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Background: Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis. Hypothesis/Purpose: The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects. Results: Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher. Conclusion: An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes. Registration: NCT02075775 (ClinicalTrials.gov identifier). [ABSTRACT FROM AUTHOR]

Background: Meniscal and chondral damage is common in the patient undergoing revision anterior cruciate ligament (ACL) reconstruction. Purpose: To determine if meniscal and/or articular cartilage pathology at the time of revision ACL surgery significantly influences a patient's outcome at 6-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were prospectively enrolled between 2006 and 2011. Data collection included baseline demographics, surgical technique, pathology, treatment, and scores from 4 validated patient-reported outcome instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx Activity Rating Scale. Patients were followed up at 6 years and asked to complete the identical set of outcome instruments. Regression analysis assessed the meniscal and articular cartilage pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction. Results: An overall 1234 patients were enrolled (716 males, 58%; median age, 26 years). Surgeons reported the pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (43%), lateral femoral condyle (29%), medial tibial plateau (11%), lateral tibial plateau (17%), patella (30%), and trochlea (21%). Six-year follow-up was obtained on 79% of the sample (980/1234). Meniscal pathology and articular cartilage pathology (medial femoral condyle, lateral femoral condyle, lateral tibial plateau, trochlea, and patella) were significant drivers of poorer patient-reported outcomes at 6 years (IKDC, KOOS, WOMAC, and Marx). The most consistent factors driving outcomes were having a medial meniscal excision (either before or at the time of revision surgery) and patellofemoral articular cartilage pathology. Six-year Marx activity levels were negatively affected by having either a repair/excision of the medial meniscus (odds ratio range, 1.45-1.72; P ≤.04) or grade 3-4 patellar chondrosis (odds ratio, 1.72; P =.04). Meniscal pathology occurring before the index revision surgery negatively affected scores on all KOOS subscales except for sports/recreation (P <.05). Articular cartilage pathology significantly impaired all KOOS subscale scores (P <.05). Lower baseline outcome scores, higher body mass index, being a smoker, and incurring subsequent surgery all significantly increased the odds of reporting poorer clinical outcomes at 6 years. Conclusion: Meniscal and chondral pathology at the time of revision ACL reconstruction has continued significant detrimental effects on patient-reported outcomes at 6 years after revision surgery. [ABSTRACT FROM AUTHOR]

Background: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described. Purpose: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics. Results: A total of 159 patients (13%) underwent tunnel grafting—64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group (P ≤.001). Patients who required 2-stage grafting had more previous ACLRs (P <.001) and were less likely to have received a bone–patellar tendon–bone or a soft tissue autograft at primary ACLR procedure (P ≤.021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone–patellar tendon–bone allograft (P ≤.008) and less likely to receive a soft tissue autograft (P ≤.003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) (P ≤.01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group. Conclusion: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. [ABSTRACT FROM AUTHOR]

Background: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). Hypotheses: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. Study Design: Cohort study; Level of evidence, 2. Methods: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. Results: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P =.001), female patients (aOR = 2.9; P <.001), recreational participants (aOR = 2.0; P =.016), and those with a previous medial meniscal excision (aOR = 1.9; P =.013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. Conclusion: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs. [ABSTRACT FROM AUTHOR]

The article presents research which analyzed the cost-effectiveness of early and delayed repair for anterior cruciate ligament injuries. Topics covered include the importance of surgical reconstruction to treat tear in anterior cruciate ligament (ACL) as well as use of Markov decision model to assess the repair. Also mentioned is the application of the Multicenter Orthopaedic Outcomes Network (MOON) database in the study.

The article discusses a study on the ability of meniscus tears and articular cartilage lesions to predict Knee injury and Osteoarthritis Outcome Scores (KOOS), Marx Activity Level outcomes and International Knee Documentation Committee (IKDC) score after anterior cruciate ligament reconstruction (ACLR). Conducted was a regression model for variables including surgical technique, meniscus tears (MT) and articular cartilage injury (ACI). Conclusions indicated MT and ACI as predictors of IKDC.

Data from large prospectively collected anterior cruciate ligament (ACL) cohorts are being utilized to address clinical questions regarding ACL injury demographics and outcomes of ACL reconstruction. These data are affected by patient and injury factors as well as surgical factors associated with the site of data collection. The aim of this article is to compare primary ACL reconstruction data from patient cohorts in the United States and Norway, demonstrating the similarities and differences between two large cohorts. Primary ACL reconstruction data from the Multicenter Orthopaedic Outcomes Network (MOON) in the United States and the Norwegian National Knee Ligament Registry (NKLR) were compared to identify similarities and differences in patient demographics, activity at injury, preoperative Knee injury and Osteoarthritis Outcome Score (KOOS), time to reconstruction, intraarticular pathology, and graft choice. Seven hundred and thirteen patients from the MOON cohort were compared with 4,928 patients from the NKLR. A higher percentage of males (NKLR 57%, MOON 52%; P < 0.01) and increased patient age (NKLR 27 years, MOON 23 years; P < 0.001) were noted in the NKLR population. The most common sports associated with injury in the MOON cohort were basketball (20%), soccer (17%), and American football (14%); while soccer (42%), handball (26%), and downhill skiing (10%) were most common in the NKLR. Median time to reconstruction was 2.4 (Interquartile range [IQR] 1.2–7.2) months in the MOON cohort and 7.9 (IQR 4.2–17.8) months in the NKLR cohort ( P < 0.001). Both meniscal tears (MOON 65%, NKLR 48%; P < 0.001) and articular cartilage defects (MOON 46%, NKLR 26%; P < 0.001) were more common in the MOON cohort. Hamstring autografts (MOON 44%, NKLR 63%) and patellar tendon autografts (MOON 42%, NKLR 37%) were commonly utilized in both cohorts. Allografts were much more frequently utilized in the MOON cohort (MOON 13%, NKLR 0.04%; P < 0.001). Significant diversity in patient, injury, and surgical factors exist among large prospective cohorts collected in different locations. Surgeons should investigate and consider the characteristics of these cohorts when applying knowledge gleaned from these groups to their own patient populations. [ABSTRACT FROM AUTHOR]

The underlying theme throughout this series of studies authored by the Multicenter anterior cruciate ligament (ACL) Revision Study consortium has been to determine the modifiable predictors or risk factors of long‐term outcomes of revision ACL reconstruction. The observational studies described and summarized in the manuscript are both clinically relevant and of great interest in finding out the long‐term consequences of the intervention and its relationship to the original injury. The successful completion of these studies has important implications for both therapy and future clinical trials. The identification of modifiable risk factors will play an important role in secondary prevention, while the identification of nonmodifiable risk factors will aid us in counseling our patients and making surgical decisions. Thus, we expect a profound clinical impact on patients' care. More importantly, this project represents an important step forward in bringing evidence to bear in clinical decision making in orthopedic surgery. [ABSTRACT FROM AUTHOR]

