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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: 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: Evidence on return to sports/work after high tibial osteotomy (HTO) is limited, especially in a young, high-demand population. Purpose: To (1) identify whether preoperative knee pathology or intraoperative correction was associated with successful return to duty (RTD) and (2) assess whether postoperative complications and reoperation were associated with failure to RTD. Study Design: Case series; Level of Evidence, 4. Methods: We performed a retrospective cohort study of a consecutive series of patients in the Military Health System aged 18 to 55 years with medial compartment osteoarthritis who underwent HTO between 2003 and 2018. Concomitant meniscal and cartilage procedures were included, while cases with concomitant ligamentous procedures were excluded. The inclusion criteria were as follows: active-duty military status, minimum 2-year follow-up, preoperative knee radiographs, and pre- and postoperative long-leg alignment radiographs. Preoperative Kellgren-Lawrence grades and pre- and postoperative hip-knee-ankle angles were measured. The primary outcome was RTD. Failure was defined as knee-related medical separation from the military or conversion to total knee arthroplasty. The secondary outcome was reoperation. Results: A total of 55 HTOs were performed in 50 patients who met the inclusion criteria, with a mean age of 39 years old (range, 22.8-55 years). The mean follow-up was 5 years (range, 2.1-10.7 years). Ten knees (18.2%) failed HTO (1 conversion to total knee arthroplasty, 9 medical separations), 15 additional knees (27.3%) had permanent activity restrictions, and 30 knees (54.5%) returned to duty without restrictions. Reoperation occurred in 36.4% of knees and was associated with medical separation (P = .039). Younger age was associated with medical separation (P = .003) and permanent restrictions (P = .006). Patients with a postoperative varus deformity of >5° were more likely to undergo medical separation (P = .023). Conclusion: In a young, high-demand population, HTO succeeded in returning 54.5% of knees to full duty without restriction despite 36.4% of knees requiring reoperation. Residual varus deformity or reoperation was associated with lower RTD rates. No association was identified between RTD and preoperative osteoarthritis grading or deformity.

Background: Sulcus-deepening trochleoplasty has been established as an effective treatment for patellar instability due to trochlear dysplasia. However, arthrofibrosis is a known complication following trochleoplasty, which may require manipulation under anesthesia (MUA) with or without lysis of adhesions (LOA) to increase the knee range of motion (ROM), especially flexion. Purpose: To prospectively follow patients for ROM improvements and subsequent complications after undergoing MUA with or without LOA in the setting of sulcus-deepening trochleoplasty. Study Design: Case series; Level of evidence, 4. Methods: A total of 76 knees with severe trochlear dysplasia were prospectively enrolled and underwent sulcus-deepening trochleoplasty, with a mean (±SD) follow-up of 32.5 ± 19.3 months. Concomitant procedures included medial patellofemoral ligament reconstruction, lateral retinacular release, and tibial tubercle osteotomy. Physical examination including ROM and findings of recurrent patellar instability were collected for all patients. Arthrofibrosis was defined as active and passive flexion less than 90° within 3 months of surgery combined with a plateau in progress with physical therapy. Paired-samples and independent-samples t tests were used. A P value less than .05 was considered significant. Results: A total of 62 knees met inclusion and exclusion criteria and were included in the study. Of these patients, 11 experienced arthrofibrosis as a complication and underwent MUA within 3 months of their index procedure. Of these 11 patients, 9 subsequently underwent arthroscopic LOA following MUA because acceptable ROM could not be achieved with manipulation alone. Patients with arthrofibrosis had a premanipulation mean ROM that was significantly different from those without arthrofibrosis (77.3° ±18.6° vs 133.3° ± 12.7°, respectively; P < .001). In the arthrofibrotic group, postoperative ROM increased significantly after MUA and/or LOA compared with the preoperative ROM (127.3° ± 12.5° vs 77.3° ± 18.6°, respectively; P < .001). ROM in the arthrofibrotic group after MUA/LOA was not significantly different from that in the nonarthrofibrotic group (flexion, 127.3° ± 12.5° vs 133.3° ± 12.7°, respectively; P = .156). No complications from the MUA or LOA were reported at subsequent follow-up visits. Conclusion: When indicated in the setting of severe trochlear dysplasia, sulcus-deepening trochleoplasty is a treatment for disabling recurrent patellar instability with a known complication of arthrofibrosis. Initiation of postoperative physical therapy within 3 days of surgery may reduce the incidence of arthrofibrosis. If arthrofibrosis is encountered after a sulcus-deepening trochleoplasty, MUA without LOA is not as effective as when following other procedures of the knee, whereas MUA with LOA is an effective procedure likely to result in ROM and patient outcome scores similar to those of a nonarthrofibrotic knee after the same procedure. Both MUA and LOA appear to be safe based on the limited number of patients in this study without complication.

