Resident Performance on the Fundamentals of Arthroscopic Surgery Training (FAST) Workstation Does Not Predictably Improve With Postgraduate Year.

Purpose: To identify differences in performance on the Fundamentals of Arthroscopic Surgery Training (FAST) workstation between residents across different postgraduate years and training sites. Methods: During the 2018-2019 academic year, 102 orthopaedic surgery residents from 4 training sites completed 6 FAST modules. Failure was defined as either completion time exceeding benchmark time or commission of task-specific errors. With the exception of knot tying, each module was completed by participants twice-once with each hand serving as the camera hand. Time to completion (except for knot tying) and errors were recorded for each of the modules. Completion times and failure rates were compared between postgraduate years, seniority groups, and training sites. Results: In all modules for which time was recorded, except for the suture-passage module, there was no significant difference in time to completion based on seniority (P < .01 for suture passage and P > .05 for all others). Significant differences in completion time were observed between sites for all modules except for the suture-passage module (P = .957 for suture passage and P < .05 for all others). Site predicted failure by at least 1 measure (time or technical error) for all modules (P < .05) except for number probing and suture passage. Failure rate across training years varied for each module. Conclusions: Time to completion and rate of failure did not predictably decrease with level of training. Training site proved to be a significant predictor of performance. Factors such as hand dominance and familiarity with the equipment proved to be important considerations for some modules. Clinical Relevance: Objective assessment of arthroscopic skills among orthopaedic trainees is difficult. Using reproducible methodology to assess trainees on specific skills at all postgraduate years and at multiple training sites may provide important information about orthopaedic training.

Associating Outcomes After Hip Arthroscopy With Patient Resilience.

Background: Higher patient resilience has been shown to be associated with improved patient-reported outcome measures (PROMs) at 6 months after hip arthroscopy. Purpose: To examine the relationship between patient resilience and PROMs at minimum 2 years after hip arthroscopy. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were 89 patients (mean age, 36.9 years; mean follow-up, 4.6 years). Patient demographics, surgical details, and preoperative International Hip Outcome Tool-12 (iHOT-12) and visual analog scale (VAS) pain scores were collected retrospectively. Postoperative variables were collected via a survey and included the Brief Resilience Scale (BRS), Patient Activation Measure-13 (PAM-13), Pain Self-efficacy Questionnaire-2 (PSEQ-2), VAS satisfaction, and postoperative iHOT-12, and VAS pain scores. Based on the number of standard deviations from the mean BRS score, patients were stratified as having low resilience (LR; n = 18), normal resilience (NR; n = 48), and high resilience (HR; n = 23). Differences in PROMs were compared between the groups, and a multivariate regression analysis was performed to assess the relationship between pre- to postoperative change (Δ) in PROMs and patient resilience. Results: There were significantly more smokers in the LR group compared with the NR and HR groups (P = .033). Compared with the NR and HR groups, patients in the LR group had significantly more labral repairs (P = .006), significantly worse postoperative iHOT-12, VAS pain, VAS satisfaction, PAM-13, and PSEQ-2 scores (P < .001 for all), and significantly lower ΔVAS pain and ΔiHOT-12 scores (P = .01 and .032, respectively). Regression analysis showed significant associations between ΔVAS pain and NR (ß = -22.50 [95% CI, -38.81 to -6.19]; P = .008) as well as HR (ß = -28.31 [95% CI, -46.96 to -9.67; P = .004) and between ΔiHOT-12 and NR (ß = 18.94 [95% CI, 6.33 to 31.55]; P = .004) as well as HR (ß = 20.63 [95% CI, 6.21 to 35.05]; P = .006). Male sex was a significant predictor of ΔiHOT-12 (ß = -15.05 [95% CI, -25.42 to -4.69]; P = .006). Conclusion: The study results indicate that lower postoperative resilience scores were associated with significantly worse PROM scores, including pain and satisfaction, at 2 years after hip arthroscopy.

The Utility of MRI in Evaluating Ruptures of the Patellar Tendon.

