Low Tensile Strength Suture With Transosseous Tunnels and Suture Anchors 5 mm in Diameter or Greater Are Associated With Higher Failure Rates in Primary Patellar Tendon Repair.

Purpose: To determine the rate of and risk factors for clinical failure and return to military duty following primary patellar tendon repair with either transosseous trunnel repair or suture anchor repair. Methods: The Military Health System Data Repository (MDR) was queried to identify all adult patients undergoing surgical treatment of a patellar tendon rupture in the Military Health System from 2014 to 2018. Patients who underwent either transosseous tunnel repair or suture anchor repair were included. Health records were examined to collect additional data. Univariate analysis and multivariate logistic regression models were used to determine independent risk factors for rerupture. Results: A total of 450 knees in 437 patients were included. Transosseous tunnel repair was the most frequently used technique (314/450, 77%), followed by suture anchor repair (113/450, 25%). Rerupture occurred in 33 knees (7%). There was no difference in rerupture rate between transosseous tunnel repair and suture anchor repair (P = .15), and this result persisted within the multivariate logistic regression model. Among transosseous tunnel repairs, use of low tensile strength suture was an independent risk factor for repair failure (odds ratio [OR], 3.4; P = .016). Among suture anchor repairs, use of anchors 5.0 mm in diameter or greater (OR, 12.0; P = .027) was an independent risk factor for repair failure. Conclusions: There is no statistically significant difference in failure rate between transosseous tunnel repair and suture anchor repair in primary patellar tendon ruptures. However, the use of low tensile strength suture with transosseous tunnels and the use of suture anchors 5.0 mm in diameter or greater resulted in significantly higher failure rates. These data suggest that use of high tensile strength suture in transosseous tunnel repair and use of suture anchors less than 5.0 mm in diameter in suture anchor repair result in lower failure rate in primary patellar tendon repair. Level of Evidence: Level III, retrospective cohort study.

Disparities in Demographics in Hip Arthroplasty Between U.S. Active Duty Military and the ACS-NSQIP Clinical Registry.

INTRODUCTION: Patient demographics, such as sex and age, are known risk factors for undergoing revision following primary total hip arthroplasty (THA). The military population is unique because of the increased rates of primary and secondary osteoarthritis of the hip. Treatment options are limited for returning patients to their line of duty; however, THA has been shown to be an effective option. The primary purpose of this study was to evaluate and contrast the demographic differences of patients undergoing primary THA between the U.S. active duty military population and the general population. The secondary goal was to identify the proportion of primary THA performed at the MTF within the military health system (MHS). METHODS: This was an exempt study determined by the local institutional review board. A retrospective analysis of the MHS Data Repository (MDR) and the National Surgical Quality Improvement Program (NSQIP) was performed. The databases were used to identify the patients who underwent THA from January 1, 2015 to December 31, 2020. The MDR was used to identify demographics such as sex, age, setting of surgery, geographic location, previous military deployments, history of deployment-related injuries, branch of service, and rank. The NSQIP database was queried for sex and age. The median age of the population was compared using the Mann-Whitney U test and gender was compared using the Chi-square test. RESULTS: The MDR was used to evaluate 2,734 patients, whereas the NSQIP database was used to evaluate 223,832 patients. In the military population, patients who underwent THA were 87.7% male with an average age of 45 years, whereas in the general population as measured via the NSQIP database, 45.2% patients were male with an average age of 66.0 years. Comparing the two groups, we demonstrated that the military patients were significantly more likely to be younger (P < .001) and males (P < .001). Only 29.6% of primary THAs were performed within the MTF. CONCLUSIONS: Patients in the MHS are undergoing THA at a younger age and are more likely to be male compared to the general population. A significant portion of primary THAs in the MHS are also being performed at civilian institutions. These demographics may result in increased risk of revision; however, long-term studies are warranted to evaluate survivorship in this unique population.

The Adductor Sling Technique for Pediatric Medial Patellofemoral Ligament Reconstruction Better Resists Dislocation Loads When Compared With Adductor Transfer at Time Zero in a Cadaveric Model.

