Surgeon Performance as a Predictor for Patient-Reported Outcomes After Arthroscopic Partial Meniscectomy

Background

Surgeon performance has been investigated as a factor affecting patient outcomes after orthopaedic procedures to improve transparency between patients and providers.

Purpose/Hypothesis

The purpose of this study was to identify whether surgeon performance influenced patient-reported outcomes (PROMs) 1 year after arthroscopic partial meniscectomy (APM). It was hypothesized that there would be no significant difference in PROMs between patients who underwent APM from various surgeons.

Study Design

Case-control study; Level of evidence, 3.

Methods

A prospective cohort of 794 patients who underwent APM between 2018 and 2019 were included in the analysis. A total of 34 surgeons from a large multicenter health care center were included. Three multivariable models were built to determine whether the surgeon-among demographic and meniscal pathology factors-was a significant variable for predicting the Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain subscale, the Patient Acceptable Symptom State (PASS), and a 10-point improvement in the KOOS-Pain at 1 year after APM. Likelihood ratio (LR) tests were used to determine the significance of the surgeon variable in the models.

Results

The 794 patients were identified from the multicenter hospital system. The baseline KOOS-Pain score was a significant predictor of outcome in the 1-year KOOS-Pain model (odds ratio [OR], 2.1 [95% CI, 1.77-2.48]; P < .001), the KOOS-Pain 10-point improvement model (OR, 0.57 [95% CI, 0.44-0.73), and the 1-year PASS model (OR, 1.42 [95% CI, 1.15-1.76]; P = .002) among articular cartilage pathology (bipolar medial cartilage) and patient-factor variables, including body mass index, Veterans RAND 12-Item Health Survey-Mental Component Score, and Area Deprivation Index. The individual surgeon significantly impacted outcomes in the 1-year KOOS-Pain mixed model in the LR test (P = .004).

Conclusion

Patient factors and characteristics are better predictors for patient outcomes 1 year after APM than surgeon characteristics, specifically baseline KOOS-Pain, although an individual surgeon influenced the 1-Year KOOS-Pain mixed model in the LR test. This finding has key clinical implications; surgeons who wish to improve patient outcomes after APM should focus on improving patient selection rather than improving the surgical technique. Future research is needed to determine whether surgeon variability has an impact on longer-term patient outcomes.

Development and Operationalization of an Automated Workflow for Correlation of Knee MRI and Arthroscopy Findings

OBJECTIVE

In this study, we sought to establish and evaluate an automated workflow to prospectively capture and correlate knee MRI findings with surgical findings in a large medical center.

METHODS

This retrospective analysis included data from patients who had undergone knee MRI followed by arthroscopic knee surgery within 6 months during a 2-year period (2019-2020). Discrete data were automatically extracted from a structured knee MRI report template implementing pick lists. Operative findings were recorded discretely by surgeons using a custom-built web-based telephone application. MRI findings were classified as true-positive, true-negative, false-positive, or false-negative for medial meniscus (MM), lateral meniscus (LM), and anterior cruciate ligament (ACL) tears, with arthroscopy used as the reference standard. An automated dashboard displaying up-to-date concordance and individual and group accuracy was enabled for each radiologist. Manual correlation between MRI and operative reports was performed on a random sample of 10% of cases for comparison with automatically derived values.

RESULTS

Data from 3,187 patients (1,669 male; mean age, 47 years) were analyzed. Automatic correlation was available for 60% of cases, with an overall MRI diagnostic accuracy of 93% (MM, 92%; LM, 89%; ACL, 98%). In cases reviewed manually, the number of cases that could be correlated with surgery was higher (84%). Concordance between automated and manual review was 99% when both were available (MM, 98%; LM, 100%; ACL, 99%).

CONCLUSION

This automated system was able to accurately and continuously assess correlation between imaging and operative findings for a large number of MRI examinations.

The osteoarthritis prevention study (TOPS) - A randomized controlled trial of diet and exercise to prevent Knee Osteoarthritis: Design and rationale

Background

Osteoarthritis (OA), the leading cause of disability among adults, has no cure and is associated with significant comorbidities. The premise of this randomized clinical trial is that, in a population at risk, a 48-month program of dietary weight loss and exercise will result in less incident structural knee OA compared to control.

Methods/design

The Osteoarthritis Prevention Study (TOPS) is a Phase III, assessor-blinded, 48-month, parallel 2 arm, multicenter randomized clinical trial designed to reduce the incidence of structural knee OA. The study objective is to assess the effects of a dietary weight loss, exercise, and weight-loss maintenance program in preventing the development of structural knee OA in females at risk for the disease. TOPS will recruit 1230 ambulatory, community dwelling females with obesity (Body Mass Index (BMI) ​≥ ​30 ​kg/m2) and aged ≥50 years with no radiographic (Kellgren-Lawrence grade ≤1) and no magnetic resonance imaging (MRI) evidence of OA in the eligible knee, with no or infrequent knee pain. Incident structural knee OA (defined as tibiofemoral and/or patellofemoral OA on MRI) assessed at 48-months from intervention initiation using the MRI Osteoarthritis Knee Score (MOAKS) is the primary outcome. Secondary outcomes include knee pain, 6-min walk distance, health-related quality of life, knee joint loading during gait, inflammatory biomarkers, and self-efficacy. Cost effectiveness and budgetary impact analyses will determine the value and affordability of this intervention.

Discussion

This study will assess the efficacy and cost effectiveness of a dietary weight loss, exercise, and weight-loss maintenance program designed to reduce incident knee OA.

Trial registration

ClinicalTrials.gov Identifier: NCT05946044.

The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions

CONTEXT

Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed.

EVIDENCE ACQUISITION

Articles were collected from peer-reviewed sources available on PubMed using a combination of search terms, including psychology, resilience, mental health, recovery, and anterior cruciate ligament reconstruction. Further evaluation of the included bibliographies were used to expand the evidence.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR.

CONCLUSION

The impact of psychology on patients' responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes.

STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT)

B.

The Effect of Aspiration and Corticosteroid Injection After ACL Injury on Postoperative Infection Rate

BACKGROUND

Injecting bioactive substances into the knee is common in orthopaedic practice, and recently it has been shown to mitigate risk factors for posttraumatic osteoarthritis. Therefore, understanding the influence of these injections on postoperative infection rate is imperative.

HYPOTHESIS

Postinjury aspiration and corticosteroid injection (CSI) of the knee before anterior cruciate ligament (ACL) reconstruction (ACLR) would not increase the risk of postoperative infection.

STUDY DESIGN

Cohort Study; Level of evidence, 3.

METHODS

All patients between the ages of 10 and 65 years who underwent primary bone-patellar tendon-bone ACLR by 1 fellowship-trained sports medicine orthopaedic surgeon between January 1, 2011, and September 8, 2020, at 1 of 2 major academic centers were evaluated for inclusion. A total of 693 patients were included, with 273 patients receiving postinjury and preoperative aspiration and CSI. A postoperative infection was defined as a patient returning to the operating room for an intra-articular washout. The intervals-measured in days-between the CSI and ACLR and between ACLR and the final follow-up were recorded. To further evaluate the infection risk in each cohort (total cohort; aspiration and injection cohort; no aspiration and injection cohort), the upper 95% confidence bound for the infection risk was calculated for each cohort.

RESULTS

There were no postoperative infections in the 693 patients included in this study. The upper 95% confidence bounds were 0.4%, 1.1%, and 0.7% for the total cohort, the cohort that underwent aspiration and injection, and the cohort that did not, respectively. The median number of days between the surgical date and that of the aspiration and injection was 34 days, and the mean follow-up for the entire cohort was 337.4 days (95% CI, 307.6-367.3).

CONCLUSION

Postinjury and preoperative aspiration and CSI is a safe intervention that can be used before ACLR. Future studies with larger sample sizes, longer patient follow-ups, and multiple surgeons would be helpful to both better understand infection risk and better identify the influence of CSI on preventing posttraumatic osteoarthritis.

Radiographic Changes Five Years After Treatment of Meniscal Tear and Osteoarthritic Changes

OBJECTIVE

Meniscal tear in persons aged ≥45 years is typically managed with physical therapy (PT), and arthroscopic partial meniscectomy (APM) is offered to those who do not respond. Prior studies suggest APM may be associated with greater progression of radiographic changes.

METHODS

We assessed changes between baseline and 60 months in the Kellgren-Lawrence (KL) grade and OARSI radiographic score (including subscores for joint space narrowing and osteophytes) in subjects aged 45-85 years enrolled into a seven-center randomized trial comparing outcomes of APM with PT for meniscal tear, osteoarthritis changes, and knee pain. The primary analysis classified subjects according to treatment received. To balance APM and PT groups, we developed a propensity score and used inverse probability weighting (IPW). We imputed a 60-month change in the OARSI score for subjects who underwent total knee replacement (TKR). In a sensitivity analysis, we classified subjects by randomization group.

RESULTS

We analyzed data from 142 subjects (100 APM, 42 PT). The mean ± SD weighted baseline OARSI radiographic score was 3.8 ± 3.5 in the APM group and 4.0 ± 4.9 in the PT group. OARSI scores increased by a mean of 4.1 (95% confidence interval [95% CI] 3.5-4.7) in the APM group and 2.4 (95% CI 1.7-3.2) in the PT group (P < 0.001) due to changes in the osteophyte component. We did not observe statistically significant differences in the KL grade. Sensitivity analyses yielded similar findings to the primary analysis.