Background: Although the identification of patellar tendon rupture is a clinical diagnosis aided by standard radiography, magnetic resonance imaging (MRI) may aid in identifying the location of the rupture and concomitant pathology. Purpose: To evaluate the characteristics of patellar tendon tears needing surgical repair and to determine whether patient or injury factors were predictive of tear location. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients who underwent primary patellar tendon repair for rupture between May 15, 2017, and April 10, 2020, were reviewed retrospectively. Exclusion criteria included age <18 years, surgical treatment of multiligamentous knee injury, laceration injury, and knee arthroplasty. Radiographs, MRI scans, MRI reports, clinic notes, and operative notes were evaluated. Statistical analysis was performed to determine factors associated with tear location, complications, and reoperation. Results: In total, 147 patients and 156 tendon tears were included; 82.1% of the tears were patellar avulsions, 14.7% were midsubstance or complex tears, and 3.2% were tibial avulsions. Patient and injury characteristics (body mass index, race, medical comorbidities, presence of patellar tendinitis, mechanism of injury, Insall-Salvati ratio, and the presence of infrapatellar bone fragments) were not predictive of tear location (P > .05). Patellar tendon ruptures were able to be clinically diagnosed correctly in >99% of cases. MRI was used to evaluate 77 (49.4%) knees. Patients who underwent MRI before surgery were more likely to have a history of preexisting tendinitis (P = .015) and a lower preoperative Insall-Salvati ratio (1.68 vs 1.52; P = .017). Conclusion: Patient and injury factors were not predictive of tear location. The majority of patellar tendon tears were avulsion-type injuries from the inferior patella. MRI was not necessary to aid in the diagnosis of patellar tendon rupture, as 99.4% of tears were able to be diagnosed clinically without advanced imaging.

Open Repair of Complete Proximal Hamstring Avulsions in Workers' Compensation Patients.

Background: Several studies have reported excellent results after surgical repair of proximal hamstring avulsions. However, the effect on these patients of receiving workers' compensation has not yet been explored. Hypothesis: Workers' compensation patients undergoing proximal hamstring repair of complete tears will have similar outcomes when compared with a matched control group of non-workers' compensation patients. Study Design: Cohort study; Level of evidence, 3. Methods: Workers' compensation patients who underwent complete proximal hamstring avulsion open repair between 2010 and 2019 were identified (WC group). A control group was matched by age (±3 years), sex, and body mass index (BMI; ±3). Demographics and patient-reported outcome measures were compared, including standard and custom Marx activity rating scale (MARS), standard and custom lower extremity functional scale (LEFS), and visual analog scale (VAS) for pain. Rate and time to return to work were recorded. Results: The WC group was composed of 20 patients (8 men, 12 women) with a mean age of 52.3 years and BMI of 32.4. The 20 matched controls (8 men, 12 women) who underwent repair had a mean age of 50.6 years and a mean BMI of 31.2. There was no difference between the groups regarding age (P = .924), sex (P > .999), or BMI (P = .330). The WC group reported similar mean MARS (3.3 vs 5.4; P = .174), custom MARS (87.5 vs 97.0; P = .215), and VAS pain (3.3 vs 3.8; P = .698) scores compared with controls. However, the WC group had significantly lower standard LEFS (69.1 vs 94.1; P < .001) and custom LEFS (62.3 vs 87.9; P < .001) scores, returned to work at a lower rate (70.0% vs 94.1%; P = .039), and required more time to return to work after repair (4.3 vs 3.5 months; P = .029) compared with controls. Conclusion: Workers' compensation patients who underwent open proximal hamstring repair for complete avulsions experienced inferior patient-reported outcomes, required more time to return to work, and returned to work at a lower rate than a matched control group.

Outcomes After Repair of Quadriceps Tendon Rupture in Patients Aged 40 Years and Younger.