Purpose: Fear of reinjury is an important factor in determining who returns to sport following anterior cruciate ligament reconstruction (ACLR). Evidence from other musculoskeletal injuries indicates fear of reinjury may be related to stiffened movement patterns observed in individuals following ACLR. The relationship between fear of reinjury and performance on dynamic tasks, however, has not been investigated. Therefore, the purpose of this study was to investigate the relationship between fear of reinjury and jump-landing biomechanics.Methods: Thirty-six females (height = 168.7 ± 6.5 cm, body mass = 67.2 ± 10.0 kg, age = 18.9 ± 1.5 years) with a history of ACLR (time from surgery = 26.1 ± 13.3 months) participated in the study. Each participant performed five trials of a standard jump-landing task. 3D motion capture and surface electromyography was used to record peak kinematics and lower extremity muscle activation on the injured limb during the jump landings. Spearman's rank correlations established the relationship between TSK-11 scores and each biomechanical variable of interest.Results: There was a significant, negative relationship between fear of reinjury (TSK-11: 19.9 ± 4.5) and knee (p = 0.006), hip (p = 0.003), and trunk flexion (p = 0.013). There was also a significant, positive relationship between hip adduction (p = 0.007), and gluteus maximus preparatory activation (p = 0.001).Conclusions: The results of this study indicate that higher fear of reinjury is associated with stiffened movement patterns that are associated with increased risk of a second ACL injury. Similar movement patterns have been observed in patients with low back pain. Clinicians should evaluate psychological and emotional consequences of injury in addition to the physical consequences as they appear to be related.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Background: Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage. Hypothesis: Larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: Subjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery. Results: A total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus (P < .001). For the medial compartment, patients who had <33% of the medial meniscus excised at the time of the primary reconstruction had 4.8-times greater odds of progression of articular cartilage injury than those with an intact medial meniscus (P = .02). Odds of significant chondral surface change increased by 5% in the lateral compartment and 6% in the medial compartment for each increased year of age (P ≤ .02). For the patellofemoral compartment, the use of allograft in primary reconstruction was associated with a 15-fold increased odds of progression of articular cartilage damage relative to a patellar tendon autograft (P < .001). Each 1-unit increase in BMI at the time of revision surgery was associated with a 10% increase in the odds of progression of articular cartilage damage (P = .046) in the patellofemoral compartment. Conclusion: Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment. [ABSTRACT FROM AUTHOR]

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction. Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC (P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales (P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales (P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale (P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC (P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales (P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales (P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient’s last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort. Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. Purpose/Hypothesis: The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes. Conclusion: Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels. Registration: NCT00625885 [ABSTRACT FROM AUTHOR]

Purpose: Diabetes has been associated with adverse outcomes after various types of surgery. There are no previously published data regarding the effect of diabetes on outcomes from anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to test the hypotheses that diabetes is associated with worse clinical outcomes and a higher prevalence of subsequent surgeries after ACLR. Methods: Anterior cruciate ligament-deficient patients (n = 2198) undergoing unilateral ACLR from a multicenter prospective study were included. Patients who self-reported diabetes on the basis of comorbidity questions before surgery were identified from the database. They were compared with the remainder of the cohort who did not self-report diabetes. All patients were followed up for a minimum of 2 yr after their index surgery. A minimum 2-yr follow-up was attained on 1905/2198 (87%) via completed outcome questionnaires and 2096/2198 (95%) regarding subsequent surgery. The primary outcome measures were three validated outcome instruments. The secondary outcome measure was the incidence of additional surgery on the ipsilateral and contralateral knees. Results: Patients with diabetes had a significantly higher activity level at 2 yr (OR = 2.96; 95% CI, 1.30-6.77; P = 0.01), but otherwise slightly worse clinical outcomes, compared with patients without diabetes (OR range = 0.42-0.59). The prevalence of subsequent surgeries in patients with diabetes was not significantly different from the prevalence in patients without diabetes. Conclusions: Patients with diabetes maintain a higher activity level after ACLR despite slightly lower patient-reported outcome scores compared with patients without diabetes and do not have a higher rate of subsequent surgery. [ABSTRACT FROM AUTHOR]

Background: Bioabsorbable interference screws are used frequently for graft fixation in ACL (anterior cruciate ligament) reconstruction. The resorption properties of many available screws that are marketed as bioabsorbable are not well defined. The CALAXO (Smith & Nephew Endoscopy) and MILAGRO (DePuy Synthes) bioabsorbable screws contain polymers of poly(lactic-co-glycolic acid) (PLGA) plus additives to encourage osseointegration over time. The purpose of this study was to evaluate radiographic and magnetic resonance imaging (MRI) properties and compare patient-reported outcomes at a minimum of two years of follow-up after ACL reconstruction using CALAXO or MILAGRO bioabsorbable interference screws.Methods: A cohort of patients who underwent ACL reconstruction in which the fixation used was either CALAXO or MILAGRO screws returned for repeat radiographs for evaluation of tunnel widening, repeat MRI for evaluation of graft integrity and screw breakdown, and completion of the pain and symptom items of the KOOS (Knee injury and Osteoarthritis Outcome Score) questionnaire.Results: At a mean of three years (range, 2.5 to 4.0 years) after surgery, thirty-one patients with sixty-two CALAXO screws and thirty-six patients with seventy-two MILAGRO screws returned for repeat evaluation. Two blinded, independent reviewers found no significant differences between the two screw types when comparing radiographs for tibial or femoral tunnel widening or MRIs for graft integrity, tibial and femoral foreign body reactions, or femoral screw degradation. Both reviewers found a significant difference between the two screw types when comparing tibial screw degradation properties (p < 0.01). All analyzed CALAXO screws were rated as partially intact or degraded; the MILAGRO screws were more likely to be rated as intact. No significant differences were noted between the two screw types when comparing the two KOOS subscales.Conclusions: CALAXO screws in the tibial tunnel were more likely to be rated as degraded or partially degraded compared with MILAGRO screws at a mean of three years after implantation for ACL reconstruction. Although these newer-generation bioabsorbable screws were designed to promote osseointegration, no tunnel narrowing was noted, and in the majority of cases the remains of the screws were present at approximately three years. [ABSTRACT FROM AUTHOR]

The article presents a study that measures the frequency of meniscal repairs, discover the failure rate for a meniscal repair as reflected by subsequent meniscectomies. The study determines the risk factors for a subsequent meniscectomy after repair in a large population-based cohort. It supports the notion that repairing a meniscus is a safe and effective procedure in the long term.

The article focuses on a study that was conducted to determine the strength and resistance to displacement of physeal-sparing techniques used to fix tibial eminence fractures. It performed a prospective analysis of bone mineral density using dual-energy x-ray absorptiometry on all specimens. The study found that physeal-sparing fixation of tibial eminence fractures with ultra–high molecular weight polyethylene suture–suture button provides consistent fixation.

Injury to the anterior cruciate ligament (ACL) threatens an active lifestyle and exposes the patient to risk of early osteoarthritis (OA). ACL reconstruction is typically chosen by individuals to allow a return to their previous work and sports activities. Primary ACL reconstruction (ACLR) has in general been effective at restoring functional stability, but patients' modifiable predictors of both short- and long-term validated outcomes and OA are largely unknown. The Multicenter Orthopaedic Outcomes Network (MOON) consortium was established in 2002 to enroll and longitudinally follow a population cohort of ACL reconstructed patients. The objective was to establish patient-specific predictive models of clinically important outcomes. Over the past 10 years, the overarching aims of this NIAMS-funded prospective multicenter cohort of ACL reconstructions has been threefold: (1) to identify both short- and long-term prognosis and predictors of sports function, activity level, and general health through validated patient-reported outcomes, (2) to identify the symptoms and signs of OA, and (3) to quantify the incidence of ACL reconstruction graft and/or contralateral ACL failures and additional surgical procedures. This manuscript summarizes the Kappa Delta Ann Doner Vaughan Award paper and presentation at the 2012 ORS/AAOS Annual Meeting. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31:2-9, 2012 [ABSTRACT FROM AUTHOR]

Background: Meniscal repair offers the potential to avoid the long-term articular cartilage deterioration that has been shown to result after meniscectomy. Failure of the meniscal repair can occur several years postoperatively. Limited evidence on the long-term outcomes of meniscal repair exists.Methods: We performed a systematic review of studies reporting the outcomes of meniscal repair at a minimum of five years postoperatively. Pooling of data and meta-analysis with a random-effects model were performed to evaluate the results.Results: Thirteen studies met the inclusion criteria. The pooled rate of meniscal repair failure (reoperation or clinical failure) was 23.1% (131 of 566). The pooled rate of failure varied from 20.2% to 24.3% depending on the status of the anterior cruciate ligament (ACL), the meniscus repaired, and the technique utilized. The rate of failure was similar for the medial and the lateral meniscus as well as for patients with an intact and a reconstructed ACL.Conclusions: A systematic review of the outcomes of meniscal repair at greater than five years postoperatively demonstrated very similar rates of meniscal failure (22.3% to 24.3%) for all techniques investigated. The outcomes of meniscal repair at greater than five years postoperatively have not yet been reported for modern all-inside repair devices. [ABSTRACT FROM AUTHOR]

The article discusses a study to evaluate arthroscopic agreement on anterior cruciate ligament (ACL) tunnel positioning among different evaluating surgeons. Participants included twelve surgeons. The findings demonstrated that operating surgeons are more likely to judge their tunnels favorably than observers, and that surgeons do not currently uniformly agree on ideal single-bundle tunnel placement, with the transtibial (TT) technique yielding more poorly placed tunnels.