Purpose: To characterize the ability of the intact medial patellofemoral ligament (MPFL) and the adductor transfer and adductor sling MPFL reconstruction techniques to resist subluxation and dislocation in a cadaveric model. Methods: Nine fresh-frozen cadaveric knees were placed on a custom testing fixture with the femur fixed parallel to the floor, the tibia placed in 20° of flexion, and the patella attached to a load cell. The patella was displaced laterally, and subluxation load (in newtons), dislocation load (in newtons), maximum failure load (in newtons), patellar displacement at failure, and mode of failure were recorded. Testing was conducted with the MPFL intact and after the adductor sling and adductor transfer reconstruction techniques. Statistical analysis was completed using 1-way repeated-measures analysis of variance with the Holm-Sidák post hoc test. Results: The subluxation load was not significantly different between groups. The native MPFL dislocation load was significantly higher than the dislocation loads of both reconstruction techniques, but no significant difference between the dislocation loads of the 2 reconstruction techniques occurred. The native MPFL failure load was significantly higher than the failure loads of both reconstruction techniques. The adductor sling failure load was significantly higher than the adductor transfer failure load. The mode of failure varied across groups. The native MPFL failed by femoral avulsion, patellar avulsion, and midsubstance tear. The main mode of failure for adductor transfer was pullout, whereas failure for the adductor sling technique most often occurred at the sutures. Most of the native MPFLs and all adductor sling reconstructions failed after dislocation. The adductor transfer reconstructions were much more variable, with failures spanning from before subluxation through dislocation. Conclusions: Our cadaveric model showed that neither the adductor transfer technique nor the adductor sling technique restored failure load to that of the native condition. There was no significant difference in the subluxation or dislocation loads between the 2 MPFL reconstructions, but the adductor sling technique resulted in a higher load to failure. The adductor transfer technique frequently failed before subluxation or dislocation when compared with the adductor sling technique and the native MPFL. Clinical Relevance: The best technique for MPFL reconstruction in patients with open physes is a topic of debate. Given the long-term consequences of MPFL injury and potential for growth plate disturbance, it is important to study MPFL reconstruction techniques thoroughly, including in the laboratory setting.

Editorial Commentary: Endoscopic Hip Abductor Repair Results in Excellent Outcomes in Challenging Patients: Surgical Indications Require Additional Clarification.

Hip abductor pathology exists on a spectrum, potentially involving symptoms of pain, weakness, loss of active motion, and disordered movement. Imaging findings may include tendinosis, detachment of a portion of the footprint, fluid imbibition with undersurface tearing at the footprint, or full-thickness detachment of 1 or both tendons with or without evidence of fatty infiltration or atrophy of the associated muscle bellies. Yet, sometimes there are no imaging findings at all. Endoscopic repair of hip abductor tendon tears is growing in popularity and interest. Recent research suggests that with treatment of concomitant pathology, excellent clinical results are durable, even in patients with potentially poor prognoses (eg - older patients with poor preoperative patient reported outcome measures). While techniques have become increasingly refined, surgical indications remain vague and confusing. Future research could consider why some patients are taken to the operating room, while most are not.

Grit and postoperative opioid use after total joint arthroplasty.

INTRODUCTION: Perioperative multimodal protocols following total joint replacements have significantly decreased the amount of perioperative and postoperative opioids. Further identification of those requiring more or less opioids through individualisation, may further aid in reducing the amount prescribed. Therefore, the purpose of the study was to evaluate whether a patient's grit, the measurable psychological strength of character to persevere during hardship, measured by postoperative opioid consumption. METHODS: Consecutive patients who had undergone either primary or revision total knee arthroplasty (TKA) or total hip arthroplasty (THA) from February 2019 to August 2020 at our institution logged their opioid use for the first 2 weeks postoperatively, detailing the type, dosage, and number of narcotics they consumed. Those who completed their logs and a grit questionnaire had their average morphine equivalent dose (MED) and grit score calculated. Analysis was then performed to evaluate if any association existed between these 2 variables. RESULTS: There was no correlation between grit score and postoperative opioid consumption in the first 2 weeks following discharge after total joint arthroplasty. A total of 144 patients were eligible to participate and a total of 86 patients met inclusion criteria, 48 patients in the TKA group and 38 in the THA group. Of all patients, 63% were male. The average MED was 95.5 for THAs and 192 for TKAs. The average grit score was 4.23 for THAs and 4.19 for TKAs. CONCLUSIONS: There is not an apparent association between grit score and postoperative opioid consumption in the first 2 weeks after total joint arthroplasty. General psychological resiliency may not be an important predictor of postoperative opioid use with modern postoperative protocols.

A Lack of Generalizability-Total Knee Demographics in the Active Duty Population.

