Publications by authors named "Brian Wolf"

210 Publications

Obesity and Sex Influence Fatty Infiltration of the Rotator Cuff: The ROW and MOON Cohorts.

J Shoulder Elbow Surg 2022 Jan 12. Epub 2022 Jan 12.

Departments of Physical Medicine and Rehabilitation, Orthopaedics, and Population & Data Sciences, University of Texas Southwestern, Dallas, TX, USA; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jse.2021.12.011DOI Listing
January 2022

PROMIS Versus Legacy Patient-Reported Outcome Measures for Sports Medicine Patients Undergoing Arthroscopic Knee, Shoulder, and Hip Interventions: A Systematic Review.

Iowa Orthop J 2021 12;41(2):58-71

Department of Orthopedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS®) was designed to monitor the global wellbeing of patients, with the Physical Function Computer-Adaptive Test (PF-CAT) component focused specifically on functional outcome. PROMIS aims for increased item-bank accuracy, lower administrative burden, and decreased floor and ceiling effects compared to legacy patient-reported outcome measures (PROMs). Our primary research outcomes focused on sports medicine surgical populations, which may skew younger or have wide-ranging functional statuses. Specifically, for this population, we questioned if PROMIS PF-CAT was equal to legacy PROMs in (1) construct validity and (2) convergent/divergent validities; and superior to legacy PROMs with respect to (3) survey burden and (4) floor and ceiling effects.

Methods: Searches were performed in April 2019 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilizing PubMed, Cochrane Central, and Embase databases for Level I-III evidence. This resulted in 541 records, yielding 12 studies for inclusion. PROM data was available for patients undergoing arthroscopic orthopaedic procedures of the knee, shoulder, and hip. Measures of construct validity, convergent/divergent validity, survey burden, and floor/ceiling effects were evaluated for PROMIS PF-CAT versus legacy PROMs.

Results: PROMIS PF-CAT demonstrated excellent or excellent-good correlation with legacy PROMS for physical function and quality of life for patients undergoing arthroscopic interventions of the knee, shoulder, and hip. Compared to legacy PROM instruments, PROMIS PF-CAT demonstrated the lowest overall survey burden and had the lowest overall number of floor or ceiling effects across participants.

Conclusion: PROMIS PF-CAT is an accurate, efficient evaluation tool for sports medicine surgical patients. PROMIS PF-CAT strongly correlates with legacy physical function PROMs while having a lower test burden and less incidence of floor and ceiling effects. PROMIS PF-CAT may be an optimal alternative for traditional physical function PROMs in sports medicine patients undergoing arthroscopic procedures. Further studies are required to extend the generalizability of these findings to patients during postoperative timepoints after shoulder and hip interventions III.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8662933PMC
December 2021

Periarticular Local Infiltrative Anesthesia and Regional Adductor Canal Block Provide Equivalent Pain Relief After Anterior Cruciate Ligament Reconstruction.

Arthroscopy 2021 Nov 19. Epub 2021 Nov 19.

Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, U.S.A.. Electronic address:

Purpose: To compare postoperative pain and recovery after anterior cruciate ligament reconstruction (ACLR) in patients who received an adductor canal block (ACB) or periarticular local infiltrative anesthesia (LIA).

Methods: A retrospective review of a prospectively collected ACL registry was performed. Patients underwent ACLR at a single institution between January 2015 and September 2020 and received long-acting local anesthesia with a preoperative ultrasound-guided ACB or periarticular LIA after surgery. Visual analog scale (VAS) pain scores, milligram morphine equivalents (MME) consumed in the post-anesthesia care unit (PACU), and total hospital recovery time were compared. Univariate analysis was used to compare VAS pain and MME totals between overall groups and groups propensity score matched for age, sex, body mass index, graft type, and meniscal treatment. Results are presented as mean (95%CI) unless otherwise indicated.

Results: There were 265 knees (253 patients) included (LIA, 157 knees; ACB, 108 knees). Overall, VAS pain scores before hospital discharge (LIA: 2.6 [2.4-2.8] vs ACB: 2.4 [2.1-2.7]; P = .334) and total MMEs were similar (LIA: 17.6 [16.4-18.8] vs ACB: 18.5 [17.2-19.8] (MME); P =.134). Median time to discharge also did not significantly differ (LIA: 137.5 [IQR: 116-178] vs. ACB: 147 [IQR: 123-183] (min); P = .118). Matched subanalysis (LIA and ACB; n = 94) did not reveal significant differences in VAS pain before discharge (LIA: 2.4 [2.1-2.7] vs ACB: 2.7 [2.4-3.0]; P = .134) or total MMEs (LIA: 18.6 (17.2-20.0) vs ACB: 17.9 (16.4-19.4); P = .520).

Conclusion: The use of ACB or LIA resulted in similar early pain levels, opioid consumption, and hospital recovery times after ACLR surgery.

Level Of Evidence: III, retrospective comparison study.
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http://dx.doi.org/10.1016/j.arthro.2021.10.031DOI Listing
November 2021

Team Approach: Treatment of Shoulder Instability in Athletes.

JBJS Rev 2021 11 10;9(11). Epub 2021 Nov 10.

University of Iowa Sports Medicine, Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa.

»: Shoulder instability is a complex problem with a high rate of recurrence in athletes. Treatment of a first-time subluxation or dislocation event is controversial and depends on patient-specific factors as well as the identified pathology.

»: Athletic trainers and physical therapists are an integral part of the treatment team of an in-season athlete who has experienced a shoulder instability event. Through comprehensive physiological assessments, these providers can effectively suggest modifications to the patient's training regimen as well as an appropriate rehabilitation program.

»: Surgical intervention for shoulder stabilization should use an individualized approach for technique and timing.

»: A team-based approach is necessary to optimize the care of this high-demand, high-risk population.
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http://dx.doi.org/10.2106/JBJS.RVW.21.00087DOI Listing
November 2021

Subacromial Decompression in Patients With Shoulder Impingement With an Intact Rotator Cuff: An Expert Consensus Statement Using the Modified Delphi Technique Comparing North American to European Shoulder Surgeons.

