Background: Most patients experience sleep disturbances before rotator cuff repair, with these symptoms largely improving postoperatively. However, the relationship between the resolution or persistence of sleep disturbance and patient-reported outcomes after rotator cuff repair remains unknown. Purpose: To compare outcomes after rotator cuff repair between patients who reported a preoperative sleep disturbance and those who did not. Outcomes at various time points after surgery were also assessed in relation to the persistence or resolution of sleep disturbance. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing primary arthroscopic rotator cuff repair at a tertiary academic center were prospectively enrolled in a registry database. Patient characteristics were obtained preoperatively and validated patient-reported outcome measures (PROMs) were obtained pre- and postoperatively, including the visual analog scale for pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Veterans RAND 12-Item Health Survey Physical and Mental components. Sleep disturbance was evaluated via responses to Simple Shoulder Test question 2. Patients with and without sleep disturbance were compared before and after surgery. Results: In total, 293 patients were prospectively enrolled. A total of 262 (89.8%) patients reported a sleep disturbance preoperatively. Of these, 221 (84.4%) reported a resolution of sleep disturbance by 2 years postoperatively. After adjustment for age, workers’ compensation status, and Cofield tear size, patients with a preoperative sleep disturbance reported significantly worse baseline PROMs, apart from the Veterans RAND 12-Item Health Survey Mental component, before surgery. However, postoperatively, these patients had greater improvement in PROMs, and no significant remaining differences were seen at follow-up between patients with and without preoperative sleep disturbance. Among patients who reported a preoperative sleep disturbance, those whose symptoms resolved postoperatively had superior PROM scores as well as significantly greater improvements from preoperative baseline values compared with patients with persistent sleep disturbances after surgery. Conclusion: Patients with preoperative sleep disturbances reported worse baseline functional scores before rotator cuff repair compared with patients without sleep disturbance. These disturbances largely resolved after surgery, with postoperative outcomes comparable with those of patients who reported no preoperative sleep concerns. Patients whose sleep disturbances resolved postoperatively also reported superior PROM scores compared with patients whose sleep disturbances persisted postoperatively.

Background:Solitary osteochondromas, or osteocartilaginous exostoses (OCEs), represent the most common benign bone tumor. Despite frequently causing symptoms about the knee in younger populations, there is minimal previous literature investigating surgical treatment.Methods:We retrospectively reviewed the records of patients <20 years old who had undergone surgical treatment of symptomatic, pathologically confirmed, solitary periarticular knee OCE at a single pediatric center between 2003 and 2016. The clinical course, radiographic and pathological features, and complications were assessed. Prospective outreach was performed to investigate patient-reported functional outcomes.Results:Two hundred and sixty-four patients (58% male, 81% athletes) underwent excision of a solitary OCE about the knee at a mean age (and standard deviation) of 14.3 ± 2.24 years. Fifty-five percent of the procedures were performed by orthopaedic oncologists, 25% were performed by pediatric orthopaedic surgeons, and 20% were performed by pediatric orthopaedic sports medicine surgeons, with no difference in outcomes or complications based on training. Of the 264 lesions, 171 (65%) were pedunculated (versus sessile), 157 (59%) were in the distal part of the femur (versus the proximal part of the tibia or proximal part of the fibula), and 182 (69%) were medial (versus lateral). Postoperatively, 96% of the patients returned to sports at a median of 2.5 months (interquartile range, 1.9 to 4.0 months). Forty-two patients (16%) experienced minor complications not requiring operative intervention. Six patients (2%) experienced major complications (symptoms or disability at >6 months or requiring reoperation), which were more common in patients with sessile osteochondromas (p = 0.01), younger age (p = 0.01), and distal femoral lesions as compared with proximal tibial lesions (p = 0.003). Lesion recurrence was identified in 3 patients (1.1%). Overall, the median Pediatric International Knee Documentation Committee (Pedi-IKDC) and mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) scores were 97 (interquartile range, 93 to 99) and 16.7 ± 8.15, respectively, at a median duration of follow-up of 5.8 years.Conclusions:In our large cohort of pediatric patients who underwent excision of solitary knee osteochondromas, most patients were male adolescent athletes. Most commonly, the lesions were pedunculated, were located in the distal part of the femur, and arose from the medial aspect of the knee. Regardless of surgeon training or lesion location, patients demonstrated excellent functional outcomes, with minimal clinically important postoperative complications and recurrences, although patients with sessile lesions and younger age may be at higher risk for complications.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Small-diameter semitendinosus-gracilis tendon autografts may be encountered intraoperatively during anterior cruciate ligament reconstruction (ACLR); these have been shown to be at increased risk of graft rupture. One option that surgeons have pursued to reduce the theoretical failure rate of these smaller-diameter grafts is augmenting them with allograft material, thereby forming a larger-diameter hybrid autograft-allograft construct. Purpose/Hypothesis: The purpose of this study was to compare outcomes in adolescent athletes of primary ACLR using a hybrid autologous hamstring tendon and soft tissue allograft construct versus ACLR using small-diameter hamstring tendon autograft. The hypothesis was that the hybrid hamstring autograft-allograft construct would provide superior short-term results. Study Design: Cohort study; Level of evidence, 3. Methods: We performed a retrospective analysis of 47 patients aged between 12 and 20 years who underwent hybrid graft ACLR (mean diameter, 9.1 mm) at a single institution. Electronic medical records including clinic notes, radiographic images, operative notes, and pathology reports were reviewed for study analysis. A control group of 64 patients who underwent small-diameter hamstring reconstruction (mean diameter, 7.1 mm) without allograft supplementation was compiled. Corresponding clinical, radiographic, and surgical characteristics were collected for the control group to allow for comparative analysis. Results: Mean follow-up was 2.7 years for the hybrid cohort and 2.3 years for the control group. Despite a significantly larger mean graft diameter in the hybrid group as compared with the control group ( P < .001), no significant difference in retear rate was seen between cohorts (hybrid, 9%; control, 13%; P = .554). Patients with hybrid anterior cruciate ligament constructs also underwent a comparable number of reoperations overall ( P = .838). Functionally, all patients with adequate follow-up returned to sports, with no significant difference in time to return to sports between the groups ( P = .213). Radiographically, hybrid graft constructs did not undergo a significantly larger degree of tunnel lysis ( P = .126). Conclusion: A cohort of adolescents with hybrid anterior cruciate ligament grafts was shown to have retear rates and overall clinical results comparable with those of a control group that received small-diameter hamstring tendon autografts alone.

