Risk Factors for Peripheral Nerve Injury Following Revision Total Hip Arthroplasty in 112,310 Patients.

Background: Peripheral nerve injury (PNI) following revision total hip arthroplasty (rTHA) can be a devastating complication. This study assessed the frequency of and risk factors for postoperative PNI following rTHA. Methods: Patients who underwent rTHA from 2003 to 2015 were identified using the National Inpatient Sample (NIS). Demographics, medical history, surgical details, and complications were compared between patients who sustained a PNI and those who did not, to identify risk factors for the development of PNI after rTHA. Results: Overall, 112,310 patients who underwent rTHA were identified, 929 (0.83%) of whom sustained a PNI. Univariate analysis found that younger patients (p < 0.0001), females (p = 0.025), and those with a history of flexion contracture (0.65% vs. 0.22%, p = 0.005), hip dislocation (24.0% vs. 18.0%, p < 0.001), and spine conditions (4.8% vs. 2.7%, p < 0.001) had significantly higher rates of PNI. In-hospital complications associated with PNI included postoperative hematoma (2.6% vs. 1.2%, p < 0.0001), postoperative seroma (0.75% vs. 0.30%, p = 0.011), superficial wound dehiscence (0.65% vs. 0.23%, p = 0.008), and postoperative anemia (36.1% vs. 32.0%, p = 0.007). Multivariate analysis demonstrated that a history of pre-existing spine conditions (aOR: 1.7; 95%-CI: 1.3-2.4, p < 0.001), prior dislocation (aOR 1.5; 95%-CI: 1.3-1.7, p < 0.001), postoperative anemia (aOR 1.2; 95%-CI: 1.0-1.4, p = 0.01), and hematoma (aOR 2.1; 95%-CI: 1.4-3.2, p < 0.001) were associated with increased risk for PNI. Conclusions: Our findings align with the existing literature, affirming that sciatic nerve injury is the prevailing neuropathic complication after total hip arthroplasty (THA). Furthermore, we observed a 0.83% incidence of PNI following rTHA and identified pre-existing spine conditions, prior hip dislocation, postoperative anemia, or hematoma as risk factors. Orthopedic surgeons may use this information to guide their discussion of PNI following rTHA, especially in high-risk patients.

Patient Reported Clinical Outcomes Following PCL Suture Augmentation in Patients with Multiligamentous Knee Injury: A Retrospective Observational Study.

Purpose: To compare the patient-reported outcomes between patients with posterior cruciate ligament (PCL) reconstruction or repair alone versus PCL reconstruction or repair with internal bracing (IB) in the context of multi-ligament knee injuries (MLKI). Methods: All patients who underwent surgical management of MLKI at two institutions between 2006 and 2020 were retrospectively identified and offered participation in the study. Patient reported outcomes were measured via three instruments: Lysholm Knee score, Multiligament Quality of Life (ML-QOL), and the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT). The postoperative outcomes and reoperation rates were compared between the internal bracing and non-internal bracing groups. Results: Fifty-two patients were analyzed; 34 were included in the IB group (17.6% female; age 33.1 ±1.60 years), and 18 were included in the non-IB group (11.1% female; age 34.1 ±3.72 years). Mean follow-up time of the entire cohort was 1.44 ± 0.22 years (IB: 1.21 ± 0.18; non-IB: 2.1 ±0.65). There were no significant differences between PROMIS CAT [PROMIS Pain (54.4 ±1.78 vs 51.7 ±1.70, p=0.319), Physical Function (44.3 ±2.27 vs 47.9 ±1.52, p=0.294), Mobility (44.0 ±1.71 vs 46.1 ±2.10, p=0.463)], ML-QOL [ML-QOL Physical Impairment (40.7 ±4.21 vs 41.7±5.10, p=0.884), Emotional Impairment (49.2 ±4.88 vs 44.7±5.87, p=0.579), Activity Limitation (43.5 ±4.56 vs 31.5±3.62, p=0.087), Societal Involvement (44.9 ±4.96 vs 37.5 ±5.30, p=0.345)] and Lysholm knee score (61.8 ±4.55 vs 61.0 ±4.95, p=0.916) postoperatively compared to the non-IB group. Conclusion: In this group of patients, function and patient-reported outcomes between patients treated with PCL reconstruction and repair without internal brace versus those with additional internal brace augmentation were not significantly different. Further research encompassing a larger patient sample is necessary to investigate the efficacy of the internal brace for PCL injury in the context of MLKI injuries.