INTRODUCTION: Age and sex are known demographic risk factors for requiring revision surgery following primary total knee arthroplasty (TKA). Military service members are a unique population with barriers to long-term follow up after surgery. This study aims to compare demographic data between active duty military personnel and a nationwide sample to identify differences that may impact clinical and economic outcomes. METHODS: A retrospective observational analysis was performed using the Military Health System Data Repository (MDR) and the National Surgical Quality Improvement Program (NSQIP). Databases were queried for patients undergoing primary TKA between January 1, 2015 and December 31, 2020. The MDR was queried for demographic data including age, sex, duty status, facility type, geographic region, history of prior military deployment, history of deployment-related health condition, branch of military service, and military rank. National Surgical Quality Improvement Program was queried for age and sex. Median age between populations was compared with the Mann-Whitney U test, and gender was compared with a chi-squared test. RESULTS: During the study period, 2,094 primary TKA patients were identified from the MDR, and 357,865 TKA patients were identified from the NSQIP database. Military TKA patients were 79.4% male with a median age of 49.0, and NSQIP TKA patients were 38.9% were male, with a median age of 67. Military TKA patients were significantly more likely to be male (P < .001) and younger (P < .001). CONCLUSION: Patients undergoing TKA in the military are younger and more likely to be male compared to national trends. Current evidence suggests these factors may place them at a significant revision risk in the future. The application of quality metrics based on nationwide demographics may not be applicable to military members within the Military Health System.

Oral opioid prescribing to active duty US military personnel: a cross-sectional population.

INTRODUCTION: While civilian opioid prescriptions have seen a dramatic decline in recent years, there are few studies investigating trends in opioid prescription in the active duty military population. We evaluated oral opioid prescribing patterns to active duty military personnel in the Military Health System (MHS) from 2017 to 2020 to determine the incidence of opioid prescriptions as well as demographic and military-specific risk factors for receiving an oral opioid prescription. METHODS: The MHS Data Repository was queried from 2017 to 2020 to identify all outpatient oral opioid prescriptions to active duty military personnel in August of each year as well as demographic information on the study population. Data were evaluated in a logistic regression model, and ORs of receiving an oral opioid prescription were calculated for each factor. RESULTS: The proportion of active duty military personnel receiving an oral opioid prescription declined from 2.71% to 1.26% (53% relative reduction) over the study period. Within the logistic regression model, female military personnel were significantly more likely to receive opioid prescriptions compared with men, and there was a stepwise increase in likelihood of an opioid prescription with increasing age. Army and Marine personnel, personnel without a history of military deployment and those stationed within the continental USA were significantly more likely to receive an opioid prescription. DISCUSSION: The substantial decrease in oral opioid prescriptions to active duty military personnel mirrors data published in the civilian community. The identified risk factors for receiving an opioid prescription may be potential targets for future interventions to further decrease prescribing.

The Association Between Borderline Dysnatremia and Perioperative Morbidity and Mortality: Retrospective Cohort Study of the American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Hyponatremia and hypernatremia, as conventionally defined (<135 mEq/L and >145 mEq/L, respectively), are associated with increased perioperative morbidity and mortality. However, the effects of subtle deviations in serum sodium concentration within the normal range are not well-characterized. OBJECTIVE: The purpose of this analysis is to determine the association between borderline hyponatremia (135-137 mEq/L) and hypernatremia (143-145 mEq/L) on perioperative morbidity and mortality. METHODS: A retrospective cohort study was performed using data from the American College of Surgeons National Surgical Quality Improvement Program database. This database is a repository of surgical outcome data collected from over 600 hospitals across the United States. The National Surgical Quality Improvement Program database was queried to extract all patients undergoing elective, noncardiac surgery from 2015 to 2019. The primary predictor variable was preoperative serum sodium concentration, measured less than 5 days before the index surgery. The 2 primary outcomes were the odds of morbidity and mortality occurring within 30 days of surgery. The risk of both outcomes in relation to preoperative serum sodium concentration was modeled using weighted generalized additive models to minimize the effect of selection bias while controlling for covariates. RESULTS: In the overall cohort, 1,003,956 of 4,551,726 available patients had a serum sodium concentration drawn within 5 days of their index surgery. The odds of morbidity and mortality across sodium levels of 130-150 mEq/L relative to a sodium level of 140 mEq/L followed a nonnormally distributed U-shaped curve. The mean serum sodium concentration in the study population was 139 mEq/L. All continuous covariates were significantly associated with both morbidity and mortality (P<.001). Preoperative serum sodium concentrations of less than 139 mEq/L and those greater than 144 mEq/L were independently associated with increased morbidity probabilities. Serum sodium concentrations of less than 138 mEq/L and those greater than 142 mEq/L were associated with increased mortality probabilities. Hypernatremia was associated with higher odds of both morbidity and mortality than corresponding degrees of hyponatremia. CONCLUSIONS: Among patients undergoing elective, noncardiac surgery, this retrospective analysis found that preoperative serum sodium levels less than 138 mEq/L and those greater than 142 mEq/L are associated with increased morbidity and mortality, even within currently accepted "normal" ranges. The retrospective nature of this investigation limits the ability to make causal determinations for these findings. Given the U-shaped distribution of risk, past investigations that assume a linear relationship between serum sodium concentration and surgical outcomes may need to be revisited. Likewise, these results question the current definition of perioperative eunatremia, which may require future prospective investigations.