CONCLUSION

Subjects treated with APM had greater progression in the OARSI score because of osteophyte progression but not in the KL grade. The clinical implications of these findings require investigation.

One-year patient-reported outcomes following primary arthroscopic rotator cuff repair vary little by surgeon

Background

This study's purpose was to investigate the extent to which differences among operating surgeons may influence 1-year patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair (RCR) surgery, after controlling for general and disease-specific patient factors. We hypothesized that surgeon would be additionally associated with 1-year PROMs, specifically the baseline to 1-year improvement in Penn Shoulder Score (PSS).

Methods

We used mixed multivariable statistical modeling to assess the influence of surgeon (and alternatively surgical case volume) on 1-year PSS improvement in patients undergoing RCR at a single health system in 2018, controlling for eight patient- and six disease-specific preoperative factors as possible confounders. Contributions of predictors to explaining variation in 1-year PSS improvement were measured and compared using Akaike's Information Criterion.

Results

518 cases performed by 28 surgeons met inclusion criteria, with median (quartiles) baseline PSS of 41.9 (31.9, 53.9) and 1-year PSS improvement of 42 (29.1, 55.3) points. Contrary to expectation, surgeon and surgical case volume were neither statistically significantly nor clinically meaningfully associated with 1-year PSS improvement. Baseline PSS and mental health status (VR-12 MCS) were the dominant and only statistically significant predictors of 1-year PSS improvement, with lower baseline PSS and higher VR-12 MCS predicting larger 1-year PSS improvement.

Conclusion

Patients generally reported excellent 1-year outcomes following primary RCR. This study did not find evidence that the individual surgeon or surgeon case volume influences 1-year PROMs, independently of case-mix factors, following primary RCR in a large employed hospital system.

Predictors of Return to Activity at 2 Years After Anterior Cruciate Ligament Reconstruction Among Patients With High Preinjury Marx Activity Scores: A MOON Prospective Cohort Study

BACKGROUND

Predictors of return to activity after anterior cruciate ligament reconstruction (ACLR) among patients with relatively high preinjury activity levels remain poorly understood.

PURPOSE/HYPOTHESIS

The purpose of this study was to identify predictors of return to preinjury levels of activity after ACLR, defined as achieving a Marx activity score within 2 points of the preinjury value, among patients with Marx activity scores of 12 to 16 who had been prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) cohort. We hypothesized that age, sex, preinjury activity level, meniscal injuries and/or procedures, and concurrent articular cartilage injuries would predict return to preinjury activity levels at 2 years after ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

All unilateral ACLR procedures from 2002 to 2008 performed in patients enrolled in the MOON, with preinjury Marx activity scores ranging from 12 to 16, were evaluated with a specific focus on return to preinjury activity levels at 2 years postoperatively. Return to activity was defined as a Marx activity score within 2 points of the preinjury value. The proportion of patients able to return to preinjury activity levels was calculated, and multivariable modeling was performed to identify risk factors for patients' inability to return to preinjury activity levels.

RESULTS

A total of 1188 patients were included in the final analysis. The median preinjury Marx activity score was 16 (interquartile range, 12-16). Overall, 466 patients (39.2%) were able to return to preinjury levels of activity, and 722 patients (60.8%) were not able to return to preinjury levels of activity. Female sex, smoking at the time of ACLR, fewer years of education, lower 36-Item Short Form Health Survey Mental Component Summary scores, and higher preinjury Marx activity scores were predictive of patients' inability to return to preinjury activity levels. Graft type, revision ACLR, the presence of medial and/or lateral meniscal injuries, a history of meniscal surgery, the presence of articular cartilage injuries, a history of articular cartilage treatment, and the presence of high-grade knee laxity were not predictive of a patient's ability to return to preinjury activity level.

CONCLUSION

At 2 years after ACLR, most patients with high preinjury Marx activity scores did not return to their preinjury level of activity. The higher the preinjury Marx activity score that a patient reported at the time of enrollment, the less likely he/she was able to return to preinjury activity level. Smoking and lower mental health at the time of ACLR were the only modifiable risk factors in this cohort that predicted an inability to return to preinjury activity levels. Continued effort and investigation are required to maximize functional recovery after ACLR in patients with high preinjury levels of activity.

External Validation of the KOOS-ACL in the MOON Group Cohort of Young Athletes Followed for 10 Postoperative Years

BACKGROUND

The Knee injury and Osteoarthritis Outcome Score-Anterior Cruciate Ligament (KOOS-ACL) is a short form version of the KOOS, developed to target populations of young active patients with ACL tears. The KOOS-ACL consists of 2 subscales: Function (8 items) and Sport (4 items). The KOOS-ACL was developed and validated using data from the Stability 1 study from baseline to postoperative 2 years.

PURPOSE

To validate the KOOS-ACL in an external sample of patients matching the outcome's target population.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 1.

METHODS

The Multicenter Orthopaedic Outcomes Network group cohort of 839 patients aged 14 to 22 years who tore their ACLs while playing sports was used to assess internal consistency reliability, structural validity, convergent validity, responsiveness to change, and floor/ceiling effects of the KOOS-ACL at 4 time points: baseline and postoperative 2, 6, and 10 years. Detection of treatment effects between graft type (hamstring tendon vs bone-patellar tendon-bone) were also compared between the full-length KOOS and KOOS-ACL.

RESULTS

The KOOS-ACL demonstrated acceptable internal consistency reliability (α = .82-.89), structural validity (Tucker-Lewis index and comparative fit index = 0.98-0.99; standardized root mean square residual and root mean square error of approximation = 0.04-0.07), convergent validity (Spearman correlation with International Knee Documentation Committee subjective knee form = 0.66-0.85; Western Ontario and McMaster Universities Osteoarthritis Index function = 0.84-0.95), and responsiveness to change across time (large effect sizes from baseline to postoperative 2 years; d = 0.94 [Function] and d = 1.54 [Sport]). Stable scores and significant ceiling effects were seen from 2 to 10 years. No significant differences in KOOS or KOOS-ACL scores were detected between patients with different graft types.

CONCLUSION

The KOOS-ACL shows improved structural validity when compared with the full-length KOOS and adequate psychometric properties in a large external sample of high school and college athletes. This strengthens the argument to use the KOOS-ACL to assess young active patients with ACL tears in clinical research and practice.

The Corticosteroid Meniscectomy Trial of Extended-Release Triamcinolone Injection After Arthroscopic Partial Meniscectomy: Protocol for a Double-Blind Randomized Controlled Trial

Background

Meniscal tear in older adults often accompanies knee osteoarthritis and is commonly treated with arthroscopic partial meniscectomy (APM) when patients have persistent pain after a trial of physical therapy. Cross-sectional evidence suggests that synovitis is associated with baseline pain in this patient population, but little is known about the relationship between synovitis and postoperative recovery or progression of knee osteoarthritis.

Purpose/Hypothesis

Intra-articular extended-release triamcinolone may reduce inflammation and thereby improve outcomes and slow disease progression. This article presents the rationale behind the Corticosteroid Meniscectomy Trial (CoMeT) and describes its study design and implementation strategies.

Study Design

Randomized controlled trial.

Methods

CoMeT is a 2-arm, 3-center, randomized placebo-controlled trial designed to establish the clinical efficacy of extended-release triamcinolone administered via intra-articular injection immediately after APM. The primary outcome is change in Knee injury and Osteoarthritis Outcome Score Pain subscore at 3-month follow-up. Synovial biopsy, joint fluid aspirate, and urine and blood sample analyses will examine the associations between various objective measures of baseline inflammation and pre- and postoperative outcome measures and clinical responses to triamcinolone intervention. Quantitative 3-T magnetic resonance imaging will evaluate cartilage and meniscal composition and 3-dimensional bone shape to detect early joint degeneration.

Results

We discuss methodologic innovations and challenges.

Conclusion

To our knowledge, this is the first randomized double-blind clinical trial that will analyze the effect of extended-release triamcinolone acetonide on pain, magnetic resonance imaging measures of structural change and effusion/synovitis, soluble biomarkers, and synovial tissue transcriptomics after APM.

Meniscal and Articular Cartilage Predictors of Outcome After Revision ACL Reconstruction: A 6-Year Follow-up Cohort Study

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.

Deep learning-based automatic pipeline for quantitative assessment of thigh muscle morphology and fatty infiltration

PURPOSE

Fast and accurate thigh muscle segmentation from MRI is important for quantitative assessment of thigh muscle morphology and composition. A novel deep learning (DL) based thigh muscle and surrounding tissues segmentation model was developed for fully automatic and reproducible cross-sectional area (CSA) and fat fraction (FF) quantification and tested in patients at 10 years after anterior cruciate ligament reconstructions.

METHODS

A DL model combining UNet and DenseNet was trained and tested using manually segmented thighs from 16 patients (32 legs). Segmentation accuracy was evaluated using Dice similarity coefficients (DSC) and average symmetric surface distance (ASSD). A UNet model was trained for comparison. These segmentations were used to obtain CSA and FF quantification. Reproducibility of CSA and FF quantification was tested with scan and rescan of six healthy subjects.