Outcomes of multiligament knee injury treated with versus without internal brace suture augmentation.

PURPOSE: To compare the postoperative outcomes between Internal Brace (IB) and non-IB patients who underwent surgical management of multiple-ligament knee injuries (MLKI). METHODS: Patients who underwent surgical management of MLKI at two institutions between 2010 and 2020 were identified and offered participation in the study via the collection of postoperative functional outcomes for MLKI; Lysholm Knee score, Multiligament Quality of Life (ML-QOL), Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT), Pain Interference (PI), Physical Function (PF), and Mobility instruments (MI). The postoperative outcomes and reoperation rates were compared between the IB group and non-IB group. RESULTS: One hundred and twenty-six patients were analyzed; 89 were included in the IB group (31.5% female; age 35.6 ± 1.4 years), and 37 were included in the non-IB group (25.7% female; age 38.8 ± 2.4 years). Mean follow-up time of the entire cohort was 37.9 ± 4.7 months [IB: 21.8 + 1.63; non-IB: 76.4 ± 6.2, p < 0.001). The IB group achieved similar PROMIS CAT [PROMIS Pain (51.8 + 1.1 vs. 52.1 + 1.6, p = 0.8736), Physical Function (46.6 + 1.2 vs. 46.4 + 1.8, p = 0.9168), Mobility (46.0 + 1.0 vs. 43.7 + 1.6, p = 0.2185)], ML-QOL [ML-QOL Physical Impairment (36.6 + 2.5 vs. 43.5 ± 4.2, p = 0.1485), Emotional Impairment (42.5 + 2.9 vs. 48.6 ± 4.6, p = 0.2695), Activity Limitation (34.5 + 2.8 vs. 36.2 ± 4.3, p = 0.7384), Societal Involvement (39.1 + 3.0 vs. 41.7 + 4.2, p = 0.6434)] and Lysholm knee score (64.9 + 2.5 vs. 60.4 + 4.0, p = 0.3397) postoperatively compared the non-IB group, but the differences were not significant. CONCLUSION: In this cohort of patients with MLKI treated with versus without IB, outcomes and reoperation rates trended toward favoring IB, but the study was not sufficiently powered to reach statistical significance. Internal bracing could be useful in the management of MLKI. In the future, matched patient cohorts with more patients are warranted to further evaluate the clinical impact of the internal brace in MLKI.

Risk Factors for Peripheral Nerve Injury Following Revision Total Knee Arthroplasty in 132,960 Patients.

BACKGROUND: Peripheral nerve injury (PNI) following revision total knee arthroplasty (rTKA) is a potentially devastating injury for patients. This study assessed the frequency of and risk factors for postoperative PNI following rTKA. METHODS: Patients who underwent rTKA from 2003 to 2015 were identified using the National Inpatient Sample. Demographics, medical histories, surgical details, and complications were compared between patients who sustained a PNI and those who did not to identify risk factors for the development of PNI after rTKA. RESULTS: Overall, 132,960 patients who underwent rTKA were identified, and 737 (0.56%) sustained a postoperative PNI. After adjusting for confounders, patients with a history of a spine condition (adjusted odds ratio [aOR]: 1.7, 95%-confidence interval 1.2 to 2.4, P = .003) and postoperative anemia (aOR: 1.3, 95%-CI: 1.1 to 1.5, P = .004) had higher risk of PNI following rTKA. Intraoperative periprosthetic fracture (aOR: 1.3, 0.78 to 2.2, P = .308), rheumatoid arthritis (aOR: 1.0, 95%-CI: 0.68 to 1.6, P = .865), and history of knee dislocation (aOR: 1.1, 95%-CI: 0.85 to 1.5, P = .412), were not significantly associated with higher risk for PNI. CONCLUSIONS: This study found a 0.56% incidence of PNI following rTKA, and patients who had preexisting spine conditions or postoperative anemia were at an increased risk for this complication. Orthopedic surgeons may use the results of this study to appropriately counsel patients on the potential for a PNI following rTKA.

Anterior capsular reconstruction with acellular dermal allograft for subscapularis deficiency: a report of two cases.