The article discusses the information on outcomes and return to play (RTP) after anterior cruciate ligament reconstruction (ACLR) in soccer athletes. Soccer is the most popular sport worldwide. The soccer-related injuries is higher in younger and less skilled players. The comparison of male and female soccer athletes who returned to play after ACL reconstruction are presented.

Background: A prospective cohort study was conducted to assess the predictors of failure of nonoperative treatment, defined as the patient undergoing surgery for symptomatic, atraumatic full-thickness rotator cuff tears. We present the 10-year follow-up data of this population to determine if predictors for surgery change over time, and secondarily we report the outcomes of the cohort., Methods: At the time of enrollment, demographic, symptom, rotator cuff anatomy, and patient-reported outcome data were collected in patients with symptomatic, atraumatic full-thickness rotator cuff tears. Patients underwent a standard physical therapy protocol for 6 to 12 weeks. Patient data were then collected at 1, 2, 5, 7, and 10 years. Failure of nonoperative treatment was defined as the patient electing to undergo surgery., Results: Of the 452 patients in the original cohort, 20 patients (5%) withdrew from the study, 37 (9%) died before 10 years, and 40 (9%) were otherwise lost to follow-up. A total of 115 patients (27.0%) underwent a surgical procedure at some point during the 10-year follow-up period. Of these patients, 56.5% underwent surgery within 6 months of enrollment and 43.5%, between 6 months and 10 years. Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery. Workers' Compensation status and activity level were more important predictors of later surgery. Patient-reported outcome measures all improved following physical therapy. For patients who did not undergo a surgical procedure, patient-reported outcome measures did not decline over the 10-year follow-up period., Conclusions: Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery, whereas Workers' Compensation status and activity level were predictors of later surgery. Physical therapy was successful in >70% of patients with symptomatic, atraumatic full-thickness rotator cuff tears at 10 years. Outcome measures improved with physical therapy and did not decline over the 10-year follow-up period., Level of Evidence: Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This work was funded by the following agencies: Arthrex (unrestricted research gift), NFL Charities (medical research grant); National Institutes of Health (grant 5K23-AR05392-05 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases), American Orthopaedic Society for Sports Medicine (Career Development Award), and Pfizer (Scholars Grant in Clinical Epidemiology). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I98 )., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears., Methods: This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis., Results: A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m 2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear., Conclusions: Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients., Level of Evidence: III., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Instability after reverse shoulder arthroplasty (RSA) is one of the most frequent complications and remains a clinical challenge. Current evidence is limited by small sample size, single-center, or single-implant methodologies that limit generalizability. We sought to determine the incidence and patient-related risk factors for dislocation after RSA, using a large, multicenter cohort with varying implants., Methods: A retrospective, multicenter study was performed involving 15 institutions and 24 American Shoulder and Elbow Surgeons members across the United States. Inclusion criteria consisted of patients undergoing primary or revision RSA between January 2013 and June 2019 with minimum 3-month follow-up. All definitions, inclusion criteria, and collected variables were determined using the Delphi method, an iterative survey process involving all primary investigators requiring at least 75% consensus to be considered a final component of the methodology for each study element. Dislocations were defined as complete loss of articulation between the humeral component and the glenosphere and required radiographic confirmation. Binary logistic regression was performed to determine patient predictors of postoperative dislocation after RSA., Results: We identified 6621 patients who met inclusion criteria with a mean follow-up of 19.4 months (range: 3-84 months). The study population was 40% male with an average age of 71.0 years (range: 23-101 years). The rate of dislocation was 2.1% (n = 138) for the whole cohort, 1.6% (n = 99) for primary RSAs, and 6.5% (n = 39) for revision RSAs (P < .001). Dislocations occurred at a median of 7.0 weeks (interquartile range: 3.0-36.0 weeks) after surgery with 23.0% (n = 32) after a trauma. Patients with a primary diagnosis of glenohumeral osteoarthritis with an intact rotator cuff had an overall lower rate of dislocation than patients with other diagnoses (0.8% vs. 2.5%; P < .001). Patient-related factors independently predictive of dislocation, in order of the magnitude of effect, were a history of postoperative subluxations before radiographically confirmed dislocation (odds ratio [OR]: 19.52, P < .001), primary diagnosis of fracture nonunion (OR: 6.53, P < .001), revision arthroplasty (OR: 5.61, P < .001), primary diagnosis of rotator cuff disease (OR: 2.64, P < .001), male sex (OR: 2.21, P < .001), and no subscapularis repair at surgery (OR: 1.95, P = .001)., Conclusion: The strongest patient-related factors associated with dislocation were a history of postoperative subluxations and having a primary diagnosis of fracture nonunion. Notably, RSAs for osteoarthritis showed lower rates of dislocations than RSAs for rotator cuff disease. These data can be used to optimize patient counseling before RSA, particularly in male patients undergoing revision RSA., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Both patient and implant related variables have been implicated in the incidence of acromial (ASF) and scapular spine fractures (SSF) following reverse shoulder arthroplasty (RSA); however, previous studies have not characterized nor differentiated risk profiles for varying indications including primary glenohumeral arthritis with intact rotator cuff (GHOA), rotator cuff arthropathy (CTA), and massive irreparable rotator cuff tear (MCT). The purpose of this study was to determine patient factors predictive of cumulative ASF/SSF risk for varying preoperative diagnosis and rotator cuff status., Methods: Patients consecutively receiving RSA between January 2013 and June 2019 from 15 institutions comprising 24 members of the American Shoulder and Elbow Surgeons (ASES) with primary, preoperative diagnoses of GHOA, CTA and MCT were included for study. Inclusion criteria, definitions, and inclusion of patient factors in a multivariate model to predict cumulative risk of ASF/SSF were determined through an iterative Delphi process. The CTA and MCT groups were combined for analysis. Consensus was defined as greater than 75% agreement amongst contributors. Only ASF/SSF confirmed by clinical and radiographic correlation were included for analysis., Results: Our study cohort included 4764 patients with preoperative diagnoses of GHOA, CTA, or MCT with minimum follow-up of 3 months (range: 3-84). The incidence of cumulative stress fracture was 4.1% (n = 196). The incidence of stress fracture in the GHOA cohort was 2.1% (n = 34/1637) compared to 5.2% (n = 162/3127) (P < .001) in the CTA/MCT cohort. Presence of inflammatory arthritis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.08-7.78; P = .035) was the sole predictive factor of stress fractures in GHOA, compared with inflammatory arthritis (OR 1.86, 95% CI 1.19-2.89; P = .016), female sex (OR 1.81, 95% CI 1.20-2.72; P = .007), and osteoporosis (OR 1.56, 95% CI 1.02-2.37; P = .003) in the CTA/MCT cohort., Conclusion: Preoperative diagnosis of GHOA has a different risk profile for developing stress fractures after RSA than patients with CTA/MCT. Though rotator cuff integrity is likely protective against ASF/SSF, approximately 1/46 patients receiving RSA with primary GHOA will have this complication, primarily influenced by a history of inflammatory arthritis. Understanding risk profiles of patients undergoing RSA by varying diagnosis is important in counseling, expectation management, and treatment by surgeons., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Humeral nonunion is estimated to occur at a rate of 1.1%-25% depending on the fracture location and pattern, mechanism of injury, patient compliance with the immobilization protocol and patient's nutritional status and medical comorbidities. Fracture nonunion can cause chronic pain and limited range of motion and may hinder normal function. There is very little data from the patients' perspective regarding their experience with a humeral nonunion. The aim of this study was to establish health-related quality of life (HRQoL) norms for patients diagnosed with a humeral nonunion., Materials and Methods: We reviewed a prospectively collected database of 185 humeral nonunions seen and treated at our quaternary referral center. We recorded patient characteristics including sex, age, history of infection, previous surgery, associated nerve palsy, handedness, and the anatomic location of the nonunion. At initial clinical evaluation, all patients were asked to complete the 12-Item Short Form Health Survey (SF-12), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Brief Pain Inventory (BPI), and a time trade-off questionnaire. These scores were compared to other well-known chronic medical conditions' HRQoL scores., Results: The cohort reported an average utility score of 0.55 ± 0.35, average SF-12 Physical Component Summary score of 30.2 ± 7.6, average SF-12 Mental Component Summary score of 42.5 ± 6.1, and average raw DASH score of 69 ± 21, which was worse than the general US population, patients with asthma, hypertension, stroke, type 2 diabetes, and AIDS. Patients with humeral nonunion are willing to trade 45% of their remaining life to obtain perfect health, and when stratified by handedness, we found that patients with a humeral nonunion of their dominant arm were willing to trade 49.7% compared with 39.7% in patients with a humeral nonunion of their nondominant arm (P = .04)., Discussion: The results of our study show that humeral nonunion is a chronic medical condition that has a debilitating effect on patients, both physically and mentally. It is important for orthopedic surgeons to acknowledge these conditions as physically and mentally debilitating to their patients. Our study highlights these physical and mental burdens and helps to quantify humeral nonunion in relation to more well-known chronic conditions, such as asthma, diabetes, AIDS, and stroke., Conclusions: Humeral nonunions have a devastating effect on a patient's physical and mental health with HRQoL measures lower than patients with other chronic conditions, such as asthma, diabetes, AIDS, and stroke. We found that our patients, on average, would trade approximately 45% of their remaining life span for perfect health., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Patients undergoing shoulder stabilization surgery have been shown to have elevated activity levels. Factors associated with shoulder activity in this patient population at baseline and after surgery are unknown., Hypothesis: Patient-specific variables are associated with shoulder activity level at baseline and at 2-year follow-up in a cohort of patients undergoing shoulder stabilization surgery., Study Design: Cohort study; Level of evidence, 2., Methods: Patients undergoing shoulder stabilization surgery were prospectively enrolled. As part of the data collection process, patients completed a previously validated Shoulder Activity Scale. A regression analysis was performed to assess the association of patient characteristics with baseline and 2-year follow-up shoulder activity levels., Results: A total of 764 (n = 612 men, n = 152 women) out of 957 patients (80%) undergoing shoulder stabilization surgery with a median age of 25 years had baseline and 2-year follow-up data and were included in the current analysis. The baseline shoulder activity level was associated with race ( P < .0001) and preoperative duration of instability ( P < .0001). At 2 years, 52% of the cohort had returned to the same or higher activity level after surgery. Predictors of higher shoulder activity level at 2-year follow-up included higher baseline activity level ( P < .0001), male sex ( P < .0001), younger age ( P = .004), higher body mass index (BMI) ( P = .03), more dislocations ( P = .03), nonsmokers ( P = .04), and race ( P = .04)., Conclusion: A longer duration of preoperative symptoms was associated with a lower baseline activity in this cohort. High baseline preoperative shoulder activity, younger age, male sex, higher BMI, number of dislocations, and nonsmoking status predicted higher shoulder activity 2 years after shoulder stabilization surgery., Registration: NCT02075775 (ClinicalTrials.gov identifier).

