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Objective.To examine the magnitude and costs of ambulatory primary care, specialist physician care, and hospital service use for musculoskeletal disorders (MSDs) in Canada’s largest province, Ontario.Methods.Administrative health databases were analyzed for fiscal year 2013–2014 for adults aged ≥ 18 years, including data on physician services, emergency department (ED) visits, and hospitalizations. International Classification of Diseases diagnostic codes were used to identify MSD services. A validated algorithm was used to estimate direct medical costs. Person-visit rates and numbers of persons and visits were tabulated by care setting, age, sex, and physician specialty. Data were examined for all MSDs combined, as well as for specific diagnostic groupings.Results.Overall, 3.1 million adult Ontarians (28.5%) made over 8 million outpatient physician visits associated with MSDs. These included 5.6 million primary care visits. MSDs accounted for 560,000 (12.3%) of all adult ED visits. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, 8.5% to day surgery, and 61.2% associated with inpatient hospitalizations. Costs due to arthritis accounted for 40% of total MSD care costs ($639 million). MSD-related imaging costs were $169 million, yielding a total cost estimate of $1.8 billion for MSDs overall.Conclusion.MSDs place a significant and costly burden on the healthcare system. Health system planning needs to consider the large and escalating demand for care to reduce both the individual and population burden.

Purpose: To better understand patients’ perspectives on virtual care (VC) delivered by advanced practice physiotherapists (APPs) for hip/knee, foot/ankle, shoulder/elbow, and low back related symptoms. Method: A patient satisfaction questionnaire was developed and distributed electronically to all patients seen by APPs from August 1, 2020 to January 31, 2021. The questionnaire contained quantitative items using a 5-point Likert scale and open-ended questions that yielded qualitative findings. Descriptive statistics were applied to the quantitative data. Qualitative findings were analyzed using a qualitative description approach to identify recurrent themes. Results: Response rate was 74% (374/505) across all clinics. Videoconference was the most common delivery method (91.7%). Overall satisfaction with VC was very high (4.7–4.8/5). Emergent qualitative themes were related to Personal Connection; Preparatory Materials; Virtual Physical Examination; Practical Advantages of VC; Virtual Waiting Room; and Technical Issues. Conclusion: Overall, across several facets including personal connection, patient experience with VC for a variety of musculoskeletal conditions was rated high. Clinically, a systematic approach to the physical examination with preparatory patient education materials was key to positive patient experience.

Purpose To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA). Methods Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale. Results The study included 25 shoulders of 22 patients who completed baseline and 12 months’ patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA. Conclusions The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings. Level of Evidence Level II, randomized controlled trial.

OBJECTIVE The influence of sex on post-total knee arthroplasty (TKA) outcomes has been variable in the literature. Though sex is often reported as an averaged effect, we undertook this study to investigate whether sex modified the influence of presurgery characteristics on post-TKA knee pain. METHODS This was a prospective study with data derived from 477 TKA osteoarthritis patients (279 women, 198 men). Questionnaires were completed presurgery and at 3 months postsurgery. The association between 3-month post-TKA knee pain and presurgery covariates (body mass index, comorbidity count, symptomatic joint count, low back pain, knee pain, and depressive symptoms) was assessed by linear regression. Sex-specific effects were evaluated using interactions. RESULTS Women had significantly worse presurgery knee pain, joint count, and depressive symptoms, and worse postsurgery knee pain, than men. With simple covariate adjustment, no sex effect on pain was found. However, sex was found to moderate the effects of comorbidities (worse for women [P = 0.013]), presence of low back pain (worse for men [P = 0.003]), and depressive symptoms (worse for men [P < 0.001]) on postsurgery pain. Worse presurgery pain was associated with worse postsurgery pain similarly for women and men. CONCLUSION The influence of some patient factors on early post-TKA pain cannot be assumed to be the same for women and men; average effects may mask underlying associations. Results suggest a need to consider sex differences in understanding TKA outcomes, which may have important implications for prognostic tool development in TKA.

Background Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs. Methods MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated. Results Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation. Conclusion This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.

