Robotic-assisted spine surgery-a narrative review.

Background and Objective: Emerging technologies have increasingly been adopted in spine surgery in the attempt to increase precision and improve outcomes. Robotic assistance is an area of significant interest, with proposed benefits including increased accuracy, decreased complication rates, and decreased radiation exposure. The purpose of this review is to provide an overview of the currently available robotic assistance systems and their associated outcomes and limitations. Methods: A review of national databases was performed using key terms "robotic", "spine", and "surgery" for literature from 2014 to 2023. Studies that aimed to describe the utilities of endoscopic surgeries, associated outcomes, limitations, and future directions were included. Studies that were not in English were excluded. Key Content and Findings: This review includes a brief overview of the history of robotic spine surgery as well as its clinical outcomes, limitations, and future directions. Conclusions: Robotic-assisted spine surgery has seen increasing use in the attempt to increase precision and improve outcomes and has been associated with increased accuracy in pedicle screw placement and decreased complication rates. Barriers to its adoption include a significant learning curve, possibly longer operative cases, and significant associated costs. As robotic assistance continues to become increasingly popular in spine surgery, it is critical for surgeons to understand the technology available and the associated outcomes to make informed decisions when considering which system to incorporate into their practice.

Improving Applicant Satisfaction in Orthopaedic Surgery Residency Matching: The Role of Preference Signaling.

Background: The orthopaedic surgery residency match is becoming increasingly more competitive with a disproportionate number of applicants to positions. As the residency application process has become more competitive, applicants have resorted to applying broadly to improve their chance of a successful match. Preference signaling was implemented for orthopaedic surgery for the 2022-2023 match cycle which allowed applicants to "signal" 30 programs of their choosing. Methods: The purpose of this study was to assess the impact of preference signaling on orthopaedic surgery applicant experiences and outcomes in the 2023 residency application cycle and match. An anonymous electronically based survey study developed using Research Electronic Data Capture (REDCap) was send to 895 applicants to a single orthopedic residency program. 148 applicants filled out some portion of the survey for a 16.5% response rate. Results: 51% of applicants applied to 61-100 programs. Applicants received more interview offers from programs they signaled compared to programs they did not signal. 50% of applicants responded that the number of allotted signals was "just right", with more applicants responding that the number of signals allotted was "too many" rather than "too few". 62% of applicants agreed that signaling increased his/her chances of receiving an interview offer at a signaled program, 66% were satisfied with the results of the match, and 50% thought signaling had a positive impact on the application process. Conclusion: Overall, preference signaling was well received by applicants and may help to connect applicants with residency programs they are specifically interested in. Level of Evidence: III.

Patient-Reported Outcomes of Total Hip Arthroplasty at an Ambulatory Surgery Center Versus a Hospital-Based Center.

INTRODUCTION: The utilization of ambulatory surgery centers (ASCs) and same-day discharge (SDD) from hospital-based centers (HBCs) after total hip arthroplasty (THA) continues to increase. There remains a paucity of literature directly comparing patient-reported outcomes by surgery site. We sought to compare outcomes between patients undergoing THA at an ASC versus HBC while controlling for medical comorbidities. METHODS: Patients undergoing primary THA with SDD (postoperative day 0) from a single HBC (1,015 patients) or stand-alone ASC (170 patients) from December 2020 to 2021 were identified. Patient demographics, comorbidities, and 90-day complications were collected. Hip Osteoarthritis Outcome Score (HOOS JR), VR-12, and procedural satisfaction scores were collected preoperatively and at 3, 6, and 12 months. Patients were matched by age and American Society of Anesthesiologists (ASA). Chi-squared analysis was conducted to compare categorical variables, and a Wilcoxon rank-sum test was used for continuous variables. Linear regression models were conducted considering age, sex, and presence of comorbidities. RESULTS: Patients undergoing THA at an ASC had markedly higher VR-12 Physical Component Scores at all time points and improved VR-12 Mental Component Scores at preoperative visit and 6 months. These patients had increased procedural satisfaction at 3 months, although there was no difference at 1 year. No notable difference was observed in 90-day complication rates between groups. After matching by age and ASA, each group had 170 patients. In the matched analysis, preoperative HOOS JR scores were markedly lower in the HBC group. However, there was no notable difference in HOOS JR scores, change in HOOS JR scores, and procedural satisfaction, at any postoperative time point. CONCLUSIONS: No notable difference was observed in patient-reported outcomes at any time point for SDD after THA performed at an ASC or an HBC when controlling for age and comorbidities. This study suggests noninferiority of stand-alone ASCs for outpatient THA, regarding patient satisfaction and patient-reported outcomes.

