Impact of State Opioid Regulation on Postoperative Opioid Prescribing Patterns for Total Knee Arthroplasty: A Retrospective Analysis.

BACKGROUND: Limited studies have assessed the impact of state regulations on opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA). This study evaluates how Florida House Bill 21 (FL-HB21) affected postoperative opioid prescribing for patients after TKA. METHODS: Institutional review board approval was obtained to retrospectively review all patients who underwent TKA during 3 months of 2017 (pre-law) and 2018 (post-law) by five arthroplasty surgeons in Florida. Prescribed opioid quantity in morphine milligram equivalents (MME), quantity of refills, and number of prescribers were recorded for each patient's 90-day postsurgical episode. The differences between pre-law and post-law prescription data and short-term postoperative pain levels were compared. RESULTS: The average total MME was notably reduced by over 30% for all time periods for the post-law group. The average MME per patient decreased by 169 MME at the time of discharge, by 245 MME during subsequent postoperative visits, and by 414 MME for the 90-day postsurgical episode ( P < 0.001 for all). The quantity of refills was unchanged (1.6 vs. 1.6, P = 0.885). The total number of prescribers per patient for the 90-day postsurgical episode was unchanged (1.31 vs. 1.24 prescribers/patient, P = 0.16). Postoperative pain levels were similar at discharge (3.6 pre-law vs. 3.3 post-law, P = 0.272). DISCUSSION: Restrictive opioid legislation was associated with notably reduced postoperative opioid (MME) prescribed per patient after TKA at the time of discharge and for the entire 90-day postsurgical episode. There was no increase in the number of prescribers or refills required by patients. LEVEL OF EVIDENCE: Level III retrospective cohort.

Short-Term Clinical and Return-to-Work Outcomes After Arthroscopic Suprapectoral Onlay Biceps Tenodesis With a Single Suture Anchor.

PURPOSE: To describe short-term outcomes of arthroscopic suprapectoral onlay biceps tenodesis using a single all-suture anchor with respect to validated outcome measures, return to work, objective strength and motion data, and biceps-specific testing. METHODS: This study describes a consecutive series of patients undergoing arthroscopic suprapectoral onlay biceps tenodesis performed by a single surgeon from January to December 2017. Patients were evaluated preoperatively and postoperatively with the American Shoulder and Elbow Surgeons questionnaire, visual analog scale, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey, and 12-Item Short Form survey, and return-to-work survey. Postoperative strength, range of motion, and biceps-specific testing was also performed. RESULTS: This study included 50 patients (26 men and 24 women), with an average age (± standard deviation) of 50.1 ± 10.9 years and average final follow-up of 21.3 ± 8.5 months. Among employed patients, 32 (71.1%) returned to work at an average of 4.6 ± 2.3 months. Light-duty workers returned to work at a significantly greater rate (85.7% vs 33.3%, P = .016) and in less time (2.6 ± 2.0 months vs 6.8 ± 4.2 months) than heavy-duty workers. No differences were found between operative and nonoperative sides in the biceps apex distance (P = .636) or range of motion in elbow flexion and extension (P > .9 for both), supination (P = .192), or pronation (P = .343) postoperatively. Strength in elbow flexion (P = .002), as well as shoulder forward elevation (P < .001) and external rotation (P < .001), increased postoperatively. Significant patient-reported improvements were noted in the American Shoulder and Elbow Surgeons score, visual analog scale pain score, Single Assessment Numeric Evaluation score, Constant-Murley score, and Veterans RAND 12-Item Health Survey and 12-Item Short Form physical component scores (P ≤ .001 for all). A postoperative Popeye deformity developed in 5 patients (10%). CONCLUSIONS: Arthroscopic suprapectoral onlay biceps tenodesis with a single all-suture anchor can provide overall excellent clinical outcomes regarding strength, motion, and validated patient-reported outcome questionnaires. Return to occupational activities may be less predictable and more prolonged for heavy laborers. A small number of patients may experience cosmetic deformity postoperatively. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The Effect of Triangulation Simulator Training on Arthroscopy Skills: A Prospective Randomized Controlled Trial.

