Publications by authors named "Paul Saluan"

40 Publications

Return to Sports After Anterior Cruciate Ligament Reconstruction: Validity and Reliability of the SPORTS Score at 6 and 12 Months.

Orthop J Sports Med 2022 Jun 8;10(6):23259671221098436. Epub 2022 Jun 8.

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Background: The Subjective Patient Outcome for Return to Sports (SPORTS) score is a single-item scale that measures athletes' ability to return to their preinjury sport based on effort and performance.

Purpose/hypothesis: The purpose of this study was to examine the psychometric properties of the SPORTS score and a modified score within the first year after anterior cruciate ligament reconstruction (ACLR). The modified version replaced "same sport" with "any sport" in the answer choices. It was hypothesized that both versions of the SPORTS score would have acceptable floor and ceiling effects and internal responsiveness, moderate convergent validity, and excellent test-retest reliability.

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

Methods: Patients were recruited preoperatively from 2 academic medical centers. The authors collected responses to the 1-item SPORTS scores at 6 and 12 months after ACLR and the Tegner activity scale, Lysholm knee score, Knee injury and Osteoarthritis Outcome Score (KOOS)-sport/recreation subscale, and Marx activity rating scale preoperatively and 6 and 12 months after ACLR. Ceiling and floor effects and responsiveness were assessed using descriptive statistics and cross-tabulations, respectively, at both follow-up time points. Spearman correlations and intraclass correlation coefficients were used to examine convergent validity and test-retest reliability, respectively.

Results: Follow-up rates at 6 and 12 months were 100% and 99%, respectively. Test-retest follow-up was 77%. Floor effects for the SPORTS scores were not observed, while ceiling effects at 12 months ranged from 38% to 40%. Cross-tabulation of the SPORTS scores showed that 64% to 66% of patients reported a change in their score from 6 to 12 months, with significant differences noted between the proportions that improved versus worsened for return to any sport. Convergent validity was observed at 6 and 12 months via moderate correlations with the Tegner, Lysholm, KOOS-sport/recreation, and Marx scores ( = 0.31 to 0.47). Fair to good test-retest reliability (intraclass correlation coefficient, 0.58 and 0.60) was found at 12 months after ACLR.

Conclusion: The SPORTS score appears to be a reliable, responsive, and valid 1-item scale that can be used during the first year after ACLR. No differences in psychometric properties were found between the SPORTS score and the modified version.
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http://dx.doi.org/10.1177/23259671221098436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9185013PMC
June 2022

Wrist Arthrotomy Saline Load Test.

Hand (N Y) 2022 Mar 27:15589447211043194. Epub 2022 Mar 27.

Cleveland Clinic Foundation, OH, USA.

Background: Failure to recognize a potential wrist arthrotomy may lead to missed septic arthritis and devastating sequelae. The saline load test is routinely used to recognize traumatic arthrotomies of other joints; however, there are limited data optimizing this test for the wrist. The purpose of this study was to investigate and perform saline load testing to identify traumatic arthrotomies of the wrist.

Methods: This was a cadaveric study of 15 wrists. Traumatic arthrotomies were created using a blunt trocar through the 3-4 portal. A 3-mL syringe with 0.1 mL markings was used to inject methylene blue dyed saline into the wrist through the 1-2 portal. Once extravasation was visible from the atherectomized site, the volume was recorded.

Results: The mean (range) volume injected to identify the arthrotomy of all wrists was 1.22 mL (range, 0.1-3.1 mL). Multivariate regression demonstrated that cadaver age, laterality, and extension range of motion were not significantly associated with the injected saline volume at extravasation ( > .05, each). Greater joint range of motion was independently associated with higher saline volume load for extravasation (odds ratio: 1.049; 95% confidence interval: 1.024-1.075; = .003).

Conclusions: We found that 2.68 and 3.02 mL of methylene blue dyed saline offered 95% and 99% sensitivity, respectively, for diagnosing traumatic wrist arthrotomy. The maximum volume of saline needed to recognize an arthrotomy was 3.1 mL. We recommend this be the minimum volume used to evaluate a traumatic wrist arthrotomy.
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http://dx.doi.org/10.1177/15589447211043194DOI Listing
March 2022

Design Features and Rationale of the BEAR-MOON (Bridge-Enhanced ACL Restoration Multicenter Orthopaedic Outcomes Network) Randomized Clinical Trial.

Orthop J Sports Med 2022 Jan 25;10(1):23259671211065447. Epub 2022 Jan 25.

BEAR-MOON Design Group: All authors are listed in the Authors section at the end of this article.

Background: BEAR (bridge-enhanced anterior cruciate ligament [ACL] restoration), a paradigm-shifting technology to heal midsubstance ACL tears, has been demonstrated to be effective in a single-center 2:1 randomized controlled trial (RCT) versus hamstring ACL reconstruction. Widespread dissemination of BEAR into clinical practice should also be informed by a multicenter RCT to demonstrate exportability and compare efficacy with bone--patellar tendon-bone (BPTB) ACL reconstruction, another clinically standard treatment.

Purpose: To present the design and initial preparation of a multicenter RCT of BEAR versus BPTB ACL reconstruction (the BEAR: Multicenter Orthopaedic Outcomes Network [BEAR-MOON] trial). Design and analytic issues in planning the complex BEAR-MOON trial, involving the US National Institute of Arthritis and Musculoskeletal and Skin Diseases, the US Food and Drug Administration, the BEAR implant manufacturer, a data and safety monitoring board, and institutional review boards, can usefully inform both clinicians on the trial's strengths and limitations and future investigators on planning of complex orthopaedic studies.

Study Design: Clinical trial.

Methods: We describe the distinctive clinical, methodological, and operational challenges of comparing the innovative BEAR procedure with the well-established BPTB operation, and we outline the clinical motivation, experimental setting, study design, surgical challenges, rehabilitation, outcome measures, and planned analysis of the BEAR-MOON trial.