Arthroscopy 2021 Oct 14. Epub 2021 Oct 14.

Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia; Orthopaedic Research Centre of Australia, Sydney, Australia.

Purpose: To perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American with European shoulder surgeon preferences.

Methods: Nineteen surgeons from North America (North American panel [NAP]) and 18 surgeons from Europe (European panel [EP]) agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤60% for an item, the results were carried forward into round 4. For round 4, the panel members outside consensus (>60%, <80%) were contacted and asked to review their response. The level of agreement and consensus was defined as 80%.

Results: There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the workup; magnetic resonance imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of nonoperative treatment for a minimum of 6 months. The NAP was likely to routinely prescribe nonsteroidal anti-inflammatory drugs (NAP 89%; EP 35%) and consider steroids for impingement (NAP 89%; EP 65%).

Conclusions: Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of no-operative treatment for a minimum of 6 months. The panel also agreed that subacromial decompression is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to nonsurgical measures.

Level Of Evidence: Level V, expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2021.09.031DOI Listing
October 2021

Anterior Cruciate Ligament Reconstruction With Concomitant Meniscal Repair: Is Graft Choice Predictive of Meniscal Repair Success?

Orthop J Sports Med 2021 Sep 14;9(9):23259671211033584. Epub 2021 Sep 14.

CU Sports Medicine, Boulder, Colorado, USA.

Background: When meniscal repair is performed during anterior cruciate ligament (ACL) reconstruction (ACLR), the effect of ACL graft type on meniscal repair outcomes is unclear.

Hypothesis: The authors hypothesized that meniscal repairs would fail at the lowest rate when concomitant ACLR was performed with bone--patellar tendon--bone (BTB) autograft.

Study Design: Cohort study; Level of evidence, 3.

Methods: Patients who underwent meniscal repair at primary ACLR were identified from a longitudinal, prospective cohort. Meniscal repair failures, defined as any subsequent surgical procedure addressing the meniscus, were identified. A logistic regression model was built to assess the association of graft type, patient-specific factors, baseline Marx activity rating score, and meniscal repair location (medial or lateral) with repair failure at 6-year follow-up.

Results: A total of 646 patients were included. Grafts used included BTB autograft (55.7%), soft tissue autograft (33.9%), and various allografts (10.4%). We identified 101 patients (15.6%) with a documented meniscal repair failure. Failure occurred in 74 of 420 (17.6%) isolated medial meniscal repairs, 15 of 187 (8%) isolated lateral meniscal repairs, and 12 of 39 (30.7%) of combined medial and lateral meniscal repairs. Meniscal repair failure occurred in 13.9% of patients with BTB autografts, 17.4% of patients with soft tissue autografts, and 19.4% of patients with allografts. The odds of failure within 6 years of index surgery were increased more than 2-fold with allograft versus BTB autograft (odds ratio = 2.34 [95% confidence interval, 1.12-4.92]; = .02). There was a trend toward increased meniscal repair failures with soft tissue versus BTB autografts (odds ratio = 1.41 [95% confidence interval, 0.87-2.30]; = .17). The odds of failure were 68% higher with medial versus lateral repairs ( < .001). There was a significant relationship between baseline Marx activity level and the risk of subsequent meniscal repair failure; patients with either very low (0-1 points) or very high (15-16 points) baseline activity levels were at the highest risk ( = .004).

Conclusion: Meniscal repair location (medial vs lateral) and baseline activity level were the main drivers of meniscal repair outcomes. Graft type was ranked third, demonstrating that meniscal repairs performed with allograft were 2.3 times more likely to fail compared with BTB autograft. There was no significant difference in failure rates between BTB versus soft tissue autografts.

Registration: NCT00463099 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/23259671211033584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445540PMC
September 2021

Articular Cartilage and Meniscus Predictors of Patient-Reported Outcomes 10 Years After Anterior Cruciate Ligament Reconstruction: A Multicenter Cohort Study.

Am J Sports Med 2021 09 29;49(11):2878-2888. Epub 2021 Jul 29.

Department of Orthopaedics, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Background: Articular cartilage and meniscal damage are commonly encountered and often treated at the time of anterior cruciate ligament reconstruction (ACLR). Our understanding of how these injuries and their treatment relate to outcomes of ACLR is still evolving.

Hypothesis/purpose: The purpose of this study was to assess whether articular cartilage and meniscal variables are predictive of 10-year outcomes after ACLR. We hypothesized that articular cartilage lesions and meniscal tears and treatment would be predictors of the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level outcomes at 10-year follow-up after ACLR.

Study Design: Cohort study (prognosis); Level of evidence, 1.

Methods: Between 2002 and 2008, individuals with ACLR were prospectively enrolled and followed longitudinally using the IKDC, KOOS, and Marx activity score completed at entry, 2, 6, and 10 years. A proportional odds logistic regression model was built incorporating variables from patient characteristics, surgical technique, articular cartilage injuries, and meniscal tears and treatment to determine the predictors (risk factors) of IKDC, KOOS, and Marx outcomes at 10 years.

Results: A total of 3273 patients were enrolled (56% male; median age, 23 years at time of enrollment). Ten-year follow-up was obtained on 79% (2575/3273) of the cohort. Incidence of concomitant pathology at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 22%; lateral femoral condyle [LFC], 15%; medial tibial plateau [MTP], 4%; lateral tibial plateau [LTP], 11%; patella, 18%; trochlea, 8%) and meniscal pathology (medial, 37%; lateral, 46%). Variables that were predictive of poorer 10-year outcomes included articular cartilage damage in the patellofemoral ( < .01) and medial ( < .05) compartments and previous medial meniscal surgery (7% of knees; < .04). Compared with no meniscal tear, a meniscal injury was not associated with 10-year outcomes. Medial meniscal repair at the time of ACLR was associated with worse 10-year outcomes for 2 of 5 KOOS subscales, while a medial meniscal repair in knees with grade 2 MFC chondrosis was associated with better outcomes on 2 KOOS subscales.