RESULTS

The proposed UNet and DenseNet had high agreement with manual segmentation (DSC >0.97, ASSD < 0.24) and improved performance compared with UNet. For hamstrings of the operated knee, the automated pipeline had largest absolute difference of 6.01% for CSA and 0.47% for FF as compared to manual segmentation. In reproducibility analysis, the average difference (absolute) in CSA quantification between scan and rescan was better for the automatic method as compared with manual segmentation (2.27% vs. 3.34%), whereas the average difference (absolute) in FF quantification were similar.

CONCLUSIONS

The proposed method exhibits excellent accuracy and reproducibility in CSA and FF quantification compared with manual segmentation and can be used in large-scale patient studies.

Association Between Structural Change Over Eighteen Months and Subsequent Symptom Change in Middle-Aged Patients Treated for Meniscal Tear

OBJECTIVE

Middle-aged subjects with meniscal tear treated with arthroscopic partial meniscectomy (APM) experience greater progression of damage to joint structures on imaging than subjects treated nonoperatively. It is unclear whether these changes are clinically relevant. The goal of this study was to assess whether worsening in magnetic resonance imaging (MRI)-assessed tissue damage over 18 months leads to subsequent worsening in knee pain over the subsequent 3.5 years.

METHODS

We used data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of APM versus physical therapy for subjects ages ≥45 years with knee pain, cartilage damage, and meniscal tear. We assessed whether change in cartilage surface area damage score (and other structural measures) from baseline to 18 months, assessed on MRI with the MRI Osteoarthritis Knee Score (MOAKS) system, was associated with change in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score (range 0-100; 100 = worst) from 18 to 60 months.

RESULTS

The primary analysis included 168 subjects with complete MRI data at baseline and 18 months and KOOS data at 18 and 60 months. We did not observe clinically important associations between change in cartilage surface area score between baseline and 18 months and change in pain scores from 18 to 60 months. Pain scores in the worst tertile for cartilage surface area damage score progression worsened by 0.45 points more than in the best tertile (95% confidence interval -4.45, 5.35). Similarly, we did not observe clinically important associations between changes in bone marrow lesions, osteophytes, or synovitis and subsequent pain.

CONCLUSION

We did not observe clinically important associations between early changes in cartilage damage and other structural measures and worsening in pain over the subsequent 3.5 years. Further follow-up is required to assess this association over a longer follow-up period.

Multi-vendor multi-site quantitative MRI analysis of cartilage degeneration 10 Years after anterior cruciate ligament reconstruction: MOON-MRI protocol and preliminary results

OBJECTIVE

To describe the protocol of a multi-vendor, multi-site quantitative MRI study for knee post-traumatic osteoarthritis (PTOA), and to present preliminary results of cartilage degeneration using MR T1ρ and T2 imaging 10 years after anterior cruciate ligament reconstruction (ACLR).

DESIGN

This study involves three sites and two MR platforms. The patients are from a nested cohort (termed as Onsite cohort) within the Multicenter Orthopaedic Outcomes Network (MOON) cohort 10 years after ACLR. Phantoms and controls were scanned for evaluating reproducibility. Cartilage was automatically segmented, and T1ρ and T2 were compared between operated, contralateral, and control knees.

RESULTS

Sixty-eight ACL-reconstructed patients and 20 healthy controls were included. In phantoms, the intra-site coefficients of variation (CVs) of repeated scans ranged 1.8-2.1% for T1ρ and 1.3-1.7% for T2. The inter-site CVs ranged 1.6-2.1% for T1ρ and 1.1-1.4% for T2. In human subjects, the intra-site scan/rescan CVs ranged 2.2-3.5% for T1ρ and 2.6-4.9% for T2 for the six major compartments. In patients, operated knees showed significantly higher T1ρ and T2 values mainly in medial femoral condyle, medial tibia and trochlear cartilage compared with contralateral knees, and showed significantly higer T1ρ and T2 values in all six compartments compared to healthy control knees. The patient contralateral knees showed higher T1ρ and T2 values mainly in the lateral femoral condyle, lateral tibia, trochlear, and patellar cartilage compared to healthy control knees.

CONCLUSION

A platform and workflow with rigorous quality control has been established for a multi-vendor multi-site quantitative MRI study in evaluating PTOA 10 years after ACLR. Our preliminary report suggests significant cartilage matrix changes in both operated and contralateral knees compared with healthy control knees.

Volume and Outcomes of Joint Arthroplasty

BACKGROUND

Joint arthroplasties are among the most commonly performed elective surgeries in the United States. Surgical outcomes are known to improve with volume but it is unclear whether this has led to consolidation among elective surgeries. We examined trends in volumes per surgeon and hospital to assess whether the known volume-outcome relationship has led to consolidation in elective joint arthroplasty and to determine if there exist volume thresholds above which outcomes do not change.

METHODS

Among Medicare beneficiaries who underwent either total knee or total hip arthroplasty from 2009 through 2015, we described volume trends and used mixed-effect models to relate annual surgeon and hospital volumes with 30-day complications or mortality. We tested for optimal volume cut points at both the hospital and surgeon level.

RESULTS

Adjusted annual complication rates were inversely associated with volume for both procedures at both the surgeon level and hospital level, but there was minimal consolidation between 2009 and 2015. Complications no longer declined after volumes of each case exceeded 260 per year. The vast majority of cases (around 93% of hip and 88% of knee arthroplasties) were performed by surgeons operating at suboptimal volumes.

CONCLUSION

More than 2 decades after the volume-outcome relationship was established for joint arthroplasty, many cases continue to be performed by low-volume surgeons, with far more cases performed by surgeons operating at suboptimal volumes. Further improvement could be expected through consolidation at both the hospital and surgeon level, with a target of at least 260 cases per surgeon annually for each operation. Payers seem best-equipped to drive consolidation.

Optimizing Use of Large Databases in Joint Arthroplasty and Orthopaedics

The potential users of "big data" need to consider many factors when choosing whether to use a large observational database for their research question and, if so, which database is the best fit for the scientific question. The first section of this paper, written by Dr. James A. Browne, provides a framework (who, what, where, when, and why?) to assess the critical elements that are included in a large database, which allows the user to determine if interrogation of the data is likely to answer the research question. The next section of this paper, written by Dr. Bryan Springer, focuses on the importance of having an a priori research question before deciding the best data source to answer the question; it also elaborates on the differences between administrative databases and clinical databases. The final section of the paper, written by Dr. Kurt P. Spindler, reviews the concepts of hypothesis-generating and hypothesis-testing studies and discusses in detail the differences, strengths, limitations, and appropriate uses of observational data versus randomized controlled trials.

Posteromedial Tibial Bone Bruise After Anterior Cruciate Ligament Injury: An MRI Study of Bone Bruise Patterns in 208 Patients

Background:

Bone bruise patterns after anterior cruciate ligament (ACL) rupture may predict the presence of intra-articular pathology and help explain the mechanism of injury. Lateral femoral condyle (LFC) and lateral tibial plateau (LTP) bone bruises are pathognomic to ACL rupture. There is a lack of information regarding medial tibial plateau (MTP) and medial femoral condyle (MFC) bone bruises.

Purpose:

To summarize the prevalence and location of MTP bone bruises with acute ACL rupture and to determine the predictors of MTP bone bruises.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Inclusion criteria were patients who underwent ACL reconstruction between February 2015 and November 2017, magnetic resonance imaging (MRI) within 90 days of injury, and participation in the database. Exclusion criteria included previous ipsilateral surgery, multiligamentous injuries, and incomplete imaging. Due to the large number of cases remaining (n = 600), 150 patients were selected randomly from each year included in the study, for a total of 300 patients. Two readers independently reviewed injury MRI scans using the Costa-Paz bone bruise grading system. Logistic regression was used to identify factors associated with MTP bone bruises.

Results:

Included were 208 patients (mean age, 23.8 years; mean body mass index, 25.6). The mechanism of injury was noncontact in 59% of injuries, with over half from soccer, basketball, and football. The median time from injury to MRI scan was 12 days. Of the 208 patients, 98% (203/208) had a bone bruise, 79% (164/208) had an MTP bone bruise, and 83% (172/208) had bruises in both medial and lateral compartments. The most common pattern, representing 46.6% of patients (97/208), was a bruise in all 4 locations (MFC, LFC, MTP, and LTP). Of the 164 MTP bruises, 160 (98%) involved the posterior third of the plateau, and 161 were grade 1. The presence of an MFC bruise was the only independent risk factor for an MTP bruise (odds ratio, 3.71). The resulting nomogram demonstrated MFC bruise, sport, and mechanism of injury were the most important predictors of an MTP bruise.

Conclusion:

MTP bruise after acute ACL rupture was as prevalent as lateral bruises. The presence of a posterior MTP bruise suggested anterior tibial translation at the time of injury and could portend more medial compartment pathology at the time of injury than previously recognized.

FDA/Arthritis Foundation osteoarthritis drug development workshop recap: Assessment of long-term benefit

OBJECTIVE

To summarize proceedings of a workshop convened to discuss the current state of science in the disease of osteoarthritis (OA), identify the knowledge gaps, and examine the developmental and regulatory challenges in bringing these products to market.