Results: BEAR-MOON is a 6-center, 12-surgeon, 200-patient randomized, partially blinded, noninferiority RCT comparing BEAR with BPTB ACL reconstruction for treating first-time midsubstance ACL tears. Noninferiority of BEAR relative to BPTB will be claimed if the total score on the International Knee Documentation Committee (IKDC) subjective knee evaluation form and the knee arthrometer 30-lb (13.61-kg) side-to-side laxity difference are both within respective margins of 16 points for the IKDC and 2.5 mm for knee laxity.

Conclusion: Major issues include patient selection, need for intraoperative randomization and treatment-specific postoperative physical therapy regimens (because of fundamental differences in surgical technique, initial stability construct, and healing), and choice of noninferiority margins for short-term efficacy outcomes of a novel intervention with evident short-term advantages and theoretical, but unverified, long-term benefits on other dimensions.
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http://dx.doi.org/10.1177/23259671211065447DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8793429PMC
January 2022

The "Fight Bite" Saline Joint Loading Test: Effectiveness in Detecting Simulated Traumatic Metacarpophalangeal Arthrotomies.

Hand (N Y) 2022 Jan 7:15589447211068184. Epub 2022 Jan 7.

Cleveland Clinic Foundation, OH, USA.

The saline load test is routinely used to recognize other joints' traumatic arthrotomies; however, there are currently no studies evaluating the novelty of this test for metacarpophalangeal joints (MCPJs). This study aimed to investigate the effectiveness and sensitivity of saline load testing in identifying the traumatic arthrotomies of the MCPJs using human cadavers. This was a cadaveric study of 16 hands (79 MCPJs). Traumatic arthrotomies were created using 11-blade stab-incisions, followed by blunt probing into the joint on the radial or ulnar side of the flexed MCPJs. A 3-mL syringe was used to inject intra-articular methylene-blue-dyed saline from the contralateral side. The volume at saline extravasation was recorded. Test sensitivity and factors influencing extravasation volume were assessed. The mean (range) volume injected to identify arthrotomy of all MCPJs was 0.18 mL (0.1-0.4 mL). The mean volume to identify MCPJ arthrotomy of the thumb, index, long, ring, and small fingers was 0.16 mL (0.1-0.3 mL), 0.19 mL (0.1-0.3 mL), 0.21 mL (0.1-0.4 mL), 0.17 mL (0.1-0.3 mL), and 0.16 mL (0.1-0.3 mL), respectively. Cadaver age, laterality, and joint range of motion were not significantly associated with the injected volume at extravasation( > .05, each). Injection volumes of 0.3 and 0.32 mL were required to detect arthrotomies at 95% and 99% sensitivities across all MCPJs. None of the MCPJs required > 0.4 mL to detect arthrotomy. Saline joint loading volumes to detect traumatic arthrotomy were similar for all MCPJs. Injection volumes of 0.32 mL is suggested for 99% sensitivity. Our findings provide the first report, to our knowledge, on intra-articular injection volumes expected to detect an arthrotomy of MCPJ. This is critical for further validation using in vivo clinical studies.
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http://dx.doi.org/10.1177/15589447211068184DOI Listing
January 2022

Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort.

Am J Sports Med 2022 01 24;50(1):118-127. Epub 2021 Nov 24.

The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease.

Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort.

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

Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest.

Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases.

Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.
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http://dx.doi.org/10.1177/03635465211057103DOI Listing
January 2022

Outcomes of Pediatric Posterior Cruciate Ligament Reconstruction: A Systematic Review.

Orthop J Sports Med 2021 Sep 28;9(9):23259671211032539. Epub 2021 Sep 28.

Cleveland Clinic Sports Medicine, Cleveland, Ohio, USA.

Background: Little has been reported in the literature regarding surgical treatment of posterior cruciate ligament (PCL) injuries in pediatric patients.

Purpose/hypothesis: The purpose was to evaluate presentation, injury pattern, outcomes, and complications of surgically managed PCL injuries in pediatric patients. It was hypothesized that pediatric patients would have good patient-reported outcomes and no significant radiographic changes or complications.

Study Design: Systematic review; Level of evidence, 4.

Methods: A literature search was performed using PubMed, Medline, EMBASE, Scopus, and Cochrane databases between 1975 and December 16, 2019. Search terms included "posterior cruciate ligament," "peel-off injury," "avulsion," "PCL," "pediatric," "skeletally immature," and "adolescent." Included were studies on pediatric patients with PCL injuries managed operatively. Exclusion criteria included case reports, studies not reporting clinical results, reviews, abstract or conference papers, or papers not in the English language. Quality assessment was performed on all included studies using the MINORS (Methodological Index for Non-Randomized Studies) criteria.

Results: Four articles comprising 43 knees in 42 patients met the criteria and were included. Motor vehicle accidents were the most common mechanism of injury (39.5%; n = 17/43), followed by sports-related injuries (35%; n = 15/43). All studies commented on tear pattern, with the following distribution: 42% (n = 18/43) midsubstance tears, 37% (n = 16/43) tibial avulsions, and 21% (n = 9/43) femoral avulsions. Overall, good patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score and Pediatric International Knee Documentation Committee, Tegner, and Lysholm scores) and return to activity, as well as satisfactory posterior stability (KT-1000 arthrometer, posterior drawer test, and kneeling radiographs) and range of motion, were reported. There was no significant leg-length discrepancy or angular deformity reported. Arthrofibrosis was reported in 7% of postoperative knees and was the most commonly reported complication. Osteoarthritis was reported in 21% (n = 9/43) of knees. The average MINORS score was 7 (range, 6-8) for noncomparative studies and 10 for comparative studies.

Conclusion: Good patient-reported outcomes and return to activity can be obtained using repair or reconstruction. This evidence was limited by the quality of the included studies and overall small sample size; however, this review serves as a baseline for futures studies on PCL repair/reconstruction in pediatric patients.
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http://dx.doi.org/10.1177/23259671211032539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8485165PMC
September 2021

Do Narcotic Use, Physical Therapy Location, or Payer Type Predict Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction?

Orthop J Sports Med 2021 Apr 26;9(4):2325967121994833. Epub 2021 Apr 26.

Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA.

Background: Opioid use and public insurance have been correlated with worse outcomes in a number of orthopaedic surgeries. These factors have not been investigated with anterior cruciate ligament reconstruction (ACLR).