BACKGROUND CONTEXT An important step in improving spinal care is understanding how current health-care resources and associated cost are being utilized and distributed across a health-care system. PURPOSE Our objective was to examine the magnitude and distribution of direct health care costs for spinal conditions across physician type and hospital setting. DESIGN/SETTING Cross-sectional analysis of administrative health data for the fiscal year 2013–2014 from the province of Ontario, Canada. PATIENT SAMPLE Adult population aged 18+ years (N=10,841,302). OUTCOME MEASURES Person visit rates and total number of people and visits by specific care settings were calculated for all spinal conditions as well as stratified by nontrauma and trauma-related conditions. Variation in rates by age and sex was examined. The proportion of patients seeing physicians of different specialties was calculated for each condition grouping. Direct medical costs were estimated and their percentage distribution by care setting calculated for nontrauma and trauma-related conditions. Additionally, costs for spinal imaging overall and stratified by type of scan were determined. METHODS Administrative health databases were analyzed, including data on physician services, emergency department visits, and hospitalizations. ICD-9 and -10 diagnostic codes were used to identify nontraumatic (degenerative or inflammatory) and traumatic spinal disorders. A validated algorithm was used to estimate direct medical costs. RESULTS Overall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions; the majority (1.1 million) of these visits were for nontrauma conditions. Approximately, 86% of outpatient visits were in primary care. Emergency Department (ED) visits for nontrauma spinal conditions (130,000 out of 156,000 ED visits) accounted for 2.8% of all ED visits in the province. Total costs for spine-related care were $264 million (CDN) with 64% of costs due to nontrauma conditions. For these nontrauma conditions, ED visits cost $28 million for 130,000 visits ($215 per visit). For $32 million spent in primary care, 890,000 visits were made ($36 per visit). Spine imaging costs were $66.5 million, yielding a combined total of $330 million in health care spending for spinal conditions. CONCLUSIONS Spinal conditions place a large and costly burden on the health-care system. The disproportionate annual cost associated with ED visits represents a potential opportunity to redirect costs to fund more clinically and cost-effective models of care for nontraumatic spinal conditions.

Background Reverse total shoulder arthroplasty (RSA) with glenoid bone grafting has become a common option for management of glenoid bone loss associated with glenohumeral osteoarthritis. The objectives of this review were to determine (1) the rate of graft union, (2) the revision and complication rates, and (3) functional outcomes following primary RSA with glenoid bone grafting. Methods A comprehensive search of the MEDLINE, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was completed for studies reporting clinical outcomes following primary RSA with glenoid bone grafting. Pooled and frequency-weighted means were calculated where applicable. Results Overall, 11 studies and 393 patients were included in the study. The mean patient age was 73 ± 2.2 years, and the mean follow-up period was 34 ± 10 months. The overall graft union rate was 95%, but the rate was 97% among cases using autograft bone (8 studies, n = 254). When stratified by technique, concentric bone grafts had a 100% union rate (4 studies, n = 139). Conversely, eccentric grafts had an overall union rate of 92% (7 studies, n = 240), which improved to 94% when using autograft bone (4 studies, n = 115). At final follow-up, the revision rate was 2%, the complication rate was 18%, and there was consistent improvement in range of motion and functional outcome scores. Conclusion Glenoid bone grafting during primary RSA results in excellent early-term clinical outcomes, low complication and revision rates, and high rates of graft union.

In an effort to develop an effective source of clinically relevant cells and tissues for cartilage repair a directed differentiation method was used to generate articular chondrocytes and cartilage tissues from human embryonic stem cells (hESCs). It has previously been demonstrated that chondrocytes derived from hESCs retain a stable cartilage-forming phenotype following subcutaneous implantation in mice. In this report, the potential of hESC-derived articular-like cartilage to repair osteochondral defects created in the rat trochlea was evaluated. Articular cartilage-like tissues were generated from hESCs and implanted into the defects. After 6 and 12 weeks, the defects were evaluated histologically and immunohistochemically, and the quality of repair was assessed using a modified ICRS II scoring system. Following 6 and 12 weeks after implantation, hESC-derived cartilage tissues maintained their proteoglycan and type II collagen-rich matrix and scored significantly higher than control defects, which had been filled with fibrin glue alone. Implants were found to be well integrated with native host tissue at the basal and lateral surfaces, although implanted human cells and host cells remained regionally separated. A subset of implants underwent a process of remodeling similar to endochondral ossification, suggesting the potential for a single cartilaginous implant to promote the generation of new subchondral bone in addition to repair of the articular cartilage. The ability to create cartilage tissues with integrative and reparative properties from an unlimited and robust cell source represents a significant advance for cartilage repair that can be further developed in large animal models before clinical- setting application.

