Publications by authors named "Riley J Williams"

130 Publications

Differences in the Demographics and Preferred Management of Knee Cartilage Injuries in Soccer Players Across FIFA Centers of Excellence.

Cartilage 2021 May 30:19476035211018857. Epub 2021 May 30.

Sports Medicine Institute (FIFA Medical Center of Excellence), Hospital for Special Surgery, New York, NY, USA.

Objective: We sought to report on the demographics and epidemiology of knee cartilage injuries and preferred management in soccer players, across FIFA Medical Centers of Excellence (FMCE).

Design: A descriptive questionnaire focusing on characteristics of knee cartilage injuries and their management in soccer players during the 10-year period prior to the distribution of the questionnaire was sent to all FMCE around the world in September 2019 via an online platform. Voluntary responses from centers were processed and analyzed. Descriptive characteristics were reported using median and interquartile ranges (IQR) for continuous variables and frequencies and percentages (%) for discrete variables.

Results: A total of 15 centers from 5 continents responded to the questionnaire and reported on a total of 4526 soccer players. Among centers, the median age was 27 years (IQR: 23-38), the median rate of male players was 75% (IQR: 68-90), and the median rate of professional players was 10% (IQR: 5-23). The most common reported etiology for cartilage injury was traumatic (median 40%, IQR: 13-73). The most common nonoperative treatment utilized was physical therapy (median 90%, IQR: 51%-100%) and the most common operative treatment utilized was bone marrow stimulation/micro-fracture (median 40%, IQR: 19-54%). The utilization of other cartilage restoration procedures varied across centers.

Conclusions: Our findings highlight different tendencies in the management of these injuries across FMCE and emphasize the need for collaborative efforts focusing on establishing consensus guidelines for the optimal management of these challenging injuries in soccer players.
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http://dx.doi.org/10.1177/19476035211018857DOI Listing
May 2021

Effect of Preoperative Imaging and Patient Factors on Clinically Meaningful Outcomes and Quality of Life After Osteochondral Allograft Transplantation: A Machine Learning Analysis of Cartilage Defects of the Knee.

Am J Sports Med 2021 May 28:3635465211015179. Epub 2021 May 28.

Sports Medicine and Shoulder Service, Institute for Cartilage Repair Hospital for Special Surgery, New York, New York, USA.

Background: Fresh osteochondral allograft transplantation (OCA) is an effective method of treating symptomatic cartilage defects of the knee. This restoration technique involves the single-stage implantation of viable, mature hyaline cartilage into a chondral or osteochondral lesion. The extent to which preoperative imaging and patient factors predict achieving clinically meaningful outcomes among patients undergoing OCA for cartilage lesions of the knee remains unknown.

Purpose: To determine the predictive relationship of preoperative imaging, preoperative patient-reported outcome measures (PROMs), and patient demographics with achievement of the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for functional and quality-of-life PROMs at 2 years after OCA for symptomatic cartilage defects of the knee.

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

Methods: Data were analyzed for patients who underwent OCA before May 1, 2018, by 2 high-volume fellowship-trained cartilage surgeons. The International Knee Documentation Committee (IKDC) subjective form, Knee Outcome Survey-Activities of Daily Living (KOS-ADL), and mental and physical component summaries of the SF-36 were administered preoperatively and at 2 years postoperatively. A total of 42 predictive models were created using 7 unique architectures to detect achievement of the MCID for each of the 4 outcome measures and the SCB for the IKDC and KOS-ADL. Data inputted into the models included sex, age, body mass index, baseline PROMs, lesion size, concomitant ligamentous or meniscal tear, and presence of "bone bruise" or osseous edema. Shapley additive explanations plot analysis identified predictors of reaching the MCID and SCB.

Results: Of the 185 patients who underwent OCA for the knee and met eligibility criteria from an institutional cartilage registry, 153 (83%) had 2-year follow-up. Preoperative magnetic resonance imaging (MRI), baseline PROMs, and patient demographics best predicted reaching the 2-year MCID and SCB of the IKDC and KOS-ADL PROMs, with areas under the receiver operating characteristic curve of the top-performing models ranging from good (0.88) to excellent (0.91). MRI faired poorly (areas under the curve, 0.60-0.68) in predicting the MCID for the mental and physical component summaries. Higher body mass index, knee malalignment, absence of preoperative osseous edema, concomitant anterior cruciate ligament or meniscal injury, larger defect size, and the implantation of >1 OCA graft were consistent findings contributing to failure to achieve the MCID or SCB at 2 years postoperatively.

Conclusion: Our machine learning models demonstrated that preoperative MRI, baseline PROMs, and patient demographics reliably predict the ability to reach clinically meaningful thresholds for functional knee outcomes 2 years after OCA for cartilage defects. Although clinical improvement in knee function can be reliably predicted, improvements in quality of life after OCA depend on a comprehensive preoperative assessment of the patient's perception of his or her mental and physical health. Absence of osseous edema, concomitant anterior cruciate ligament or meniscal injury, larger lesion size on MRI, knee malalignment, and elevated body mass index are predictive of failure to achieve 2-year functional benefits after OCA of the knee.
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http://dx.doi.org/10.1177/03635465211015179DOI Listing
May 2021

High variability and lack of standardization in the evaluation of return to sport after ACL reconstruction: a systematic review.

Knee Surg Sports Traumatol Arthrosc 2021 May 12. Epub 2021 May 12.

Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA.

Purpose: Return to sport (RTS) after ACL reconstruction (ACLR) has been recognized as an important outcome, which is associated with success of the surgery. This study aimed to assess the methods used to determine return to sport after ACLR in the published literature, report on variability of methods and evaluate their strength in establishing accurate RTS data.

Methods: Electronic databases (PubMed, Cochrane Library and Embase) were searched via a defined search strategy with no limits, to identify relevant studies from January 2008 to December 2020 for inclusion in the review. Defined eligibility criteria included studies specifically measuring and reporting on return to sport after ACLR with a clear methodology. Each included study was assessed for the definition of successful RTS, successful return to pre-injury level of sport and for methods used to determine RTS.

