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Objectives: Increased posterior tibial slope (PTS) is a known risk factor for anterior cruciate ligament (ACL) injury and incidence of concomitant meniscal tears. However, the impact of PTS on the severity of concomitant meniscal injury has not been investigated. Therefore, our aim was to characterize the association between PTS and concomitant meniscal injury severity among patients with ACL injury. Methods: We retrospectively identified patients who underwent primary ACL reconstruction at a single institution from 2015-2021. Patients were excluded for multiligament injury, MRI >12 weeks before surgery, or >1 year between injury and surgery. We collected patient demographics, preoperative course, surgical details and measured medial and lateral PTS. The primary outcome was the presence of a high severity meniscus tear at time of arthroscopy, defined as a medial or lateral complex, bucket-handle, root, or Zone 3 radial tear. We determined the association between PTS and high severity meniscus tears using univariate and logistic regression. Results: We included 219 patients (47.0% female, age 25.3 ± 10.3 years, BMI 25.6 ± 4.5 kg/m2) in the analysis. Eighty-three patients (37.9%) underwent a medial meniscus procedure while 110 patients (50.2%) underwent a lateral meniscus procedure. Mean medial PTS was 4.3 ± 2.8° and mean lateral PTS was 5.0 ± 3.1°. The rate of high severity meniscus tear was 11.4% or 11.0% for a medial or lateral meniscus tear, respectively. BMI was positively associated with medial or lateral high severity meniscus tears (OR 1.122, 95% CI 1.041-1.210, p=0.003). Neither medial nor lateral PTS were associated with high severity meniscus tears (all p>0.05). Conclusions: PTS was not associated with high severity meniscus tears in patients undergoing ACL reconstruction within one year of injury. While BMI was an independent factor associated with meniscus tear severity, delays in surgery did not increase the odds of severe meniscus tear incidence when taking into account PTS.

Background Reverse shoulder arthroplasty (RSA) improves function in selected patients with complex shoulder problems. However, we presume patient function would vary if performed primarily or for revision and would vary with other patient-specific factors. Questions/purposes We compared (1) the shoulder scores and (2) complications in patients with RSA for revision arthroplasty with patients who had RSA as a primary procedure; and (3) identified patient-specific factors that affect (1) and (2). Patients and Methods We retrospectively compared 28 RSAs for failed arthroplasty with a control group consisting of 28 primary RSAs. We determined the Penn Shoulder (PENN), American Shoulder and Elbow Surgeons (ASES), and Single Assessment Numeric Evaluation (SANE) scores. Followup for shoulder outcome measures averaged 17.4 (range, 4.1–34) and 20.8 months (range, 7.3–34.9) for the study and control groups, respectively. Results All scores were higher in primary RSA than in revision RSA (PENN score, 79.5 versus 57.1; ASES score, 81.4 versus 56.3; SANE score, 73.8% versus 48.8%), and ROM was better (122.7° versus 83.75°). Both groups experienced increases in active forward flexion. Ten of the 28 study RSAs (35.7%) versus five of the 28 control RSAs (17.8%) had complications. No patient-specific factors other than reason for surgery correlated with scores. Conclusions Revision RSA is associated with lower function compared with primary RSA. However, we believe it a reasonable alternative and patients undergoing RSA for revision arthroplasty can expect improvements in function and shoulder scores to a mean of 50% of normal shoulders but must also accept a high complication rate. Level of Evidence Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Background: Quantifying glenoid bone loss (GBL) in patients with shoulder instability is essential for guiding surgical management and determining the need for bone augmentation procedures. Purpose/Hypothesis: The purpose of this study was to evaluate the diagnostic agreement and cost-effectiveness of 3-dimensional (3D) zero echo time (ZTE) magnetic resonance imaging (MRI) compared with 3D computed tomography (CT) for assessing GBL. It was hypothesized that ZTE MRI would demonstrate strong concordance with CT and serve as a cost-effective, radiation-free alternative. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Patients undergoing MRI with both 3D ZTE and 2-dimensional proton density fat-saturated (PD FS) sequences, as well as 3D CT of the ipsilateral shoulder, were retrospectively reviewed. Patients with recurrent instability between imaging studies were excluded. GBL was measured independently by 2 raters using the perfect-circle linear method. Interrater and intrarater reliability were assessed using intraclass correlation coefficients (ICCs). Concordance with CT was evaluated using concordance correlation coefficients (CCCs). Cost-effectiveness was preliminarily assessed using institutional imaging charges and diagnostic agreement. Results: Eleven patients were included; 81.8% had ≥3 instability episodes. Mean GBL was 13.2% ± 9.3% (PD FS), 12.8% ± 8.9% (ZTE), and 12.7% ± 8.9% (CT). Inter- and intrarater reliability were excellent (ICC > 0.9). ZTE (CCC, 0.999; 95% CI, 0.997-0.999) and PD FS (CCC, 0.988; 95% CI, 0.974-0.994) demonstrated excellent agreement with CT. Estimated patient-billed costs were $1652 for CT + MRI, versus $1019 for either ZTE MRI or PD FS MRI alone. Corresponding institutional costs were $593 for CT + MRI and $329 for either ZTE or PD FS MRI. Conclusion: 3D ZTE MRI is a reliable and reproducible alternative to CT for quantifying GBL in shoulder instability. With excellent diagnostic agreement, elimination of ionizing radiation, and reduced costs, ZTE MRI may serve as a single-modality solution for preoperative evaluation in select patients.