Background: Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited., Methods: We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates., Results: A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m 2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men., Conclusions: Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Ankle fractures are one of the most common injuries managed by orthopedic surgeons. Although the etiology of posttraumatic osteoarthritis in anatomically reduced ankle fractures is not completely known, several studies suggest that undetected intra-articular pathology at the time of injury may play a role. The purpose of this study is to report the operative findings of ankle arthroscopy as an adjunct to ankle fracture open reduction and internal fixation., Methods: A retrospective review was performed of all ankle fractures treated consecutively at our institution by a single surgeon from August 2010 to October 2019, which were found using Current Procedural Terminology codes. A total of 84 patients met our inclusion criteria for whom patient demographics and clinical history were collected. Pre- and postoperative diagnoses from every operative report were noted as well as intra-articular intervention made during the time of arthroscopy., Results: The study included 49 men (58.3%) and 35 women (41.7%), with a mean age of 39.0 (range, 12-69; SD = 15.0) years. Sixty-three patients (75%) had new diagnoses detected by the addition of ankle arthroscopy. The most common new pathology seen arthroscopically were osteochondral lesions (n = 36, 41.9%) and posterior malleolus fractures (n = 28, 32.6%). Thirty-four patients had a total of 40 additional arthroscopic procedures in conjunction with their fracture management. Complications were noted in 13 patients, with hardware removal (n = 8) being the most common (62%)., Conclusion: Ankle arthroscopy can act as a significant diagnostic and prognostic tool and can help address intra-articular injuries without adding considerable cost or serious adverse events., Level of Evidence: Level IV, retrospective case series., Competing Interests: Ethics Approval: Ethical approval for this study was obtained from the Texas Orthopedic Hospital Institutional Review Board (TOH222e). Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2021.)