Results: One hundred and seventy-one studies were included. Of the included studies, six studies (4%) were level of evidence 1 and seventy-two studies (42%) were level of evidence 4. Forty-one studies (24%) reported on return to a specific sport and 130 studies (76%) reported on return to multiple sports or general sport. Sixteen studies (9%) reported on RTS in the pediatric population, 36 (21%) in the adult population and 119 (70%) reported on a mixed-aged population. The most commonly used definition of successful RTS was return to the same sport (44 of 125 studies, 35%). The most common method used to determine RTS was a non-validated study-specific questionnaire (73 studies, 43%), which was administered in various ways to the patients. Time of RTS assessment was variable and ranged between 6 months and 27 years post-surgery.

Conclusion: This review demonstrates high variability in defining, evaluating and reporting RTS following ACLR. The findings of this study reveal low reliability and unproven validity of methods used to evaluate RTS and highlight the challenges in interpreting and using RTS data reported in literature.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-021-06594-9DOI Listing
May 2021

Sports Medicine and Artificial Intelligence: A Primer.

Am J Sports Med 2021 Apr 26:3635465211008648. Epub 2021 Apr 26.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.

Artificial intelligence (AI) represents the fourth industrial revolution and the next frontier in medicine poised to transform the field of orthopaedics and sports medicine, though widespread understanding of the fundamental principles and adoption of applications remain nascent. Recent research efforts into implementation of AI in the field of orthopaedic surgery and sports medicine have demonstrated great promise in predicting athlete injury risk, interpreting advanced imaging, evaluating patient-reported outcomes, reporting value-based metrics, and augmenting the patient experience. Not unlike the recent emphasis thrust upon physicians to understand the business of medicine, the future practice of sports medicine specialists will require a fundamental working knowledge of the strengths, limitations, and applications of AI-based tools. With appreciation, caution, and experience applying AI to sports medicine, the potential to automate tasks and improve data-driven insights may be realized to fundamentally improve patient care. In this Current Concepts review, we discuss the definitions, strengths, limitations, and applications of AI from the current literature as it relates to orthopaedic sports medicine.
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http://dx.doi.org/10.1177/03635465211008648DOI Listing
April 2021

Regarding "Editorial Commentary: Artificial Intelligence in Sports Medicine Diagnosis Needs to Improve".

Arthroscopy 2021 05;37(5):1365-1367

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.

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http://dx.doi.org/10.1016/j.arthro.2021.03.011DOI Listing
May 2021

Continued decline in the prevalence of the Clostridioides difficile BI/NAP1/027 strain across the United States Veterans Health Administration.

Diagn Microbiol Infect Dis 2021 Jun 22;100(2):115308. Epub 2021 Jan 22.

Oklahoma City VA Health Care System, Pharmacy Service (119), Oklahoma City, OK, USA.

In 2018, we demonstrated a decreased prevalence of the hypervirulent Clostridioides difficile BI/NAP1/027 strain across the United States (US) Veterans Health Administration (VHA) from 2011 through 2016. The objective of this retrospective study was to update the prevalence of the BI/NAP1/027 strain within the VHA from 2017 through 2020. Patients with positive tests for the presence of toxigenic C. difficile at any Veterans Affairs Medical Center found to also routinely test for BI/NAP1/027 strain presence were included between July 1, 2016 and June 30, 2020. In total, 7490 patients had 8148 positive C. difficile tests that had a corresponding BI/NAP1/027 test. Of those, there were 1031 (12.6%) presumptive positive tests for the BI/NAP1/027 strain. The overall prevalence of BI/NAP1/027 decreased from a high of 15.4% in 2017 to 8.21% in 2020. Statistically significant reductions in rates from 2017 to 2020 occurred in 4 of 9 US Census Bureau regions.
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http://dx.doi.org/10.1016/j.diagmicrobio.2021.115308DOI Listing
June 2021

Association Between Preoperative Mental Health and Clinically Meaningful Outcomes After Osteochondral Allograft for Cartilage Defects of the Knee: A Machine Learning Analysis.

Am J Sports Med 2021 03 8;49(4):948-957. Epub 2021 Feb 8.

Sports Medicine and Shoulder Service-Institute for Cartilage Repair, Hospital for Special Surgery, New York, New York, USA.

Background: Fresh osteochondral allograft transplantation (OCA) is an effective method of treating symptomatic cartilage defects of the knee. This cartilage restoration technique involves the single-stage implantation of viable, mature hyaline cartilage into the chondral or osteochondral lesion. Predictive models for reaching the clinically meaningful outcome among patients undergoing OCA for cartilage lesions of the knee remain under investigation.

Purpose: To apply machine learning to determine which preoperative variables are predictive for achieving the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) at 1 and 2 years after OCA for cartilage lesions of the knee.

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

Methods: Data were analyzed for patients who underwent OCA of the knee by 2 high-volume fellowship-trained cartilage surgeons before May 1, 2018. The International Knee Documentation Committee questionnaire (IKDC), Knee Outcome Survey-Activities of Daily Living (KOS-ADL), and Mental Component (MCS) and Physical Component (PCS) Summaries of the 36-Item Short Form Health Survey (SF-36) were administered preoperatively and at 1 and 2 years postoperatively. A total of 84 predictive models were created using 7 unique architectures to detect achievement of the MCID for each of the 4 outcome measures and the SCB for the IKDC and KOS-ADL at both time points. Data inputted into the models included previous and concomitant surgical history, laterality, sex, age, body mass index (BMI), intraoperative findings, and patient-reported outcome measures (PROMs). Shapley Additive Explanations (SHAP) analysis identified predictors of reaching the MCID and SCB.

Results: Of the 185 patients who underwent OCA for the knee and met eligibility criteria from an institutional cartilage registry, 135 (73%) patients were available for the 1-year follow-up and 153 (83%) patients for the 2-year follow-up. In predicting outcomes after OCA in terms of the IKDC, KOS-ADL, MCS, and PCS at 1 and 2 years, areas under the receiver operating characteristic curve (AUCs) of the top-performing models ranged from fair (0.72) to excellent (0.94). Lower baseline mental health (MCS), higher baseline physical health (PCS) and knee function scores (KOS-ADL, IKDC Subjective), lower baseline activity demand (Marx, Cincinnati sports), worse pain symptoms (Cincinnati pain, SF-36 pain), and higher BMI were thematic predictors contributing to failure to achieve the MCID or SCB at 1 and 2 years postoperatively.

