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Background: Limited studies have compared graft-glenoid apposition and glenoid augmentation area between the Latarjet procedure and distal clavicle graft in glenohumeral stabilization. Additionally, preoperative planning is typically performed using computed tomography (CT), and few studies have used 3-dimensional (3D) magnetic resonance imaging (MRI) reformations to assess graft dimensions. Purpose: The purpose of this study was 2-fold: (1) to compare bony apposition, glenoid augmentation, and graft width among coracoid and distal clavicle bony augmentation techniques and (2) to determine the viability of 3D MRI to assess bone graft dimensions. Study Design: Controlled laboratory study. Methods: A total of 24 patients with recurrent glenohumeral instability and bone loss were included in this study. 3D CT and 3D MRI reformations were utilized to measure pertinent dimensions for 5 orientations of coracoid and distal clavicle autografts: (1) standard Latarjet procedure (SLJ), (2) congruent arc Latarjet procedure (CLJ), (3) distal clavicle attached by its posterior surface (DCP), (4) distal clavicle attached by its inferior surface (DCI), and (5) distal clavicle attached by its resected end (DCR). Glenoid augmentation was defined as the graft surface area contributing to the glenoid. Bone-on-bone apposition was defined as the graft-glenoid contact area for bone healing potential, and graft width was pertinent for fixation technique. Glenoid bone loss ranged from 0% to 34%. Paired t tests were used to compare graft sizes between patients and compare 3D CT versus 3D MRI measurements. Results: The CLJ had the largest graft surface area (mean, 318.41 ± 74.44 mm2), while the SLJ displayed the most bone-on-bone apposition (mean, 318.41 ± 74.44 mm2). The DCI had the largest graft width (mean, 20.62 ± 3.93 mm). Paired t tests revealed no significant differences between the Latarjet techniques, whereas distal clavicle grafts varied significantly with orientation. All 3D CT and 3D MRI measurements were within 1 mm of each other, and only 2 demonstrated a statistically significant difference (coracoid width: 13.03 vs 13.98 mm, respectively [ P = .010]; distal clavicle thickness: 9.69 vs 10.77 mm, respectively [ P = .002]). 3D CT and 3D MRI measurements demonstrated a strong positive correlation ( r > 0.6 and P < .001 for all dimensions). Conclusion: Glenoid augmentation, bony apposition, and graft width varied with coracoid or distal clavicle graft type and orientation. Differences between 3D CT and 3D MRI were small and likely not clinically significant. Clinical Relevance: 3D MRI is a viable method for preoperative planning and graft selection in glenoid bone loss.

Physician leadership of the interdisciplinary sports medicine team depends on fundamental leadership skills that often are overlooked in medical school. These leadership skills include effective communication, emotional intelligence, teamwork, selfless service, integrity, and critical thinking while utilizing an athlete-centered approach. Development of these skills will help to navigate team management and important decisions, such as return to play. The leadership session at the Advanced Team Physician Course sought to acknowledge the gap in medical training regarding leadership education and began to address it in a forum specifically for team physicians. Here we provide a summary of the lectures and presentations from the 2018 Advanced Team Physician Course in an effort to benefit a broader physician audience. This material should act as a framework for current and future team physicians to solidify their role as the leader of the medical team in caring for the athlete.

This study aimed to assess the views and leadership competencies of incoming medical students and determine whether leadership traits predicted patient-centeredness in these students. Incoming medical students at one institution from 2017-2020 (N=428) completed a Leadership Needs Assessment assessing self-reported ability and the importance of competency in teamwork, selfless service, integrity, critical thinking, and emotional intelligence. Participants in the entering class of 2020 (n=92) also completed the Johns Hopkins University Patient-Centeredness Assessment to evaluate patient-centered attitudes. This cohort repeated both surveys at the completion of the first year to assess for changes in the perceived importance of leadership qualities, self-reported competencies, and patient-centeredness. Participants self-reported the highest competency (mean, SD) in integrity (7.92, 1.19) and the lowest in critical thinking (6.59, 1.12). Leadership Development Opportunity (difference between leadership expectation and self-reported ability) was largest in teamwork (2.31, 1.11) and smallest in integrity (0.97, 1.18). Post-first-year assessments were compared in the 2020 cohort, and statistically significant increases (mean, p-value) were found in critical thinking (0.31, p

There is a high rate of second anterior cruciate ligament (ACL) injury (ipsilateral graft or contralateral ACL) upon return-to-sport (RTS) following ACL reconstruction (ACLR). While a significant amount of epidemiological data exists demonstrating sex differences as risk factors for primary ACL injury, less is known about sex differences as potential risk factors for second ACL injury. The purpose of this study is to determine if there are sex-specific differences in potential risk factors for second ACL injury at the time of clearance for RTS.Ten male and eight female athletes (age: 20.8 years ±6.3, height: 173.2 cm ±10.1, mass: 76.6 kg ±18.3) participated in the study following ACLR at time of RTS (mean 10.2 months). Performance in lower extremity isokinetic and isometric strength testing, static and dynamic postural stability testing, and a single leg stop-jump task was compared between the sexes.Normalized for body weight, males had significantly greater isokinetic knee flexion (141±14.1 Nm/kg vs. 78±27.4 Nm/kg, p=0.001) and extension strength (216±45.5 Nm/kg vs. 159±53.9 Nm/kg, p=0.013) as well as isometric flexion (21.1±6.87% body weight vs. 12.5±5.57% body weight, p=0.013) and extension (41.1±7.34% body weight vs. 27.3±11.0% body weight, p=0.016) strength compared to females. In the single-leg stop jump task, males had a greater maximum vertical ground reaction force during landing (332±85.5% vs. 259±27.4% body weight, p=0.027) compared to females.Based on these results, there are significant differences between sexes following ACLR at the time of RTS. Lower knee flexion and extension strength may be a potential risk factor for second ACL injury among females. Alternatively, the increased maximum vertical force observed in males may be a potential risk factor of second ACL injury in males. Although these results should be interpreted with some caution, they support that rehabilitation programs in the post-ACLR population should be individualized based on the sex of the individual.Level 3.

