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Background In-season return to play after anterior glenohumeral instability is associated with high rates of recurrent instability and the need for surgical stabilization. We are not aware of previous studies that have investigated in-season return to play after posterior glenohumeral instability; furthermore, as posterior shoulder instability in collision athletes occurs frequently, understanding the expected outcome of in-season athletes may improve the ability of physicians to provide athletes with a better understanding of the expected outcome of their injury and their ability to return to sport. Questions/purposes (1) What proportion of athletes returned to play during the season after posterior instability in collegiate football players? (2) How much time did athletes lose to injury, what proportion of athletes opted to undergo surgery, and what proportion of athletes experienced recurrent instability after a posterior instability episode during a collegiate football season? Methods A multicenter, prospective, observational study of National Collegiate Athletic Association (NCAA) Division 1 Football Bowl Subdivision athletes was performed at three US Military Service Academies. Ten athletes who sustained a posterior instability event during the regular football season and who pursued a course of nonoperative treatment were identified and prospectively observed through the subsequent season. All athletes in the observed cohort attempted an initial course of nonoperative treatment during the season. All athletes sustained subluxation events initially identified through history and physical examination at the time of injury. None of the athletes sustained a dislocation event requiring a manual reduction. Intraarticular pathology consisting of posterior labral pathology was further subsequently identified in all subjects via MRI arthrogram. Return to play was the primary outcome of interest. Time lost to injury, surgical intervention, and subsequent instability were secondary outcomes. Results Of the 10 athletes who opted for a trial of initial nonoperative management, seven athletes were able to return to play during the same season. Although these seven athletes returned within 1 week of their injury (median of 1 day), 5 of 7 athletes sustained recurrent subluxation events with a median (range) of four subluxation events per athlete (0 to 8) during the remainder of the season. Seven athletes were treated surgically after the completion of their season, four of whom returned to football. Conclusion This study suggests that although collegiate football players are able to return to in-season sport after a posterior glenohumeral instability event, they will likely sustain multiple recurrent instability events and undergo surgery after the season is completed. The results of this study can help guide in-season management of posterior shoulder instability by allowing more appropriate postinjury counseling and decision making through the identification of those athletes who may require additional attention from medical staff during the season and possible modifications to training regimens to minimize long-term disability. Further prospective studies involving a larger cohort over several seasons should be performed through collaborative studies across the NCAA that better assess function and injury risk factors before beginning collegiate athletics. This would better characterize the natural history and associated functional limitations that athletes may encounter during their collegiate careers. Level of evidence Level IV, prognostic study.

Background: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages. Purpose: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis. Results: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0). Conclusion: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Objectives: Patient reported outcomes (PROs) serve as a means of measuring improvement and quality of care. Legacy PROs rely on a list of questions that have had to demonstrate accuracy, responsiveness, and validity in testing for intended measurements. While certain legacy PROs such as the International Knee Documentation Committee (IKDC) survey have demonstrated these properties well, a lengthy PRO creates a time burden on patients, making patient adherence and completion a challenge. In recent years, PROs such as the Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys have been developed which leverage computer adaptive testing that produce equivalent accuracy, responsiveness, and validity of legacy PROs, but use only 4-12 questions per survey. This results in significant reduction in time to complete. As these new PROs are now being adopted, the ability to compare outcomes to prior studies that relied on legacy PROs is necessary. While prior studies have examined correlation between legacy PROs and PROMIS computer adaptive tests, no studies to date have developed effective prediction models utilizing PROMIS surveys to create an IKDC index score. The objective of this study was to develop a predictive model utilizing PROMIS PF and PI to effectively recreate IKDC survey scores. Methods: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient reported outcomes and intraoperative variables. As part of inclusion in MOTION, research patients who underwent knee surgery were asked to complete the IKDC as well as the PROMIS PF and PROMIS PI at varying time points. This cohort of patients that completed both IKDC and PROMIS scores were included in the present analysis. Nonlinear multivariable predictive models using both Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference (MCID) analysis. Results: A total of 1,011 knee patients (Age: 37.7±14.4 years; 30% Female) completed the IKDC, PROMIS PF, and PROMIS PI providing 1,618 complete observations. The algorithms for both the Gaussian and beta distribution were strongly validated to predict the IKDC (Table 1). The MCID for IKDC was 27.0 (95% confidence intervals: 15.0-39.7) whereas the IKDC-index MCIDs for the Gaussian and beta distribution models were both 13.3 (95% confidence intervals 2.7-27.9), suggesting that the derived IKDC-index is effective and can reliably re-create IKDC scores. The surface plots of this nonlinear multivariable model also confirm the necessity that nonlinear prediction is necessary for effective modeling of legacy PRO scores (Figures 1 & 2). Conclusions: PROMIS PF and PI predictive models are able to approximate the IKDC score within 9.3-10.0 points. Given the 27.0 point minimally clinically important difference for the IKDC survey in this cohort, the results of this study can be used to compare PROMIS PF and PI scores to prior IKDC data by creating an IKDC index score. Moreover, repeated use of the IKDC-index from PROMIS PF and PI allows for a lower MCID than using the conventional IKDC survey. PROMIS PF and PI scores can be substituted in both clinical and research settings to reduce patient time burden, increase completion rates, and still create data that can effectively be compared with studies utilizing legacy IKDC scores.

Background: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. Purpose: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using “leave 1 out” techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. Results: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. Conclusion: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online ( https://osf.io/ctmnd/ ), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

Background: COVID-19 is a severe respiratory virus that spreads via person-to-person contact through respiratory droplets. Since being declared a pandemic in early March 2020, the World Health Organization had yet to release guidelines regarding the return of college or professional sports for the 2020-2021 season. Purpose: To survey the head orthopedic surgeons and primary care team physicians for the National Collegiate Athletic Association (NCAA) Football Bowl Subdivision (FBS) football teams so as to gauge the management of common COVID-19 issues for the fall 2020 college football season. Study Design: Cross-sectional study. Methods: The head team orthopaedic surgeons and primary care physicians for all 130 FBS football teams were surveyed regarding their opinions on the management of college football during the COVID-19 pandemic. A total of 30 questions regarding testing, return-to-play protocol, isolating athletes, and other management issues were posed via email survey sent on June 5, 2020. Results: Of the 210 team physicians surveyed, 103 (49%) completed the questionnaire. Overall, 36.9% of respondents felt that it was unsafe for college athletes to return to playing football during fall 2020. While the majority of football programs (96.1%) were testing athletes for COVID-19 as they returned to campus, only 78.6% of programs required athletes to undergo a mandatory quarantine period before resuming involvement in athletic department activities. Of the programs that were quarantining their players upon return to campus, 20% did so for 1 week, 20% for 2 weeks, and 32.9% quarantined their athletes until they had a negative COVID-19 test. Conclusion: While US Centers for Disease Control and Prevention guidelines evolve and geographic regions experience a range of COVID-19 infections, determining a universal strategy for return to socialization and participation in sports remains a challenge. The current study highlighted areas of consensus and strong agreement, but the results also demonstrated a need for clarity and consistency in operations, leadership, and guidance for medical professionals in multiple areas as they attempt to safely mitigate risk for college football players amid the COVID-19 pandemic.