Conclusion: Our machine learning models were effective in predicting outcomes and elucidating the relationships between baseline factors contributing to achieving the MCID for OCA of the knee. Patients who preoperatively report poor mental health, catastrophize pain symptoms, compensate with higher physical health and knee function, and exhibit lower activity demands are at risk for failing to reach clinically meaningful outcomes after OCA of the knee.
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http://dx.doi.org/10.1177/0363546520988021DOI Listing
March 2021

Osteochondral Autograft Transfer for Focal Cartilage Lesions of the Knee With Donor-Site Back-Fill Using Precut Osteochondral Allograft Plugs and Micronized Extracellular Cartilage Augmentation.

Arthrosc Tech 2021 Jan 20;10(1):e181-e192. Epub 2021 Jan 20.

Sports Medicine and Shoulder Surgery Service, Hospital for Special Surgery, New York, New York.

Osteochondral autograft transfer (OAT) allows for the treatment of focal chondral lesions of the femoral condyles. Patients undergoing OAT have been shown to have the greatest rate and quickest return to sport of any cartilage-restoration procedure. Disadvantages encountered with the OAT procedure include limited donor sources, small treatable lesion size, and donor-site morbidity. Here, we describe our preferred technique of open OAT with donor-site back-filling using precut fresh osteochondral allograft plugs and micronized extracellular cartilage augmentation. Advantages to this technique include single-stage transfer of living autologous osteochondral grafts allowing for early ambulation, predictable return to sport, enhanced long-term graft survival, and decreased donor-site morbidity secondary to fresh osteochondral allograft back-fill.
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http://dx.doi.org/10.1016/j.eats.2020.09.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7823117PMC
January 2021

Outcomes associated with recent guideline recommendations removing metronidazole for treatment of non-severe Clostridioides difficile infection: a retrospective, observational, nationwide cohort study.

Int J Antimicrob Agents 2021 Mar 17;57(3):106282. Epub 2021 Jan 17.

Pharmacy Service, Oklahoma City VA Health Care System, Oklahoma City, USA.

Objectives: The 2017 Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for Clostridioides difficile (C. difficile) infection (CDI) removed metronidazole as a preferred option for initial episodes of non-severe CDI. This study aimed to determine if the shift away from metronidazole improved clinical outcomes of initial episodes of non-severe CDI.

Methods: The study was a retrospective, observational, nationwide cohort study using a Veterans Health Administration national clinical administrative database. Adult patients treated for non-severe CDI before and after the February 2018 publication of the 2017 IDSA/SHEA C. difficile Clinical Practice Guidelines were included. The primary outcome was the composite of treatment failure or probable recurrence.

Results: A total of 3608 patients were included, with 1809 in the pre-guideline cohort (mean [SD] age, 65.5 [14.2] years; 1602 [88.6%] male) and 1799 in the post-guideline cohort (mean [SD] age, 64 [14.6] years; 1584 [88%] male). Overall composite of treatment failure or probable recurrence was similar between both cohorts (318 of 1809 [17.6%] pre-guideline cohort vs. 317 of 1799 [17.6%] post-guideline cohort [P = 0.97]).

Conclusion: The shift away from metronidazole as a preferred option in initial non-severe Clostridioides difficile infection did not improve the composite of treatment failure or recurrence.
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http://dx.doi.org/10.1016/j.ijantimicag.2021.106282DOI Listing
March 2021

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up.

Arthroscopy 2021 04 2;37(4):1086-1095.e1. Epub 2020 Dec 2.

Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.

Methods: A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated.

Results: There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated.

Conclusions: AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction.

Level Of Evidence: IV (Case Series).
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http://dx.doi.org/10.1016/j.arthro.2020.11.045DOI Listing
April 2021

Do Self-Reported Drug Allergies Influence Clinically Significant Outcome Improvement Following Osteochondral Allograft Transplantation? A Nested Cohort Study.

Cartilage 2020 Nov 27:1947603520976770. Epub 2020 Nov 27.

Hospital for Special Surgery, New York, NY, USA.

Objective: To compare clinical outcomes for patients who underwent osteochondral allograft transplantation (OCA) based on the presence or absence of one or more self-reported drug allergies.

Design: Prospective data were collected from 245 consecutive patients after OCA of the knee from one large academic institution. Patient-reported allergies were obtained via chart review. Patient-reported outcome measures, including activities of daily living of the Knee Outcome Survey (KOS-ADL), Marx Activity Scale, International Knee Documentation Committee (IKDC), and visual analogue scale (VAS) pain were all collected. The minimal clinically important difference (MCID) for each outcome was quantified using a distribution-based method. Independent tests were used to compare patient-reported outcome measures between those with and without self-reported allergies, while chi-square analysis of association was used to compare rates of MCID achievement.

Results: Of 245 patients included, 83 (33.9%) reported having at least one drug allergy at the time of OCA. There were no statistically significant differences with regard to patient demographics, including age, body mass index, gender, or sports participation between those with and without a reported allergy. Similarly, there were no significant differences found between baseline preoperative patient-reported outcomes. Overall, both cohorts demonstrated a significant improvement from baseline scores at 2 years postoperatively. There were no differences found between any patient-reported outcome at 2 years postoperatively. The presence of at least one self-reported drug allergy was not a significant risk factor for failing to achieve the MCID in any specific outcome measure.

Conclusions: The presence of one or more drug allergy was not associated with worse patient-reported outcomes or lower rates of clinically significant outcome improvement after OCA.
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http://dx.doi.org/10.1177/1947603520976770DOI Listing
November 2020

Osteochondral Allograft Transplant of the Patella Using Femoral Condylar Allografts: Magnetic Resonance Imaging and Clinical Outcomes at Minimum 2-Year Follow-up.

Orthop J Sports Med 2020 Oct 28;8(10):2325967120960088. Epub 2020 Oct 28.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.

Background: Fresh osteochondral allograft transplant (OCA) has good outcomes in the knee. However, donor tissue for patellar OCA is limited. Outcomes after nonorthotopic OCA of the patella using more readily available femoral condylar allograft (FCA) tissue have not been previously reported.

Purpose: To assess short-term magnetic resonance imaging (MRI) and minimum 2-year clinical outcomes of nonorthotopic patellar OCA using an FCA donor.