The purpose of this study was to assess the effectiveness of the Feagin Leadership Program (FLP) in teaching leadership domains and emotional intelligence. An anonymous survey of 178 graduates of FLP (2011–2019) including the Trait Emotional Intelligence Questionnaire-Short Form (TEIQue-SF) was used to assess emotional intelligence and program views. ANOVA was used to compare the difference in emotional intelligence domains between groups. Respondents reported the FLP most improved skills in communication, emotional intelligence, and team building. Medical students (18, 38.3%) and faculty/staff (5/14, 35.7%) reported the most relevant domain was emotional intelligence; residents/fellows reported the most relevant domain was teamwork (8/37, 21.6%). Respondents in residency/fellowship had the highest score in emotionality (P = .01). These results suggest that a healthcare leadership program tailored to medical trainees was effective in improving their competency in various leadership domains, and that emotional intelligence and teamwork were the most relevant components of the program.

Background Anterior cruciate ligament (ACL) injury is extremely common among athletes. Rate of second ACL injury due to surgical graft rupture or contralateral limb ACL injury is approximately 15-32%. Psychological readiness to return to sport (RTS) may be an important predictor of successful RTS outcomes. Psychological readiness can be quantified using the ACL Return to Sport after Injury (ACL-RSI) questionnaire, with higher scores demonstrating greater psychological readiness. Purpose The purpose of this study was to investigate differences in functional performance and psychological readiness to return to sport among athletes who have undergone primary ACL reconstruction (ACLR). Study Design Descriptive cohort study Methods Eighteen athletes who had undergone primary ACLR were tested at time of RTS clearance. The cohort was divided into two groups, high score (HS) and low score (LS), based on median ACL-RSI score, and performance on static and dynamic postural stability testing, lower extremity isokinetic and isometric strength testing, and single leg hop testing was compared between the groups using an independent samples t-test. Results The median ACL-RSI score was 74.17. The average ACL-RSI score was 83.1±6.2 for the HS group and 61.8±8.0 for the LS group. High scorers on the ACL-RSI performed significantly better on isometric knee flexion as measured via handheld dynamometry (22.61% ±6.01 vs. 12.12% ±4.88, p=0.001) than the low score group. Conclusion The findings suggest that increased knee flexion strength may be important for psychological readiness to RTS after primary ACLR. Further research is indicated to explore this relationship, however, a continued emphasis on improving hamstring strength may be appropriate during rehabilitation following ACLR to positively impact psychological readiness for RTS. Level of Evidence III

The athlete with shoulder instability poses a unique challenge to the sports medicine team. Clinical studies support surgical intervention followed by a phased approach to rehabilitation. In the latter phases, it is important to tailor this program to the individual’s specific athletic needs, which requires ongoing qualitative assessment and objective measurement. Passing a return-to-sport testing battery has been shown to decrease the risk of recurrent instability. What is lacking in the literature is a consensus for how to best measure shoulder performance when the required athletic demands are widely varied by hand dominance, sport played, and playing position. Multiple upper-extremity tests have been described in the literature, but there is no consensus on which tests should be used to direct rehabilitation and to safely return the athlete to unrestricted athletic exposure. Using available evidence, we suggest a framework for return-to-play testing that integrates traditional rehabilitation phases with performance testing and graduated sports exposure. Level of Evidence: Level V, expert opinion.

Introduction Increasingly, physicians find themselves in demanding leadership positions. However, leadership education for medical trainees remains lacking with most physicians reporting that they are ill-equipped to tackle the challenges of leadership. Here, we set out to describe the Feagin Leadership Program (FLP) and assess its reception and impact on trainees over the past 12 years. Materials and Methods During the 1-year FLP, selected scholars from Duke University, Wake Forest University, and the University of North Carolina participate in five leadership sessions, individual coaching, a leadership forum, and a multidisciplinary team–based capstone project. A 28-question survey with six optional free-response questions was distributed to the Feagin Alumni Network, and descriptive statistics were assessed. Results Since its founding, 212 scholars have graduated from the FLP and 117 (55%) alumni have gone on to surgical specialties. A survey was distributed among all Feagin alumni. A total of 56 (26%) surveys were completed. Forty-three percent (n = 24) had held at least one leadership position since completing the FLP. When asked about the impact of their experience, 96% (n = 54) said that the program encouraged them to pursue a position of leadership within their field, 95% (n = 53) stated that it prepared them for such a position, and 93% (n = 52) stated that the program positively influenced their decision to be involved with current or future positions of leadership. Conclusions Over the last 12 years, the FLP has demonstrated a high perceived impact on personal growth, leadership proficiency, and the decision to pursue leadership positions in medicine. The current dearth of leadership education for surgical trainees can best be addressed with models such as the FLP, with adoption benefiting medical trainees, the medical community, and patients they serve.

Background:Treatment of a first-time anterior shoulder dislocation (FTASD) is sensitive to patient preferences. The operative or nonoperative management debate provides an excellent opportunity to learn how surgeons apply patient preferences in treatment decisions.Purpose:To determine how patient preferences (repeat dislocation risk, recovery difficulties, fear of surgery, treatment costs) and surgeon factors influence a surgeon’s treatment plan for FTASD.Study Design:Cross-sectional study.Methods:Eight clinical vignettes of hypothetical patients with FTASD (including age, sex, and activity level) were presented to members of the Magellan Society. A second set of matched vignettes with patient preferences and clinical variables were also presented. The vignettes represented scenarios in which evidence does not favor one treatment over another. Respondents were asked how they would manage each hypothetical case. Respondents also estimated the risk of redislocation for the nonoperative cases for comparison with the published rates. Finally, respondents completed a Likert-scale questionnaire to determine their perceptions on factors influencing their decisions.Results:A total of 103 orthopaedic surgeons completed the survey; 48% practiced in an academic hospital; 79% were in practice for 10 years or longer; and 75% had completed a sports medicine fellowship. Patient preferences were the single most important factor influencing treatment recommendation, with activity type and age also important. Just 62% of the surgeon estimates of the risk of redislocation were consistent with the published rates. The inclusion of patient preferences to clinical variables changed treatment recommendations in 62.5% of our hypothetical cases. Respondents rated patient treatment preference as the leading factor in their treatment decision making.Conclusion:Patient preferences were important when deciding the appropriate treatment for FTASD. Respondents were inconsistent when applying evidence in their decision making and estimates of recurrent instability. Decision support tools that deliver patient preferences and personalized evidence-based outcome estimates improve the quality of decision making at the point of care.