Purpose/hypothesis: To evaluate if narcotic use, physical therapy location, and insurance type are predictors of patient-reported outcomes after ACLR. It was hypothesized that at 1 year postsurgically, increased postoperative narcotic use would be associated with worse outcomes, physical therapy obtained within the authors' integrated health care system would lead to better outcomes, and public insurance would lead to worse outcomes and athletic activity.

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

Methods: All patients undergoing unilateral, primary ACLR between January 2015 and February 2016 at a large health system were enrolled in a standard-of-care prospective cohort. Knee injury and Osteoarthritis Score (KOOS) and the Hospital for Special Surgery Pediatric-Functional Activity Brief Scale (HSS Pedi-FABS) were collected before surgery and at 1 year postoperatively. Concomitant knee pathology was assessed arthroscopically and electronically captured. Patient records were analyzed to determine physical therapy location, insurance status, and narcotic use. Multivariable regression analyses were used to identify significant predictors of the KOOS and HSS Pedi-FABS score.

Results: A total of 258 patients were included in the analysis (mean age, 25.8; 51.2% women). In multivariable regression analysis, narcotic use, physical therapy location, and insurance type were not independent predictors of any KOOS subscales. Public insurance was associated with a lower HSS Pedi-FABS score (-4.551, = .047) in multivariable analysis. Narcotic use or physical therapy location was not associated with the HSS Pedi-FABS score.

Conclusion: Increased narcotic use surrounding surgery, physical therapy location within the authors' health care system, and public versus private insurance were not associated with disease-specific KOOS subscale scores. Patients with public insurance had worse HSS Pedi-FABS activity scores compared with patients with private insurance, but neither narcotic use nor physical therapy location was associated with activity scores. Physical therapy location did not influence outcomes, suggesting that patients be given a choice in the location they received physical therapy (as long as a standardized protocol is followed) to maximize compliance.
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http://dx.doi.org/10.1177/2325967121994833DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085373PMC
April 2021

Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review.

Am J Sports Med 2022 04 13;50(5):1430-1441. Epub 2021 May 13.

Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.

Background: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients.

Purpose: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance.

Study Design: Systematic review; Level of evidence, 4.

Methods: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted.

Results: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity.

Conclusion: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment.

Registration: CRD42019136059 (PROSPERO).
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http://dx.doi.org/10.1177/03635465211008656DOI Listing
April 2022

Early Operative Versus Delayed Operative Versus Nonoperative Treatment of Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-analysis.

Am J Sports Med 2021 12 15;49(14):4008-4017. Epub 2021 Mar 15.

Investigation performed at Hospital for Special Surgery, New York, New York, USA.

Background: Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries.

Purpose/hypothesis: The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates.

Study Design: Systematic review and meta-analysis; Level of evidence, 4.

Methods: A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (<5 patients), non-English language manuscripts, multiligamentous injuries, and nonclinical studies.

Results: A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; = .006) and irreparable meniscal tear (odds ratio, 0.31; = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences ( = .413) or proportion with difference ≥3 mm ( = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%.

Conclusion: Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.
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http://dx.doi.org/10.1177/0363546521990817DOI Listing
December 2021

What Are the Predictors of Poor Patient-Reported Outcomes After Shoulder Instability Surgery?

Orthop J Sports Med 2020 Dec 29;8(12):2325967120966343. Epub 2020 Dec 29.

Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA.

Background: Prospectively collected responses to Patient Acceptable Symptom State (PASS) questions after shoulder instability surgery are limited. Responses to these outcome measures are imperative to understanding their clinical utility.

Purpose/hypothesis: The purpose of this study was to evaluate which factors predict unfavorable patient-reported outcomes after shoulder instability surgery, including "no" to the PASS question. We hypothesized that poor outcomes would be associated with male adolescents, bone loss, combined labral tears, and articular cartilage injuries.

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

Methods: Patients aged ≥13 years undergoing shoulder instability surgery were included in point-of-care data collection at a single institution across 12 surgeons between 2015 and 2017. Patients with anterior-inferior labral tears were included, and those with previous ipsilateral shoulder surgery were excluded. Demographics, American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, and surgical findings were obtained at baseline. ASES and SANE scores, PASS responses, and early revision surgery rates were obtained at a minimum of 1 year after the surgical intervention. Regression analyses were performed.

Results: A total of 234 patients met inclusion criteria, of which 176 completed follow-up responses (75.2%). Nonresponders had a younger age, greater frequency of glenoid bone loss, fewer combined tears, and more articular cartilage injuries ( < .05). Responders' mean age was 25.1 years, and 22.2% were female. Early revision surgery occurred in 3.4% of these patients, and 76.1% responded yes to the PASS question. A yes response correlated with a mean 25-point improvement in the ASES score and a 40-point improvement in the SANE score. On multivariate analysis, combined labral tears (anterior-inferior plus superior or posterior tears) were associated with greater odds of responding no to the PASS question, while both combined tears and injured capsules were associated with lower ASES and SANE scores ( < .05). Sex, bone loss, and grade 3 to 4 articular cartilage injuries were not associated with variations on any patient-reported outcome measure.

Conclusion: Patients largely approved of their symptom state at ≥1 year after shoulder instability surgery. A response of yes to the PASS question was given by 76.1% of patients and was correlated with clinically and statistically significant improvements in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across patient-reported outcome measures, whereas sex, bone loss, and cartilage injuries were not.
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http://dx.doi.org/10.1177/2325967120966343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7780330PMC
December 2020

Interrater Agreement of an Arthroscopic Anterior Cruciate Ligament Tear Classification System.

Orthop J Sports Med 2020 Dec 3;8(12):2325967120966323. Epub 2020 Dec 3.

Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA.

Background: Anterior cruciate ligament (ACL) rupture is the most common ligament injury treated surgically by orthopaedic surgeons. The gold standard for the treatment of the majority of primary ACL tears is ACL reconstruction. However, novel methods of repair, such as bridge-enhanced ACL repair (BEAR), are currently being investigated as alternatives to reconstruction. To assess patients for midsubstance repair suitability, clarify the prognostic implications of injury location and damage, and evaluate the results of a repair technique, it is important to have a baseline classification system or grading scale that is reproducible across surgeons, particularly for multicenter collaboration. Currently, no such system or scale exists.