Background: Increased posterior tibial slope (PTS) is a known risk factor for anterior cruciate ligament (ACL) injury and incidence of concomitant meniscal tears. However, the effect of PTS on the severity of concomitant meniscal injury has not been investigated. Purposes: To characterize the association between PTS and concomitant meniscal injury severity among patients with ACL injury and identify risk factors for high-severity meniscal tears. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We retrospectively identified patients who underwent primary ACL reconstruction (ACLR) at a single institution from 2015 to 2021. Patients were excluded if they had a multiligament injury, underwent magnetic resonance imaging (MRI) >12 weeks before surgery, or had >1 year between the injury and surgery. We collected patient demographics, preoperative course, surgical details, and measured medial and lateral PTS. The primary outcome was the presence of a high-severity meniscal tear identified at the time of arthroscopy, defined as a medial or lateral complex, bucket-handle, root, or Zone 3 radial tear. We determined the association between PTS and high-severity meniscal tears using both univariate and logistic regression analyses. Results: We included 219 patients—47% women, aged 25.3 ± 10.3 years, with a body mass index (BMI) of 25.6 ± 4.5 kg/m2— in the analysis. A total of 41 patients (18.7%) underwent a medial meniscal procedure, 68 patients (31.1%) underwent a lateral meniscal procedure, 42 patients had both medial and lateral meniscal procedures (19.2%), and 68 patients had no meniscal tear (31.1%). The mean medial PTS was 4.3°± 2.8°, and the mean lateral PTS was 5°± 3.1°. The rate of any high-severity meniscal tear was 11.4% or 11% for a high-severity medial or lateral meniscal tear, respectively. BMI was positively associated with medial or lateral high-severity meniscal tears (odds ratio, 1.12 [95% CI, 1.04-1.21]; P = .003). Neither medial nor lateral PTS was associated with high-severity meniscal tears (all, P > .05). Conclusion: Our study shows that neither medial nor lateral PTS was associated with high-severity meniscal tears in patients undergoing ACLR within 1 year of injury, given the available numbers in this study. While BMI was an independent factor associated with meniscal tear severity, delays in surgery did not increase the odds of severe meniscal tear incidence when taking into account PTS. Our study does not support the use of PTS to alter the timing or indications for ACLR out of concern for an increase in the severity of encountered meniscal tears.

Purpose The United States Medical Licensing Examination (USMLE) Step 1 exam changed from a 3-digit score format to pass/fail in 2022. The current study aimed to examine how medical students perceive this change, factors associated with those perceptions, and determine their preferred exam scoring format. Design and Methods A cross-sectional survey of US medical students was distributed from March through June 2024. The survey gathered data including demographic and school information, desired specialty, research involvement, and Step 1 scoring preference. Results The survey was completed by 192 students from 18 different US allopathic schools. Of students surveyed, 65.5% preferred pass/fail scoring, while 34.5% preferred a 3-digit-score format. Older age increased likelihood of preferring a 3-digit score (β = 0.345, P = .047, odds ratio [OR] 1.41). A later graduation year decreased the likelihood of preferring a 3-digit score (β = −0.576, P = .020, OR 0.56). Gender (β = 0.293, P = .320, OR 1.34), specialty competitiveness (β = −0.095, P = .776, OR 1.10), and research productivity (β = 0.0047, P = .990, OR 1.00) had no significant effect on Step 1 scoring preference. Conclusion Medical students seem to prefer a pass/fail Step 1 regardless of gender, desired specialty and research productivity. However, pass/fail preference differed by graduating class year and age, with younger class years and students preferring pass/fail. While prior literature largely surveyed preference among medical educators, student sentiment on Step 1 scoring supports recent changes to the USMLE Step score format.