Introduction Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense’s Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care. Materials and Methods MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management. Results This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report. Conclusions MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency’s Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

Purpose To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of 10- and 15-μg bimatoprost implant in subjects with open-angle glaucoma (OAG) and ocular hypertension (OHT) after initial and repeated administrations. Design Randomized, 20-month, multicenter, subject- and efficacy evaluator-masked, parallel-group, phase 3 clinical study. Participants Adults with OAG or OHT in each eye, open iridocorneal angle inferiorly in the study eye, and study eye baseline IOP (hour 0; 8 am ) of 22–32 mmHg after washout. Methods Study eyes received bimatoprost implant 10 μg (n = 198) or 15 μg (n = 198) on day 1 with readministration at weeks 16 and 32, or twice-daily topical timolol maleate 0.5% (n = 198). Intraocular pressure was measured at hours 0 and 2 at each visit. Main Outcome Measures Primary end points were IOP and change from baseline IOP through week 12. Safety measures included treatment-emergent adverse events (TEAEs) and corneal endothelial cell density (CECD). Results Both dose strengths of bimatoprost implant were noninferior to timolol in IOP lowering after each administration. Mean diurnal IOP was 24.0, 24.2, and 23.9 mmHg at baseline and from 16.5–17.2, 16.5–17.0, and 17.1–17.5 mmHg through week 12 in the 10-μg implant, 15-μg implant, and timolol groups, respectively. The incidence of corneal and inflammatory TEAEs of interest (e.g., corneal endothelial cell loss, iritis) was higher with bimatoprost implant than timolol and highest with the 15-μg dose strength. Incidence of corneal TEAEs increased after repeated treatment; with 3 administrations at fixed 16-week intervals, incidence of ≥20% CECD loss was 10.2% (10-μg implant) and 21.8% (15-μg implant). Mean best-corrected visual acuity (BCVA) was stable; 3 implant-treated subjects with corneal TEAEs had >2-line BCVA loss at their last visit. Conclusions Both dose strengths of bimatoprost implant met the primary end point of noninferiority to timolol through week 12. One year after 3 administrations, IOP was controlled in most subjects without additional treatment. The risk-benefit assessment favored the 10-μg implant over the 15-μg implant. Ongoing studies are evaluating other administration regimens to reduce the potential for CECD loss. The bimatoprost implant has potential to improve adherence and reduce treatment burden in glaucoma.

Purpose To examine the microstructural changes in the inner nuclear layer (INL) and ganglion cell layer (GCL) in a primary open-angle glaucoma (POAG) subject at 2 timepoints, 4 months apart. Patients and methods This case-control study (1 POAG subject and 1 normal control) used the single cell, 3-dimensional volumetric imaging capability of an adaptive optics-optical coherence tomography-scanning laser ophthalmoscopy system to examine the inner retina. Results At the area of greatest glaucomatous change in the POAG subject [3-degrees temporal (T), 3-degrees inferior (I), right eye], the GCL was greatly thinned at both timepoints, yet retinal ganglion cell soma remained visible amid a meshwork of capillaries. Microcystic lesions in the INL were visible at both timepoints, ranging in diameter from 8 to 43 μm on day 1 to 11 to 64 μm at 4 months, with an average diameter increase of ∼124%. Small hyperreflective features (not seen in the contralateral eye or control subject) at a depth midway through the INL seemed correlated to the development of microcysts. Conclusions We demonstrate the ability to image microcystic lesions early in their development and have quantified longitudinal changes. The presence of small hyperreflective structures at a layer midway through the INL seems to be a precursor to their formation and is a potential biomarker for assessing POAG severity and progression. The adaptive optics imaging system is also able to visualize retinal ganglion cells in this subject, despite severe thinning of the GCL.

Purpose: To report an unusual case of ectopia lentis and angle closure in a patient with chronic eye rubbing. Methods: A 57-year-old male with a history of poorly controlled atopic dermatitis presented with right eye pain, decreased vision, and an intraocular pressure (IOP) of 55 mm Hg. He had no past history of ocular disease and no reported history of trauma. He did report a history of chronic eye rubbing. Results: Best corrected visual acuity was hand motions. The examination revealed severe atopic keratoconjunctivitis in both eyes, microcystic corneal edema of the right eye, and 2+ nuclear sclerosis in both eyes. Gonioscopy showed no visible angle structures OD and an open angle OS. Topical and oral IOP-lowering medications and a laser iridotomy were unsuccessful at lowering IOP. He was taken to the operating room for a lensectomy and was found to have 9 clock hours of zonular dehiscence and a dislocated lens. After lensectomy, the IOP improved to 9 mm Hg on postoperative day 1. A follow-up examination at 2 weeks showed improved acuity to 20/150 with a pinhole and an IOP of 10 mm Hg. A dilated examination OS did not reveal significant phacodonesis, and the patient was referred for a possible sutured sulcus lens or anterior chamber intraocular lens. Conclusions: It is important for the provider to consider ectopia lentis in the differential for patients with pupillary block angle closure. For patients with atopic disease, one should be aware that eye rubbing may be a cause of zonular dehiscence, even in the absence of reported trauma or prior intraocular surgery.

Purpose To examine refractive outcomes after phacoemulsification in eyes with prior trabeculectomy. Design Retrospective observational case-control study METHODS:: Comparison of eyes of glaucoma patients undergoing cataract surgery after trabeculectomy (study group) with a matched group with medically controlled glaucoma (control group). Laser interferometry was used to obtain ocular biometry. We measured the difference between the expected and actual postoperative refraction using third-generation and fourth-generation intraocular lens (IOL) prediction formulae (Haigis, Holladay 2, Hoffer Q, and SRK-T). A residual difference of >1.0 D of hyperopia or myopia was considered a "refractive surprise." Results In total, 86 eyes (85 patients) were included, including 23 eyes (22 patients) in the study group and 63 eyes (63 patients) in the control group. The mean follow-up was 12.2±4.1 months. Eyes (n=13) with trabeculectomy and a preoperative intraocular pressure (IOP)≤9 mm Hg had significantly more large myopic surprises than the control group for all IOL formulae (P=0.015 Haigis, P=0.003 Holladay 2, P=0.004 Hoffer Q, P=0.003 SRK-T). Eyes (n=10) with trabeculectomy and preoperative IOP>9 mm Hg, however, did not have significantly more myopic errors than the control (P>0.05, all formulae). An "IOP spike" defined as a >50% rise in IOP from baseline within 1 month of cataract surgery in the subgroup with preoperative IOP≤9 mm Hg (n=8) was associated with increased risk of large myopic surprise (3/8 subset vs. 1/63 control eyes for all formulae; P=0.004 Haigis, P=0.004 Holladay 2, P=0.001 Hoffer Q, P=0.004 SRK-T) as well as for large myopic and hyperopic surprises overall (4/8 subset vs. ≤2/63 depending upon formulae; all P≤0.001). Conclusions Low posttrabeculectomy IOP (≤9 mm Hg) is a risk factor for significant myopic surprise when undergoing subsequent cataract surgery despite using laser interferometry to measure ocular biometry and later generation formulae to determine IOL power. In addition, an IOP spike was associated with a 50% risk for large refractive surprise in this low IOP group.

