Risk Factors Associated With Poor Outcomes After Quadriceps Tendon Repair.

Background: Ruptures of the quadriceps tendon present most frequently in older adults and individuals with underlying medical conditions. Purpose: To examine the relationship between patient-specific factors and tear characteristics with outcomes after quadriceps tendon repair. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review was conducted on all patients who underwent quadriceps tendon repair between January 1, 2016, and January 1, 2021, at a single institution. Patients <18 years and those with chronic quadriceps tendon tears (>6 weeks to surgery) were excluded. Information was collected regarding patient characteristics, presenting symptoms, tear characteristics, physical examination findings, and postoperative outcomes. Poor outcome was defined as a need for revision surgery, complications, postoperative range of motion of (ROM) <110° of knee flexion, and extensor lag of >5°. Results: A total of 191 patients met the inclusion criteria. Patients were aged 58.5 ± 13.2 years at the time of surgery, were predominantly men (90.6%), and had a mean body mass index (BMI) of 32.2 ± 6.3 kg/m2. Patients underwent repair with either suture anchors (15.2%) or transosseous tunnels (84.8%). Postoperatively, 18.5% of patients experienced knee flexion ROM of <110°, 11.3% experienced extensor lag of >5°, 8.5% had complications, and 3.2% underwent revision. Increasing age (odds ratio [OR], 1.03 [95% CI, 1.004-1.07]) and female sex (OR, 3.82 [95% CI, 1.25-11.28]) were significantly associated with postoperative knee flexion of <110°, and increasing age (OR, 1.08 [95% CI, 1.04-1.14]) and greater BMI (OR, 1.14 [95% CI, 1.05-1.23]) were significantly associated with postoperative extensor lag of >5°. Current smoking status (OR, 15.44 [95% CI, 3.97-65.90]) and concomitant retinacular tears (OR, 9.62 (95% CI, 1.67-184.14]) were associated with postoperative complications, and increasing age (OR, 1.05 [95% CI, 1.02-1.08]) and greater BMI (OR, 1.08 [95% CI, 1.02-1.14]) were associated with risk of acquiring any poor outcome criteria. Conclusion: Patient-specific characteristics-such as increasing age, greater BMI, female sex, retinacular involvement, and current smoking status-were found to be risk factors for poor outcomes after quadriceps tendon repair. Further studies are needed to identify potentially modifiable risk factors that can be used to set patient expectations and improve outcomes.

Prior Meniscectomy in Patients Undergoing Primary Total Knee Arthroplasty is Associated With Worse Short-Term Outcomes.

BACKGROUND: Patients undergoing total knee arthroplasty (TKA) who have prior meniscectomy may have increased rates of postoperative infection, arthrofibrosis, and revision. However, aside from an increased risk of complications, it is unclear whether prior meniscectomy impacts functional outcomes after TKA. This study was conducted to compare functional outcomes following TKA in patients who did and did not have a prior meniscectomy. We hypothesized that patients who had a prior ipsilateral meniscectomy would have worse functional outcomes after undergoing TKA. METHODS: A retrospective matched case-control study was conducted at a tertiary academic center. Patients who underwent both meniscectomy and TKA (cases) or TKA alone (controls) from 2013 to 2020 were identified from our institutional database using current procedural terminology codes. Cases were matched in a 1:3 ratio to controls using age, sex, race, body mass index, and a comorbidity index. Inclusion criteria comprised a minimum of 1-year follow-up for the Knee Injury and Osteoarthritis Outcome Score Junior (KOOS-JR). Exclusion criteria included patients undergoing revision TKA and patients who had a history of ligamentous knee surgery or fracture. T- and Chi-squared analyses were conducted, with significance threshold being P < .05. A total of 589 cases and 1,767 controls were included after matching. There were no significant differences in demographic variables. Cases underwent TKA after their meniscectomy at a mean of 2.9 years (range: 42 days to 16 years). RESULTS: While no significant difference existed for preoperative KOOS-JR scores (46.4 versus 46.4; P = .984), postoperative KOOS-JR scores were significantly lower in the case group (71.9 versus 75.3; P = .001). The case group also achieved the KOOS-JR minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) at significantly lower rates than the control group [(MCID: 71.0 versus 77.3%; P = .011) (PASS: 69.4 versus 76.7%; P = .001);]. CONCLUSION: Patients who had a prior meniscectomy may experience lower postoperative functional outcome scores after TKA and had a lower rate of achieving the MCID and PASS for KOOS-JR. Patient expectations should be adjusted accordingly.

