Mark R. Lafave

USING THE MODIFIED DELPHI METHOD TO ESTABLISH CLINICAL CONSENSUS FOR THE DIAGNOSIS AND TREATMENT OF PATIENTS WITH ROTATOR CUFF PATHOLOGY

BackgroundPatients presenting to the healthcare system with rotator cuff pathology do not always receive high quality care. High quality care occurs when a patient receives care that is accessible, appropriate, acceptable, effective, efficient, and safe. The aim of this study was twofold: 1) to develop a clinical pathway algorithm that sets forth a stepwise process for making decisions about the diagnosis and treatment of rotator cuff pathology presenting to primary, secondary, and tertiary healthcare settings; and 2) to establish clinical practice guidelines for the diagnosis and treatment of rotator cuff pathology to inform decision-making processes within the algorithm.MethodsA three-step modified Delphi method was used to establish consensus. Fourteen experts representing athletic therapy, physiotherapy, sport medicine, and orthopaedic surgery were invited to participate as the expert panel. In round 1, 123 best practice statements were distributed to the panel. Panel members were asked to mark “agree” or “disagree” beside each statement, and provide comments. The same voting method was again used for round 2. Round 3 consisted of a final face-to-face meeting.ResultsIn round 1, statements were grouped and reduced to 44 statements that met consensus. In round 2, five statements reached consensus. In round 3, ten statements reached consensus. Consensus was reached for 59 statements representing five domains: screening, diagnosis, physical examination, investigations, and treatment. The final face-to-face meeting was also used to develop clinical pathway algorithms (i.e., clinical care pathways) for three types of rotator cuff pathology: acute, chronic, and acute-on-chronic.ConclusionThis consensus guideline will help to standardize care, provide guidance on the diagnosis and treatment of rotator cuff pathology, and assist in clinical decision-making for all healthcare professionals.

Epidemiological analysis of injury in one year of Canadian professional rodeo

OBJECTIVES To document injury rates and treatment use during one competitive season of Canadian professional rodeo. DESIGN Prospective cohort study. SETTING Canadian professional rodeo competition. SUBJECTS Competitors, included professional cowboys from Australia, Brazil, New Zealand, the United States, and Canada. METHODS Data were gathered prospectively at 15 of 68 professional rodeos in Canada, constituting 22% of all Canadian professional rodeos. Data were collected by four certified athletic therapists using a standardized form. MAIN RESULTS Overall, 94 athletes were injured during 3,882 individual competitor exposures (CEs). The composite injury rate was 2.3 per 100 CEs. This rate is lower than that reported in contact sports. Within the context of rodeo injuries, bareback riders and bull riders had similar high injury rates (4.6 and 3.6 per 100 CEs, respectively). Saddle bronc riders and steer wrestlers had moderate injury rates (1.4 and 0.9 per 100 CEs, respectively), whereas calf ropers had low injury rates (0.5 per 100 CEs). The knee and ankle were the most frequently treated sites of the body, followed by the shoulder, elbow, and lower back. Acute injury care and prophylactic taping were the most frequent services provided. CONCLUSIONS In order to study injury patterns in more detail and to assess risk factors for injury, a larger scale epidemiological study should be undertaken. Through such risk-based analysis, preventative strategies could be identified.

Initial Validity and Reliability of the Banff Patella Instability Instrument

Background: Patellofemoral instability is a well-recognized problem, but there are currently no published patient-reported quality of life outcome measures that are disease specific for the treatment of this population. Purpose: To establish the content validity, initial construct validity, and initial reliability of the Banff Patella Instability Instrument (BPII). Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The content of the BPII was validated using a modified 3-stage Ebel procedure and analysis of floor and ceiling effects. As a measure of internal consistency, the Cronbach α was utilized to assess how reliably the 32 items of the questionnaire measured a similar construct. Test-retest reliability of the BPII was calculated using an intraclass correlation coefficient (ICC). Construct validity was evaluated on 150 questionnaires completed by patients with a confirmed diagnosis of patellofemoral instability. A one-way between-group analysis of variance was employed to determine if the BPII was able to differentiate between patients presenting at the initial orthopaedic consultation relative to patients presenting at 6 months and 12 months postoperatively. Results: Content validity was clearly established as each item in the BPII achieved a minimum of 83.3% agreement (range, 83.3%-100%) for relevance among the expert panelists. The average agreement was 96.9%; 24 items achieved 100% agreement. There was no evidence of floor or ceiling effects. Reliability (internal consistency) of the BPII was established at the initial orthopaedic consultation (α = .91), 6 months postoperatively (α = .97), and 12 months postoperatively (α = .97). Test-retest analysis resulted in an ICC of 0.98 between tests. Construct validity was established as there was a statistically significant difference in BPII scores at the initial orthopaedic consultation and 6-month and 12-month postoperative appointments (F2,146 = 75.62; P < .001). Conclusion: The BPII demonstrates content validity, strong initial reliability, and a statistically significant level of construct validity in patients with patellofemoral instability. This population includes patients with recurrent patellofemoral instability as well as surgically stabilized patients.