Disability reflects physical impairment and the influence of psychosocial factors. We investigated the relationship between disability and psychosocial factors in patients with upper extremity pathology. Ninety-two patients at a hand clinic were evaluated to assess disability, pain intensity, health status and psychosocial factors (pain catastrophizing, depression). Statistical analyses evaluated the relationships among disability and patient and psychosocial factors. Moderate levels of disability from all types of pathology were reported and associated with pain catastrophizing, pain and depression. Health status Short Form 36 domains were not correlated with disability as determined by Disabilities of the Arm, Shoulder and Hand (DASH) scores. A strong correlation was found between DASH and QuickDASH scores, but the QuickDASH scored significantly higher by 4 points. Pain catastrophizing was the strongest predictor of disability and explained 59% and 63% of variation in disability scores. Independent of pathology, those patients experiencing psychosocial issues, as well as demographic factors (i.e. employment status and age), were more likely to have disability with hand conditions and surgical procedures. We conclude from this study that psychological factors affect patient-reported outcomes. Level of evidence: IV

Background: Little is known regarding the rates and risk factors for long-term postoperative opioid use among opioid-naïve patients undergoing elective shoulder surgery. Purpose: To identify (1) the proportion of opioid-naïve patients undergoing elective shoulder surgery, (2) the rates of postoperative opioid use among these patients, and (3) the risk factors associated with long-term postoperative opioid use. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of a private administrative claims database was performed to identify those individuals who underwent elective shoulder surgery between 2007 and 2015. “Opioid-naïve” patients were identified as those patients who had not filled an opioid prescription in the 180 days before the index surgery. Within this subgroup, we tracked postoperative opioid prescription refill rates and used a logistic regression to identify patient variables that were predictive for long-term opioid use, which we defined as continued opioid refills beyond 180 days after surgery. Results were reported as odds ratios (ORs). Results: Over the study period, 79,287 patients were identified who underwent elective shoulder surgery, of whom 79.5% were opioid naïve. Among opioid-naïve patients, the rate of postoperative opioid use declined over time, and 14.6% of patients were still using opioids beyond 180 days. The greatest proportion of opioid-naïve patients still filling opioid prescriptions beyond 180 days postoperatively was seen after open rotator cuff repair (20.9%), whereas arthroscopic labral repair had the lowest proportion (9.8%). Overall, a history of alcohol abuse (OR 1.56), a history of depression (OR 1.46), a history of anxiety (OR, 1.31), female sex (OR, 1.11), and higher Charlson Comorbidity Index (OR 1.02) had the most significant influence on the risk for long-term opioid use among opioid naïve patients. Conclusions: Most patients were opioid naïve before elective shoulder surgery; however, among opioid-naïve patients, 1 in 7 patients were still using opioids beyond 180 days after surgery. Among all variables, a history of mental illness most significantly increased the risk of long-term opioid use after elective shoulder surgery.

Background Despite the optimization of biomechanical and patient factors in the setting of rotator cuff repair (RCR), postoperative retear rates remain high in many series reported in the literature. Preclinical studies have suggested bone marrow stimulation (BMS) at the rotator cuff footprint may reduce the rate of retear after RCR. The objective of this meta-analysis was to analyze the clinical evidence investigating the effect of arthroscopic RCR, with and without BMS, on rotator cuff healing and functional outcomes. Methods PubMed, MEDLINE, Embase, and the Cochrane Library were searched through December 2017. Two reviewers selected studies based on the inclusion criteria and assessed methodologic quality. Pooled analyses were performed for continuous and binomial variables where appropriate. Results Four studies (365 patients), including 2 Level I randomized controlled trials and 2 Level III retrospective comparative cohort studies were included. There was no statistical difference in the Disabilities of the Arm, Shoulder and Hand score, University of California Los Angeles Shoulder Rating Scale score, or the Constant score between the BMS and conventional repair groups. The pooled retear rates were 18.4% (28 of 152) and 31.8% (56 of 176) for patients treated with and without BMS, respectively. The pooled analysis of rotator cuff retear rates from the 4 studies (328 patients) showed a statistically significant difference favoring BMS over conventional repair (odds ratio, 0.42; 95% confidence interval, 0.25-0.73; P = .002; I2 = 0%). Conclusion BMS reduces the retear rate after RCR but shows no difference in functional outcomes compared with conventional repair. This study provides evidence for the use of BMS as a potential cost-effective biological approach toward improving rotator cuff healing.