Objectives: To evaluate the diagnostic utility of leukocyte count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) for distinguishing between septic and aseptic nonunions., Design: A single-gate (cohort) design was used, using 1 set of eligibility criteria applied to a consecutive sample of nonunions., Setting: Private quaternary referral center., Patients/participants: Inclusion criteria were consecutive patients (≥18 years) with a nonunion requiring surgery that allowed for direct or medullary canal tissue sampling from the nonunion site. The cohort included 204 subjects with 211 nonunions., Intervention: Blood samples were drawn for laboratory analysis of WBC, ESR, and CRP before surgery., Main Outcome Measurements: The reference standard used to define infection was the fracture-related infection confirmatory criteria. Measures of diagnostic accuracy were calculated. To assess the additional diagnostic gain of each index lab test while simultaneously considering the others, logistic regression models were fit., Results: The prevalence of infection was 19% (40 of 211 nonunion sites). The positive likelihood ratios (95% confidence interval) for WBC, ESR, and CRP were 1.07 (0.38-3.02), 1.27 (0.88-1.82) and 1.57 (0.94-2.60), respectively. Multivariable modeling adjusted for the effect of preoperative antibiotics showed that WBC (P = 0.42), ESR (P = 0.48), and CRP (P = 0.23) were not significant predictors of infection., Conclusions: In this consecutive sample of 211 nonunions in whom standard clinical practice would be to obtain index lab tests, our findings showed that WBC, ESR, and CRP were not significant predictors of infection., Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Although the rate of periprosthetic joint infection following shoulder arthroplasty is low, it is a morbid and costly complication. Airborne particulates have long been recognized as a potential source of wound contamination, and operating room-mounted and smaller localized laminar airflow devices have been developed to minimize airborne particulates. This randomized controlled trial evaluated the effectiveness of a localized laminar flow device in reducing the intrusion of ambient airborne particles and bacteria into the surgery site during shoulder arthroplasty as measured by overall particle counts and colony-forming units (CFUs)., Methods: Patients undergoing primary anatomic or reverse shoulder arthroplasty were eligible for participation. After providing informed consent, patients were randomly assigned to the Air Barrier System (ABS) group or control group. For all patients, the ABS was placed on the surgical field; however, it was only turned on by the technician for those randomized to the ABS. Study participants, surgeons, and surgical staff were blinded to group assignment. Bacterial CFUs were collected from within 5 cm of the surgical wound every 10 minutes, whereas airborne particulates were collected every minute. Poisson regression models were used to determine whether differences existed in CFUs and particulate counts between the ABS and control groups., Results: A total of 43 patients were randomized into the ABS (n = 21) or control (n = 22) group. Surgical time (P = .53) and the average staff count (P = .16) in the operating room did not differ between groups. Poisson regression showed that the ABS group had significantly lower CFUs (β = -0.583, P < .001) along with surgical time and particulates with a diameter ≥ 5 μm. Staff count and particulates with a diameter < 5 μm were not significant predictors of CFUs. Infection was not a primary outcome; however, no postoperative infections have been reported in either study group with a minimum of 1-year follow-up for all patients., Discussion: This double-blinded, randomized trial demonstrated that a localized laminar flow device dramatically reduced the count of CFUs in the air directly above the wound and beneath the ABS (adjusted for the number of operating room personnel and surgical time). The use of the device was not associated with a longer case duration; however, some additional setup time was required prior to surgical incision to place the device. Further study is required to determine the clinical implications of this finding-specifically, whether such devices result in lower rates of periprosthetic joint infection after shoulder arthroplasty., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: In the setting of anterior shoulder instability, it is important to assess the reliability of orthopaedic surgeons to diagnose pathologic characteristics on the 2 most common imaging modalities used in clinical practice: standard plain radiographs and magnetic resonance imaging (MRI)., Purpose: To assess the intra- and interrater reliability of diagnosing pathologic characteristics associated with anterior shoulder instability using standard plain radiographs and MRI., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: Patient charts at a single academic institution were reviewed for anterior shoulder instability injuries. The study included 40 sets of images (20 radiograph sets, 20 MRI series). The images, along with standardized evaluation forms, were distributed to 22 shoulder/sports medicine fellowship-trained orthopaedic surgeons over 2 points in time. Kappa values for inter- and intrarater reliability were calculated., Results: The overall response rate was 91%. For shoulder radiographs, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.49), estimate of glenoid lesion surface area (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.35), and estimate of Hill-Sachs surface area (κ = 0.50). Intrarater agreement was moderate for radiographs (κ = 0.48-0.57). For shoulder MRI, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.44), glenoid lesion surface area (κ = 0.35), Hill-Sachs lesion (κ = 0.33), Hill-Sachs surface area (κ = 0.28), humeral head edema (κ = 0.41), and presence of a capsulolabral injury (κ = 0.36). Fair agreement was found for specific type of capsulolabral injury (κ = 0.21). Intrarater agreement for shoulder MRI was moderate for the presence of glenoid lesion (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.52), estimate of Hill-Sachs surface area (κ = 0.50), humeral head edema (κ = 0.51), and presence of a capsulolabral injury (κ = 0.53), and agreement was substantial for glenoid lesion surface area (κ = 0.63). Intrarater agreement was fair for determining the specific type of capsulolabral injury (κ = 0.38)., Conclusion: Fair to moderate agreement by surgeons was found when evaluating imaging studies for anterior shoulder instability. Agreement was similar for identifying pathologic characteristics on radiographs and MRI. There was a trend toward better agreement for the presence of glenoid-sided injury. The lowest agreement was observed for specific capsulolabral injuries., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: T.J.M. has received educational support from DJO, Smith & Nephew, and Stryker. K.A.M. has received educational support from Alliqua Biomedical and Arthrex; honoraria from Alliqua Biomedical; consulting fees from Arthrex, Stryker, and Zimmer Biomet; speaking fees from Alliqua Biomedical and Arthrex; and hospitality payments from Amniox Medical, Apollo Surgical Group, and Wright Medical. C.M.H. has received research support from Rotation Medical, Tornier, Wright Medical, and Zimmer Biomet; nonconsulting payments from Pacira Pharmaceuticals; and hospitality payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Injuries to the posterolateral corner (PLC) may occur concurrently with anterior cruciate ligament (ACL) injury., Purpose/hypothesis: This study evaluated the outcomes of patients who underwent operative management of PLC injuries concurrently with ACL reconstruction in a prospective multicenter cohort. We hypothesized that there would be no differences in outcomes between patients who were treated with PLC repair and PLC reconstruction., Study Design: Cohort study; Level of evidence, 3., Methods: Patients undergoing ACL reconstruction were enrolled into a prospective longitudinal multicenter cohort between 2002 and 2008. Those with complete 6-year follow-up data (patient-reported outcomes and subsequent surgery information) were identified. Excluded from the study were patients with posterior cruciate ligament injuries. Patients who underwent PLC repair were compared with those who underwent PLC reconstruction with regard to interval from injury to surgery, need for revision surgery, and long-term outcomes at 6 years., Results: During the identified time frame, 3026 identified patients underwent primary ACL reconstruction; 34 (1.1%) also underwent concurrent PLC surgery (15 repairs, 19 reconstructions [18 allografts, 1 autograft]). With the numbers available, we did not detect significant differences between groups regarding the rate of meniscal or chondral injuries. Median time to PLC reconstruction was 121 days as compared with 19 days for concurrent ACL reconstruction and PLC repair ( P = .01). There were no between-group differences in Marx activity scores prior to surgery ( P = .4). At 6-year follow-up, there were no between-group differences in Knee injury and Osteoarthritis Outcome Score ( P = .36-.83) or International Knee Documentation Committee score ( P = .84); however, patients treated with PLC reconstructions had lower Marx activity scores (4.1 vs 9.4; P = .02). There was 1 ACL revision in the PLC reconstruction group, and 1 of the PLC repairs was revised to a reconstruction during the follow-up period., Conclusion: Good outcomes were achieved at 6-year follow-up with both repair and reconstruction of PLC injuries treated concurrently with ACL reconstruction. The PLC reconstruction group had lower activity levels 6 years after surgery. The present data suggest that, for appropriately selected patients undergoing acute surgical treatment of combined ACL and PLC injuries, PCL repair can achieve good long-term outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Research reported in this publication was partially supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award R01AR053684 (K.P.S.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. R.W.W. has received educational support from Arthrex and Smith & Nephew and hospitality payments from Medical Device Business Systems. R.G.M. has received educational support from Arthrex. K.P.S. has received research support from DonJoy and Smith & Nephew; has received consulting fees from Cytori, Mitek, and the National Football League Flexion Therapeutics, and Samumed; has received hospitality payments from Biosense Webster and DePuy; and receives royalties from commercial product nPhase. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: The Knee injury and Osteoarthritis Outcome Score (KOOS) has demonstrated inferior psychometric properties when compared with the International Knee Documentation Committee (IKDC) subjective knee form when assessing outcomes after anterior cruciate ligament (ACL) reconstruction. The KOOS, Joint Replacement (KOOS, JR) is a validated short-form instrument to assess patient-reported outcomes (PROs) after knee arthroplasty, and the purpose of this study was to determine if augmenting the KOOS, JR with additional KOOS items would allow for the creation of a short-form KOOS-based global knee score for patients undergoing ACL reconstruction, with psychometric properties similar to those of the IKDC., Hypothesis: An augmented version of the KOOS, JR could be created that would demonstrate convergent validity with the IKDC but avoid the ceiling effects and limitations previously noted with several of the KOOS subscales., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: Based on preoperative and 2-year postoperative responses to the KOOS questionnaires from a sample of 1904 patients undergoing ACL reconstruction, an aggregate score combining the KOOS, JR and the 4 KOOS Quality of Life subscale questions, termed the KOOS global , was developed. Psychometric properties of the KOOS global were then compared with those of the IKDC subjective score. Convergent validity between the KOOS global and IKDC was assessed with a Spearman correlation (ρ). Responsiveness of the 2 instruments was assessed by calculating the pre- to postoperative effect size and relative efficiency. Finally, the presence of a preoperative floor or postoperative ceiling effect was defined with the threshold of 15% of patients reporting either the worst possible (0 for KOOS global and IKDC) or the best possible (100 for KOOS global and IKDC) scores, respectively., Results: The newly developed KOOS global was responsive after ACL reconstruction and demonstrated convergent validity with the IKDC. The KOOS global significantly correlated with the IKDC scores (ρ = 0.91, P < .001), explained 83% of the variability in IKDC scores, and was similarly responsive (relative efficiency = 0.63). While there was a higher rate of perfect postoperative scores with the KOOS global (213 of 1904, 11%) than with the IKDC (6%), the KOOS global was still below the 15% ceiling effect threshold., Conclusion: The large ceiling effects limit the ability to use several of the KOOS subscales with the younger, more active ACL population. However, by creating an aggregate score from the KOOS, JR and 4 KOOS Quality of Life subscale questions, the 11-item KOOS global offers a responsive PRO tool after ACL reconstruction that converges with the information captured with the IKDC. Also, by offering the ability to calculate multiple scores from a single questionnaire, the KOOS global may provide the orthopaedic community a single PRO platform to be used across knee-related subspecialties. Registration: NCT00478894 ( ClinicalTrials.gov identifier).