Objectives: To identify the demographics and characteristics of operative acromioclavicular joint separations, as well as characterize reconstruction techniques and associated complications. Methods: The United States Military Health System Data Repository was queried for patients with a Current Procedural Terminology (CPT) code for coracoclavicular ligament reconstruction between October 2013 and March 2020. Patient demographics, radiology and operative reports, and clinical notes were reviewed to characterize reconstruction techniques and associated postoperative complications. Results: A total of 956 coracoclavicular ligament reconstructions (896 primary repairs or reconstructions, 60 revision reconstructions) were performed between October 2013 and March 2020. The 896 primary coracoclavicular ligament reconstructions were indicated for a range of acromioclavicular joint separation severities: three grade two separations, 392 grade three separations, 48 grade four separations, and 386 grade 5 separations; the remaining 67 patients did not have a definitive injury grade defined by the treating surgeon. Of the primary procedures, 356 were performed acutely within 6 weeks of injury, while 538 were performed greater than 6 weeks after injury. Two hundred and twenty eight primary procedures were categorized as repairs, while 652 were categorized as reconstructions utilizing a graft. Following these procedures, there were 104 major complications requiring return to the operating room, including 48 symptomatic failures requiring revision, 18 fractures of the clavicle or coracoid, 25 deep surgical site infections and 9 cases of symptomatic hardware requiring removal of hardware, and 4 cases of adhesive capsulitis requiring manipulation under anesthesia. There were 160 minor postoperative complications, including 5 non-operative fractures of the clavicle or coracoid, 16 superficial surgical site infections, 7 cases of non-operative adhesive capsulitis, 57 cases of neuropathy, 1 deep venous thrombosis, and 74 cases of persistent acromioclavicular joint pain. There were no significant differences in complication rates between injury grade, acute versus chronic treatment, repair versus reconstruction, or suspensory versus non-suspensory technique. The rate of major complications was 1.8 per 100 person-years and the rate of minor complications was 2.77 per 100 person-years. The overall complication rate was 4.57 per 100 person-years. At the conclusion of the acromioclavicular joint separation care, 60 service members necessitated medical separation from the military. Conclusions: Coracoclavicular ligament reconstruction is a relatively common and safe procedure in a physically active population. The rate of major complication was 1.8 per 100 person-years, while the overall complication rate in our series was 4.57 complications per 100 person-years. Complications are rare, however, when they occur, they frequently require one or more secondary surgeries to treat.