BACKGROUND: Despite the promising clinical results of autologous osteochondral transplantation in the treatment of osteochondral lesions of the talus, the occurrence of knee donor-site morbidity remains a concern. However, the proportion of patients experiencing donor-site morbidity is not well established because of important variations in estimates drawn by heterogeneous studies with loss to followup, often made at short-term (< 1 year). Therefore, both a meta-analysis of studies that assumed no patients lost to followup had donor-site morbidity and assumed all patients lost to followup had donor-site morbidity may help to estimate the true risk of donor-site morbidity. QUESTIONS/PURPOSES: To evaluate the proportion of patients who developed knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, by (1) meta-analysis of the proportion of patients experiencing donor-site morbidity in the best-case scenario as reported, in which no patients lost to followup were assumed to have donor-site morbidity and (2) meta-analysis of the percentage of patients who had donor-site morbidity in the worst-case scenario, in which all patients lost to followup were assumed to have donor-site morbidity and (3) present the characteristics of studies associated with the reporting of donor-site morbidity. METHODS: A systematic search of the PubMed, Embase and The Cochrane Library databases was performed from their inception to October 2017 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were clinical studies that reported knee donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus, mean followup ≥ 1 year, full-text studies published in a peer-review journal and written in English. Quality of evidence (Case Series Quality Appraisal Checklist), sample size, mean patient age, study design, mean followup time, and observed rate of knee donor-site morbidity were evaluated. Twenty-six studies with 915 ankles (904 patients) were included in the systematic review and meta-analysis. Approximately half of the included studies were of small cohort (n < 30, 12 studies), and 12 of 26 studies did not report at all on loss to followup. In the studies that reported loss to followup (14 of 26), a total of 32 patients (35 ankles) were reported lost. Random-effects models were used to estimate the risk of donor-site morbidity as between-study heterogeneity was determined to be high in both meta-analyses that assumed that no patients lost to followup experienced donor-site morbidity (I(2) = 82.1%) and the one that assumed all patients lost to followup experienced donor-site morbidity (I(2) = 88.7%). Multivariable metaregression was used to estimate the association between study characteristics and the observed proportion of patients who experienced of donor-site morbidity. If there was evidence of an association between a study characteristic and proportion, a subgroup analysis was performed. RESULTS: The estimated proportion of donor-site morbidity was 6.7% (95% confidence interval [CI], 2.8–11.8), assuming that no patients lost to followup experienced donor-site morbidity and 10.8% (95% CI, 4.8–18.3) assuming that all patients lost to followup experienced donor-site morbidity after a mean followup of 43.8 ± 24.7 months (range, 15.9–120 months). There was a negative association between study sample size and proportion of donor-site morbidity (β = -0.26; 95% CI, -0.39 to -0.12; p < 0.001 assuming that no patients lost to followup experienced donor-site morbidity and β = -0.31; 95% CI, -0.48 to -0.13; p < 0.001 assuming that all patients lost to followup experienced donor-site morbidity); that is, as study size increased, the proportion of patients reported with donor-site morbidity decreased. In larger studies (n ≥ 30), the estimated percentage of donor-site morbidity was 2.8% (95% CI, 1.2%–5.0%; I(2) = 47.6%) assuming that no patients lost to followup experienced donor-site morbidity, and 5.0% (95% CI, 2.1%–9.0%; I(2) = 74.5%) assuming all patients lost to followup experienced donor-site morbidity. High between-study heterogeneity (differences in methodology) could not be completely explained by variability in study sample size, mean patient age, design, or mean followup time, and may be attributable to other factors such as inconsistent definitions of donor-site morbidity. CONCLUSIONS: The estimated proportion of donor-site morbidity after autologous osteochondral transplantation for osteochondral lesion of the talus ranged from 6.7% to 10.8% in the current meta-analysis. However, subgroup analysis demonstrated that larger studies (n ≥ 30) estimated a lower donor-site morbidity risk (< 5.0%) than smaller studies (n < 30). This estimate should be interpreted in light of the fact that nearly half of the included studies did not report on loss to followup, and so their estimates of donor-site morbidity may be low. In addition, high between-study heterogeneity and the inclusion of predominantly retrospective studies with small sample sizes likely contributed to estimates that suffered from a high risk of bias, probably in favor of the surgical treatment being studied. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Hypotony maculopathy is a condition that may result in visual deterioration from choroidal folds or optic disc edema. Optic disc edema can result from altered translaminar pressure gradients (lowered intraocular pressure, increased cerebrospinal fluid pressure, or increased orbital pressure). We report a case of bilateral optic disc edema in a patient with glaucoma and thyroid-related orbitopathy. The patient's disc edema was initially presumed to be secondary to her orbitopathy, but persisted after bilateral orbital decompression. Ultimately, disc edema and choroidal folds in the right eye resolved after trabeculectomy revision and an increase in intraocular pressure. This case serves as a reminder of the causes of optic disc edema and demonstrates delayed reversal of hypotony maculopathy.

Purpose The purpose of this study is to determine the incidence of anterolateral ligament (ALL) tears on magnetic resonance imaging (MRI) in patients diagnosed with anterior cruciate ligament (ACL) tears. Furthermore, this study sought to determine the inter- and intraobserver reliability in diagnosing an ALL tear. Methods The MRI radiologic database at a community military hospital was queried for ACL tears over the period of January 2011 to April 2015. During this time, 181 MRIs were identified as having ACL tears. The MRIs were then independently reviewed by an orthopaedic surgeon and a musculoskeletal (MSK) trained radiologist. Both reviewers, independently confirmed the ACL tears, and the ALL was noted to be either torn, intact, or not visualized on axial, sagittal, and coronal images. Four weeks later the same MRIs were then reviewed for the presence and location of an ALL tear to determine inter- and intraobserver reliability. Results The MSK radiologist found ALL tears on MRI in 28.2% of the cases, while the orthopaedic surgeon found ALL tears in 39.8% of the cases; 5.5% of the MRIs were characterized as having a nonvisualized ALL. The interobserver reliability was noted to have a kappa value of 0.333. The intraobserver reliability of the MSK radiologist and orthopaedic surgeon demonstrated a kappa value of 0.654 and 0.251, respectively. Conclusions This study shows that the majority of patients with a known ACL tear on MRI do not have a tear of the ALL. Additionally, the interobserver reliability of surgeons and radiologist is fair. In this study, the MSK radiologist had higher intraobserver reliability when looking for an ALL tear. Level of Evidence Level IV, case control study.

Purpose To evaluate the risk factors for and frequency of an acute intraocular pressure (IOP) elevation (spike) after phacoemulsification in patients with glaucoma. Setting Academic glaucoma clinics and operating rooms. Design Retrospective case series. Methods Charts of consecutive glaucoma patients without previous incisional glaucoma surgery having phacoemulsification by the same surgeon between August 1996 and July 2012 were reviewed to obtain demographic information, preoperative glaucoma medications, severity and treatment measures, intraoperative course, and postoperative outcomes. A postoperative IOP spike was defined as IOP greater than 50% above baseline IOP. Main outcome measures were the number of eyes with a postoperative IOP spike and risk factors associated with an IOP spike after phacoemulsification. Results Of 271 eyes (271 patients) included in the study, 45 (17%) had an IOP spike. Risk factors for postoperative IOP spike by multivariate analysis included longer axial length (AL) or associated characteristics (wider angle grade on gonioscopy, deeper anterior chamber, and male sex), higher number of preoperative IOP-lowering medications, previous laser trabeculoplasty, and lack of postoperative oral acetazolamide. One eye (0.4%) required trabeculectomy during the 90-day postoperative period. Conclusions A significant proportion of glaucoma patients having phacoemulsification had an IOP spike. Patients requiring a higher number of IOP-lowering medications or laser trabeculoplasty for IOP control preoperatively and those with a greater AL should be treated more aggressively with IOP-lowering medication in the immediate postoperative period. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Background. Optic disk hemorrhage is known to be a risk factor for glaucoma progression. Cataract surgery by phacoemulsification results in large intraocular pressure fluctuations. We aim to investigate whether phacoemulsification is associated with optic disc hemorrhage in patients with glaucoma. Methods. This is a retrospective review of consecutive university clinic based glaucoma patients undergoing phacoemulsification alone, with at least 3 visits in the year before and at least 5 visits in the year following phacoemulsification. The presence of optic disk hemorrhage was evaluated with slit lamp biomicroscopy at each clinic visit prior to and following phacoemulsification. Results. We evaluated 158 eyes of 158 subjects; 15 (9.5%) had ODH noted at least once during the 2-year study period. Four eyes had ODH identified on postoperative day 1, for a cross-sectional prevalence of 2.5%. Fourteen ODH episodes were noted preoperatively versus 12 episodes postoperatively (P=0.68). Aspirin use was associated with ODH (P=0.015). Conclusions. Our cross-sectional study found a prevalence of ODH immediately after CE that was similar to other published rates, and our longitudinal study did not find an increase in ODH in the year after phacoemulsification when compared to the year prior to surgery.