Up to 30% of spine facet osteoarthritis patients with lumbar spinal stenosis (SF-OA ​+ ​LSS) have little to no improvement in their pain after surgery. Lack of meaningful improvement in pain following surgery provides a unique opportunity to identify specific predictive biomarker signatures that might be associated with the outcomes of surgical treatment. The objective of the present study was to determine whether a microRNA (miRNA) biomarker signature could be identified in presurgical blood plasma that corresponded with levels of SF-OA ​+ ​LSS patient post-surgical pain intensity one year later.RNA was extracted from baseline plasma of SF-OA ​+ ​LSS patients and prepared for miRNA sequencing. Statistical approaches were performed to identify differentially expressed miRNAs associated with reduced 1-year postsurgical pain (n ​= ​56). Using an integrated computational approach, we further created predicted gene and pathway networks for each identified miRNA.We identified a panel of 4 circulating candidate miRNAs (hsa-miR-155-5p, hsa-let-7e-5p, hsa-miR-125a-5p, hsa-miR-99b-5p) with higher levels at presurgical baseline that were associated with greater changes in % NPRS20Δ, reflecting reduced pain intensity levels at one year. Genes encoding hsa-let-7e-5p, hsa-miR-125a-5p, and hsa-miR-99b-5p are part of an evolutionarily conserved miRNA cluster. Using integrated computational analyses, we showed that mammalian target of rapamycin, transforming growth factor-β1 receptor, Wnt signaling, epithelial-mesenchymal transition regulators, and cholecystokinin signaling were enriched pathways of predicted gene targets.Taken together, our findings suggest that 4 presurgical baseline circulating miRNAs correlate with 1-year postsurgical SF-OA ​+ ​LSS patient pain intensity and represent possible candidate biomarker signature of surgical pain response.

As a result of the coronavirus disease 2019 (COVID-19) pandemic, tele-health for orthopedic care is expanding rapidly. The authors sought to identify the evidence describing the effectiveness, barriers, and clinical applications of telehealth for orthopedic assessments and consultations. MEDLINE, PubMed, EMBASE, and the Cochrane Library were searched from inception to March 2020. Forty-seven studies were included, with the most common conditions evaluated being trauma related and the primary modality being videoconferencing. Available literature supports the use of telehealth for orthopedic consultations and assessments because it yields moderate-to-high patient and provider satisfaction, accurate examinations, cost-effectiveness, and reduced wait times. Most commonly reported concerns were professional liability, network security, and technical issues. Given the COVID-19 pandemic, rapid implementation and uptake of virtual assessment for patient care has occurred. The current evidence suggests that telehealth is capable of providing prompt access to quality, cost-efficient orthopedic consultations and assessments. [ Orthopedics . 2021;44(4):198––206.]

Good Life with osteoArthritis in Denmark (GLA:D®) is a program for the management of patients with hip and knee osteoarthritis (OA). Adapted for the Canadian population, the GLA:DTM Canada program implements evidence-based strategies to support the prevention, early diagnosis and effective management of hip and knee OA. GLA:D assists local communities in implementing OA strategies across the spectrum of disease severity. An integral part of this program is a national quality and outcomes registry, which includes data concerning participant characteristics and both patient-reported and functional outcomes. This registry helps healthcare providers and healthcare decision makers ensure that individuals with OA receive effective, high-quality care through the GLA:D Canada program.