Effect of Trochlear Dysplasia on Outcomes After Isolated Soft Tissue Stabilization for Patellar Instability

Background: Trochlear dysplasia is a well-described risk factor for patellofemoral instability. Despite its clear association with the incidence of patellar instability, it is unclear whether the presence of high-grade trochlear dysplasia influences clinical outcome after patellofemoral stabilization. Purpose: To determine whether isolated proximal soft tissue stabilization for patellofemoral instability is as successful in patients with high-grade dysplasia compared with low-grade or no dysplasia, as measured by disease-specific quality-of-life and pain scores. Study Design: Case series; Level of evidence, 4. Methods: A total of 277 patellofemoral stabilization procedures were performed during the study period. An isolated stabilization was performed in 233 patients, and 203 of these patients (87%) had adequate lateral radiographs and complete Banff Patella Instability Instrument (BPII) scores available for assessment. Of these, 152 patients underwent a medial patellofemoral ligament reconstruction (MPFL-R) and 51 patients received a medial patellofemoral ligament imbrication (MPFL-I). There were 21 patients with no trochlear dysplasia, 89 patients with low-grade dysplasia (Dejour type A), and 93 patients with high-grade dysplasia (Dejour types B-D). An independent-samples t test was used to determine the difference between the pre- and postoperative BPII scores. A Spearman rho correlation was calculated between 3 trochlear dysplasia groups and the BPII scores at a mean 24 months after patellofemoral stabilization. An independent-samples t test was used to assess the influence of trochlear bump size on outcomes by stratifying data and assessing for a relationship to BPII scores. Results: The independent-samples t test demonstrated statistically significant improvements in pre- to postoperative BPII scores for both groups. The MPFL-R group improved from a mean BPII score of 24.36 to 65.16 (P < .001), and the MPFL-I group improved from a mean of 28.92 to 73.45 (P < .01). For the MPFL-R patient cohort, the Spearman rho correlation demonstrated a significant relationship between postoperative BPII scores and presence of a trochlear bump and degree of dysplasia (P ≤ .05). Overall, a trochlear bump of ≥5 mm was associated with lower postoperative BPII scores (t(193) = 2.65, η2 = 0.04). Conclusion: This research has established a statistically significant correlation between trochlear dysplasia and disease-specific outcomes after MPFL-R surgery. Overall, there was evidence of significant improvement in disease-specific quality-of-life scores after patellofemoral stabilization surgery. This study is the largest cohort reported to date and therefore adds substantially to the evidence that trochlear dysplasia is a significant risk factor for and predictor of outcome among patients with patellofemoral instability.

Intra-Rater and Inter-Rater Reliability of the Balance Error Scoring System in Pre-Adolescent School Children

This study was designed to test the intra- and inter-rater reliability of the University of North Carolinas Balance Error Scoring System in 9- and 10-year-old children. Additionally, a modified version of the Balance Error Scoring System was tested to determine if it was more sensitive in this population (“raw scores”). Forty-six normally developing fourth-grade students underwent balance testing. Twelve trials measured static and dynamic balance. Four adult raters scored the balance tests to yield Cronbachs alpha scores of reliability. Intra-rater University of North Carolina Balance Error Scoring System α varied from .73 to .94 and .94 to .99 when using the raw scores. The inter-rater University of North Carolina Balance Error Scoring System α of the four raters ranged from .77 to .95 and from .88 to .98 when using the raw scores. The University of North Carolina Balance Error Scoring System shows high reliability when used with fourth-grade elementary school children; however, raw scores may show greater reliability in a population of children.