Background: Injury to the quadriceps tendon is rare and most commonly occurs in middle-aged men. Few reports are available regarding outcomes after quadriceps tendon rupture in younger patients. Purpose/Hypothesis: To review the clinical outcomes of patients who underwent quadriceps tendon repair at age ≤40 years. We hypothesized that this cohort would experience better clinical outcomes in comparison to historical older controls. Study Design: Case series; Level of evidence, 4. Methods: Using an institutional database, we retrospectively identified patients who underwent quadriceps tendon repair between January 2009 and December 2017. Patients were included in the study if they were aged ≤40 years at the time of surgery and had sustained an isolated, complete tendon rupture. Patient and injury characteristics were recorded. Patients were contacted to complete a custom survey, the 2000 International Knee Documentation Committee (IKDC) form, the Lysholm scale, and the Tegner scale. Results: Included were 38 patients (86.8% male; mean age, 32.0 ± 6.9 years; age range, 15-40 years), with a mean follow-up of 5.9 ± 2.3 years (range, 2.4-11.3 years). At final follow-up, the mean IKDC score was 74.1 ± 22.6 (range, 26.4-100.0), and the mean Lysholm score was 85.4 ± 20.0 (range, 30-100), which were similar if not inferior to historical controls of patients >40 years. Only 16 patients (42.1%) had unchanged or higher Tegner scores after surgery, whereas 22 patients (57.9%) reported lower postoperative activity level. Overall, 91.2% (31/34) of workers returned at a mean 3.9 months after surgery, whereas 63% (12/19) of athletes were able to return to play at 8.8 months. At final follow-up, 12 patients (31.6%) reported persistent pain and stiffness in their knees. Additionally, 3 patients (7.9%) reported pain without stiffness, and 4 (10.5%) reported stiffness without pain. Patients reporting pain or stiffness had significantly lower IKDC scores, Lysholm scores, postoperative Tegner scores, and change in their Tegner score at final follow-up in comparison to those who did not report pain or stiffness. Conclusion: Although patients aged ≤40 years had satisfactory outcomes after quadriceps tendon repair, this injury resulted in significant long-term sequelae in a substantial percentage of patients, despite their youth. Further, this group did not have better outcomes compared with historical controls aged > 40 years.

A Scoping Review of Injuries in Amateur and Professional Men's Ice Hockey.

Background: Orthopaedic injuries are common in ice hockey at all levels and can result in physical and psychological adverse effects on these athletes. Purpose: Primarily, to summarize published data on orthopaedic hockey injuries at the junior through professional level. Secondarily, to characterize the literature based on anatomic site injured, return-to-play rates, cause/mechanism of injury, time lost, and treatments used. Study Design: Scoping review; Level of evidence, 4. Methods: PubMed, EMBASE, Cochrane library, and SCOPUS were searched using the terms "hockey" and "injuries" using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and 4163 studies involving orthopaedic injuries were identified. Our inclusion criteria consisted of accessible full-text articles that evaluated orthopaedic injuries in men's ice hockey athletes of all levels. We excluded case reports and articles evaluating women's ice hockey injuries, as well as those evaluating nonorthopaedic injuries, such as concussions; traumatic brain injuries; and facial, dental, and vascular injuries, among others. Studies were divided based on level of play and anatomic site of injury. Level of evidence, year published, country of corresponding author, method of data collection, incidence of injury per athlete-exposure, and time lost were extracted from each article. Results: A total of 92 articles met the inclusion criteria and were performed between 1975 and 2020, with the majority published between 2015 and 2020. These were divided into 8 anatomic sites: nonanatomic-specific (37%), intra-articular hip (20.7%), shoulder (9.8%), knee (8.7%), trunk/pelvis (7.6%), spine (7.6%), foot/ankle (6.5%), and hand/wrist (2.2%). Of these studies, 71% were level 4 evidence. Data were obtained mostly via surveillance programs and searches of publicly available information (eg, injury reports, player profiles, and press releases). Conclusion: This scoping review provides men's hockey players and physicians taking care of elite ice hockey athletes of all levels with a single source of the most current literature regarding orthopaedic injuries. Most research focused on nonanatomic-specific injuries, intra-articular hip injuries, knee injuries, and shoulder injuries, with the majority having level 4 evidence.

Adolescent Quadriceps Tendon Rupture, an Early Complication After ACL Reconstruction: A Case Report.

CASE: A healthy adolescent male patient initially presented with complete rupture of the anterior cruciate ligament (ACL) after a plant-twist injury during a high school football game. Four weeks after ACL reconstruction with autograft bone-patella tendon-bone, the patient slipped and fell, sustaining hyperflexion of the knee, resulting in rupture of the ipsilateral quadriceps tendon. CONCLUSION: Although this rare complication has previously been reported in the adult population, to the best of our knowledge, this is the first known report of an adolescent patient sustaining a quadriceps tendon rupture after ACL reconstruction.

