Publications by authors named "James E Carpenter"

82 Publications

Returning to Activity After Anterior Cruciate Ligament Revision Surgery: An Analysis of the Multicenter Anterior Cruciate Ligament Revision Study (MARS) Cohort at 2 Years Postoperative.

Am J Sports Med 2022 06;50(7):1788-1797

Investigation performed at Slocum Research and Education Foundation, Eugene, Oregon, USA.

Background: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes).

Hypotheses: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA.

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

Methods: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level.

Results: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; = .001), female patients (aOR = 2.9; < .001), recreational participants (aOR = 2.0; = .016), and those with a previous medial meniscal excision (aOR = 1.9; = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels.

Conclusion: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.
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http://dx.doi.org/10.1177/03635465221094621DOI Listing
June 2022

American Board of Orthopaedic Surgery's Initiatives Toward Competency-Based Education.

JB JS Open Access 2022 Apr-Jun;7(2). Epub 2022 May 19.

Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa.

The American Board of Orthopaedic Surgery (ABOS) is the national organization charged with defining education standards for graduate medical education in orthopaedic surgery. The purpose of this article is to describe initiatives taken by the ABOS to develop assessments of competency of residents to document their progress toward the independent practice of orthopaedic surgery and provide feedback for improved performance during training. These initiatives are called the ABOS Knowledge, Skills, and Behavior Program. Web-based assessment tools have been developed and validated to measure competence. These assessments guide resident progress through residency education and better define the competency level by the end of training. The background and rationale for these initiatives and how they serve as steps toward competency-based education in orthopaedic residency education in the United States will be reviewed with a vision of a hybrid of time and competency-based orthopaedic residency education that will remain 5 years in length, with residents assessed using standardized tools.
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http://dx.doi.org/10.2106/JBJS.OA.21.00150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9119638PMC
May 2022

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

Acromioclavicular Joint Disk Tearing in Young Non-Arthritic Individuals: A Case Series.

J Orthop Case Rep 2020 May-Jun;10(3):90-94

Department of Orthopaedic Surgery, University of Michigan Medical School, MedSport Domino's Farms, 24 Frank Lloyd Wright Drive, Lobby A, Suite 1000, Ann Arbor, MI 48106 USA.

Introduction: Degeneration of the fibrocartilaginous acromioclavicular (AC) joint disk can become significant in later life and lead to primary osteoarthritis and shoulder pain. Younger, non-arthritic individuals may develop residual shoulder symptoms due to tearing of the disk itself.

Case Report: Six patients (seven shoulders) were included in this case series. They were athletic and between the ages of 17 and 22. They typically presented with lingering symptoms of pain, popping, and instability in and around the AC joint after prior trauma or injury involving their shoulder. For most, symptoms lasted longer than 2 months before they sought additional treatment. Plain films were negative, and magnetic resonance imaging occasionally demonstrated pathology at the AC joint. Conservative treatment provided limited relief. All patients included in this series underwent arthroscopic distal clavicle resection. Intraoperatively, the disk could be seen as acutely torn or degenerative in all cases. In some, it was hypermobile and could be manually subluxed in and out of the joint.

Conclusions: A torn AC joint disk may cause lingering symptoms in young patients without radiographic evidence of arthritis. Further study is needed to determine if these findings are truly causative or merely incidental.
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http://dx.doi.org/10.13107/jocr.2020.v10.i03.1764DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051580PMC
May 2021

Low-oxygen hormetic conditioning improves field performance of sterile insects by inducing beneficial plasticity.

Evol Appl 2021 Feb 4;14(2):566-576. Epub 2020 Nov 4.

Department of Entomology and Nematology University of Florida Gainesville Florida USA.

As part of sterile insect technique (SIT) programs, irradiation can effectively induce sterility in insects by damaging germline genomic DNA. However, irradiation also induces other off-target side effects that reduce the quality and performance of sterilized males, including the formation of damaging free radicals that can reduce sterile male performance. Thus, treatments that reduce off-target effects of irradiation on male performance while maintaining sterility can improve the feasibility and economy of SIT programs. We previously found that inducing a form of rapid, beneficial plasticity with a 1-hr anoxic-conditioning period (physiological conditioning hormesis) prior to and during irradiation improves male field performance in the laboratory while maintaining sterility in males of the cactus moth, . Here, we extend this work by testing the extent to which this beneficial plasticity may improve male field performance and longevity in the field. Based on capture rates after a series of mark release-recapture experiments, we found that anoxia-conditioned irradiated moths were active in the field longer than their irradiated counterparts. In addition, anoxia-conditioned moths were captured in traps that were farther away from the release site than unconditioned moths, suggesting greater dispersal. These data confirmed that beneficial plasticity induced by anoxia hormesis prior to irradiation led to lower postirradiation damage and increased flight performance and recapture duration under field conditions. We recommend greater consideration of beneficial plasticity responses in biological control programs and specifically the implementation of anoxia-conditioning treatments applied prior to irradiation in area-wide integrated pest management programs that use SIT.
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http://dx.doi.org/10.1111/eva.13141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7896707PMC
February 2021

Use of the Behavior Assessment Tool in 18 Pilot Residency Programs.

JB JS Open Access 2020 Oct-Dec;5(4). Epub 2020 Nov 23.

Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota.

Background: The purpose of this study was to determine the feasibility and evaluate the effectiveness of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) for measuring professionalism.