Copyright © 2018 by the American Society of Plastic Surgeons. Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. Results: Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm2 was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room. Conclusion: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.

Background:Surgical management of rotator cuff tears is controversial and complex, ranging from nonoperative management to reverse shoulder arthroplasty.Purpose:To systematically review and evaluate the outcomes of graft augmentation or interposition versus rotator cuff repair (RCR) alone and evaluate via meta-analysis whether the use of a graft leads to superior outcomes versus RCR alone.Study Design:Systematic review and meta-analysis.Methods:An electronic literature search (Medline, Embase, CINAHL) was conducted. Studies with a minimum follow-up of 1 year and minimum sample size of 10 that provided clinical results of RCR or rotator cuff reconstruction using any type of augmentation tissue or matrix were included. Methodological quality was evaluated by assessment of the risk of bias in the included studies. Studies comparing outcomes of RCR with graft augmentation or interposition versus repair alone (control group) were subjected to meta-analysis.Results:The authors identified 774 articles and included 36 in the systematic review; 5 of the 36 studies underwent meta-analysis. Except for one outcome measure in a single study, all surgical interventions (RCR alone, RCR with augmentation, and RCR with interposition) improved clinical scores and outcome measures. Because of variability in study outcomes, no graft option was found to be superior. Compared with RCR alone, graft augmentation or interposition provided significantly lower retear rates ( P = .05) and higher American Shoulder and Elbow Surgeons (ASES) scores ( P = .005), but improvements in UCLA (University of California, Los Angeles) scores ( P = .29) and pain scores ( P = .1) did not reach statistical significance.Conclusion:In the meta-analysis, graft augmentation or interposition appeared to provide a lower retear rate and improved ASES scores when compared with RCR alone. Future prospective, randomized, controlled, and appropriately powered trials are needed for more definitive recommendations.

Background: Mentorship is a key aspect of leadership development for orthopaedic surgeons, but there are few formalized mentorship programs in medical training. The individualized development plan (IDP) is a tool that potentially improves mentorship opportunities through identifying specific competency deficiencies and facilitating communication with mentors. Purpose: To assess the views of prospective orthopaedic surgery sports medicine fellows on the skills necessary for career development and the utility of an IDP for longitudinal career mentorship during a sports medicine fellowship. Study Design: Cross-sectional study. Methods: Candidates who interviewed for an orthopaedic surgery sports medicine fellowship voluntarily completed an anonymous IDP as well as a survey to assess their perceptions of the IDP tool to define their career goals and its use for longitudinal mentorship. The IDP included quantitative and qualitative responses for the self-assessment of multiple skill domains (general research, teaching, professional, interpersonal, leadership, and management) using a 5-point Likert scale (1 = needs improvement, 5 = highly proficient). Quantitative results were analyzed using analysis of variance and Student t test. Results: A total of 25 candidates completed the IDP and survey. The mean ± standard deviation composite score of all skill domains was 3.62 ± 0.91. The candidates’ greatest deficit was in grant writing (2.28 ± 0.94; P < .01), while their greatest strength was getting along with others (4.52 ± 0.65; P < .01). Candidates identified, as short-term goals, obtaining a fellowship training position, completion of research/academic projects, and improvement of surgical skills; their common long-term goals included having a role in an academic institution, professional society, and/or research and innovation environment. The majority of participants agreed that the IDP is a valuable tool to characterize career and personal goals (74%) and facilitate longitudinal fellowship mentorship (83.3%). Conclusion: The majority of candidates valued the IDP for their short- and long-term goals. Program implementation of an IDP could be beneficial in allowing trainees to effectively identify areas of weakness and strengths while facilitating efficient communication of these needs to mentors.

BACKGROUND Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children and adolescents than adults. The reasons for higher subsequent injury rates in this population are incompletely understood. METHODS We analyzed a continuous cohort of patients who were

Meniscus tears are a common knee injury and are associated with the development of post-traumatic osteoarthritis (OA). The purpose of this study is to evaluate potential OA mediators in the synovial fluid and serum of meniscus tear subjects compared to those in the synovial fluid of radiographic non-OA control knees.Sixteen subjects with an isolated unilateral meniscus injury and six subjects who served as reference controls (knee Kellgren-Lawrence grade 0-1) were recruited. Twenty-one biomarkers were measured in serum from meniscus tear subjects and in synovial fluid from both groups. Meniscus tear subjects were further stratified by tear type to assess differences in biomarker levels.Synovial fluid total matrix metalloproteinase (MMP) activity and prostaglandin E2 (PGE2) were increased 25-fold and 290-fold, respectively, in meniscus tear subjects as compared to reference controls (p0.05). Synovial fluid MMP activity and PGE2 concentrations were positively correlated in meniscus tear subjects (R = 0.83, p0.0001). In meniscus tear subjects, synovial fluid levels of MMP activity, MMP-2, MMP-3, sGAG, COMP, IL-6, and PGE2 were higher than serum levels (p0.05). Subjects with complex meniscus tears had higher synovial fluid MMP-10 (p0.05) and reduced serum TNFα and IL-8 (p0.05) compared to other tear types.Given the degradative and pro-inflammatory roles of MMP activity and PGE2, these molecules may alter the biochemical environment of the joint. Our findings suggest that modulation of PGE2 signaling, MMP activity, or both following a meniscus injury may be targets to promote meniscus repair and prevent OA development.