Conclusion: Articular cartilage injury in the patellofemoral and medial compartments at the time of ACLR and a history of medial meniscal surgery before ACLR were associated with poorer 10-year ACLR patient-reported outcomes, but meniscal injury present at the time of ACLR was not. There was limited and conflicting association of medial meniscal repair with these outcomes.
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http://dx.doi.org/10.1177/03635465211028247DOI Listing
September 2021

Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort.

Am J Sports Med 2021 08 14;49(10):2589-2598. Epub 2021 Jul 14.

University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.

Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.

Study Design: Cohort study; Level of evidence, 2.

Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.

Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores ( = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized ( = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts ( = .87) or between BTB autografts and soft tissue allografts ( = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft ( = .010; OR, 0.56; 95% CI, 0.36-0.87).

Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.
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http://dx.doi.org/10.1177/03635465211027170DOI Listing
August 2021

Beach Chair Versus Lateral Decubitus Position: Differences in Suture Anchor Position and Number During Arthroscopic Anterior Shoulder Stabilization.

Am J Sports Med 2021 07 21;49(8):2020-2026. Epub 2021 May 21.

University of Iowa, UI Sports Medicine, Iowa City, Iowa, USA.

Background: Arthroscopic shoulder capsulolabral repair using glenoid-based suture anchor fixation provides consistently favorable outcomes for patients with anterior glenohumeral instability. To optimize outcomes, inferior anchor position, especially at the 6-o'clock position, has been emphasized. Proponents of both the beach-chair (BC) and lateral decubitus (LD) positions advocate that this anchor location can be consistently achieved in both positions.

Hypothesis: Patient positioning would be associated with the surgeon-reported labral tear length, total number of anchors used, number of anchors in the inferior glenoid, and placement of an anchor at the 6-o'clock position.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: This study was a cross-sectional analysis of a prospective multicenter cohort of patients undergoing primary arthroscopic anterior capsulolabral repair. Patient positioning in the BC versus LD position was determined by the operating surgeon and was not randomized. At the time of operative intervention, surgeon-reported labral tear length, total anchor number, anchor number in the inferior glenoid, and anchor placement at the 6-o'clock position were evaluated between BC and LD cohorts. Descriptive statistics and between-group differences (continuous: test [normal distributions], Wilcoxon rank sum test [nonnormal distributions], and chi-square test [categorical]) were assessed.

Results: In total, 714 patients underwent arthroscopic anterior capsulolabral repair (BC vs LD, 406 [56.9%] vs 308 [43.1%]). The surgeon-reported labral tear length was greater for patients having surgery in the LD position (BC vs LD [mean ± SD], 123.5°± 49° vs 132.3°± 44°; = .012). The LD position was associated with more anchors placed in the inferior glenoid and more frequent placement of anchors at the 6-o'clock (BC vs LD, 22.4% vs 51.6%; < .001). The LD position was more frequently associated with utilization of ≥4 total anchors (BC vs LD, 33.5% vs 46.1%; < .001).

Conclusion: Surgeons utilizing the LD position for arthroscopic capsulolabral repair in patients with anterior shoulder instability more frequently placed anchors in the inferior glenoid and at the 6-o'clock position. Additionally, surgeon-reported labral tear length was longer when utilizing the LD position. These results suggest that patient positioning may influence the total number of anchors used, the number of anchors used in the inferior glenoid, and the frequency of anchor placement at the 6 o'clock position during arthroscopic capsulolabral repair for anterior shoulder instability. How these findings affect clinical outcomes warrants further study.

Registration: NCT02075775 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/03635465211013709DOI Listing
July 2021

The Impact of Resident Involvement on Postoperative Complications After Shoulder Arthroscopy: A Propensity-Matched Analysis.

J Am Acad Orthop Surg Glob Res Rev 2020 09;4(9):e20.00138

From the Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA.

Purpose: Shoulder arthroscopy is the second most frequently performed procedure by orthopaedic surgeons taking the American Board of Orthopaedic Surgery part II examination. However, the impact of resident involvement on outcomes after shoulder arthroscopy is poorly understood. The aim of this study was to investigate whether resident involvement in shoulder arthroscopic procedures affects postoperative complication rates and surgical time using propensity score-matched cohorts.

Methods: The American College of Surgeons National Surgical Quality Improvement Program registry was queried to identify patients who underwent common shoulder arthroscopic procedures between 2006 and 2012. Cases without information on resident involvement, treatment of septic arthritis or osteomyelitis of the shoulder, or concomitant open or miniopen procedures were excluded from the study. A 1:1 propensity score match was used based on demographic and comorbidity factors to match cases with resident involvement to nonresident cases. Patient demographics, comorbidities, surgical time, length of hospital stay, and 30-day postoperative complications were compared between the two groups.

Results: Overall, 15,857 patients who underwent shoulder arthroscopy were identified. After propensity score matching, 3474 cases (50% with resident involvement) were included. Appropriate matching was verified with no difference in demographic or health characteristics. No significant differences in the overall rate of 30-day complications was noted in resident-involved versus nonresident group (P = 0.576). No significant difference was observed in postoperative surgical or medical complications. Resident involvement was significantly longer surgical time (75.9 ± 35.9 versus 75.1 ± 40.5 minutes, P = 0.03) when compared with cases performed without a resident.

Conclusions: Resident involvement in shoulder arthroscopy is not associated with increased risk for medical or surgical 30-day postoperative complications. Resident participation in shoulder arthroscopy cases did increase surgical time; however, this finding is likely clinically insignificant.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494138PMC
September 2020

Return to Sport After Anterior Cruciate Ligament Reconstruction in a Cohort of Division I NCAA Athletes From a Single Institution.

Orthop J Sports Med 2021 Feb 19;9(2):2325967120982281. Epub 2021 Feb 19.

Department of Orthopaedic Surgery, University of Iowa Health Care, Iowa City, Iowa, USA.

Background: Anterior cruciate ligament (ACL) tears are common in collegiate athletes. The rate of return to the preinjury level of sport activities after ACL reconstruction continues to evolve.