Methods: Through collaboration between the American Board of Orthopaedic Surgery and American Orthopaedic Association's Council of Residency Directors, 18 residency programs piloted the use of the ABOSBT. Residents requested assessments from faculty at the end of their clinical rotations, and a 360° request was performed near the end of the academic year. Program Directors (PDs) rated individual resident professionalism (based on historical observation) at the outset of the study, for comparison to the ABOSBT results.

Results: Nine thousand eight hundred ninety-two evaluations were completed using the ABOSBT for 449 different residents by 1,012 evaluators. 97.6% of all evaluations were scored level 4 or 5 (high levels of professional behavior) across all of the 5 domains. In total, 2.4% of all evaluations scored level 3 or below reflecting poorer performance. Of 431 residents, the ABOSBT identified 26 of 32 residents who were low performers (2 or more < level 3 scores in a domain) and who also scored "below expectations" by the PD at the start of the pilot project (81% sensitivity and 57% specificity), including 13 of these residents scoring poorly in all 5 domains. Evaluators found the ABOSBT was easy to use (96%) and that it was an effective tool to assess resident professional behavior (81%).

Conclusions: The ABOSBT was able to identify 2.4% low score evaluations (
Level Of Evidence: Level II.
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http://dx.doi.org/10.2106/JBJS.OA.20.00103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682982PMC
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

The Use of Recombinant Human Growth Hormone to Protect Against Muscle Weakness in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Pilot, Randomized Placebo-Controlled Trial.

Am J Sports Med 2020 07 26;48(8):1916-1928. Epub 2020 May 26.

Department of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.

Background: Anterior cruciate ligament (ACL) tears are common knee injuries. Despite undergoing extensive rehabilitation after ACL reconstruction (ACLR), many patients have persistent quadriceps muscle weakness that limits their successful return to play and are also at an increased risk of developing knee osteoarthritis (OA). Human growth hormone (HGH) has been shown to prevent muscle atrophy and weakness in various models of disuse and disease but has not been evaluated in patients undergoing ACLR.

Hypothesis: Compared with placebo treatment, a 6-week perioperative treatment course of HGH would protect against muscle atrophy and weakness in patients undergoing ACLR.

Study Design: Randomized controlled trial; Level of evidence, 2.

Methods: A total of 19 male patients (aged 18-35 years) scheduled to undergo ACLR were randomly assigned to the placebo (n = 9) or HGH (n = 10) group. Patients began placebo or HGH treatment twice daily 1 week before surgery and continued through 5 weeks after surgery. Knee muscle strength and volume, patient-reported outcome scores, and circulating biomarkers were measured at several time points through 6 months after surgery. Mixed-effects models were used to evaluate differences between treatment groups and time points, and as this was a pilot study, significance was set at < .10. The Cohen was calculated to determine the effect size.

Results: HGH was well-tolerated, and no differences in adverse events between the groups were observed. The HGH group had a 2.1-fold increase in circulating insulin-like growth factor 1 over the course of the treatment period ( < .05; = 2.93). The primary outcome measure was knee extension strength, and HGH treatment increased normalized peak isokinetic knee extension torque by 29% compared with the placebo group ( = .05; = 0.80). Matrix metalloproteinase-3 (MMP3), which was used as an indirect biomarker of cartilage degradation, was 36% lower in the HGH group ( = .05; = -1.34). HGH did not appear to be associated with changes in muscle volume or patient-reported outcome scores.

Conclusion: HGH improved quadriceps strength and reduced MMP3 levels in patients undergoing ACLR. On the basis of this pilot study, further trials to more comprehensively evaluate the ability of HGH to improve muscle function and potentially protect against OA in patients undergoing ACLR are warranted.

Registration: NCT02420353 ( ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/0363546520920591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351248PMC
July 2020

The American Board of Orthopaedic Surgery Response to COVID-19.

J Am Acad Orthop Surg 2020 Jun;28(11):e465-e468

From the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN (Dr. Wright), Department of Orthopaedic Surgery, Penn State Hershey Medical Center, Hershey, PA (Dr. Armstrong), Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee/Campbell Clinic, Memphis, TN (Dr. Azar), Department of Orthopaedic Surgery and Rehabilitation, Stritch School of Medicine, Loyola University-Chicago, Maywood, IL (Dr. Bednar), Orthopaedic Surgery, University of Michigan, Ann Arbor, MI (Dr. Carpenter), Public Member, Cedar Rapids, IA (Mr. Evans), Orthopaedic Surgery, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA (Dr. Flynn), Department of Orthopaedic Surgery, University of Nebraska, Omaha, NE (Dr. Garvin), Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL (Dr. Jacobs), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr. Kang), Resurgens Orthopaedics, Atlanta, GA (Dr. Lundy), Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN (Dr. Mencio), Department of Orthopedic Surgery and Neurosurgery, Mayo Clinic, Jacksonville, FL (Dr. Murray), Hospital of the University of Pennsylvania, Philadelphia, PA (Dr. Nelson), Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Evanston, IL (Dr. Peabody), Department of Orthopaedic Surgery, Prisma Health-Upstate, Greenville, SC (Dr. Porter), Orthopaedics, Emory University, Atlanta, GA (Dr. Roberson), Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT (Dr. Saltzman), Orthopaedic Surgery and Rehabilitation, Penn State Health System, State College, PA (Dr. Sebastianelli), University of Washington, Harborview Medical Center, Seattle, WA (Dr. Taitsman), Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Van Heest), and American Board of Orthopaedic Surgery, Chapel Hill, NC (Dr. Martin), and Wake Forest School of Medicine, Winston-Salem, NC (Dr. Martin).