Green Sea Turtles (Chelonia mydas) Accumulate Heavy Metals Near a Former Skeet Shooting Range in Kailua, O'ahu, Hawai'i.

The present study determined if green sea turtles (Chelonia mydas) in Kailua Bay, Oahu, in the Hawaiian Islands have elevated blood and scute lead (Pb), arsenic (As), and antimony (Sb) concentrations resulting from lead deposition at a historic skeet shooting range. Blood and scute samples were collected and analyzed for Pb, As, and Sb via inductively coupled plasma-mass spectrometry. Prey, water, and sediment samples were also analyzed. Turtle samples in Kailua Bay (45) have blood Pb concentrations (328 ± 195 ng/g) greater than a reference population (Howick Group of Islands, 29.2 ± 17.1 ng/g). Compared with other green turtle populations, only turtles in Oman, Brazil, and San Diego, CA have blood Pb concentrations greater than turtles in Kailua Bay. The estimated daily exposure of Pb from algae sources in Kailua Bay (0.12 mg/kg/day) was significantly lower than the no observed adverse effect level (100 mg/kg) of red-eared slider turtles. However, the chronic effects of Pb on sea turtles is poorly understood and continued monitoring of this population will increase our understanding of the Pb and As loads of sea turtles in Kailua Bay. Environ Toxicol Chem 2023;42:1109-1123. © 2023 SETAC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

A history of shoulder instability is more common in young patients undergoing total shoulder arthroplasty.

BACKGROUND: Previous studies have shown an association between shoulder instability and the development of glenohumeral arthritis leading to total shoulder arthroplasty (TSA). The primary goal of this study was to evaluate if a history of shoulder instability was more common in patients aged <50 years undergoing TSA. The secondary objective was to determine if a history of prior surgical stabilization is more common in patients aged <50 years undergoing TSA. METHODS: Using the military health system data repository (MDR) and the Military Analysis and Reporting Tool (M2), we identified 489 patients undergoing primary TSA from October 1, 2013, to May 1, 2020, within the Military Health System (MHS). Patients aged <50 years were matched 1:2 with patients aged ≥50 years based on sex, race, and military status, with the final study population comprising 240 patients who underwent primary TSA during the study period. Electronic medical records were examined, and factors showing univariate association (P < .2) were included in a binary logistic regression analysis to determine associations between demographic or clinical factors and TSA prior to age 50 years. RESULTS: The groups differed significantly in shoulder arthritis subtype, with the older group having significantly more primary osteoarthritis (78% vs. 51%, P < .001). The younger group had significantly more patients with a history of shoulder instability (48% vs. 12%, P < .001), prior ipsilateral shoulder surgery of any type (74% vs. 34%, P < .001), and prior ipsilateral shoulder stabilization surgery (31% vs. 5%, P < .001). In the resultant logistic regression model, a history of shoulder instability (OR 5.0, P < .001) and a history of any prior ipsilateral shoulder surgery (OR 3.5, P < .001) were associated with TSA prior to the age of 50 years. CONCLUSIONS: Shoulder instability is a risk factor for TSA before age 50 years. It is unclear how surgical stabilization influences the development of secondary glenohumeral arthritis in shoulder instability. Patients should be counseled that recurrent instability could lead to earlier TSA, regardless of whether surgical stabilization is performed.

Machine Learning to Predict Discharge Destination After Total Knee Arthroplasty and Total Hip Arthroplasty.