DESIGN

Summary of the one-day workshop held virtually on June 22nd, 2021.

RESULTS

Speakers selected by the Planning Committee presented data on the current approach to assessment of OA therapies, biomarkers in OA drug development, and the assessment of disease progression and long-term benefit.

CONCLUSIONS

Demonstrated by numerous failed clinical trials, OA is a challenging disease for which to develop therapeutics. The challenge is magnified by the slow time of onset of disease and the need for clinical trials of long duration and/or large sample size to demonstrate the effect of an intervention. The OA science community, including academia, pharmaceutical companies, regulatory agencies, and patient communities, must continue to develop and test better clinical endpoints that meaningfully reflect disease modification related to long-term patient benefit.

Evaluation of Health Care Disparities in Patients With Anterior Cruciate Ligament Injury: Does Race and Insurance Matter?

Background:

It is unknown whether race- or insurance-based disparities in health care exist regarding baseline knee pain, knee function, complete meniscal tear, or articular cartilage damage in patients who undergo anterior cruciate ligament reconstruction (ACLR).

Hypothesis:

Black patients and patients with Medicaid evaluated for ACLR would have worse baseline knee pain, worse knee function, and greater odds of having a complete meniscal tear.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A cohort of patients (N = 1463; 81% White, 14% Black, 5% Other race; median age, 22 years) who underwent ACLR between February 2015 and December 2018 was selected from an institutional database. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, KOOS Function subscale, and intraoperatively assessed complete meniscal tear (tear that extended through both the superior and the inferior meniscal surfaces) were determined via multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS).

Results:

The 3 factors most strongly associated with worse KOOS Pain and KOOS Function were lower VR-12 MCS score, increased BMI, and increased age. Except for age, the other two factors had an unequal distribution between Black and White patients. Univariate analysis demonstrated equal baseline median KOOS Pain scores (Black, 72.2; White, 72.2) and KOOS Function scores (Black, 68.2; White, 68.2). After adjusting for confounding variables, there was no significant difference between Black and White patients in KOOS Pain, KOOS Function, or complete meniscal tears. Insurance status was not a significant predictor of KOOS Pain, KOOS Function, or complete meniscal tear.

Conclusion:

There were clinically significant differences between Black and White patients evaluated for ACLR. After accounting for confounding factors, no difference was observed between Black and White patients in knee pain, knee function, or complete meniscal tear. Insurance was not a clinically significant predictor of knee pain, knee function, or complete meniscal tear.

No clinically meaningful difference in 1-year patient-reported outcomes among major approaches for primary total hip arthroplasty

BACKGROUND

Debate continues around the most effective surgical approach for primary total hip arthroplasty (THA). This study's purpose was to compare 1-year patient-reported outcome measures (PROMs) of patients who underwent direct anterior (DA), transgluteal anterolateral (AL)/direct lateral (DL), and posterolateral (PL) approaches.

METHODS

A prospective consecutive series of primary THA for osteoarthritis (n = 2390) were performed at 5 sites within a single institution with standardised care pathways (20 surgeons). Patients were categorised by approach: DA (n = 913; 38%), AL/DL (n = 505; 21%), or PL (n = 972; 41%). Primary outcomes were pain, function, and activity assessed by 1-year postoperative PROMs. Multivariable regression modeling was used to control for differences among the groups. Wald tests were performed to test the significance of select patient factors and simultaneous 95% confidence intervals were constructed.

RESULTS

At 1-year postoperative, PROMs were successfully collected from 1842 (77.1%) patients. Approach was a statistically significant factor for 1-year HOOS pain (p = 0.002). Approach was not a significant factor for 1-year HOOS-PS (p = 0.16) or 1-year UCLA activity (p = 0.382). Pairwise comparisons showed no significant difference in 1-year HOOS pain scores between DA and PL approach (p > 0.05). AL/DL approach had lower (worse) pain scores than DA or PL approaches with differences in adjusted median score of 3.47 and 2.43, respectively (p < 0.05).

CONCLUSIONS

Patients receiving the AL/DL approach had a small statistical difference in pain scores at 1 year, but no clinically meaningful differences in pain, activity, or function exist at 1-year postoperative.

Twenty-Year Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Prospectively Collected Data

BACKGROUND

Several long-term (≥20 years) follow-up studies after anterior cruciate ligament (ACL) reconstruction have been published in recent years, allowing for a systematic evaluation of outcomes.

PURPOSE

To summarize outcomes at ≥20 years after ACL reconstruction and identify patient and surgical factors that affect these results.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Prospective studies of primary ACL reconstructions with hamstring or bone-patellar tendon-bone (BTB) autograft via an arthroscopic or a mini-open technique and with a mean follow-up of ≥20 years were identified. When possible, the mean scores for each outcome measure were calculated. Factors identified in individual studies as predictive of outcomes were described.

RESULTS

Five studies met the inclusion and exclusion criteria with a total of 2012 patients. The pooled mean follow-up for patient-reported outcome measures was 44.2% (range, 29.6%-92.7%) and in-person evaluation was 33.2% (range, 29.6%-48.9%). Four studies (n = 584) reported graft tears at a mean rate of 11.8% (range, 2%-18.5%) and 4 studies (n = 773) reported a contralateral ACL injury rate of 12.2% (range, 5.8%-30%). Repeat non-ACL arthroscopic surgery (4 studies; n = 177) to the ipsilateral knee occurred in 10.4% (range, 9.5%-18.3%) and knee arthroplasty (1 study; n = 217) in 5%. The pooled mean of the International Knee Documentation Committee subjective knee function (IKDC) score was 79.1 (SD, 21.8 [3 studies; n = 644]). In 2 studies (n?= 221), 57.5% of patients continued to participate in strenuous activities. The IKDC-objective score was normal or nearly normal in 82.3% (n = 496; 3 studies), with low rates of clinically significant residual laxity. Moderate-severe radiographic osteoarthritis (OA) (IKDC grade C or D) was present in 25.9% of patients (n = 605; 3 studies). Medial meniscectomy is associated with increased risk of radiographic OA. Radiographic OA severity is associated with worse patient-reported knee function, but the association with knee pain is unclear.

CONCLUSION

Currently available prospective evidence for ACL reconstruction with hamstring or BTB autograft provides several insights into outcomes at 20 years. The rates of follow-up at 20 years range from 30% to 93%. IKDC-objective scores were normal or nearly normal in 82% and the mean IKDC-subjective score was 79 points.

Do Patellar Tendon Repairs Have Better Outcomes than Quadriceps Tendon Repairs? A Prospective Cohort Analysis

Patellar tendon (PT) and quadriceps tendon (QT) ruptures represent significant injuries and warrant surgical intervention in most patients. Outcome data are predominantly retrospective analyses with low sample sizes. There are also minimal data comparing QT and PT repairs and the variables impacting patient outcomes. The level of evidence of the study is level II (prognosis). From the prospective OME cohort, 189 PT or QT repairs were performed between February 2015 and October 2019. Of these, 178 were successfully enrolled (94.2%) with 1-year follow-up on 141 (79.2%). Baseline demographic data included age, sex, race, BMI, years of education, smoking status, and baseline VR-12 MCS score. Surgical and follow-up data included surgeon volume, fixation technique, baseline, and 1-year Knee Injury and Osteoarthritis Outcome Score-Pain (KOOS-Pain), Knee Injury and Osteoarthritis Outcome Score-Physical Function (KOOS-PS), and 1-year Patient Acceptable Symptom State (PASS) scores and complications. Multivariable regression analysis was utilized to identify prognosis and significant risk factors for outcomes-specifically, whether KOOS-Pain or KOOS-PS were different between QT versus PT repairs. There were 59 patients in the PT cohort and 82 patients in QT cohort. Baseline demographic data demonstrated that PT cohort was younger (45.1 vs. 59.5 years, p <0.001), included significantly fewer patients of White race (51.7 vs. 80.0%, p = 0.001), lesser number of years of education (13.9 vs. 15.2 years, p = 0.020), a higher percentage of "high" surgeon volume (72.9% vs. 43.9%, p = 0.001) and 25.4% of PT repairs had supplemental fixation (QT had zero, p <0.001). Multivariable analysis identified gender (female-worse, p = 0.001), years of education (higher-better, p = 0.02), and baseline KOOS-Pain score (higher-better, p <0.001) as the risk factors that significantly predicted KOOS-Pain score. The risk factors that significantly predicted KOOS-PS were gender (female worse, p = 0.033), race (non-White-worse, p <0.001), baseline VR-12 MCS score (higher-better, p <0.001), and baseline KOOS-PS score (higher better, p = 0.029). KOOS-Pain and KOOS-PS scores improved after both QT and PT repairs. Patient reported pain and function at 1 year were similar between PT and QT repairs after adjusting for known risk factors. Multivariable analysis identified female gender and low baseline KOOS scores as predictors for worse outcomes.

Descriptive Characteristics and Outcomes of Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction With and Without Tunnel Bone Grafting

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.