Plate vs. intramedullary screw fixation of chevron olecranon osteotomies: a biomechanical study.

Background: Intra-articular distal humerus fractures frequently require olecranon osteotomies for adequate exposure, but fixation of olecranon osteotomies is associated with high rates of hardware-related complications requiring subsequent reoperation for removal. Intramedullary screw fixation is an attractive option to attempt to minimize hardware prominence. The purpose of this biomechanical study is to directly compare intramedullary screw fixation (IMSF) with plate fixation (PF) of chevron olecranon osteotomies. It was hypothesized that PF would be biomechanically superior to IMSF. Methods: Chevron olecranon osteotomies of 12 matched pairs of fresh-frozen human cadaveric elbows were repaired with either precontoured proximal ulna locking plates or cannulated screws with a washer. Displacement and amplitude of displacement at the dorsal and medial aspects of the osteotomies under cyclic loading conditions were measured. Finally, the specimens were loaded to failure. Results: The IMSF group had significantly greater medial displacement (P = .034) and dorsal amplitude (P = .029) than the PF group. Medial displacement was negatively correlated with bone mineral density in the IMSF group (r = -0.66, P = .035) but not in the PF group (r = .160, P = .64). Mean load to failure between groups, however, was not statistically significant (P = .183). Conclusions: While there was no statistically significant difference in the load to failure between the two groups, IMSF repair resulted in significantly greater displacement of the medial osteotomy site during cyclic loading and greater amplitude of displacement dorsally with loading force. Decreased bone mineral density was associated with an increased displacement of the medial repair site. These results suggest that IMSF of olecranon osteotomies may result in increased fracture site displacement when compared to PF; this displacement may be greater in patients with poor bone quality.

Substantial clinical benefit values demonstrate a high degree of variability when stratified by time and geographic region.

Background: A Substantial Clinical Benefit (SCB) value is the amount of change in a patient-reported outcome measure required for a patient to feel they significantly improved from an intervention. Previously published SCB values are often cited by researchers when publishing outcomes data. Where these SCB values are set can have a large impact on the conclusions drawn from a study citing them. As such, the goal of this study was to determine the generalizability of SCB values for a procedure when stratified by time from surgery and geographic region. Methods: A nationwide outcomes database was utilized to obtain preoperative, one-year, and two-year postoperative outcome measurements for patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse TSA. The data were divided into three geographic regions: the South, the Midwest, and the West. An East region was not included due to its limited number of patients. SCB values were calculated for four outcomes measures: Single Assessment Numeric Evaluation score, American Shoulder Elbow Surgeons score, Visual Analog Scale, and Western Ontario Osteoarthritis of the Shoulder score. SCB values were calculated for each region, for each procedure, and at both one and two years postoperatively. To determine the variability of potential SCBs within each region, simulated datasets were created to determine a distribution of possible calculated SCBs. Results: A total of 380 anatomic TSA patients and 543 reverse TSA patients were included for analysis. There was a high degree of variability of SCB values when stratified by procedure, time, and region. While some simulated datasets did produce homogenous SCB distributions among regions, some outcome measures demonstrated a large heterogeneity in distribution among regions, with concomitant large distributions of values within individual regions. Conclusions: There is notable heterogeneity of SCB values when stratified by region or time. The current method of citing previously published SCB values for determining the efficacy of an intervention may be inappropriate. It is likely that this variability holds true in other areas of orthopedics.