Importance: Anterior cruciate ligament (ACL) injury can be a devastating injury that without surgery may lead to chronic instability. Although surgical reconstruction recreates the stabilising constraint of the native ACL, postoperative pain and subsequent arthrosis may follow., Objectives: The primary objective of this systematic review is to determine whether the presence of a bone bruise following ACL rupture adversely affects the clinical outcomes following surgical reconstruction., Evidence Review: A standardised research protocol was used as outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies included for review were those of high level of evidence (I or II) and had MRI data on the presence of bone bruise and clinical outcome measures in patients who underwent surgical reconstruction of the ACL after traumatic rupture. Articles were searched using PubMed/ Medline, Cochrane Library, CINAHL and EMBASE databases using a keyword search. Article references and conference proceedings were subsequently reviewed on identification of articles found via the keyword search. Non-English literature, animal and basic science studies, studies focused on the skeletally immature and low level of evidence (III, IV, V) were excluded. A quantitative analysis of the data retrieved was summarised., Findings: Five studies met the inclusion criteria. Follow-up ranged from the time of surgical reconstruction to 165 months. Although a variety of clinical outcome measures were used across studies, bone bruise cohorts did not demonstrate clinically inferior outcome scores., Conclusions and Relevance: Although osteochondral injury is frequently identified following ACL injury, the presence of a bone bruise alone does not appear to significantly adversely affect the clinical outcome of surgically reconstructed ACLs. However, factors such as articular cartilage injury and alteration in joint loading may be important variables for further research., Level of Evidence: IV., Competing Interests: Competing interests None declared.

Background: Limited information exists regarding predictors of general quality of life following anterior cruciate ligament (ACL) reconstruction with up to six-year follow-up. We hypothesized that certain variables evaluated at the time of ACL reconstruction will predict the general quality of life as measured by the Short Form-36 (SF-36)., Methods: All unilateral ACL reconstructions from 2002 to 2004 in patients currently enrolled in a prospective multicenter cohort were evaluated. Patients preoperatively completed the SF-36 validated outcome instrument. Surgeons documented intra-articular pathological conditions and treatment, as well as the ACL reconstruction surgical technique. At baseline and at a minimum of two and six years postoperatively, patients completed the SF-36. Longitudinal analysis was performed for the two-year and six-year end points., Results: Of the initial 1512 subjects, at least one follow-up questionnaire was obtained from 1411 subjects (93%). The cohort was 44% female, and the median patient age at enrollment was twenty-three years. The mean scores were 41.9 points for the Physical Component Summary (PCS) and 51.7 points for the Mental Component Summary (MCS) at baseline, 53.6 points for the PCS and 52.0 points for the MCS at two years, and 54.0 points for the PCS and 52.4 points for the MCS at six years. Significant predictors of a higher PCS score were a higher baseline PCS score, younger age, lower baseline body mass index, having >50% of the lateral meniscus excised, or having no treatment done on a lateral meniscal tear. In contrast, significant predictors of a lower PCS score were a shorter follow-up time since surgery, revision ACL reconstruction, smoking at baseline, fewer years of education, and chondromalacia of the lateral tibial plateau. The mean utility gained at six years after ACL reconstruction was 5.3 quality-adjusted life years (QALYs)., Conclusions: Large improvements in the PCS (with an effect size of 1.2) were noted at two years and were maintained at six years after ACL reconstruction. Lower education and smoking were significant predictors of lower PCS and MCS scores. ACL reconstruction resulted in a relatively high gain of QALYs., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

With an estimated 200,000 anterior cruciate ligament reconstructions performed annually in the United States, there is an emphasis on determining patient-specific information to help educate patients on expected clinically relevant outcomes. The Multicenter Orthopaedic Outcomes Network consortium was created in 2002 to enroll and longitudinally follow a large population cohort of anterior cruciate ligament reconstructions. The study group has enrolled >4,400 anterior cruciate ligament reconstructions from seven institutions to establish the large level I prospective anterior cruciate ligament reconstruction outcomes cohort. The group has become more than a database with information regarding anterior cruciate ligament injuries; it has helped to establish a new benchmark for conducting multicenter, multisurgeon orthopaedic research. The changes in anterior cruciate ligament reconstruction practice resulting from the group include the use of autograft for high school, college, and competitive athletes in their primary anterior cruciate ligament reconstructions. Other modifications include treatment options for meniscus and cartilage injuries, as well as lifestyle choices made after anterior cruciate ligament reconstruction., (Copyright 2015 by the American Academy of Orthopaedic Surgeons.)

Purpose: The purpose of this study was to perform a systematic review of the available literature to define the level of quality evidence for determining the sensitivity and specificity of different radiographic views in detecting knee osteoarthritis and to determine the impact of different grading systems on the ability to detect knee osteoarthritis., Methods: A systematic review of the literature was conducted to identify studies that evaluated the standing anteroposterior (AP) and 45° posteroanterior (PA) views for tibiofemoral and patellofemoral arthritis and those comparing the use of the Kellgren-Lawrence versus the joint space narrowing (JSN) radiographic grading systems using arthroscopy as the gold standard. A comprehensive search of PubMed, Scopus, CINAHL, the Cochrane Database, Clinicaltrial.gov, and EMBASE was performed using the keywords "osteoarthritis," "knee," "x-ray," "sensitivity," and "arthroscopy.", Results: Six studies were included in the evaluation. The 45° flexion PA view showed a higher sensitivity than the standing AP view for detecting severe arthritis involving either the medial or lateral tibiofemoral compartment. There was no difference in the specificities for the 2 views. The direct comparison of the Kellgren-Lawrence and the JSN radiographic grading systems found no clinical difference between the 2 systems regarding the sensitivities, although the specificity was greater for the JSN system., Conclusions: The ability to detect knee osteoarthritis continues to be difficult without using advanced imaging. However, as an inexpensive screening tool, the 45° flexion PA view is more sensitive than the standing AP view to detect severe tibiofemoral osteoarthritis. When evaluating the radiograph for severe osteoarthritis using either the Kellgren-Lawrence or JSN grading system, there is no clinical difference in the sensitivity between the 2 methods; however, the JSN may be more specific for ruling in severe osteoarthritis in the medial compartment., Level of Evidence: Level I, systematic review of Level I studies., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: For many orthopaedic disorders, symptoms correlate with disease severity. The objective of this study was to determine if pain level is related to the severity of rotator cuff disorders., Methods: A cohort of 393 subjects with an atraumatic symptomatic full-thickness rotator-cuff tear treated with physical therapy was studied. Baseline pretreatment data were used to examine the relationship between the severity of rotator cuff disease and pain. Disease severity was determined by evaluating tear size, retraction, superior humeral head migration, and rotator cuff muscle atrophy. Pain was measured on the 10-point visual analog scale (VAS) in the patient-reported American Shoulder and Elbow Surgeons (ASES) score. A linear multiple regression model was constructed with use of the continuous VAS score as the dependent variable and measures of rotator cuff tear severity and other nonanatomic patient factors as the independent variables. Forty-eight percent of the patients were female, and the median age was sixty-one years. The dominant shoulder was involved in 69% of the patients. The duration of symptoms was less than one month for 8% of the patients, one to three months for 22%, four to six months for 20%, seven to twelve months for 15%, and more than a year for 36%. The tear involved only the supraspinatus in 72% of the patients; the supraspinatus and infraspinatus, with or without the teres minor, in 21%; and only the subscapularis in 7%. Humeral head migration was noted in 16%. Tendon retraction was minimal in 48%, midhumeral in 34%, glenohumeral in 13%, and to the glenoid in 5%. The median baseline VAS pain score was 4.4., Results: Multivariable modeling, controlling for other baseline factors, identified increased comorbidities (p = 0.002), lower education level (p = 0.004), and race (p = 0.041) as the only significant factors associated with pain on presentation. No measure of rotator cuff tear severity correlated with pain (p &gt; 0.25)., Conclusions: Anatomic features defining the severity of atraumatic rotator cuff tears are not associated with the pain level. Factors associated with pain are comorbidities, lower education level, and race., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Patient activity level may be an important prognostic variable relating to outcomes in patients with shoulder disorders. Little is known about the predictors of activity level in patients with shoulder disorders., Hypothesis: Tear size and patient variables would be predictive of shoulder activity level in a cohort of patients who have selected initial nonoperative treatment for a symptomatic, atraumatic rotator cuff tear on magnetic resonance imaging (MRI)., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Patients with an atraumatic rotator cuff tear on MRI were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) shoulder study of nonoperative treatment. As part of routine data collection, these patients were asked to complete a previously validated shoulder activity scale. A regression analysis was performed to assess the association of shoulder activity level to rotator cuff tear characteristics, including tendon involvement and retraction, and patient factors such as age, sex, smoking, and occupation., Results: A total of 434 patients (220 male, 214 female) with a mean age of 62.7 years (range, 31-90 years) completed the activity scale. Shoulder activity was not associated with severity of the rotator cuff tear, but it was negatively associated with age (P = .0001) and female sex (P = .001). The only other factor associated with shoulder activity level in this cohort was occupation (P = .0006)., Conclusion: Shoulder activity level in patients with an atraumatic rotator cuff tear confirmed on MRI is not associated with severity of the tear but is affected by age, sex, and occupation.