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

Methods: A prospective institutional cartilage registry was reviewed to identify patients treated with patellar OCA using an FCA donor between August 2009 and June 2016. OCA plugs were obtained from the FCA at its trochlear-condylar junction and implanted into the recipient patellar lesion. Early postoperative MRI scans were graded by a blinded musculoskeletal radiologist using the Osteochondral Allograft MRI Scoring System (OCAMRISS). International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), Knee Outcomes Survey-Activities of Daily Living (KOS-ADL), and pain visual analog scale (VAS) scores were collected preoperatively and at minimum 2 years postoperatively, and outcomes were compared using the paired test.

Results: A total of 25 patients were included for clinical outcome analysis and 20 patients for MRI analysis. MRI scans obtained at a mean of 11.4 months (range, 6-22 months) postoperatively showed a mean total OCAMRISS score of 9.0 (range, 7-11); mean bone, cartilage, and ancillary subscores were 2.6, 3.7, and 2.6, respectively. At the latest follow-up (mean, 46.5 months; range, 24-85 months), postoperative improvements were noted in IKDC (from 45.0 to 66.2; = .0002), KOS-ADL (from 64.3 to 80.4; = .0012), and VAS (from 5.1 to 3.4; = .001) scores, with IKDC and KOS-ADL scores above the corresponding previously reported minimal clinically important difference.

Conclusion: In this study, patellar OCA using nonorthotopic FCA led to significant short-term improvements in pain and patient-reported outcomes. The majority of nonorthotopic patellar grafts demonstrated full osseous incorporation and good restoration of the articular surface on MRI at short-term follow-up.
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http://dx.doi.org/10.1177/2325967120960088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605000PMC
October 2020

Clinical outcomes and reoperation rates of stable and unstable ramp lesions in the setting of ACL rupture.

Knee Surg Sports Traumatol Arthrosc 2020 12 10;28(12):4034-4036. Epub 2020 Oct 10.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, USA.

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http://dx.doi.org/10.1007/s00167-020-06315-8DOI Listing
December 2020

Machine Learning Outperforms Logistic Regression Analysis to Predict Next-Season NHL Player Injury: An Analysis of 2322 Players From 2007 to 2017.

Orthop J Sports Med 2020 Sep 25;8(9):2325967120953404. Epub 2020 Sep 25.

Machine Learning Orthopaedics Lab, Cleveland Clinic, Cleveland, Ohio, USA.

Background: The opportunity to quantitatively predict next-season injury risk in the National Hockey League (NHL) has become a reality with the advent of advanced computational processors and machine learning (ML) architecture. Unlike static regression analyses that provide a momentary prediction, ML algorithms are dynamic in that they are readily capable of imbibing historical data to build a framework that improves with additive data.

Purpose: To (1) characterize the epidemiology of publicly reported NHL injuries from 2007 to 2017, (2) determine the validity of a machine learning model in predicting next-season injury risk for both goalies and position players, and (3) compare the performance of modern ML algorithms versus logistic regression (LR) analyses.

Study Design: Descriptive epidemiology study.

Methods: Professional NHL player data were compiled for the years 2007 to 2017 from 2 publicly reported databases in the absence of an official NHL-approved database. Attributes acquired from each NHL player from each professional year included age, 85 performance metrics, and injury history. A total of 5 ML algorithms were created for both position player and goalie data: random forest, K Nearest Neighbors, Naïve Bayes, XGBoost, and Top 3 Ensemble. LR was also performed for both position player and goalie data. Area under the receiver operating characteristic curve (AUC) primarily determined validation.

Results: Player data were generated from 2109 position players and 213 goalies. For models predicting next-season injury risk for position players, XGBoost performed the best with an AUC of 0.948, compared with an AUC of 0.937 for LR ( < .0001). For models predicting next-season injury risk for goalies, XGBoost had the highest AUC with 0.956, compared with an AUC of 0.947 for LR ( < .0001).

Conclusion: Advanced ML models such as XGBoost outperformed LR and demonstrated good to excellent capability of predicting whether a publicly reportable injury is likely to occur the next season.
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http://dx.doi.org/10.1177/2325967120953404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522848PMC
September 2020

Long-term hydroxychloroquine use in patients with rheumatic conditions and development of SARS-CoV-2 infection: a retrospective cohort study.

Lancet Rheumatol 2020 Nov 21;2(11):e689-e697. Epub 2020 Sep 21.

Pharmacy Service, Medical Service, Oklahoma City Veterans Affairs Healthcare System, Oklahoma City, OK, USA.

Background: Hydroxychloroquine is one of several agents being evaluated in the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to examine whether patients with rheumatological conditions receiving chronic hydroxychloroquine therapy are at less risk of developing SARS-CoV-2 infection than those not receiving hydroxychloroquine.

Methods: This retrospective cohort study included de-identified information of all veterans in the US Veterans Health Administration clinical administrative database aged 18 years or older with rheumatoid arthritis, systemic lupus erythematosus, or associated rheumatological conditions (based on International Classification of Diseases, 10th edition, diagnostic codes) who were alive on March 1, 2020. A propensity score was calculated for each patient, and each patient who was receiving hydroxychloroquine was matched to two patients who were not receiving hydroxychloroquine (controls). The primary endpoint was the proportion of patients with PCR-confirmed SARS-CoV-2 infection among those receiving chronic hydroxychloroquine versus the propensity-matched patients not receiving chronic hydroxychloroquine between March 1 and June 30, 2020. Secondary outcomes were hospital admission associated with SARS-CoV-2 infection; intensive care requirement associated with SARS-CoV-2 infection; mortality associated with SARS-CoV-2 infection; and overall rates of any hospital admission and mortality (ie, all cause). Multivariate logistic regression analysis was done to determine independent variables for the development of active SARS-CoV-2 infection.

Findings: Between March 1 and June 30, 2020, 10 703 patients receiving hydroxychloroquine and 21 406 patients not receiving hydroxychloroquine were included in the primary analysis. The incidence of active SARS-CoV-2 infections during the study period did not differ between patients receiving hydroxychloroquine and patients not receiving hydroxychloroquine (31 [0·3%] of 10 703 78 [0·4%] of 21 406; odds ratio 0·79, 95% CI 0·52-1·20, p=0·27). There were no significant differences in secondary outcomes between the two groups in patients who developed active SARS-CoV-2 infection. For all patients in the study, overall mortality was lower in the hydroxychloroquine group than in the group of patients who did not receive hydroxychloroquine (odds ratio 0·70, 95% CI 0·55-0·89, p=0·0031). In multivariate logistic regression analysis, receipt of hydroxychloroquine was not associated with the development of active SARS-CoV-2 infection (odds ratio 0·79, 95% CI 0·51-1·42).