Anterior glenohumeral instability with an irreparable subscapularis tear is a challenging problem for the orthopedic shoulder surgeon. Current techniques, including tendon transfers, yield inconsistent results with high rates of recurrent instability. Acellular dermal allografting has been used in young patients with massive superior rotator cuff tears with early success, but acellular dermal allografting is comparatively unstudied in anterior deficiency. We present two cases of anterior capsular reconstruction with an acellular dermal allograft in patients ages 66 and 58 years with irreparable subscapularis tendon tears. Follow-up for both patients exceeded 4 years, with forward flexion >140°, external rotation exceeding 60°, a Single Assessment Numeric Evaluation score >90 points, a visual analog scale score of 0 points, and an American Shoulder and Elbow Score of 98 points. In conclusion, acellular dermal allografting can be used to reconstruct the anterior capsule in patients with massive irreparable subscapularis tears, similar to its use in superior capsular reconstruction in patients with massive posterosuperior rotator cuff tears.

Volume, indications, and number of surgeons performing reverse total shoulder arthroplasty continue to expand: a nationwide cohort analysis from 2016-2020.

Background: Since its approval, reverse total shoulder arthroplasty (rTSA) has continued to increase in usage, with expanding indications beyond rotator cuff arthropathy. Existing literature has captured further increased utilization over the last decade through 2017. However, this data has not been updated to include a contemporary cohort of patients. This study sought to determine the trends of anatomic total shoulder arthroplasty (aTSA), rTSA, and hemiarthroplasty (HA) usage based on primary diagnosis and total number of surgeons performing each procedure annually from 2016-2020. Methods: Patients who underwent primary rTSA, aTSA, and HA from 2016-2020 were identified in the Premier Healthcare Database. Primary indication diagnoses for procedures were identified using International Classification of Diseases 10th edition codes. Temporal trends in patient and hospital demographics, primary indication, and procedure utilization were captured on an annualized basis. The number of surgeons performing each procedure annually was noted. Descriptive statistics were employed with significance set at P < .05. Results: From 2016 to 2020, 154,499 patients undergoing primary shoulder arthroplasty were identified: 48,890 aTSA, 95,808 rTSA, and 9801 HA. In 2016, rTSA comprised a slight majority (55%) of all arthroplasty cases but increased to nearly 70% of all arthroplasty cases in 2020. The absolute numbers of aTSA and HA cases decreased over time, while rTSA volume increased from 14,781 in 2016 to a high of 23,644 cases in 2019. There was a corresponding 12% increase in the number of surgeons performing rTSA across the same time period, contrasted with a 42.1% decrease in surgeons performing HA and a 14.3% decrease for aTSA. Glenohumeral osteoarthritis remains the most common indication for rTSA and aTSA, while HA is used primarily for proximal humerus fractures or hardware complications. Conclusion: The volume of primary rTSA in the United States has continued to increase from 2016 to 2020 with concurrent decreases in the number of primary aTSA and HA cases performed. Primary rTSA accounts for nearly 70% of all primary shoulder arthroplasty cases. The number of surgeons performing rTSA continues to increase, while there has been a decrease in the number of surgeons performing aTSA and HA.

Utilization of technology-assisted total hip arthroplasty in the United States from 2005 to 2018.

BACKGROUND: Successful outcomes in total hip arthroplasty (THA) rely in part on accurate component positioning, which may be optimized through the use of computer navigation and robot-assistance. Therefore, we queried a large national database to characterize national trends in technology-assisted THA utilization, determine whether these technologies were associated with increased hospital charges, and identify demographic factors associated with technology-assisted THA. METHODS: Using the Nationwide Inpatient Sample database, patients that underwent conventional THA, computer-navigated THA, and robot-assisted THA from 2005 to 2018 were identified. Patient and hospital demographics, charge data, and payer characteristics were collected. Temporal trends in utilization were reported. Univariate analyses were performed to compare differences between groups with multiple logistic regression analysis to account for confounders. RESULTS: In total, 3,428,208 patients undergoing THA from 2005 to 2018 were identified, of which 63,136 (1.8%) used computer navigation and 32,660 (1.0%) used robot-assistance. National utilization of computer navigation in THA increased from 0.1% to 1.9% between 2005 and 2018, while utilization of robot-assisted THA increased from <0.1% to 2.1% from 2008 to 2018. On multivariate analysis, technology-assisted THA was most commonly performed in urban hospitals in the Northeastern United States. Median hospital charges were increased for technology-assisted THAs relative to conventional THAs ($66,089 ± $254 vs $55,418 ± $43). CONCLUSIONS: Computer navigation and robot-assistance in THA demonstrated a consistent increase in utilization during the period examined, representing 4.0% of THAs performed in 2018. Patient and hospital characteristics including risk of mortality, geographic region, and teaching status were associated with increased utilization. Utilization of computer navigation was associated with increased hospital charges.