The COVID-19 pandemic has disrupted every aspect of society in a way never previously experienced by our nation's orthopaedic surgeons. In response to the challenges the American Board of Orthopaedic Surgery has taken steps to adapt our Board Certification and Continuous Certification processes. These changes were made to provide flexibility for as many Candidates and Diplomates as possible to participate while maintaining our high standards. The American Board of Orthopaedic Surgery is first and foremost committed to the safety and well-being of our patients, physicians, and families while striving to remain responsive to the changing circumstances affecting our Candidates and Diplomates.
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http://dx.doi.org/10.5435/JAAOS-D-20-00392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195847PMC
June 2020

Surgical Versus Nonsurgical Management of Rotator Cuff Tears: A Matched-Pair Analysis.

J Bone Joint Surg Am 2019 Oct;101(19):1775-1782

Department of Orthopaedic Surgery, The University of Michigan, Ann Arbor, Michigan.

Background: Rotator cuff disease is a major medical and economic burden due to a growing aging population, but management of rotator cuff tears remains controversial. We hypothesized that there is no difference in outcomes between patients who undergo rotator cuff repair and matched patients treated nonoperatively.

Methods: After institutional review board approval, a prospective cohort of patients over 18 years of age who had a full-thickness rotator cuff tear seen on magnetic resonance imaging (MRI) were retrospectively evaluated. After clinical evaluation, each patient elected to undergo either rotator cuff repair or nonsurgical treatment. Demographic information was collected at enrollment, and self-reported outcome measures (the Normalized Western Ontario Rotator Cuff Index [WORCnorm], American Shoulder and Elbow Surgeons score [ASES], Single Assessment Numerical Evaluation [SANE], and pain score on a visual analog scale [VAS]) were collected at baseline and at 6, 12, and >24 months. The Functional Comorbidity Index (FCI) was used to assess health status at enrollment. The size and degree of atrophy of the rotator cuff tear were classified on MRI. Propensity score analysis was used to create rotator cuff repair and nonsurgical groups matched by age, sex, symptom duration, FCI, tear size, injury mechanism, and atrophy. The Student t test, chi-square test, and regression analysis were used to compare the treatment groups.

Results: One hundred and seven patients in each group were available for analysis after propensity score matching. There were no differences between the groups with regard to demographics or rotator cuff tear characteristics. For all outcome measures at the time of final follow-up, the rotator cuff repair group had significantly better outcomes than the nonsurgical treatment group (p < 0.001). At the time of final follow-up, the mean outcome scores (and 95% confidence interval) for the surgical repair and nonsurgical treatment groups were, respectively, 81.4 (76.9, 85.9) and 68.8 (63.7, 74.0) for the WORCnorm, 86.1 (82.4, 90.3) and 76.2 (72.4, 80.9) for the ASES, 77.5 (70.6, 82.5) and 66.9 (61.0, 72.2) for the SANE, and 14.4 (10.2, 20.2) and 27.8 (22.5, 33.5) for the pain VAS. In the longitudinal regression analysis, better outcomes were independently associated with younger age, shorter symptom duration, and rotator cuff repair.

Conclusions: Patients with a full-thickness rotator cuff tear reported improvement in pain and functional outcome scores with nonoperative treatment or surgical repair. However, patients who were offered and chose rotator cuff repair reported greater improvement in outcome scores and reduced pain compared with those who chose nonoperative treatment.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.18.01473DOI Listing
October 2019

Predictors of Patient-Reported Outcomes at 2 Years After Revision Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2019 08 18;47(10):2394-2401. Epub 2019 Jul 18.

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

Background: Patient-reported outcomes (PROs) are a valid measure of results after revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes when compared with primary ACL reconstruction. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for patients.

Purpose/hypothesis: The purpose was to describe PROs after revision ACL reconstruction and test the hypothesis that patient- and technique-specific variables are associated with these outcomes.

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

Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons over 52 sites. Data included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale. Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors to determine the positive and negative predictors of PRO scores at 2 years after revision surgery.

Results: A total of 1205 patients met the inclusion criteria and were successfully enrolled: 697 (58%) were male, with a median cohort age of 26 years. The median time since their most recent previous ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained from 989 patients (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male sex, and having a longer time since the most recent previous ACL reconstruction, while negative predictors included having a lateral meniscectomy before the revision ACL reconstruction or having grade 3/4 chondrosis in either the trochlear groove or the medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between the most recent previous ACL reconstruction and revision surgery were significant positive predictors for having a better (ie, higher) 2-year KOOS, while having a lateral meniscectomy before the revision ACL reconstruction was a consistent predictor for having a significantly worse (ie, lower) 2-year KOOS. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male sex, and being a nonsmoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery.

Conclusion: PROs after revision ACL reconstruction are associated with a variety of patient- and surgeon-related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectations as well as potentially improve outcomes.
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http://dx.doi.org/10.1177/0363546519862279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335592PMC
August 2019

Relationship Between Sports Participation After Revision Anterior Cruciate Ligament Reconstruction and 2-Year Patient-Reported Outcome Measures.

Am J Sports Med 2019 07 21;47(9):2056-2066. Epub 2019 Jun 21.

