Surgical Approach Does Not Influence Instability Risk in Revision Total Hip Arthroplasty.

BACKGROUND: Although the direct anterior (DA) approach has increased in popularity for primary total hip arthroplasty (THA), there is limited evidence regarding its use for revision THA. It is unknown whether the dislocation benefit seen in the primary setting translates to revision cases. METHODS: This retrospective review compared the dislocation rates of revision THA performed through DA versus postero-lateral (PL) approaches at a single institution (2011 to 2021). Exclusion criteria included revision for instability, ≥ 2 prior revisions, approaches other than DA or PL, and placement of dual-mobility or constrained liners. There were 182 hips in 173 patients that met the inclusion criteria. The average follow-up was 6.5 years (range, 2 to 8 years). RESULTS: There was a trend toward more both-component revisions being performed through the PL approach. There were no differences in dislocation rates between the DA revision and PL revision cohorts, which were 8.1% (5 of 72) and 7.5% (9 of 120), respectively (P = .999). Dislocation trended lower when the revision approach was discordant from the primary approach compared to cases where primary and revision had a concordant approach (4.9 versus 8.5%), but this was not statistically significant (P = .740). No significant differences were found in return to operating room, 90-day emergency department visits, or 90-day readmissions. However, the length of stay was significantly shorter in patients who had DA revisions after a primary PL procedure (P = .021). CONCLUSIONS: Dislocation rates following revision THA did not differ between the DA and PL approaches irrespective of the primary approach. Surgeons should choose their revision approach based on their experience and the specific needs of the patient.

Variability of Sagittal Plane Proximal Tibial Morphology and Its Effect on Stem Placement in Total Knee Arthroplasty.

The tibial joint line is offset posteriorly relative to the tibial sagittal anatomic axis. This can have consequences when using stemmed implants during total knee arthroplasty. We retrospectively analyzed native knee lateral radiographs in 100 patients. The distance between the sagittal anatomic axis and the center of a simulated tibial resection was calculated as a percentage of overall tibial width. Analysis of 5 manufacturers' baseplates showed that the tibial stem attached on average 10% anterior to the midline. We measured the impingement point of a 12-mm-diameter stem starting from this position. The tibial joint surface was offset posteriorly from the anatomic axis in all patients by an average of 23.5% of the tibial width (range: 13.1%-33.2%). A 12-mm tibial stem would impinge within 40 mm in 2% (2/100) of patients and within 60 mm in 19% (19/100). There was a weak but statistically significant correlation between proximal tibial offset and distance to impingement. During total knee arthroplasty, the center of the cut tibia is offset posteriorly from the sagittal anatomic axis. In patients with high offset, tibial stem extensions can impinge against the posterior tibia, causing baseplate malpositioning, diminished cement mantle, or fracture.

Lower Extremity Girth Does Not Predict Complications in TKA.

BACKGROUND: Obese patients have increased complications after total knee arthroplasty (TKA). A body mass index (BMI) cutoff of 40 is frequently used to determine eligibility for TKA. Patients with a BMI <40 and extremely large legs which may predispose them to complications are approved for surgery because they fall below this cutoff. Alternatively, patients with truncal obesity and a BMI >40 are accepted because they have thin legs. We sought to determine whether BMI or girth should be used to determine eligibility. METHODS: 453 patients who underwent TKA were included. A lower extremity girth (LEG) ratio was calculated dividing the width of the soft tissue envelope by bone width on lateral radiographs. Receiver operator curves were generated to predict 90-day complications. RESULTS: There was no difference in median LEG ratio between patients with or without a complication (P = .08). Receiver operator curves indicated that size of the soft tissue envelope had no utility in predicting complications. There was no correlation between LEG ratio and specific complications such as infection, malalignment, or wound complications. Using a LEG ratio threshold of 4.834, the sensitivity and specificity for predicting complications were 48% and 64%, respectively. The median BMI for patients with no complication was 32.3 and 35 for patients with a complication (P = .07). CONCLUSION: Complications are not necessarily associated with size of the soft tissue envelope in TKA.Decisions concerning TKA should not be made solely on the size of a patient's leg. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Matching in Orthopaedic Surgery.

In 2016, 1,137 fourth year medical students submitted applications for orthopedic surgery residency positions. Students applied to an average of 79 programs, resulting in in a total of 89,846 applications being submitted for 727 first year residency positions. This ratio of 124 applications per position is two SDs above the mean relative to other medical specialties. The average applicant for orthopaedic surgery residency attends 2.4 away rotations, as attending 2 away rotations increases an applicant's odds of matching, and submits 83 applications. This excessive number of applications overburdens programs, subjects applicants to considerable costs, and diminishes the quality of fit between interviewees and programs. Eighty-three percent of program directors use step 1 United States Medical Licensing Examination scores as a screening tool to decrease the number of applications necessary for review. The average matched applicant attended 11.5 interviews, and Step 1 scores, research productivity, and Alpha Omega Alpha (AOA) status can be used to predict the number of applications necessary to obtain 12 interviews. AOA membership has the strongest influence on interview yield. Applicants report spending an average of approximately $7,000 on the interview process, and 72% borrow money to cover these costs. Post-interview contact, although forbidden by the National Resident Matching Program , has been reported by 60% to 64% of applicants.