Purpose/hypothesis: The purpose was to determine the return-to-sport rate after ACL reconstruction in a cohort of National Collegiate Athletic Association Division I athletes in different sports. It was hypothesized that, with intensive supervision of rehabilitation, the return-to-sport rate would be optimal.

Study Design: Case series; Level of evidence, 4.

Methods: We retrospectively reviewed the records of 75 collegiate athletes from a single institution who had undergone unilateral or bilateral ACL reconstruction between 2001 and 2013 and participated in an extensive supervised rehabilitation program. Prospectively collected athlete data as well as data about preinjury exposure, associated lesions, surgical technique, time lost to injury, number of games missed, time to return to full sport activity or retire, and subsequent surgical procedures were extracted from the medical and athletic trainer records.

Results: The 75 patients (40 male, 35 female; mean age, 20.1 years) underwent 81 reconstruction procedures (73 primary, 8 revision). The mean follow-up was 19.3 months. The overall return-to-sport rate was 92%. After reconstruction, 9 athletes (12%) retired from collegiate sports, but 3 of them returned to sport activities after graduation. Overall, 8 athletes (11%) experienced an ACL graft retear.

Conclusion: The return-to-sport rate in our National Collegiate Athletic Association Division I athletes compared favorably with that reported in other studies in the literature. The strict follow-up by the surgeon, together with the high-profile, almost daily technical and psychological support given mainly by the athletic trainers during the recovery period, may have contributed to preparing the athletes for a competitive rate of return to sport at their preinjury level.
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http://dx.doi.org/10.1177/2325967120982281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900794PMC
February 2021

Familial thrombocytopenia flare-up following the first dose of mRNA-1273 Covid-19 vaccine.

Am J Hematol 2021 05 1;96(5):E134-E135. Epub 2021 Mar 1.

Department of Hematology and Oncology, Maimonides Medical Center, Brooklyn, New York, USA.

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http://dx.doi.org/10.1002/ajh.26128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014325PMC
May 2021

Male Sex, Western Ontario Shoulder Instability Index Score, and Sport as Predictors of Large Labral Tears of the Shoulder: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

Arthroscopy 2021 06 15;37(6):1740-1744. Epub 2021 Jan 15.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA.

Purpose: To identify factors predictive of a large labral tear at the time of shoulder instability surgery.

Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects.

Results: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007).

Conclusions: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf.

Level Of Evidence: I, prognostic study.
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http://dx.doi.org/10.1016/j.arthro.2021.01.007DOI Listing
June 2021

PROMIS is a Valid Patient-Reported Outcome Measure for Patients undergoing ACL Reconstruction with Multi-ligament Knee Reconstruction and Repair Procedures.

Knee 2021 Jan 14;28:294-299. Epub 2021 Jan 14.

University of Iowa Department of Orthopedics and Rehabilitation, Iowa City, IA, 52246, United States.

Background: This study aimed to (1) compare PROMIS with previously validated legacy instruments and (2) to assess between group differences of PROMIS PF-CAT [Physical Function Computer Adaptive Test] for patients undergoing isolated primary ACL reconstruction [ACLR] vs. primary ACL reconstruction with additional ligamentous intervention [MLIK].

Level Of Evidence: II; Prospective Cohort Study.

Methods: At a single preoperative timepoint, 42 [MLIK] and 73[ACLR] patients completed: Short Form 36 Health Survey (SF-36) Mental (MCS) and Physical Component Summary (PCS), Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol-5 dimensions (EQ-5D) and Marx Knee Scale. Spearman correlation coefficients (non-parametric data) assessed correlations between PROMIS PF-CAT and legacy PROs [Patient-Reported Outcome instruments]. Floor and ceiling effects were assessed using chi-square tests. Between group differences were assessed (Wilcoxon Rank sum test).

Results: PROMIS PF-CAT for the MLIK cohort [Table 2] demonstrated an excellent-good correlation with SF-36 Physical Function (PCS; r = 0.64, p < 0.01), EQ-5D (r = 0.68, p < 0.01), and KOOS Quality of Life (QOL) (r = 0.68, p < 0.01); good correlation with KOOS ADL (r = 0.52, p = 0.01), KOOS Sports (r = 0.44, p < 0.01), KOOS Pain (r = 0.44, p < 0.01) and WOMAC Function (r = 0.52,p = 0.01). PROMIS PF-CAT scores differed for ACL vs. MLIK cohorts (41.9 ± 6.6 vs. 37.6 ± 9.0, p < 0.01). PROMIS PF-CAT demonstrated the fewest floor and ceiling effects [Table 4] versus legacy PRO instruments.

Conclusion: PROMIS PF-CAT demonstrated strong correlations with previously validated PRO instruments and offers a favorable alternative for patients undergoing ACLR with MLIK repair/reconstruction procedures. Preoperative PROMIS PF-CAT scores were greater for patients undergoing primary ACLR versus MLIK intervention.
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http://dx.doi.org/10.1016/j.knee.2020.12.012DOI Listing
January 2021

Estimation of Location and Extent of Labral Tear Based on Preoperative Range of Motion in Patients Undergoing Arthroscopic Stabilization for Anterior Shoulder Instability.

Arthrosc Sports Med Rehabil 2020 Dec 16;2(6):e711-e721. Epub 2020 Nov 16.

Department of Orthopedics, Division of Sports Medicine and Shoulder Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.

Purpose: To determine whether range of motion (ROM) varies with the location and extent of labral tear seen in patients undergoing arthroscopic anterior shoulder stabilization.

Methods: Consecutive patients undergoing arthroscopic anterior shoulder stabilization who were enrolled in the Multicenter Orthopaedic Outcomes Network Shoulder Instability database underwent a preoperative physical examination and intraoperative examination under anesthesia in which ROM was recorded. Intraoperatively, the location and extent of the labral tear was recorded using conventional clock-face coordinates. Patients were grouped by combinations of quadrants involved in the labral tear (G1-G7): G1 = anterior only, G2 = anterior + inferior, G3 = anterior + inferior + posterior, G4 = all quadrants, G5 = superior + anterior, G6 = superior + anterior + inferior, and G7 = posterior + superior + anterior. Statistical analyses were performed with the Kruskal-Wallis rank-sum test. When < .05, a post-hoc Dunn's test was performed. For categorical variables, the χ test was performed. We performed a series of bivariate negative binomial regression models testing pairwise combinations of ROM parameters predicting the count of labral tear locations (possible: 0-5) within each quadrant.