Purpose: To assess the effectiveness of a specific nonoperative physical therapy program in treating atraumatic full-thickness rotator cuff tears using a multicenter prospective cohort study design., Materials and Methods: Patients with atraumatic full-thickness rotator cuff tears who consented to enroll provided data via questionnaire on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcome assessments (Short Form 12 score, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff score, Single Assessment Numeric Evaluation score, and Shoulder Activity Scale). Physicians recorded physical examination and imaging data. Patients began a physical therapy program developed from a systematic review of the literature and returned for evaluation at 6 and 12 weeks. At those visits, patients could choose 1 of 3 courses: (1) cured (no formal follow-up scheduled), (2) improved (continue therapy with scheduled reassessment in 6 weeks), or (3) no better (surgery offered). Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit. A Wilcoxon signed rank test with continuity correction was used to compare initial, 6-week, and 12-week outcome scores., Results: The cohort consists of 452 patients. Patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months., Conclusion: Nonoperative treatment using this physical therapy protocol is effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: Subsequent surgeries have a profound effect on patient satisfaction and outcome after primary anterior cruciate ligament reconstruction (ACLR). There have been no prospective studies to date describing the rate and predictors (surgical and patient variables) of all subsequent knee surgeries at short-term and midterm follow-up along with analyses of surgical and patient variables that are associated with subsequent surgeries., Purpose: To report the rate and predictors of all subsequent surgeries at short-term and midterm follow-up along with associated patient variables., Study Design: Case-control study; Level of evidence, 3., Methods: A total of 980 patients (540 male) were prospectively enrolled in a Multicenter Orthopaedic Outcomes Network (MOON) cohort from January 2002 to December 2003. The 2- and 6-year follow-up information for subsequent procedures was obtained. Operative reports were obtained, and all procedures were categorized., Results: One hundred eighty-five patients underwent a subsequent surgery on the ipsilateral leg (18.9%) and 100 on the contralateral knee (10.2%) at 6-year follow-up. On the ipsilateral knee, there was a 7.7% rate of ACL revisions, a 13.3% rate of cartilage procedures, a 5.4% rate of arthrofibrosis procedures, and a 2.4% rate of procedures related to hardware. For the contralateral knee, there was a 6.4% rate of primary ACL ruptures. Younger age at the index surgery and the use of allografts were predictors (risk factors) for subsequent surgery. Revision ACLR, female sex, body mass index, and surgical exposure were not significant predictors., Conclusion: At 6-year follow-up, 18.9% of patients who had undergone ACLR underwent subsequent surgeries on the ipsilateral knee. The rates between an ipsilateral ACLR graft versus a contralateral normal ACL tear were similar (7.7% vs 6.4%, respectively). Younger age and the use of allografts were risk factors for subsequent surgery.

Purpose: The hypothesis of this study was that single-legged horizontal hop test ratios would correlate with IKDC, KOOS, and Marx activity level scores in patients 2 years after primary ACL reconstruction., Methods: Individual patient-reported outcome tools and hop test ratios on 69 ACL reconstructed patients were compared using correlations and multivariable modeling. Correlations between specific questions on the IKDC and KOOS concerning the ability to jump and hop ratios were also performed., Results: The triple-hop ratio was moderately but significantly correlated with the IKDC, KOOS Sports and Recreation subscale, and the KOOS Knee Related Quality of Life subscale, as well as with the specific questions related to jumping. Similar but weaker relationship patterns were found for the single-hop ratio and timed hop. No significant correlations were found for the Marx activity level or crossover-hop ratio. Multivariable modeling showed almost no significant additional contribution to predictability of the IKDC or KOOS subscores by gender, BMI, or the number of faults on either leg., Conclusions: The triple-hop test is most significantly correlated with patient-reported outcome scores. Multivariable modeling indicates that less than a quarter of the variability in outcome scores can be explained by hop test results. This indicates that neither test can serve as a direct proxy for the other; however, assessment of patient physical function by either direct report using validated outcome tools or by the hop test will provide relatively comparable data.

Background: Although the reliability of determining acromial morphology has been examined, to date, there has not been an analysis of interobserver and intraobserver reliability on determining the presence and measuring the size of an acromial enthesophyte., Questions/purposes: The hypothesis of this study was that there will be poor intraobserver and interobserver reliability in the (1) determination of the presence of an acromial enthesophyte, (2) determination of the size of an acromial enthesophyte, and (3) determination of acromial morphology., Patients and Methods: Fifteen fellowship-trained orthopedic shoulder surgeons reviewed the radiographs of 15 patients at two different intervals. Measurement of acromial enthesophytes was performed using two techniques: (1) enthesophyte length and (2) enthesophyte-humeral distance. Acromial morphology was also determined. Interobserver and intraobserver agreement was determined using intraclass correlation and kappa statistical methods., Results: The interobserver reliability was fair to moderate and the intraobserver reliability moderate for determining the presence of an acromial enthesophyte. The measurement of the enthesophyte length showed poor interobserver and intraobserver reliability. The measurement of the enthesophyte-humeral distance showed poor interobserver reliability and moderate intraobserver reliability. The interobserver and intraobserver reliability in determining acromial morphology was found to be moderate and good, respectively., Conclusions: There is fair to moderate reliability among fellowship-trained shoulder surgeons in determining the presence of an acromial enthesophyte. However, there is poor reliability among observers in measuring the size of the enthesophyte. This study suggests that the enthesophyte-humeral distance may be more reliable than the enthesophyte length when measuring the size of the enthesophyte.