Five-Year Surveillance of Vitamin D Levels in NCAA Division I Football Players: Risk Factors for Failed Supplementation.

BACKGROUND: Monitoring vitamin D levels in athletes and determining their response to supplementation in cases of deficiency is thought to be necessary to modulate the risks associated with vitamin D deficiency. HYPOTHESIS/PURPOSE: To report the results of a 5-year-long surveillance program of vitamin D in the serum of football players on a National Collegiate Athletic Association (NCAA) Division I team and to examine whether factors including age, body mass index (BMI), race, position played, and supplement type would affect the response to 12-month oral vitamin D replacement therapy in athletes with deficiency. We hypothesized that yearly measurements would decrease the proportion of athletes with vitamin D insufficiency over the years and that the aforementioned factors would affect the response to the supplementation therapy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We measured serum 25(OH)D levels (25-hydroxyvitamin D) in 272 NCAA Division I football players from our institution annually between 2012 and 2017. Athletes with insufficient vitamin D levels (<32 ng/mL) received supplementation with vitamin D3 alone or combined vitamin D3/D2. The percentage of insufficient cases between the first 2 years and last 2 years of the program was compared, and yearly team averages of vitamin D levels were calculated. Associations between player parameters (age, BMI, race, team position, supplement type) and failed supplementation were evaluated. RESULTS: The prevalence of vitamin D insufficiency decreased significantly during the study period, from 55.5% in 2012-2013 to 30.7% in 2016-2017 (P = .033). The mean 25(OH)D level in 2012 was 36.3 ng/mL, and this increased to 40.5 ng/mL in 2017 (P < .001); however, this increase was not steady over the study period. Non-Hispanic athletes and quarterbacks had the highest average 25(OH)D levels, and Black players and running backs had the lowest overall levels. There were no significant differences in age, BMI, race, or playing position between athletes with and without failed vitamin D supplementation. Athletes receiving vitamin D3 alone had a more successful rate of conversion (48.15%) than those receiving combined vitamin D3/D2 (22.22%; P = .034). CONCLUSION: To decrease the prevalence of vitamin D deficiency in football players, serum vitamin D measurements should be performed at least once a year, and oral supplementation therapy should be provided in cases of deficiency. Black players might be at increased risk of vitamin D insufficiency. Oral vitamin D3 may be more effective in restoring vitamin D levels than combined vitamin D3/D2 therapy.

Return to Sport Following Operative Treatment of Displaced Medial Sesamoid Fractures in NCAA Division I Football Players.

Level of Evidence: Level V.

Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review.

Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.

Resident Involvement in Arthroscopic Knee Surgery Is Not Associated With Increased Short-term Risk to Patients.

BACKGROUND: Whether resident involvement in surgical procedures affects intra- and/or postoperative outcomes is controversial. PURPOSE/HYPOTHESIS: The purpose of this study was to compare operative time, adverse events, and readmission rate for arthroscopic knee surgery cases with and without resident involvement. We hypothesized that resident involvement would not negatively affect these variables. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of the prospectively maintained National Surgical Quality Improvement Program was performed. Patients who underwent arthroscopic knee surgery between 2005 and 2012 were identified. Multivariate Poisson regression with robust error variance was used to compare the rates of postoperative adverse events and readmission within 30 days between cases with and without resident involvement. Multivariate linear regression was used to compare operative time between cohorts. Because of multiple statistical comparisons, a Bonferroni correction was used, and statistical significance was set at P < .004. RESULTS: A total of 29,539 patients who underwent arthroscopic knee surgery were included in the study, and 11.3% of these patients had a resident involved with the case. The overall rate of adverse events was 1.62%. On multivariate analysis, resident involvement was not associated with increased rates of adverse events or readmission. Resident cases had a mean 6-minute increase in operative time (P < .001). CONCLUSION: Overall, resident involvement in arthroscopic knee surgery was not associated with an increased risk of adverse events or readmission. Resident involvement was associated with only a mean increased operative time of 6 minutes, a difference that is not likely to be clinically significant. These results support the safety of resident involvement with arthroscopic knee surgery.