Objectives: In biomechanical studies, suture tapes have demonstrated improved load to failure and tissue tear-through for labral repair compared to suture, suggesting that a tape construct in labral repair may reduce failure rates. However, clinical studies, especially comparative, are lacking. The purpose of this study was to 1) determine the rate of recurrent instability at a minimum 2-year follow-up for shoulders with isolated anterior, isolated posterior, or combined anterior and posterior instability and 2) compare survivability and risk factors for failure in a persistently high-demand military population. Methods: We performed a retrospective cohort study of active duty servicemembers who underwent arthroscopic shoulder stabilization performed by 3 fellowship-trained sports surgeons at a single high-volume military facility between 2010 and 2020. Based on the purported benefits of tape constructs, the surgeons at this facility transitioned to use of suture tape in 2015. We included all patients who underwent isolated anterior or posterior or combined labral repair. We excluded all patients who underwent superior labral repair or with follow-up less than 2 years. We collected patient demographics, prior instability events, details of surgery, and revision procedures. We measured glenoid bone loss using the circle method and used the Hills-Sachs index to evaluate for presence of off-track lesions. Intraoperative details included size and location of the tear, concurrent lesions, number of anchors, and suture type used. The primary outcome was repair failure, defined as recurrent shoulder instability events including subjective subluxation and dislocation, recurrence of pain consistent with instability, functionally limiting apprehension, or undergoing a revision stabilization procedure. We performed survival analysis and univariate and multivariate logistic regression analyses to identify factors most associated with failure. Results: We identified 448 arthroscopic stabilization procedures in total (211 anterior, 79 posterior, and 158 combined anterior/posterior labral repairs). We excluded all patients undergoing superior labral repair (27 anterior, 23 posterior, and 27 combined) and then further excluded patients with less than 2 years follow-up (21 anterior, five posterior, and 21 combined), leaving 163 anterior, 51 posterior, and 110 combined procedures for analysis (Table 1). On univariate analysis, patients who experienced failure after anterior labral repair were more likely to be older (21.4 versus 20.5 years, p = 0.041) and to have bone loss >10% (p = 0.012). The only factor significantly associated with failure after posterior repair was use of sutures alone (p = 0.044), and notably, no patient who underwent suture tape fixation experienced failure (0/18). For combined labral tears, failure was associated with more anchors (5.5 vs 5.0, p = 0.016). Survival curves for repairs demonstrate the overall long-term failure rates after repair (Figure 1). We performed multivariate logistic regression to determine factors associated with higher likelihood of failure after anterior (Table 2) and combined (Table 3) repairs. Labral tape was associated with a lower chance of failure for anterior repairs (p = 0.041). There was a similar trend that did not reach significance after combined repairs (p = 0.085). Because the failure event rate was zero after posterior repair performed with labral tapes, coefficients and confidence intervals were unable to be calculated and this multivariate analysis was not performed. Conclusions: In addition to previously established risk factors for failure following arthroscopic stabilization procedures, use of suture tape was protective against failure in a young, high-demand military population. Overall failure rates were consistent with previously published literature in similar populations and this clinical study validates prior biomechanical studies supporting the use of suture tape. Further clinical study on the use of suture tape in labral repair is warranted.

Objectives: To identify the demographics and characteristics of lateral clavicle fractures treated with coracoclavicular ligament repair or reconstruction, as well as to the subsequent postoperative complications. Methods: The United States Military Health System Data Repository was queried for patients with a Current Procedural Terminology (CPT) code for coracoclavicular ligament reconstruction between October 2013 and March 2020. Radiographs were evaluated for the presence of a lateral clavicle fracture at the time of initial injury and classified based on the modified Neer classification. The electronic health records to include operative reports and clinical notes were then reviewed for patient demographics, operative technique, and clinical course. Results: A total of 965 patients underwent coracoclavicular ligament repair or reconstruction between October 2013 and March 2020. Forty patients (4.6%) were identified with concomitant lateral clavicle fractures. The mean age of 29.575 years (SD 10.1) of which 85% male and 80% were active duty. Based on the Neer classification, there were three type I, 18 type IIB, 12 type III, and seven type V. Twenty-two of these injuries were addressed acutely (55%), while 18 were managed chronically (45%). Open reduction internal fixation of the distal clavicle was performed in 16 of the 40 patients (40%). An equivalent distribution of concomitant coracoclavicular ligament repair versus reconstruction was performed amongst the forty total patients. Postoperatively, two patients went on to nonunion and seven patients had loss of coracoclavicular reduction. Five patients returned to the operating room for removal of symptomatic hardware (3), revision (1), and irrigation and debridement (1). At the conclusion of their fracture care, five (12.5%) of patients necessitated medical separation from the military. Conclusions: A small subset of coracoclavicular reconstructions performed in the military occur for a concomitant lateral clavicle fracture. The majority of military patients who underwent coracoclavicular ligament repair or reconstruction in the setting of a lateral clavicle regained full, pain-free range of motion. Although malunion and nonunion are known complications of this injury pattern, only two patients went on to develop these complications. However, postoperative complications were common, occurring in 25% of patients. At the conclusion of their fracture care, five (12.5%) of patients necessitated medical separation from the military.