Management of Failed Rotator Cuff Repairs: A Review.

Failed rotator cuff repairs present a complex issue for treating surgeons. Many methods of management exist for this pathology including revision repair with biologic augmentation, repairs with allograft, tendon transfers, superior capsular reconstruction, balloon arthroplasty, bursal acromial reconstruction, and reverse total shoulder arthroplasty. This review discusses the current literature associated with these management options.

Suture Tape Augmentation for the Repair of Index Finger Radial Collateral Ligament Injury: A Biomechanical Study.

PURPOSE: Despite their clinical importance in maintaining the stability of the pinch mechanism, injuries of the radial collateral ligament (RCL) of the index finger may be underrecognized and underreported. The purpose of this biomechanical study was to compare the repair of index finger RCL tears with either a standard suture anchor or suture tape augmentation. METHODS: The index fingers from 24 fresh-frozen human cadavers underwent repair of torn RCLs using either a standard suture anchor or suture tape augmentation. Following the repairs, the initial displacement of the repair with a 3-N ulnar deviating load was evaluated. Next, the change in displacement (cyclic deformation) of the repair after 1,000 cycles of 3 N of ulnar deviating force was calculated (displacement of the 1000th cycle - displacement of the first cycle). Finally, the amount of force required to cause clinical failure (30° ulnar deviation) of the repair was determined. RESULTS: Suture tape augmentation repairs displayed significantly less cyclic deformation (0.8 ± 0.5 mm) after cyclic loading than suture anchor repairs (1.8 ± 0.7 mm). There was no significant difference in the force required to cause the clinical failure of the repairs between the suture tape (35.1 ± 18.1 N) and suture anchor (24.5 ± 9.2 N) repairs. CONCLUSIONS: Index finger RCL repair with suture tape augmentation results in decreased deformation with repetitive motion compared with RCL repair alone. CLINICAL RELEVANCE: Suture tape augmentation may allow for early mobilization following index finger RCL repair by acting as a brace that protects the repaired ligament from deforming forces.

The Clinically Important Difference and Patient Acceptable Symptomatic State for Commonly Used Patient-Reported Outcomes After Knee Cartilage Repair.

BACKGROUND: In patients undergoing cartilage restoration of the knee, limited information is available regarding clinically important difference (CID) and Patient Acceptable Symptomatic State (PASS) estimates for commonly used patient-reported outcome measures (PROMs). PURPOSE: The objective of this study was to determine the CID and PASS in the population with knee cartilage restoration for the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee Subjective Knee Form (IKDC) score, and the Lysholm score. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: Between 2012 and 2017, patients who underwent a cartilage restoration procedure were prospectively enrolled. Patients completed the KOOS, IKDC, and Lysholm, all of which were scored from 0 to 100, and completed relevant anchor questions at baseline and 1 year postoperatively. Receiver operating characteristic curve analyses were conducted to determine CID and PASS cutoff points. Multivariable regression analyses were performed to determine the effect of age, sex, and baseline score on likelihood of achieving CID and PASS. RESULTS: Of the 113 patients enrolled, 53 (47%) were male, and the mean age was 36 years. The CID values for the PROMs were 10.7 for KOOS Symptoms, 8.3 for KOOS Pain, 8.8 for KOOS Activities of Daily Living (ADL), 30.0 for KOOS Sports and Recreation, 18.8 for KOOS Quality of Life (QOL), 9.2 for IKDC, and 13.0 for Lysholm. The PASS values were 71.5 for KOOS Symptoms, 72.2 for KOOS Pain, 86.8 for KOOS ADL, 43.8 for KOOS Sports and Recreation, 50.0 for KOOS QOL, 62.1 for IKDC, and 70.0 for Lysholm. Patients with higher baseline scores were more likely to achieve PASS for the IKDC (odds ratio, 2.28; P = .03). Baseline score did not have an effect on the likelihood of achieving CID. Younger age was an independent predictor of achieving PASS and CID across all outcomes (P < .05), but sex did not have such an effect. CONCLUSION: This study determined CID and PASS values for the KOOS, IKDC, and Lysholm scores among patients treated with knee cartilage restoration. Younger age was a positive prognostic variable, and higher baseline scores implied achieving PASS for the IKDC. The information in this study can be used in designing randomized controlled trials, counseling individual patients as to anticipated outcomes, and conducting responder analyses when evaluating new cartilage technology from a regulatory perspective.