Individually, each of us must accept responsibility to be effective, ethical leaders. We have to continually learn to be better leaders, just as we continually learn to be technically better surgeons. Organizationally, ISAKOS and all professional entities must work diligently to create cultures that are unwaveringly committed to leadership education and support ethical leadership competencies. We need to intentionally emphasize, just as we emphasize surgical technique education, educational offerings on leadership competencies such as teamwork and emotional intelligence, which will lead to better patient care. We need to create patient-centered cultures that promote selfless service and are steadfast in upholding integrity. If we do not intentionally commit to patient-centered, ethical leadership, then we become technicians answering to managers, and my greatest concern will be realized—there will no longer exist a Sports Medicine profession to lead.

Context Anatomic differences of the knee in first-time patellar dislocators have not been clearly elucidated. Objective To compare structural differences of the knee in those who have sustained an acute first-time patellar dislocation resulting in a medial patellofemoral ligament (MPFL) tear by sex and age (≤17 years old, ≥18 years old). Design Case series. Setting Retrospective magnetic resonance imaging analysis. Patients or Other Participants Thirty-five acute first-time patellar dislocators with an associated MPFL tear. Main Outcome Measure(s) Patellar height using 3 methods, patellar alignment using congruency angles, and trochlear morphology using the sulcus angle. We compared the means of these variables by sex and age. The intraclass correlation coefficient was then calculated to assess the agreement of the independent reviewers. Results A total of 21 left and 14 right knees were analyzed. The MPFL tear location did not differ by sex (P = .34) or age (P = .43). Patellar height did not differ as measured by the Caton-Deschamps ratio (P = .29 for sex, P = .49 for age), Insall-Salvati index (P = .15 for sex, P = .33 for age), or patellotrochlear index (P = .67 for sex, P = .49 for age). The congruence angle (P = .81 for sex, P = .06 for age) and trochlear morphology as measured by the sulcus angle (P = .64 for sex, P = .45 for age) were similar between groups. Conclusions Patellar height and trochlear morphology did not differ by sex or age among patients whose first-time patellar dislocations resulted in an MPFL tear. In addition, the location of the tear did not appear to vary by sex or age.

Background. First-time anterior shoulder dislocations (FTASD) provide an opportunity to examine the value of integrating stated-preference data with decision modeling to differentiate between patients whose preferred management strategy involves operative or nonoperative treatment. The objective of this study was to evaluate the efficacy of a FTASD decision tool intervention with individual preference measurement compared with a text-based control in a randomized controlled trial. Methods. Two hundred respondents between 18 and 35 years of age at risk for experiencing an FTASD were enrolled from the orthopedic clinics and randomized to receive either an interactive decision tool intervention capable of eliciting patient preferences for treatment of an FTASD or a text-based control on shoulder dislocations and treatments. The primary outcome was preference for operative or nonoperative treatment choice. Secondary outcomes included the decisional conflict scale (DCS), stage of decision making, patient activation and engagement, awareness of preference sensitive decisions, knowledge retention, and instrument acceptability. Results. One hundred respondents were randomized to the intervention and 100 to the control. A total of 154 men and 46 women with an average age of 23.6 years completed the survey. Participants in the intervention group made treatment decisions that aligned more closely with evidence-based recommendations than those in the control group ( P = 0.016). Secondary outcomes showed no difference between intervention and control, excluding several DCS subscales. Discussion. An interactive, preference-based decision tool for treatment of FTASD affects patient decision making by guiding respondents toward treatment decisions that align more closely with evidence-based recommendations in the absence of a consultation with an orthopedic provider compared with a standard-of-care control tool. Additional study is needed to evaluate the long-term effects of this tool on treatment outcomes, patient adherence, and satisfaction. LEVEL OF EVIDENCE: 2

Background: The human shoulder joint is the most mobile joint in the body. While in vivo shoulder kinematics under minimally loaded conditions have been studied, it is unclear how glenohumeral cartilage responds to high-demand loaded exercise. Hypothesis: A high-demand upper extremity exercise, push-ups, will induce compressive strain in the glenohumeral articular cartilage, which can be measured with validated magnetic resonance imaging (MRI)–based techniques. Study Design: Descriptive laboratory study. Methods: High-resolution MRI was used to measure in vivo glenohumeral cartilage thickness before and after exercise among 8 study participants with no history of upper extremity injury or disease. Manual MRI segmentation and 3-dimensional modeling techniques were used to generate pre- and postexercise thickness maps of the humeral head and glenoid cartilage. Strain was calculated as the difference between pre- and postexercise cartilage thickness, normalized to the pre-exercise cartilage thickness. Results: Significant compressive cartilage strains of 17% ± 6% and 15% ± 7% (mean ± 95% CI) were detected in the humeral head and glenoid cartilage, respectively. The anterior region of the glenoid cartilage experienced a significantly higher mean strain (19% ± 6%) than the posterior region of the glenoid cartilage (12% ± 8%). No significant regional differences in postexercise humeral head cartilage strain were observed. Conclusion: Push-ups induce compressive strain on the glenohumeral joint articular cartilage, particularly at the anterior glenoid. This MRI-based methodology can be applied to further the understanding of chondral changes in the shoulder under high-demand loading conditions. Clinical Relevance: These results improve the understanding of healthy glenohumeral cartilage mechanics in response to loaded upper extremity exercise. In the future, these methods can be applied to identify which activities induce high glenohumeral cartilage strains and deviations from normal shoulder function.