Results: A total of 467 patients were included, with 13 (2.8%) in G1, 221 (47.3%) in G2, 40 (8.6%) in G3, 51 (10.9%) in G4, 18 (3.9%) in G5, 121 (25.9%) in G6, and 3 (0.6%) in G7. Multiple statistically significant differences were noted in ROM, specifically active internal rotation at side (IRS) ( = .005), active abduction ( = .02), passive IRS ( = .02), and passive external rotation in abduction ( = .0007). Regression modeling revealed a positive correlation between passive abduction and predicted count of labral tear locations in the superior quadrant and between passive IRS and predicted count of labral tear location in the inferior quadrant.

Conclusions: In patients undergoing arthroscopic shoulder stabilization for anterior instability, ROM varies with location and extent of labral tear. However, the clinical relevance of such small ROM differences remains undetermined.

Level Of Evidence: II, prospective comparative study.
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http://dx.doi.org/10.1016/j.asmr.2020.05.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754526PMC
December 2020

What Are the Effects of Remplissage on 6-Month Strength and Range of Motion After Arthroscopic Bankart Repair? A Multicenter Cohort Study.

Orthop J Sports Med 2020 Feb 27;8(2):2325967120903283. Epub 2020 Feb 27.

Investigation performed at The Ohio State University Wexner Medical Center, Department of Orthopaedics, Columbus, Ohio, USA.

Background: Patients who have undergone shoulder instability surgery are often allowed to return to sports, work, and high-level activity based largely on a time-based criterion of 6 months postoperatively. However, some believe that advancing activity after surgery should be dependent on the return of strength and range of motion (ROM).

Hypothesis: There will be a significant loss of strength or ROM at 6 months after arthroscopic Bankart repair with remplissage compared with Bankart repair alone.

Study Design: Cohort study; Level of evidence, 2.

Methods: A total of 38 patients in a prospective multicenter study underwent arthroscopic Bankart repair with remplissage (33 males, 5 females; mean age, 27.0 ± 10.2 years; 82% with ≥2 dislocation events in the past year). Strength and ROM were assessed preoperatively and at 6 months after surgery. Results were compared with 104 matched patients who had undergone Bankart repair without remplissage, although all had radiographic evidence of a Hill-Sachs defect.

Results: At 6 months, there were no patients in the remplissage group with anterior apprehension on physical examination. However, 26% had a ≥20° external rotation (ER) deficit with the elbow at the side, 42% had a ≥20° ER deficit with the elbow at 90° of abduction, and 5% had persistent weakness. Compared with matched patients who underwent only arthroscopic Bankart repair, the remplissage group had greater humeral bone loss and had a greater likelihood of a ≥20° ER deficit with the elbow at 90° of abduction ( = .004). Risk factors for a ≥20° ER deficit with the elbow at 90° of abduction were preoperative stiffness in the same plane ( = .02), while risk factors for a ≥20° ER deficit with the elbow at the side were increased number of inferior quadrant glenoid anchors ( = .003), increased patient age ( = .02), and preoperative side-to-side deficits in ER ( = .04). The only risk factor for postoperative ER weakness was preoperative ER weakness ( = .04), with no association with remplissage ( = .26).

Conclusion: Arthroscopic Bankart repair with remplissage did not result in significant strength deficits but increased the risk of ER stiffness in abduction compared with Bankart repair without remplissage at short-term follow-up.
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http://dx.doi.org/10.1177/2325967120903283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686606PMC
February 2020

Increased Prevalence and Associated Costs of Psychiatric Comorbidities in Patients Undergoing Sports Medicine Operative Procedures.

Arthroscopy 2021 02 24;37(2):686-693.e1. Epub 2020 Oct 24.

University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.

Purpose: To evaluate the prevalence of preoperatively diagnosed psychiatric comorbidities and the impact of these comorbidities on the healthcare costs of ten common orthopaedic sports medicine procedures.

Methods: Patients undergoing 10 common sports medicine procedures from 2007 to 2017q1 were identified using the Humana claims database. These procedures included anterior cruciate ligament reconstruction; posterior cruciate ligament reconstruction; medial collateral ligament repair/reconstruction; Achilles repair/reconstruction; Rotator cuff repair; meniscectomy/meniscus repair; hip arthroscopy; arthroscopic shoulder labral repair; patellofemoral instability procedures; and shoulder instability repair. Patients were stratified by preoperative diagnoses of depression, anxiety, bipolar disorder, or schizophrenia. Cohorts included patients with ≥1 psychiatric comorbidity (psychiatric) versus those without psychiatric comorbidities (no psychiatric). Differences in costs across groups were compared using Mann-Whitney U tests, with significance defined as P < .05. Linear regression analysis was used to assess rates of procedures per year from 2006 to 2016.

Results: In total, 226,402 patients (57.7% male) from 2007 to 2017q1 were assessed. The prevalence of ≥1 psychiatric comorbidity within the entire database was 10.31% (reference) versus 21.21% in those patients undergoing the 10 investigated procedures. Patients with psychiatric comorbidity most frequently underwent rotator cuff repair (28%), hip labral repair (26.3%) and meniscectomy/meniscus repair (25.0%%) had ≥1 psychiatric comorbidity. Compared with the no psychiatric cohort, diagnosis of ≥1 psychiatric comorbidity was associated with increased health care costs for all 10 sports medicine procedures ($9678.81 vs $6436.20, P < .0001).

Conclusions: The prevalence of preoperatively diagnosed psychiatric comorbidities among patients undergoing orthopaedic sports medicine procedures is high. The presence of psychiatric comorbidities preoperatively was associated with increased postoperative costs following all investigated orthopaedic sports medicine procedures.

Level Of Evidence: Level III; retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2020.10.032DOI Listing
February 2021

"Ossifying" mucoepidermoid carcinoma: A deceptive clinical presentation.

