Analysis of Changing Practice Trends in Anterior Cruciate Ligament Reconstruction: A Multicenter, Single-Institution Database Analysis.

PURPOSE: To identify trends in anterior cruciate ligament reconstruction (ACLR), including graft choice, femoral tunnel drilling techniques, and augmentation techniques, and to assess how various surgeon factors impact these trends. METHODS: A retrospective review of primary ACLRs performed between 2014 and 2022 was completed using a multicenter institutional database. Patient demographic characteristics, graft type, femoral drilling technique, use of extra-articular tenodesis, and use of suture augmentation were recorded from the medical record. Surgeon fellowship training (sports trained vs non-sports trained), experience (high [minimum of 15 years in practice] vs low), and volume (high [minimum of 15 ACLRs/year] vs low) were used to stratify technique utilization. The z test for proportions was used to compare categorical variables. Pearson correlation analyses identified trends and assessed statistical significance, defined as P < .05. RESULTS: Our cohort consisted of 2,032 ACLRs performed in 2,006 patients. The average patient age was 28.3 ± 11.6 years, with more procedures performed in male patients (67.3%). The average length of surgeon experience was 19.7 ± 11.4 years, with an average annual procedural volume of 4.0 ± 5.4 ACLRs. Most surgeons were sports trained (n = 55, 64.7%), high experience (n = 44, 57.1%), and low volume (n = 80, 94.1%). There was an increasing annual proportion of ACLRs performed by sports-trained surgeons (R = 0.748, P = .020) and low-experience surgeons (R = 0.940, P < .001). Autograft reconstructions were most often performed by sports-trained (71.2%), low-experience (66.1%), and high-volume (76.9%) surgeons. There was an increasing proportion of autograft ACLRs that used quadriceps tendon among sports-trained (R = 0.739, P = .023), high-experience (R = 0.768, P = .016), and low-volume (R = 0.785, P = .012) surgeons. Independent drilling techniques were used in an increasing proportion of ACLRs performed by non-sports-trained (R = 0.860, P = .003) and high-volume (R = 0.864, P = .003) surgeons. Augmentation of ACLR with concomitant suture augmentation (n = 24, 1.2%) or extra-articular tenodesis (n = 6, 0.3%) was rarely performed. CONCLUSIONS: In our multicenter institution, the quadriceps tendon autograft has been increasingly used in ACLR by sports-trained, low-volume, and high-experience surgeons. Independent drilling techniques have been increasingly used by non-sports-trained and high-volume surgeons. CLINICAL RELEVANCE: Surgeons must stay current with the literature that affects their procedures to ensure that evidence-based medicine is being practiced.

Capsular Repair, Labral Repair, and Femoroplasty are Increasingly Performed for the Arthroscopic Treatment of Femoroacetabular Impingement Syndrome.

PURPOSE: To provide an updated assessment of hip arthroscopy use by using an institutional database that is specific to the treatment of femoroacetabular impingement syndrome (FAIS). METHODS: All patients undergoing hip arthroscopy for the treatment of FAIS were retrospectively identified between the years 2014 and 2022 via Current Procedural Terminology coding in a multi-institutional, single health system database. A longitudinal analysis was performed to identify trends in the use of arthroscopic techniques including capsular and labral treatment, osteoplasty, and traction set-up. RESULTS: During the study, 789 arthroscopic hip procedures in 733 patients were analyzed (56 staged bilateral). Between 2016 and 2022, the number of hip arthroscopies performed each year increased by 1,490% (R2 = 0.87, P = .001). Capsular repair (R2 = 0.92, P < .001), labral repair (R2 = 0.75, P = .002), and femoroplasty (R2 = 0.70, P = .004) were performed in an increasing proportion of cases over our study period whereas labral debridement (R2 = -0.84, P < .001) became less used. Postless traction systems were employed in 84% (663/789) of hip arthroscopies overall, were used in at least 70% of hip arthroscopies each year, and did not undergo any significant changes in use (R2 = 0.02, P = .73). CONCLUSIONS: Capsular repair, labral repair, and femoroplasty were increasingly performed for the arthroscopic treatment of FAIS whereas the use of labral debridement decreased significantly over our study period. Postless traction systems were used in the majority of cases each year. CLINICAL RELEVANCE: As comparative literature continues to define the safety and efficacy of hip arthroscopy, understanding how novel techniques or procedures are incorporated in clinical practice is important.