PURPOSE: To prospectively evaluate the transferability of skills acquired on a low-cost, at-home, nonanatomic triangulation simulation system to cadaveric models. METHODS: We randomized 28 medical students into either a simulator-training group (n = 14) or group with no training (control, n = 14). All subjects were pretested using a standardized checklist of arthroscopic skills on cadaveric knees and shoulders. Training-group subjects practiced on the triangulation simulator for 90 minutes per week for 4 consecutive weeks. Control subjects received no training. All subjects completed a post-test checklist of arthroscopic skills on cadaveric knees and shoulders, as well as 4 training tasks on the simulator. A blinded orthopaedic surgeon evaluated the arthroscopic videos using the Arthroscopic Surgical Skill Evaluation Tool (ASSET) score. RESULTS: Training-group knee and shoulder ASSET scores increased from 12.2 ± 1.85 to 14.6 ± 2.76 (P = .02) and from 14.6 ± 3.5 to 17.9 ± 4.5 (P = .29), respectively. In the control group, knee and shoulder ASSET scores increased from 14.3 ± 3.12 to 14.25 ± 4.67 (P = .99) and from 14.2 ± 2.7 to 17.07 ± 6.7 (P = .58), respectively. There were no significant differences in the mean post-test ASSET scores between the training group and control group for either knee or shoulder arthroscopy. The post-test ASSET safety subscore during knee arthroscopy was significantly higher in the training group (P = .03). The training group was able to complete significantly more simulator tasks compared with controls (P = .003) at post-testing. A significant positive correlation was found between knee arthroscopy performance and the number of tasks completed during simulation post-testing (P = .043). There was no significant correlation between shoulder arthroscopy performance and simulation performance (P = .532). CONCLUSIONS: Basic triangulation skills may be acquired by training on a low-cost, at-home, nonanatomic triangulation simulation system, although the degree of transferability and universal joint applicability, as well as the existence of an early ceiling effect in skill development, could not be shown. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

Accuracy of patient-specific instrumentation in shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: There has been significant recent emphasis on the use of patient-specific instrumentation (PSI) in shoulder arthroplasty. However, clinical data are lacking to support the increased time and expense associated with PSI. Our purposes were to determine whether PSI significantly improves implantation accuracy during total shoulder arthroplasty (TSA) and to analyze available techniques and correlation with clinical outcomes. We hypothesized that PSI may improve glenoid component position radiographically but without correlation with clinical outcomes. METHODS: The MEDLINE, Scopus, Embase, and Cochrane Library databases were queried. Included articles reported use of any preoperative or intraoperative PSI techniques, models, or guides to assist with TSA prosthesis implantation. The primary outcomes were mean deviation from the preoperative plan in version (in degrees), inclination (in degrees), and entry-point offset on the glenoid (in millimeters). RESULTS: Among the included articles, 518 TSA procedures (352 anatomic and 166 reverse) were performed. The mean postoperative errors in both version and inclination angles were 5° or less in 20 articles (90.9%) using PSI. Meta-analysis revealed no statistically significant differences in version error (P > .999, I 2 = 64.6%), inclination error (P = .702, I 2 = 82.2%), or positional offset (P = .777, I 2 = 85.7%) between PSI and standard instrumentation. No data regarding patient-reported outcome measures, range of motion, strength, or glenoid component loosening and longevity were reported. CONCLUSIONS: Meta-analysis revealed no significant differences in accuracy between PSI and standard instrumentation. Although PSI may possess the potential to improve TSA techniques, further investigations regarding long-term clinical outcomes, impact on operating room time, and cost-effectiveness are warranted before PSI can be routinely recommended over conventional instrumentation.

Preoperative Mental Health Scores and Achieving Patient Acceptable Symptom State Are Predictive of Return to Work After Arthroscopic Rotator Cuff Repair.

BACKGROUND: The incidence of rotator cuff repairs has risen dramatically over the past 10 years, most notably in the working-class population. Return to work (RTW) is a valuable outcome measure to set patient expectations before surgery. PURPOSE: To establish the rate of RTW after rotator cuff repair with respect to stratified levels of occupational demand (sedentary, light, moderate, and heavy) and to identify clinical factors significantly associated with postoperative RTW. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who received rotator cuff repair between 2014 and 2017 were queried from a prospectively maintained institutional registry. Work status was evaluated from clinical and physical therapy notes, and RTW was stratified based on duty level. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) values were calculated for American Shoulder and Elbow Surgeons (ASES) score and subjective Constant score through use of an anchor-based approach. Patient demographic factors, preoperative ASES scores, Constant scores, and health-related quality of life scores, as well as change in postoperative scores exceeding the thresholds for MCID, SCB, and PASS, were analyzed to determine significant associations with RTW without restriction. RESULTS: In total, 89 patients with documented pre- and postoperative work status underwent surgery. Rates of RTW for sedentary, light, moderate, and heavy duties were 100%, 84.0%, 77.4%, and 63.3%, respectively, within return at less than 7 postoperative months on average. RTW was associated with achieving PASS (P = .004) but not achieving MCID and SCB (P = .429 and .452, respectively). Injury to a patient's dominant side had reduced odds (0.057; 95% CI, 0.004-0.763; P = .030) for RTW at full duty. Tear characteristics and type of insurance were not associated with RTW. Preoperative Veterans RAND Mental Component Score (>53.3; area under the curve, 70.4%) was predictive of returning to work. CONCLUSION: A vast majority of patients undergoing rotator cuff repair can expect to return to work within 8 months of surgery. Preoperative mental health scores can predict future return to work, which supports the concept that mental health status plays an important role in the outcomes after rotator cuff repair surgery.

Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty.