Oral Surg Oral Med Oral Pathol Oral Radiol 2021 Feb 16;131(2):217-220. Epub 2020 Oct 16.

Oral and Maxillofacial Surgery Department Director, Nassau University Medical Center, East Meadow, NY, USA.

Mucoepidermoid carcinoma is the most common salivary gland malignancy, accounting for 27% of all salivary gland cancers. Identified in 1921 and first analyzed in 1945, mucoepidermoid carcinoma has demonstrated a widely diverse histology with several morphologic variants having been described. One rare feature is the formation of intratumoral bone, which has been previously reported once in the English language literature. Though the etiology of these calcifications is still not known, it is believed that this finding is independent of overall disease prognosis. This case report illustrates this unusual feature in a 48-year-old Hispanic woman who initially presented with a floor of mouth swelling. Computed tomography examination subsequently revealed a soft tissue mass with intralesional radiopacities. Despite its relative rarity, it is important for practitioners to be aware of this unique presentation in that it may help to avoid misdiagnosis and delays in treatment.
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http://dx.doi.org/10.1016/j.oooo.2020.10.011DOI Listing
February 2021

Are there racial differences between patients undergoing surgery for shoulder instability? Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Group.

J Shoulder Elbow Surg 2021 Feb 6;30(2):229-236. Epub 2020 Nov 6.

Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA.

Background: The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability.

Methods: Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient's home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery.

Results: Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%.

Conclusion: We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.
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http://dx.doi.org/10.1016/j.jse.2020.09.043DOI Listing
February 2021

Ultrasound-aided Diagnosis of a Symptomatic Bennett Lesion in a Collegiate Baseball Pitcher.

Curr Sports Med Rep 2020 Nov;19(11):454-456

Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.

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http://dx.doi.org/10.1249/JSR.0000000000000769DOI Listing
November 2020

Rate of infection following revision anterior cruciate ligament reconstruction and associated patient- and surgeon-dependent risk factors: Retrospective results from MOON and MARS data collected from 2002 to 2011.

J Orthop Res 2021 02 19;39(2):274-280. Epub 2020 Oct 19.

Bridger Orthopedic and Sports Medicine, Bozeman, Montana, USA.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon-dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting postoperative infections. Allografts had a higher risk of infection than autografts (odds ratio, 6.8; 95% CI, 0.9-54.5; p = .045). Diabetes (odds ratio, 28.6; 95% CI, 5.5-149.9; p = .004) was a risk factor for infection. Patient age, sex, BMI, and smoking status were not associated with risk of infection after rACLR.
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http://dx.doi.org/10.1002/jor.24871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854959PMC
February 2021

Meniscal Repair in the Setting of Revision Anterior Cruciate Ligament Reconstruction: Results From the MARS Cohort.

Am J Sports Med 2020 10 21;48(12):2978-2985. Epub 2020 Aug 21.

All authors are listed in the Authors section at the end of this article.

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented.

Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting.

Study Design: Case-control study; Level of evidence, 3.

Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment.

Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction.

Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both <10% and consistent with success rates of primary ACL reconstruction meniscal repair. Medial tears underwent reoperation for failure at a significantly higher rate than lateral tears.
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http://dx.doi.org/10.1177/0363546520948850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8171059PMC
October 2020

Clinical Outcomes After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Clinical Outcomes Consensus Group.

Orthop J Sports Med 2020 Jul 23;8(7):2325967120934751. Epub 2020 Jul 23.

Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA.

A stringent outcome assessment is a key aspect of establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. To establish a standardized assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, Pennsylvania, USA, in June 2019. The aim was to establish a consensus on what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used, and at what follow-up time those outcomes should be assessed. The group reached consensus on 9 statements by using a modified Delphi method. In general, outcomes after ACL treatment can be divided into 4 robust categories: early adverse events, patient-reported outcomes (PROs), ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. A comprehensive assessment after ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained reinjuries, validated knee-specific PROs, and health-related quality of life questionnaires. In the midterm to long-term follow-up, the presence of osteoarthritis should be evaluated. This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment.
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http://dx.doi.org/10.1177/2325967120934751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378729PMC
July 2020

Return to Collegiate Athletics After Distal Femoral Osteotomy: A Report of Three Cases and Review of the Literature.

Iowa Orthop J 2020 ;40(1):143-146

University of Iowa, Department of Orthopedics and Reabilitation, Iowa City, IA.

Background: The authors present three cases of high-level athletes with successful return to competitive collegiate athletics following distal femoral osteotomy for knee lateral compartment overload.

Conclusion: Distal femoral varus osteotomy (DFO) is used to treat valgus knee malalignment and to offload the lateral knee compartment in the setting of symptomatic cartilage or meniscus pathology. DFO can be considered a viable treatment for collegiate athletes, with satisfactory outcomes and ability to return to sport participation at pre-injury functional levels..
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368529PMC
February 2021

Anterior Cruciate Ligament Reconstruction: A Comparative Clinical Study Between Adjustable and Fixed Length Suspension Devices.

Iowa Orthop J 2020 ;40(1):121-127

Brigham and Women's Hospital, Department of Orthopaedic Surgery, Boston, MA.

Background: Adjustable-length cortical suspension devices provide technical advantages over fixed-length devices for femoral graft fixation during anterior cruciate ligament (ACL) reconstruction but have shown increased lengthening during cyclic loading in biomechanical studies. The purpose of this study was to prospectively measure graft elongation in vivo along with patient reported outcomes.

Methods: Thirty-seven skeletally mature patients diagnosed with anterior cruciate insufficiency who underwent ACL reconstruction using autogenous hamstring graft were included in this study. Thirteen patients received an ACL reconstruction using a fixed loop device (FL) and twenty-four patients were treated with an adjustable-length device (AL) based on surgeon preference. Bilateral knee laxity was measured with a KT1000 Arthrometer before surgery and immediately after surgery with the patient under anesthesia, and at the 6-week, 3-month, and 6-month clinical follow-up appointments. All measurements were made by the same operator with maximum force testing. Differences between the affected knee and the contralateral knee were measured. Patient reported outcomes were collected at 6 and 24 months post-operatively.