Interpretation: Hydroxychloroquine was not associated with a preventive effect against SARS-CoV-2 infection in a large group of patients with rheumatological conditions.

Funding: None.
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http://dx.doi.org/10.1016/S2665-9913(20)30305-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505552PMC
November 2020

SF-36 Physical Component Score Is Predictive of Achieving a Clinically Meaningful Improvement after Osteochondral Allograft Transplantation of the Femur.

Cartilage 2020 Sep 17:1947603520958132. Epub 2020 Sep 17.

Hospital for Special Surgery, New York, NY, USA.

Background: Osteochondral allograft (OCA) transplantation is an increasingly common treatment for patients with symptomatic focal chondral lesions of the knee. There has been increasing interest in determining predictive factors to maximize patient benefit after this operation. The aim of the present study is to evaluate the predictive association of the physical component (PCS) and mental component (MCS) scores of the Short Form 36 (SF-36) questionnaire for achievement of the minimal clinically important difference (MCID) after OCA transplantation.

Methods: This retrospective study of a longitudinally maintained institutional registry included 91 patients who had undergone OCA transplantation for symptomatic focal osteochondral lesions of the femoral condyle. Included patients were those with complete preoperative questionnaires for the SF-36 and IKDC and completed postoperative IKDC at 2-year follow-up. Multivariate analysis was performed evaluating predictive association of the preoperative MCS and PCS with achievement of the MCID for the IKDC questionnaire.

Results: Logistic multivariate modeling demonstrated a statistically significant association between lower preoperative PCS and achievement of the MCID ( = 0.022). A defect diameter >2 cm was also associated with achievement of MCID ( = 0.049). Preoperative MCS did not demonstrate a significant association ( = 0.09) with achievement of the MCID.

Conclusions: For this cohort of 91 patients, the preoperative SF-36 PCS and lesion size were predictive of achievement of the MCID at 2-year follow-up after femoral OCA transplantation. These findings support an important role of baseline physical health scores for predicting which patients will obtain a meaningful clinical benefit from this surgery.
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http://dx.doi.org/10.1177/1947603520958132DOI Listing
September 2020

Clinical and Research Medical Applications of Artificial Intelligence.

Arthroscopy 2021 05 21;37(5):1694-1697. Epub 2020 Aug 21.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.

Artificial intelligence (AI), including machine learning (ML), has transformed numerous industries through newfound efficiencies and supportive decision-making. With the exponential growth of computing power and large datasets, AI has transitioned from theory to reality in teaching machines to automate tasks without human supervision. AI-based computational algorithms analyze "training sets" using pattern recognition and learning from inputted data to classify and predict outputs that otherwise could not be effectively analyzed with human processing or standard statistical methods. Though widespread understanding of the fundamental principles and adoption of applications have yet to be achieved, recent applications and research efforts implementing AI have demonstrated great promise in predicting future injury risk, interpreting advanced imaging, evaluating patient-reported outcomes, reporting value-based metrics, and augmenting telehealth. With appreciation, caution, and experience applying AI, the potential to automate tasks and improve data-driven insights may be realized to fundamentally improve patient care. The purpose of this review is to discuss the pearls, pitfalls, and applications associated with AI.
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http://dx.doi.org/10.1016/j.arthro.2020.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7441013PMC
May 2021

Development and Validation of the Hospital for Special Surgery Anterior Cruciate Ligament Reconstruction Preoperative Expectations Survey.

J Am Acad Orthop Surg 2020 Jun;28(12):e517-e523

From the Department of Orthopaedic Surgery, Hospital for Special Surgery (Dr. Kahlenberg and Mr. Zhang), New York, NY, the Department of Orthopaedic Surgery, Rush University (Dr. Mehta), Chicago, IL, the Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery (Dr. Fabricant), New York, NY, the Department of Biostatistics, Hospital for Special Surgery (Mr. Nguyen), the Sports Medicine and Shoulder Service, Hospital for Special Surgery (Dr. Williams and Dr. Allen), and Sports Medicine and Shoulder Service, Surgery, Hospital for Special Surgery (Dr. Nwachukwu), New York, NY.

Introduction: Understanding and meeting the patients' preoperative expectations for anterior cruciate ligament (ACL) reconstruction (ACLR) is critical for achieving successful patient-centered outcomes. There is currently no standardized method to assess preoperative expectations of ACLR based on the patient-derived methods. The purpose of this study was to develop and test a patient-derived patient expectations survey specific to primary ACLR. We hypothesized that a valid and reliable patient-derived survey could be developed to measure these expectations and that patients would have diverse expectations before surgery.

Methods: The Hospital for Special Surgery ACL-expectation score was developed through a four-phase iterative process that included item generation and pilot survey development, item reduction, survey readability, and survey validation. Seventy-two patients were involved in the development phase, and 80 patients were included in the validation phase. Discriminant validity testing was performed regarding age and sex. Cronbach alpha was calculated to assess the internal consistency of responses in the survey.

Results: The final survey instrument consisted of 10 questions scored on a visual analog scale from 1 to 10, for a maximum score of 50 points. No statistically significant differences were observed in the score between men and women (P = 0.517) nor between age quartiles (P = 0.807). No statistically significant difference was observed in the scores when each sex was stratified by age quartile (P = 0.275 for men, P = 0.878 for women). Cronbach alpha for all items was 0.745, indicating excellent internal consistency. The intraclass correlation coefficient for test-retest reliability was 0.774, indicating a strong correlation.

Conclusion: The Hospital for Special Surgery ACL-expectations score is a patient-derived, tested and reliable preoperative expectations measure with excellent psychometrics for active adults undergoing ACLR. We suggest future clinical studies in ACLR to incorporate this tool as a preoperative measure of patient expectations.
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http://dx.doi.org/10.5435/JAAOS-D-19-00484DOI Listing
June 2020

Non-treatment of stable ramp lesions does not degrade clinical outcomes in the setting of primary ACL reconstruction.