Discharge destination impacts costs and perioperative planning for primary total knee (TKA) or hip arthroplasty (THA). The purpose of this study was to create a tool to predict discharge destination in contemporary patients. Models were developed using more than 400,000 patients from the National Surgical Quality Improvement Program database. Models were compared with a previously published model using area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA). AUC on patients with TKA was 0.729 (95% confidence interval [CI]: 0.719 to 0.738) and 0.688 (95% CI: 0.678 to 0.697) using the new and previous models, respectively. AUC on patients with THA was 0.768 (95% CI: 0.758 to 0.778) and 0.726 (95% CI: 0.714 to 0.737) using the new and previous models, respectively. DCA showed substantially improved net clinical benefit. The new models were integrated into a web-based application. This tool enhances clinical decision making for predicting discharge destination following primary TKA and THA. (Journal of Surgical Orthopaedic Advances 32(4):252-258, 2023).

Prospective Evaluation of Push-up Performance and Patient-Reported Outcomes Following Open Dorsal Wrist Ganglion Excision in the Active-Duty Military Population.

Background Dorsal wrist ganglia (DWG) are a common wrist pathology that affects the military population. This study prospectively evaluates push-up performance, functional measures, and patient-reported outcomes 6 months after open DWG excision in active-duty patients. Methods Twenty-seven active-duty patients were enrolled and 18 had complete follow-up. Included patients had DWG diagnosis, unilateral involvement, and no previous surgery. The number of push-ups performed within 2 minutes was measured preoperatively and at 6 months. Range of motion (ROM), grip strength, Pain Catastrophization Scale (PCS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, Mayo Wrist Score, and visual analog scale (VAS) pain score were measured preoperatively and at 2 weeks, 6 weeks, 3 months, and 6 months. Results Push-up performance did not significantly change overall. Wrist flexion, extension, and radial deviation returned to preoperative ranges. Wrist ulnar deviation significantly increased from preoperative range. Grip strength deficit between operative and unaffected extremities significantly improved to 0.7 kg at 6 months from preoperative deficit of 2.7 kg. Mean scores significantly improved for the validated outcome measures-PCS from 6.3 to 0.67, VAS pain scores from 1.37 to 0.18, DASH scores from 12.8 to 4.3, and Mayo Wrist Scores from 80.3 to 89.4. No surgical complications or recurrences were reported. Conclusions Findings suggest that almost half of active patients may improve push-up performance after DWG excision at 6 months. Significant improvements were seen in wrist pain, ROM, grip strength, and all patient-reported outcomes, which is useful when counseling patients undergoing excision.

Machine-learning Models Predict 30-Day Mortality, Cardiovascular Complications, and Respiratory Complications After Aseptic Revision Total Joint Arthroplasty.