Changes From Baseline in Patient- Reported Outcomes at 1 Year Versus 2 Years After Rotator Cuff Repair: A Systematic Review and Meta-analysis

BACKGROUND

Most orthopaedic journals currently require reporting outcomes of surgical interventions for at least 2 postoperative years, but there have been no rigorous studies on this matter. Various patient-reported outcome (PRO) measures (PROMs) have been used to assess the status of the shoulder after rotator cuff repair (RCR).

HYPOTHESIS

We hypothesized that the mean shoulder-specific PROMs at 1 year improve substantially over baseline but that there is no clinically meaningful difference between the mean 1- and 2-year PROMs after RCR.

STUDY DESIGN

Meta-analysis; Level of evidence, 2.

METHODS

We conducted a systematic review of published randomized controlled trials (RCTs) and prospective cohort studies (level of evidence 1 and 2) reporting the shoulder-specific American Shoulder and Elbow Surgeons (ASES), the Constant, or the Western Ontario Rotator Cuff (WORC) Index scores at baseline, 1 year, and 2 years after RCR. The methodologic quality of studies was assessed. Also, the random effects meta-analyses of changes in PROMs for each of the first and second postoperative years were conducted.

RESULTS

Fifteen studies (n = 11 RCTs; n = 4 cohort studies) with a total of 1371 patients were included. Studies were highly heterogeneous, but no visual evidence of major publication bias was observed. The weighted means of the baseline PROMs were 46.2 points for the ASES score, 46.4 points for the Constant score, and 38.8 points for the WORC Index. The first-year summary increments were 41.1 (95% CI, 36.0-46.2) points for the ASES score, 34.2 (95% CI, 28.8-39.6) points for the Constant score, and 42.9 (95% CI, 37.3-48.4) points for the WORC Index. In contrast, the second-year summary increments were 2.3 (95% CI, 1-3.6) points for the ASES score, 3.2 (95% CI, 1.9-4.4) points for the Constant score, and 2 (95% CI, -0.1 to 4) points for the WORC Index.

CONCLUSION

All PROMs improved considerably from baseline to 1 year, but only very small gains that were below the minimal clinically important differences were observed between 1 year and 2 years after RCR. This study did not find any evidence for requiring a minimum of 2 years of follow-up for publication of PROs after RCR. Our results suggest that focusing on 1-year PROMs after RCR would foster more timely reporting, better control of selection bias, and better allocation of research resources.

Returning to Activity After Anterior Cruciate Ligament Revision Surgery: An Analysis of the Multicenter Anterior Cruciate Ligament Revision Study (MARS) Cohort at 2 Years Postoperative

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.

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

Background:

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

Purpose/Hypothesis:

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

Study Design:

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

Methods:

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

Results:

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

Conclusion:

The SPORTS score appears to be a reliable, responsive, and valid 1-item scale that can be used during the first year after ACLR. No differences in psychometric properties were found between the SPORTS score and the modified version.

Opioid Use After Simple Arthroscopic Knee Surgery

BACKGROUND

Evidence-based prescribing guidelines are lacking for opioids after most orthopaedic surgical procedures.

HYPOTHESIS

Opioids are commonly overprescribed after simple knee arthroscopy.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A cohort of 174 patients who underwent simple arthroscopic knee surgery were prospectively evaluated using data from the Outcome Management and Evaluation database. All patients received 10 combined hydrocodone 5 mg and acetaminophen 325 mg pills postoperatively. Patients were excluded if they (1) had revision surgery, (2) had concomitant complex surgery (eg, ligament surgery, osteotomy), (3) had current opioid use, (4) had open surgery for removal of hardware, (5) or had bilateral knee surgery. Total opioid consumption was reported at the first postoperative visit, and a distribution was created based on patient response. Based on the distribution, patients were separated into low (0-2 pills) versus high (3 or more pills) opioid consumption groups for evaluating risk factors for opioid use. The risk factors included were age, body mass index, smoking status, education level, baseline pain (Knee injury and Osteoarthritis Outcome Score pain subscale [KOOS Pain]), and baseline mental health (Veterans RAND 12-Item Health Survey Mental Component Score), as well as intraoperative findings such as synovial characteristics and extent of osteoarthritis in the multivariate model.

RESULTS

Total opioid consumption ranged from 0 to 19 pills. The median pill count was 2 (25th; 75th interquartile range, 0; 4). Of total patients, 59% were categorized as having low opioid consumption, and the remaining 41% were in the high opioid consumption group. Only 23 patients (13.2%) took 6 or more pills. Preoperative pain as measured by KOOS Pain score was a significant predictor of high opioid consumption postoperatively (odds ratio, 0.97; 95% CI, 0.95-0.99; P = .003).

CONCLUSION

The clinically relevant conclusion is that opioids are overprescribed after simple arthroscopic knee surgery. Based on distribution, the authors recommend that 4 pills be prescribed after simple arthroscopic knee surgery. After accounting for confounding variables, preoperative pain was associated with higher postoperative opioid consumption.

Validity of Research Based on Public Data in Sports Medicine: A Quantitative Assessment of Anterior Cruciate Ligament Injuries in the National Football League

BACKGROUND

Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players.

PURPOSE

To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams' medical staff to the NFL Injury Surveillance System database linked to the League's electronic health record. An ACL "capture rate" for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest.

RESULTS

A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams' medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play.

CONCLUSION

The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.

Creating Crosswalks for Knee Outcomes After ACL Reconstruction Between the KOOS and the IKDC-SKF

BACKGROUND

Anterior cruciate ligament (ACL) registries do not all use the same patient-reported outcome measures, limiting comparisons and preventing pooling of data for meta-analysis. Our objective was to create a statistical crosswalk to convert cohort and registry mean Knee Injury and Osteoarthritis Outcome Scores (KOOS) to International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores and vice versa to allow these comparisons.

METHODS

Data from 3 ACL registries were pooled (n = 14,412) and were separated into a training data set (70% of the sample) or a validation data set (30% of the sample). The KOOS and the IKDC-SKF scores were available prior to the operation and at 1, 2, and 5 or 6 years postoperatively. We used equipercentile equating methods to create crosswalks in the training data set and examined accuracy in the validation data set as well as bootstrapping analyses to assess the impact of sample size on accuracy.

RESULTS

Preliminary analyses suggested that crosswalks could be attempted: large correlations between scores on the 2 measures (r = 0.84 to 0.94), unidimensionality of scores, and subpopulation invariance were deemed sufficient. When comparing actual scores with crosswalked scores in the validation data set, negligible bias was observed at the group level; however, individual score deviations were variable. The crosswalks are successful for the group level only.

CONCLUSIONS

Our crosswalks successfully convert between the KOOS and the IKDC-SKF scores to allow for a group-level comparison of registry and other cohort data.

CLINICAL RELEVANCE

These crosswalks allow comparisons among different national ligament registries as well as other research cohorts and studies; they also allow data from different patient-reported outcome measures to be pooled for meta-analysis. These crosswalks have great potential to improve our understanding of recovery after ACL reconstruction and aid in our ongoing efforts to improve outcomes and patient satisfaction, as well as to allow the continued analysis of historical data.

Prognostic value of patient-reported outcome measures in adult heart-transplant patients: a systematic review

Background

The aim of this systematic review was to describe the prognostic value of patient-reported outcome measures (PROMs) in adult heart-transplant (HT) patients.

Methods

A systematic search was performed on Ovid Medline, CINAHL Plus, Web of Science, and PubMed. The study protocol was registered on the PROSPERO database (CRD42021225398), and the last search was performed on January 7, 2021. We included studies of adult HT patients where generic and disease-specific PROMs were used as prognostic indicators for survival, readmissions, HT complications, and the onset of new comorbidities. We excluded studies that used clinician-reported and patient-experience outcomes. The Quality in Prognosis Studies tool (QUIPS) was used to measure the risk of bias of the included studies.

Results

We included five observational studies between 1987 and 2015, whose populations’ mean age ranged from 43 to 56 years and presented a higher proportion of males than females. The Kansas City Cardiomyopathy Questionnaire demonstrated a negative correlation with readmissions (coefficient = − 1.177, p = 0.031), and the EQ-5D showed a negative correlation with the onset of neuromuscular disease after HT (coefficient = − 0.158, p < 0.001). The Millon Behavioral Health Inventory and the Nottingham Health Profile demonstrated a statistically significant association as survival predictors (p = 0.002 and p < 0.05, respectively). A moderate overall risk of bias was reported in three studies, one study resulted in a low risk of bias, and a proportion of more than 75% of males in each of the studies. High heterogeneity between the studies impeded establishing a link between PROMs and prognostic value.

Conclusion

There is low evidence supporting PROMs usage as prognostic tools in adult HT patients. Comparing outcomes of PROMS to routine prognostic in wider and systematic settings is warranted. Systematic use of PROMs in clinical settings is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00431-4.

Five-Year Structural Changes in Patients with Meniscal Tear and Osteoarthritis: Data from an RCT of Arthroscopic Partial Meniscectomy vs. Physical Therapy

OBJECTIVE

Data from long-term follow-up of several randomized controlled trials (RCTs) of arthroscopic partial meniscectomy (APM) vs. non-operative therapy or sham have suggested that APM may be associated with increased risk of worsening in radiographic features of osteoarthritis (OA). Our objective was to estimate the risk of MRI-based OA structural changes using baseline, 18-month, and 60-month MRI data from an RCT of APM vs. physical therapy in participants with meniscal tear and OA.