Objective: OsteoDIP aims to collect and provide, in a simple searchable format, curated high throughput RNA expression data related to osteoarthritis. Design: Datasets are collected annually by searching “osteoarthritis gene expression profile” in PubMed. Only publications containing patient data and a list of differentially expressed genes are considered. From 2020, the search has expanded to include non-coding RNAs. Moreover, a search in GEO for “osteoarthritis” datasets has been performed using ‘Homo sapiens' and ‘Expression profiling by array’ filters. Annotations for genes linked to osteoarthritis have been downloaded from external databases. Results: Out of 1204 curated papers, 63 have been included in OsteoDIP, while GEO curation led to the collection of 28 datasets. Literature data provides a snapshot of osteoarthritis research derived from 1924 human samples, while GEO datasets provide expression for additional 1012 patients. Similar to osteoarthritis literature, OsteoDIP data has been created mostly from studies focused on knee, and the tissue most frequently investigated is cartilage. GEO data sets were fully integrated with associated clinical data. We showcase examples and use cases applicable for translational research in osteoarthritis. Conclusions: OsteoDIP is publicly available at http://ophid.utoronto.ca/OsteoDIP. The website is easy to navigate and all the data is available for download. Data consolidation allows researchers to perform comparisons across studies and to combine data from different datasets. Our examples show how OsteoDIP can integrate with and improve osteoarthritis researchers’ pipelines.

Objective: MicroRNAs act locally and systemically to impact osteoarthritis (OA) pathophysiology, but comprehensive profiling of the circulating miRNome in early vs late stages of OA has yet to be conducted. Sequencing has emerged as the preferred method for microRNA profiling since it offers high sensitivity and specificity. Our objective was to sequence the miRNome in plasma from 91 patients with early [Kellgren–Lawrence (KL) grade 0 or 1 (n = 41)] or late [KL grade 3 or 4 (n = 50)] symptomatic radiographic knee OA to identify unique microRNA signatures in each disease state. Design: MicroRNA libraries were prepared using the QIAseq miRNA Library Kit and sequenced on the Illumina NextSeq 550. Counts were produced for microRNAs captured in miRBase and for novel microRNAs. Statistical, bioinformatics, and computational biology approaches were used to refine and interpret the final list of microRNAs. Results: From 215 differentially expressed microRNAs (FDR < 0.01), 97 microRNAs showed an increase or decrease in expression in ≥85% of samples in the early OA group as compared to the median expression in the late OA group. Increasing this threshold to ≥95%, seven microRNAs were identified: hsa-miR-335-3p, hsa-miR-199a-5p, hsa-miR-671-3p, hsa-miR-1260b, hsa-miR-191-3p, hsa-miR-335-5p, and hsa-miR-543. Four novel microRNAs were present in ≥50% of early OA samples and had 27 predicted gene targets in common with the prioritized set of predicted gene targets from the 97 microRNAs, suggesting common underlying mechanisms. Conclusion: Sequencing of well-characterized patient cohorts produced unbiased profiling of the circulating miRNome and identified a unique panel of 11 microRNAs in early radiographic knee OA.

Background Recent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty. Methods PubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means. Results Twenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits. Conclusion ED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.

Purpose To summarize the available evidence and examine the relationship between the critical shoulder angle (CSA) and (1) the incidence of chronic full-thickness rotator cuff tears (RCTs) and (2) outcomes after rotator cuff repair (RCR). Methods A comprehensive search of MEDLINE, Embase, and CINAHL was completed. Comparative studies were included and the influence of the CSA on either the incidence of chronic, full-thickness RCTs, or outcomes following RCR was evaluated. Demographic variables and outcomes were collected. Results Seven comparative studies analyzed the influence of the CSA on the incidence of chronic, full-thickness RCTs (the control group constituted patients with a normal rotator cuff). High heterogeneity limited pooling of studies, but the majority concluded that a greater CSA significantly increased the likelihood of a chronic, full-thickness RCT. Conversely, 5 comparative studies analyzed the influence of CSA on outcomes following RCR, and although a greater CSA was associated with a greater re-tear rate, the majority reported that CSA did not significantly influence postoperative functional outcomes, including patient-reported outcome measures (PROMs), range of motion (ROM), and strength. Conclusions Based on the available evidence, there appears to be a relationship between a greater CSA and the presence of a chronic, full-thickness RCT. Furthermore, a greater CSA may be associated with a greater re-tear rate following RCR; however, CSA does not appear to influence functional outcomes following RCR. Despite these observations, the available evidence is of poor quality, and the clinical utility and role of the CSA in the diagnosis and surgical management of a chronic, full-thickness RCT remains in question. Level of Evidence Level IV: Systematic review of Level II-IV studies.