Objectives: Revision ACL reconstruction can be potentially devastating for a patient. As such, it is important to identify prognostic factors placing patients at increased risk for re-rupture. There are no data on the effects of patellar tendonopathy on failure of ACL reconstruction when using bone-patellar tendon-bone (BPTB) autograft. The purpose of this study was to investigate the effects of patellar tendinopathy on the risk of graft failure in primary ACL reconstruction when using BPTB autograft. Methods: All patients undergoing ACL reconstruction at a single institution from 2005 to 2015 were examined. A total of 168 patients undergoing primary BPTB autograft for primary ACL reconstruction were identified. Patient MRIs were reviewed for the presence and grade of patellar tendinopathy by two musculoskeletal fellowship-trained radiologists; both were blinded to the aim of the study, patient demographics, surgical details and outcomes. Patients were divided into two cohorts: failure and non-failure of the ACL graft, defined as rupture of the ACL graft. Statistical analyses were run to examine the role of patellar tendinopathy in failure of ACL reconstruction using BPTB autograft. Results: At a mean follow up of 18 months, there were 7 (4.2%) patients with graft failure. Moderate or high-grade patellar tendinopathy was associated with ACL graft failure (p=0.011). Age, gender and side of reconstruction were not associated with risk of re-rupture, though the majority of patients in our study who failed were younger than 20 years of age. Use of patellar tendon with moderate to severe tendinopathy was associated with a relative risk of rupture of 6.1 as compared to autograft tendon without tendinopathy (95% CI 1.37-27.3). Conclusion: The presence of moderate or severe patellar tendinopathy significantly increases the risk of graft failure when using BPTB autograft for primary ACL reconstruction. Consideration of patellar tendinopathy should be made when determining the optimal graft choice for patients undergoing primary ACL reconstruction with autograft tendons.

Purpose (1) To systematically assess the clinical outcomes of arthroscopic rotator interval closure (RIC) procedures for shoulder instability and (2) to report the different technical descriptions and surgical indications for this procedure. Methods Two independent reviewers searched 4 databases (PubMed, Embase, Web of Science, and Cochrane) from database inception until October 15, 2017. The inclusion criteria were studies that reported outcomes of shoulder stabilization using arthroscopic RIC as an isolated or adjunctive surgical procedure. The methodologic quality of studies was assessed with the Methodological Index for Non-Randomized Studies tool and Grading of Recommendations Assessment, Development and Evaluation system for randomized controlled trials. Results Fifteen studies met our search criteria (524 patients). Of the studies, 12 were graded Level IV evidence; 2, Level III; and 1, Level II. Six different RIC technique descriptions were reported, with 2 studies not defining the details of the procedure. The most common method of RIC was arthroscopic plication of the superior glenohumeral ligament to the middle glenohumeral ligament (8 of 15 studies). The most commonly used patient-reported outcome measure was the Rowe score, with all studies reporting a minimum postoperative score of 80 points. The rate of return to preinjury level of sport ranged from 22% to 100%, and the postoperative redislocation rate ranged from 0% to 16%. Conclusions The indications for RIC were poorly reported, and the surgical techniques were inconsistent. Although most studies reported positive clinical results, the heterogeneity of outcome measures limited our ability to make definitive statements about which types of rotator interval capsular closure are warranted for select subgroups undergoing arthroscopic shoulder stabilization. Level of Evidence Level IV, systematic review of Level II through IV studies.

Meniscal tears are common injuries, and while partial meniscectomy is a frequent treatment option, general meniscus loss is a risk factor for the development of osteoarthritis. The goal of this study was to measure the in vivo tibiofemoral cartilage contact patterns in patients with meniscus tears in relation to biomarkers of cartilage catabolism in the synovial fluid of these joints. A combination of magnetic resonance imaging and biplanar fluoroscopy was used to determine the in vivo motion and cartilage contact mechanics of the knee. Subjects with isolated medial meniscus tears were analyzed while performing a quasi-static lunge, and the contralateral uninjured knee was used as a control. Synovial fluid was collected from the injured knee and matrix metalloproteinase (MMP) activity, sulfated glycosaminoglycan, cartilage oligomeric matrix protein, prostaglandin E2, and the collagen type II cleavage biomarker C2C were measured. Contact strain in the medial compartment increased significantly in the injured knees compared to contralateral control knees. In the lateral compartment, the contact strain in the injured knee was significantly increased only at the maximum flexion angle (105°). The average cartilage strain at maximum flexion positively correlated with total MMP activity in the synovial fluid. These findings show that meniscal injury leads to loss of normal joint function and increased strain of the articular cartilage, which correlated to elevated total MMP activity in the synovial fluid. The increased strain and total MMP activity may reflect, or potentially contribute to, the early development of osteoarthritis that is observed following meniscal injury.

Anterior cruciate ligament (ACL) injuries are one of the most common knee injuries, with over 100,000 ACL reconstructions performed in the United States every year. There are a number of graft options available for use in ACL repair. Hamstring tendon autografts are commonly used for ACL reconstruction. The advantages cited for autografts versus allografts are as follows: lower cost, no risk of immunological reactions, and better integration and remodeling. The healing response depends on the interplay between the bone and tendon in which collagen fiber continuity is re-established. This process is achieved by bony ingrowth of immature trabecular bone into immature, disorganized collagen fibers. Gradually, the collagen fibers reorganize into a parallel array until the tendoosseous junction is re-established. Studies of the healing response involved in ACL autograft reconstruction have been well documented in animal studies, but most studies of the graft healing response in human patients have been limited to biopsy specimens. To our knowledge, there are no examples in the literature of the ACL graft healing response in the tibial and femoral tunnels of human whole knee specimens. Beynnon et al, in a previous study, performed biomechanical testing on a recovered human ACL graft but did not specifically examine the healing response. We report the case of a young male patient who subsequently required resection of his knee for osteosarcoma of the tibia 4 months after ACL reconstruction with a hamstring tendon autograft. The patient and his parents provided written informed consent for print and electronic publication of this case report.