Background: Chronic Monteggia lesions in children may cause pain, deformity, decreased range of motion, and neurological symptoms. Numerous surgical techniques have been advocated to reconstruct long-standing Monteggia injures in efforts to maximize long-term upper limb function. The purpose of this investigation was to assess the clinical and radiographic results of a modified surgical technique for missed Monteggia fracture-dislocations. Methods: A retrospective evaluation of 52 patients who underwent surgical reconstruction of missed Monteggia fracture-dislocations at a tertiary pediatric hospital was performed. The median patient age at the time of surgery was 6.8 years, and the median time from injury to surgery was 12.9 weeks. Electronic medical records, including clinic notes, radiographic images, and operative reports, were reviewed for study analysis. Median clinical and radiographic follow-up was 19.1 months. Results: The median elbow range of motion improved from 108 degrees of flexion and 5 degrees short of full extension preoperatively to 140 degrees of flexion (P<0.001) and full extension (P=0.10) postoperatively. Forearm range of motion also improved from a median of 80 degrees of pronation and 58 degrees of supination preoperatively to 80 degrees of pronation (P=0.54) and 80 degrees of supination (P<0.001) postoperatively. Congruent radiocapitellar alignment was maintained in 39 patients (75%). Nine patients (17%) had redislocation of the radiocapitellar joint, and 4 patients (8%) had radiographic resubluxation. Six of the 9 patients who experienced redislocation underwent early revision and achieved uncomplicated longer term results. Patients who received repair of the native annular ligament were more likely to achieve lasting radiocapitellar joint stability (P=0.03) when compared with patients who received annular ligament reconstruction or if the annular ligament was not addressed. Conclusion: Meaningful improvements in elbow motion and radiocapitellar stability can be safely achieved in the majority of children following surgical reconstruction of missed Monteggia lesions. Level of Evidence: Level IV—retrospective case series.

Background: The Surgical Training and Educational Platform (STEP) was developed by the American Society for Surgery of the Hand (ASSH) as a cost-effective set of surgical simulation modules designed to assess critical skills in hand surgery. Previous study demonstrated that STEP can differentiate between novice trainees and board-certified, certificate of added qualification hand surgeons. The purpose of this study was to assess construct validity of STEP by testing its ability to differentiate psychomotor skill level among intermediate trainees. Methods: We evaluated 30 residents from 2 orthopaedic residency programs on 8 modules: (1) lag screw fixation, (2) depth of plunge during bicortical drilling, (3) flexor tendon repair, (4) phalangeal fracture pinning, (5) central axis scaphoid fixation, (6) full-thickness skin graft harvest, (7) microsurgery, and (8) wrist arthroscopy. Spearman correlation was used to correlate total and task-specific scores to case log numbers, months in training, and number of hand surgery rotations. Results: Senior residents had significantly higher mean number of total cases in their total case log (mean difference 96.2, 95% confidence interval [CI] 67.5-124.8, p < 0.01) and number of task-specific cases. Moderate correlation was observed between case log numbers and scaphoid fixation score (rs = 0.423, 95% CI 0.07-0.69) and total score (rs = 0.584, 95% CI 0.25-0.79). Moderate correlation was observed between months in training with: scaphoid fixation (rs = 0.377, 95% CI 0.01-0.66) and microsurgery (rs = 0.483, 95% CI 0.13-0.73); strong correlation was seen with total score (rs = 0.656, 95% CI 0.35-0.83). Moderate correlation with number of hand surgery rotations was observed with tendon repair (rs = 0.362, 95% CI −0.01 to 0.65), skin graft (rs = 0.385, 95% CI 0.01-0.66), wrist arthroscopy (rs = 0.391, 95% CI 0.02-0.67), microsurgery (rs = 0.461, 95% CI 0.10-0.71), and scaphoid fixation (rs = 0.578, 95% CI 0.25-0.79); and strong correlation was seen with total score (rs = 0.670, 95% CI 0.37-0.84). Discussion/Conclusion: The STEP is a validated ASSH education tool that provides a cost-effective simulation for the assessment of fundamental psychomotor skills in hand surgery. Total STEP score correlated with total task-related case volumes as well as months in training and number of hand rotations. Scoring could be modified to improve the fidelity of assessing surgical performance. And, while both time and human resource consuming to perform, administer, and score, this study demonstrates construct validity of STEP in assessing the progression of surgical skill through residency.