Purpose of review To examine the current literature covering the long-term effect of cataract extraction on intraocular pressure (IOP). Recent findings As a result of the high rate of cataract surgery, the impact on IOP continues to be the subject of multiple studies in different populations. Recent publications include those that distinguish patients with open angles from those with more narrow angles, as well as prospective analyses that address the impact of regression to the mean and other types of bias on the effect of postoperative IOP lowering. Summary There are sufficient data to suggest that cataract surgery provides a lowering effect on IOP in the long term. This effect appears to be proportional to preoperative IOP. Eyes with higher preoperative IOP have the greatest average lowering, whereas eyes with IOP in the lower range of statistically normal tend to have an IOP that is unchanged from baseline or even higher following cataract surgery. In patients with narrow angles, the IOP-lowering effect appears to also be proportional to the degree of anterior chamber deepening induced by cataract surgery.

The objective of this study was to evaluate the effects of continuous subacromial bupivacaine infusion on supraspinatus muscle and rotator cuff tendon healing using gross, biomechanical, and histologic analyses.Thirty-three New Zealand White rabbits underwent unilateral supraspinatus transection and rotator cuff repair (RCR). Rabbits were assigned to 1 of 3 groups: (1) RCR only, (2) RCR with continuous saline infusion for 48 hours, or (3) RCR with continuous 0.25% bupivacaine with epinephrine (1:200,000) infusion for 48 hours. Rabbits were euthanized postoperatively at 2 weeks (for histologic assessment) or 8 weeks (for biomechanical and histologic assessment).Tensile testing showed a significantly higher load to failure in intact tendons compared with repaired tendons (P.01); however, no statistical differences were detected among RCR only, RCR saline, and RCR bupivacaine groups. Histologically, the enthesis of repaired tendons showed increased cellularity and disorganized collagen fibers compared with intact tendons, with no differences between treatment groups. Muscle histology demonstrated scattered degenerative muscle fibers at 2 weeks in RCR saline and RCR bupivacaine groups, but no degeneration was noted at 8 weeks.The healing supraspinatus tendons exposed to bupivacaine infusion showed similar histologic and biomechanical characteristics compared with untreated and saline-infused RCR groups. Muscle histology showed fiber damage at 2 weeks for the saline and bupivacaine-treated groups, with no apparent disruption at 8 weeks, suggesting a recovery process. Therefore, subacromial bupivacaine infusion in this rabbit rotator cuff model does not appear to impair muscle or tendon after acute injury and repair.

PURPOSE To report the outcomes of combined Ahmed glaucoma valve (AGV) placement, intravitreal fluocinolone acetonide implant, and cataract extraction procedure in the treatment of chronic noninfectious uveitis. PATIENTS AND METHODS Retrospective case series of patients with chronic noninfectious uveitis who underwent AGV placement, intravitreal fluocinolone acetonide implantation, and cataract extraction in a single surgical session performed at 1 institution from January 2009 to November 2014. Outcome measures included intraocular pressure (IOP) and glaucoma medication use. Secondary outcome measures included visual acuity, systemic anti-inflammatory medications, number of uveitis flares, and complications. RESULTS Fifteen eyes of 10 patients were studied, with a mean age of 40.3±15.7 and mean follow-up duration of 26 months (range, 13 to 39 mo). Before surgery, the IOP was 18.5±7.3 mm Hg and patients were using 1.5±1.5 topical glaucoma medications. At the 12-month follow-up, IOP was 12.8±3.2 mm Hg (P=0.01) and patients were using 0.5±0.8 (P=0.03) topical glaucoma medications. At 36 months of follow-up, late, nonsustained hypotony had occurred in 3 eyes (20%), and 1 eye (6%) had received a second AGV for IOP control. Before treatment, patients had 2.7±1.5 uveitis flares in the year before surgery while on an average of 2.1±0.6 systemic anti-inflammatory medications, which decreased to an average of 0.1±0.3 (P

Background:The Goutallier classification of fatty infiltration of the rotator cuff was developed for use in axial computed tomography arthrography. Now the Goutallier classification is being used with magnetic resonance imaging (MRI). Not only is there debate on the validity of the use of this system in MRI, but current literature is unclear as to the clinical use of the Goutallier classification.Hypothesis:There will be significant inter- and intraobserver variability of the Goutallier classification grading system for patients with chronic rotator cuff tears.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:An online database consisting of 35 single MRI images from 35 patients with chronic rotator cuff tears was designed and sent to members of the American Shoulder and Elbow Society. Surgeons were asked to identify the stage of rotator cuff fatty infiltration using the Goutallier classification system. Thirty surgeons responded and completed the survey in its entirety. At a minimum of 2 months later, 28 of the 30 initial respondents completed evaluations of the same online database. The responding surgeons were divided dichotomously according to their demographics and the interobserver reliability of the groups compared. A kappa analysis was performed to determine inter- and intraobserver reliability using 95% confidence intervals (95% CIs). A simplified 3-tiered classification was proposed combining Goutallier grades 0 and 1 as well as grades 2 and 3.Results:Statistical analysis of all respondent data demonstrated moderate intraobserver variability with a κ value of 0.56 (95% CI, 0.53-0.60). In addition, moderate interobserver variability was shown with a κ value of 0.43 (range, 0.16-0.74). With the simplified classification, intraobserver reliability was 0.70 (95% CI, 0.66-0.74) and interobserver reliability was 0.61 (range, 0.21-0.87). Correlation analysis showed no correlation with the presence or absence of fellowship training or board certification with either the Goutallier classification or the proposed modification ( P > .05). Sports versus shoulder/elbow fellows had statistically better intraobserver variability (κ = 0.63 vs 0.50) with the Goutallier classification. Years in practice was negatively correlated with the level of agreement for both classifications (– r value, P < .05). The number of rotator cuff repairs performed per year negatively correlated with the level of agreement in the proposed modification only ( r = −0.44, P = .022). Percent of practice dedicated to the shoulder did not correlate significantly with either classification ( P > .05).Conclusion:There is significant inter- and intraobserver variability observed among experienced shoulder surgeons using the Goutallier classification for assessing fatty infiltration of the rotator cuff muscles after chronic rotator cuff tears. Respondents were more likely to agree with themselves than with other respondents. A simplification of the MRI classification system is proposed that takes into consideration the variability determined by this study.

Purpose To evaluate the clinical effect of topical difluprednate in pediatric patients for treatment of noninfectious uveitis. Design Retrospective, observational case series. Methods Twenty-six eyes of 14 pediatric patients with noninfectious uveitis who were treated with topical difluprednate were evaluated. Anterior and posterior cell grade, visual acuity, intraocular pressure (IOP), and cystoid macular edema (CME) were recorded at each visit. Main outcome measures were changes in anterior segment cell, CME, visual acuity, and IOP and development of a visually significant cataract. Results A significant (≥ 2-grade decrease or decrease to 0 in anterior segment cell) reduction in anterior segment inflammation was observed during treatment with topical difluprednate in 88% of eyes (22/25) when used as an adjuvant to systemic immunomodulatory therapy. In addition, improvement in CME associated with uveitis was seen in response to topical therapy with difluprednate in 78% of eyes with CME (7/9). A significant IOP response (IOP increase of ≥ 10 mm Hg from baseline and IOP ≥ 24 mm Hg) was seen in 50% of eyes (13/26) and in 50% of patients (7/14); 3 eyes of 2 patients required glaucoma surgery. Cataract formation or progression was observed in 39% of eyes (10/26) and in 43% of patients (6/14); 5 eyes of 3 patients required cataract surgery. Conclusions Difluprednate is an effective agent for both control of anterior segment inflammation and reduction of CME in pediatric patients with uveitis when used as an adjuvant to systemic immunomodulatory therapy. A high rate of steroid-induced IOP elevation and cataract formation is seen in this population. Close monitoring of pediatric patients receiving difluprednate is recommended.