Lack of standardization among clinical trials of injection therapies for knee osteoarthritis: a systematic review.

Purpose: Osteoarthritis (OA) of the knee is a debilitating, expensive, and prevalent disease, and interest in the non-surgical management of knee OA has grown recently. Our objective was to systematically assess the level of heterogeneity among all clinical trials and published studies regarding injections for knee osteoarthritis, in terms of treatment of interest, outcomes evaluated, and time points of outcome assessment. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to review all published studies and publically available clinical trials from 1 January 2013 to 3 May 2019evaluating intra-articular injections to treat knee OA. Their treatment group and specifics of methodology were scrutinized and compared. Results: 84 published studies and 114 clinical trials were included. Within the 84 published studies, the most common injection treatment studied was hyaluronic acid [N = 22; 26.2%]. In total, 29 different injection treatment groups were utilized. The most common time point for patient evaluation post-injection was 6 months (N = 33 studies; 50.0%), and ranged from 1 week (N = 9 studies; 13.6%) to 7 years (N = 1 study; 1.5%). The most common patient-reported outcome (PRO) measure assessed in the included studies was Western Ontario and McMaster's University Osteoarthritis Index (WOMAC) [N = 44 studies; 66.7%]. For the 114 clinical trials identified, the most common injection treatment studied is platelet-rich plasma in isolation (N = 19; 16.7%). Forty-two different injection treatment types/groups are utilized. The most common PRO measure assessed was WOMAC (N = 77 trials; 67.5%). Overall there were 34 different patient-reported outcome measures used. Conclusions: Research efforts to find the most effective injection therapy for knee OA continue with a tremendous number of injection therapies still being evaluated. Substantial heterogeneity exists in these completed and ongoing trials in terms of patient demographics, OA grades, outcome scores and relatively short-term timing of assessments, with no clear standardization of testing protocol despite proposing to answer the same clinical question. We recommend that studies of this genre going forward be standardized in terms of outcome measures and longer-term follow-up time points, and should incorporate functional assessment evaluations and imaging studies.

Biocatalytically Initiated Precipitation Atom Transfer Radical Polymerization (ATRP) as a Quantitative Method for Hemoglobin Detection in Biological Fluids.

The hemoglobin content of blood is an important health indicator, and the presence of microscopic amounts of hemoglobin in places where it normally does not occur, e.g. in blood plasma or in urine, is a sign of diseases such as hemolytic anemia or urinary tract infections. Thus, methods to detect and quantify hemoglobin are important for clinical laboratories, blood banks, and for point-of-care diagnostics. The precipitation polymerization of N-isopropylacrylamide by hemoglobin-catalyzed atom transfer radical polymerization (ATRP) is used as an assay for hemoglobin quantification relying on the formation of turbidity as a simple optical read-out. Dose-response curves for pure hemoglobin and for hemoglobin in blood plasma, in urine, in erythrocytes, and in full blood are obtained. Turbidity formation increases with the concentration of hemoglobin. Concentrations of hemoglobin as low as 6.45 × 10-3 mg mL-1 in solution, 4.88 × 10-1 mg mL-1 in plasma, and 1.65 × 10-1 mg mL-1 in urine could be detected, which is below the clinically relevant concentrations in the respective body fluids. Total hemoglobin in full blood is also accurately determined. The reaction can be regarded as a polymerization-based signal amplification for the sensing of hemoglobin, as the analyte catalyzes the formation of radicals which add many monomer units into detectable polymer chains. While most established hemoglobin tests involve the use of highly toxic reagents such as potassium cyanide, the polymerization-based test uses simple and stable organic reagents. Thus, it is an environmentally friendlier alternative to established chemical assays for hemoglobin.

