross-table lateral (0.76). Intraobserver reliability for osteoarthritis grade was poor (weighted kappa = 0.57). For all data points, interobserver reliability was considerably worse, with 95% confidence intervals spanning below 0.55., Conclusions: While the described measurements of adult structural hip anatomy provide excellent reliability for a given reader, these measurements are less reliable across readers. Taken in isolation, these measurements, as performed by observers with varied clinical experience and clinical backgrounds, are limited in determining a consistent radiographic diagnosis.

Background: Tearing an anterior cruciate ligament (ACL) graft is a devastating occurrence after ACL reconstruction (ACLR). Identifying and understanding the independent predictors of ACLR graft failure is important for surgical planning, patient counseling, and efforts to decrease the risk of graft failure., Hypothesis: Patient and surgical variables will predict graft failure after ACLR., Study Design: Prospective cohort study., Methods: A multicenter group initiated a cohort study in 2002 to identify predictors of ACLR outcomes, including graft failure. First, to control for confounders, a single surgeon's data (n = 281 ACLRs) were used to develop a multivariable regression model for ACLR graft failure. Evaluated variables were graft type (autograft vs allograft), sex, age, body mass index, activity at index injury, presence of a meniscus tear, and primary versus revision reconstruction. Second, the model was validated with the rest of the multicenter study's data (n = 645 ACLRs) to evaluate the generalizability of the model., Results: Patient age and ACL graft type were significant predictors of graft failure for all study surgeons. Patients in the age group of 10 to 19 years had the highest percentage of graft failures. The odds of graft rupture with an allograft reconstruction are 4 times higher than those of autograft reconstructions. For each 10-year decrease in age, the odds of graft rupture increase 2.3 times., Conclusion: There is an increased risk of ACL graft rupture in patients who have undergone allograft reconstruction. Younger patients also have an increased risk of ACL graft failure., Clinical Relevance: Given these risks for ACL graft rupture, allograft ACLRs should be performed with caution in the younger patient population.

In the present study, thirteen genes involved in the reverse cholesterol transport (RCT) pathway were investigated for their associations with three fat depositions, eight fatty acid compositions and two growth-related phenotypes in a Wagyu x Limousin reference population, including 6 F(1) bulls, 113 F(1) dams, and 246 F(2) progeny. A total of 37 amplicons were used to screen single nucleotide polymorphisms (SNPs) on 6 F(1) bulls. Among 36 SNPs detected in 11 of these 13 genes, 19 were selected for genotyping by the Sequenom assay design on all F(2) progeny. Single-marker analysis revealed seven SNPs in ATP binding cassette A1, apolipoproteins A1, B and E, phospholipid transfer protein and paraoxinase 1 genes significantly associated with nine phenotypes (P<0.05). Previously, we reported genetic networks associated with 19 complex phenotypes based on a total of 138 genetic polymorphisms derived from 71 known functional genes. Therefore, after Bonferroni correction, these significant (adjusted P<0.05) and suggestive (adjusted P<0.10) associations were then used to identify genetic networks related to the RCT pathway. Multiple-marker analysis suggested possible genetic networks involving the RCT pathway for kidney-pelvic-heart fat percentage, rib-eye area, and subcutaneous fat depth phenotypes with markers derived from paraoxinase 1, apolipoproteins A1 and E, respectively. The present study confirmed that genes involved in cholesterol homeostasis are useful targets for investigating obesity in humans as well as for improving meat quality phenotypes in a livestock production.

Quantitative or complex traits are determined by the combined effects of many loci, and are affected by genetic networks or molecular pathways. In the present study, we genotyped a total of 138 mutations, mainly single nucleotide polymorphisms derived from 71 functional genes on a Wagyu x Limousin reference population. Two hundred forty six F(2) animals were measured for 5 carcass, 6 eating quality and 8 fatty acid composition traits. A total of 2,280 single marker-trait association runs with 120 tagged mutations selected based on the HAPLOVIEW analysis revealed 144 significant associations (P < 0.05), but 50 of them were removed from the analysis due to the small number of animals (< or = 9) in one genotype group or absence of one genotype among three genotypes. The remaining 94 single-trait associations were then placed into three groups of quantitative trait modes (QTMs) with additive, dominant and overdominant effects. All significant markers and their QTMs associated with each of these 19 traits were involved in a linear regression model analysis, which confirmed single-gene associations for 4 traits, but revealed two-gene networks for 8 traits and three-gene networks for 5 traits. Such genetic networks involving both genotypes and QTMs resulted in high correlations between predicted and actual values of performance, thus providing evidence that the classical Mendelian principles of inheritance can be applied in understanding genetic complexity of complex phenotypes. Our present study also indicated that carcass, eating quality and fatty acid composition traits rarely share genetic networks. Therefore, marker-assisted selection for improvement of one category of these traits would not interfere with improvement of another.