Background: No standardized return-to-activity or sport guidelines currently exist after anterior cruciate ligament (ACL) reconstruction. Isokinetic testing and unilateral hop testing, which have construct validity, are often used to make the determination of when a patient is ready to return to sport. Neither of these measures has been reported to be predictive of subsequent injuries. Purpose: To compare the performance on 2 functional tests of ACL reconstruction patients released to return to activity versus those who have not been released based on clinical impairment measures. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 98 patients were examined by the treating orthopaedic surgeon 6 months after ACL reconstruction for traditional impairment measures, including swelling, range of motion, strength, and graft stability. After this examination, all subjects completed the functional testing, consisting of the Functional Movement Screen (FMS) and the Lower Quarter Y Balance Test (YBT-LQ), by an experienced tester who was blinded to the results of the clinical examination. On the basis of the clinical examination, all patients were grouped as being ready to return to sport or not being ready. Performance on the functional tests, as measured by overall performance and side-to-side asymmetry, was compared between the 2 groups using independent-samples t tests ( P < .05). Results: No difference existed between the groups with regard to the descriptive characteristics, with the exception that the group not cleared was younger (21.0 ± 7.4 years) than the group that was cleared (25.6 ± 13.2 years). Performance on the YBT-LQ revealed that no differences existed between groups when examining reach symmetry for any of the reach directions. In addition, no differences were found between groups when looking at the average reach score normalized to limb length for either the surgical or nonsurgical leg. Patients in the cleared group exhibited a similar score on the FMS (12.7 ± 2.9) compared with the noncleared group (12.8 ± 2.7). Similarly, no differences were observed for the number of asymmetries; however, both groups averaged 1 asymmetry during the testing. Conclusion: Clinical impairment measures do not appear to be related to measured functional ability. Performance on both functional tests, the FMS and YBT-LQ, at 6 months would suggest that the typical patient in both groups would be at a greater risk of lower extremity injury, based on currently published research.

Charles William Hargett,1 Joseph P Doty,2 Jennifer N Hauck,3 Allison MB Webb,4 Steven H Cook,5 Nicholas E Tsipis,4 Julie A Neumann,6 Kathryn M Andolsek,7 Dean C Taylor6 1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, 2Feagin Leadership Program, 3Department of Anesthesiology, 4School of Medicine, 5Department of Neurosurgery, 6Department of Orthopaedic Surgery, 7Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC, USA Purpose: Despite increasing awareness of the importance of leadership in healthcare, our understanding of the competencies of effective leadership remains limited. We used a concept mapping approach (a blend of qualitative and quantitative analysis of group processes to produce a visual composite of the group’s ideas) to identify stakeholders’ mental model of effective healthcare leadership, clarifying the underlying structure and importance of leadership competencies.Methods: Literature review, focus groups, and consensus meetings were used to derive a representative set of healthcare leadership competency statements. Study participants subsequently sorted and rank-ordered these statements based on their perceived importance in contributing to effective healthcare leadership in real-world settings. Hierarchical cluster analysis of individual sortings was used to develop a coherent model of effective leadership in healthcare.Results: A diverse group of 92 faculty and trainees individually rank-sorted 33 leadership competency statements. The highest rated statements were “Acting with Personal Integrity”, “Communicating Effectively”, “Acting with Professional Ethical Values”, “Pursuing Excellence”, “Building and Maintaining Relationships”, and “Thinking Critically”. Combining the results from hierarchical cluster analysis with our qualitative data led to a healthcare leadership model based on the core principle of Patient Centeredness and the core competencies of Integrity, Teamwork, Critical Thinking, Emotional Intelligence, and Selfless Service.Conclusion: Using a mixed qualitative-quantitative approach, we developed a graphical representation of a shared leadership model derived in the healthcare setting. This model may enhance learning, teaching, and patient care in this important area, as well as guide future research. Keywords: core competencies, healthcare leadership, medical education, mental models, mixed methods research

Kelly R Murphy,John E McManigle,Benjamin M Wildman-Tobriner,Amy Little Jones,Travis J Dekker,Barrett A Little,Joseph P Doty,Dean C Taylor Duke Healthcare Leadership Program, Duke University School of Medicine, Durham, NC, USA Abstract: The medical community has recognized the importance of leadership skills among its members. While numerous leadership assessment tools exist at present, few are specifically tailored to the unique health care environment. The study team designed a 24-item survey (Healthcare Evaluation & Assessment of Leadership [HEAL]) to measure leadership competency based on the core competencies and core principles of the Duke Healthcare Leadership Model. A novel digital platform was created for use on handheld devices to facilitate its distribution and completion. This pilot phase involved 126 health care professionals self-assessing their leadership abilities. The study aimed to determine both the content validity of the survey and the feasibility of its implementation and use. The digital platform for survey implementation was easy to complete, and there were no technical problems with survey use or data collection. With regard to reliability, initial survey results revealed that each core leadership tenet met or exceeded the reliability cutoff of 0.7. In self-assessment of leadership, women scored themselves higher than men in questions related to patient centeredness (P=0.016). When stratified by age, younger providers rated themselves lower with regard to emotional intelligence and integrity. There were no differences in self-assessment when stratified by medical specialty. While only a pilot study, initial data suggest that HEAL is a reliable and easy-to-administer survey for health care leadership assessment. Differences in responses by sex and age with respect to patient centeredness, integrity, and emotional intelligence raise questions about how providers view themselves amid complex medical teams. As the survey is refined and further administered, HEAL will be used not only as a self-assessment tool but also in “360” evaluation formats. Keywords: emotional intelligence, patient centeredness, sex, specialty, age, leadership assessment

In brief Syndesmosis ankle sprains, though potentially disabling, often appear benign initially. These sprains are characterized by a rotational mechanism of injury, long recovery, and, frequently, heterotopic ossification. Diagnosis and grading are based on physical exam findings and imaging studies. Treatment ranges from aggressive functional rehabilitation to surgical stabilization. Long-term results can be good if the ankle mortise is anatomically reduced and a synostosis between the tibia and fibula does not form.