Investigation performed at Slocum Research and Education Foundation, Eugene, Oregon, USA.

Background: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery.

Hypotheses: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level.

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

Methods: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates.

Results: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC ( < .0001), KOOS-Symptoms ( = .01), KOOS-Sports and Recreation ( = .04), and KOOS-Quality of Life ( < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, = .18), after controlling for known covariates.

Conclusion: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.
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http://dx.doi.org/10.1177/0363546519856348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939628PMC
July 2019

Clinical Outcomes After Anterior Shoulder Stabilization in Overhead Athletes: An Analysis of the MOON Shoulder Instability Consortium.

Am J Sports Med 2019 05;47(6):1404-1410

Investigation performed at the University of Michigan, Ann Arbor, Michigan, USA.

Background: Traumatic anterior shoulder instability is a common condition affecting sports participation among young athletes. Clinical outcomes after surgical management may vary according to patient activity level and sport involvement. Overhead athletes may experience a higher rate of recurrent instability and difficulty returning to sport postoperatively with limited previous literature to guide treatment.

Purpose: To report the clinical outcomes of patients undergoing primary arthroscopic anterior shoulder stabilization within the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Consortium and to identify prognostic factors associated with successful return to sport at 2 years postoperatively.

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

Methods: Overhead athletes undergoing primary arthroscopic anterior shoulder stabilization as part of the MOON Shoulder Instability Consortium were identified for analysis. Primary outcomes included the rate of recurrent instability, defined as any patient reporting recurrent dislocation or reoperation attributed to persistent instability, and return to sport at 2 years postoperatively. Secondary outcomes included the Western Ontario Shoulder Instability Index and Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow questionnaire score. Univariate regression analysis was performed to identify patient and surgical factors predictive of return to sport at short-term follow-up.

Results: A total of 49 athletes were identified for inclusion. At 2-year follow-up, 31 (63%) athletes reported returning to sport. Of those returning to sport, 22 athletes (45% of the study population) were able to return to their previous levels of competition (nonrefereed, refereed, or professional) in at least 1 overhead sport. Two patients (4.1%) underwent revision stabilization, although 14 (28.6%) reported subjective apprehension or looseness. Age ( P = .87), sex ( P = .82), and baseline level of competition ( P = .37) were not predictive of return to sport. No difference in range of motion in all planes ( P > .05) and Western Ontario Shoulder Instability Index scores (78.0 vs 80.1, P = .73) was noted between those who reported returning to sport and those who did not.

Conclusion: Primary arthroscopic anterior shoulder stabilization in overhead athletes is associated with a low rate of recurrent stabilization surgery. Return to overhead athletics at short-term follow-up is lower than that previously reported for the general athletic population.
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http://dx.doi.org/10.1177/0363546519837666DOI Listing
May 2019

Physiologic Preoperative Knee Hyperextension Is a Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group.

Am J Sports Med 2018 10 8;46(12):2836-2841. Epub 2018 Jun 8.

Investigation performed at The Carrell Clinic, Dallas, Texas, USA; Department of Orthopaedics, Washington University School of Medicine, St Louis, Missouri, USA; Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA; and Reedsburg Area Medical Center, Reedsburg, Wisconsin, USA.

Background: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture.

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

Methods: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR.

Results: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as "younger" and those above as "older" (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03).

Conclusion: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/0363546518777732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170681PMC
October 2018

Descriptive Epidemiology of the MOON Shoulder Instability Cohort.

Am J Sports Med 2018 04 5;46(5):1064-1069. Epub 2018 Mar 5.

Investigation performed at CU Sports Medicine and Performance Center, Department of Orthopedics, University of Colorado School of Medicine, Boulder, Colorado, USA.

Background: Shoulder instability is a common diagnosis among patients undergoing shoulder surgery.

Purpose: To perform a descriptive analysis of patients undergoing surgery for shoulder instability through a large multicenter consortium.

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

Methods: All patients undergoing surgery for shoulder instability who were enrolled in the MOON Shoulder Instability Study were included. Baseline demographics included age, sex, body mass index, and race. Baseline patient-reported outcomes (PROs) included the American Shoulder and Elbow Surgeons (ASES) score, Shoulder Activity Score, Western Ontario Shoulder Instability Index (WOSI), 36-Item Health Survey (RAND-36), and Single Assessment Numeric Evaluation (SANE). The preoperative physician examination included active range of motion (ROM) and strength testing. Preoperative imaging assessments with plain radiography, magnetic resonance imaging (MRI), and computed tomography were also included and analyzed.

Results: Twenty-six surgeons had enrolled 863 patients (709 male, 154 female) across 10 clinical sites. The mean age for the cohort was 24 years (range, 12-63 years). Male patients represented 82% of the cohort. The primary direction of instability was anterior for both male (74%) and female (73%) patients. Football (24%) and basketball (13%) were the most common sports in which the primary shoulder injury occurred. No clinically significant differences were found in preoperative ROM between the affected and unaffected sides for any measurement taken. Preoperative MRI scans were obtained in 798 patients (92%). An anterior labral tear was the most common injury found on preoperative MRI, seen in 66% of patients, followed by a Hill-Sachs lesion in 41%. Poor PRO scores were recorded preoperatively (mean: ASES, 72.4; WOSI, 43.3; SANE, 46.6).