Background: Tenodesis of the long head of the biceps tendon is a common procedure used to alleviate pain caused by instability or inflammation of the tendon. The purpose of this study is to report on the incidence and types of complications following an open subpectoral biceps tenodesis (OBT) procedure. Hypothesis: Our hypothesis was that the rate of adverse events after OBT was low. Methods: From January 2005 to December 2007, all patients that underwent an OBT with bioabsorbable interference screw fixation performed by 1 of the 2 senior authors for biceps tendonitis were reviewed, excluding tenotomy, revision cases, or fixation methods other than interference screw fixation. Results: Over a 3-year period, 7 of 353 patients had complications with OBT with an incidence of 2.0%. The mean age of patients with complications was 44.67 years, with 57.1% males and 42.9% females. There were 2 patients (0.57%) with persistent bicipital pain. Two patients (0.57%) had failure of fixation resulting in a Popeye deformity. One patient (0.28%) presented with a deep postoperative wound infections that necessitated irrigation and debridement with intravenous antibiotics. Another patient (0.28%) developed a musculotaneous neuropathy. Another patient (0.28%) developed reflex sympathetic dystrophy necessitating pain management and stellate ganglion block. Conclusion: The incidence of complications after subpectoral biceps tenodesis with interference screw fixation in a population of 353 patients over the course of 3years was 2.0%. Level of evidence: IV, Case Series, Treatment Study. 2010 Journal of Shoulder and Elbow Surgery Board of Trustees.

The treatment of cartilage injuries secondary to patellar instability is multifactorial. These factors include the time frame of patellar instability, the pathoanatomic factors, the extent of symptoms, and the size and location of the cartilage injury. The chondral or osteochondral injury which occurs with acute patellar instability is managed with either reduction and internal fixation or removal. The treatment of the patellar instability component is controversial in the acute setting, especially when there is no need for an osteochondral surgery. In such cases, patellar dislocations are treated nonoperatively. However, if the patient is indicated for surgery for treatment of osteochondral fracture and intra-operatively the medial patellofemoral ligament (MPFL) remains pathologically lax and presents with a discrete MPFL injury site, there is the option of acute repair. Chondral injury associated with recurrent patellar instability may be subdivided into 2 overlapping groups: (1) chondral damage resulting from the instability episodes (distal medial region of the patellar and/or lateral proximal region of the lateral femoral condyle) and (2) chondrosis secondary to the chronic lateral tracking of the patella (chronic patellar subluxation) from patholaxity of the MPFL (lateral chondrosis to patella and trochlea in addition to the injuries sustained from the actual instability episodes). The treatment is based on the patient's chief complaints and the unique underlying pathoanatomy. Many of these patients will have one or more predisposing factors, such as patella alta, trochlear dysplasia, patholaxity of the MPFL and an excessively lateral position of the tibial tuberosity. Therefore, the key to managing this patient population is to address each patient's specific pathoanatomy, which by definition will include addressing the MPFL patholaxity. The goals are to stabilize the patella, normalize patellofemoral contact area and/or forces, and then restore the articular cartilage based on relevant symptoms. As of this writing, treatment options in the United States include debridement, marrow stimulation, osteochondral auto and allograft, autologous chondrocyte implantation, and the use of particulate articular cartilage.

Purpose: The purpose of this study was to evaluate glenoid labral heights before injury and after repair with 2 suture anchors: (1) traditional suture anchor secured with knots and (2) knotless suture anchor. Methods: Ten matched pairs of human cadaveric glenoids were examined. In each specimen the labrum was detached from the 3-o’clock position to the 6:30 clock position on the anteroinferior glenoid, and labral repair was performed with either (1) traditional Bio-SutureTak suture anchors (n 10) (Arthrex, Naples, FL) or (2) knotless PushLock suture anchors (n 10, contralateral side) (Arthrex). By use of a 3-dimensional digitizer, the labral height, measured from the deepest point of the glenoid articular surface to the highest tip of the labrum, was measured in all specimens before injury and after repair at the 3:30, 4:30, and 5:30 clock positions. The degree of labral height increase was computed as a percent increase in labral height from before injury to after repair. Results: Labral height increased significantly for all specimens from before injury (5.35 mm) to after repair (8.05 mm) (159.1% 13.7%, P .0001). Increases in labral height from before injury to after repair were similar (P .05) for Bio-SutureTak suture anchors (164.6% 18.7%, P .0001) and PushLock suture anchors (153.6% 5.8%, P .0001). The amount of labral height increase did not vary by anatomic location (157.0% 50.2%, 168.9% 51.0%, and 150.4% 35.2% at 3:30, 4:30, and 5:30, respectively; P .46). Conclusions: An increase in labral height can be achieved to create a significant height increase from before injury to after labral repair. The difference in labral height afforded by a traditional suture anchor and a knotless anchor is not statistically significant. Clinical Relevance: Both traditional and knotless suture anchor constructs provide a reliable restoration of labral height in an acute Bankart model.

Context:Posterior hip pain is a relatively uncommon but increasingly recognized complaint in the orthopaedic community. Patient complaints and presentations are often vague or nonspecific, making diagnosis and subsequent treatment decisions difficult. The purposes of this article are to review the anatomy and pathophysiology related to posterior hip pain in the athletic patient population.Evidence Acquisition:Data were collected through a thorough review of the literature via a MEDLINE search of all relevant articles between 1980 and 2010.Results:Many patients who complain of posterior hip pain actually have pain referred from another part of the body—notably, the lumbar spine or sacroiliac joint. Treatment options for posterior hip pain are typically nonoperative; however, surgery is warranted in some cases.Conclusions:Recent advancements in the understanding of hip anatomy, pathophysiology, and treatment options have enabled physicians to better diagnosis athletic hip injuries and select patients for appropriate treatment.

Context: Historically, the term greater trochanteric pain syndrome has been used to describe a spectrum of conditions that cause lateral-sided hip pain, including greater trochanteric bursitis, snapping iliotibial band, and/or strains or tendinopathy of the abductor mechanism. Diagnosis of these conditions may be difficult because clinical presentations are variable and sometimes inconclusive. Especially difficult is differentiating intrinsic pain from pain referred to the greater trochanteric region. The purposes of this article are to review the relevant anatomy and pathophysiology of the lateral hip. Evidence Acquisition: Data were collected through a thorough review of the literature conducted through a MEDLINE search of all relevant papers between 1980 and January 2010. Results: Recent advances in imaging and an improved understanding of pathomechanics have helped to guide the evaluation, diagnosis, and appropriate treatment for patients presenting with lateral hip pain. Conclusion: Various diagnostic tools and treatment modalities can be used to effectively manage the athletic patient presenting with lateral hip pain.

Purpose Because recurrent or persistent defects in the rotator cuff after repair are common, we sought to clarify the correlation between structural integrity of the rotator cuff and clinical outcomes through a systematic review of relevant studies. Methods Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched for all literature published from January 1966 to December 2008 that used the key words shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, integrity, healed, magnetic resonance imaging (MRI), computed tomography arthrography (CTA), and ultrasound. The inclusion criteria were studies (Levels I to IV) that reported outcomes after arthroscopic rotator cuff repair in healed and nonhealed repairs based on ultrasound, CTA, and/or MRI. Exclusionary criteria were studies that included open repair or subscapularis repair and studies that did not define outcomes based on healed versus nonhealed but rather used another variable (i.e., repair technique). Data were abstracted from the studies including patient demographics, tear characteristics, surgical procedure, rehabilitation, strength, range of motion, clinical scoring systems, and imaging studies. Results Thirteen studies were included in the final analysis: 5 used ultrasound, 4 used MRI, 2 used CTA, and 2 used combined CTA/MRI for diagnosis of a recurrent tear. Statistical improvement in patients who had an intact cuff at follow-up was seen in Constant scores in 6 of 9 studies; in University of California, Los Angeles scores in 1 of 2 studies; in American Shoulder and Elbow Surgeons scores in 0 of 3 studies; and in Simple Shoulder Test scores in 0 of 2 studies. Increased range of motion in forward elevation was seen in 2 of 5 studies and increased strength in forward elevation in 5 of 8 studies. Conclusions The results suggest that some important differences in clinical outcomes likely exist between patients with healed and nonhealed rotator cuff repairs. Further study is needed to conclusively define this difference and identify other important prognostic factors related to clinical outcomes. Level of Evidence Level IV, systematic review.