Purpose: To develop an arthroscopic ACL tear classification system and to evaluate its interobserver reliability.

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

Methods: Eleven fellowship-trained orthopaedic surgeon investigators reviewed 75 video clips containing arthroscopic evaluation of a torn ACL and then completed the 6-question ACL Pathology Evaluation Form. Agreement statistics including exact agreement, Fleiss κ, Gwet agreement coefficient 1 (AC1), and Gwet AC2 were then calculated to assess interobserver reliability.

Results: In aggregate, the multiple assessments of observer reproducibility revealed that surgeon participants in this study, when evaluating the same injury, agreed roughly 80% of the time on whether (1) at least 50% of the tibial footprint remained, (2) the remaining tibial stump was ≥10 mm, and (3) the injury was therefore reparable using the BEAR procedure. Participants also agreed roughly 60% of the time on exactly how many suturable bundles were available. These characteristics are believed to be most important, among those studied, in determining whether a torn ACL is amenable to midsubstance repair.

Conclusion: This study is the first of its kind to demonstrate the interobserver reliability of arthroscopic classification of ACL tears. We have demonstrated that this classification system, though not ideally reproducible, is reliable enough across surgeons at multiple institutions for use in multicenter studies.

Registration: NCT03776162 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/2325967120966323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720329PMC
December 2020

Machine Learning Outperforms Regression Analysis to Predict Next-Season Major League Baseball Player Injuries: Epidemiology and Validation of 13,982 Player-Years From Performance and Injury Profile Trends, 2000-2017.

Orthop J Sports Med 2020 Nov 11;8(11):2325967120963046. Epub 2020 Nov 11.

Orthopaedic Machine Learning Laboratory, Cleveland Clinic, Cleveland, Ohio, USA.

Background: Machine learning (ML) allows for the development of a predictive algorithm capable of imbibing historical data on a Major League Baseball (MLB) player to accurately project the player's future availability.

Purpose: To determine the validity of an ML model in predicting the next-season injury risk and anatomic injury location for both position players and pitchers in the MLB.

Study Design: Descriptive epidemiology study.

Methods: Using 4 online baseball databases, we compiled MLB player data, including age, performance metrics, and injury history. A total of 84 ML algorithms were developed. The output of each algorithm reported whether the player would sustain an injury the following season as well as the injury's anatomic site. The area under the receiver operating characteristic curve (AUC) primarily determined validation.

Results: Player data were generated from 1931 position players and 1245 pitchers, with a mean follow-up of 4.40 years (13,982 player-years) between the years of 2000 and 2017. Injured players spent a total of 108,656 days on the disabled list, with a mean of 34.21 total days per player. The mean AUC for predicting next-season injuries was 0.76 among position players and 0.65 among pitchers using the top 3 ensemble classification. Back injuries had the highest AUC among both position players and pitchers, at 0.73. Advanced ML models outperformed logistic regression in 13 of 14 cases.

Conclusion: Advanced ML models generally outperformed logistic regression and demonstrated fair capability in predicting publicly reportable next-season injuries, including the anatomic region for position players, although not for pitchers.
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http://dx.doi.org/10.1177/2325967120963046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672741PMC
November 2020

Osteochondritis Dissecans of the Knee: An Interrater Reliability Study of Magnetic Resonance Imaging Characteristics.

Am J Sports Med 2020 07 25;48(9):2221-2229. Epub 2020 Jun 25.

Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

Background: Imaging characteristics of osteochondritis dissecans (OCD) lesions quantified by magnetic resonance imaging (MRI) are often used to inform treatment and prognosis. However, the interrater reliability of clinician-driven MRI-based assessment of OCD lesions is not well documented.

Purpose: To determine the interrater reliability of several historical and novel MRI-derived characteristics of OCD of the knee in children.

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

Methods: A total of 42 OCD lesions were evaluated by 10 fellowship-trained orthopaedic surgeons using 31 different MRI characteristics, characterizing lesion size and location, condylar size, cartilage status, the interface between parent and progeny bone, and features of both the parent and the progeny bone. Interrater reliability was determined via intraclass correlation coefficients (ICCs) with 2-way random modeling, Fleiss kappa, or Krippendorff alpha as appropriate for each variable.

Results: Raters were reliable when the lesion was measured in the coronal plane (ICC, 0.77). Almost perfect agreement was achieved for condylar size (ICC, 0.93), substantial agreement for physeal patency (ICC, 0.79), and moderate agreement for joint effusion (ICC, 0.56) and cartilage status (ICC, 0.50). Overall, raters showed significant variability regarding interface characteristics (ICC, 0.25), progeny (ICC range, 0.03 to 0.62), and parent bone measurements and qualities (ICC range, -0.02 to 0.65), with reliability being moderate at best for these measurements.

Conclusion: This multicenter study determined the interrater reliability of MRI characteristics of OCD lesions in children. Although several measurements provided acceptable reliability, many MRI features of OCD that inform treatment decisions were unreliable. Further work will be needed to refine the unreliable characteristics and to assess the ability of those reliable characteristics to predict clinical lesion instability and prognosis.
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http://dx.doi.org/10.1177/0363546520930427DOI Listing
July 2020

Smartphone Data Capture Efficiently Augments Dictation for Knee Arthroscopic Surgery.

J Am Acad Orthop Surg 2020 Feb;28(3):e115-e124

From the Cleveland Clinic Lerner College of Medicine (Mr. Featherall), the Department of Orthopaedic Surgery, Cleveland Clinic (Dr. Oak, Mr. Strnad, Dr. Farrow, Dr. Jones, Dr. Miniaci, Dr. Parker, Dr. Rosneck, Dr. Saluan, and Dr. Spindler), and the Cleveland Clinic Sports Health Center, Cleveland Clinic (Dr. Farrow, Dr. Jones, Dr. Miniaci, Dr. Parker, Dr. Rosneck, Dr. Saluan, and Dr. Spindler), Cleveland, OH.