Concurrent Validation of the Banff Patella Instability Instrument to the Norwich Patellar Instability Score and the Kujala Score in Patients With Patellofemoral Instability.

Background: The Banff Patella Instability Instrument (BPII) is a disease-specific, patient-reported, quality-of-life outcome measure designed to assess patients with patellofemoral instability. The iterative assessment of the validity, reliability, and responsiveness of a health-related patient-reported outcome measure is vital to the development of a high-quality evaluation tool. Purpose: To assess the concurrent validity of the BPII to the Norwich Patellar Instability (NPI) score and the Kujala score. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 74 patients with a confirmed diagnosis of recurrent patellofemoral instability completed the BPII, NPI, and Kujala scores at the initial orthopaedic consultation. A Pearson r correlation coefficient was computed to determine the relationship between each of these patient-reported outcomes. Results: There were statistically significant correlations between the BPII and the NPI score (r = −0.53; P < .001) as well as the BPII and the Kujala score (r = 0.50; P < .001). Conclusion: This study demonstrated a moderately strong correlation of the BPII to other outcome measures used to evaluate patients with patellofemoral instability. This study adds further validity to the BPII in accordance with the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guidelines.

Medial Patellofemoral Ligament Reconstruction Femoral Tunnel Accuracy: Relationship to Disease-Specific Quality of Life

Background: Medial patellofemoral ligament (MPFL) reconstruction is a procedure aimed to reestablish the checkrein to lateral patellar translation in patients with symptomatic patellofemoral instability. Correct femoral tunnel position is thought to be crucial to successful MPFL reconstruction, but the accuracy of this statement in terms of patient outcomes has not been tested. Purpose: To assess the accuracy of femoral tunnel placement in an MPFL reconstruction cohort and to determine the correlation between tunnel accuracy and a validated disease-specific, patient-reported quality-of-life outcome measure. Study Design: Case series; Level of evidence, 4. Methods: Between June 2008 and February 2014, a total of 206 subjects underwent an MPFL reconstruction. Lateral radiographs were measured to determine the accuracy of the femoral tunnel by measuring the distance from the center of the femoral tunnel to the Schöttle point. Banff Patella Instability Instrument (BPII) scores were collected a mean 24 months postoperatively. Results: A total of 155 (79.5%) subjects had adequate postoperative lateral radiographs and complete BPII scores. The mean duration of follow-up (±SD) was 24.4 ± 8.2 months (range, 12-74 months). Measurement from the center of the femoral tunnel to the Schöttle point resulted in 143 (92.3%) tunnels being categorized as “good” or “ideal.” There were 8 failures in the cohort, none of which occurred in malpositioned tunnels. The mean distance from the center of the MPFL tunnel to the center of the Schöttle point was 5.9 ± 4.2 mm (range, 0.5-25.9 mm). The mean postoperative BPII score was 65.2 ± 22.5 (range, 9.2-100). Pearson r correlation demonstrated no statistically significant relationship between accuracy of femoral tunnel position and BPII score (r = –0.08; 95% CI, –0.24 to 0.08). Conclusion: There was no evidence of a correlation between the accuracy of MPFL reconstruction femoral tunnel in relation to the Schöttle point and disease-specific quality-of-life scores. Graft failure was not related to femoral tunnel placement. The patellofemoral instability population is complex, and patients present with multiple risk factors that, in addition to the accuracy of femoral tunnel position, contribute to quality of life and warrant further investigation.

Factor Analysis and Item Reduction of the Banff Patella Instability Instrument (BPII) Introduction of BPII 2.0