Conclusion: The MOON Shoulder Instability Study has enrolled the largest cohort of patients undergoing shoulder stabilization to date. Anterior instability is most common among shoulder instability patients, and most patients undergoing shoulder stabilization are in their early 20s or younger. The results of this study provide important epidemiological information for patients undergoing shoulder stabilization surgery.
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http://dx.doi.org/10.1177/0363546518755752DOI Listing
April 2018

Establishing minimally important differences for the American Shoulder and Elbow Surgeons score and the Western Ontario Rotator Cuff Index in patients with full-thickness rotator cuff tears.

J Shoulder Elbow Surg 2018 May 4;27(5):e160-e166. Epub 2018 Jan 4.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA.

Background: The American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Rotator Cuff Index (WORC) are frequently used measures in clinical research for patients with rotator cuff tears (RCTs). The minimally important differences (MIDs) for these measures have not been established in patients with RCTs. The purpose of this study was to establish the MIDs for patients with known RCTs treated both surgically or nonsurgically.

Methods: We included 222 subjects with full-thickness RCTs. The WORC and ASES were collected at baseline and at 4, 8, 16, 32, 48, and 64 weeks, as was an end of study form with questions about change in the condition after treatment. We calculated anchor-based and distribution-based MIDs. We used regression modeling to determine change in MIDs as predicted by several variables.

Results: For the anchor-based method, we found an MID of 21.9 for the ASES and -282.6 for the WORC. When using the distribution-based method of ½ and ⅓ the standard deviation, we arrived at an MID of 26.9 and 17.9 points for the ASES and -588.7 and -392.5 points for the WORC. No variables predicted MID changes.

Conclusion: This is the first study to report MIDs for the ASES and WORC in a population of patients with only full-thickness RCTs. This information will directly improve our ability to determine when patients with RCTs are changing in a meaningful manner and accurately power clinical studies using these outcome measures.
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http://dx.doi.org/10.1016/j.jse.2017.10.042DOI Listing
May 2018

Risk Factors and Predictors of Significant Chondral Surface Change From Primary to Revision Anterior Cruciate Ligament Reconstruction: A MOON and MARS Cohort Study.

Am J Sports Med 2018 Mar 15;46(3):557-564. Epub 2017 Dec 15.

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

Background: Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage.

Hypothesis: Larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction.

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

Methods: Subjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery.

Results: A total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus ( P < .001). For the medial compartment, patients who had <33% of the medial meniscus excised at the time of the primary reconstruction had 4.8-times greater odds of progression of articular cartilage injury than those with an intact medial meniscus ( P = .02). Odds of significant chondral surface change increased by 5% in the lateral compartment and 6% in the medial compartment for each increased year of age ( P ≤ .02). For the patellofemoral compartment, the use of allograft in primary reconstruction was associated with a 15-fold increased odds of progression of articular cartilage damage relative to a patellar tendon autograft ( P < .001). Each 1-unit increase in BMI at the time of revision surgery was associated with a 10% increase in the odds of progression of articular cartilage damage ( P = .046) in the patellofemoral compartment.

Conclusion: Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment.
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http://dx.doi.org/10.1177/0363546517741484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004295PMC
March 2018

Does Increased Body Mass Index Influence Outcomes After Rotator Cuff Repair?

Arthroscopy 2018 03 2;34(3):754-761. Epub 2017 Nov 2.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A.. Electronic address:

Purpose: To investigate the influence of pre-existing obesity (body mass index [BMI] ≥ 30) on outcomes after rotator cuff repair surgery.

Methods: We collected data on adult patients who underwent surgical repair for symptomatic full-thickness rotator cuff tears confirmed by imaging between 2012 and 2015. The required follow-up was 3 years. At baseline and 6, 12, 24, and 36 months, the American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff index, and visual analog scale pain scores were collected. Complications were assessed by a chart review. Obesity was defined as BMI ≥ 30. Chi-square analysis and Student's t-test examined differences between categorical and continuous variables at baseline. Generalized estimating equations examined the effects of fixed factors on outcome variables longitudinally from baseline to 36 months.

Results: Thirty-nine percent of 213 subjects were obese (mean BMI = 29.2; range, 16-48; standard deviation, 5.8). There were no statistically significant differences between obese and nonobese subjects in other baseline characteristics. When controlling for covariates, obese subjects reported no differences in Western Ontario Rotator Cuff, American Shoulder and Elbow Surgeons, or visual analog scale pain scores when compared with nonobese subjects at baseline and over 3 years from surgery. Although obese patients were more likely to have inpatient surgery, there was no difference in the incidence of postoperative complications.

Conclusions: Contrary to our hypothesis, obese participants who underwent rotator cuff repair reported no difference in functional outcome or pain scores compared with nonobese participants over 3 years. In addition, obesity was not associated with postoperative complications in this study. However, as we hypothesized, obese participants were more likely than nonobese participants to have repair in the inpatient setting.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2017.08.248DOI Listing
March 2018

Medical Team Training Improves Team Performance: AOA Critical Issues.

J Bone Joint Surg Am 2017 Sep;99(18):1604-1610

1Department of Orthopaedic Surgery (J.E.C.), University of Michigan (J.P.B.), Ann Arbor, Michigan 2Department of Orthopaedics, Greenville Health System, Greenville, South Carolina.