Cholesterol is an essential substance involved in many functions, such as maintaining cell membranes, manufacturing vitamin D on surface of the skin, producing hormones, and possibly helping cell connections in the brain. When cholesterol levels rise in the blood, they can, however, have dangerous consequences. In particular, cholesterol has generated considerable notoriety for its causative role in atherosclerosis, the leading cause of death in developed countries around the world. Homeostasis of cholesterol is centered on the metabolism of lipoproteins, which mediate transport of the lipid to and from tissues. As a synopsis of the major events and proteins that manage lipoprotein homeostasis, this review contributes to the substantial attention that has recently been directed to this area. Despite intense scrutiny, the majority of phenotypic variation in total cholesterol and related traits eludes explanation by current genetic knowledge. This is somewhat disappointing considering heritability estimates have established these traits as highly genetic. Thus, the continued search for candidate genes, mutations, and mechanisms is vital to our understanding of heart disease at the molecular level. Furthermore, as marker development continues to predict risk of vascular illness, this knowledge has the potential to revolutionize treatment of this leading human disease.

Background: There is no consensus for the optimal postoperative rehabilitation protocol after rotator cuff repairs., Objective: To determine if there is sufficient level I or II evidence available in the literature for establishment of a uniform, optimal rotator cuff rehabilitation protocol., Data Sources: A systematic review of level I and II English-language, prospective, randomized controlled trials published between 1966 and 2008 was performed. MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and secondary references were appraised for studies that met the inclusion criteria. Search terms included rotator cuff, supraspinatus, infraspinatus, subscapularis, teres minor, rehab, rehabilitation, physical therapy, and physiotherapy., Study Selection: Inclusion criteria were English-language level I or level II studies, including randomized clinical trials involving the rehabilitation of rotator cuff repairs. Exclusion criteria were non-English language, level IV or V studies, or studies involving shoulder rehabilitation of diagnoses other than rotator cuff repairs. Three independent reviewers arrived at a consensus for including 4 studies in this review out of 12 studies identified by the literature search., Data Extraction: Included studies underwent worksheet quality appraisal independently by each of the 3 authors identifying strengths, weaknesses, and biases. The quality appraisal was then discussed among the authors and consensus reached regarding the strengths, weaknesses, and value of the included studies., Results: Two studies examined the use of continuous passive motion for rotator cuff rehabilitation, and 2 studies compared an unsupervised, standardized rehabilitation program to a supervised, individualized rehabilitation program. These studies did not support the use of continuous passive motion in rotator cuff rehabilitation, and no advantage was shown with a supervised, individualized rehabilitation protocol compared to an unsupervised, standardized home program. Each investigation had weaknesses in study design that decreased the validity of its findings., Conclusion: There is not enough high-level evidence to develop an evidence-based medicine approach to rotator cuff rehabilitation. There is a need for well-designed level I and level II trials to elucidate the optimal rotator cuff repair rehabilitation protocol.

Bayesian analysis was performed to examine the single-nucleotide polymorphism (SNPs) neighborhood patterns in cattle using 15,110 SNPs, each with a flanking sequence of 500 bp. Our analysis confirmed three well-known features reported in plants and/or other animals: (1) the transition is the most abundant type of SNPs, accounting for 69.8% in cattle; (2) the transversion occurs most frequently (38.56%) in cattle when the A + T content equals two at their immediate adjacent sites; and (3) C <--> T and A <--> G transitions have reverse complementary neighborhood patterns and so do A <--> C and G <--> T transversions. Our study also revealed several novel SNP neighborhood patterns that have not been reported previously. First, cattle and humans share an overall SNP pattern, indicating a common mutation system in mammals. Second, unlike C <--> T/A <--> G and A <--> C/G <--> T, the true neighborhood patterns for A <--> T and C <--> G might remain mysterious because the sense and antisense sequences flanking these mutations are not actually recognizable. Third, among the reclassified four types of SNPs, the neighborhood ratio between A + T and G + C was quite different. The ratio was lowest for C <--> G, but increased for C <--> T/A <--> G, further for A <--> C/G <--> T, and the most for A <--> T. Fourth, when two immediate adjacent sites provide structures for CpG, it significantly increased transitions compared to the structures without the CpG. Finally, unequal occurrence between A <--> G and C <--> T in five paired neighboring structures indicates that the methylation-induced deamination reactions were responsible for approximately 20% of total transitions. In addition, conversion can occur at both CpG sites and non-CpG sites. Our study provides new insights into understanding molecular mechanisms of mutations and genome evolution.