BACKGROUND: Single Assessment Numeric Evaluation (SANE) offers a simple method of evaluating patients' sense of functional improvement after shoulder arthroplasty. METHODS: Patients receiving total shoulder arthroplasties were retrospectively queried between 2014 and 2017. Patients completed questionnaires involving SANE, American Shoulder and Elbow Surgeons (ASES) score, and Constant scores at the 1-year interval. Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were calculated using the anchor-based methodology. RESULTS: A total of 207 patients with an average age of 66.7 ± 10.3 years and a body mass index of 31.5 ± 7.3 were available for analysis. The SANE score was the only score to have acceptable area under curve (AUC) (70.5%) for achieving MCID with a cutoff of 28.8. In terms of SCB, ASES (88%) and SANE (70.5%) had acceptable AUC with cutoffs of 20.7 and 50.2, respectively. All 3 scores had excellent AUC (>80%) for PASS with cutoffs of 81.9, 75.5, and 24.5 for ASES, SANE, and Constant scores, respectively. Normalized SANE scores were weakly correlated with ASES and Subjective Constant after normalizing for scale (R2 < 0.4). Achieving MCID by SANE was correlated with achieving MCID by Constant (P < .001). Achieving SCB and PASS by SANE was correlated with achieving SCB and PASS by ASES and Constant (ASES: P = .007, P < .001; Constant: P < .001, P < .001). CONCLUSION: The present study establishes clinically significant outcomes for SANE. Achievement of clinically significant outcomes in SANE was correlated with achieving meaningful outcomes with legacy measures of ASES and Constant scores. SANE may be used as a simple and efficient measure of patient outcome after total shoulder arthroplasty.

Return to Sport Following Hemiarthroplasty With Concentric Reaming Versus Total Shoulder Arthroplasty: A Matched Pair Analysis.

The purpose of this study was to establish functional outcomes regarding return to sport activity for patients receiving anatomical total shoulder arthroplasty (aTSA) vs the ream and run procedure (hemi RR). Patients who underwent hemi RR and who underwent aTSA with a polyethylene glenoid component for end-stage glenohumeral arthritis were retrospectively identified from 2000 to 2014. Patients were matched regarding age, body mass index, sex, and hand dominance. Patients were surveyed to determine their level of sport and satisfaction after surgery. At a mean follow-up of 69.1±24.8 months, a total of 26 hemi RR and 30 aTSA patients met inclusion/exclusion criteria. Mean±SD age at the time of surgery was 53.0±8.5 years. There was no statistical difference between the two cohorts regarding patients who reported no postoperative problems (69.2% vs 76.7%, P=.529), reoperation (11.5% vs 6.7%, P=.522), return to overall sport (94.4% vs 86.4%, P=.395), return to high-demand upper-extremity sport (92.3% vs 81.3%, P=.390), and return to same or better level of intensity sport (83.3% vs 72.7%, P=.424). Patients returned to sport at a mean of 7.5±5.7 months and 6.2±3.6 months in the hemi RR and aTSA cohorts, respectively (P=.485). Radiographic measurements of medialization (mean, -2.4±5.0 vs -2.2±5.7; P=.913) and postoperative decentering (mean, 3.6%±2.6% vs 4.3%±3.3%; P=.795) were equivalent for the two cohorts. Hemi RR was found to have high and equivalent rates of sporting outcomes, clinical outcomes, and radiographic outcomes compared with aTSA. As appropriately indicated patients are counseled for surgery, realistic expectations regarding sports should be discussed. [Orthopedics. 2019; 42(5):276-284.].

Novel 3-dimensionally printed patient-specific guide improves accuracy compared with standard total shoulder arthroplasty guide: a cadaveric study.

BACKGROUND: Patient-specific instrumentation (PSI) systems for total shoulder arthroplasty (TSA) can improve glenoid component placement, but may involve considerable expense and production delays. The purpose of this study was to evaluate a novel technique for in-house production of 3-dimensionally printed, patient-specific glenoid guides. We hypothesized that our PSI guide would improve the accuracy of glenoid guide pin placement compared with a standard TSA guide. METHODS: We randomized 20 cadaveric shoulders to receive pin placement via the PSI guide (n = 10, study group) or standard TSA guide (n = 10, control group). PSI guides were designed to fit each glenoid based on 3-dimensional scapular models constructed from computed tomography scans. A presurgical plan was created for the guide pin trajectory in neutral version and inclination based on individual scapular anatomy. After pin placement, 3-dimensional models from repeated computed tomography scans were superimposed to calculate deviation from the presurgical plan for each specimen. RESULTS: Inclination deviation was significantly lower in the PSI group than in the standard guide group (1.5° ± 1.6° vs. 6.4° ± 5.0°, P = .009). The glenoid entry site exhibited significantly less deviation in the PSI group (0.8 ± 0.6 mm vs. 2.1 ± 1.2 mm, P = .008). The average production cost and time for the PSI guides were $29.95 and 4 hours 40 minutes per guide, respectively. CONCLUSIONS: The PSI guide significantly improved the accuracy of glenoid pin placement compared with the standard TSA guide. Our PSI guides can be produced in-house, inexpensively, and with substantially reduced time compared with commercially available guides.