BACKGROUND: Aseptic revision THA and TKA are associated with an increased risk of adverse outcomes compared with primary THA and TKA. Understanding the risk profiles for patients undergoing aseptic revision THA or TKA may provide an opportunity to decrease the risk of postsurgical complications. There are risk stratification tools for postoperative complications after aseptic revision TKA or THA; however, current tools only include nonmodifiable risk factors, such as medical comorbidities, and do not include modifiable risk factors. QUESTIONS/PURPOSES: (1) Can machine learning predict 30-day mortality and complications for patients undergoing aseptic revision THA or TKA using a cohort from the American College of Surgeons National Surgical Quality Improvement Program database? (2) Which patient variables are the most relevant in predicting complications? METHODS: This was a temporally validated, retrospective study analyzing the 2014 to 2019 National Surgical Quality Improvement Program database, as this database captures a large cohort of aseptic revision THA and TKA patients across a broad range of clinical settings and includes preoperative laboratory values. The training data set was 2014 to 2018, and 2019 was the validation data set. Given that predictive models learn expected prevalence of outcomes, this split allows assessment of model performance in contemporary patients. Between 2014 and 2019, a total of 24,682 patients underwent aseptic revision TKA and 17,871 patients underwent aseptic revision THA. Of those, patients with CPT codes corresponding to aseptic revision TKA or THA were considered as potentially eligible. Based on excluding procedures involving unclean wounds, 78% (19,345 of 24,682) of aseptic revision TKA procedures and 82% (14,711 of 17,871) of aseptic revision THA procedures were eligible. Ten percent of patients in each of the training and validation cohorts had missing predictor variables. Most of these missing data were preoperative sodium or hematocrit (8% in both the training and validation cohorts). No patients had missing outcome data. No patients were excluded due to missing data. The mean patient was age 66 ± 12 years, the mean BMI was 32 ± 7 kg/m 2 , and the mean American Society of Anesthesiologists (ASA) Physical Score was 3 (56%). XGBoost was then used to create a scoring tool for 30-day adverse outcomes. XGBoost was chosen because it can handle missing data, it is nonlinear, it can assess nuanced relationships between variables, it incorporates techniques to reduce model complexity, and it has a demonstrated record of producing highly accurate machine-learning models. Performance metrics included discrimination and calibration. Discrimination was assessed by c-statistics, which describe the area under the receiver operating characteristic curve. This quantifies how well a predictive model discriminates between patients who have the outcome of interest versus those who do not. Relevant ranges for c-statistics include good (0.70 to 0.79), excellent (0.80 to 0.89), and outstanding (> 0.90). We estimated 95% confidence intervals (CIs) for c-statistics by 500-sample bootstrapping. Calibration curves quantify reliability of model predictions. Reliable models produce prediction probabilities for outcomes that are similar to observed probabilities of those outcomes, so a well-calibrated model should demonstrate a calibration curve that does not deviate substantially from a line of slope 1 and intercept 0. Calibration curves were generated on the 2019 validation data. Shapley Additive Explanations (SHAP) visualizations were used to investigate feature importance to gain insight into how models made predictions. The models were built into an online calculator for ongoing testing and validation. The risk calculator, which is freely available ( http://nb-group.org/rev2/ ), allows a user to input patient data to calculate postoperative risk of 30-day mortality, cardiac, and respiratory complications after aseptic revision TKA or THA. A post hoc analysis was performed to assess whether using data from 2020 would improve calibration on 2019 data. RESULTS: The model accurately predicted mortality, cardiac complications, and respiratory complications after aseptic revision THA or TKA, with c-statistics of 0.88 (95% CI 0.83 to 0.93), 0.80 (95% CI 0.75 to 0.84), and 0.78 (95% CI 0.74 to 0.82), respectively, on internal validation and 0.87 (95% CI 0.77 to 0.96), 0.70 (95% CI 0.61 to 0.78), and 0.82 (95% CI 0.75 to 0.88), respectively, on temporal validation. Calibration curves demonstrated slight over-confidence in predictions (most predicted probabilities were higher than observed probabilities). Post hoc analysis of 2020 data did not yield improved calibration on the 2019 validation set. Important risk factors for all models included increased age and higher ASA, BMI, hematocrit level, and sodium level. Hematocrit and ASA were in the top three most important features for all models. The factor with the strongest association for mortality and cardiac complication models was age, and for the respiratory model, chronic obstructive pulmonary disease. Risk related to sodium followed a U-shaped curve. Preoperative hyponatremia and hypernatremia predicted an increased risk of mortality and respiratory complications, with a nadir of 138 mmol/L; hyponatremia was more strongly associated with mortality than hypernatremia. A hematocrit level less than 36% predicted an increased risk of all three adverse outcomes. A BMI less than 24 kg/m 2 -and especially less than 20 kg/m 2 -predicted an increased risk of all three adverse outcomes, with little to no effect for higher BMI. CONCLUSION: This temporally validated model predicted 30-day mortality, cardiac complications, and respiratory complications after aseptic revision THA or TKA with c-statistics ranging from 0.78 to 0.88. This freely available risk calculator can be used preoperatively by surgeons to educate patients on their individual postoperative risk of these specific adverse outcomes. Unanswered questions that remain include whether altering the studied preoperative patient variables, such as sodium or hematocrit, would affect postoperative risk of adverse outcomes; however, a prospective cohort study is needed to answer this question. LEVEL OF EVIDENCE: Level III, therapeutic study.

Bony Edema and Clinical Examination Findings Predict the Need for Distal Clavicle Excision at the Time of Shoulder Arthroscopy.

