John B. Schrock

A Cost-Effectiveness Analysis of Surgical Treatment Modalities for Chondral Lesions of the Knee: Microfracture, Osteochondral Autograft Transplantation, and Autologous Chondrocyte Implantation

Background: Numerous surgical options exist to treat chondral lesions in the knee, including microfracture (MFx), osteochondral autograft transplantation (OAT), first-generation autologous chondrocyte implantation (ACI-1), and next-generation ACI (ACI-2). Purpose: To compare the cost-effectiveness of MFx, OAT, and ACI-1. The secondary purpose of this study was to compare the functional outcomes of MFx, OAT, ACI-1, and ACI-2. Study Design: Systematic review; Level of evidence, 2. Methods: Two independent reviewers conducted an online literature search of 2 databases for level 1 and 2 studies using the Lysholm, International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and/or Hospital for Special Surgery (HSS) Knee Score. A weighted mean difference in pre- to postoperative functional outcome score was calculated for each treatment. The mean per-patient costs associated with MFx, OAT, and ACI-1 were determined from a recent publication based on review of a national private insurance database. The cost for each procedure was then divided by the weighted mean difference in functional outcome score to give the cost-per-point change in outcome score. Results: A total of 12 studies (6 level 1, 6 level 2) met the inclusion criteria for the functional outcome analysis, including 730 knees (MFx, n = 300; OAT, n = 90; ACI-1, n = 68; ACI-2, n = 272). The mean follow-up was not significantly different between groups (MFx, 29.4 months; OAT, 38.3 months; ACI-1, 19.0 months; ACI-2, 26.7 months). The mean increase in functional outcome score was 23 for MFx, 19 for OAT, 20 for ACI-1, and 35 for ACI-2. The change in functional outcome score was significantly greater for ACI-2 when compared with all other treatments (P < .0001). The cost-per-point change in functional outcome score was

Trends in Authorship Characteristics in The American Journal of Sports Medicine, 1994 to 2014

200.59 for MFx,

The 50 Most Cited Articles in Rotator Cuff Repair Research

313.84 for OAT, and

A Cross-sectional Analysis of Minimum USMLE Step 1 and 2 Criteria Used by Orthopaedic Surgery Residency Programs in Screening Residency Applications

536.59 for ACI-1. Conclusion: MFx, OAT, ACI-1, and ACI-2 are effective surgical procedures for the treatment of cartilage defects in the knee. All 4 treatments led to an increase in functional outcome scores postoperatively with a short-term follow-up. ACI-2 had a statistically greater improvement in functional outcome scores as compared with the other 3 procedures. MFx was found to be the most cost-effective treatment option and ACI-1 the least cost-effective.

How should I fixate the subscapularis in total shoulder arthroplasty? A systematic review of pertinent subscapularis repair biomechanics

Background: Trends in author qualifications, the number of authors per article, and the internationalization of author groups in sports medicine journals have not been widely investigated. Purpose: To examine trends in authorship characteristics in a single prominent sports medicine journal. Study Design: Systematic review. Methods: Articles published in The American Journal of Sports Medicine (AJSM) in 1994, 2004, and 2014 were reviewed. For each article, the academic degree(s) of the first and last author, the total number of authors, the country of the author group, and academic institution status were recorded. Results: A total of 708 articles met the inclusion criteria: 129 in 1994, 244 in 2004, and 335 in 2014. There were significant differences in the proportion of first authors with an MD degree (80% in 1994, 75% in 2004, 67% in 2014; P = .01), a dual MD/PhD degree (4.7% in 1994, 6.2% in 2004, 9.3% in 2014; P < .001), and a bachelor’s degree (0% in 1994, 0% in 2004, 3.9% in 2014; P < .001). The proportion of last authors with an MD/PhD significantly increased over the 2 decades studied (7% in 1994, 13% in 2004, 17% in 2014; P = .01). The mean number of authors per article also significantly increased (3.8 in 1994, 4.3 in 2004, 5.8 in 2014; P < .0001). The proportion of articles published by an international group and the proportion of articles published by an academic institution increased over the 20-year span as well (both P < .0001). Conclusion: Within the past 2 decades, there has been a significant increase in the average number of authors per article in AJSM, as well as a higher proportion of international groups and academic institutions publishing in the journal. More nonphysicians are publishing in AJSM, with a significantly higher percentage of first authors with a bachelor’s degree as their highest degree. This is likely due to a combination of a general increased interest in research as well as increased competition among medical students. These factors have likely led to larger research groups and thus a significantly higher average number of authors per article.

The Evolving Treatment Patterns of NCAA Division I Football Players by Orthopaedic Team Physicians Over the Past Decade, 2008-2016:

Analysis of the number of citations within a given specialty provides information on the classic publications of that specialty. The goals of this study were to identify the 50 most cited articles on rotator cuff repair and to analyze various characteristics of these articles. The ISI Web of Science (Thomson Reuters, Philadelphia, Pennsylvania) was used to conduct a search for the term rotator cuff repair. The 50 most cited articles were retrieved, and the following objective characteristics of each article were recorded: number of times cited, citation density, journal, country of origin, and language. The following subjective characteristics of each article were also recorded: article type (clinical vs basic science), article subtype, and level of evidence for clinical articles. Of the 50 most cited articles on rotator cuff repair, the number of citations ranged from 138 to 677 (mean, 232±133 citations) and citation density ranged from 3.8 to 53.5 citations per year (mean, 16.9±9.2 citations per year). The articles were published between 1974 and 2011, with most of the articles published in the 2000s (29 articles), followed by the 1990s (16 articles). The articles originated from 8 countries, with the United States accounting for 30 articles (60%). Overall, 66% of the articles were clinical and 34% were basic science. The most common article subtype was the clinical case series (48%). Of the 33 clinical articles, 24 (73%) were level IV. Among the 50 most cited articles on rotator cuff repair, the case series was the most common article subtype, showing the effect that publication of preliminary outcomes and new surgical techniques has had on surgeons performing rotator cuff repair. [Orthopedics. 2016; 39(6):e1045-e1051.].