Risk Factors Associated With a Noncontact Anterior Cruciate Ligament Injury to the Contralateral Knee After Unilateral Anterior Cruciate Ligament Injury in High School and College Female Athletes: A Prospective Study.

BACKGROUND: The incidence of contralateral anterior cruciate ligament (CACL) injuries after recovery from a first-time anterior cruciate ligament (ACL) disruption is high in women; however, little is known about the risk factors associated with this trauma. HYPOTHESIS: Patient characteristics, strength, anatomic alignment, and neuromuscular characteristics of the contralateral uninjured leg at the time of the first ACL trauma are associated with risk of subsequent CACL injury, and these risk factors are distinct from those for a first-time ACL injury. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Sixty-one women who suffered a first-time noncontact ACL injury while participating in high school or college sports and underwent measurement of potential risk factors on their contralateral limb soon after the initial ACL injury and before reconstruction were followed until either a CACL injury or an ACL graft injury occurred, or until the last date of contact. RESULTS: Follow-up information was available for 55 (90.0%) of the 61 athletes and 11 (20.0%) suffered a CACL injury. Younger age, decreased participation in sport before the first ACL disruption, decreased anterior stiffness of the contralateral knee, and increased hip anteversion were associated with increases in the risk of suffering a CACL injury. CONCLUSION: A portion of CACL injury risk factors were modifiable (time spent participating in sport and increasing anterior knee stiffness with bracing), while others were nonmodifiable (younger age and increased hip anteversion). The relationship between younger age at the time of an initial ACL injury and increased risk of subsequent CACL trauma may be explained by younger athletes having more years available to be exposed to at-risk activities compared with older athletes. A decrease of anterior stiffness of the knee is linked to decreased material properties and width of the ACL, and this may explain why some women are predisposed to bilateral ACL trauma while others only suffer the index injury. The risk factors for CACL injury are unique to women who suffer bilateral ACL trauma compared with those who suffer unilateral ACL trauma. This information is important for the identification of athletes who may benefit from risk reduction interventions.

Clinical Outcomes of Revision Osteochondral Allograft Transplantation.

PURPOSE: To assess the survivorship, clinical outcomes, and radiographic outcomes of patients who have undergone revision osteochondral allograft (OCA) to the knee in a retrospective case series. METHODS: Nine patients who underwent revision OCA by the senior author between January 2003 and December 2015 with a minimum follow up of 2 years were reviewed retrospectively. Patients completed patient-reported outcome surveys containing the visual analog scale, the International Knee Documentation Committee, the Knee injury and Osteoarthritis Outcome Score, Lysholm score, and the Short-Form 12. Radiographic analysis included anteroposterior view graded via the Kellgren and Lawrence scale. Complications and reoperations were analyzed, with failure defined as conversion to arthroplasty. (Institutional review board 15050301.) RESULTS: One of 10 consecutive patients was lost to follow up, for an overall follow-up rate of 90% (5 males, 4 females); mean follow up, 4.53 ± 3.17 years. The median patient age at the time of revision OCA was 33 years (interquartile range [IQR], 8.6), the median defect size was 4.0 cm2 (IQR, 0), and the median time from index OCA to revision OCA was 2.9 years (IQR, 1.9). Five patients (50%) underwent subsequent surgery at a median of 1.92 years (IQR, 7.25), with 1 progressing to arthroplasty at 23 months after revision OCA, for an overall failure rate of 11%. There were no significant differences in any of the patient-reported outcome assessments compared with prerevision OCA (postindex OCA) values at final follow up (P > .05 for all). Similarly, there were no significant differences in Kellgren and Lawrence score before and after surgery (P = .1). CONCLUSIONS: At a mean 4.5 years following revision OCA, there was an 89% graft survivorship rate in a series of 9 patients, with no statistical changes in the radiographic progression of arthritis. LEVEL OF EVIDENCE: Level IV, case series.