Seventy Percent of Abstracts Presented at the AANA Annual Meeting Are Later Published.

Purpose: To assess the future publication rates of abstracts presented at AANA annual meetings between 2015 and 2019. Methods: Abstracts presented at the 2015-2019 AANA annual meetings were identified. The PubMed and Google Scholar databases were searched for a corresponding manuscript for each abstract using the name of the first author, abstract title, and keywords. A level of evidence and anatomic category were assigned to each abstract. For each corresponding manuscript identified, the authors, journal of publication, journal impact factor (IF), time to publication, and number of citations were recorded. Results: Overall, 70.5% of abstracts presented at the 2015-2019 AANA annual meetings (275 of 390) went on to future publication, with 63.6% (248 of 390) achieving publication within 3 years. The median time to publication from presentation was 12.8 months. Arthroscopy (29.8%) was the most frequent journal of publication. The average IF of publishing journals was 4.92 ± 3.41, with 61.8% of manuscripts (170 of 275) published in journals with an IF of at least 4.00. Published manuscripts received an average of 36.30 ± 47.6 citations per manuscript. A stronger level of evidence was associated with an increased likelihood of future publication (P = .008). Conclusions: Pre-publication literature presented at the AANA annual meetings has continued to be associated with a strong likelihood of future publication in Arthroscopy and Arthroscopy, Sports Medicine, and Rehabilitation, as well as other respected peer-reviewed journals. Clinical Relevance: Exposure to pre-publication literature may have an impact on clinical management. It is important to understand the quality of research presented in abstracts from AANA annual meetings. Knowing how many abstracts are ultimately published in peer-reviewed journals provides an indicator of the quality and reliability of the research.

Predictors of Readmission and Reoperation Following Shoulder Arthroplasty in Patients Under 45 Years of Age.

BACKGROUND: The use of shoulder arthroplasty has increased among all age groups, albeit most prominently in older patients. While previous studies have investigated predictors of short-term readmission and reoperation in the general population, there is a paucity of literature available on these in patients under 45 years of age. This study aimed to identify the predictors of 30-day readmission and reoperation following shoulder arthroplasty in patients under 45 years of age. METHODS: A retrospective query in the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2019 was used to identify patients who underwent primary reverse and anatomic total shoulder arthroplasty and hemiarthroplasty. Multivariate logistic regression was used to identify predictors of 30-day readmission and reoperation. RESULTS: A total of 530 patients were included. Multivariate regression revealed that Black race and Hispanic ethnicity were independent predictors of readmission. Functional dependence, hypertension requiring medication, and prolonged length of stay predicted reoperation. Finally, low hematocrit and prolonged length of stay predicted morbidity. DISCUSSION: Identifying and accounting for these risk factors for poor outcomes may help improve perioperative risk stratification. As a result, these findings have the potential to reduce healthcare costs associated with readmission and reoperation following shoulder arthroplasty in young patients. Our results also highlight the underlying disparities in healthcare outcomes among racial and ethnic groups that must be considered.

Regulatory and Ethical Aspects of Orthobiologic Therapies.

Orthobiologic therapies show significant promise to improve outcomes for patients with musculoskeletal pathology. There are considerable research efforts to develop strategies that seek to modulate the biological environment to promote tissue regeneration and healing and/or provide symptomatic relief. However, the regulatory pathways overseeing the clinical translation of these therapies are complex, with considerable worldwide variation. The introduction of novel biologic treatments into clinical practice raises several ethical dilemmas. In this review, we describe the process for seeking approval for biologic therapies in the United States, Europe, and Japan. We highlight a number of ethical issues raised by the clinical translation of these treatments, including the design of clinical trials, monitoring outcomes, biobanking, "off-label" use, engagement with the public, marketing of unproven therapies, and scientific integrity.

Exosomes Derived from Non-Classic Sources for Treatment of Post-Traumatic Osteoarthritis and Cartilage Injury of the Knee: In Vivo Review.