Opioid Prescribing Practices of Orthopaedic Surgeons: Results of a National Survey.

INTRODUCTION: Opioids are widely used after orthopaedic procedures. Nonmedical opioid use is a growing public health issue. METHODS: An anonymous online survey was distributed by e-mail to the orthopaedic societies of all 50 states and several large private practices to assess practicing orthopaedic surgeons' opioid prescribing practices. RESULTS: A total of 555 orthopaedic surgeons practicing in 37 states responded. The most commonly prescribed opioid for both teenagers and adults was hydrocodone/acetaminophen. Of note, 42.3% reported that a patient they have prescribed opioids for developed an opioid dependency, whereas 35.3% do not believe that opioid use is a problem in their practice. Of note, 30.3% reported prescribing refills, and factors significantly associated with increased prescribing of refills included a greater number of years in practice (P < 0.001) and practicing in a suburban rather than an urban or rural environment (P = 0.03). CONCLUSION: Orthopaedic surgeons rarely prescribe any refills, tend to prescribe less opioids to teenagers than adults, and prescribe fairly uniformly for patients who are treated nonsurgically or undergo minor or arthroscopic surgery. They exhibit considerable variation in prescribing for fractures and major procedures.

National Football League Skilled and Unskilled Positions Vary in Opportunity and Yield in Return to Play After an Anterior Cruciate Ligament Injury.

BACKGROUND: Anterior cruciate ligament (ACL) injuries pose a significant risk to the careers of players in the National Football League (NFL). The relationships between draft round and position on return to play (RTP) among NFL players are not well understood, and the ability to return to preinjury performance levels remains unknown for most positions. PURPOSE: To test for differences in RTP rates and changes in performance after an ACL injury by position and draft round. We hypothesized that skilled positions would return at a lower rate compared to unskilled positions. We further hypothesized that early draft-round status would relate to a greater rate of RTP and that skilled positions and a lower draft round would correlate with decreased performance for players who return to sport. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Utilizing a previously established database of publicly available information regarding ACL tears among NFL players, athletes with ACL tears occurring between the 2010 and 2013 seasons were identified. Generalized linear models and Kaplan-Meier time-to-event models were used to test the study hypotheses. RESULTS: The overall RTP rate was 61.7%, with skilled players and unskilled players returning at rates of 64.1% and 60.4%, respectively (P = .74). Early draft-round players and unskilled late draft-round players had greater rates of RTP compared to skilled late draft-round players and both unskilled and skilled undrafted free agents (UDFAs). Skilled early draft-round players constituted the only cohort that played significantly fewer games after an injury. Unskilled UDFAs constituted the only cohort to show a significant increase in the number of games started and ratio of games started to games played, starting more games in which they played, after an injury. CONCLUSION: Early draft-round and unskilled players were more likely to return compared to their later draft-round and skilled peers. Skilled early draft-round players, who displayed relatively high rates of RTP, constituted the only cohort to show a decline in performance. Unskilled UDFAs, who exhibited relatively low rates of RTP, constituted the only cohort to show an increase in performance. The significant effect of draft round and position type on RTP may be caused by a combination of differences in talent levels and in opportunities given to returning to play.

A Comparison of Operative and Nonoperative Treatment of Anterior Cruciate Ligament Injuries.

Intention to resume high-risk sports activity is a major motivating factor for patients who elect anterior cruciate ligament (ACL) reconstruction rather than nonoperative treatment. Some patients are able to cope with an ACL-deficient knee and resume preinjury activity levels, including level-1 sports (football, basketball, soccer, etc.), following nonoperative treatment; however, activity levels correlate with injury risk in ACL-deficient knees. Patients who have an ACL injury along with concomitant meniscal injury are at increased risk for osteoarthritis. It is unclear what effect reconstruction of an isolated ACL injury has on future osteoarthritis risk in ACL-deficient patients who are identified as "copers." There are distinct biomechanical differences between copers and noncopers, but no reliable screening tools are currently able to predict which patients will become copers following nonoperative treatment of an ACL injury. A trial of nonoperative treatment, including perturbation exercises, to determine whether reconstruction is needed does not increase the risk of additional knee injury.

The Financial and Professional Impact of Anterior Cruciate Ligament Injuries in National Football League Athletes.