Results: No difference was found between the FL and AL groups in either knee laxity or patient reported outcomes. Average side-to-side difference at 6 months was 1.8 ± 2.6 mm for the FL group and 1.7 ± 2.4 mm for the AL group (p=.874). One patient in the FL group (7.7%) and two in the AL group (9.5%) had a side to side difference in laxity greater 5 mm. Patient reported outcomes did not differ between groups and no patients underwent revision surgery.

Conclusions: The adjustable-length cortical suspension device (AL) did not demonstrate increased laxity as compared to fixed-length devices. There was no difference in patient reported outcomes between the groups..
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368520PMC
February 2021

Modified Outpatient Physical Therapy Improvement in Movement Assessment Log (mOPTIMAL): A Responsive and Reliable Tool for Patients with Non-Operative Shoulder Pain.

Iowa Orthop J 2020 ;40(1):91-99

Department of Physical Therapy and Rehabilitation Science.

Background: Medicare regulations require that physical therapists report functional limitations and severity modifiers utilizing a claims-based data collection tool. The Modified Outpatient Physical Therapy Improvement in Movement Assessment Log (mOPTIMAL) captures key constructs about patient confidence and difficulty but has not been evaluated for responsiveness/ reliability during a routine clinical encounter with patients who have shoulder pathology. The purposes of this retrospective study are to 1) explore if mOPTIMAL changes after a single session with a physical therapist, and 2) determine if the tool is reliable among people with non-operative shoulder pain.

Methods: We included 106 individuals (58% female; mean age 45.8; range: 18-94 yrs.) with "non-operative" shoulder pathology who were seen in outpatient physical therapy from 2011 to 2012. Subjects completed a mOPTIMAL survey and a pain scale before and immediately after the initial physical therapy visit. The mOPTIMAL is a patient-centered instrument that assesses how much "Difficulty" and "Confidence" a client has in performing a battery of functional tasks. T-tests, Cronbach's Alpha, and Intra-class Correlations were used to assess responsiveness, internal consistency, and reliability, respectively.

Results: After a single visit, participants reported improved Confidence with sleeping, dressing/ bathing, throwing, carrying, and lifting (adjusted for ceiling effects; p<0.002) but no change in pain. Cronbach's Alpha and Intra-class Correlations were excellent (0.821-0.923; 0.967, respectively).

Conclusions: mOPTIMAL is a reliable and responsive tool with excellent internal consistency. This observational study revealed that patient Confidence may change independent of Pain after a single physical therapy visit. Taken together, the mOPTIMAL appears to be an excellent tool to report severity modifiers in compliance with Medicare regulations..
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368525PMC
February 2021

Incidence and Predictors of Subsequent Surgery After Anterior Cruciate Ligament Reconstruction: A 6-Year Follow-up Study.

Am J Sports Med 2020 08;48(10):2418-2428

Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Background: The cause of subsequent surgery after anterior cruciate ligament (ACL) reconstruction varies, but if risk factors for specific subsequent surgical procedures can be identified, we can better understand which patients are at greatest risk.

Purpose: To report the incidence and types of subsequent surgery that occurred in a cohort of patients 6 years after their index ACL reconstruction and to identify which variables were associated with the incidence of patients undergoing subsequent surgery after their index ACL reconstruction.

Study Design: Cohort study; Level of evidence, 2.

Methods: Patients completed a questionnaire before their index ACL surgery and were followed up at 2 and 6 years. Patients were contacted to determine whether any underwent additional surgery since baseline. Operative reports were obtained, and all surgical procedures were categorized and recorded. Logistic regression models were constructed to predict which patient demographic and surgical variables were associated with the incidence of undergoing subsequent surgery after their index ACL reconstruction.

Results: The cohort consisted of 3276 patients (56.3% male) with a median age of 23 years. A 6-year follow-up was obtained on 91.5% (2999/3276) with regard to information on the incidence and frequency of subsequent surgery. Overall, 20.4% (612/2999) of the cohort was documented to have undergone at least 1 subsequent surgery on the ipsilateral knee 6 years after their index ACL reconstruction. The most common subsequent surgical procedures were related to the meniscus (11.9%), revision ACL reconstruction (7.5%), loss of motion (7.8%), and articular cartilage (6.7%). Significant risk factors for incurring subsequent meniscus-related surgery were having a medial meniscal repair at the time of index surgery, reconstruction with a hamstring autograft or allograft, higher baseline Marx activity level, younger age, and cessation of smoking. Significant predictors of undergoing subsequent surgery involving articular cartilage were higher body mass index, higher Marx activity level, reconstruction with a hamstring autograft or allograft, meniscal repair at the time of index surgery, or a grade 3/4 articular cartilage abnormality classified at the time of index ACL reconstruction. Risk factors for incurring subsequent surgery for loss of motion were younger age, female sex, low baseline Knee injury and Osteoarthritis Outcome Score symptom subscore, and reconstruction with a soft tissue allograft.

Conclusion: These findings can be used to identify patients who are at the greatest risk of incurring subsequent surgery after ACL reconstruction.
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http://dx.doi.org/10.1177/0363546520935867DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8359736PMC
August 2020

Surgical Stabilization of Shoulder Instability in Patients With or Without a History of Seizure: A Comparative Analysis.

Arthroscopy 2020 10 12;36(10):2664-2673.e3. Epub 2020 Jun 12.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A.

Purpose: To compare patients from a large multicenter cohort with a history of seizure and those without a history of seizure regarding preoperative and intraoperative findings and surgical procedures performed.

Methods: Patients undergoing shoulder stabilization from 2011 to 2018 at 11 orthopaedic centers were prospectively enrolled. Those with a history of seizure were identified and compared with non-seizure controls. Preoperative demographic, history, physical examination, and imaging findings were collected. Intraoperative findings and surgical procedures performed were recorded. The Mann-Whitney test, χ test, and logistic regression analysis were used to examine differences between the groups and define independent risk factors. Owing to the number of statistical tests performed, the false discovery method was used to determine adjusted P values to achieve α < .05.