Background: The statistical significance of a given study outcome can be liable to small changes in findings. P values are common, but imperfect statistical methods to convey significance, and inclusion of the fragility index (FI) and fragility quotient (FQ) may provide a clearer perception of statistical strength. Purpose/Hypothesis: The purpose was to examine the statistical stability of studies comparing primary single-bundle to double-bundle anterior cruciate ligament reconstruction (ACLR) utilizing autograft and independent tunnel drilling. It was hypothesized that the study findings would be vulnerable to a small number of outcome event reversals, often less than the number of patients lost to follow-up. Study Design: Systematic review; Level of evidence, 2. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the authors searched PubMed for comparative studies and randomized controlled trials (RCTs) published in select journals, based on impact factor, between 2005 and 2020. Risk-of-bias assessment and methodology scoring were conducted for the included studies. A total of 48 dichotomous outcome measures were examined for possible event reversals. The FI for each outcome was determined by the number of event reversals necessary to alter significance. The FQ was calculated by dividing the FI by the respective sample size. Results: Of the 1794 studies screened, 15 comparative studies were included for analysis; 13 studies were RCTs. Overall, the mean FI and FQ were 3.14 (IQR, 2-4) and 0.050 (IQR, 0.032-0.062), respectively. For 72.9% of outcomes, the FI was less than the number of patients lost to follow-up. Conclusion: Studies comparing single-bundle versus double-bundle ACLR may not be as statistically stable as previously thought. Comparative studies and RCTs are at substantial risk for statistical fragility, with few event reversals required to alter significance. The reversal of fewer than 4 outcome events in a treatment group can alter the statistical significance of a given result; this is commonly less than the number of patients lost to follow-up. Future comparative study analyses might consider including FI and FQ with P values in their statistical analysis.

Background: With emerging treatments for anterior cruciate ligament (ACL) injury, analysis of patient preferences is lacking to align clinical care and research with patient priorities. Purposes: To identify patient priorities for outcomes after surgical intervention if they were to sustain an ACL tear, analyze what outcome measures influenced preferences, and determine whether patient demographics influenced preferences. Study Design: Cross-sectional study. Methods: The authors screened patients aged 18 to 30 years who presented for upper extremity complaints to a single institution in 2023. Patients were excluded for current lower extremity injury or history of a knee injury requiring surgical consultation. The authors designed a discrete choice experiment through literature review of outcome measures for bridge-enhanced ACL restoration (BEAR) and ACL reconstruction (ACLR) with hamstring tendon autograft. Measures included return to sports, risk of arthritis, risk of reinjury, and hamstring strength. Patients chose surgery A (ACLR with hamstring tendon autograft) or surgery B (BEAR) and then rated the importance of each outcome measure on their selection. Results: In total, 100 participants (36 female; mean age, 25.1 ± 4.0 years) completed the discrete choice experiment. Overall, 56.0% participated in sports and 80.0% were employed. Based on surgery choice group, there were no significant differences in sex, age, Marx Activity Scale score, sports participation, or employment status between patients who selected BEAR or ACLR with hamstring tendon autograft (all P > .361). Return to sports and hamstring strength were significant priorities for patients in procedure selection (P ≤ .011). Of the patients who selected ACLR with hamstring tendon autograft, 31.6% would not elect to undergo this procedure. Conclusion: In this discrete choice experiment of adults without prior ACL injury, return to sports and hamstring strength were identified as patient priorities when selecting a procedure for ACL injury. Risk of reinjury, however, was not a significant factor in procedure selection. Importantly, these priorities were maintained regardless of patient characteristics, activity level, or employment status.

Background: Lower socioeconomic status and public insurance lead to a longer delay to surgery and a higher likelihood of concomitant pathology before undergoing anterior cruciate ligament reconstruction (ACLR). However, few studies have examined the influence of community deprivation on ACLR timing and outcomes. Purpose/Hypothesis: The primary aim of this study was to define the effect of the area deprivation index (ADI) and insurance classification on access to orthopaedic care after an ACL rupture, and the secondary aim was to determine whether these variables were associated with a second ACL injury after primary ACLR. It was hypothesized that patients with a greater national ADI percentile and Medicaid insurance would experience longer delays to care and an increased risk of reinjury after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was performed to evaluate patients undergoing primary ACLR between 2016 and 2019. The national ADI percentile was obtained utilizing the Neighborhood Atlas website. The relationship between national ADI percentile and care characteristics (eg, time to specialized care) was investigated using the Spearman rho correlation coefficient (r). The association between patient and care characteristics and second ACL injury after the index procedure (ie, graft rerupture or contralateral ACL rupture) was investigated using binary logistic regression. Results: A total of 197 patients met the inclusion criteria. Longer times from injury to surgery (r = 0.238; P < .001) and from specialized care to surgery (r = 0.217; P = .002) were associated with a greater national ADI percentile. The second injury group reported significantly greater national ADI (P = .026) and included a greater percentage of patients with Medicaid insurance (31.3%) compared with the no second injury group. Patients experienced 5.1% greater odds of a second ACL injury for each additional month between evaluation and surgery. Conclusion: Greater national ADI percentile and Medicaid insurance status were associated with adverse ACLR timing and outcomes. Patients with a greater national ADI percentile took significantly longer to obtain surgery after ACL injury. Those who sustained a second ACL injury after ACLR had an overall higher mean national ADI percentile and included a greater proportion of patients with Medicaid compared with those who did not sustain a second ACL injury. Future studies should critically investigate the underlying factors of these associations to reach equity in orthopaedic care.