Objectives: Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children/adolescents than adults. These re-injuries result in significant time lost from sport, and may contribute to worse long-term outcomes and post-traumatic osteoarthritis. The reasons for higher subsequent injury rates in this unique population are incompletely understood. Methods: We analyzed a single center continuous cohort of patients under the age of eighteen years. Subjects underwent primary ACL reconstruction between 2006 and 2014 with minimum 2-year follow up. Age, sex, graft type, duration of physical therapy, time to return to sport, and length of follow-up were evaluated using multivariable logistic regression modeling to assess their contribution to the risk of subsequent ACL injury. Results: A total of 109 subjects met all study inclusion/exclusion criteria. Eighty-two subjects (75%) had follow-up data and were included in the final analysis. Mean age was 14 +/- 1.9 years (range 8 - 17 years). Mean follow-up was 47.7 +/- 15.6 months (range 28 - 91 months). Seventeen patients (20.7%) sustained an ACL graft rupture, eleven patients (13.4%) sustained a contralateral ACL tear, and one patient (1.2%) sustained both. The combined subsequent injury incidence was 35.4% (29 of 82 subjects). The odds of subsequent ACL injury decreased by 0.29 for every yearly increase in age (OR 0.71, 95% CI 0.53 - 0.92, p = 0.008), and decreased by 0.16 for every monthly increase in time to return to sport (OR 0.84, 95% CI 0.69 - 0.99, p = 0.048). Sex, graft type, duration of physical therapy, sport, and length of follow up did not have a statistically significant impact on the rate of subsequent ACL injury (p > 0.05). Conclusion: Subsequent ACL injuries (ipsilateral or contralateral) are common after primary ACL reconstruction in children and adolescents (combined incidence 35%). Within this high-risk population, younger age and an earlier return to sport portend a higher risk of a second injury.

Background: Although surgical management of a first-time anterior shoulder dislocation (FTASD) can reduce the risk of recurrent dislocation, other treatment characteristics, costs, and outcomes are important to patients considering treatment options. While patient preferences, such as those elicited by conjoint analysis, have been shown to be important in medical decision-making, the magnitudes or effects of patient preferences in treating an FTASD are unknown. Purpose: To test a novel shared decision-making tool after sustained FTASD. Specifically measured were the following: (1) importance of aspects of operative versus nonoperative treatment, (2) respondents’ agreement with results generated by the tool, (3) willingness to share these results with physicians, and (4) association of results with choice of treatment after FTASD. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A tool was designed and tested using members of Amazon Mechanical Turk, an online panel. The tool included an adaptive conjoint analysis exercise, a method to understand individuals’ perceived importance of the following attributes of treatment: (1) chance of recurrent dislocation, (2) cost, (3) short-term limits on shoulder motion, (4) limits on participation in high-risk activities, and (5) duration of physical therapy. Respondents then chose between operative and nonoperative treatment for hypothetical shoulder dislocation. Results: Overall, 374 of 501 (75%) respondents met the inclusion criteria, of which most were young, active males; one-third reported prior dislocation. From the conjoint analysis, the importance of recurrent dislocation and cost of treatment were the most important attributes. A substantial majority agreed with the tool’s ability to generate representative preferences and indicated that they would share these preferences with their physician. Importance of recurrence proved significantly predictive of respondents’ treatment choices, independent of sex or age; however, activity level was important to previous dislocators. A total of 125 (55%) males and 33 (23%) females chose surgery after FTASD, as did 37% of previous dislocators compared with 45% of nondislocators. Conclusion: When given thorough information about the risks and benefits, respondents had strong preferences for operative treatment after an FTASD. Respondents agreed with the survey results and wanted to share the information with providers. Recurrence was the most important attribute and played a role in decisions about treatment.

To provide a systematic review of the literature regarding five topics in meniscal allograft transplantation (MAT): optimal timing for transplantation, outcomes, return to competition, associated procedures, and prevention of osteoarthritis. A systematic literature search was conducted using the PubMed (MEDLINE), ScienceDirect, and EBSCO-CINAHL databases. Articles were classified only in one topic, but information contained could be reported into other topics. Information was classified according to type of study (animal, in vitro human, and in vivo human) and level of evidence (for in vivo human studies). Specific inclusion criteria were determined for the outcomes and prevention of osteoarthritis topics. Twenty-four studies were finally included: two optimal timing, seven outcomes, three return to competitive sport, 16 MAT and associated procedures, and 5 MAT and prevention of osteoarthritis (some studies were categorized in more than one topic). These studies corresponded to 2 animal studies and 31 in vivo human studies (1 level II, 1 level III, and 29 level IV). The principal conclusions were as follows: (a) there is no evidence to support that MAT has to be performed at the same time or immediately after meniscectomy to prevent development of postmeniscectomy syndrome; (b) MAT successfully improves symptoms, function, and quality of life at 7-to-14 years of follow-up (level IV evidence); (c) the overall failure rate (need for knee arthroplasty) is 10–29 % at long-term follow-up; (d) MAT allows return to same level of competition in 75–85 % of patients at short- to mid-term follow-up (only three studies level IV evidence with small sample size); (e) associated cartilage procedures or anterior cruciate ligament reconstruction to MAT does not worsen the results; (f) MAT may prevent progression of cartilage damaged at long-term follow-up, but may not prevent degeneration in previously healthy cartilage. Systematic review of level II–IV studies, Level IV.