Effective teamwork and communication can decrease medical errors in environments where the culture of safety is enhanced. Health care can benefit from programs that are based on teamwork, as in other high-stress industries (e.g., aviation), with crew resource management programs, simulator use, and utilization of checklists. Medical team training (MTT) with a strong leadership commitment was used at our institution to focus specifically on creating open, yet structured, communication in operating rooms. Training included the 3 phases of the World Health Organization protocol to organize communication and briefings: preoperative verification, preincision briefing, and debriefing at or near the end of the surgical case. This training program led to measured improvements in job satisfaction and compliance with checklist tasks, and identified opportunities to improve training sessions. MTT provides the potential for sustainable change and a positive impact on the environment of the operating room.
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http://dx.doi.org/10.2106/JBJS.16.01290DOI Listing
September 2017

Do Medical Comorbidities Affect Outcomes in Patients With Rotator Cuff Tears?

Orthop J Sports Med 2017 Aug 21;5(8):2325967117723834. Epub 2017 Aug 21.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Background: The effects of medical comorbidities on clinical outcomes in patients with rotator cuff tears (RCTs) have not been fully elucidated. This study investigates the association between medical comorbidities, as measured by the Functional Comorbidity Index (FCI), and clinical outcomes in patients treated surgically or nonsurgically for symptomatic, full-thickness RCTs.

Hypothesis: Patients with RCTs who have more comorbidities will have worse outcome scores.

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

Methods: We collected the following outcome measures at baseline and at regular intervals up to 64 weeks in all patients: FCI, the Western Ontario Rotator Cuff Index (WORC), and the American Shoulder and Elbow Surgeons (ASES) score. Changes in outcomes were compared separately for surgical and nonsurgical patients using paired tests. The relationship of the FCI and all outcomes of interest at baseline, at 64-week follow-up, and for changes from baseline was explored using linear regression modeling.

Results: Of the 222 study patients (133 males; mean age, 60.0 ± 9.6 years), 140 completed the 64-week WORC and 120 completed the 64-week ASES. Overall, 128 patients underwent RCT repair, and 94 patients were treated nonsurgically. Both treatment groups improved compared with baseline at 64 weeks on the ASES score and WORC. At 64 weeks, patients with higher baseline FCI scores had worse WORC score (by 74.5 points; = .025) and ASES score (by 3.8 points; < .01). A higher FCI score showed a trend toward predicting changes in the WORC and ASES scores at 64 weeks compared with baseline, but this did not reach statistical significance (WORC change, = .15; ASES change, = .07).

Conclusion: Patients with higher FCI scores at baseline reported worse baseline functional scores and demonstrated less improvement with time. The magnitude of this change may not be clinically significant for single comorbidities.
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http://dx.doi.org/10.1177/2325967117723834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5570119PMC
August 2017

Comparison of Outcomes 1 Year After Rotator Cuff Repair With and Without Concomitant Biceps Surgery.

Arthroscopy 2017 Nov 16;33(11):1928-1936. Epub 2017 Aug 16.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A.

Purpose: To compare the outcomes of patients who undergo a long head of the biceps (LHB) procedure (tenotomy or tenodesis) concomitant with rotator cuff repair (RCR) to those of patients who undergo isolated RCR.

Methods: Prospectively collected data were retrospectively reviewed on 80 patients, >18 years old, who underwent repair of a full-thickness rotator cuff tear and with 1-year patient-reported outcome scores collected June 2012 to March 2015. The exclusion criteria were concomitant procedures other than LHB tenotomy, tenodesis, or subacromial decompression; prior shoulder surgery; or other shoulder pathology. The 3 patient groups are as follows: RCR + tenotomy, RCR + tenodesis, and isolated RCR. The primary outcome measures were American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) index, and visual analog scale (VAS) for pain. A t-test measured the mean improvement in LHB patients compared with isolated RCR patients and compared the LHB tenotomy and tenodesis groups. Stepwise linear progression used LHB tenotomy or tenodesis as the primary predictor.

Results: The biceps procedure group had more female patients (22 vs 7, P = .01); otherwise there were no significant baseline differences. The LHB procedure group had significantly worse baseline ASES scores (mean, 48.9 vs 58.7; P = .032). All RCR patients showed significant improvement in all 3 outcome measures. Patients who had either LHB tenotomy or tenodesis (n = 45) demonstrated significantly greater mean improvement in ASES (mean, 42.7 vs 23.8; P = .002), VAS (mean, 49.2 vs 35.7; P = .020), and WORC scores (mean, 928 vs 743; P = .029) at 1-year follow-up compared with patients who had isolated RCR. ASES scores at 1 year were significantly better in the biceps group (91.6 vs 82.5; P = .023). Linear regression found a biceps procedure to be predictive of a significantly greater improvement in ASES score (P = .01). Analysis of variance revealed that both the LHB tenotomy (P = .04) and tenodesis (P = .01) groups demonstrated more favorable improvement in ASES when compared with RCR alone.

Conclusions: Patients who underwent a concomitant biceps procedure when indicated at the time of RCR demonstrated inferior baseline patient-reported outcome measures and greater improvement after 1 year, as well as more favorable ASES scores at 1 year compared with isolated RCR patients.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2017.05.009DOI Listing
November 2017

Surgical Predictors of Clinical Outcomes After Revision Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2017 Sep 11;45(11):2586-2594. Epub 2017 Jul 11.

Investigation performed at Department of Orthopaedics, Washington University School of Medicine, St Louis, Missouri, USA, and Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction.

Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes.

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

Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction.

Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort.

Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.
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http://dx.doi.org/10.1177/0363546517712952DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5675127PMC
September 2017

Subsequent Surgery After Revision Anterior Cruciate Ligament Reconstruction: Rates and Risk Factors From a Multicenter Cohort.

Am J Sports Med 2017 Jul 30;45(9):2068-2076. Epub 2017 May 30.

Investigation performed at the Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA.

Background: While revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR.

Purpose: To report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR.

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

Methods: A total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation.

Results: Of the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged <20 years had twice the odds of patients aged 20 to 29 years to undergo a reoperation. The use of an allograft at the time of revision ACLR (odds ratio [OR], 1.79; P = .007) was a significant predictor for reoperations at 2 years, while staged revision (bone grafting of tunnels before revision ACLR) (OR, 1.93; P = .052) did not reach significance. Patients with grade 4 cartilage damage seen during revision ACLR were 78% less likely to undergo subsequent operations within 2 years. Sex, body mass index, smoking history, Marx activity score, technique for femoral tunnel placement, and meniscal tearing or meniscal treatment at the time of revision ACLR showed no significant effect on the reoperation rate.

Conclusion: There was a significant reoperation rate after revision ACLR at 2 years (11%), with meniscal procedures most commonly involved. Independent risk factors for subsequent surgery on the ipsilateral knee included age <20 years and the use of allograft tissue at the time of revision ACLR.
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http://dx.doi.org/10.1177/0363546517707207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513777PMC
July 2017

CARE guidelines for case reports: explanation and elaboration document.

J Clin Epidemiol 2017 Sep 18;89:218-235. Epub 2017 May 18.

Department of Orthopaedic Surgery, 24 Frank Lloyd Wright Drive, Lobby A, Ann Arbor, MI 48106, USA; Department of Epidemiology, School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA.

Background: Well-written and transparent case reports (1) reveal early signals of potential benefits, harms, and information on the use of resources; (2) provide information for clinical research and clinical practice guidelines, and (3) inform medical education. High-quality case reports are more likely when authors follow reporting guidelines. During 2011-2012, a group of clinicians, researchers, and journal editors developed recommendations for the accurate reporting of information in case reports that resulted in the CARE (CAse REport) Statement and Checklist. They were presented at the 2013 International Congress on Peer Review and Biomedical Publication, have been endorsed by multiple medical journals, and translated into nine languages.

Objectives: This explanation and elaboration document has the objective to increase the use and dissemination of the CARE Checklist in writing and publishing case reports.

Article Design And Setting: Each item from the CARE Checklist is explained and accompanied by published examples. The explanations and examples in this document are designed to support the writing of high-quality case reports by authors and their critical appraisal by editors, peer reviewers, and readers.

Results And Conclusion: This article and the 2013 CARE Statement and Checklist, available from the CARE website [www.care-statement.org] and the EQUATOR Network [www.equator-network.org], are resources for improving the completeness and transparency of case reports.
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http://dx.doi.org/10.1016/j.jclinepi.2017.04.026DOI Listing
September 2017

Evaluation of American Academy of Orthopaedic Surgeons Appropriate Use Criteria for the management of full-thickness rotator cuff tears.

J Shoulder Elbow Surg 2016 Jul 26;25(7):1100-6. Epub 2016 Feb 26.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA. Electronic address:

Background: The American Academy of Orthopaedic Surgeons (AAOS) recently released Appropriate Use Criteria (AUC) to aid in determining the appropriateness of treatment options. This study compares AAOS AUC recommendations with a cohort of patients treated for known full-thickness rotator cuff tears (RCTs).

Methods: Prospectively collected demographic information, treatment allocation, and American Shoulder and Elbow Surgeons (ASES) shoulder and Western Ontario Rotator Cuff Index scores of 134 patients were retrospectively reviewed. Other criteria required by the AAOS AUC were collected by retrospective record review. Criteria were entered into the AAOS AUC Web-based application to rate the "appropriateness" of treatment options. Ratings were compared with actual treatments and outcomes at 32- or 48-week follow-up.

Results: There was excellent agreement between the AUC recommendations and the actual treatment administered (κ = .945; 95% confidence interval, 0.892-1.000; P <.0001). The administered treatment was "appropriate" for 79% of patients, "may be appropriate" for 19%, and "rarely appropriate" for 2%. Response to previous treatment (P <.0001), American Society of Anesthesiologists Physical Status Classification (P <.0001), and presence of muscle atrophy or fatty infiltration (P = .047) were the only variables that significantly and independently predicted discordance between treatment and the AUC recommendation. In the cases (n = 3) of discordance, the American Shoulder and Elbow Surgeons score improved significantly more (P = .049) than when there was agreement.

Conclusions: Improved clinical outcomes may be achieved for full-thickness RCTs when AAOS AUC recommendations are followed; however, because improved clinical outcomes may also be achieved when the recommendations are not followed, further investigation is needed in a population of patients in whom there is discordance between AAOS AUC recommendations and the treatment administered.
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http://dx.doi.org/10.1016/j.jse.2015.12.009DOI Listing
July 2016

Qualitative Assessment and Quantitative Analysis of the Long Head of the Biceps Tendon in Relation to the Pectoralis Major Tendon Humeral Insertion: An Anatomic Study.

Arthroscopy 2016 06 23;32(6):990-8. Epub 2016 Feb 23.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A.