OBJECTIVE To evaluate rates of prescription opioid use among patients with presurgical knee, hip, and spine osteoarthritis (OA) and associations between use and sociodemographic and health status characteristics. METHODS Participants were patients with presurgical, end-stage OA of the knee (n = 77), hip (n = 459), and spine (n = 168). Data were collected on current use of opioids and other pain medications, as well as measures of sociodemographic and health status variables and depression and pain (0-10 numeric rating scale). Rates of opioid use were calculated by sex, age, and surgical site. Multivariable logistic regression was used to examine associations between opioid use (sometimes/daily versus never) and other study variables. RESULTS The mean age of participants was 65.6 years; 55.5% were women, 15% of patients reported "sometimes" using opioids, and 15% reported "daily use." Use of opioids was highest among patients with spine OA (40%) and similar among patients with knee and hip OA (28% and 30%, respectively). Younger women (ages

Background The accuracy of surgeons in utilizing the clock face method for anchor placement has never been investigated. Our hypothesis was that shoulder arthroscopy surgeons would be able to place suture anchors at predetermined positions with accuracy and reliability. Methods Ten cadaveric shoulders were used. Five fellowship-trained shoulder arthroscopy surgeons were directed to place a suture anchor at 3:30, 4:30, and 5:30 clock in two shoulders each. The position of the anchors was determined with computed tomography. The accuracy of placement was calculated and data analyzed with one-way analysis of variance. The intraclass correlation coefficients were calculated. Results The overall accuracy was 57%. The accuracy of anchor placement at the 3:30 position was 40% (average position 2:24 o’clock), it was 50% at the 4:30 position (average position 3:42 o’clock) and 80% at the 5:30 position (average position 5:03 o’clock). No statistical difference in accuracy between the placement of the superior, middle, and inferior anchors (p = 0.145) was seen. The intraclass correlation coefficient for inter-surgeon reliability was 0.4 (fair) while the intraclass correlation coefficient for intra-surgeon reliability was 0.6 (moderate). Discussion The findings of this study suggest a moderate degree of accuracy and fair to moderate inter- and intra-surgeon reliability when using the clock face system to guide anchor placement.

The procedure for aspiration of bone marrow from the femur of patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) may vary from an OR (operating room) to OR based on the surgeon’s skill and may lead to varied extent of clotting of the marrow and this, in turn, presents difficulty in the isolation of mesenchymal stem cells (MSCs) from such clotted bone marrow. We present a simple detailed protocol for aspirating bone marrow from such patients, isolation, and characterization of MSCs from the aspirated bone marrow specimens and show that the bone marrow presented no clotting or exhibited minimal clotting. This represents an economical source and convenient source of MSCs from bone marrow for use in regenerative medicine. Also, we presented the detailed protocol and showed that the MSCs derived from such bone marrow specimens exhibited MSCs characteristics and generated micromass cartilages, the recipe for regenerative medicine for osteoarthritis. The protocols we presented can be used as standard operating procedures (SOPs) by researchers and clinicians.

Background: Clinical studies of shoulder dislocations typically include adult patients (>16 years of age). Only small case series of patients aged 10 to 16 years are available to guide management. Purpose: Using a cohort of patients aged 10 to 16 years, this study sought to determine (1) the incidence density rate (IDR) of primary anterior shoulder dislocations requiring closed reduction (CR) and (2) the rate of and risk factors for repeat shoulder CR. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: With use of administrative databases, patients aged 10 to 16 years who underwent CR of a primary anterior shoulder dislocation in Ontario, Canada, between April 2002 and September 2010 were gathered. IDRs for the entire cohort and demographic subgroups were calculated. The main outcome, repeat shoulder CR, was sought until September 2012. The cumulative incidence of repeat CR was calculated at multiple time points for the entire cohort and age subgroups. A competing risk model identified risk factors for repeat CR (reported as hazard ratios [HRs] with 95% CIs). Results: There were 1937 patients aged 10 to 16 years who underwent primary CR (median age, 15.0 years; 79.7% male). The incidence of primary CR was highest among male patients aged 16 years (164.4 per 100,000 person-years), but primary dislocations were rare in 10- to 12-year-old children (n = 115; 5.9% of all dislocations). Repeat CR was observed in 740 patients (38.2%) after a median of 0.8 years; however, the rate of repeat CR was age dependent: it was highest among 14- to 16-year-old patients (37.2%-42.3%) and considerably lower among 10- to 13-year-old patients (0%-25.0%). Male sex (HR, 1.2 [95% CI, 1.0-1.5]; P = .04) and older patient age (HR, 1.2 [95% CI, 1.1-1.3]; P < .001) significantly increased the odds of repeat CR. Conclusion: Among 14- to 16-year-old patients, the rate of primary and recurrent shoulder CR mirrors that of high-risk adults (17-20 years of age) from previously published data; however, the rate of shoulder CR (primary or recurrent) is considerably lower among 10- to 13-year-olds. In addition to older patient age, male sex increased the odds of repeat shoulder CR. Going forward, clinicians should counsel male patients and those aged 14 to 16 years regarding their increased risk of recurrence after the nonoperative management of a primary anterior shoulder dislocation.