To provide a systematic review of the literature regarding five topics in meniscal allograft transplantation: graft biology, shrinkage, extrusion, sizing, and fixation. A systematic literature search was conducted using the PubMed (MEDLINE), ScienceDirect, and EBSCO-CINAHL databases. Articles were classified only in one topic, but information contained could be reported into other topics. Information was classified according to type of study (animal, in vitro human, and in vivo human) and level of evidence (for in vivo human studies). Sixty-two studies were finally included: 30 biology, 3 graft shrinkage, 11 graft extrusion, 17 graft size, and 6 graft fixation (some studies were categorized in more than one topic). These studies corresponded to 22 animal studies, 22 in vitro human studies, and 23 in vivo human studies (7 level II, 10 level III, and 6 level IV). The principal conclusions were as follows: (a) Donor cells decrease after MAT and grafts are repopulated with host cells form synovium; (b) graft preservation alters collagen network (deep freezing) and causes cell apoptosis with loss of viable cells (cryopreservation); (c) graft shrinkage occurs mainly in lyophilized and gamma-irradiated grafts (less with cryopreservation); (d) graft extrusion is common but has no clinical/functional implications; (e) overall, MRI is not superior to plain radiograph for graft sizing; (f) graft width size matching is more important than length size matching; (g) height appears to be the most important factor influencing meniscal size; (h) bone fixation better restores contact mechanics than suture fixation, but there are no differences for pullout strength or functional results; and (i) suture fixation has more risk of graft extrusion compared to bone fixation. Systematic review of level II–IV studies, Level IV.

Context: Upper quarter injuries have a higher incidence in female swimmers; however, to date, there are few ways to assess the basic functional ability of this region. The upper quarter Y balance test (YBT-UQ) may assist in this process because it was developed to provide a fundamental assessment of dynamic upper quarter ability at the limit of stability. Objective: To examine how sex affects performance on the YBT-UQ in swimmers. Design: Cohort study. Patients or Other Participants: Forty-three male and 54 female National Collegiate Athletic Association Division I college swimmers were recruited preseason. Main Outcome Measure(s): We measured YBT-UQ performance for the left and right limbs in the medial, inferolateral, and superolateral directions. The maximum score for each direction was normalized to upper extremity length. The average of the greatest normalized reach scores in each reach direction was used to develop a composite score (average distance in 3 directions/limb length [LL] × 100). To examine reach symmetry between sexes, the difference in centimeters between the left and right sides was calculated for each reach direction prior to normalization. Statistical analysis was conducted using an independent-samples t test (P < .05). Results: Average scores in the medial (women: 92.5 ± 7.4%LL, men: 100.0 ± 8.7%LL; P < .01) and inferolateral (women: 85.6 ± 10.3%LL, men: 89.8 ± 10.8%LL; P = .05) directions and composite score (women: 83.4 ± 8.3%LL, men: 88.3 ± 8.9%LL; P < .01) were higher in men than in women. No differences were observed for reach symmetry in any direction. Conclusions: Performance on several YBT-UQ indices was worse for female than male collegiate swimmers. These results may have implications for the use of preseason and return-to-sport testing in swimmers as a measurement of upper quarter function and symmetry.

Purpose Anterior shoulder anatomy is as complex and variable as its descriptive terminology. A detailed understanding of normal anatomic variability is critical to accurate performance, description, and evaluation of the procedures involving the rotator interval. We aimed to define, arthroscopically, the anatomic variability in the rotator interval region of the shoulder and to compare these results to the findings of previous cadaveric studies. Methods The rotator interval anatomy of 104 consecutive patients was classified according to the system of DePalma. Anatomic variability was evaluated and compared with findings of previous authors. Results Shoulders were classified as follows: 59% type 1 (rotator interval capsular opening [RICO] superolateral to the MGHL); 1% type 2 (RICO inferomedial to the middle glenohumeral ligament [MGHL]); 22% type 3 (2 RICOs: 1 above and 1 below the MGHL); 9% type 4 (large RICO, no MGHL); 0% type 5 (the MGHL is manifested as 2 small RICOs); 7% Type 6 (no RICO); and 3% distinct Buford complex. We found a larger percentage of type 1 shoulders and a lower percentage of type 3 shoulders relative to prior open cadaveric dissections. No difference in the distribution of DePalma types was noted based surgical indication. Conclusions The anatomy of the rotator interval as viewed arthroscopically is complex and variable. While DePalma types 1 and 3 are most commonly encountered, other anatomic variants are frequent and should be considered when assessing and manipulating structures in region of the rotator interval and anterior shoulder.

Displaced flaps of glenoid labral tissue are an uncommonly encountered finding on MRI of the shoulder, and are of unclear clinical significance. The purpose of this study is to describe the imaging characteristics of displaced glenoid labral flaps, evaluate for any common concomitant injuries, and identify the typical clinical presentation and management of patients with this lesion. This retrospective, observational study was approved by the institutional review board. Nineteen patients with flap-type tears of the labrum on preoperative MRI were identified. Each examination was retrospectively reviewed by two radiologists for size, location, and signal intensity of the displaced flap of tissue, in addition to any co-existing labrum or cartilage pathological conditions and clinical information. All displaced flaps extended from the inferior margin of the glenoid into the axillary recess. The average size of the visualized flap was 10.9 by 6.0 by 2.6 mm. Seventy percent of the flaps had signal intensity isointense to labrum and hypointense to hyaline cartilage on T2-weighted images. All 19 patients had concomitant labral pathological conditions and 63% had cartilage defects, visualized on MRI. Clinical evidence of shoulder instability was seen in 83% of patients, and 67% were managed surgically. Glenoid labral flap tears have distinct imaging characteristics that may aid in their identification. Their presence should prompt careful evaluation of the glenoid articular cartilage. Recognition of a labral flap tear may have clinical importance, as 83% of patients with this finding demonstrated clinical evidence of shoulder instability, often requiring surgical intervention.

Medial collateral ligament injuries are common in the athletic population. Partial injuries are treated nonoperatively with excellent outcomes. Complete ruptures may be treated nonoperatively, although some will require surgery. A comprehensive rehabilitation program is critical to outcome, but a standardized program for all injuries does not exist. Most of the literature regarding nonoperative and postoperative rehabilitation include observational reports and case studies. Level I studies comparing rehabilitation protocols have not been published. The goal of the injured athlete is to not only return to play with no functional limitations, but to also address risk factors and prevent future injuries.