Purpose: To qualitatively assess and to quantitatively analyze the long head of the biceps tendon (LHBT) in the region of the pectoralis major (PM).

Methods: From 11 fresh cadaveric donors, 20 cadaveric shoulders without operative scars were dissected-mean age, 76.9 years (range, 61 to 93 years); male, 75%; left-sided, 55%; mean height, 67.8 inches (range, 61 to 71 inches); mean weight, 148.1 pounds (range, 106 to 176 pounds). Two specimens with discovered ruptures were excluded. The LHBT circumference was measured at the anterior edge of supraspinatus, suprapectorally, midpectorally, and subpectorally. The muscle was then removed from the LHBT and the circumference was again measured at the supra-, mid-, and subpectoral levels. These data were used to calculate the area of the tendon. All measurements were performed by 2 independent observers. Statistical analysis was performed to assess reliability of data and the difference between serial measurements.

Results: The mean calculated percentage tendon decreased from 86.7% at the superior edge of the PM to 49.8% at the midpoint of the PM and to 17.5% at the inferior edge of the PM.

Conclusions: Distal to the PM, the LHBT was composed of a small percentage of tendon to muscle, which may have implications for the mechanical strength of fixation of tenodesis. The anatomic location of the musculotendinous junction of the LHBT began proximal to the superior edge of the PM tendon, which implies that restoration of anatomic tensioning may require a more proximal docking site than previously described. Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may not be optimal.

Clinical Relevance: Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may affect the mechanical strength or optimal choice of fixation location.
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http://dx.doi.org/10.1016/j.arthro.2015.11.048DOI Listing
June 2016

Core Concepts: Orthopedic Intern Curriculum Boot Camp.

Orthopedics 2016 Jan-Feb;39(1):e62-7. Epub 2016 Jan 5.

Orthopedic surgical interns must gain a broad array of clinical skills in a short time. However, recent changes in health care have limited resident-patient exposures. With the reported success of simulation training in the surgical literature, the American Board of Orthopaedic Surgery (ABOS) and Residency Review Committee for Orthopaedic Surgery have required that surgical simulation training be a component of the intern curricula in orthopedic surgical residencies. This study examined the short-term effectiveness of an orthopedic "intern boot camp" covering 7 of 17 simulation training concept modules published by the ABOS. Eight orthopedic post-graduate year 1 (PGY-1) residents (study group) completed a structured 3-month curriculum and were compared with 7 post-graduate year 2 (PGY-2) residents (comparison group) who had just completed their orthopedic surgical internship. Seven core skills were assessed using both task-specific and global rating scales. The PGY-1 residents demonstrated a statistically significant improvement in all 7 modules with respect to their task-specific pre-test scores: sterile technique (P=.001), wound closure (P<.001), knot tying (P=.017), casting and splinting (P<.001), arthrocentesis (P=.01), basics of internal fixation (P<.001), and compartment syndrome evaluation (P=.004). After the camp, PGY-1 and -2 scores in task-specific measures were not significantly different. A 3-month simulation-based boot camp instituted early in orthopedic internship elevated a variety of clinical skills to levels exhibited by PGY-2 residents.
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http://dx.doi.org/10.3928/01477447-20151228-03DOI Listing
September 2016

Surgical Versus Nonsurgical Management of Rotator Cuff Tears: Predictors of Treatment Allocation.

Am J Sports Med 2015 Oct 12;43(10):2368-72. Epub 2015 Aug 12.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA

Background: Rotator cuff tears are a common shoulder disorder resulting in significant disability to patients and financial burden on the health care system. While both surgical and nonsurgical management are accepted treatment options, there is a paucity of data to support a treatment algorithm for care providers. Defining variables to guide treatment allocation may be important for patient education and counseling, as well as to deliver the most efficient care plan at the time of presentation.

Purpose: To identify independent variables at the time of initial clinical presentation that are associated with preferred allocation to surgical versus nonsurgical management for patients with known full-thickness rotator cuff tears.

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

Methods: A total of 196 consecutive adult patients with known full-thickness rotator cuff tears were enrolled into a prospective cohort study. Robust data were collected for each subject at baseline, including age, sex, body mass index (BMI), shoulder activity score, smoking status, size of cuff tear, duration of symptoms, functional comorbidity index, the American Shoulder and Elbow Surgeons (ASES) score, the Western Ontario Rotator Cuff index (WORC), and the Veterans Rand 12-Item Health Survey (VR-12). Logistic regression was performed to identify variables associated with treatment allocation, and the corresponding odds ratios were calculated.

Results: Of the 196 patients enrolled, 112 underwent surgical intervention and 84 nonoperative management. With covariates controlled for, significant baseline patient characteristics predictive of eventual allocation to surgical treatment included younger age, lower BMI, and durations of symptoms less than 1 year. Increasing age, higher BMI, and duration of symptoms longer than 1 year were predictive of nonsurgical treatment. Factors that were not associated with treatment allocation included sex, tear size, functional comorbidity score, or any of the patient-derived outcome scores at presentation (ASES, WORC, VR-12, shoulder activity score).

Conclusion: Patient demographics at the time of initial presentation for a symptomatic rotator cuff tear are more predictive of treatment allocation to a surgical or nonoperative approach than the patient-derived outcome scores for activity level and shoulder disability. Further study is warranted to help define appropriate indications for treatment allocation in patients with rotator cuff tears.
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http://dx.doi.org/10.1177/0363546515593954DOI Listing
October 2015
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