Alpine Skiing Injuries.

CONTEXT:: Alpine skiing is a popular sport worldwide but has significant risk for injury. The epidemiology of skiing-related injuries has been described, which has led to the identification of risk factors for specific types of injuries. EVIDENCE ACQUISITION:: Pertinent literature from peer-reviewed publications was reviewed. STUDY DESIGN:: Clinical review. LEVEL OF EVIDENCE:: Level 5. RESULTS:: The adoption of international standards for ski-boot-binding systems has changed the profile of skiing-related injuries over time, as has the widespread use of helmets. An understanding of mechanisms of injury, risk factors, and preventative measures may decrease the incidence of skiing-related injuries. CONCLUSION:: Advances in standards for skiing equipment have been effective at decreasing both the frequency and severity of skiing-related injuries, but additional efforts are required to improve the safety of the sport.

Alpine Ski Racing Injuries.

CONTEXT: This article reviews the epidemiology of alpine ski racing-related injuries, risk factors, mechanisms of injury, and injury prevention strategies. EVIDENCE ACQUISITION: Pertinent literature from peer-reviewed publications from 1976 through 2018. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: The rate of injury in alpine ski racing is high. In general, knee injuries are the most common, with anterior cruciate ligament (ACL) disruptions being the most significant in terms of time loss from sport. Three specific mechanisms of ACL injury in alpine ski racers have recently been described (slip-catch, dynamic snowplow, and landing back-weighted). In contrast to other sports, female ski racers are not clearly at greater risk for ACL injury, especially at the highest level of competition. A high percentage of ski racers are able to return to their previous level of competition after ACL injury. Risk factors for injury and methods of injury prevention have been proposed; however, the rate of injury, particularly ACL injuries, has not decreased significantly. CONCLUSION: Alpine ski racing has a high injury rate. ACL injuries in particular remain problematic. Further study is needed to identify modifiable risk factors and implementation of injury prevention strategies.

The Conservative Treatment of Osteoarthritis of the Knee.

Osteoarthritis has one of the highest associations for all-cause mortality in the United States. Comorbidities are common in patients with end-stage disease. In most cases, it is critical to exhaust conservative modalities of care before resorting to surgical intervention. This article discusses common conservative approaches focusing on injectable treatments that can be employed prior to total knee replacement. [Orthopedics. 2018; 41(5):256-260.].

Relationship Between Quantitative MRI Biomarkers and Patient-Reported Outcome Measures After Cartilage Repair Surgery: A Systematic Review.

BACKGROUND: Treatment of articular cartilage injuries remains a clinical challenge, and the optimal tools to monitor and predict clinical outcomes are unclear. Quantitative magnetic resonance imaging (qMRI) allows for a noninvasive biochemical evaluation of cartilage and may offer advantages in monitoring outcomes after cartilage repair surgery. HYPOTHESIS: qMRI sequences will correlate with early pain and functional measures. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A PubMed search was performed with the following search terms: knee AND (cartilage repair OR cartilage restoration OR cartilage surgery) AND (delayed gadolinium-enhanced MRI OR t1-rho OR T2 mapping OR dgemric OR sodium imaging OR quantitative imaging). Studies were included if correlation data were included on quantitative imaging results and patient outcome scores. RESULTS: Fourteen articles were included in the analysis. Eight studies showed a significant relationship between quantitative cartilage imaging and patient outcome scores, while 6 showed no relationship. T2 mapping was examined in 11 studies, delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) in 4 studies, sodium imaging in 2 studies, glycosaminoglycan chemical exchange saturation transfer (gagCEST) in 1 study, and diffusion-weighted imaging in 1 study. Five studies on T2 mapping showed a correlation between T2 relaxation times and clinical outcome scores. Two dGEMRIC studies found a correlation between T1 relaxation times and clinical outcome scores. CONCLUSION: Multiple studies on T2 mapping, dGEMRIC, and diffusion-weighted imaging showed significant correlations with patient-reported outcome measures after cartilage repair surgery, although other studies showed no significant relationship. qMRI sequences may offer a noninvasive method to monitor cartilage repair tissue in a clinically meaningful way, but further refinements in imaging protocols and clinical interpretation are necessary to improve utility.