Knee Surg Sports Traumatol Arthrosc 2020 Nov 1;28(11):3576-3586. Epub 2020 May 1.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.

Purpose: The purpose of this study was to evaluate the clinical outcomes of various methods of treatment of stable and unstable ramp lesions compared to patients with no meniscal pathology at the time of primary ACL reconstruction.

Methods: All patients with a preoperative MRI performed at our facility who were enrolled in an institutional ACL registry and 1-year clinical follow-up were identified. A musculoskeletal radiologist reviewed preoperative MRI scans for evidence of a ramp lesion. Ramp lesions were classified as stable if a peripheral tear of the posterior horn of the medial meniscus was identified by MRI, but did not displace into the medial compartment with anteriorly directed probing at the time of surgery. Ramp lesions were classified as unstable if a tear was identified by preoperative MRI at the meniscocapsular junction and the meniscus was displaceable into the medial compartment with probing. Reoperation rates for ACL graft failure or recurrent medial meniscus pathology were collected. Patient-reported outcome scores (IKDC, SF12 PCS, SF12 MCS, and Marx Activity scale) were recorded at baseline and final follow-up.

Results: A total of 162 patients were included in the analysis with median 2-year (range 1-5 years) clinical follow-up. Patients with a repaired unstable ramp lesion had a significantly higher likelihood of reoperation for recurrent medial meniscus pathology than patients without meniscal pathology at the time of index surgery. Patients with an untreated stable ramp lesion had a similar rate of reoperation when compared to patients without meniscal pathology. At final follow-up, there was no difference between groups in IKDC score, SF12 PCS/MCS, or Marx activity score or change in any score.

Conclusions: Patients with untreated stable ramp lesions have similar clinical outcomes at median 2-year (range 1-5 years) follow-up when compared to patients without a ramp lesion. Treatment of stable ramp lesions at the time of ACL reconstruction does not have clinical benefit.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-020-06017-1DOI Listing
November 2020

An Expert Consensus Statement on the Management of Large Chondral and Osteochondral Defects in the Patellofemoral Joint.

Orthop J Sports Med 2020 Mar 26;8(3):2325967120907343. Epub 2020 Mar 26.

Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA.

Background: Cartilage lesions of the patellofemoral joint constitute a frequent abnormality. Patellofemoral conditions are challenging to treat because of complex biomechanics and morphology.

Purpose: To develop a consensus statement on the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint using a modified Delphi technique.

Study Design: Consensus statement.

Methods: A working group of 4 persons generated a list of statements related to the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint to form the basis of an initial survey for rating by a group of experts. The Metrics of Osteochondral Allografts (MOCA) expert group (composed of 28 high-volume cartilage experts) was surveyed on 3 occasions to establish a consensus on the statements. In addition to assessing agreement for each included statement, experts were invited to propose additional statements for inclusion or to suggest modifications of existing statements with each round. Predefined criteria were used to refine statement lists after each survey round. Statements reaching a consensus in round 3 were included within the final consensus document.

Results: A total of 28 experts (100% response rate) completed 3 rounds of surveys. After 3 rounds, 36 statements achieved a consensus, with over 75% agreement and less than 20% disagreement. A consensus was reached in 100.00% of the statements relating to functional anatomy of the patellofemoral joint, 88.24% relating to surgical indications, 100.00% relating to surgical technical aspects, and 100.00% relating to rehabilitation, with an overall consensus of 95.5%.

Conclusion: This study established a strong expert consensus document relating to the functional anatomy, surgical indications, donor graft considerations for osteochondral allografts, surgical technical aspects, and rehabilitation concepts for the management of large chondral and osteochondral defects in the patellofemoral joint. Further research is required to clinically validate the established consensus statements and better understand the precise indications for surgery as well as which techniques and graft processing/preparation methods should be used based on patient- and lesion-specific factors.
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http://dx.doi.org/10.1177/2325967120907343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7099674PMC
March 2020

Development and Validation of the Hospital for Special Surgery Anterior Cruciate Ligament Postoperative Satisfaction Survey.

Arthroscopy 2020 07 10;36(7):1897-1903. Epub 2020 Mar 10.

Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To develop and validate a standardized patient satisfaction measurement tool for adult patients undergoing primary anterior cruciate ligament reconstruction (ACLR).

Methods: A 4-phase iterative process that included item generation and pilot survey development, item reduction, survey readability, and survey validation was used. To develop and validate the Hospital for Special Surgery ACL Satisfaction Survey (HSS ACL-SS), 70 patients were included in the survey development phase and 77 patients were included in the validation phase. The HSS ACL-SS was compared with other currently used ACLR outcome measures including the International Knee Documentation Committee score, Tegner-Lysholm score, Short Form 12 (SF-12) Mental Component Score, and SF-12 Physical Component Score. Test-retest reliability, internal consistency, convergent and discriminant validity, and floor and ceiling effects were assessed.

Results: The HSS ACL-SS consists of 10 items identified by patients as being important for satisfaction after ACLR. In the validation phase, the mean score on the HSS ACL-SS (of 50) among all patients was 37.9 ± 9.9 (range, 10-50). Statistically significant positive correlations were seen between the HSS ACL-SS score and the International Knee Documentation Committee score (r = 0.351, P = .002) and Tegner-Lysholm score (r = 0.333, P = .003). No statistically significant correlation was found between the satisfaction score and the SF-12 Mental or Physical Component Score. The lowest possible score (10 of 50 points) was achieved in 1 patient (1.3%) and the highest possible score (50 of 50 points) was achieved in 7 patients (9.1%), indicating no significant floor or ceiling effects of the instrument. Internal consistency for all 10 items was strong (Cronbach α, 0.995). The mean intraclass correlation coefficient between test and retest responses was 0.701, indicating moderate agreement.

Conclusions: The HSS ACL-SS is a validated and reliable patient-derived satisfaction measure with excellent psychometric properties for active adults undergoing ACLR. The results of this study show that the HSS ACL-SS may be a useful tool to measure postoperative patient satisfaction.

Level Of Evidence: Level II, development of diagnostic or monitoring criteria in consecutive patients.
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http://dx.doi.org/10.1016/j.arthro.2020.02.043DOI Listing
July 2020

Synthetic Biphasic Scaffolds versus Microfracture for Articular Cartilage Defects of the Knee: A Retrospective Comparative Study.