Osteoarthritis of the knee is one of the most common chronic, debilitating musculoskeletal conditions. Current conservative treatment modalities such as weight loss, non-steroidal anti-inflammatory drugs, and intra-articular steroid injections often only provide temporary pain relief and are unsatisfactory for long-term management. Though end stage osteoarthritis of the knee can be managed with total knee arthroplasty (TKA), finding alternative non-surgical options to delay or prevent the need for TKA are needed due to the increased healthcare costs and expenditures associated with TKA. Exosomes have been of particular interest given recent findings highlighting that stem cells may at least partially mediate some of their effects through the release of extracellular vesicles, such as exosomes. As such, better understanding the biological mechanisms and potential therapeutic effects of these exosomes is necessary. Here, we review in vivo studies that highlight the potential clinical use of exosomes derived from non-classical sources (not bone marrow or adipose derived MSCs derived MSCs) for osteoarthritis of the knee.

Effect of Combined Leukocyte-Poor Platelet-Rich Plasma and Hyaluronic Acid on Bone Marrow-Derived Mesenchymal Stem Cell and Chondrocyte Metabolism.

OBJECTIVE: Given the potential applications of combined biologics, the authors sought to evaluate the in vitro effect of combined platelet-rich plasma (PRP) and hyaluronic acid (HA) on cellular metabolism. DESIGN: Bone marrow-derived mesenchymal stem cells (BMSCs) and chondrocytes were obtained from the femurs of Sprague-Dawley rats. An inflammatory model was created by adding 10 ng/mL interleukin-1-beta to culture media. Non-crosslinked high-molecular-weight HA, activated-PRP (aPRP), and unactivated-PRP (uPRP) were tested. Cellular proliferation and gene expression were measured at 1 week. Genes of interest included aggrecan, matrix metalloproteinase (MMP)-9, and MMP-13. RESULTS: Combined uPRP-HA was associated with a significant increase in chondrocyte and BMSC proliferation at numerous preparations. There was a trend of increased chondrocyte aggrecan expression with combined PRP-HA. The greatest and only significant decrease in BMSC MMP-9 expression was observed with combined PRP-HA. While a significant reduction of BMSC MMP-13 expression was seen with PRP and HA-alone, a greater reduction was observed with PRP-HA. MMP-9 chondrocyte expression was significantly reduced in cells treated with PRP-HA. PRP-alone and HA-alone at identical concentrations did not result in a significant reduction. The greatest reduction of MMP-13 chondrocyte expression was observed in chondrocytes plus combined PRP-HA. CONCLUSIONS: We demonstrated a statistically significant increase in BMSC and chondrocyte proliferation and decreased expression of catabolic enzymes with combined PRP-HA. These results demonstrate the additive in vitro effect of combined PRP-HA to stimulate cellular growth, restore components of the articular extracellular matrix, and reduce inflammation.

COVID-19 and Orthopaedics: Recovery After the Pandemic Surge.

The novel Coronavirus (COVID-19) pandemic has placed an immense strain on health care systems and orthopedic surgeons across the world. To limit the spread, federal and state governments mandated the cancellation of all nonurgent surgical cases to address surging hospital admissions and manage workforce and resource reallocation. During the pandemic surge, thousands of surgical cancellations have been required. We outline our experience through the onset and advance of the surge, detail our incident response and discuss the transition toward recovery. Level of Evidence: Level V.

The Effect of the COVID-19 Pandemic on Orthopedic Practices in New York.

The SARS-CoV-2 (COVID-19) crisis has strained hospitals and health systems across the world. In the United States, New York City has faced a surge of cases as the epicenter of the North American outbreak. Northwell Health, as the largest regional health system in New York City, has implemented various practices and policies to adapt to the evolving situation and prepare for future global events. [Orthopedics. 2020;43(4):245-249.].

Three-Dimensional Bioprinting in Orthopaedics.

Three-dimensional (3D)-printing technology has evolved dramatically in the last 30 years, from large machines with poor resolution to those with micron-level capabilities that sit on a desktop. This technology is being utilized in numerous medical applications, particularly in orthopaedic surgery. Over the past decade, technological advances have allowed for the application of this technology to the field of tissue engineering through the process of 3D bioprinting. Of interest to orthopaedic surgeons, active areas of research utilizing this technology involve the bioprinting of articular cartilage, bone, menisci, and intervertebral discs.