Criteria for return to play after operative management of acromioclavicular joint separation: a systematic review.

Background: Acromioclavicular (AC) joint separation is a common cause of shoulder injury among athletes. High-grade injuries may require operative fixation, and comprehensive return-to-play guidelines have not yet been established. The purpose of this study was to summarize criteria for return to play after operative management of AC joint separation. Methods: A systematic review of the literature was performed from January 1999 to April 2020 to evaluate clinical evidence regarding criteria for return to play after operative management of isolated AC joint separation. Results: Sixty-three studies with at least 1 explicitly stated return-to-play criterion were identified out of an initial database search of 1253 published articles. Eight separate categories of return-to-play criteria were identified, the most common of which was time from surgery (95.2%). Return-to-play timelines ranged from 2 to 12 months, the most common timeline being 6 months (37.8%). Only 4 (6.3%) studies used conditional criteria to guide return to play, which included range of motion, strength, clinical stability, radiographic stability, functional assessment, safety assessment, and hardware removal. Conclusion: Most published studies use only time-based criteria for return to play after surgery for AC joint separation, and only a small number of studies use additional subjective or objective criteria. While this systematic review helps provide a foundation for developing a comprehensive return-to-play checklist, further investigation is needed to establish safe and effective guidelines that will enable athletes to safely return to sport and minimize the recurrence of injury.

Orthopaedic Resident Arthroscopic Knot-Tying Skills Are Improved Using a Training Program and Knot-Tying Workstation.

PURPOSE: To quantify an orthopaedic trainee's ability to tie arthroscopic knots before and after a short cadaveric-based arthroscopy training period using a commercially available knot-tying workstation. METHODS: During a weeklong cadaveric arthroscopic training camp, 15 third- and fourth-year orthopaedic residents were evaluated using a commercially available benchtop knot-tying workstation. At the beginning of the week (baseline), each participant was asked to tie 3 knots of his or her choice backed up by 3 half-hitches using nonabsorbable suture. Successful knots fit the sizer and elongated less than 3 mm after application of a 15-lb load. Afterward, residents watched a video demonstrating a sample knot and were encouraged to practice over the ensuing days. At the end of the week (post-training), residents were asked to tie 3 knots. The time to completion and success of each knot were recorded. To compare baseline and post-training knot success, t tests and χ2 analysis were performed. RESULTS: During baseline testing, residents successfully tied 26.7% of their knots (12 of 45 knots) in 352 ± 116 seconds (mean ± standard deviation). During post-training testing, residents successfully tied 66.7% of knots (30 of 45 knots, P = .00014) in 294 ± 63 seconds (P = .023), showing significant improvement in the time and ability to tie arthroscopic knots. CONCLUSIONS: With a short cadaveric-based training period, orthopaedic trainees showed a significant improvement in their ability to tie arthroscopic knots on a commercially available benchtop knot-tying workstation. Given the initial low percentage of successfully tied knots and the limited opportunities for trainees to improve, trainees should be encouraged to practice and improve their skills. CLINICAL RELEVANCE: With training, residents can improve arthroscopic knot-tying abilities, which may allow them to successfully perform this critical task in the operating room.

Radiologic Measurements in the Assessment of Patellar Instability: A Systematic Review and Meta-analysis.