Operative Time as an Independent and Modifiable Risk Factor for Short-Term Complications After Knee Arthroscopy.

PURPOSE: To determine whether operative time is an independent risk factor for 30-day complications after arthroscopic surgical procedures on the knee. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried between 2005 and 2016 for all arthroscopic knee procedures including lateral release, loose body removal, synovectomy, chondroplasty, microfracture, and meniscectomy. Cases with concomitant procedures were excluded. Correlations between operative time and adverse events were controlled for variables such as age, sex, body mass index, patient comorbidities, and procedure using a multivariate Poisson regression with robust error variance. RESULTS: A total of 78,864 procedures met our inclusion and exclusion criteria. The mean age of patients was 51.0 ± 14.3 years; mean operative time, 31.2 ± 18.1 minutes; and mean body mass index, 31.0 ± 7.8. Arthroscopic lateral release (coefficient, 5.8; 95% confidence interval [CI], 4.8-6.8; P < .001), removal of loose bodies (coefficient, 4.2; 95% CI, 3.2-5.3; P < .001), synovectomy (coefficient, 1.8; 95% CI, 1.2-2.3; P < .001), and microfracture (coefficient, 6.5; 95% CI, 5.8-7.2; P < .001) had significantly greater durations of surgery in comparison with meniscectomy. The overall rate of adverse events was 1.24%. After we adjusted for demographic characteristics and the procedure, a 15-minute increase in operative duration was associated with an increased risk of transfusion (relative risk [RR], 1.5; 95% CI, 1.3-1.8; P < .001), death (RR, 1.6; 95% CI, 1.2-2.1; P = .005), dehiscence (RR, 1.6; 95% CI, 1.2-2.2; P = .002), surgical-site infection (RR, 1.3; 95% CI, 1.2-1.3; P = .001), sepsis (RR, 1.3; 95% CI, 1.2-1.4; P < .001), readmission (RR, 1.1; 95% CI, 1.1-1.2; P < .001), and extended length of stay (RR, 1.4; 95% CI, 1.3-1.4; P < .001). CONCLUSIONS: Marginal increases in operative time are associated with an increased risk of adverse events such as surgical-site infection, sepsis, extended length of stay, and readmission. Efforts should be made to maximize surgical efficiency. LEVEL OF EVIDENCE: Level IV, retrospective database study.

Figure-of-eight Reconstruction of the Sternoclavicular Joint: Outcomes of Sport and Work.

Instability of the sternoclavicular joint is a challenging condition given the proximity of neurovascular structures and minimal osseous constraint, and little is known regarding return to activity. A prospectively maintained institutional registry was retrospectively queried for all sternoclavicular joint reconstructions performed from 2005 to 2016. All included patients were asked to answer questions from a previously established survey to assess return to sport, work, and satisfaction following surgery. Ten patients (12 shoulders) were available for long-term follow-up (71.4%; range, 26-145 months). There were significant improvements in both visual analog scale (-2.3±3.0) and American Shoulder and Elbow Surgeons (+29.7±29.6) scores (P<.001, respectively). Seven patients reported good to excellent satisfaction, and all patients reported they would undergo the surgery again in hindsight. Regarding sports, 4 of 9 (44.4%) were able to return to sport, 1 of 9 (11.1%) was able to return to same or better intensity, and 4 of 8 (50%) were able to perform a push-up having done so prior to injury. In total, 3 of 7 (42.9%) returned to work, with 1 of 7 (14.3%) returning to same or better intensity. None of the heavy-duty workers were able to return to their preinjury level of duty. Although figure-of-eight reconstruction of the sternoclavicular joint provides consistent clinical improvement and acceptable levels of patient satisfaction, most patients were unable to return to preinjury activity. Patients should be counseled preoperatively regarding appropriate expectations. Workers with strenuous responsibilities should be advised to find alternative employment opportunities. [Orthopedics. 2019; 42(4):205-210.].

Open Biceps Tenodesis Associated With Slightly Greater Rate of 30-Day Complications Than Arthroscopic: A Propensity-Matched Analysis.