Cartilage 2020 Feb 11:1947603520903418. Epub 2020 Feb 11.

Sports Medicine Service, Hospital for Special Surgery, New York, NY, USA.

Objective: The purpose of this study was to compare the results of a biphasic synthetic scaffold (TruFit, Smith & Nephew) to microfracture for the treatment of knee cartilage defects and identify patient- and lesion-specific factors that influence outcomes.

Design: Prospectively collected data from 132 patients (mean age, 41.8 years; 69% male) with isolated chondral or osteochondral femoral defects treated with biphasic synthetic scaffolds ( = 66) or microfracture ( = 66) were reviewed. Clinical outcomes were evaluated longitudinally over 5 years with the Short Form-36 (SF-36), Activities of Daily Living of the Knee Outcome Survey (KOS-ADL), International Knee Documentation Committee (IKDC), and Marx Activity Scale. Cartilage-sensitive magnetic resonance imaging (MRI) was performed to evaluate osseous integration and cartilage fill in a subgroup of patients. Multivariate regression analysis was used to identify predictors of clinical outcomes within the scaffold group.

Results: Both groups demonstrated clinically significant improvements in knee clinical scores over 5 years ( < 0.01). There were no significant differences in KOS-ADL and IKDC scores between groups up to 5 years postoperatively. Marx activity level scores in the microfracture group declined over time, while significant improvements in activity level scores were observed in the scaffold group over 5 years ( < 0.01). Good-quality tissue fill and cartilage isointensity were more often observed in the scaffold group compared with the microfracture group, particularly with longer time intervals. Increasing age, high body mass index, prior microfracture, and traumatic etiology were predictors for inferior outcomes in the scaffold group.

Conclusions: Activity level and MRI appearance following treatment of cartilage lesions with the biphasic synthetic scaffold were superior to microfracture over time in this nonrandomized, retrospective comparison.
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http://dx.doi.org/10.1177/1947603520903418DOI Listing
February 2020

Stem Cell Treatment for Knee Articular Cartilage Defects and Osteoarthritis.

Curr Rev Musculoskelet Med 2020 Feb;13(1):20-27

Department of Orthopaedic Surgery, Division of Sports Medicine and Shoulder Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA, 90095-6902, USA.

Purpose Of Review: To review the current basic science and clinical literature on mesenchymal stem cell (MSC) therapy for articular cartilage defects and osteoarthritis of the knee.

Recent Findings: MSCs derived from bone marrow, adipose, and umbilical tissue have the capacity for self-renewal and differentiation into the chondrocyte lineage. In theory, MSC therapy may help restore cartilage focally or diffusely where nascent regenerative potential in the intra-articular environment is limited. Over the last several years, in vitro and animal studies have elucidated the use of MSCs in isolation as injectables, in combination with biological delivery media and scaffolding, and as surgical adjuvants for cartilage regeneration and treatment of knee degenerative conditions. More recently, clinical and translational literature has grown more convincing from early descriptive case series to randomized controlled trials showing promise in efficacy and safety. Studies describing MSC for knee cartilage regeneration applications are numerous and varied in quality. Future research directions should include work on elucidating optimal cell concentration and dosing, as well as standardization in methodology and reporting in prospective trials. Backed by promise from in vitro and animal studies, preliminary clinical evidence on MSC therapy shows promise as a nonoperative therapeutic option or an adjuvant to existing surgical cartilage restoration techniques. While higher quality evidence to support MSC therapy has emerged over the last several years, further refinement of methodology will be necessary to support its routine clinical use.
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http://dx.doi.org/10.1007/s12178-020-09598-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083980PMC
February 2020

Fluid imbibition at the bone-cartilage interface is associated with need for early chondroplasty following osteochondral allografting of the knee.

J Clin Orthop Trauma 2019 Oct 30;10(Suppl 1):S13-S19. Epub 2019 Mar 30.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.

Purpose: To determine the clinical significance of fluid imbibition at the bone-cartilage interface seen on postoperative MRI scans after osteochondral grafting of chondral lesions of the knee.

Methods: Retrospective review of patients enrolled in a prospective cartilage repair registry. Included patients underwent osteochondral autografting or allografting of the knee, had minimum one year of clinical follow-up, and underwent at least two postoperative MRI scans. The primary outcome was reoperation for arthroscopic debridement and chondroplasty or graft revision. Secondary outcomes included the radiographic fate of fluid imbibition.

Results: A total of 48 knees in 46 patients were analyzed, with mean 39 months clinical follow-up. Nine patients (19%) had fluid imbibition on at least one postoperative MRI scan, all of whom received allograft. Of these, two (22%) required eventual graft revision, four (45%) underwent arthroscopic chondroplasty but did not require revision, and three (33%) did not require any additional surgery by final follow-up. No demographic or surgical variable was associated with the presence of fluid imbibition. Fluid imbibition was significantly associated with need for chondroplasty (p = 0.05), but not graft revision.

Conclusions: Fluid imbibition on postoperative MRI following osteochondral allografting of the knee is associated with the need for arthroscopic chondroplasty, but should not be interpreted as a sign of a failing graft.

Level Of Evidence: Level IV, Case Series.
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http://dx.doi.org/10.1016/j.jcot.2019.03.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823826PMC
October 2019

The Effects of Space Microgravity on Hip and Knee Cartilage: A New Frontier in Orthopaedics.

Surg Technol Int 2019 11;35:421-425

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York.

Introduction: Given the expansion of commercial and recreational space exploration, orthopaedic surgeons will need to understand the implications of microgravity on cartilaginous damage and to anticipate the resulting pathology from accelerated chondrolysis. The purpose of this systematic review is to evaluate the effects of space and microgravity on hip and knee articular cartilage, including its impact on joint mobility and functional status.

Materials And Methods: A review of the current literature was performed utilizing the terms "joints," "joint mobility," "articular cartilage," "knee," "hip," "space," "microgravity," and "osteoarthritis" in PubMed and Google Scholar from 1990 to 2018, yielding a total of 1,400 citations following the removal of 500 duplicates. Following screening by eligibility criteria, five reports were included.