Introduction: The objectives of this study are (1) to develop a provider-friendly, evidence-based data capture system for lower-limb orthopaedic surgeries and (2) to assess the performance of the data capture system on the dimensions of agreement with operative note and implant log, consistency of data, and speed of provider input.

Methods: A multidisciplinary team developed a database and user interfaces for Android and iOS operating systems. Branching logic and discrete fields were created to streamline provider data input. One hundred patients were randomly selected from the first four months of data collection (February to June 2015). Patients were limited to those undergoing anterior cruciate ligament reconstruction, meniscal repair, partial meniscectomy, or a combination of these procedures. Duplicate data on these 100 patients were collected through chart review. These two data sets were compared. Cohen's kappa statistic was used to assess agreement.

Results: The database and smartphone data capture tool show almost perfect agreement (kappa > 0.81) for all data tested. In addition, data are more comprehensive with near-perfect provider completion (100% for all data tested). Furthermore, provider data entry is extremely efficient (median 151-second completion time).

Conclusion: A well-designed database and user-friendly interface have greater potential for research utility, clinical efficiency, and, thus, cost-effectiveness when compared with standard voice-dictated operative notes. Widespread utilization of such tools can accelerate the pace and improve the quality of orthopaedic clinical research.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.5435/JAAOS-D-19-00074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964865PMC
February 2020

Robotically Simulated Pivot Shift That Represents the Clinical Exam.

J Orthop Res 2019 12 26;37(12):2601-2608. Epub 2019 Aug 26.

Department of Orthopaedic Surgery, and Orthopaedic and Rheumatologic Research Center, Cleveland Clinic, Cleveland, Ohio.

A thorough understanding of anterior cruciate ligament (ACL) function and the effects of surgical interventions on knee biomechanics requires robust technologies and simulation paradigms that align with clinical insight. In vitro orthopedic biomechanical testing for the elucidation of ACL integrity doesn't have an established testing paradigm to simulate the clinical pivot shift exam on cadaveric specimens. The study aim was to develop a robotically simulated pivot shift that represents the clinical exam. An orthopedic surgeon performed a pivot shift on an instrumented ACL-deficient cadaver leg to capture 6 degree-of-freedom motion/loads. The same knee was mounted to the robot and the sensitivity of the motion/loading profiles quantified. Three loading profile candidates that generated positive pivot shifts on the instrumented knee were selected and applied to 7 ACL-intact/deficient specimens and resulted in the identification of a profile that was able to induce a positive pivot shift in all ACL-deficient specimens ( p < 0.001). The simulated shifts began at 22 ± 8° and ended at 33 ± 6° of flexion with the average magnitude of the shifts being 12.8 ± 3.2 mm in anterior tibial translation and 17.6 ± 4.3° in external tibial rotation. The establishment and replication of a robotically simulated clinical pivot shift across multiple specimens show the robustness of the loading profile to accommodate anatomical and experimental variability. Further evaluation and refinement should be undertaken to create a useful tool in evaluating ACL function and reconstruction techniques. Statement of clinical significance: Creation and successful demonstration of the simulated clinical pivot shift validates a profile for robotic musculoskeletal simulators to analyze ACL related clinical questions. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2601-2608, 2019.
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http://dx.doi.org/10.1002/jor.24439DOI Listing
December 2019

Predictors of Pain and Function Before Knee Arthroscopy.

Orthop J Sports Med 2019 May 15;7(5):2325967119844265. Epub 2019 May 15.

Investigation performed at Cleveland Clinic Sports Health, Cleveland, Ohio, USA.

Background: Patient-reported outcome measures are commonly used to measure knee pain and functional impairment. When structural abnormality is identified on examination and imaging, arthroscopic partial meniscectomy and chondroplasty are commonly indicated for treatment in the setting of pain and decreased function.

Purpose: To evaluate the relationship between patient characteristics, mental health, intraoperative findings, and patient-reported outcome measures at the time of knee arthroscopy.

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

Methods: Between February 2015 and October 2016, patients aged 40 years and older who were undergoing routine knee arthroscopy for meniscal and cartilage abnormality, without reconstructive or restorative procedures, were prospectively enrolled in this study. Routine demographic information was collected, and the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain, Quality of Life (QoL), and Physical Function Short Form (PS) subscales and the mental and physical component subscales of the Veterans RAND 12-Item Health Survey (VR-12 MCS and VR-12 PCS) were administered preoperatively on the day of surgery. Intraoperative findings were collected in a standardized format. Patient demographics, intraoperative findings, and the VR-12 MCS were used as predictor values, and a multivariate analysis was conducted to assess for relationships with the KOOS and VR-12 as dependent variables.

Results: Of 661 eligible patients, baseline patient-reported outcomes and surgical data were used for 638 patients (97%). Lower scores on both subscales of the VR-12 were predicted by female sex, positive smoking history, fewer years of education, and higher body mass index (BMI). All KOOS subscales were negatively affected by lower VR-12 MCS scores, female sex, lower education level, and higher BMI in a statistically meaningful way. Positive smoking history was associated with worse scores on the KOOS-PS. Abnormal synovial status was associated with worse KOOS-Pain.

Conclusion: The demographic factors of sex, smoking status, BMI, and education level had an overwhelming impact on preoperative KOOS and VR-12 scores. Of interest, mental health as assessed by the VR-12 MCS was also a consistent predictor of KOOS scores. The only intraoperative finding with a significant association was abnormal synovial status and its effect on KOOS-Pain scores.
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http://dx.doi.org/10.1177/2325967119844265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537074PMC
May 2019

A smart decision: smartphone use for operative data collection in arthroscopic shoulder instability surgery.

J Am Med Inform Assoc 2019 10;26(10):1030-1036

Sports Health, Cleveland Clinic, Cleveland, Ohio, USA.

Objective: This study tested validity, accuracy, and efficiency of the Orthopaedic Minimal Data Set Episode of Care (OME) compared with traditional operative report in arthroscopic surgery for shoulder instability. As of November 2017, OME had successfully captured baseline data on 97% of 18 700 eligible cases.