Perspectives of Orthopedic Patients on Medical Cannabis: A Survey of More Than 2500 Patients.

Nationwide perspectives on cannabis have changed dramatically over recent decades. Although cannabis remains illegal at the federal level, medical cannabis (MC) is now legal in most states, and research has continued to show its effectiveness in a variety of medical conditions. However, both perception and acceptance of MC by the general public are evolving and remain poorly understood. Treating patients effectively with these novel therapeutics requires an understanding of the complex interplay of social and legal factors that could affect patient use. This cross-sectional survey study of more than 2500 patients sought to assess current patient perspectives on MC and to investigate factors related to its use that may represent barriers to broader patient use. Most respondents would consider using MC for chronic pain or other medical conditions. Most respondents were aware of the legal status of MC in their state, and 9 of 10 respondents believed that MC should be legal throughout the United States. General public knowledge of the utility of MC is an area needing improvement because older patients were significantly less likely to believe that MC is safe to use or that MC is safer than prescription opioids. As has been reported in previous literature, social stigma and cost appear to remain barriers for patient use of MC. Our findings provide further insight into current patient perspectives on MC, aiding both medical providers and researchers as we continue to provide access to and research MC. [Orthopedics. 2022;45(6):e309-e314.].

How Patients Dispose of Unused Prescription Opioids: A Survey of over 300 Postoperative Patients.

Introduction Diversion of unused prescription opioids is a common source of opioid sensitization in the community. Educating patients about safe opioid use has been shown to be effective in decreasing opioid use. However, decreasing diversion will also require educating patients on proper opioid disposal. A survey was administered to better understand patients' habits with opioid disposal for opioids prescribed after orthopedic surgery. Methods A cross-sectional survey study of 469 patients who had undergone orthopedic surgery was conducted to learn their preferences and habits regarding the disposal of unused prescription opioids received after orthopedic surgery. Results The survey respondents consisted of 48.8% female and 51.2% male patients. Ninety-four point two percent (94.2%) of those receiving opioid prescriptions reported having leftover unused opioids. In terms of voluntary disposal, 68.8% claimed to dispose of their prescription opioids while 31.2% did not. Gender, but not age, had a significant effect on plans for opioid disposal and how seriously respondents viewed issues of opioid misuse. When asked their preferred location for prescription opioid disposal, the most common preference was a local pharmacy. Discussion This survey identified that most patients do not store their prescription opioids in a locked location, claim to dispose of their unused prescription opioids, and would prefer to dispose of them at a pharmacy if possible. This information points to the need for close prescriber-to-pharmacy collaboration to promote the safe disposal of prescription opioids and mitigate drug diversion.

Cumulative Intraarticular Injections Are Not a Risk Factor for Periprosthetic Joint Infection Following total Knee Arthroplasty.

BACKGROUND: While injections within 90 days prior to total knee arthroplasty (TKA) are associated with an increased risk of periprosthetic joint infection (PJI), there is a paucity of literature regarding the impact of cumulative injections on PJI risk. This study was conducted to assess the association between cumulative corticosteroid and hyaluronic acid (HA) injections and PJI risk following TKA. METHODS: This retrospective study using an injection database included patients undergoing TKA with a minimum 1-year follow-up from 2015 to 2020. Patients with injections within 90 days prior to surgery were excluded. The sum of corticosteroid and HA injections within five years prior to TKA was recorded. The primary outcome was PJI within 90 days following TKA. Area under the curve (AUC) values were calculated for a cumulative number of injections. RESULTS: 648 knees with no injections and 672 knees with injections prior to TKA were included, among whom 243 received corticosteroids, 151 received HA, and 278 received both. No significant differences in early PJI rates existed between patients who received injections (0.60%) or not (0.93%) (P = .541). No significant differences existed in early PJI rates between patients injected with corticosteroids (0.82%), HA (0.66%), or both (0.36%) (P = .832). No cutoff number of injections was predictive for PJI. DISCUSSION: A cumulative amount of steroid or HA injections, if given more than 90 days prior to TKA, does not appear to increase the risk of PJI within 90 days postoperatively. Multiple intraarticular corticosteroid injections and HA injections may be safely administered before TKA, without increased risk for early PJI.

Knee Arthroplasty with Prior Ligamentous Knee Surgery: A Matched Case-Control Study.