Changing trends in the management of proximal humerus fractures in New York State.

PURPOSE: Reverse shoulder arthroplasty (RSA) as an alternative to hemiarthroplasty (HA) as treatment for proximal humerus fractures has prompted a re-evaluation of utilization trends. METHODS: Operative treatment for proximal humeral fractures were analyzed using a New York State database. RESULTS: After introduction as an ICD-9 code, RSA increased to 39.3% (m = +5.2%/year, r = 0.984). When stratifying by age ≥65, HA decreased to 7.7% (m = -2.8%/year, r = 0.962) while RSA increased to 50.6% (m = +6.4%/year, r = 0.985). CONCLUSION: RSA overtook HA as the arthroplasty procedure of choice for proximal humerus fractures. In patients ≥65, RSA passed ORIF as the most prevalent procedure in 2017. LEVEL OF EVIDENCE: III, Descriptive Epidemiology Study, Large Database Analysis.

Degenerative Meniscus Lesions: An Expert Consensus Statement Using the Modified Delphi Technique.

PURPOSE: The purpose of this study was to perform an evidence-based, expert consensus survey using the Delphi panel methodology to develop recommendations for the treatment of degenerative meniscus tears. METHODS: Twenty panel members were asked to respond to 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds served to develop a Likert-style questionnaire for round 3. In round 4, the panel members outside consensus were contacted and asked to either change their score in view of the group's response or argue their case. The level of agreement for round 4 was defined as 80%. RESULTS: There was 100% agreement on the following items: insidious onset, physiological part of aging, tears often multiplanar, not all tears cause symptoms, outcomes depend on degree of osteoarthritis, obesity is a predictor of poor outcome, and younger patients (<50 years) have better outcomes. There was between 90% and 100% agreement on the following items: tears are nontraumatic, radiographs should be weightbearing, initial treatment should be conservative, platelet-rich plasma is not a good option, repairable and peripheral tears should be repaired, microfracture is not a good option for chondral defects, the majority of patients obtain significant improvement and decrease in pain with surgery but results are variable, short-term symptoms have better outcomes, and malalignment and root tears have poor outcomes. CONCLUSIONS: This consensus statement agreed that degenerative meniscus tears are a normal part of aging. Not all tears cause symptoms and, when symptomatic, they should initially be treated nonoperatively. Repairable tears should be repaired. The outcome of arthroscopic partial meniscectomy depends on the degree of osteoarthritis, the character of the meniscus lesion, the degree of loss of joint space, the amount of malalignment, and obesity. The majority of patients had significant improvement, but younger patients and patients with short-term symptoms have better outcomes. LEVEL OF EVIDENCE: Level V - expert opinion.

A Novel Strategy to Enhance Microfracture Treatment With Stromal Cell-Derived Factor-1 in a Rat Model.