Materials And Methods: This study analyzes 100 cases entered into OME through smartphones by 12 surgeons at an institution from February to October 2015. A blinded reviewer extracted the same variables from operative report into a separate database. Completion rates and agreement were compared. They were assessed using raw percentages and McNemar's test (with continuity correction). Agreement between nominal variables was assessed by unweighted Cohen's kappa and a concordance correlation coefficient measured agreement between continuous variables. Efficiency was assessed by median time to complete.

Results: Of 37 variables, OME demonstrated equal or higher completion rates for all but 1 and had significantly higher capture rates for 49% (n = 18; P < .05). Of 33 nominal variables, raw proportional agreement was ≥0.90 for 76% (n = 25). Raw proportional agreement was perfect for 15% (n = 5); no agreement statistic could be calculated due to a single variable in operative note and OME. Calculated agreement statistic was substantial or better (κ > 0.61) for 51% (n = 17) for the 33 nominal variables. All continuous variables assessed (n = 4) demonstrated poor agreement (concordance correlation coefficient <0.90). Median time for completing OME was 103.5 (interquartile range, 80.5-151) seconds.

Conclusions: The OME smartphone data capture system routinely captured more data than operative report and demonstrated acceptable agreement for nearly all nominal variables, yet took <2 minutes to complete on average.
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http://dx.doi.org/10.1093/jamia/ocz074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748799PMC
October 2019

Quadriceps tendinopathy: a review, part 2-classification, prognosis, and treatment.

Ann Transl Med 2019 Feb;7(4):72

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.

Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy in the non-athlete population. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the previous part we reviewed: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In this part we discuss: (I) classification; (II) prognosis; and (III) treatment results.
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http://dx.doi.org/10.21037/atm.2019.01.63DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6409233PMC
February 2019

Quadriceps tendinopathy: a review-part 1: epidemiology and diagnosis.

Ann Transl Med 2019 Feb;7(4):71

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA.

Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Historically, they have been labeled as Jumper's knee due to the high prevalence seen in the athletic community. In many published reports, the name "patellar tendinopathy" is used to describe this disorder of the quadriceps tendon at the patellar insertion, and the names are often used interchangeably. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the first part we review: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In the second part we discuss: (I) classification; (II) prognosis; and (III) treatment results.
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http://dx.doi.org/10.21037/atm.2019.01.58DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6409230PMC
February 2019

Comparison of Standard and Right/Left International Knee Documentation Committee Subjective Knee Form Scores.

Am J Sports Med 2019 04 21;47(5):1203-1208. Epub 2019 Mar 21.

Cleveland Clinic Sports Health Center, Garfield Heights, Ohio, USA.

Background: The International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) is a validated patient-reported outcome used in clinical research. No studies exist directly comparing the standard unilateral adult version (IKDC-SKF) with the bilateral adult version (R/L IKDC-SKF).

Hypotheses: The first hypothesis is that no clinically relevant difference would be observed between standard IKDC-SKF scores and involved R/L scores. The second hypothesis is that a relevant difference would be observed between involved and uninvolved scores on the R/L IKDC-SKF.

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

Methods: One hundred patients were enrolled via a crossover study design. Participants were split into 2 groups per simple randomization. One group completed the standard IKDC-SKF first and the R/L IKDC-SKF second. The other group completed forms in the reverse order. A 10-minute washout period was administered between questionnaires. Participants reported their preferred form in a postquestionnaire survey. A 5-point threshold for clinical relevance was set a priori, which is less than multiple published minimal detectable change and minimal clinically important difference metrics of the standard IKDC-SKF, ranging from 6.3 to 20.5. Data were analyzed with Bland-Altman plots, paired t tests, correlations, and chi-square tests.

Results: Paired t tests between the standard IKDC-SKF and the involved R/L IKDC-SKF scores demonstrated a statistically significant mean difference of 1.4 ( P = .008; 95% CI, 0.4-2.4). However, the 95% CI falls under the clinically relevant threshold of 5. Standard and involved knee scores from the R/L IKDC-SKF were highly correlated, with a rho of 0.95. Patients consistently distinguished the injured knee from the uninjured knee across a range of scores via the R/L IKDC-SKF ( P < .001). The postquestionnaire survey showed that 55 patients preferred the R/L IKDC-SKF, 30 preferred the standard IKDC-SKF, and 15 had no preference. Post hoc analysis showed a significant preference for "R/L vs standard IKDC-SKF" ( P = .014) and "R/L IKDC-SKF vs no preference" ( P < .003).

Conclusion: No clinically relevant difference was observed between the standard IKDC-SKF and the involved knee score of the R/L IKDC-SKF. Therefore, for symptomatic unilateral knee diagnosis, either form can be used. The R/L IKDC-SKF showed a consistent and clinically relevant difference between involved and uninvolved knees. Patients in this study preferred the R/L IKDC-SKF.
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http://dx.doi.org/10.1177/0363546519829770DOI Listing
April 2019

Prospective Evaluation of the Patient Acceptable Symptom State to Identify Clinically Successful Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2019 04 18;47(5):1159-1167. Epub 2019 Mar 18.

Cleveland Clinic Orthopaedics Sports Health, Cleveland, Ohio, USA.

Background: The length of most patient-reported outcome measures creates significant response burden, which hampers follow-up rates. The Patient Acceptable Symptom State (PASS) is a single-item, patient-reported outcome measure that asks patients to consider all aspects of life to determine whether the state of their joint is satisfactory; this measure may be viable for tracking outcomes on a large scale.

Hypothesis: The PASS question would identify clinically successful anterior cruciate ligament reconstruction (ACLR) at 1-year follow-up with high sensitivity and moderate specificity. We defined "clinically successful" ACLR as changes in preoperative to postoperative scores on the Knee injury and Osteoarthritis Outcome Score (KOOS) pain subscale and the KOOS knee-related quality of life subscale in excess of minimal clinically important difference or final KOOS pain or knee-related quality of life subscale scores in excess of previously defined PASS thresholds.

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

Methods: Patients enrolled in a prospective longitudinal cohort completed patient-reported outcome measures immediately before primary ACLR. At 1-year follow-up, patients completed the same patient-reported outcome measures and answered the PASS question: "Taking into account all the activity you have during your daily life, your level of pain, and also your activity limitations and participation restrictions, do you consider the current state of your knee satisfactory?"