BACKGROUND: Anterior cruciate ligament (ACL) injuries can have negative consequences on the careers of National Football League (NFL) players, however no study has ever analyzed the financial impact of these injuries in this population. PURPOSE: To quantify the impact of ACL injuries on salary and career length in NFL athletes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Any player in the NFL suffering an ACL injury from 2010 to 2013 was identified using a comprehensive online search. A database of NFL player salaries was used to conduct a matched cohort analysis comparing ACL-injured players with the rest of the NFL. The main outcomes were the percentage of players remaining in the NFL and mean salary at 1, 2, 3, and 4 years after injury. Cohorts were subdivided based on initial salary: group A, <$500,000; group B, ≤$500,000 to $2,000,000; and group C, >$2,000,000. Mean cumulative earnings were calculated by multiplying the percentage of players remaining in the league by their mean salaries and compounding this each season. RESULTS: NFL athletes suffered 219 ACL injuries from 2010 to 2013. The 7504 other player seasons in the NFL during this time were used as controls. Significantly fewer ACL-injured players than controls remained in the NFL at each time point (P < .05). In group A, significantly less ACL-injured players remained in the NFL at 1 to 3 seasons after injury (P < .05), and in group B, significantly less ACL-injured players remained in the NFL at 1 and 2 seasons after injury (P < .05). There was no significant decrease in group C. Players in groups A and B remaining in the NFL also had a lower mean salary than controls (P < .05 in season 1). The mean cumulative earnings over 4 years for ACL-injured players was $2,070,521 less per player than uninjured controls. CONCLUSION: On average, ACL-injured players earned $2,070,521 less than salary-matched controls over the 4 years after injury. Players initially earning less than $2 million per year have lower mean salaries and are less likely to remain in the league than uninjured controls. The careers of players initially earning over $2 million per year, meanwhile, are not negatively affected. This demonstrates the degree of negative impact these injuries have on the careers of NFL players. It also indicates that a player's standing within the league before injury strongly influences how much an ACL injury will affect his career.

Displaced Proximal Humerus Fractures in Older Patients: Shoulder Surgeons Versus Traumatologists.

Proximal humerus fractures are relatively common, with treatment dependent on fracture-specific, patient-specific, and surgeon-specific factors. This study sought to identify preferences among shoulder specialists and orthopedic traumatologists in the treatment of proximal humerus fractures. An anonymous Internet survey of fellowship-trained shoulder surgeons and traumatologists was conducted with radiographs and select computed tomography images of 15 unique displaced proximal humerus fractures. Participants were asked to classify each case according to Neer criteria and choose management from a list of options. Groups were analyzed using chi-square test for independence, paired t test, and Fleiss' kappa within and between each group. Among shoulder surgeons, there were a total of 19 cases selected for nonoperative management, 204 cases selected for open reduction and internal fixation (ORIF), and 122 cases selected for arthroplasty. Among traumatologists, there were 44 cases selected for nonoperative management, 234 for ORIF, and 67 for arthroplasty. Fleiss' kappa for intraobserver agreement on treatment choice was 0.26 for shoulder surgeons and 0.18 for traumatologists, and chi-square test for independence was significant between the 2 groups (P<.001). Paired t test of the average treatment proportions was significant for nonoperative management and arthroplasty (P=.003) but not significant for differences in rates of ORIF. These results confirm poor consistency in Neer classification among surgeons and suggest that shoulder surgeons were more likely to consider arthroplasty for treatment and that traumatologists were more likely to use ORIF or to manage patients nonoperatively. These variations in care may translate to differences in outcome and cost. [Orthopedics. 2016; 39(3):e509-e513.].

Anterior Cruciate Ligament Injuries in National Football League Athletes From 2010 to 2013: A Descriptive Epidemiology Study.

BACKGROUND: There is a high incidence of anterior cruciate ligament (ACL) injuries among National Football League (NFL) athletes; however, the incidence of reinjury in this population is unknown. PURPOSE: This retrospective epidemiological study analyzed all publicly disclosed ACL tears occurring in NFL players between 2010 and 2013 to characterize injury trends and determine the incidence of reinjury. STUDY DESIGN: Descriptive epidemiological study. METHODS: A comprehensive online search identified any NFL player who had suffered an ACL injury from 2010 to 2013. Position, playing surface, activity, and date were recorded. Each player was researched for any history of previous ACL injury. The NFL games database from USA Today was used to determine the incidence of ACL injuries on artificial turf and grass fields. Databases from Pro Football Focus and Pro Football Reference were used to determine the injury rate for each position. RESULTS: NFL players suffered 219 ACL injuries between 2010 and 2013. Forty players (18.3%) had a history of previous ACL injury, with 27 (12.3%) retears and 16 (7.3%) tears contralateral to a previous ACL injury. Five players (2.28%) suffered their third ACL tear. Receivers (wide receivers and tight ends) and backs (linebackers, fullbacks, and halfbacks) had significantly greater injury risk than the rest of the NFL players, while perimeter linemen (defensive ends and offensive tackles) had significantly lower injury risk than the rest of the players. Interior linemen (offensive guards, centers, and defensive tackles) had significantly greater injury risk compared with perimeter linemen. ACL injury rates per team games played were 0.050 for grass and 0.053 for turf fields (P > .05). CONCLUSION: In this retrospective epidemiological study of ACL tears in NFL players, retears and ACL tears contralateral to a previously torn ACL constituted a substantial portion (18.3%) of total ACL injuries. The significant majority of ACL injuries in players with a history of previous ACL injury were retears. Skilled offensive players and linebackers had the greatest injury risk, and significantly more ACL tears occurred among interior linemen than perimeter linemen. The month of August had the highest incidence of ACL injuries, probably because of expanded roster sizes at that point in the NFL season.

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.