BACKGROUND: Microfracture is one of the most widely used techniques for the repair of articular cartilage. However, microfracture often results in filling of the chondral defect with fibrocartilage, which exhibits poor durability and sub-optimal mechanical properties. Stromal cell-derived factor-1 (SDF-1) is a potent chemoattractant for mesenchymal stem cells (MSCs) and is expressed at high levels in bone marrow adjacent to developing cartilage during endochondral bone formation. Integrating SDF-1 into an implantable collagen scaffold may provide a chondro-conductive and chondro-inductive milieu via chemotaxis of MSCs and promotion of chondrogenic differentiation, facilitating more robust hyaline cartilage formation following microfracture. OBJECTIVE: This work aimed to confirm the chemoattractive properties of SDF-1 in vitro and develop a one-step method for incorporating SDF-1 in vivo to enhance cartilage repair using a rat osteochondral defect model. METHODS: Bone marrow-derived MSCs (BMSCs) were harvested from the femurs of Sprague-Dawley rats and cultured in low-glucose Dulbecco's modified Eagle's medium containing 10% fetal bovine serum, with the medium changed every 3 days. Passage 1 MSCs were analyzed by flow cytometry with an S3 Cell Sorter (Bio-Rad). In vitro cell migration assays were performed on MSCs by labeling cells with carboxyfluorescein diacetate, succinimidyl ester (CFDA-SE; Bio-Rad). For the microfracture model, a 1.6-mm-diameter osteochondral defect was created in the femoral trochleae of 20 Sprague-Dawley rats bilaterally until bone marrow spillage was seen under saline irrigation. One knee was chosen at random to receive implantation of the scaffold, and the contralateral knee was left unfilled as an empty control. Type I collagen scaffolds (Kensey Nash) were coated with either gelatin only or gelatin and SDF-1 using a dip coating process. The rats received implantation of either a gelatin-only scaffold (N = 10) or gelatin-and-SDF-1 scaffold (N = 10) at the site of the microfracture. Femurs were collected for histological analyses at 4- and 8-week time points post-operatively, and sections were stained with Safranin O/Fast Green. The samples were graded blindly by two observers using the Modified O'Driscoll score, a validated scoring system for chondral repair. A minimum of 10 separate grading scores were made per sample and averaged. Quantitative comparisons of cell migration in vitro were performed with one-way ANOVA. Cartilage repair in vivo was also compared among groups with one-way ANOVA, and the results were presented as mean ± standard deviation, with P-values < 0.05 considered as statistically significant. RESULTS: MSC migration showed a dose-response relationship with SDF-1, with an optimal dosage for chemotaxis between 10 and 100 ng/ml. After scaffold implantation, the SDF-1-treated group demonstrated complete filling of the cartilage defect with mature cartilage tissue, exhibiting strong proteoglycan content, smooth borders, and good incorporation into marginal cartilage. Modified O'Driscoll scores after 8 weeks showed a significant improvement of cartilage repair in the SDF-1 group relative to the empty control group (P < 0.01), with a trend toward improvement when compared with the gelatin-only-scaffold group (P < 0.1). No significant differences in scores were found between the empty defect group and gelatin-only group. CONCLUSION: In this study, we demonstrated a simple method for improving the quality of cartilage defect repair in a rat model of microfracture. We confirmed the chemotactic properties of SDF-1 on rat MSCs and found an optimized dosage range for chemotaxis between 10 and 100 ng/ml. Furthermore, we demonstrated a strategy to incorporate SDF-1 into gelatin-collagen I scaffolds in vivo at the site of an osteochondral defect. SDF-1-treated defects displayed robust hyaline cartilage resurfacing of the defect with minimal fibrous tissue, in contrast to the empty control group. The results of the in vitro and in vivo studies together suggest that SDF-1-mediated signaling may significantly improve the quality of cartilage regeneration in an osteochondral defect.

Editorial Commentary: Shoulder Repair All-Suture Fixators: Anchors Away or Tell Us Why Not?

The current array of shoulder repair anchors, techniques, and constructs vary greatly and offer many choices to optimize soft-tissue healing to bone. The widely used all-suture anchor designs represent an innovative option that allows for versatile delivery and a low-profile anchor construct that minimizes bone drilling and preserves native bone. Various reports of tissue reactions to copolymer and biocomposite materials and now all-suture anchors have been published raising concerns in some cases over safety, adverse events, and clinical performance. Other studies have described reactions in which the clinical correlative significance remains unclear. Determination of what matters and what is significant will help to decide if radiographic tunnel enlargement does occur over time and if it changes our clinical decision-making and choice of which anchors to use.

Viscosupplementation for Osteoarthritis of the Knee: A Key Opinion Leader Panel Discussion.

With a sharp rise in the prevalence of osteoarthritis of the knee (OAK) in a younger population, new management strategies are needed to preserve mobility, improve patients' quality of life, and reduce the effects of potential disease-related comorbidities. Viscosupplementation with the use of hyaluronic acid (HA) injection is a treatment option for OAK that can provide lubrication and elastic shock absorption, leading to potential pain relief, improved function, and reduced stiffness. A key opinion leader (KOL) panel discussion was held December 3, 2016, with the objective of sharing opinions, ideas, information, and trends regarding OAK and the potential treatment and management offered by viscosupplementation. The panel concluded that viscosupplementation with HA injections presents a viable, cost-effective, and safe alternative for the treatment of OAK. DISCLOSURES: This panel discussion and report was facilitated by Magellan Rx Manage-ment and funded by Sanofi. Bert and Ruane report fees from Sanofi outside of this project. Sgaglione reports royalty payments from Zimmer Biomet and Wolters Kluwer. Dasa has received fees from Bioventus and Myoscience. All the authors received an honorarium for work on this project. Lopes is employed by Magellan Rx Management.