Results: A total of 555 patients enrolled in our cohort; 464 were eligible for this study. Of these, 300 patients (64.7%) completed 1-year follow-up, of whom 83.3% reported satisfaction with their knee after surgery. The PASS question demonstrated high sensitivity to identify clinically successful ACLR (92.6%; 95% CI, 88.4%-95.6%). The specificity of the question was 47.1% (95% CI, 35.1%-59.5%). The overall agreement between the PASS and our KOOS-based criteria for clinically successful intervention was 81.9%, and the kappa value indicated moderate agreement between the two methods (κ = 0.44).

Conclusion: The PASS question identifies individuals who have experienced clinically successful ACLR with high sensitivity. The limitation of the PASS is its low specificity, which we calculated to be 47.1%. Answering "no" to the PASS question meant that a patient neither improved after surgery nor achieved an acceptable final state of knee health. The brevity, interpretability, and correlation of the PASS question with significant improvements on various KOOS subscales make it a viable option in tracking ACLR outcomes on a national or global scale.
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http://dx.doi.org/10.1177/0363546519831008DOI Listing
April 2019

Current Concepts: Evaluation and Treatment of Discoid Meniscus in the Pediatric Athlete.

Am J Orthop (Belle Mead NJ) 2018 Dec;47(12)

NYU-Langone Medical Center, Department of Orthopaedic Surgery, 301 East 17th Street, New York, NY 10003, USA. Email:

Discoid meniscus is a rare anatomical variant with altered morphology and structure that can sometimes present symptomatically, typically in the pediatric population. The discoid meniscus is usually in the lateral compartment of the knee and is characterized by a partial or complete filling-in of central meniscal tissue, increased meniscal thickness, disorganization of longitudinal collagen fibers, and sometimes lack of peripheral attachments. These changes to both the macro- and micro-structure of the meniscus predispose affected patients to increased rates of both meniscal tears and mechanical symptoms. Surgical management of symptomatic discoid meniscus is directed toward symptom resolution while preserving sufficient functional meniscal tissue to delay or prevent the development of osteoarthritis. Modern surgical techniques consist of arthroscopic saucerization of the discoid meniscus with repair of associated meniscal tears and stabilization of peripheral attachments. Although long-term outcome data are lacking, short- and mid-term outcomes for patients treated with arthroscopic partial meniscectomy and meniscal repair and/or stabilization as needed are generally good.
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http://dx.doi.org/10.12788/ajo.2018.0107DOI Listing
December 2018

The Effects of Endurance Sports on Children and Youth.

Sports Med Arthrosc Rev 2019 Mar;27(1):35-39

Cleveland Clinic Department of Orthopaedics, Cleveland, OH.

In the United States, youth participation in sports continues to increase yearly. This increase in participation, in conjunction with the trend toward early sports specialization and year round training, has led to a similar increase in athletically developed injuries. These injuries vary in nature and acuity, with the type of injury often related to the athlete's age, sport, and level of training. Endurance athletes are at an elevated risk of injury as they frequently push their body to the limit during their arduous training. Pediatric endurance athletes can be particularly vulnerable, especially to overuse injuries, given their unique and ever-changing physiological state. It is important to understand the specific challenges facing not only the physical, but also the emotional well-being of these pediatric endurance athletes to maximize performance while minimizing injury and potential long-term sequelae.
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http://dx.doi.org/10.1097/JSA.0000000000000230DOI Listing
March 2019

Evaluation of the Schöttle Technique in the Pediatric Knee.

Orthop J Sports Med 2017 Nov 21;5(11):2325967117740078. Epub 2017 Nov 21.

Cleveland Clinic Orthopaedic and Rheumatologic Institute, Garfield Heights, Ohio, USA.

Background: The Schöttle point is commonly used for anatomic femoral tunnel placement during medial patellofemoral ligament (MPFL) reconstruction. This technique has not been previously validated in the skeletally immature patient, in whom femoral tunnel placement may put the distal femoral physis at risk of iatrogenic injury.

Hypothesis: Interobserver reliability for femoral tunnel placement will be higher in adult knees compared with pediatric knees.

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

Methods: We selected 30 perfect lateral radiographs for this study: 20 from pediatric knees (mean patient age, 10 years; range, 8-11 years) and 10 from adult knees (mean patient age, 18.5 years; range, 18-23 years). Six observers with varying levels of clinical experience evaluated each radiograph and approximated the site of the MPFL femoral tunnel using the Schöttle technique. Intra- and interobserver reliabilities for femoral tunnel placement were evaluated. Statistical analysis was used to compare measurements.

Results: During initial interobserver measurements, the diameter of the composite perfect circles averaged 9.0 and 6.8 mm in adult and pediatric knees, respectively ( = .004). At repeat measurement, circles averaged 9.8 and 7.3 mm in adult and pediatric knees, respectively ( = .0001). Femoral tunnel placement intraobserver variance averaged 2.9 mm in adult knees (range, 1.9-4.0 mm) and 2.3 mm in pediatric knees (range, 1.9-2.9 mm). This difference was not significant ( = .14).

Conclusion: This study demonstrated that interobserver variance is actually greater in adult knees compared with pediatric knees, although interobserver variance was significantly different for both populations. Additionally, intraobserver variance is small on repeat measures, demonstrating that the Schöttle technique is reproducible for individual observers. Sources of this increased variance between observers are differences in agreement on the bony landmarks required for the Schöttle technique. Due to this variability in tunnel placement, we recommend caution when the Schöttle technique is used in pediatric knees to avoid iatrogenic injury to the distal femoral physis during femoral tunnel placement.
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http://dx.doi.org/10.1177/2325967117740078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5700790PMC
November 2017

Outcomes After Arthroscopic Bankart Repair: Patients With First-Time Versus Recurrent Dislocations.

Am J Sports Med 2017 Jul 6;45(8):1776-1782. Epub 2017 Apr 6.

Cleveland Clinic Sports Health, Ohio, USA.

Background: The young athletic population makes up the largest portion of shoulder instability and, when treated nonoperatively, has a recurrent dislocation rate as high as 71%. It is unknown how the outcomes of those who have a recurrent dislocation are affected versus those who have a stabilization procedure after a first-time dislocation.