METHODS

We used data from the MeTeOR (Meniscal Tear in Osteoarthritis Research) Trial. MRIs were read using the MRI OA Knee Score (MOAKS). We used linear mixed effects models to examine the association between treatment group and continuous MOAKS summary scores, and Poisson regression to assess categorical change in joint structure. Analyses assessed change from baseline to 18 months and 18-to-60 months. We performed both intention-to-treat and as-treated analyses.

RESULTS

The analytic sample included 302 participants. For both treatment groups, more change was seen over the earlier (baseline - 18 months) interval than the later interval. APM was associated with increased risk of any worsening in cartilage surface area damage score (relative risk 1.35, 95% CI 1.14-1.61), osteophytes, and effusion-synovitis over the earlier time period. Only change in osteophytes was significantly different between treatment groups in the later time period.

CONCLUSION

These findings suggest the association between APM and MRI-based changes is most apparent in the 18 months after surgery. The reason for the attenuation of this association over longer follow-up merits further investigation.

Meniscal Treatment as a Predictor of Worse Articular Cartilage Damage on MRI at 2 Years After ACL Reconstruction: The MOON Nested Cohort

BACKGROUND

Patients undergoing anterior cruciate ligament reconstruction (ACLR) are at an increased risk for posttraumatic osteoarthritis (PTOA). While we have previously shown that meniscal treatment with ACLR predicts more radiographic PTOA at 2 to 3 years postoperatively, there are a limited number of similar studies that have assessed cartilage directly with magnetic resonance imaging (MRI).

HYPOTHESIS

Meniscal repair or partial meniscectomy at the time of ACLR independently predicts more articular cartilage damage on 2- to 3-year postoperative MRI compared with a healthy meniscus or a stable untreated tear.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A consecutive series of patients undergoing ACLR from 1 site within the prospective, nested Multicenter Orthopaedic Outcomes Network (MOON) cohort underwent bilateral knee MRI at 2 to 3 years postoperatively. Patients were aged <36 years without previous knee injuries, were injured while playing sports, and had no history of concomitant ligament surgery or contralateral knee surgery. MRI scans were graded by a board-certified musculoskeletal radiologist using the modified MRI Osteoarthritis Knee Score (MOAKS). A proportional odds logistic regression model was built to predict a MOAKS-based cartilage damage score (CDS) relative to the contralateral control knee for each compartment as well as for the whole knee, pooled by meniscal treatment, while controlling for sex, age, body mass index, baseline Marx activity score, and baseline operative cartilage grade. For analysis, meniscal injuries surgically treated with partial meniscectomy or meniscal repair were grouped together.

RESULTS

The cohort included 60 patients (32 female; median age, 18.7 years). Concomitant meniscal treatment at the time of index ACLR was performed in 17 medial menisci (13 meniscal repair and 4 partial meniscectomy) and 27 lateral menisci (3 meniscal repair and 24 partial meniscectomy). Articular cartilage damage was worse in the ipsilateral reconstructed knee (P < .001). A meniscal injury requiring surgical treatment with ACLR predicted a worse CDS for medial meniscal treatment (medial compartment CDS: P = .005; whole joint CDS: P < .001) and lateral meniscal treatment (lateral compartment CDS: P = .038; whole joint CDS: P = .863). Other predictors of a worse relative CDS included age for the medial compartment (P < .001), surgically observed articular cartilage damage for the patellofemoral compartment (P = .048), and body mass index (P = .007) and age (P = .020) for the whole joint.

CONCLUSION

A meniscal injury requiring surgical treatment with partial meniscectomy or meniscal repair at the time of ACLR predicted worse articular cartilage damage on MRI at 2 to 3 years after surgery. Further research is required to differentiate between the effects of partial meniscectomy and meniscal repair.

MOON's Strategy for Obtaining Over Eighty Percent Follow-up at 10 Years Following ACL Reconstruction

ABSTRACT

The Multicenter Orthopaedic Outcomes Network (MOON) study of anterior cruciate ligament (ACL) reconstruction has achieved >80% follow-up for study subjects who were enrolled from 2002 to 2005; patient-reported outcome measures (PROMs) were reported at 2, 6, and 10 years through a carefully designed protocol that included surgeon involvement to encourage subjects to complete and return questionnaires. The process included emails and telephone calls from the central coordinating center, from research coordinators at each local institution, and lastly, from the subjects' surgeons for those who were less inclined to complete the follow-up. In order to quantify the effect of site and surgeon involvement, the enrollment year of 2005 was monitored for the 10-year follow-up (n = 516 subjects). In contact efforts made by the coordinating center, 73.8% (381) of study subjects were reached by the central site coordinator, contact information was verified, and questionnaires were subsequently sent, completed, and returned. An additional 54 subjects (10.5% of the overall study population) returned the questionnaire after local study site involvement, indicating the importance of individual surgeon and local site involvement to improve follow-up rates in multicenter studies in orthopaedic surgery. Follow-up rates were higher when a specific individual (the surgeon or the research coordinator) was given the task of final follow-up.

MOntelukast as a potential CHondroprotective treatment following Anterior cruciate ligament reconstruction (MOCHA Trial): study protocol for a double-blind, randomized, placebo-controlled clinical trial

BACKGROUND

After anterior cruciate ligament (ACL) reconstruction, patient-reported outcomes are improved 10 years post-surgery; however, cytokine concentrations remain elevated years after surgery with over 80% of those with combined ACL and meniscus injuries having posttraumatic osteoarthritis (PTOA) within 10-15 years. The purpose of this multicenter, randomized, placebo-controlled trial is to assess whether a 6-month course of oral montelukast after ACL reconstruction reduces systemic markers of inflammation and biochemical and imaging biomarkers of cartilage degradation.

METHODS

We will enroll 30 individuals undergoing primary ACL reconstruction to participate in this IRB-approved multicenter clinical trial. This trial will target those at greatest risk of a more rapid PTOA onset (age range 25-50 with concomitant meniscus injury). Patients will be randomly assigned to a group instructed to take 10 mg of montelukast daily for 6 months following ACL reconstruction or placebo. Patients will be assessed prior to surgery and 1, 6, and 12 months following surgery. To determine if montelukast alters systemic inflammation following surgery, we will compare systemic concentrations of prostaglandin E2, monocyte chemoattractant protein-1, and pro-inflammatory cytokines between groups. We will also compare degradative changes on magnetic resonance imaging (MRI) collected 1 and 12 months following surgery between groups with reductions in early biomarkers of cartilage degradation assessed with urinary biomarkers of type II collagen breakdown and bony remodeling.

DISCUSSION

There is a complex interplay between the pro-inflammatory intra-articular environment, underlying bone remodeling, and progressive cartilage degradation. PTOA affects multiple tissues and appears to be more similar to rheumatoid arthritis than osteoarthritis with respect to inflammation. There is currently no treatment to delay or prevent PTOA after ACL injury. Since there is a larger and more persistent inflammatory response after ACL reconstruction than the initial insult of injury, treatment may need to be initiated after surgery, sustained over a period of time, and target multiple mechanisms in order to successfully alter the disease process. This study will assess whether a 6-month postoperative course of oral montelukast affects multiple PTOA mechanisms. Because montelukast administration can be safely sustained for long durations and offers a low-cost treatment option, should it be proven effective in the current trial, these results can be immediately incorporated into clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04572256 . Registered on October 1, 2020.

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

Background:

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

Purpose:

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

Study Design:

Clinical trial.

Methods:

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

Results:

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

Conclusion:

Major issues include patient selection, need for intraoperative randomization and treatment-specific postoperative physical therapy regimens (because of fundamental differences in surgical technique, initial stability construct, and healing), and choice of noninferiority margins for short-term efficacy outcomes of a novel intervention with evident short-term advantages and theoretical, but unverified, long-term benefits on other dimensions.

Are There Racial Disparities in Knee Symptoms and Articular Cartilage Damage in Patients Presenting for Arthroscopic Partial Meniscectomy?

The purpose of the present study was to examine whether Black patients presenting for arthroscopic partial meniscectomy (APM) have worse baseline knee pain, worse knee function, and greater articular cartilage damage than White patients.

Same knee, different goals: patients and surgeons have different priorities related to ACL reconstruction

PURPOSE

The priorities of patients should be shared by those treating them. Patients and surgeons are likely to have different priorities surrounding anterior cruciate ligament reconstruction (ACLR), with implications for shared decision-making and patient education. The optimal surgical approach for ACLR is constantly evolving, and the magnitude of treatment effect necessary for evidence to change surgical practice is unknown. The aim of this study was to determine (1) the priorities of surgeons and patients when making decisions regarding ACLR and (2) the magnitude of reduction in ACLR graft failure risk that orthopaedic surgeons require before changing practice.

METHODS

This study followed a cross-sectional survey design. Three distinct electronic surveys were administered to pre-operative ACLR patients, post-operative ACLR patients, and orthopaedic surgeons. Patients and surgeons were asked about the importance of various outcomes and considerations pertaining to ACLR. Surgeons were asked scenario-based questions regarding changing practice for ACLR based on new research.