Purpose: The purpose of this study was to compare the clinical outcome of single-row (SR) and double-row (DR) suture anchor fixation in arthroscopic rotator cuff repair with a systematic review of the published literature. Methods: We searched all published literature from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials for the following key words: shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, arthroscopicassisted, single row, double row, and transosseous equivalent. The inclusion criteria were cohort studies (Levels I to III) that compared SR and DR suture anchor configuration for the arthroscopic treatment of full-thickness rotator cuff tears. The exclusion criteria were studies that lacked a comparison group, and, therefore, case series were excluded from the analysis. Results: There were 5 studies that met the criteria and were included in the final analysis: 5 in the SR group and 5 in the DR group. Data were abstracted from the studies for patient demographics, rotator cuff tear characteristics, surgical procedure, rehabilitation, range of motion, clinical scoring systems, and imaging studies. Conclusions: There are no clinical differences between the SR and DR suture anchor repair techniques for arthroscopic rotator cuff repairs. At present, the data in the published literature do not support the use of DR suture anchor fixation to improve clinical outcome, but there are some studies that report that DR suture anchor fixation may improve tendon healing. Level of Evidence: Level III, systematic review of Levels I to III studies. Key Words: Rotator cuff—Rotator cuff tear—Arthroscopic rotator cuff repair—Single row—Double row—Transosseous equivalent.

Loss of subscapularis function can be a significant complication after any surgery that involves its tenotomy. Recently, this complication has received more recognition after anterior approaches for shoulder replacement. It is unclear, however, whether this occurs in younger patients, and if so, how long it persists postoperatively. This study investigated the time it takes for subscapularis function to return after open tenotomy in young patients with instability. Sixteen consecutive patients underwent an anterior stabilization procedure for glenohumeral instability in which the subscapularis was taken down to perform an anterior capsular shift. Each patient was followed up prospectively for return of subscapularis function as determined by the belly-press and lift-off tests. The average time for subscapularis function to return was 8.4 weeks for the lift-off test and 8.8 weeks for the belly-press test. All patients had a negative belly-press test by 12 weeks and a negative lift-off test by 20 weeks.

This article examines the current literature reporting updates on trabeculectomy techniques, complications, and cost-effectiveness.Trabeculectomy continues to be the standard for glaucoma surgery when a low intraocular pressure is required. Recent publications describe technique modifications that successfully increase efficacy and lower complications. There is also an ongoing effort to define the role of trabeculectomy in the management of glaucoma from a cost and public health standpoint.The current literature continues to support the use of trabeculectomy as a method of lowering intraocular pressure in glaucoma management. Efficacy has been improved by ongoing surgical innovation, and reported complication rates are lower than those previously noted. Trabeculectomy has a favorable cost-benefit profile when compared with medical therapy or other surgical techniques. In spite of these ongoing changes, trabeculectomy appears to be decreasing in frequency in favor of newer surgeries and medications.

The purpose of this study was to describe the findings of MR imaging and radiographic changes that occur in osseous structures adjacent to soft-tissue hemangiomas of the extremities and to correlate them with patient symptomatology, the size of the hemangiomas, and their proximity to adjacent bone.We retrospectively reviewed the radiographs and MR images of 35 patients with soft-tissue hemangiomas of the extremities. The pattern and extent of the osseous change were categorized as periosteal, cortical, or medullary. Symptomatology, size, and proximity of the hemangioma to the adjacent bone were compared with the presence or absence of osseous change. Statistical analysis was performed using the Student's t test.Osseous change was noted on radiographs in 13 (37%) of 35 patients and on MR images in 11 (31%) of 35 patients with a total of 14 patients (40%) showing osseous change on at least one study. Periosteal change was present in eight (23%) of 35 patients; cortical change, in 11 (31%) of 35 patients; and medullary change, in 10 (29%) of 35 patients. Direct contact between the soft-tissue hemangioma and the adjacent bone was seen in 13 of 14 patients with osseous change. In those patients without osseous change, the average distance between the soft-tissue hemangioma and bone was 1.06 cm (range, 0-4 cm). No correlation was found between symptoms and the presence of osseous change.Soft-tissue hemangiomas of the extremities frequently result in adjacent osseous change that can be categorized as either periosteal, cortical, or medullary. Only medullary changes correspond with hemangioma size, whereas all three categories of change correlate with the proximity of the hemangioma to the adjacent bone. The presence of osseous change does not correlate with patient symptomatology.

To examine traumatic intraocular pressure (IOP) elevation and glaucoma after open-globe injury. Retrospective, observational case series. Review of patients with open-globe repair at the University of Washington from May 1997 through July 2010. Traumatic IOP elevation and glaucoma were defined respectively as intraocular pressure (IOP) ≥22 mm Hg at >1 visit or need for glaucoma medication, and long-term (at least 3 months) glaucoma medication use or glaucoma surgery. We included 515 eyes (515 patients). The mean follow-up was 12.6±20.1 months. One hundred twenty eyes (23.3%) developed traumatic IOP elevation, of which 32 (6.2%) developed glaucoma; six eyes (1.2%) required glaucoma surgery. The mean time to development of traumatic IOP elevation was 1.5±3.4 months (range 1 day to 2 years). Kaplan–Meier 6- and 12-month estimates for development of traumatic IOP elevation were 27.2 and 32.4%, respectively, and for development of traumatic glaucoma were 7.1 and 11.0%, respectively. Multivariate regression revealed associations between traumatic IOP elevation and older age, and traumatic glaucoma and prior penetrating keratoplasty, initial vitreous hemorrhage, Zone II injury, and penetrating keratoplasty after open-globe repair. Traumatic glaucoma was controlled (IOP

In this study, we used 3-dimensional analysis to comprehensively map the osseous morphology of the acetabulum. Human cadaveric specimens were dissected to the joint capsule for computer navigation analysis. Data points outlining acetabular anatomy-determined using optical sensors-were translated into graphical environments. A clock face template was laid over the transverse plane to determine the projections of acetabular arcs onto the transverse plane. A custom-written software program was used to compute the resulting surface area and was applied to the acetabular articular surface and the fossa. Two independent observers performed all measurements. Sixteen hips were included. Lateral center edge angle was 36.2° and femoral neck shaft angle was 131°. Mean arc lengths of the acetabular fossa from 3 o'clock (anterior) to 9 o'clock (posterior) were 26, 28, 28, 30, 29, 28, and 27 mm at 3, 2, 1, 12, 11, 10, and 9 o'clock, respectively. The smallest aspect of the acetabulum is the anterior aspect, and the largest is the superior (12 o'clock); the size increases progressively from anterior to superior. In most cases, the superior arc length, or sourcil, corresponds to the 2 o'clock position, and thus the lateral center edge angle may not necessarily correspond to the lateral aspect of the acetabulum.

When a patient who's physically active complains of hip pain, don't be too quick to label it a "hip pointer" that requires time and rest to heal. Consider this more nuanced-and effective-approach.