BACKGROUND: Numerous diagnostic imaging measurements related to patellar instability have been evaluated in the literature; however, little has been done to compare these findings across multiple studies. PURPOSE: To review the different imaging measurements used to evaluate patellar instability and to assess the prevalence of each measure and its utility in predicting instability. We focused on reliability across imaging modalities and between patients with and without patellar instability. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: We performed a systematic review of the literature using the PubMed, SCOPUS, and Cochrane databases. Each database was searched for variations of the terms "patellar instability," "patellar dislocation," "trochlear dysplasia," "radiographic measures," "computed tomography," and "magnetic resonance imaging." Studies were included if they were published after May 1, 2009, and before May 1, 2019. A meta-analysis using a random effects model was performed on several measurements, comparing instability and control groups to generate pooled values. RESULTS: A total of 813 articles were identified, and 96 articles comprising 7912 patients and 106 unique metrics were included in the analysis. The mean patient age was 23.1 years (95% CI, 21.1-24.5), and 41% were male. The tibial tubercle-trochlear groove (TT-TG) distance was the most frequently included metric (59 studies), followed by the Insall-Salvati ratio and Caton-Deschamps index (both 26 studies). The interobserver intraclass correlation coefficients were excellent or good for the TT-TG distance and Insall-Salvati ratio in 100% of studies reporting them; however, for the Caton-Deschamps index and Blackburne-Peel ratio, they were excellent or good in only 43% and 40% of studies. Pooled magnetic resonance imaging values for TT-TG distance (P < .01), Insall-Salvati ratio (P = .01), and femoral sulcus angle (P = .02) were significantly different between the instability and control groups. Values for tibial tubercle-posterior cruciate ligament distance (P = .36) and Caton-Deschamps index (P = .09) were not significantly different between groups. CONCLUSION: The most commonly reported measurements for evaluating patellar instability assessed patellar tracking and trochlear morphology. The TT-TG distance was the most common measurement and was greater in the patellar instability group as compared with the control group. In addition, the TT-TG, tibial tubercle-posterior cruciate ligament, and patellar tendon-trochlear groove distances were highly reproducible measurements for patellar tracking, and the Insall-Salvati ratio had superior reproducibility for assessing patellar height.

Cartilage Disease of the Patellofemoral Joint: Realignment, Restoration, Replacement.

Chondral lesions of the patellofemoral joint are common, and when symptomatic they can be difficult to manage. Not only are there various degrees of injury with multiple etiologies, but patellofemoral anatomy is complex and the patient's lower extremity alignment may contribute to the pathology. Treatment depends on the location, size, and depth of the lesion and may require realignment or concomitant stabilizing procedures. Tibial tubercle osteotomy can be performed in isolation or combined with various cartilage-based treatments, including marrow stimulation techniques, autologous chondrocyte implantation, osteochondral autograft, and osteochondral allograft. End-stage lesions, failed primary patellofemoral cartilage restoration with diffuse involvement, or isolated primary patellofemoral arthritis may be amenable to treatment with patellofemoral arthroplasty. Recent investigations in properly indicated patients using advanced techniques have shown that management of patellofemoral cartilage disease is now more effective and predictable than in the past.

Resilience in the Orthopaedic Patient.

➤: Resilience is a dynamic psychological construct that refers to the ability to adapt and improve when facing adversity or other stressors. ➤: Recent investigations in various orthopaedic subspecialties have demonstrated that resilience may contribute to favorable mental health and physical function after a surgical procedure. ➤: More research, using well-designed prospective studies, is necessary to better define the role that resilience and other factors play in the health and outcomes of patients with orthopaedic conditions. ➤: Orthopaedic surgeons can consider incorporating resilience assessments into their practices to aid in identifying patients who will do well with a surgical procedure and those who may benefit from specialized therapy to optimize their health and function.

The Fate of the Fixed Syndesmosis Over Time.

BACKGROUND: A prior study demonstrated statistical widening of the syndesmosis within weeks of elective screw removal. However, no information is available as to the radiographic outcomes of screw retention. The aim of this study was to evaluate radiographic syndesmotic widening and talar shift over time in patients treated with syndesmotic screws and to compare screw removal with retention along with other potential risk factors that may have led to tibia-fibula diastasis after weightbearing. METHODS: One hundred sixty-six skeletally mature patients with ankle fractures and concomitant syndesmotic injuries were treated with syndesmotic reduction and screw fixation. The syndesmosis was evaluated intraoperatively either by a stress test or direct visualization. If the syndesmosis was incompetent, it was reduced and stabilized with syndesmotic screws to maintain reduction. Anteroposterior, mortise, and lateral radiographs at presentation, postoperatively, and at follow-up after weightbearing were evaluated. We measured the medial clear space (MCS), tibia-fibula overlap (OL), and tibia-fibula clear space (CS). Screws that were retained were graded as loose/broken or intact. RESULTS: The fibula shifted an insignificant amount on postoperative mortise radiographs after elective syndesmotic screw removal at 3 months or more after initial fixation, indicated by a slightly greater CS and lower OL. The MCS did not change from preoperative to postoperative screw removal. There was no change in the radiographic markers from the postoperative to final follow-up images in those whose screws became loose or broken. Likewise, there was no radiographic difference if screws remained intact versus those that were loose or broken. CONCLUSION: In contradistinction to prior work, we found that only very mild widening (0.5 mm) of the tibia-fibula space occurred after weightbearing following syndesmotic fixation. The removal of syndesmotic screws at 3 months resulted in a slightly lower OL (<1 mm) and greater CS (0.5 mm) on mortise radiographs than screw retention even if the retained screws loosened or broke. This was not associated with any talar subluxation, and these differences were not statistically significant. The mortise remained intact whether the syndesmotic screws were removed, were loosened or broken, or remained solid. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Factors affecting pain in acute ankle fractures: A prospective evaluation.