RESULTS

Surgeons were more likely to prioritize outcomes related to the surgical knee itself, whereas patients were more likely to prioritize outcomes related to their daily lifestyle and activities. Knee instability and risk of re-injury were unanimous top priorities among all three groups. A mean relative risk reduction in ACLR graft failure of about 50% was required by orthopaedic surgeons to change practice regardless of the type of change, or patient risk profile.

CONCLUSION

There are discrepancies between the priorities of surgeons and patients, and orthopaedic surgeons appear resistant to changing practice for ACLR.

LEVEL OF EVIDENCE

IV.

Effectiveness of a Web-Based Electronic Prospective Data Collection Tool for Surgical Data in Shoulder Arthroplasty

Background

The purpose of this study was to demonstrate the validity and efficiency of the Outcomes Management and Evaluation (OME) system, a prospectively designed electronic data collection tool, for collecting comprehensive and standardized surgical data in shoulder arthroplasty.

Methods

Surgical data from the first 100 cases of shoulder arthroplasty that were collected into the OME database were analyzed. Surgeons completed a traditional narrative operative note and also an OME case report using an encrypted smartphone. A blinded reviewer extracted data from the operative notes and implant logs in the electronic medical records (EMR) by manual chart review. OME and EMR data were compared with regard to data counts and agreement between 39 variables related to preoperative pathology, including rotator cuff status and glenoid wear, and surgical procedures. Data counts were assessed using both raw percentages and with McNemar's test (with continuity correction). Agreement of nominal variables was analyzed using Cohen's unweighted kappa (κ) and of ordinal variables using the linearly weighted Cohen's test. Efficiency was assessed by calculating the median time needed to complete OME.

Results

Compared to the EMR, the OME database had significantly higher data counts for 56% (22 of 39) of the variables assessed. A high level of proportional and statistical agreement was demonstrated between the data in the two datasets. 10 of 39 variables had 100% agreement but could not be statistically compared because both datasets had the same single response under those variables. Among the 29 variables that were compared, 79% (23 of 29) of variables had >80% raw proportional agreement, and 69% (20 of 29) of variables showed at least substantial agreement (κ > 0.6). The median time for completing OME surgery data entry was 92 seconds (IQR 70 - 126).

Conclusion

The prospectively designed, electronic data entry system (OME) is an efficient and valid tool for collecting comprehensive and standardized surgical data on shoulder arthroplasty.

Level of Evidence

Level IV.

Anterior Cruciate Ligament Reconstruction With Concomitant Meniscal Repair: Is Graft Choice Predictive of Meniscal Repair Success?

Background

When meniscal repair is performed during anterior cruciate ligament (ACL) reconstruction (ACLR), the effect of ACL graft type on meniscal repair outcomes is unclear.

Hypothesis

The authors hypothesized that meniscal repairs would fail at the lowest rate when concomitant ACLR was performed with bone--patellar tendon--bone (BTB) autograft.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent meniscal repair at primary ACLR were identified from a longitudinal, prospective cohort. Meniscal repair failures, defined as any subsequent surgical procedure addressing the meniscus, were identified. A logistic regression model was built to assess the association of graft type, patient-specific factors, baseline Marx activity rating score, and meniscal repair location (medial or lateral) with repair failure at 6-year follow-up.

Results

A total of 646 patients were included. Grafts used included BTB autograft (55.7%), soft tissue autograft (33.9%), and various allografts (10.4%). We identified 101 patients (15.6%) with a documented meniscal repair failure. Failure occurred in 74 of 420 (17.6%) isolated medial meniscal repairs, 15 of 187 (8%) isolated lateral meniscal repairs, and 12 of 39 (30.7%) of combined medial and lateral meniscal repairs. Meniscal repair failure occurred in 13.9% of patients with BTB autografts, 17.4% of patients with soft tissue autografts, and 19.4% of patients with allografts. The odds of failure within 6 years of index surgery were increased more than 2-fold with allograft versus BTB autograft (odds ratio = 2.34 [95% confidence interval, 1.12-4.92]; P = .02). There was a trend toward increased meniscal repair failures with soft tissue versus BTB autografts (odds ratio = 1.41 [95% confidence interval, 0.87-2.30]; P = .17). The odds of failure were 68% higher with medial versus lateral repairs (P < .001). There was a significant relationship between baseline Marx activity level and the risk of subsequent meniscal repair failure; patients with either very low (0-1 points) or very high (15-16 points) baseline activity levels were at the highest risk (P = .004).

Conclusion

Meniscal repair location (medial vs lateral) and baseline activity level were the main drivers of meniscal repair outcomes. Graft type was ranked third, demonstrating that meniscal repairs performed with allograft were 2.3 times more likely to fail compared with BTB autograft. There was no significant difference in failure rates between BTB versus soft tissue autografts.

Registration

NCT00463099 (ClinicalTrials.gov identifier).

Effect of Baseline Mental Health on 1-Year Outcomes After Hip Arthroscopy: A Prospective Cohort Study

Background:

Patient factors, including mental health, sex, and smoking, have been found to be more predictive of preoperative hip pain and function than intra-articular findings during hip arthroscopy for femoroacetabular impingement (FAI); however, little is known about how these factors may influence patients’ postoperative outcomes.

Hypothesis:

We hypothesized that lower patient-reported mental health scores would be significant risk factors for worse patient-reported outcomes (PROs) 1 year after arthroscopic hip surgery for FAI and that baseline intra-articular pathology would fail to demonstrate an association with outcomes 1 year after FAI surgery.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A prospective cohort of patients undergoing hip arthroscopy for FAI were electronically enrolled. Baseline and 1-year follow-up PROs were collected, including Hip disability and Osteoarthritis Outcome Score for pain (HOOS-Pain), HOOS–Physical Function Short Form (HOOS-PS), and Veterans RAND 12-Item Health Survey–Mental Component Score (VR-12 MCS). Intra-articular operative findings and treatment were documented at the time of surgery. Proportional odds logistic regression models were built for 1-year outcomes (HOOS-Pain, HOOS-PS, and VR-12 MCS). Risk factors included patient characteristics and intraoperative anatomic and pathologic findings.

Results:

Overall, 494 patients underwent hip arthroscopy for FAI, and 385 (78%) were evaluated at 1 year with at least 1 PRO. The median patient age was 33 years, mean body mass index was 25.5 kg/m², and 72% were female. Multivariable analysis demonstrated that better baseline HOOS-Pain, HOOS-PS, and VR-12 MCS were significantly associated with improvement in the 1-year scores for each PRO. Higher VR-12 MCS was significantly associated with better 1-year HOOS-Pain and HOOS-PS, while current and former smokers had worse 1-year outcomes than those who never smoked. In ranking each variable’s relative importance, baseline HOOS-Pain and HOOS-PS and baseline VR-12 MCS were identified as the strongest predictors of 1-year HOOS-Pain and HOOS-PS in our multivariable model.

Conclusion:

During hip arthroscopy for FAI, patient factors, including baseline hip pain and function, mental health, and smoking, were independently associated with 1-year PROs of hip pain and function, while intra-articular pathology such as the presence of labral tear and its treatment, tear size, tear location, and anchors placed were not independently associated.

Articular Cartilage and Meniscus Predictors of Patient-Reported Outcomes 10 Years After Anterior Cruciate Ligament Reconstruction: A Multicenter Cohort Study

BACKGROUND

Articular cartilage and meniscal damage are commonly encountered and often treated at the time of anterior cruciate ligament reconstruction (ACLR). Our understanding of how these injuries and their treatment relate to outcomes of ACLR is still evolving.

HYPOTHESIS/PURPOSE

The purpose of this study was to assess whether articular cartilage and meniscal variables are predictive of 10-year outcomes after ACLR. We hypothesized that articular cartilage lesions and meniscal tears and treatment would be predictors of the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level outcomes at 10-year follow-up after ACLR.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 1.

METHODS

Between 2002 and 2008, individuals with ACLR were prospectively enrolled and followed longitudinally using the IKDC, KOOS, and Marx activity score completed at entry, 2, 6, and 10 years. A proportional odds logistic regression model was built incorporating variables from patient characteristics, surgical technique, articular cartilage injuries, and meniscal tears and treatment to determine the predictors (risk factors) of IKDC, KOOS, and Marx outcomes at 10 years.

RESULTS

A total of 3273 patients were enrolled (56% male; median age, 23 years at time of enrollment). Ten-year follow-up was obtained on 79% (2575/3273) of the cohort. Incidence of concomitant pathology at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 22%; lateral femoral condyle [LFC], 15%; medial tibial plateau [MTP], 4%; lateral tibial plateau [LTP], 11%; patella, 18%; trochlea, 8%) and meniscal pathology (medial, 37%; lateral, 46%). Variables that were predictive of poorer 10-year outcomes included articular cartilage damage in the patellofemoral (P < .01) and medial (P < .05) compartments and previous medial meniscal surgery (7% of knees; P < .04). Compared with no meniscal tear, a meniscal injury was not associated with 10-year outcomes. Medial meniscal repair at the time of ACLR was associated with worse 10-year outcomes for 2 of 5 KOOS subscales, while a medial meniscal repair in knees with grade 2 MFC chondrosis was associated with better outcomes on 2 KOOS subscales.