Purpose: To evaluate the correlation between lamina cribrosa (LC) morphology and glaucoma severity in patients with primary forms of open-angle glaucoma (OAG) using enhanced depth imaging spectral-domain optical coherence tomography (SD-OCT) and Humphrey visual field test (HVF). Subjects and Methods: Patients with OAG (n = 166), divided into normal-tension glaucoma (NTG) and high-tension glaucoma (HTG) groups (n = 66 and n = 100), were imaged using SD-OCT to obtain horizontal B-scan images of the optic nerve head (ONH). Laminar depth (LD) and laminar thickness (LT) were measured at the center of ONH. Results: The mean (±standard deviation) values of LD, LT, and visual field mean deviation (MD) were 555.4 ± 142.3 μm, 179.9 ± 49.7 μm, and − 5.7 ± 6.4 dB, respectively. In the multivariate linear regression analysis, LD, LT, and intraocular pressure (IOP) were significantly correlated with MD (P = 0.007, P = 0.037, and P = 0.004, respectively). In the subgroup analyses, only LD was associated with MD in the NTG group (n = 66), whereas LT and IOP were correlated with MD in the HTG group (n = 100). Neither axial length nor central corneal thickness was associated with LD or LT. Conclusions: Glaucoma severity, as measured by HVF MD, shows significant correlations with LD and LT, with greater severity associated with increasing LD and decreasing LT. Normal- and high-tension OAG patients have different associations with LD and LT, which implies that the pathogenesis of these two entities might be different.

The purpose of this study was to determine the most common causes of failed anterior cruciate ligament reconstruction (ACLR) using modern reconstructive techniques at a single, high-volume institution. In addition, the clinical outcomes of patients undergoing revision ACLR will be reported. The surgical logs of four senior knee surgeons were retrospectively reviewed for all patients who had undergone ACLR between 2002 and 2009. Patients were excluded if they did not have both the primary and revision surgery on the same knee with the same surgeon. Out of 1944 ACL reconstructions, 28 patients (56 reconstructions) were included in the study. Radiographic studies, operative reports, KT-1000 scores, and chart notes were used to identify all potential factors that may have led to failure. All patients were invited to return for a follow-up examination and survey. Of the 28 patients, the mean age at the index and revision procedure was 22 +/- 11 (range, 12 to 50) and 24 +/- 11 (range, 14 to 57), respectively. In 20 cases, the cause of failure was determined to be acute trauma (sports, work, or accident); in 1 case, the cause was biologic failure; while in 7 cases, the cause was technical error. During the study period the surgeons performed a combined total of 1944 procedures, for an overall failure rate of 1.8%. Twenty patients (71%) were available for follow-up at a mean 30.2 +/- 17.7 months. The overall postrevision outcomes were good to excellent for a majority of patients, with an average Lysholm score of 84 +/- 15.5 and International Knee Documentation Committee score of 77.2 +/- 13.8. The pre- and postoperative KT-1000 scores were 12.1 +/- 2.8 and 6.7 +/- 2.8, respectively. The results from this study suggest that traumatic re-injury, and not surgical/surgeon error, is the most common cause of ACLR failure using anatomic reconstructive principles and strong fixation. In addition, good to excellent outcomes following revision ACLR can be expected in the majority of patients.

Purpose To examine the development and management of glaucoma in patients with ocular chemical burns. Design Retrospective, observational case series. Methods setting: University of Washington Eye Clinics. patient population: Twenty-nine eyes (18 patients) with ocular chemical burns seen between 1997 and 2010 with a minimum of 3 months of follow-up. observation procedure: Eyes were graded using the Roper-Hall scale. main outcome measures: Long-term use of glaucoma medications (3 months or more) and need for glaucoma surgery. Results The mean age was 45 ± 17 years, with a mean follow-up of 75 ± 47 months (median, 66 months). Roper-Hall grade III or IV eyes (n = 20) had significantly higher intraocular pressure at presentation (35.9 vs 16.4 mm Hg; P = .001) and over follow-up were more likely to require long-term glaucoma medications (P = .003) or to undergo glaucoma surgery (P = .016) than Roper-Hall grade I or II eyes. Thirteen eyes (12 Roper-Hall grade III or IV) underwent glaucoma surgery. Eight eyes underwent glaucoma tube implant surgery; 4 required at least 1 revision. Seven eyes underwent diode laser cyclophotocoagulation; 4 required repeat treatment. Most (89%) eyes had controlled intraocular pressure at the last follow-up. However, 76% of eyes with visual acuity of 20/200 or worse at initial evaluation did not have improved vision at the last follow-up. Conclusions Eyes with Roper-Hall grade III or IV ocular chemical burns were more likely to have glaucoma and to require surgery for it. Outcomes of glaucoma management generally were good, although tube implant surgeries often had complications requiring revision.

Isolated, full-thickness chondral lesions of the glenohumeral joint remain significant problems for athletes, workers, and the elderly. Microfracture has been established as an effective therapeutic solution for such cartilage defects of the knee, because of its low surgical morbidity and ease as a first-line treatment with good clinical outcomes. Although the indications for microfracture and the surgical techniques are similar for cartilage injuries of the shoulder and knee joints, the literature includes no reviews of the use of microfracture in the humeral head or glenoid surface. Overall, microfracture is a minimally invasive, technically simple surgical procedure that provides an excellent option for patients with isolated full-thickness chondral defects. In this article, we describe the subtleties of microfracture in the glenohumeral joint and outline the clinical course of a typical patient.

Background Microfracture is an effective surgical treatment for isolated, full-thickness cartilage defects with current data focused on applications in the knee. No studies describing clinical outcomes of patients who have undergone microfracture in the shoulder joint have been reported. Hypothesis Treatment of glenohumeral joint articular defects using microfracture would demonstrate similar short-term clinical outcomes when compared with other joints. Study Design Case series; Level of evidence, 4. Methods From March 2001 to August 2007, 16 patients (17 shoulders) who underwent arthroscopic microfracture of the humeral head and/or glenoid surface were retrospectively reviewed. All patients were examined by an independent, blinded examiner and completed surveys containing the Simple Shoulder Test (SST), American Shoulder and Elbow Score (ASES), and visual analog scale (VAS). Results Two patients were lost to follow-up, for a follow-up rate of 88%. Three patients went on to subsequent shoulder surgery and were considered to have failed results. The mean age was 37.0 years (range, 18-55 years) with an average follow-up of 27.8 months (range, 12.1-89.2 months). The average size of humeral and glenoid defects was 5.07 cm2 (range, 1.0-7.84 cm2) and 1.66 cm2 (range, 0.4-3.75 cm2), respectively. There was a statistically significant decrease from 5.6 ± 1.7 to 1.9 ± 1.4 (P < .01) in VAS after surgery as well as statistically significant improvements (P < .01) in SST (5.7 ± 2.1 to 10.3 ± 1.3) and ASES (44.3 ± 15.3 to 86.3 ± 10.5). Twelve (92.3%) patients claimed they would have the procedure again. Conclusion Microfracture of the glenohumeral joint provides a significant improvement in pain relief and shoulder function in patients with isolated, full-thickness chondral injuries. Longer term studies are required to determine if similar results are maintained over time.

Chondrolysis is a devastating complication of surgery on any joint, resulting in the rapid and extensive destruction of the articular cartilage. Associated with this destruction is an equally large inflammatory response that causes adhesions in the lining of the involved joint. The inflammatory response manifests as arthrofibrosis and is typically seen within six months after the operation. Management of this unique complication is difficult because most patients are very young and have active lifestyles. Chondrolysis causes more immediate symptoms of pain and limited range of motion than does osteoarthritis, which often takes years to become symptomatic. The exact cause of postoperative chondrolysis is unknown; however, several hypotheses have been entertained, such as the use of thermal treatment1, occult infection with Propionibacterium acnes 2,3, idiopathic or iatrogenic osteochondral injury, high temperature of fluid during arthroscopic irrigation4, improperly placed implants, and the use of nonsteroidal anti-inflammatory medications. Recently, the use of intra-articular pain pumps for the administration of local anesthetics has come under scrutiny because of a possible association with early chondrolysis in the glenohumeral joint5-10. We are unaware, however, of any previously reported cases of chondrolysis in the knee associated with the use of an intra-articular pain pump. Here we report the case of a patient with chondrolysis of the knee; this case of our patient was clinically similar to several cases of patients with chondrolysis of the shoulder who had been referred for treatment at our institution. The patient and her parents were informed that data concerning the case would be submitted for publication, and they consented. A seventeen-year-old girl sustained anterior cruciate ligament and lateral meniscal tears during a tackling injury in a soccer game (Fig. 1). She underwent a routine anterior cruciate ligament reconstruction with use of …