Background: The incidence of pectoralis major tendon tears is increasing, and repair is generally considered; however, a paucity of comparative data are available to demonstrate the superiority of operative treatment. Purpose/Hypothesis: The purpose of this study is to compare the outcomes of operative and nonoperative treatment of pectoralis major tendon tears. We hypothesized that repair would result in superior outcomes compared with nonoperative treatment. Methods: In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed by use of MEDLINE, SPORTDiscus, CINAHL, Cochrane, EMBASE, and Web of Science databases. We included English-language studies that had a minimum of 6 months of average follow-up and 5 cases per study. The MINORS (Methodological Index for Non-Randomized Studies) was used to assess the quality of the existing literature. Meta-analysis of pooled mechanisms of injury and outcomes was completed. Pooled effect sizes were calculated from random-effects models. Continuous variables were assessed by use of mixed-model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed via the Freeman-Tukey log-linear transformation for variance stabilization and then assessed through use of a mixed model with a study level random effect and subsequently back-transformed. Significance was set at P < .05. Results: A total of 23 articles with 664 injuries met the inclusion criteria for comparison. All patients were male, with an average age of 31.48 years; 63.2% of injuries occurred during weight training, and the average follow-up was 37.02 months. Included studies had moderately high methodological quality. Operative treatment was significantly superior to nonoperative treatment, with relative improvements of functional outcome by 23.33% (0.70 improvement by Bak criteria which is scored 1-4; P = .027), full isometric strength 77.07% (P < .001), isokinetic strength 28.86% (P < .001) compared with the uninjured arm, cosmesis satisfaction 13.79% (P = .037), and resting deformity 98.85% (P < .001). The overall complication rate for operative treatment was 14.21%, including a 3.08% rate of rerupture. Conclusion: Pectoralis major tendon repair resulted in significantly superior outcomes compared with nonoperative treatment, with an associated 14.21% complication rate. Statistically significant improvements were noted in functional outcome, isokinetic strength, isometric strength, cosmesis, and resting deformity.

Objectives: To review patient outcome measures at 1 year in patients who underwent the Bridge-Enhanced-ACL-Restoration (BEAR) procedure in the BEAR III clinical trial. Methods: Prospective analysis was performed for 151 consecutive patients who underwent the BEAR procedure as part of the BEAR III clinical trial. IKDC and KOOS scores were collected at baseline, 6, 9, and 12 months. Marx Activity Scales were collected at baseline, 9 and 12 months. Patients were analyzed based upon age greater than or less than 18. Results: All timepoints for IKDC [6 months (70+14; N=147), 9 months (79+15; N=139), and 12 months (83+16; N=130)] were statistically improved compared to baseline (45+14; N=150; p<0.0001). All timepoints for all five KOOS subscales [6 months (N=148), 9 months (N=145), and 12 months (N=138)] were statistically improved compared to baseline (P<0.0001). All postoperative timepoints for the MARX activity scale [9 months (9.6+5.5; N=141), 12 months (9.1+5.3; N=130)] were statistically inferior to baseline (12.8+4.5; N=150); p<0.0001]. All postoperative IKDC scores were statistically superior in patients <18 compared to >18 (p<0.001) but baseline scores were similar (48+13 <18 vs 44+15 >18; p=0.14). All preoperative KOOS domains were statistically similar between age groups except for the Function: Sports and Recreational Activities (41+27 <18 vs 31+27 >18; p=0.04). All postoperative KOOS domain scores were statistically superior in patients <18 compared to >18 (range p<0.03 to p<0.001) except for 1 year Quality of Life (70+21 <18 vs 67+22 >18; p=0.49). All Marx activity scores were statistically superior in patients <18 but age did not affect change from baseline at 9 or 12 months Conclusions: There were statistically significant improvements in IKDC and KOOS at all timepoints after BEAR. Marx Activity Scale scores were statistically inferior to baseline. Younger age consistently demonstrated statistically better postoperative scores. Further analysis at longer time intervals is warranted.