Background: Although magnetic resonance imaging (MRI) is a standard method of assessing the extent and features of rotator cuff disease, the authors are not aware of any studies that have assessed the interobserver agreement among orthopaedic surgeons reviewing MRI scans for rotator cuff disease., Hypothesis: Fellowship-trained orthopaedic shoulder surgeons will have good interobserver agreement in predicting the more salient features of rotator cuff disease such as tear type (full thickness versus partial thickness), tear size, and number of tendons involved but only fair agreement with more complex features such as muscle volume, fat content, and the grade of partial-thickness cuff tears., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: Ten fellowship-trained orthopaedic surgery shoulder specialists reviewed 27 MRI scans of 27 shoulders from patients with surgically confirmed rotator cuff disease. The ability to interpret full-thickness versus partial-thickness tears, acromion type, acromioclavicular joint spurs or signal changes, biceps lesions, size and grade of partial-thickness tears, acromiohumeral distance, number of tendons involved and amount of retraction for full-thickness tears, size of full-thickness tears, and individual muscle fatty infiltration and atrophy were assessed. Surgeons completed a standard evaluation form for each MRI scan. Interobserver agreement was determined and a kappa level was derived., Results: Interobserver agreement was highest (>80%) for predicting full- versus partial-thickness tears of the rotator cuff, and for quantity of the teres minor tendon. Agreement was slightly less (>70%) for detecting signal in the acromioclavicular joint, the side of the partial-thickness tear, the number of tendons involved in a full-thickness tear, and the quantity of the subscapularis and infraspinatus muscle bellies. Agreement was less yet (60%) for detecting the presence of spurs at the acromioclavicular joint, a tear of the long head of the biceps tendon, amount of retraction of a full-thickness tear, and the quantity of the supraspinatus. The best kappa statistics were found for detecting the difference between a full- and partial-thickness rotator cuff tear (0.77), and for the number of tendons involved for full-thickness tears (0.55). Kappa for predicting the involved side of a partial-thickness tear was 0.44; for predicting the grade of a partial-thickness tear, it was -0.11., Conclusions: Fellowship-trained, experienced orthopaedic surgeons had good agreement for predicting full-thickness rotator cuff tears and the number of tendons involved and moderate agreement in predicting the involved side of a partial-thickness rotator cuff tear, but poor agreement in predicting the grade of a partial-thickness tear.

Background: Changes in the dominant shoulder and elbow of professional pitchers have been noted on radiographs, magnetic resonance imaging scans, and ultrasound studies. The relationship of these findings to future injury and to time lost from play has not been identified., Hypothesis: Degenerative changes of the shoulder and elbow are common findings on the radiographs of asymptomatic Major League Baseball pitchers. The changes are cumulative with increased pitching. These findings are not predictive of time on the disabled list., Study Design: Cohort study (prognosis); Level of evidence, 4., Methods: Fifty-seven asymptomatic Major League Baseball pitchers participating in the St Louis Cardinals spring training camp underwent routine preseason radiographic screening of their dominant shoulder and elbow between 1986 and 1998. Radiographs were reviewed for osteophytes, cystic changes, joint-space narrowing, and loose bodies. All findings were recorded as present or absent. Public baseball records were reviewed for arm dominance, age, years of professional pitching, professional innings pitched, shoulder or elbow injury or surgery, and time on the disabled list. These factors were statistically evaluated for their possible association with findings seen on preseason radiographs., Results: Shoulder radiographs were available for 57 pitchers, and elbow radiographs were available for 56 pitchers. Both groups had an average age of 29 years. The average number of radiographic findings was 3 for the shoulder and 7 for the elbow. Comparing pitchers on the disabled list for a shoulder or elbow injury with those not on the disabled list demonstrated no significant difference in the age, number of seasons pitched, or number of innings pitched between the 2 groups. When individual radiographic findings were compared, no single finding was predictive of disabled list status (P >.05 in all cases). The sum of radiographic findings for the shoulder was significantly correlated with the number of innings pitched in professional baseball (Pearson correlation coefficient, 0.46; P =.0004). The elbow data showed a similar correlation (Pearson correlation coefficient, 0.38; P =.003). When select individual radiographic findings were evaluated for an association with the number of innings pitched, the presence of acromioclavicular joint findings in the shoulder and radial head osteophytes and radioulnar joint findings in the elbow increased with an increase in innings pitched (P <.05)., Conclusion: Professional pitchers develop degenerative changes over time in both the shoulder and elbow of their dominant (pitching) arm due to chronic repetitive stresses placed across the joints. These findings do not predict time spent on the Major League Baseball disabled list.

Rotator cuff repair surgery for full-thickness tears is common and accepted in orthopaedics today. Given that a significant number of people have asymptomatic rotator cuff tears, the indications for surgery are, however, somewhat unclear. Multiple factors such as duration of symptoms, acuity and size of the tear, patient age, and others require consideration and can influence the decision to perform surgery. This article reviews these variables and the indications for surgery to repair full-thickness rotator cuff tears.