Results: Dysregulation of osteogenesis and weakened structural integrity of hip and knee cartilage were demonstrated secondary to microgravity. Adequate cartilage repair requires Earth-like conditions as signified by a statistically significant increase in serum cartilage oligomeric matrix protein concentrations in astronauts. Reduced loading led to the degradation of knee ligaments and menisci which may pose a risk for subluxation or dislocation. Murine studies demonstrated decreased articular cartilage thickness in the medial femoral condyle and patella as assessed by ultrasound. Additionally, glycosaminoglycan levels in unloaded rats were lower than weight-bearing rats, with a concomitant increase in matrix metalloproteinase-13 protein, degrading collagen. Return to weight-bearing demonstrated partial recovery of cartilaginous degeneration.

Conclusions: Space and associated microgravity conditions adversely impact articular cartilage as demonstrated in murine and human studies. The pathogenetic process occurs due to the mechanically responsive nature of cartilage, with an increase in cartilage metabolism in microgravity. There remains a marked paucity of literature regarding the gravitational force necessary for adequate cartilage survival and the impact of space-related radiation on cartilage repair. Additionally, further studies should assess pharmacologic interventions, such as recombinant human fibroblast growth factor to stimulate cartilaginous growth.
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November 2019

Return to Play After Bipolar Patellofemoral Osteochondral Allograft Transplantation for a Professional Basketball Player: A Case Report.

JBJS Case Connect 2019 Jul-Sep;9(3):e0291

Sports Medicine and Shoulder Surgery Division, Hospital for Special Surgery, New York, New York.

Case: Extensive and multiple symptomatic chondral lesions in the knee of a professional athlete presents unique challenges when considering optimal management. We present the case of a professional National Basketball Association player with symptomatic and extensive patellofemoral chondral lesions, who failed 24 months of nonoperative management and was treated surgically with bipolar patellofemoral osteochondral allograft transplantation (OCA) consisting of 3 large grafts to the patella, medial trochlea, and lateral trochlea. The player was able to return to his preinjury level of play 10 months postoperatively and remains asymptomatic at same level of play 3 years after surgery. Postoperative magnetic resonance imaging at 16 months demonstrated good restoration of the articular architecture of the patellofemoral joint.

Conclusions: Bipolar OCA treatment for extensive chondral patellofemoral injury may be considered in high-level, high-demand athletes who wish to return to play professionally.
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http://dx.doi.org/10.2106/JBJS.CC.18.00291DOI Listing
June 2020

Procedure length is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction.

Knee Surg Sports Traumatol Arthrosc 2020 Feb 24;28(2):432-438. Epub 2019 Jul 24.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Purpose: The purpose was to characterize the independent effect of procedure length on the rates of 30-day perioperative complications, hospital readmissions, and overnight hospital stay in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). We hypothesized that longer procedure length in primary ACLR increases the risk for post-operative complications.

Methods: Primary ACLR cases from 2005 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Patients were categorized into two cohorts based on procedure length, either less than or greater than 90 min. Two equal-sized propensity-matched cohorts were generated to account for differences in baseline and operative characteristics. Thirty-day clinical outcomes were compared using bivariate analyses between propensity-matched groups that controlled for patient-specific factors and concurrent meniscal repair. Multivariate logistic regression models were used to identify independent predictors of hospital readmission and overnight hospital stay.

Results: In total, 12,077 ACLR cases were identified. The rate of any 30-day complication was increased in longer procedures relative to shorter procedures (1.6% vs 0.9%, p = 0.006), as were the rates of returning to the operating room (0.6% vs 0.3%, p = 0.03), hospital readmission (1.0% vs 0.3%, p = 0.001), and overnight hospital stay (16.2% vs 6.0%, p < 0.001). Obesity was a risk factor for both hospital readmission and overnight hospital stay, while hypertension, diabetes, chronic obstructive pulmonary disease, and a smoking history were associated with increased rates of overnight hospital stay. The most common reasons for hospital readmission were deep vein thrombosis or pulmonary embolism (25.0% of all readmitted patients), surgical site infection (25.0%), and post-operative pain (14.1%).

Conclusions: In this propensity-matched analysis adjusting for baseline patient characteristics and operative factors, procedure length of greater than or equal to 90 min in ACLR was independently associated with an increased risk of hospital readmission and overnight hospital stay. As a surrogate measure of surgical complexity, operative time may be a useful perioperative variable for post-operative risk stratification and patient counseling.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-019-05622-zDOI Listing
February 2020

Concussion in American Versus European Professional Soccer: A Decade-Long Comparative Analysis of Incidence, Return to Play, Performance, and Longevity.

Am J Sports Med 2019 08 15;47(10):2287-2293. Epub 2019 Jul 15.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.

Background: The incidence and effect of sports-related concussions (SRCs) within the global sport of professional soccer is poorly described.

Purpose: To comparatively examine the effects of SRC on athletes in Major League Soccer (MLS) and the English Premier League (EPL) in terms of incidence, return to play (RTP), performance, and career longevity.

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

Methods: Contracts, transactions, injury reports, and performance statistics from 2008 to 2017 were obtained and cross-referenced across 6 publicly available websites detailing MLS and EPL data, including official league publications. For each league, players who sustained a concussion were compared with the 2008-2017 uninjured player pool. RTP and games missed were analyzed and compared. Career length was analyzed with Kaplan-Meier survival curves. Player performance changes were evaluated before and after concussion.

Results: Of the 1784 eligible MLS and 2001 eligible EPL players evaluated over the 10-year period, the incidence of publicly reported concussions per 1000 athlete-exposures was 20.22 and 18.68, respectively ( = .53). The incidence of reported concussions steadily increased in both leagues. MLS players missed a mean 7.3 games after concussion (37.0 days missed); EPL players missed a mean 0.6 games after concussion (10.9 days missed) ( < .0001, < .0001). Statistical performance in terms of games started, assists, shots on goal, and total shots after concussion was significantly reduced at all nongoalie positions for players in the EPL; however, MLS nongoalie positions with concussion had no significant decreases in these categories. Goalies in both leagues had no significant change in performance or games started. The probability of playing a full season after concussion was not significantly decreased when compared with the uninjured pool in both leagues.

Conclusion: This study established the SRC incidence among elite soccer players in 2 international professional leagues and identified major RTP and performance differences between EPL and MLS players. While career longevity was unaffected, the approach to managing concussion as in MLS may better promote player safety and preserve on-field performance.
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http://dx.doi.org/10.1177/0363546519859542DOI Listing
August 2019