Performance of PROMIS Computer Adaptive Testing As Compared With Established Instruments for Multiple-Ligament Knee Injuries.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) is a patient-reported outcome metric that has been validated for anterior cruciate ligament (ACL) injuries, ACL reconstructions, and meniscal injuries. Thus far, the system has not been validated for multiligament knee injuries. The Multiligament Quality of Life (MLQOL) questionnaire is a validated, disease-specific patient-reported outcome instrument for this population that can serve as a gold standard for validation of the newer PROMIS. PURPOSE/HYPOTHESIS: The purpose of this study was to further validate the PROMIS CAT for multiligament knee reconstruction. We hypothesized that the PROMIS CAT modules would correlate with the Lysholm knee score (Lysholm), Tegner activity scale (Tegner), and MLQOL for postoperative multiligamentous knee injury patients and that the PROMIS CAT would use fewer question items than the Lysholm, Tegner, and MLQOL while still avoiding floor and ceiling effects. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 30 patients meeting the inclusion criteria were retrospectively identified and agreed to participate (87% male; mean ± SD age, 36.3 ± 13.5 years). Consenting patients were administered the Lysholm, Tegner, MLQOL, and PROMIS CAT for Physical Function, Mobility, and Pain Interference. Spearman correlations were used to test agreement across survey instruments. Floor and ceiling effects were assessed for all instruments. RESULTS: PROMIS Pain Interference had excellent correlation with MLQOL Activity Limitations (r = 0.71, P < .0001). Excellent-good correlations were detected between PROMIS Physical Function and MLQOL Activity Limitations (r = -0.63, P = .0002) and PROMIS Mobility and MLQOL Activity Limitations (r = -0.62, P < .0002). Good correlations were found between the Lysholm and the PROMIS Physical Function and PROMIS Mobility (for each, r = 0.50, P = .005). Additional correlations were present with other subsections. There were no floor or ceiling effects for the PROMIS CAT instrument in any category. CONCLUSION: The PROMIS CAT correlates well with existing outcome measures for multiligament knee injury patients without floor or ceiling effects. The PROMIS CAT is a concise adjunct to the validated injury-specific outcome tool for multiligament knee injury. Surgeons should consider implementing the PROMIS CAT because of its broad validity, including ACL injuries, meniscal tears, and now multiligament knee injuries.

Trends in computer navigation and robotic assistance for total knee arthroplasty in the United States: an analysis of patient and hospital factors.

BACKGROUND: Computer navigation and robotic assistance technologies are used to improve the accuracy of component positioning in total knee arthroplasty (TKA), with the goal of improving function and optimizing implant longevity. The purpose of this study was to analyze trends in the use of technology-assisted TKA, identify factors associated with the use of these technologies, and describe potential drivers of cost. METHODS: The Nationwide Inpatient Sample database was used to identify patients who underwent TKA using conventional instrumentation, computer navigation, and robot-assisted techniques between 2005 and 2014. Variables analyzed include patient demographics, hospital and payer types, and hospital charges. Descriptive statistics were used to describe trends. Univariate and multivariate analyses were performed to identify differences between conventional and technology-assisted groups. RESULTS: Our analysis identified 6,060,901 patients who underwent TKA from 2005 to 2014, of which 273,922 (4.5%) used computer navigation and 24,084 (0.4%) used robotic assistance. The proportion of technology-assisted TKAs steadily increased over the study period, from 1.2% in 2005 to 7.0% in 2014. Computer navigation increased in use from 1.2% in 2005 to 6.3% in 2014. Computer navigation was more likely to be used in the Western United States, whereas robot-assisted TKAs were more likely to be performed in the Northeast. Increased hospital charges were associated with the use of technology assistance ($53,740.1 vs $47,639.2). CONCLUSIONS: The use of computer navigation and robot-assisted TKA steadily increased over the study period, accounting for 7.0% of TKAs performed in the United States in 2014. Marked regional differences in the use of these technologies were identified. The use of these technologies was associated with increased hospital charges.