PURPOSE: To compare the early complication risk associated with open biceps tenodesis (OBT) and arthroscopic biceps tenodesis (ABT) and determine which preoperative factors may influence complication rate. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively queried from 2008 to 2016 for all procedures with CPT codes for ABT (29828) and OBT (23430). Patients were excluded if they received concomitant rotator cuff repair or shoulder arthroplasty. Patients undergoing OBT and ABT were matched by propensity scores based on age, body mass index, operative time, proportion of smokers, and proportion of concomitant subacromial decompression, distal clavicle excision, SLAP, and debridement. The incidence of adverse events in the 30-day postoperative period was compared. RESULTS: A total of 8,032 patients met the inclusion and exclusion criteria. Prior to propensity match, patients receiving OBT and ABT, respectively, differed with respect to age (49.4 ± 13.8 vs 51.4 ± 13.2; P < .001), body mass index (29.6 ± 6.8 vs 29.9 ± 7.0; P = .029), and operative time (91.2 ± 51.3 vs 85.3 ± 43.4; P < .001). Following propensity match, 6,330 remained in the study (3,165 ABT and 3,165 OBT). OBT had significantly greater incidence of any adverse events (1.58% vs 0.95%; P = .032) and anemia requiring transfusion (0.35% vs 0%; P = .001). Multivariate analysis suggested that OBT (relative risk [RR] = 1.7, 95% confidence interval [CI], 1.1-2.7; P = .020), old age (RR = 1.6, 95% CI, 1.0-2.5), history of dyspnea (RR = 3.8, 95% CI, 1.8-7.7; P < .001), and congestive heart failure (RR = 5.5, 95% CI, 1.3-22.7; P = .019) were associated with developing a postoperative adverse event within 30 days of surgery. CONCLUSIONS: Both procedures were found to have a low rate of complications, although OBT had a slightly greater (1.58% vs 0.95%) rate of 30-day complications than ABT. Early complication rate should not serve as impetus to direct surgical technique as number needed to treat is high, although ABT may be considered in more high-risk individuals. LEVEL OF EVIDENCE: Level III, retrospective comparative database study.

Magnetic Resonance Imaging Findings of the Asymptomatic Elbow Predict Injuries and Surgery in Major League Baseball Pitchers.

BACKGROUND: Repetitive pitching produces significant stress on the elbow that may result in structural abnormalities discernable on magnetic resonance imaging (MRI) without causing symptoms. PURPOSE: To determine whether there exists an association between subclinical MRI findings in asymptomatic elbows of Major League Baseball (MLB) players and future placement on the disabled list (DL) or future operative procedure. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: MRI scans of the elbows of professional-level baseball pitchers, taken during routine presigning imaging at a single organization from 2005 to 2017, were retrospectively reviewed. Publicly available databases were queried to exclude pitchers with an injury before the earliest session of elbow MRI. Three blinded reviewers reviewed all MRI scans independently to evaluate for the presence of chondral damage to the joint, loose bodies, ulnar collateral ligament (UCL) heterogeneity or tears, flexor pronator mass defects, and signs of posteromedial (PM) impingement. Binary imaging findings were related to future placement on the DL for elbow complaints and future elbow surgery. RESULTS: A total of 41 pitchers had asymptomatic MRI findings with no prior DL placement. For players who eventually went on the DL, there were a statistically greater number of players with UCL heterogeneity (P = .021), humeral-sided partial UCL tears (P = .031), and PM impingement (P = .004) on preinjury MRI compared with players who remained healthy. PM impingement was related to future elbow-related surgery (P = .003). Pitchers with UCL heterogeneity were associated with reduced career strike zone percentage, innings pitched, and fastball percentage (P < .05 for all). CONCLUSION: UCL heterogeneity, PM impingement, and humeral-sided partial tears were correlated with future DL placement for elbow-related reasons in MLB pitchers. Asymptomatic PM impingement may be a precursor to future surgery.

Establishing clinically significant outcome after arthroscopic rotator cuff repair.

BACKGROUND: Outcomes reporting in rotator cuff repair (RCR) literature has been variable. The minimal clinical important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) bridge the gap between statistical significance and clinical relevance. METHODS: The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (Constant) scores were collected preoperatively and 1 year postoperatively for patients undergoing RCR between 2014 and 2017. An anchor-based approach was used to calculate the MCID, SCB change, and PASS for the ASES questionnaire. RESULTS: The study included 288 patients who underwent RCR. The MCID, SCB, and PASS were, respectively, 11.1, 17.5, and 86.7 for ASES, 4.6, 5.5, and 23.3 for the Constant score, and 16.9, 29.8, and 82.5 for the SANE score. Factors associated with reduced odds of achieving MCID were current smoking for ASES (odds ratio, 0.056) and single-row repair for the Constant score (odds ratio, 0.310). Workers' compensation patients had reduced odds of achieving ASES SCB (odds ratio, 0.267) and were associated with reduced odds of achieving PASS by ASES (odds ratio, 0.244), SANE (OR, 0.452), and Constant (odds ratio, 0.313). Lower preoperative scores were associated with achieving MCID and SCB and higher preoperative Constant scores associated with PASS (P < .001). CONCLUSION: This study establishes MCID, SCB, and PASS for ASES, Constant, and SANE scores in patients undergoing RCR. Factors associated with failing to achieve clinically significant values included current smoking, single-row repairs, high body mass index, and workers' compensation status.

Establishing Clinically Significant Outcomes After Meniscal Allograft Transplantation.