Arthroscopic knotless rotator cuff repair: Factors associated with construct selection and recent trends from a manual review of 1617 cases.

PURPOSE: Our aim was to identify predictors of construct selection and recent trends for arthroscopic knotless rotator cuff repair (RCR). METHODS: A manual review of 1617 operative reports was performed. RESULTS: A medium-sized tear had a threefold increase in odds of single row (SR) knotless repair (OR, 6.91; p = 0.009) versus SR knotted (OR, 3.05; p = 0.003). Generalist orthopaedic surgeons were 79% less likely to perform SR knotless repairs versus sports medicine trained specialists (p < 0.001). CONCLUSION: There was a significant increase from 2009 to 2016 in SR knotless and double row medial row knotless constructs contrasting the declining use of the SR knotted technique.

Employment Contracts: The Good, the Bad, and the Ugly.

Recent trends indicate that a greater number of orthopaedic surgeons who complete their residency and/or fellowship training are accepting employment positions at hospitals. Moreover, established orthopaedic surgeons with successful private practices have begun to consider whether aligning with hospitals and larger health systems can be effectively accomplished. A comprehensive evaluation of institution-based employment opportunities is essential for orthopaedic surgeons considering hospital-based employment. Surgeons should be aware of the healthcare, clinical, and administrative opportunities of private practice employment versus hospital-based employment before accepting a clinical position.

Impact of recent guideline changes on aspirin prescribing after knee arthroplasty.

BACKGROUND: Prior to 2012, the American Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP) differed in their recommendations for postoperative pharmacologic venous thromboembolism prophylaxis (VTEP) after total joint arthroplasty. More specifically, aspirin (ASA) monotherapy was not endorsed by the ACCP as an acceptable prophylaxis. In 2012, the ACCP supported ASA monotherapy compared with no prophylaxis. Our aim was to investigate the impact of the convergence of ACCP and AAOS recommendations on surgeon prescribing patterns after knee arthroplasty (KA). METHODS: This is a retrospective chart review. We collected data to assess preoperative VTE risk and examined VTEP prescriptions on postoperative day 1 (POD1) and at discharge (D/C) from 7/2008 to 12/2011 (pre-period) and 1/2012 to 7/2014 (post-period). Adult patients undergoing primary and revision KA were identified by ICD-9 procedure codes. Patients on preoperative full-dose anticoagulation and with hypercoagulability disorders were excluded. RESULTS: Of 368 records reviewed, 329 were included in the analysis. There were no differences between the two period groups for age, sex, BMI, estrogen therapy, malignancy, smoking status, prior VTE, bilateral procedures, or surgery within 3 months. On POD1, in the pre-period, 4.6 % were prescribed ASA monotherapy versus 44.4 % in the post-period (p < 0.001). On D/C, in the pre-period, 13.9 % were prescribed ASA versus 55.6 % in the post-period (p < 0.001). CONCLUSIONS: Our results indicate a statistically significant change in orthopedist prescribing patterns after guideline convergence. Furthermore, there was no apparent change in VTE risk between the two study groups when excluding patients necessitating full anticoagulation. Prior literature has shown that the divergence in guidelines influenced physicians away from ASA and toward more potent anticoagulants in order to avoid potential litigation. Once its role in VTEP was supported by the ACCP, it appears that ASA monotherapy was readily and rapidly incorporated into clinical practice. ASA may be favored over other VTEP agents for its lower bleeding risk profile and cost. This study highlights the profound impact clinical practice guidelines have on clinician prescribing patterns. Although prospective randomized trials are needed to compare the efficacy of ASA with other VTEP agents, ASA is now a predominant part of the VTEP armamentarium after KA.