Male Sex, Decreased Activity Level, and Higher BMI Associated With Lower Completion of Patient-Reported Outcome Measures Following ACL Reconstruction.

BACKGROUND: Patient-reported outcome (PRO) surveys have become increasingly important in both improving patient care and assessing outcomes. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate which variables are associated with compliance with completing PRO surveys in patients who have undergone anterior cruciate ligament reconstruction (ACLR). The authors hypothesized that older patient age and longer time since ACLR would be associated with lower completion rates of PRO surveys preoperatively and at postoperative time points. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients who underwent ACLR by a sports medicine fellowship-trained orthopaedic surgeon at a single institution and were electronically assigned PRO surveys through a data collection system preoperatively between December 2013 and March 2015 were included. Postoperatively, PRO surveys were sent to patients' email addresses at 6, 12, and 24 months. Demographics, history, and operative and postoperative information were evaluated for an association with survey completion rates. RESULTS: A total of 256 patients met the inclusion criteria. There were 140 (54.7%) male and 116 (45.3%) female patients, with an overall mean age of 28.6 ± 11.9 years. Only 19 (7.4%) patients completed all preoperative and postoperative surveys at all time points. Less than half of the patients (n = 104; 40.6%) completed both the preoperative survey and at least 1 postoperative survey. There was a steady decrease in the completion rate of PRO surveys postoperatively over time (Pearson r = -0.995, P = .005). Male patients had significantly worse compliance with completing PRO surveys preoperatively and at a minimum of 1 time point postoperatively (P = .044). Patients who did not identify as athletes or report frequent exercise (≥3 times/wk) had significantly worse compliance with completing any PRO surveys (P = .046). Lower body mass index was associated with greater odds of compliance with completing the preoperative survey and 24-month postoperative survey (odds ratio, 0.902; P = .029). CONCLUSION: An inverse relationship was found between the surgery-to-survey period and percentage of those completing PRO surveys, with poor overall compliance. Male sex and not self-identifying as an athlete or performing frequent physical exercise were associated with lower completion rates of PRO surveys, while lower body mass index was associated with a greater rate of completion.

Utility of Modern Arthroscopic Simulator Training Models: A Meta-analysis and Updated Systematic Review.

PURPOSE: To determine the utility of modern arthroscopic simulators in transferring skills learned on the model to the operating room. METHODS: A meta-analysis and systematic review of all English-language studies relevant to validated arthroscopic simulation models using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines from 1999 to 2016 was performed. Data collected included the specific simulator model, the joint used, participant demographic characteristics, participant level of training, training session information, type and number of tasks, pre- and post-training assessments, and overall outcomes of simulator performance. Three independent reviewers analyzed all studies. RESULTS: Fifty-seven studies with 1,698 participants met the study criteria and were included. Of the studies, 25 (44%) incorporated an arthroscopic training program into the study methods whereas 32 (56%) did not. In 46 studies (81%), the studies' respective simulator models were used to assess arthroscopic performance, whereas 9 studies (16%) used Sawbones models, 8 (14%) used cadaveric models, and 4 (7%) evaluated subject performance on a live patient in the operating room. In 21 studies (37%), simulator performance was compared with experience level, with 20 of these (95%) showing that clinical experience correlated with simulator performance. In 25 studies (44%), task performance was evaluated before and after simulator training, with 24 of these (96%) showing improvement after training. All 4 studies that included live-patient arthroscopy reported improved operating room performance after simulator training compared with the performance of subjects not participating in a training program. CONCLUSIONS: This review suggests that (1) training on arthroscopic simulators improves performance on arthroscopic simulators and (2) performance on simulators for basic diagnostic arthroscopy correlates with experience level. Limited data suggest that simulator training can improve basic diagnostic arthroscopy skills in vivo. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up.