Background: Deciding to perform a distal clavicle excision for acromioclavicular joint arthritis, especially in conjunction with other arthroscopic shoulder procedures, is challenging for surgeons. Studies have reported mixed results on the value of magnetic resonance imaging (MRI) in decision making. Purpose: We sought to correlate MRI findings with clinical symptoms and the surgeon's decision to perform a distal clavicle excision. Methods: We compared MRI, clinical examination, and MRI findings of 200 patients who underwent distal clavicle excision for symptomatic acromioclavicular joint arthritis with 200 patients who underwent arthroscopic shoulder procedures for other reasons. Univariate statistics were used to determine correlations between physical examination findings, MRI findings, and the decision to perform distal clavicle excision. A binary logistic regression model was used to determine independent predictors of need for distal clavicle excision. Results: There was no difference in mean age, sex, and race between groups. Advanced acromioclavicular joint osteoarthritis was strongly correlated with positive physical examination findings. Bony edema correlated strongly with tenderness at the acromioclavicular joint but not pain with cross-body adduction testing. There was no association between higher MRI grade of osteoarthritis and the need for distal clavicle excision. Regression analysis identified both physical examination findings and bony edema on MRI as independent predictors of the need for distal clavicle excision. Conclusion: In the setting of positive clinical examination findings and bony edema of the distal clavicle, surgeons should feel reassured that distal clavicle excision is likely indicated.

Clinical outcomes of open hip abductor tendon repair with minimum two-year follow-up.

BACKGROUND: The results of open hip abductor tendon repair remains poorly defined. We sought to present the results and complications of this procedure using modern suture anchor fixation. MATERIALS AND METHODS: Our prospective institutional hip preservation registry was queried for all patients who underwent open hip abductor tendon repair with minimum 2-year follow-up were identified. Demographic, clinical, intraoperative, and functional outcome details were recorded. Patient-reported outcome scores (PROs) including the modified Harris Hip Score (mHHS), HOS-ADL, HOS-S, and iHOT-33 were collected for the preoperative and final postoperative state. Risk factors for lower final mHHS and change in mHHS were analysed using a multiple regression model. RESULTS: A total of 21 patients with mean 48 months clinical follow-up (range 24-84 months). Median mHHS improved from 49.50 preoperatively to 82.50 postoperatively (p < 0.001), median HOS-ADL improved from 60.29 to 82.35 (p = 0.001), median HOS-S improved from 37.50 to 60.00 (p = 0.04), and median iHOT-33 improved from 29.81 to 70.15 (p = 0.001). All patients had +4 or +5 hip abductor strength at final in-person examination at mean 17 months postoperatively. All patients with a preoperative Trendelenburg gait had complete resolution at final examination. There 2 complications, and no patient had re-tear or revision surgery. LCEA < 25° and a history of prior ipsilateral hip surgery were independently predictive of smaller improvement in mHHS at final follow-up. CONCLUSIONS: Open abductor tendon repair is a safe and effective procedure that provides sustained symptomatic and functional improvements at mid-term follow-up.

Opioid prescribing in the U.S. Military Health System, 2014 to 2018: fewer prescriptions, fewer pills, and shorter treatment duration.

ABSTRACT: Prescription opioids remain an important driver of the opioid crisis in the United States. The purpose of this study was to examine recent changes in opioid prescribing patterns in the Military Health System (MHS) which is a nationwide health system service active duty military personnel and civilian beneficiaries. All patients prescribed opioid analgesics by MHS providers and filled at MHS pharmacies between 2014 and 2018 were identified. Prescriptions were converted to oral morphine equivalents (OMEs) and categorized based on prescribing specialty and formulation. Total opioid prescription counts and opioid prescription counts weighted by the annual number of outpatient encounters for each specialty were calculated, as were total OMEs and daily OMEs per prescription. A total of 3,427,308 prescriptions were included. Primary care providers and surgeons wrote 47% and 29% of opioid prescriptions, respectively. Over the study period, there was a 56% decline in annual opioid prescriptions, 25% decline in median total OMEs, and a 57% decline in opioid prescriptions per patient encounter. The proportion of prescriptions written for >90 OMEs per day declined 21%. Declines in opioid prescriptions and quantities were observed in nearly all specialties over the study period. The results of this study suggest a broad-based shift towards less opioid prescribing.

A Machine-Learning Algorithm to Predict the Likelihood of Prolonged Opioid Use Following Arthroscopic Hip Surgery.