We aimed to evaluate the timing, operative details, and outcomes of total knee arthroplasty (TKA) in patients with prior ligamentous knee surgery (LKS). All consecutive patients undergoing TKA with prior LKS at a single institution were identified from a large prospectively collected database. Patients were matched on a 2:1 basis according to age, sex, and body mass index to a group of patients without previous LKS undergoing primary TKA. A total of 39 patients with prior LKS and a mean age of 55.6 years (range: 42.8-76.4) were identified and matched with 78 patients without LKS with a mean age of 57.6 years (range: 44.0-79.4) undergoing primary TKA (p = 0.24). Significantly more posterior stabilized implants were used in patients with LKS compared with control patients (29 [74.3%] vs. 27 [34.6%], p < 0.001). In the LKS group, 15 patients (38.4%) required hardware removal. Postoperative complications and rate of further surgery were greater in the LCS group, but the difference was not significant (10.6 vs. 6.4%, p = 0.25). Mean difference in pre- to postoperative knee flexion and clinical outcome scores (12-item Short Form Survey, International Knee Documentation Committee, and Oxford Knee Score) were similar between the two groups, with no cases of loosening or osteolysis. TKA with prior LKS often warranted hardware removal and generally more constrained implants. Those patients with prior LKS undergoing subsequent TKA have higher complication rates and an increased rate of subsequent surgery related to post-TKA stiffness.

Complications in the Management of Distal Radius Fractures: How Do We Avoid them?

PURPOSE OF THIS REVIEW: Distal radius fractures are one of the most common fractures in the upper extremity. The purpose of this review is to outline common complications that may arise when caring for distal radius fractures and to describe the treatment strategies when faced with such complications. RECENT FINDINGS: Tendon complications are not uncommon after distal radius fractures. Recent literature highlights new plating technology for dorsal plating techniques. Moreover, new literature has outlined parameters for flexor tendon complications when using volar locking plates in an effort to avoid flexor tendon irritation and rupture. In summary, it is important to understand the various complications that can arise when treating distal radius fractures in an effort to avoid suboptimal outcomes.

Pain Management After Outpatient Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Effective pain management after anterior cruciate ligament (ACL) reconstruction improves patient satisfaction and function. PURPOSE: To collect and evaluate the available evidence from randomized controlled trials (RCTs) on pain control after ACL reconstruction. STUDY DESIGN: Systematic review. METHODS: A systematic literature review was performed using PubMed, Medline, Google Scholar, UpToDate, Cochrane Reviews, CINAHL, and Scopus following PRISMA guidelines (July 2014). Only RCTs comparing a method of postoperative pain control to another method or placebo were included. RESULTS: A total of 77 RCTs met inclusion criteria: 14 on regional nerve blocks, 21 on intra-articular injections, 4 on intramuscular/intravenous injections, 12 on multimodal regimens, 6 on oral medications, 10 on cryotherapy/compression, 6 on mobilization, and 5 on intraoperative techniques. Single-injection femoral nerve blocks provided superior analgesia to placebo for up to 24 hours postoperatively; however, this also resulted in a quadriceps motor deficit. Indwelling femoral catheters utilized for 2 days postoperatively provided superior analgesia to a single-injection femoral nerve block. Local anesthetic injections at the surgical wound site or intra-articularly provided equivalent analgesia to regional nerve blocks. Continuous-infusion catheters of a local anesthetic provided adequate pain relief but have been shown to cause chondrolysis. Cryotherapy improved analgesia compared to no cryotherapy in 4 trials, while in 4 trials, ice water and water at room temperature provided equivalent analgesic effects. Early weightbearing decreased pain compared to delayed weightbearing. Oral gabapentin given preoperatively and oral zolpidem given for the first week postoperatively each decreased opioid consumption as compared to placebo. Ibuprofen reduced pain compared to acetaminophen. Oral ketorolac reduced pain compared to hydrocodone-acetaminophen. CONCLUSION: Regional nerve blocks and intra-articular injections are both effective forms of analgesia. Cryotherapy-compression appears to be beneficial, provided that intra-articular temperatures are sufficiently decreased. Early mobilization reduces pain symptoms. Gabapentin, zolpidem, ketorolac, and ibuprofen decrease opioid consumption. Despite the vast amount of high-quality evidence on this topic, further research is needed to determine the optimal multimodal approach that can maximize recovery while minimizing pain and opioid consumption. CLINICAL RELEVANCE: These results provide the best available evidence from RCTs on pain control regimens after ACL reconstruction.