Purpose: To report the postoperative outcomes of patients with first-time dislocations versus patients with recurrent dislocations before surgery.

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

Methods: Current Procedural Terminology codes were used to identify patients who had arthroscopic Bankart repair between 2003 and 2013. A total of 173 eligible patients were identified across 8 fellowship-trained surgical practices. The first phase of the study was a retrospective chart review. Patients were identified as having a first-time dislocation or as having recurrent dislocations when they had >1 dislocation before surgical intervention. The second phase consisted of a survey to record a Simple Shoulder Test score and return to sport and to report postoperative instability and whether patients had further surgery on the shoulder.

Results: A total of 121 patients participated, providing 70% follow-up at an average of 51 months. There were 53 patients in the recurrent dislocation group and 68 in the first-time dislocation group. The postoperative instability rate was 29% in the first-time dislocation group and 62% in the recurrent dislocation group; this difference was significant ( P < .001). The odds of postoperative instability were 4 times higher in the recurrent dislocation group (odds ratio = 4.14). The first-time dislocation group reported a 7% rate of repeat operation to address instability, whereas the recurrent dislocation group reported a rate of 32%; this difference was significant ( P < .001). The odds of needing additional surgery on the index shoulder was 6 times higher in the recurrent dislocation group (odds ratio = 6.01).

Conclusion: Patients with first-time dislocations had lower postoperative instability rates and reoperation rates when compared with patients with recurrent dislocations before surgery. Young patients with shoulder instability should be offered early surgical intervention to lower the risk of postoperative instability and reoperation.
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July 2017

No Clinically Significant Difference Between Adult and Pediatric IKDC Subjective Knee Evaluation Scores in Adults.

Sports Health 2017 Sep/Oct;9(5):450-455. Epub 2017 Jan 12.

Background: Two versions of the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form currently exist: the original version (1999) and a recently modified pediatric-specific version (2011). Comparison of the pediatric IKDC with the adult version in the adult population may reveal that either version could be used longitudinally.

Hypothesis: We hypothesize that the scores for the adult IKDC and pediatric IKDC will not be clinically different among adult patients aged 18 to 50 years.

Study Design: Randomized crossover study design.

Level Of Evidence: Level 2.

Methods: The study consisted of 100 participants, aged 18 to 50 years, who presented to orthopaedic outpatient clinics with knee problems. All participants completed both adult and pediatric versions of the IKDC in random order with a 10-minute break in between. We used a paired t test to test for a difference between the scores and a Welch's 2-sample t test to test for equivalence. A least-squares regression model was used to model adult scores as a function of pediatric scores, and vice versa.

Results: A paired t test revealed a statistically significant 1.6-point difference between the mean adult and pediatric scores. However, the 95% confidence interval (0.54-2.66) for this difference did not exceed our a priori threshold of 5 points, indicating that this difference was not clinically important. Equivalence testing with an equivalence region of 5 points further supported this finding. The adult and pediatric scores had a linear relationship and were highly correlated with an R of 92.6%.

Conclusion: There is no clinically relevant difference between the scores of the adult and pediatric IKDC forms in adults, aged 18 to 50 years, with knee conditions.

Clinical Relevance: Either form, adult or pediatric, of the IKDC can be used in this population for longitudinal studies. If the pediatric version is administered in adolescence, it can be used for follow-up into adulthood.
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http://dx.doi.org/10.1177/1941738116685299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582692PMC
September 2017

Shoulder and Elbow Injuries in the Adolescent Athlete.

Sports Med Arthrosc Rev 2016 Dec;24(4):188-194

Cleveland Clinic Foundation, Cleveland, OH.

With the recent increase in youth sports participation and single-sport youth athletes over the past 30 years, there has been an increase in the number of acute and overuse sports injuries in this population. This review focuses on overuse and traumatic injuries of the shoulder and elbow in young athletes. In particular we discuss little league shoulder, glenohumeral internal rotation deficit, glenohumeral instability, superior labrum anterior posterior lesions, Little League elbow, Panner disease, osteochondritis dissecans of the capitellum, posteromedial elbow impingement, and posterolateral rotatory instability of the elbow. There is a significant emphasis on the evaluation and management of upper extremity injury in the overhead thrower.
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http://dx.doi.org/10.1097/JSA.0000000000000131DOI Listing
December 2016

Patellofemoral Pain and Instability in Adolescent Athletes.

Sports Med Arthrosc Rev 2016 Dec;24(4):144-149

Cleveland Clinic Sports Health, Garfield Heights, OH.

Injuries and disorders of the patellofemoral joint in the adolescent athlete can encompass a wide spectrum of symptomatology and pathology. Anterior knee pain is a common presenting symptom in sports medicine clinics, and can have numerous underlying etiologies. This activity-related pain may be the manifestation of enthesopathy, tendinopathy, fat pad impingement, or numerous other conditions, but is more commonly related to more subtle skeletal and muscular imbalances. Treatment is typically nonoperative in nature, and excellent results are reported with physical therapy. Patellofemoral instability usually has a more dramatic onset in the form of dislocation or subluxation events, commonly experienced during athletics. Concomitant injuries to the patellofemoral articular cartilage are common. Again, treatment is typically nonoperative initially, but recurrent or recalcitrant instability may necessitate reconstructive or realignment procedures. Skeletal maturity often dictates what procedures can be safely attempted.
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http://dx.doi.org/10.1097/JSA.0000000000000133DOI Listing
December 2016

Sports Injuries in Pediatric and Adolescent Athletes.

Authors:
Paul Saluan

Sports Med Arthrosc Rev 2016 Dec;24(4):143

Cleveland Clinic, Garfield Heights, OH.

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http://dx.doi.org/10.1097/JSA.0000000000000132DOI Listing
December 2016

Medial Patellofemoral Ligament Reconstruction.

JBJS Rev 2015 Jul;3(7)

Department of Orthopaedic Surgery, Cleveland Clinic, 5555 Transportation Boulevard, Cleveland, OH 44125.

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http://dx.doi.org/10.2106/JBJS.RVW.N.00089DOI Listing
July 2015
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