BACKGROUND: Traditionally, the primary outcome in meniscal allograft transplantation (MAT) has been long-term survivorship; however, short-term clinically significant outcomes are necessary to fully evaluate patient improvement after surgery. PURPOSE: To (1) establish the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) with respect to patient-reported outcome measures (PROMs) and (2) evaluate preoperative and intraoperative variables correlated with achieving these threshold values. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A prospectively maintained institutional registry was queried for all MATs performed between 1999 and 2017. The following PROM scores were collected: International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS). Patients who completed preoperative and postoperative PROMs within a 1-month window were included to calculate the distribution-based MCID at this interval. An anchor question regarding satisfaction with surgery was asked at the same time point and was employed to determine the PASS using nonparametric receiver operating characteristic curve/area under the curve analysis. Multivariate regression analysis was performed to correlate patient demographics, medical history, and concomitant procedures to propensity in achieving the MCID and PASS. RESULTS: A total of 98 patients who underwent MAT met the inclusion/exclusion criteria, of whom 10 underwent concomitant ligamentous procedures, 65 underwent concomitant cartilage procedures, and 7 underwent concomitant realignment procedures. The mean patient age was 29.4 ± 9.0 years, and the mean body mass index (BMI) was 26.8 ± 5.2 kg/m2. The distribution-based MCID and PASS were determined for the Lysholm score (12.3 and 66.5) and IKDC (9.9 and 36.0) as well as the KOOS Pain (9.9 and N/A ), Symptoms (9.7 and 73.0), Activities of Daily Living (9.5 and N/A), Sport (13.3 and N/A), and Quality of Life (14.6 and 53.0) subscales, respectively. A preoperative Short Form Physical Component Summary (SF PCS) score greater than 32.0 was predictive of postoperative satisfaction. Patients with work-related claims had a reduced likelihood of achieving the MCID for the IKDC and the PASS for the KOOS Symptoms. An increased BMI was also associated with failing to achieve the PASS for the KOOS Quality of Life (QOL). CONCLUSION: This study established the MCID and PASS for the Lysholm score, IKDC, and KOOS in patients undergoing MAT. Workers' compensation and higher BMI were associated with failing to achieve clinically significant values. Lower preoperative Lysholm, IKDC, and KOOS scores were predictive of achieving the MCID, while higher preoperative SF PCS scores were associated with achieving satisfaction after MAT.

Comparative analysis of work-related outcomes in hemiarthroplasty with concentric glenoid reaming and total shoulder arthroplasty.

BACKGROUND: Anatomic total shoulder arthroplasty (aTSA) has demonstrated high levels of return to work, although there are fears of glenoid component loosening with higher work demand. METHODS: A retrospective query was performed of all patients who received hemiarthroplasty with ream-and-run resurfacing (Hemi RR) between 2005 and 2014. Included patients were matched to an aTSA cohort by age, body mass index, sex, and hand dominance. Preoperative and postoperative work status, by level of duty and occupation, was collected. RESULTS: Twenty-five patients receiving Hemi RR and 28 patients receiving TSA completed this questionnaire (82.8% compliance). Mean follow-up was 69.1 ± 24.8 months. In total, 100% of Hemi RR patients returned to work, and 89.3% of TSA patients returned to work (P = .091). The Hemi RR patients had higher rates of return to work for heavy-duty workers only (7 of 7 vs. 2 of 4, P = .038), although only 1 patient in the TSA group reported failure to work was due to shoulder reasons. Mean duration of return to work was 2.5 ± 4.8 months for patients receiving Hemi RR and 1.98 ± 2.6 months for those receiving TSA (P = .653). CONCLUSIONS: Hemi RR had a high return to heavy-duty work, likely due to fewer surgeon-imposed restrictions. The results of this study may help manage return to work expectations after Hemi RR according to the level of duty and suggest Hemi RR is a viable option for heavy-duty laborers with end-stage glenohumeral arthritis.

Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques.

BACKGROUND: Acromioclavicular (AC) instability is a frequent injury affecting young and athletic populations. Symptomatic, high-grade dislocations may be managed by a myriad of operative techniques that utilize different grafts to achieve reduction. Comparative data are lacking on the ability of these techniques to achieve excellent patient outcomes and stable AC reduction and to minimize complications. PURPOSE: To systematically review the outcomes and complications of different techniques of AC joint reconstruction. STUDY DESIGN: Systematic review and meta-analysis. METHODS: The MEDLINE, Scopus, Embase, and Cochrane Library databases were accessed to perform a systematic review of the scientific literature from 2000 to 2018 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following keywords: "acromioclavicular" and "reconstruction." Included articles were evaluated for loss of reduction, complication rate, revision rate, and change in coracoclavicular distance. Articles were stratified by graft and surgical material used: suture only, Endobutton with suture, TightRope, GraftRope, synthetic artificial ligament, tendon graft, and Weaver-Dunn coracoacromial ligament transfer. These outcomes were pooled using a random-effects model and stratified by surgical technique and arthroscopic versus open reconstruction. RESULTS: Fifty-eight articles were included in the analysis, with 63 homogeneous populations composed of 1704 patients. The mean age was 37.1 years (range, 15-80 years) with a mean follow-up of 34.3 months (range, 1.5-186 months). The overall failure rate was 20.8% (95% CI, 16.9%-25.2%). The overall pooled complication rate was 14.2% (95% CI, 10.5%-18.8%). The most common complications were infection (6.3% [95% CI, 4.7%-8.2%]), fracture to the coracoid or distal clavicle (5.7% [95% CI, 4.3%-7.6%]), and hardware/button failure (4.2% [95% CI, 3.1%-5.8%]). There were no differences between arthroscopic and open techniques in regard to loss of reduction (P = .858), overall complication rate (P = .774), and revision rate (P = .390). Open surgery had a greater rate of clavicular/coracoid fractures than arthroscopic surgery (P = .048). Heterogeneity, best assessed from the pooled loss of reduction, was measured as I2 = 64.0%. CONCLUSION: Open and arthroscopic AC joint reconstruction techniques have no differences in loss of reduction, the complication rate, and the revision rate based on the available literature. Complications are significant, and profiles vary between surgical techniques, which should be evaluated in the decision making of selecting the technique.