Hypothesis: Classification systems for glenohumeral instability (GHI) are opinion based, not validated, and poorly defined. The hypothesis driving this investigation is that a classification system with content validity will have high inter-observer and intra-observer agreement., Materials and Methods: The classification system was developed by first conducting systematic literature review that identified 18 systems for classifying GHI. The frequency of characteristics used was recorded. Additionally, 31 members of the American Shoulder and Elbow Surgeons responded to a survey to identify features important to characterize GHI. Frequency, etiology, direction, and severity (FEDS) were most important. Frequency was defined as solitary (1 episode), occasional (2 to 5 times/y), or frequent (>5 times/year). Etiology was defined as traumatic or atraumatic. Direction referred to the primary direction of instability (anterior, posterior, or inferior). Severity was subluxation or dislocation. For reliability testing, 50 GHI patients completed a questionnaire at their initial visit. One of 6 sports medicine fellowship-trained physicians completed a similar questionnaire after examining the patient. Patients returned after 2 weeks and were examined by the original physician and 2 other physicians. Interrater and intrarater agreement for the FEDS classification system was calculated., Results: Agreement between patients and physicians was lowest for frequency (39%; κ = 0.130) and highest for direction (82%; κ = 0.636). Physician intrarater agreement was 84% to 97% for the individual FEDS characteristics (κ = 0.69-0.87), and interrater agreement was 82% to 90% (κ = 0.44-0.76)., Conclusions: The FEDS system has content validity and is highly reliable for classifying GHI. Physical examination using provocative testing to determine the primary direction of instability produces very high levels of interrater and intrarater agreement., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Acronyms are words formed by taking the first initial or other parts of words from a compound term. They are designed to help communicate ideas efficiently. In the literature pertaining to shoulder surgery, a variety of acronyms have been offered for normal anatomic states, physical examination findings, pathologic conditions, surgical techniques, and outcome instruments, with new acronyms offered each year. The purpose of this article is to review and clearly define acronyms used by shoulder specialists., (Copyright © 2011 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Hypothesis: An abrasion on the humeral head under the articulating portion of the biceps tendon has been observed in patients with pain and stiffness after superior labrum anterior posterior (SLAP) repair. This study examined this humeral head abrasion (HHA) and its association with various diagnoses involving pathology of the biceps-labral complex. We hypothesized that it would be more common in failed SLAP repairs than other diagnoses., Materials and Methods: A retrospective chart review was performed of 253 patients who underwent shoulder arthroscopy by a single surgeon during a 5-year period. Postoperative diagnoses were used to confirm one of the following diagnoses: failed SLAP repair, biceps tendonitis, SLAP lesion with biceps tendonitis, and isolated SLAP lesion. Operative reports and surgical images were analyzed to identify the presence or absence of HHA. Demographic data, including age, sex, handedness, and onset of injury, were also collected. The frequency of this lesion among the different diagnoses and patient characteristics was compared by χ² analysis., Results: HHA was observed in 13 of 18 patients (72.2%) with failed SLAP repairs, in 8 of 18 (44.4%) with biceps tendonitis, in 11 of 20 (55%) with SLAP lesion and biceps tendonitis, and in 1 of 71 (1.4%) with isolated SLAP lesions, significantly differing in frequency by diagnosis (P < .001). Patients with HHA were an older median age than those without (48 vs 40; P = .004)., Discussion: HHA is common in patients with a pathologic biceps-labral complex, especially those with failed SLAP repair. We speculate that this lesion is due to inflammation of the biceps tendon resulting in increased biceps-humeral head contact pressure., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Objective: The study was conducted to quantify activity level 2 years after anterior cruciate ligament reconstruction and identify explanatory variables measured at baseline (demographics, concomitant meniscal/articular cartilage injuries and their treatment) associated with activity level at short-term follow-up (2 years)., Study Design: Cohort study; Level of evidence, 2., Methods: In 2002, the Multicenter Orthopaedic Outcomes Network (MOON) consortium began enrolling patients undergoing anterior cruciate ligament reconstruction at 6 recruitment sites. The current study reports 2-year follow-up of patients enrolled in 2002. Participants completed a series of validated, patient-oriented questionnaires that included activity level assessment. Measurement of intra-articular pathology, techniques of anterior cruciate ligament reconstruction, and secondary procedures were recorded at baseline by participating surgeons. Multivariable proportional odds ordinal logistic regression was used to assess predictors of activity level after adjusting for baseline patient characteristics. Interquartile range (IQR) odds ratios (ORs) are given for continuous variables. The fitted model that used ORs to specify predicted probabilities of exceeding any activity level was translated into predicted mean activity level., Results: Of the 446 patients who underwent unilateral anterior cruciate ligament reconstruction, follow-up was obtained on 393 (88%). Male patients comprise 56% of the cohort, with a median age of 23 years. The median and IQR International Knee Documentation Committee subjective score was 53 (range, 40-65) preoperatively and increased to 84 (range, 74-92) 2 years postoperatively. Median and IQR activity level was 12 (range, 8-16) at baseline, and declined to 9 (range, 3-13) at follow-up. The proportion of participants returning to the same or higher level of activity 2 years after anterior cruciate ligament reconstruction was 45%. After controlling for other baseline factors such as age, marital and student status, contralateral knee status, sport and competition level, and articular cartilage/meniscal injuries, factors associated with higher activity levels at 2 years were higher baseline activity (IQROR = 3.84; 95% confidence interval [CI], 1.98-7.43; P < .0001) and lower baseline body mass index (IQROR = 1.37; 95% CI, 1.04-1.82; P = .027). The following baseline factors were associated with lower activity: female sex (OR = 0.60; 95% CI, 0.39-0.91; P = .015), smoking within 6 months prior to surgery (OR = 0.55; 95% CI, 0.33-0.92; P = 0.023), and revision anterior cruciate ligament reconstruction (OR = 0.41; 95% CI, 0.20-0.83; P = .014). Factors presumably related to functional status of the knee such as the condition of the articular cartilage and menisci, as well as normalcy of the contralateral knee, were not predictive of activity level at 2 years., Conclusion: (1) Evaluation of posttreatment activity levels should control for patients' preoperative activity because this is a strong predictor of future activity. (2) Assuming physical activity is an important component of a healthy person, investigation of potential interventions to improve future activity could target modifiable exposures such as weight. (3) Further evaluation is needed to explore the association of sex and revision surgery on activity level following anterior cruciate ligament reconstruction.

Background: Revision anterior cruciate ligament (ACL) reconstruction has worse outcomes than primary reconstructions. Predictors for these worse outcomes are not known. The Multicenter ACL Revision Study (MARS) Group was developed to perform a multisurgeon, multicenter prospective longitudinal study to obtain sufficient subjects to allow multivariable analysis to determine predictors of clinical outcome., Purpose: To describe the formation of MARS and provide descriptive analysis of patient demographics and clinical features for the initial 460 enrolled patients to date in this prospective cohort., Study Design: Cross-sectional study; Level of evidence, 2., Methods: After training and institutional review board approval, surgeons began enrolling patients undergoing revision ACL reconstruction, recording patient demographics, previous ACL reconstruction methods, intra-articular injuries, and current revision techniques. Enrolled subjects completed a questionnaire consisting of validated patient-based outcome measures., Results: As of April 1, 2009, 87 surgeons have enrolled a total of 460 patients (57% men; median age, 26 years). For 89%, the reconstruction was the first revision. Mode of failure as deemed by the revising surgeon was traumatic (32%), technical (24%), biologic (7%), combination (37%), infection (<1%), and no response (<1%). Previous graft present at the time of injury was 70% autograft, 27% allograft, 2% combination, and 1% unknown. Sixty-two percent were more than 2 years removed from their last reconstruction. Graft choice for revision ACL reconstruction was 45% autograft, 54% allograft, and more than 1% both allograft and autograft. Meniscus and/or chondral damage was found in 90% of patients., Conclusion: The MARS Group has been able to quickly accumulate the largest revision ACL reconstruction cohort reported to date. Traumatic reinjury is deemed by surgeons to be the most common single mode of failure, but a combination of factors represents the most common mode of failure. Allograft graft choice is more common in the revision setting than autograft. Concomitant knee injury is extremely common in this population.