PURPOSE: To develop a machine-learning algorithm and clinician-friendly tool predicting the likelihood of prolonged opioid use (>90 days) following hip arthroscopy. METHODS: The Military Data Repository was queried for all adult patients undergoing arthroscopic hip surgery between 2012 and 2017. Demographic, health history, and prescription records were extracted for all included patients. Opioid use was divided into preoperative use (30-365 days before surgery), perioperative use (30 days before surgery through 14 days after surgery), postoperative use (14-90 days after surgery), and prolonged postoperative use (90-365 days after surgery). Six machine-learning algorithms (Naïve Bayes, Gradient Boosting Machine, Extreme Gradient Boosting, Random Forest, Elastic Net Regularization, and artificial neural network) were developed. Area under the receiver operating curve and Brier scores were calculated for each model. Decision curve analysis was applied to assess clinical utility. Local-Interpretable Model-Agnostic Explanations were used to demonstrate factor weights within the selected model. RESULTS: A total of 6,760 patients were included, of whom 2,762 (40.9%) filled at least 1 opioid prescription >90 days after surgery. The artificial neural network model showed superior discrimination and calibration with area under the receiver operating curve = 0.71 (95% confidence interval 0.68-0.74) and Brier score = 0.21 (95% confidence interval 0.20-0.22). Postsurgical opioid use, age, and preoperative opioid use had the most influence on model outcome. Lesser factors included the presence of a psychological comorbidity and strong history of a substance use disorder. CONCLUSIONS: The artificial neural network model shows sufficient validity and discrimination for use in clinical practice. The 5 identified factors (age, preoperative opioid use, postoperative opioid use, presence of a mental health comorbidity, and presence of a preoperative substance use disorder) accurately predict the likelihood of prolonged opioid use following hip arthroscopy. LEVEL OF EVIDENCE: III, retrospective comparative prognostic trial.

Characterization of Halogenated Organic Compounds in Pelagic Sharks and Sea Turtles Using a Nontargeted Approach.

Halogenated organic compounds (HOCs) in marine species collected from the Atlantic Ocean [3 shortfin mako (Isurus oxyrinchus) and 1 porbeagle (Lamna nasus)], and 12 sea turtles collected from the Pacific Ocean [3 loggerhead (Caretta caretta), 3 green (Chelonia mydas), 3 olive ridley (Lepidochelys olivacea), and 3 hawksbill (Eretmochelys imbricata)] were analyzed with a nontargeted analytical method using two-dimensional gas chromatography coupled to high-resolution time-of-flight mass spectrometry. Sharks and sea turtles had distinct HOC profiles. Halogenated methoxyphenols (halo-MeOPs) were the most abundant compound class identified in sea turtle livers, while polychlorinated biphenyls (PCBs) were the most abundant in shark livers. In addition to legacy contaminants and halo-MeOPs, a total of 110 nontargeted/novel HOCs (NHOCs) were observed in the shark livers. Shortfin mako collected from the northern Gulf of Mexico contained the largest number (89) and most diverse structural classes of NHOCs. Among all NHOCs, a group of compounds with the elemental composition C14H12-nCln (n = 5-8) exhibited the highest concentrations, followed by chlorocarbazoles and tris(chlorophenyl) methanes (TCPMs). Using nontargeted workflows, a variety of known and unknown HOCs were observed, which demonstrate the need to develop more complete chemical profiles in the marine environment.

Species and population specific gene expression in blood transcriptomes of marine turtles.

BACKGROUND: Transcriptomic data has demonstrated utility to advance the study of physiological diversity and organisms' responses to environmental stressors. However, a lack of genomic resources and challenges associated with collecting high-quality RNA can limit its application for many wild populations. Minimally invasive blood sampling combined with de novo transcriptomic approaches has great potential to alleviate these barriers. Here, we advance these goals for marine turtles by generating high quality de novo blood transcriptome assemblies to characterize functional diversity and compare global transcriptional profiles between tissues, species, and foraging aggregations. RESULTS: We generated high quality blood transcriptome assemblies for hawksbill (Eretmochelys imbricata), loggerhead (Caretta caretta), green (Chelonia mydas), and leatherback (Dermochelys coriacea) turtles. The functional diversity in assembled blood transcriptomes was comparable to those from more traditionally sampled tissues. A total of 31.3% of orthogroups identified were present in all four species, representing a core set of conserved genes expressed in blood and shared across marine turtle species. We observed strong species-specific expression of these genes, as well as distinct transcriptomic profiles between green turtle foraging aggregations that inhabit areas of greater or lesser anthropogenic disturbance. CONCLUSIONS: Obtaining global gene expression data through non-lethal, minimally invasive sampling can greatly expand the applications of RNA-sequencing in protected long-lived species such as marine turtles. The distinct differences in gene expression signatures between species and foraging aggregations provide insight into the functional genomics underlying the diversity in this ancient vertebrate lineage. The transcriptomic resources generated here can be used in further studies examining the evolutionary ecology and anthropogenic impacts on marine turtles.