Management of Chondral Lesions of the Knee: Analysis of Trends and Short-Term Complications Using the National Surgical Quality Improvement Program Database.

PURPOSE: To provide updated surgical trends of cartilage procedures differentiated by the classic groups of palliative, repair, and restorative modalities. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2010-2016 for the following cartilage procedures: chondroplasty, microfracture, arthroscopic osteochondral autograft or allograft transplantation, open osteochondral autograft or allograft transplantation, and autologous chondrocyte implantation. Demographic variables and short-term (30-day) complications were analyzed with 1-way analysis of variance and post hoc analysis. Linear regression analysis was performed to analyze trends over time. RESULTS: A total of 15,609 procedures performed between 2010 and 2016 were analyzed. On average, 342.2 ± 27.9 cartilage procedures were performed per 100,000 operations. There was a linear increase in the management of overall cartilage procedures per 100,000 operations (P = .002). There were also linear increases in arthroscopic osteochondral autograft transplantation, arthroscopic osteochondral allograft transplantation, open osteochondral autograft transplantation, open osteochondral allograft transplantation, and autologous chondrocyte implantation (P < .001, P = .037, P = .001, P = .006, and P = .002, respectively). Meniscectomy was the most frequently performed concomitant procedure (9.7%-64.2% of cases). Chondroplasty and microfracture showed no change in frequency over time (P = .140 and P = .720, respectively). The overall complication rate was 2.1% for chondroplasty, 1.4% for microfracture, 1.8% for arthroscopic osteochondral autograft transplantation, 1.0% for arthroscopic osteochondral allograft transplantation, 1.4% for open osteochondral autograft transplantation, 1.1% for open osteochondral allograft transplantation, and 0.75% for autologous chondrocyte implantation. Deep vein thrombosis was the most common complication, occurring in 0.4% to 1.0% of cases. No statistically significant difference was found in complication rates between procedures (P = .105). CONCLUSIONS: Cartilage restoration is becoming an increasingly popular modality to address chondral defects. Minimal complication rates suggest that these procedures may be safely performed concomitantly with other interventions. LEVEL OF EVIDENCE: Level IV, retrospective database analysis.

Management of Recurrent Anterior Shoulder Instability With Bipolar Bone Loss: A Systematic Review to Assess Critical Bone Loss Amounts.

BACKGROUND: There is increasing evidence to suggest that the amount of glenoid bone loss to indicate bone block procedures may be lower than previously thought, particularly in the presence of a Hill-Sachs defect. PURPOSE: To better establish treatment recommendations for anterior shoulder instability among patients with bipolar bone lesions. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: A systematic review of the literature was performed with PubMed, EMBASE, Cochrane Library, and Scopus databases according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Studies evaluating outcomes of operative management in anterior shoulder instability that also reported glenoid bone loss in the presence of Hill-Sachs defects were included. Recurrence rates, glenoid bone loss, and humeral bone loss were pooled and analyzed with forest plots stratified by surgical procedure. Methods of quantification were analyzed for each article qualitatively. RESULTS: Thirteen articles were included in the final analysis, with a total of 778 patients. The mean ± SD age was 24.9 ± 8.6 years. The mean follow-up was 30.1 months (range, 11-240 months). Only 13 of 408 (3.2%) reviewed bipolar bone loss articles quantified humeral and/or glenoid bone loss. Latarjet procedures had the greatest glenoid bone loss (21.7%; 95% CI, 14.8%-28.6%), followed by Bankart repairs (13.1%; 95% CI, 9.0%-17.2%), and remplissage (11.7%; 95% CI, 5.5%-18.0%). Humeral bone loss was primarily reported as percentage bone loss (22.2%; 95% CI, 13.1%-31.3% in Bankart repairs and 31.7%; 95% CI, 21.6%-41.1% in Latarjet) or as volumetric defects (439.1 mm3; 95% CI, 336.3-541.9 mm3 in Bankart repairs and 366.0 mm3; 95% CI, 258.4-475.4 mm3 in remplissage). Recurrence rates were as follows: Bankart repairs, 19.5% (95% CI, 14.5%-25.8%); remplissage, 4.4% (95% CI, 1.3%-14.0%); and Latarjet, 8.7% (95% CI, 5.0%-14.7%). Bankart repairs were associated with significantly greater recurrence of instability in included articles (P = .013). CONCLUSION: There exists a need for universal and consistent preoperative measurement of humeral-sided bone loss. The presence of concomitant Hill-Sachs defects with glenoid pathology should warrant more aggressive operative management through use of bone block procedures. Previously established values of critical glenoid bone loss are not equally relevant in the presence of bipolar bone loss.