BACKGROUND: Microfracture is an effective surgical treatment for full-thickness cartilage defects of the knee; however, little is known regarding long-term outcomes after microfracture in the shoulder. PURPOSE: To present long-term clinical outcomes of patients undergoing microfracture of full-thickness articular cartilage defects of the glenohumeral joint. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Sixteen consecutive patients (17 shoulders) were retrospectively reviewed who underwent arthroscopic microfracture of the humeral head and/or glenoid surface, with or without additional procedures between 2001 and 2008 and with a minimum follow-up of 8.5 years. All patients completed pre- and postoperative surveys containing the visual analog scale, American Shoulder and Elbow Surgeons form, and Simple Shoulder Test. Complications and reoperations were analyzed. Failure was defined by biological resurfacing or conversion to arthroplasty. RESULTS: Of the original 16 patients (17 shoulders), 13 patients (14 shoulders) were available for mean follow-up at 10.2 ± 1.8 years after microfracture (range, 8.5-15.8 years), for an overall clinical follow-up rate of 82%. The patients (6 men, 7 women) were 36.1 ± 12.9 years old at time of microfracture. The average size of humeral head defects was 5.20 cm2 (range, 4.0-7.84 cm2), and the average size of glenoid defects was 1.53 cm2 (range, 1.0-3.75 cm2). Four patients (4 shoulders) underwent at least 1 reoperation, and 3 were considered to have structural failures. The average time to failure was 3.7 years after microfracture (range, 0.2-9.6 years). The overall survival rate was 76.6% at 9.6 years. For these patients, there were statistically significant improvements in visual analog scale, Simple Shoulder Test, and American Shoulder and Elbow Surgeons scores as compared with preoperative values at long-term follow-up ( P < .05 for all), without any significant change from short-term (mean, 2.3 years) to long-term (mean, 10.2 years) follow-up. There was no significant difference in Single Assessment Numeric Evaluation or Short Form-12 Physical or Mental scores between short- and long-term follow-up. When compared with short-term follow-up, in which 2 patients had already failed, 1 additional patient progressed to failure at 9.6 years after the original microfracture. Two patients (2 shoulders) were considered to have clinical failure. Owing to the overall number of failures (3 structural failure and 2 clinical failure), the total long-term success rate of glenohumeral microfracture is 66.7% in the current study. CONCLUSION: Treating full-thickness symptomatic chondral defects of the glenohumeral joint with microfracture can result in long-term improved function and reduced pain for some patients. However, in this case series, 21.4% of patients required conversion to arthroplasty <10 years after the index microfracture procedure, and 33% to 42% of patients were considered to have potential clinical failure. Additional studies with larger patient cohorts are needed.

Patient Understanding, Expectations, and Satisfaction Regarding Rotator Cuff Injuries and Surgical Management.

Rotator cuff injuries are among the most common in orthopaedics, with rotator cuff repair surgery consistently reported as one of the most commonly performed orthopaedic procedures. Patient satisfaction is becoming an increasingly important outcome metric as health care continues to evolve with regard to quality measures affecting physician reimbursement. Evidence supports that postoperative patient satisfaction, an important quality outcome metric, is highly influenced by preoperative patient expectations, which are in turn governed by patient knowledge and understanding. Many authors have delineated patient-, injury-, and surgery-specific variables associated with high preoperative expectations and satisfaction after rotator cuff surgery. Specifically, large rotator cuff tears, subscapularis tears, persistence of postoperative pain and dysfunction, worker's compensation cases, lower education level, and preoperative disability have been seen more frequently in patients reporting poor satisfaction. Others have reported variables associated with higher patient satisfaction such as being married, employed, and of older age at the time of surgery (>55 years old) predictive of higher satisfaction. Patient education preoperatively regarding details about the surgery and the postoperative plan both immediately after the procedure and for rehabilitation are critical in helping set patients' preoperative expectations that have a known effect on patients' subjective clinical outcomes.