Pain has been identified as the dominant factor in patient outcomes. The purpose of this study was to evaluate the degree of pain reported in a large series of acute ankle fractures and to determine what factors are associated with higher pain scores. We prospectively evaluated 457 consecutive patients with acute Weber B supination external rotation ankle fractures upon presentation for pain in 9 areas of the ankle. There were 231 females and 226 males, average age 46.2 (18-96) with 133 bi/tri-malleolar and 324 lateral malleolar fractures. There were 101 SE2, 73 stress (+) SE4, and 150 ligamentous SE4 injuries. The highest pain score (VAS 0-10) for the medial and lateral regions was chosen for analysis. Other factors included in the multivariate analysis were: age, ethnicity, DM, alcohol presence, and days from injury to presentation on the level of pain reported using a linear regression model and set statistical significance at 0.05. In univariate analysis, the type of injury (medial malleolus or deltoid ligament) nor instability differed with respect to medial pain. However, patients presenting with instability had more lateral pain (5.6±3) than those with stable injuries (2.6±3) (p<001). Additionally, those with bony medial injury had more lateral pain (7±2.7) than those with isolated lateral malleolar fractures (4.0±3.4) (p<0.001). Most importantly, in the multivariate analysis, the only factor that was significant for both medial and lateral pain (separate regressions) was ethnicity, with blacks having more pain given the same injury than whites (p<0.001). Latinos trended towards having more lateral pain than whites (p=0.15), but not more medial pain (p=0.3). For lateral pain, in addition to ethnicity, presence of a displaced mortise (p<0.0001), having a medial bony injury (p<0.0001), and the days from injury (p=0.008) were significant. Pain decreased with time from injury. In this evaluation of over 450 patients with Weber B, SE pattern ankle fractures we confirmed previous work in the upper extremity indicating an important difference in the reported pain by ethnicity. In particular, black patients have more pain than white or latino patients given the same injury.

Maternal preconception body mass index and offspring cord blood DNA methylation: exploration of early life origins of disease.

Maternal obesity is associated with a variety of common diseases in the offspring. One possible underlying mechanism could be maternal obesity induced alterations in DNA methylation. However, this hypothesis is yet to be tested. We performed epigenomic mapping of cord blood among 308 Black mother-infant pairs delivered at term at the Boston Medical Center using the Illumina HumanMethylation27 BeadChip. Linear regression and pathway analyses were conducted to evaluate the associations between DNA methylation levels and prepregnancy maternal BMI (<25, 25-30, ≥30 kg/m(2) ). The methylation levels of 20 CpG sites were associated with maternal BMI at a significance level of P-value <10(-4) in the overall sample, and boys and girls, separately. One CpG site remained statistically significant after correction for multiple comparisons (FDR corrected P-value = 0.04) and was annotated to a potential cancer gene, ZCCHC10. Some of the other CpG site annotated genes appear to be critical to the development of cancers and cardiovascular diseases (i.e., WNT16, C18orf8, ANGPTL2, SAPCD2, ADCY3, PRR16, ERBB2, DOK2, PLAC1). Significant findings from pathway analysis, such as infectious and inflammatory and lipid metabolism pathways, lends support for the potential impact of maternal BMI on the above stated disorders. This study demonstrates that prepregnancy maternal BMI might lead to alterations in offspring DNA methylation in genes relevant to the development of a range of complex chronic diseases, providing evidence of trans-generational influence on disease susceptibility via epigenetic mechanism.