Arthroscopic Fixation of Os Acetabuli Technique: When to Resect and When to Fix

Introduction: The purpose of this study was to analyze how program directors (PDs) of orthopaedic surgery residency programs use United States Medical Licensing Examination (USMLE) Step 1 and 2 scores in screening residency applicants. Methods: A survey was sent to each allopathic orthopaedic surgery residency PD. PDs were asked if they currently use minimum Step 1 and/or 2 scores in screening residency applicants and if these criteria have changed in recent years. Results: Responses were received from 113 of 151 PDs (75%). One program did not have the requested information and five declined participation, leaving 107 responses analyzed. Eighty-nine programs used a minimum USMLE Step 1 score (83%). Eighty-three programs (78%) required a Step 1 score ≥210, 80 (75%) required a score ≥220, 57 (53%) required a score ≥230, and 22 (21%) required a score ≥240. Multiple PDs mentioned the high volume of applications as a reason for using a minimum score and for increasing the minimum score in recent years. Discussion: A large proportion of orthopaedic surgery residency PDs use a USMLE Step 1 minimum score when screening applications in an effort to reduce the number of applications to be reviewed.

Conference Presentation Characteristics of Studies Published in The American Journal of Sports Medicine.

Background The present study aimed to review the biomechanical outcomes of subscapularis repair techniques during total shoulder arthroplasty (TSA) to assist in clinical decision making. Methods A systematic review of multiple databases was performed by searching PubMed, Scopus, Cochrane Library, Google Scholar, and all databases within EBSCOhost to find biomechanical studies of subscapularis repair techniques in cadaveric models of TSA. Results Nine studies met the inclusion criteria. In the majority of studies, lesser tuberosity osteotomy (LTO) techniques had greater load to failure and less cyclic displacement compared to subscapularis tenotomy or peel methods. LTO repairs with sutures wrapped around the humeral stem demonstrated superior biomechanical outcomes compared to techniques using only a tension band. In terms of load to failure, the strongest repair of any study was a dual-row fleck LTO using four sutures wrapped around the stem. Conclusions Several cadaveric studies have shown superior biomechanical outcomes with LTO techniques compared to tenotomy. In the majority of studies, the strongest subscapularis repair technique in terms of biomechanical outcomes is a compression LTO. Using three or more sutures wrapped around the implant and the addition of a tension suture may increase the biomechanical strength of the LTO repair.

Evolving Treatment Patterns of NFL Players by Orthopaedic Team Physicians Over the Past Decade, 2008-2016:

Background: Previous studies have analyzed the treatment patterns used to manage injuries in National Collegiate Athletic Association (NCAA) Division I football players. Hypothesis: Treatment patterns used to manage injuries in NCAA Division I football players will have changed over the study period. Study Design: Descriptive epidemiology study. Level of Evidence: Level 5. Methods: The head orthopaedic team physicians for all 128 NCAA Division I football teams were asked to complete a survey containing questions regarding experience as team physician, medical coverage of the team, reimbursement issues, and treatment preferences for some of the most common injuries occurring in football players. Responses from the current survey were compared with responses from the same survey sent to NCAA Division I team physicians in 2008. Results: Responses were received from 111 (111/119, 93%) NCAA Division I orthopaedic team physicians in 2008 and 115 (115/128, 90%) orthopaedic team physicians between April 2016 and April 2017. The proportion of team physicians who prefer a patellar tendon autograft for primary anterior cruciate ligament reconstruction (ACLR) increased from 67% in 2008 to 83% in 2016 (P < 0.001). The proportion of team physicians who perform anterior shoulder stabilization arthroscopically increased from 69% in 2008 to 93% in 2016 (P < 0.0001). Of team physicians who perform surgery for grade III posterior cruciate ligament (PCL) injuries, the proportion who use the arthroscopic single-bundle technique increased from 49% in 2008 to 83% in 2016 (P < 0.0001). The proportion of team physicians who use Toradol injections prior to a game to help with nagging injuries decreased from 62% in 2008 to 26% in 2016 (P < 0.0001). Conclusion: Orthopaedic physicians changed their injury treatment preferences for NCAA Division I football players over the study period. In particular, physicians have changed their preferred techniques for ACLR, anterior shoulder stabilization, and PCL reconstruction. Physicians have also become more conservative with pregame Toradol injections. Clinical Relevance: These opinions may help guide treatment decisions and lead to better care of all athletes.

Time Trends in Concussion Symptom Presentation and Assessment Methods in High School Athletes

Acetabular rim fractures, or os acetabuli, are hypothesized to occur as a result of an unfused ossification center or a stress fracture from repetitive impingement of an abnormally shaped femoral neck against the acetabular rim. When treated surgically, these fragments are typically excised as part of the correction for femoroacetabular impingement. However, in some patients, removal of these fragments can create symptoms of gross instability or microinstability of the hip. In these cases, internal fixation of the fragment is necessary. The purpose of this technical note is to describe indications, the arthroscopic technique, and postoperative care for fixation of acetabular rim fractures.