Analysis of Publication Trends for the 2011-2015 American Orthopaedic Society for Sports Medicine Annual Meeting Abstracts.

BACKGROUND: Academic conferences are sources of novel research that can influence clinical decision making. Orthopaedic surgery maintains a relatively high rate of publication compared with other surgical subspecialties, and sports medicine conferences hold an even higher rate within the subspecialty. The American Orthopaedic Society for Sports Medicine (AOSSM) annual meetings have been shown to have among the highest rates of publication for accepted abstracts. PURPOSE: To determine differences between 2-year publication rates of poster and podium abstracts accepted into the AOSSM annual meetings and identify factors associated with publication. STUDY DESIGN: Cross-sectional study. METHODS: The AOSSM archives were queried for all accepted poster and podium presentations for annual meetings from 2011 through 2015. Google Scholar and MEDLINE databases were used to determine which abstracts transitioned into journal articles. Publication rates were compared based on publication 2 years following presentation. Logistic regression was performed to demonstrate which variables were most correlated with successful publication. Data on publication impact factor and number of citations were collected by use of the InCites database. RESULTS: Of 628 abstracts accepted during this period, 265 were poster presentations and 363 were podium presentations. Overall, 44.7% of abstracts presented were accepted into peer-reviewed journals within 2 years of presentation. No statistical difference was found between poster and podium presentations for journal publication (P = .328). Poster presentations were published in journals with statistically lower impact factor (P = .005) and had a statistically lower number of citations (P < .001) compared with podium presentations. Multivariate logistic regression analysis demonstrated that only number of authors was correlated with publication (P = .003). CONCLUSION: Podium and poster presentations accepted into AOSSM conferences had equal rates of publication within 2 years and should influence decision making equally. The relative impact of podium presentations appeared to be greater, which suggests that the AOSSM selects podium presentations that will have greater clinical impact. Increasing number of coauthors was the only factor found to be correlated with publication.

Recurrence Rate of Instability After Remplissage for Treatment of Traumatic Anterior Shoulder Instability: A Systematic Review in Treatment of Subcritical Glenoid Bone Loss.

PURPOSE: To report outcomes after arthroscopic remplissage in patients with anterior shoulder instability and subcritical glenoid bone loss, specifically regarding recurrence of instability, return to sport, and changes in range of motion. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to perform a search using the PubMed, Embase, Cochrane Library, and Scopus databases. Forest plots were used to evaluate the overall values for recurrent instability, change in external rotation, and return to sport after arthroscopic Bankart repair with or without remplissage. The Methodological Index for Non-randomized Studies and Risk of Bias in Nonrandomized Studies-Interventions checklist were used to evaluate bias. RESULTS: Twenty-two articles met the inclusion and exclusion criteria. The Methodological Index for Non-randomized Studies and Risk of Bias in Nonrandomized Studies-Interventions checklists deemed studies as acceptable quality with low bias. Among 694 patients (522 male and 106 female patients) undergoing remplissage, the mean age was 28.3 ± 5.3 years and the mean duration of follow-up was 32.5 ± 13.9 months. The recurrence rate of instability ranged from 0% to 20%. The change in external rotation in 90° of abduction ranged from -11.3° to -1.0°, and the change in external rotation with the arm fully adducted ranged from -8.0° to +4.5°. The overall rate of return to sport ranged from 56.9% to 100% after remplissage. The rate of return to sport at the preinjury level ranged from 41.7% to 100%. In addition, arthroscopic remplissage in addition to Bankart repair had a reduced odds of recurrent instability developing, ranging from 0.07 to 0.88, when compared with isolated Bankart repair. CONCLUSIONS: Arthroscopic remplissage combined with Bankart repair is an effective procedure in the treatment of patients with engaging Hill-Sachs lesions and minimal glenoid bone loss. Patients can expect favorable rates of recurrent instability with a negligible loss of external rotation when compared with isolated Bankart repair. Treatment algorithms may be updated to include this procedure for engaging Hill-Sachs lesions, measuring between 20% and 40% in volume, with subcritical (<20%) glenoid bone loss. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.