CONCLUSION

Articular cartilage injury in the patellofemoral and medial compartments at the time of ACLR and a history of medial meniscal surgery before ACLR were associated with poorer 10-year ACLR patient-reported outcomes, but meniscal injury present at the time of ACLR was not. There was limited and conflicting association of medial meniscal repair with these outcomes.

Neither Residual Anterior Knee Laxity Up to 6 mm nor a Pivot Glide Predict Patient-Reported Outcome Scores or Subsequent Knee Surgery Between 2 and 6 Years After ACL Reconstruction

BACKGROUND

A primary goal of anterior cruciate ligament reconstruction (ACLR) is to reduce pathologically increased anterior and rotational laxity of the knee, but the effects of residual laxity on patient-reported outcomes (PROs) after ACLR remain unclear.

HYPOTHESIS

Increased residual laxity at 2 years postoperatively is predictive of a higher risk of subsequent ipsilateral knee surgery and decreases in PRO scores from 2 to 6 years after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

From a prospective multicenter cohort, 433 patients aged <36 years were identified at a minimum 2 years after primary ACLR. These patients underwent a KT-1000 arthrometer assessment and pivot-shift test and completed PRO assessments with the Knee injury and Osteoarthritis Outcome Score and International Knee Documentation Committee (IKDC) scores. Patients completed the same PROs at 6 years postoperatively, and any subsequent ipsilateral knee procedures during this period were recorded. Subsequent surgery risk and change in PROs from 2 to 6 years postoperatively were compared based on residual side-to-side KT-1000 arthrometer differences (<-1 mm, -1 to 2 mm, 2 to 6 mm, and >6 mm) in laxity at 2 years postoperatively. Multiple linear regression models were built to determine the relationship between 2-year postoperative knee laxity and 2- to 6-year change in PROs while controlling for age, sex, body mass index, smoking status, meniscal and cartilage status, and graft type.

RESULTS

A total of 381 patients (87.9%) were available for follow-up 6 years postoperatively. There were no significant differences in risk of subsequent knee surgery based on residual knee laxity. Patients with a difference >6 mm in side-to-side anterior laxity at 2 years postoperatively were noted to have a larger decrease in PROs from 2 to 6 years postoperatively (P < .05). No significant differences in any PROs were noted among patients with a difference <6 mm in side-to-side anterior laxity or those with pivot glide (IKDC B) versus no pivot shift (IKDC A).

CONCLUSION

The presence of a residual side-to-side KT-1000 arthrometer difference <6 mm or pivot glide at 2 years after ACLR is not associated with an increased risk of subsequent ipsilateral knee surgery or decreased PROs up to 6 years after ACLR. Conversely, patients exhibiting a difference >6 mm in side-to-side anterior laxity were noted to have significantly decreased PROs at 6 years after ACLR.

Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort

BACKGROUND

Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.

HYPOTHESIS

In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.

RESULTS

A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87).

CONCLUSION

BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Biologic Association Annual Summit: 2020 Report

Interest and research in biologic approaches for tissue healing are exponentially growing for a variety of musculoskeletal conditions. The recent hype concerning musculoskeletal biological therapies (including viscosupplementation, platelet-rich plasma, and cellular therapies, or “stem cells”) is driven by several factors, including demand by patients promising regenerative evidence supported by substantial basic and translational work, as well as commercial endeavors that complicate the scientific and lay understanding of biological therapy outcomes. While significant improvements have been made in the field, further basic and preclinical research and well-designed randomized clinical trials are needed to better elucidate the optimal indications, processing techniques, delivery, and outcome assessment. Furthermore, biologic treatments may have potential devastating complications when proper methods or techniques are ignored. For these reasons, an association comprising several scientific societies, named the Biologic Association (BA), was created to foster coordinated efforts and speak with a unified voice, advocating for the responsible use of biologics in the musculoskeletal environment in clinical practice, spearheading the development of standards for treatment and outcomes assessment, and reporting on the safety and efficacy of biologic interventions. This article will introduce the BA and its purpose, provide a summary of the 2020 first annual Biologic Association Summit, and outline the future strategic plan for the BA.

Composite psychosocial risk based on the fear avoidance model in patients undergoing anterior cruciate ligament reconstruction: Cluster-based analysis

OBJECTIVES

To examine associations between preoperative fear-avoidance model (FAM) risk subgroup status and patient expectation of surgical success with postoperative outcomes at 6 and 12 months after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cohort study.

SETTING

Academic medical center.

PARTICIPANTS

54 patients (25 females) undergoing unilateral ACLR.

MAIN OUTCOME MEASURES

Cluster analysis distinguished FAM risk subgroups based on preoperative fear of movement/reinjury, self-efficacy, and pain catastrophizing. Preoperative expectation for surgical success was assessed with a numeric rating scale. Six and 12-month outcomes included Subjective Patient Outcomes for Return to Sport, Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life, and International Knee Documentation Committee (IKDC) Subjective Knee Form.

RESULTS

Thirteen (24%) patients were "moderate-to-high FAM risk." Moderate-to-high FAM risk patients had lower odds of return to sport at 12 months (OR = 0.3, p = .05) and lower KOOS sports/recreation at 6 months (st. beta = -0.27, p = .05), KOOS quality of life at 12 months (st. beta = -0.42, p = .007), and IKDC at 6 (st. beta = -0.29, p = .04) and 12 months (st. beta = -0.47, p = .001). Higher expectation was associated with lower 6-month IKDC (st. beta = -0.36, p = .008) and 12-month KOOS quality of life (st. beta = -0.29, p = .05).

CONCLUSIONS

Preoperative FAM risk influences patient-reported outcomes and return to sport at 6 and 12 months.

Validation of a Risk Calculator to Personalize Graft Choice and Reduce Rupture Rates for Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament reconstructions (ACLRs) fail at an alarmingly high rate in young active individuals. The Multicenter Orthopaedic Outcomes Network (MOON) knee group has developed an autograft risk calculator that uses patient characteristics and lifestyle to predict the probability of graft rupture if the surgeon uses a hamstring tendon (HT) or a bone-patellar tendon-bone (BPTB) graft to reconstruct the ligament. If validated, this risk calculator can be used during the shared decision-making process to make optimal ACLR autograft choices and reduce rupture rates. The STABILITY 1 randomized clinical trial offers a large, rigorously collected data set of similar young active patients who received HT autograft with or without lateral extra-articular tenodesis (LET) for ACLR.

PURPOSE/HYPOTHESIS

The purpose was to validate the ACLR graft rupture risk calculator in a large external data set and to investigate the utility of BPTB and LET for ACLR. We hypothesized that the risk calculator would maintain adequate discriminative ability and calibration in the external STABILITY 1 data set when compared with the initial MOON development data set.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 1.

METHODS

The model predictors for the risk calculator include age, sex, body mass index, sport played at the time of injury, Marx Activity Score, preoperative knee laxity, and graft type. The STABILITY 1 trial data set was used for external validation. Discriminative ability, calibration, and diagnostic test validity of the model were assessed. Finally, predictor strength in the initial and validation samples was compared.

RESULTS

The model showed acceptable discriminative ability (area under the curve = 0.73), calibration (Brier score = 0.07), and specificity (85.3%) to detect patients who will experience a graft rupture. Age, high-grade preoperative knee laxity, and graft type were significant predictors of graft rupture in young active patients. BPTB and the addition of LET to HT were protective against graft rupture versus HT autograft alone.

CONCLUSION

The MOON risk calculator is a valid predictor of ACLR graft rupture and is appropriate for clinical practice. This study provides evidence supporting the idea that isolated HT autografts should be avoided for young active patients undergoing ACLR.

REGISTRATION

NCT00463099 (MOON); NCT02018354 (STABILITY 1) (ClinicalTrials.gov identifiers).

Epidemiology of Anterior Cruciate Ligament Tears in the National Football League

BACKGROUND

Anterior cruciate ligament (ACL) tears are common in contact athletics and have a significant effect on the athletic performance and well-being of affected players. The prevalence, timing, and characteristics of ACL tears in National Football League (NFL) athletes are lacking.

PURPOSE

To define the epidemiology of ACL tears among NFL athletes.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

This retrospective study includes all ACL injuries entered into the NFL injury database through the centralized leaguewide electronic health record system for the 2015-2019 seasons.

RESULTS

A total of 314 ACL injuries occurred during the 5-year study period, with a mean of 62 per year. The overall 1-season injury risk of an NFL player sustaining an ACL injury was 1.9% (95% CI, 1.7%-2.1%). Most ACL injuries occurred during games (n = 199), with a higher rate observed in the preseason games as compared with the regular season games (6.1 vs 2.7 per 10,000 player-plays; P < .01). NFL players with ≤3 of experience had a higher preseason injury rate (9.57 ACL tears per 1000 player-seasons) than those with ≥4 years of experience (5.12 ACL tears per 1000 player-seasons; P < .01). NFL athletes playing on special teams had the highest rate of ACL injuries (7.6 per 10,000 player-plays) in comparison with all other player positions.

CONCLUSION

ACL injury incidence was fairly consistent across all years studied and occurred more frequently in players with ≤3 years of NFL experience. Tears were more common during games, special teams play, and the preseason.