Results: During enrollment, 25 of 1,298 shoulder stabilization patients (1.9%) had a history of seizure. The sex ratio and age were similar between groups, as was posterior instability incidence (23.2% in control group vs 28.0% in seizure group). Seizure patients more frequently had more than 5 dislocations in the year preceding surgery (P = .016) and had increased preoperative radiographic evidence of bone loss (P < .001). Intraoperatively, seizure patients had a higher prevalence of reverse Hill-Sachs lesions (P < .001) and large (>30% of glenoid fossa) bony Bankart lesions (P < .001). Arthroscopic Bankart repair was the most common procedure in both groups. However, open procedures were performed in 15.6% of controls and 40.0% of seizure patients (P = .001). These procedures were most commonly bony procedures.

Conclusions: Seizure patients had more prior dislocations, had more preoperative bone loss, and underwent more open stabilization procedures than controls because of bone loss. Studies examining recurrence after stabilization will help establish appropriate management practices in this population.

Level Of Evidence: Level III, retrospective review of prospectively collected cohort.
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http://dx.doi.org/10.1016/j.arthro.2020.05.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751058PMC
October 2020

Preoperative Opioid Prescription Filling Is a Risk Factor for Prolonged Opioid Use After Elbow Arthroscopy.

Arthroscopy 2020 08 20;36(8):2106-2113. Epub 2020 May 20.

From the Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.

Purpose: To (1) report the frequency of postoperative opioid prescriptions after elbow arthroscopy, (2) evaluate whether filling opioid prescriptions preoperatively placed patients at increased risk of requiring more opioid prescriptions after surgery, and (3) determine patient factors associated with postoperative opioid prescription needs.

Methods: A national claims-based database was queried for patients undergoing primary elbow arthroscopy. Patients with prior total elbow arthroplasty or septic arthritis of the elbow were excluded. Patients who filled at least 1 opioid prescription between 1 and 4 months prior to surgery were defined as the preoperative opioid-use group. Monthly relative risk ratios for filling an opioid prescription were calculated for the first year after surgery. Multiple logistic regression analysis was performed to identify factors associated with opioid use at 3, 6, 9, and 12 months after elbow arthroscopy, with P < .05 defined as significant.

Results: We identified 1,138 patients who underwent primary elbow arthroscopy. The preoperative opioid-use group consisted of 245 patients (21.5%), 61 of whom (24.9%) were still filling opioid prescriptions 12 months after surgery. The multivariate analysis determined that the preoperative opioid-use group was at increased risk of postoperative opioid prescription filling at 3 months (odds ratio [OR], 9.02; 95% confidence interval [CI], 5.98-13.76), 6 months (OR, 8.74; 95% CI, 5.57-13.92), 9 months (OR, 7.17; 95% CI, 4.57-11.39), and 12 months (OR, 6.27; 95% CI, 3.94-10.07) after elbow arthroscopy. Patients younger than 40 years exhibited a decreased risk of postoperative opioid prescription filling at 3 months (OR, 0.49; 95% CI, 0.25-0.91), 6 months (OR, 0.19; 95% CI, 0.06-0.50), 9 months (OR, 0.48; 95% CI, 0.22-0.97), and 12 months (OR, 0.44; 95% CI, 0.19-0.94) after surgery.

Conclusions: Preoperative opioid filling, fibromyalgia, and psychiatric illness are associated with an increased risk of prolonged postoperative opioid after elbow arthroscopy. Patient age younger than 40 years and chronic obstructive pulmonary disease are associated with a decreased risk of postoperative opioid prescription filling within the first postoperative year.

Level Of Evidence: Level III, retrospective cohort study.
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August 2020

Preoperative Opioid Usage, Male Sex, and Preexisting Knee Osteoarthritis Impacts Opioid Refills After Isolated Arthroscopic Meniscectomy: A Population-Based Study.

Arthroscopy 2020 09 11;36(9):2478-2485. Epub 2020 May 11.

Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.

Purpose: To identify risk factors for opioid consumption after arthroscopic meniscectomy using a large national database.

Methods: Patients undergoing primary arthroscopic meniscectomy from 2007 to 2016 were retrospectively accessed from the Humana database. Patients were categorized as those who filled opioid prescriptions within 3 months (OU), within 1 month (A-OU), between 1 and 3 months (C-OU), and never filled opioid prescriptions (N-OU) before surgery. Rates of opioid use were evaluated preoperatively and longitudinally tracked for each cohort. Prolonged opioid use was defined as continued opioid prescription filling at ≥3 months after surgery. Multiple logistic regression analysis was used to identify factors associated with opioid refills at 12 months after surgery.

Results: There were 88,120 patients (53.7% female) who underwent arthroscopic meniscectomy, of whom 46.1% (n = 39,078) were N-OU. About a quarter (25.3%) of patients continued filling opioid prescriptions at 1 year postoperatively. In addition, opioid fill rate at 1 year was significantly greater in the OU group compared with the N-OU group with a relative risk of 2.89 (40.7% vs 14.1%; 95% confidence interval 2.81-2.98; P < .0001). Multiple logistic regression model identified C-OU (odds ratio 3.67; 95% confidence interval 3.53-3.82; P < .0001) as the strongest predictor of opioid use at 12 months postoperatively. Furthermore, male sex, A-OU, knee osteoarthritis, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, fibromyalgia, anxiety or depression, alcohol use disorder, and tobacco use (P < .02 for all) had significantly increased odds of opioid use at 12 months postoperatively. However, patients <40 years (P < .0001) had significantly decreased odds of opioid use 12 months postoperatively.

Conclusions: Preoperative opioid filling is a significant risk factor for opioid use at 12 months postoperatively. Male sex, preexisting knee osteoarthritis, and diagnosis of anxiety or depression were independent risk factors for opioid use 12 months following arthroscopic meniscectomy.

Level Of Evidence: Level-III, Retrospective Cohort Study.
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http://dx.doi.org/10.1016/j.arthro.2020.04.039DOI Listing
September 2020
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