Background: Clinical management of patellofemoral (PF) instability is a challenge, particularly considering the number of variables that should be taken into consideration for treatment. Quality of life is an important measure to consider with this patient population. Purpose: To factor analyze and reduce the total number of items in the Banff Patella Instability Instrument (BPII). Subsequent to the factor analysis, the new, item-reduced BPII 2.0 was tested for validity, reliability, and responsiveness. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Quality of life was measured for PF instability patients (N = 223) through use of the original BPII at their initial consultation. Data from the BPII scores were used in a principal components analysis (PCA) to factor analyze and reduce the total number of items in the original BPII, to create a revised BPII 2.0. The BPII 2.0 underwent content validation (Cronbach alpha, patient interviews, and grade-level checking), construct validation (analysis of variance comparing the initial visit and the 6-, 12-, and 24-month postoperative visits, eta-square), convergent validation (Pearson r correlation to the original BPII), responsiveness testing (eta-square, anchor-based distribution testing), and reliability testing (intraclass correlation coefficient [ICC]). Results: The BPII was successfully reduced from 32 to 23 items with excellent Cronbach alpha values in the new BPII 2.0: initial visit = 0.91; 6-month postoperative visit = 0.96; 12-month postoperative visit = 0.97; and 24-month postoperative visit = 0.76. Grade-level reading for all items was assessed as below grade 12. The BPII 2.0 was able to discriminate between all time periods with significant differences between groups (P < .05). Eta-square was 0.40, demonstrating a medium to large effect size. The BPII significantly correlated with the BPII 2.0 (0.82, 0.90, 0.90, and 0.94 at the initial visit and 6-, 12-, and 24-month postoperative visits, respectively), providing evidence of convergent validity. A significant correlation was found between the 7-point scale and 24-month postoperative BPII 2.0 scores, a sign of anchor-based responsiveness. ICC (2,k) was 0.97, indicating strong reliability. Conclusion: The BPII 2.0 is valid, reliable, and responsive for assessment of patients with PF instability, both surgically and nonsurgically treated.

An Innovative Canadian Solution for Improved Access to Care for Knee Injuries Using “Non-Physician Experts”: The Calgary Acute Knee Injury Clinic

There is a significant burden of musculoskeletal (MSK) disorders on the Canadian healthcare system which emphasizes the need for improved patient flow and integrated services throughout the MSK clinical care pathway. Improving accessibility, effectiveness, acceptability and efficiency of safe and appropriate care of MSK health using innovative models of healthcare delivery has become an important issue for Canada. This paper is a prospective study that describes and evaluates an evidence-based model for management acute knee injuries in Calgary, Alberta, Canada: the Calgary Acute Injury Knee Clinic model (C-AKIC). C-AKIC model development consisted of three stages: 1) development, implementation and evaluation of a new non-physician expert (NPE) curriculum; 2) identification of the logistics for opening the C-AKIC within an urban setting; and 3) evaluation of the accessibility, effectiveness, acceptability and efficiency of the C-AKIC model relative to the current healthcare system. NPE curriculum improved both theoretical knowledge (12% average increase) and clinical competence (33.5% average increase). NPEs evaluated and managed acute knee injuries in an interdisciplinary team (2 NPEs and a primary care physician) at the C-AKIC. Patients were significantly more satisfied with the new clinical care pathway (M = 91.20 out of 100) compared to patients who went through the existing/traditional pathway (M = 75.58 out of 100). Patients also saw fewer healthcare providers in C-AKIC clinical care pathway (M = 2.14) in a shorter period of time (M = 2.09 months) compared to the existing system: M = 2.76 months and; M = 7.24 months, respectively. This project demonstrated a unique and efficient approach to evaluation and management acute knee injuries in an urban setting by providing a potentially viable solution to the need for human resources in the healthcare workforce.

Rodeo catastrophic injuries and registry: initial retrospective and prospective report.

Objective:To introduce the Rodeo Catastrophic Injury Registry (RCIR) and quantify the nature and incidence of catastrophic injury and fatality in rodeo participants across North America. Design:Retrospective and prospective collection of catastrophic and fatal injury data in rodeo using an online registry (RCIR). Setting:Canada and the United States. Participants:North American rodeo competitors. Assessment of Risk Factors:Age, gender, level of competition, rodeo event, mechanism of injury, and use of protective equipment. Main Outcome Measures:Frequency, incidence, and nature of catastrophic injuries and fatalities among rodeo participants. Results:The incidence rate of catastrophic injury from 1989 to 2009 was 9.45 per 100 000 (49/518 286). The incidence rate of catastrophic injury during the 2007-2009 study period was 19.81 per 100 000 (19/95 892). The incidence rate of fatality from 1989 to 2009 was 4.05 per 100 000 (21/518 286). The incidence rate of fatality for the 2007-2009 study period was 7.29 per 100 000 (7/95 892). Conclusions:Thoracic compression mechanisms of injury are most pervasive and likely to be fatal in rodeo and bull riding. It is unknown whether rodeo protective vests have a protective effect in reducing catastrophic and fatal injuries. On the contrary, helmet use in bull riding and rodeo events seems to have a protective effect in reducing both catastrophic injury and fatality.