Objectives: Loss of reduction is a common postoperative complication following fixation for acromioclavicular joint (ACJ) dislocations with previously identified surgical risk factors in small military cohorts. However, those studies did not include isolated suspensory fixation or examine the effect of intraoperative overreduction. Therefore, the purpose of this study was to evaluate loss of reduction after acute fixation and risk factors associated with loss of reduction for Rockwood Type V ACJ dislocations in a young, active population with different fixation methods. Methods: We performed a retrospective cohort study of patients in the Military Health System who underwent coracoclavicular (CC) ligament repair or reconstruction between October 2013 and March 2020. Patients were included if they sustained a Type V ACJ dislocation and were treated acutely, defined as within 6 weeks. We excluded patients for inadequate pre- or postoperative imaging, less than 1 year follow-up, if a hookplate was used for fixation, pre- or postoperative fracture, or reoperation for infection or hardware removal. We reviewed the electronic health records to collect patient demographics and operative technique. Radiographs were analyzed for two measures of loss of reduction, known risk factors for loss of reduction, and overreduction of the ACJ during surgery. We defined radiographic loss of reduction as an increase in CC distance of 6 mm. Clinical loss of reduction was defined as a Rockwood grade greater than two on final imaging. We defined overreduction as the inferior border of the clavicle being inferior to the inferior aspect of the acromion and measured this difference. The primary outcome was loss of reduction. Secondary outcomes included return to duty and complications. We statistically analyzed risk factors for loss of reduction using Student t-tests, ANOVA, and logistic regression. Univariate analysis was performed with Fisher’s exact tests and logistic regression. Results: 183 patients met inclusion and exclusion criteria with a mean age of 28.6 years (SD 8.1), were 94.5% male, and 92.3% active duty. Repair occurred in 99 (54.1%). Mean time to surgery was 11.8 days (SD 9.0) from injury. Isolated suspensory fixation occurred in 91 (49.7%) patients, 47 (25.7%) were suspensory fixation with graft reconstruction, and 37 (20.2%) were isolated graft reconstruction. There was a statistically significant difference in time to surgery based on fixation type with means of 9.0 days for isolated suspensory fixation, 14.0 days for isolated graft reconstruction, and 18.1 days for suspensory fixation with graft reconstruction. Overall radiographic loss of reduction rate was 37.2%. The procedural CC distance change was the only significant variable identified on univariate analysis for radiographic loss of reduction (p=0.005). Risk factors for radiographic loss of reduction are in Table 1. Fixation type was not a statistically significant risk factor for radiographic loss of reduction on logistic regression. At the time of surgery, 55 (30.0%) were overreduced beyond a Rockwood Type I by a mean 5.2 mm (SD 2.4). With the clinical loss of reduction definition, overreduction had an odds ratio of 0.14 (CI 0.015-0.60, p=0.002) for a Rockwood Type 3 or greater at final imaging. Risk factors for clinical loss of reduction are in Table 2. Reoperation for pain or loss of reduction occurred in 9 patients (4.9%) and medical discharge occurred in 5 cases (2.7%). Conclusions: In a young, active population with Type V ACJ dislocation treated acutely, a high percentage lost reduction yet still returned to duty. AC joint overreduction was not protective for loss of reduction when defined as a radiographic CC distance increase of 6mm. Patients that were overreduced at time of fixation were seven times more likely to maintain reduction clinically, defined as a Rockwood Type II or less postoperatively. Surgeons should consider overreduction at the time of fixation to decrease the rate of clinically important loss of reduction, regardless of time to surgery.