BackgroundReported results of autologous chondrocyte implantation for chondral lesions in the patellofemoral joint have been encouraging when combined with realignment procedures.PurposeThe objective of this study was to examine the clinical results of a patient cohort undergoing autologous chondrocyte implantation of the patellofemoral joint and elucidate characteristics associated with successful implantation.Study DesignCase series; Level of evidence, 4.MethodsThe cohort included 62 patients who underwent autologous chondrocyte implantation of the PF joint. The mean defect size was 4.2 cm2 (61.6). The average age was 31.8 years (range, 15.8-49.4), and the average follow-up was 4 years (range, 2-7). Outcomes were assessed via clinical assessment and established outcome scales, including the Lysholm, International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Scale (KOOS; includes the 5 categories of Pain, Symptoms, Activities of Daily Living, Sport, and Quality of Life), Tegner, Cincinnati, and Short Form-12.ResultsMean improvement in the preoperative to postoperative scores was significant for the Lysholm (37-63, P 05). Patients undergoing anteromedialization tended toward better outcomes than those without realignment. Forty-four percent of patients needed a subsequent procedure. There were 4 clinical failures (7.7%), which were defined as progression to arthroplasty or conversion to osteochondral allograft transplantation.ConclusionAutologous chondrocyte implantation is a viable treatment option for chondral defects of the patellofemoral joint. Combined autologous chondrocyte implantation with anteromedialization improves outcomes more than autologous chondrocyte implantation alone. Patients with failed prior cartilage procedures can also expect sustained and clinically meaningful improvement.

Purpose The purpose of this systematic review was to critically evaluate the available literature in an attempt to compare the outcome of open versus arthroscopic distal clavicle resection in the treatment of acromioclavicular joint pathology. Methods From January 1966 to December 2008, Medline was searched for the following key words: "acromioclavicular joint arthritis," "acromioclavicular osteolysis," "distal clavicle excision," "acromioclavicular joint excision," "Mumford," and "clavicle." Inclusion criteria included studies that compared the outcome of open versus arthroscopic distal clavicle resection. Studies that could not be translated into the English language or were not published in a peer-reviewed journal were excluded. Data were abstracted from the studies, including patient demographics, surgical procedure, rehabilitation, strength, range of motion, and clinical scoring system. Results Seventeen studies met the inclusion criteria, including 2 Level II studies, 1 Level III and 14 Level IV studies. Arthroscopic distal clavicle excision results in more "good" or "excellent" outcomes compared with the open procedure. Both arthroscopic techniques result in success rates in excess of 90%, with the direct procedure permitting a quicker return to athletic activities. Performing distal clavicle excision in conjunction with either subacromial decompression or rotator cuff repair also has a high degree of success. A trend toward more "poor" results is seen when distal clavicle excision is performed in patients with post-traumatic acromioclavicular instability or in Workers' Compensation patients. Conclusions Our analysis suggests that among patients undergoing distal clavicle excision for acromioclavicular joint pathology, those having an arthroscopic procedure, specifically through the direct approach, can expect a faster return to activities while obtaining similar long-term outcomes compared with the open procedure. Level of Evidence Level III, systematic review.

Purpose: To evaluate the effect of screw length and diameter on the mechanical properties of biceps tenodesis (BT) with an interference screw in 2 different locations (proximal and distal). Methods: We randomized 42 fresh-frozen human cadaveric shoulders (mean age, 65 8 years) into 6 groups (n 7): arthroscopic proximal BT using 7 15–, 7 25–, 8 15–, or 8 25–mm interference screws or distal subpectoral BT with 7 15– or 8 15–mm interference screws. Each repaired specimen was mounted onto a materials testing machine, preloaded to 5 N for 2 minutes, cycled from 5 to 70 N for 500 cycles (1 Hz), and loaded to failure (1 mm/s). Displacement during cyclical loading, pullout stiffness, and ultimate load to failure were computed, and the mechanism of failure was noted. Results: All failures occurred at the tendon-screw interface. There was no statistically significant difference in ultimate displacement among all groups in the ultimate load to failure, displacement at peak load, and stiffness. Conclusions: There is no difference in ultimate load to failure, displacement at peak load, and stiffness of BT with regard to screw length or diameter at both proximal and distal tenodesis locations. These data would support use of a smaller-diameter and shorter implant for BT both proximally and distally. Clinical Relevance: The results may serve as a guide to the orthopaedic surgeon performing proximal BT in selecting the appropriate interference screw. When possible, we recommend using the smallest screw size available to minimize risk of stress fracture at the tenodesis site.

Hypothesis Patients with type II superior labrum, anterior to posterior (SLAP) lesions will have improved function and decreased pain at a minimum of 2 years after arthroscopic SLAP repair using bioabsorbable suture anchor fixation. Materials and methods The study population consisted of 48 patients who underwent arthroscopic SLAP repair. Subjective shoulder scores, range of motion, and strength (postoperative only) were assessed preoperatively and at a minimum of 2 years postoperatively. Results At an average of 3.4 years after surgery, statistically significant improvement was seen in American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, Simple Shoulder Test scores, Constant activities of daily living, visual analog scale for pain, and Short Form-12 Health Survey physical outcome scores. Improvements were made in forward flexion, abduction, external rotation, and internal rotation. Subgroup analysis of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes showed preoperative to postoperative improvements in subjective outcomes scores. Overhead laborers and nonlaborers also showed preoperative to postoperative improvements in subjective shoulder scores. Discussion No differences were seen between the outcomes of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes, suggesting that SLAP type II repair is successful independent of the patient's vocation or sport. Conclusion These results show that arthroscopic SLAP repair of type II lesions with bioabsorbable suture anchors provides a significant improvement in functional capacity and pain relief.

Purpose: The purpose of this study was to examine the results of arthroscopic debridement for isolated degenerative joint disease of the shoulder. Methods: We retrospectively identified 81 patients who had arthroscopic debridement to treat glenohumeral arthritis. Of these patients, 71 (88%) were available for follow-up. The preoperative Simple Shoulder Test score, American Shoulder and Elbow Surgeons score, Short Form 12 score, visual analog scale score for pain, and range of motion were recorded. These were compared against postoperative scores by use of the statistical paired t test. In addition, patients completed postoperative University of California, Los Angeles; Constant; and Single Assessment Numeric Evaluation scores. Forty-six preoperative radiographs were blindly evaluated and classified. Finally, the need for subsequent shoulder arthroplasty was recorded. Results: The mean follow-up for the 55 patients who did not progress to arthroplasty was 27 months. The mean preoperative and postoperative American Shoulder and Elbow Surgeons, Simple Shoulder Test, and pain visual analog scale scores all significantly improved (P .05). Furthermore, range of motion significantly improved (P .05) in flexion, abduction, and external rotation. Additional postoperative scores were as follows: University of California, Los Angeles, 28.3; Single Assessment Numeric Evaluation, 71.1; Constant score for affected shoulder, 72.0; and Constant score for unaffected shoulder, 78.5. Of the patients, 16 (22%) underwent arthroplasty at a mean of 10.1 months after debridement. Radiographic review showed that 13 shoulders with a mean joint space of 1.5 mm and grade 2.4 arthrosis went on to have shoulder arthroplasty. In contrast, 33 shoulders with a mean joint space of 2.6 mm and grade 1.9 arthrosis did not go on to have shoulder arthroplasty. Conclusions: Patients with residual joint space and an absence of large osteophytes can avoid arthroplasty and have increased function with decreased pain after arthroscopic debridement for degenerative joint disease. Significant risk factors for failure include the presence of grade 4 bipolar disease, joint space of less than 2 mm, and large osteophytes. Level of Evidence: Level IV, case series.