Introduction Simple elbow dislocations treated by closed reduction are thought to result in a satisfactory return of function in most patients. Little, however, is known about how many patients ultimately proceed to subsequent surgical treatment due to the low patient numbers and significant loss to follow-up in the current literature. The purpose of this study was to establish the rate of and risk factors for subsequent surgical treatment after closed reduction of a simple elbow dislocation at a population level. Patients and methods All patients aged 16 years or older who underwent closed reduction of a simple elbow dislocation between 1994 and 2010 were identified using a population database. Subsequent procedures performed for joint contractures, instability or arthritis were recorded. Outcomes were modelled as a function of age, sex, income quintile, co-morbidity, urban/rural status, physician speciality performing the initial reduction and whether orthopaedic consultation and/or post-reduction radiograph was performed within 28 days of the injury, in a time-to-event analysis. Results We identified 4878 elbow dislocations with a minimum 2-year follow-up: stabilisation surgery was performed in 112 (2.3%) at a median time of 1 month, contracture release in 59 (1.2%) at median 9 months and arthroplasty in seven (0.1%) at median 25 months. Admission to hospital for the initial reduction was associated with an increased risk of undergoing stabilisation (hazard ratio (HR), 2.50; 95% confidence interval (CI), 1.67–3.74) and contracture release (HR, 1.93; CI, 1.08–3.44). Multiple reduction attempts increased the risk of requiring contracture release (HR, 3.71; CI, 1.22–11.29). Survival analysis demonstrated that all subsequent procedures had taken place by 4–5 years. Conclusion Few patients with simple elbow dislocations develop complications requiring surgery, but those that do most commonly undergo soft-tissue stabilisation or contracture release within 4 years of the injury. Contrary to current thinking, surgery for instability is performed more often than joint contracture release, albeit with slightly different time patterns.

Summary Objective We investigated whether pain at rest and pain on activity were differentially associated with neuropathic pain scores in individuals with end-stage hip and knee OA. Design Study participants were 843 patients with hip or knee OA scheduled for total joint arthroplasty. In pre-surgery questionnaires, measures of socio-demographics, health status, medication use, neuropathic pain (painDETECT), pain at rest and pain on activity (WOMAC pain items), depression (HADS) and pain catastrophizing (PCS) were collected. Multivariable linear regression models were estimated for men and women separately to examine the association between neuropathic pain scores (outcome) and study measures, entered in blocks. Results Sample mean age was 65.1 years (SD: 9.6); 57.1% were women. Mean painDETECT scores were significantly higher ( P ≤ 0.001) for women (11.2 ± 6.6 out of 38) than men (9.3 ± 7.0), with 35.6% of women and 27.7% of men meeting cut-offs for possible or likely neuropathic pain. In the final regression model for women, the coefficients for both types of pain were statistically significant, although the coefficient for pain at rest was 1.6 times greater than that for pain on activity. For men, only pain at rest was significantly associated with neuropathic pain scores. Conclusions Findings support that possible neuropathic pain is experienced by a notable proportion of patients with end-stage hip and knee OA and is more strongly associated with pain at rest than pain on activity, particularly in men. Clinical presentation of pain at rest may warrant more thorough evaluation for potential neuropathic pain and have implications for appropriate pain management.

Background Multijoint involvement in osteoarthritis (OA) has long been documented clinically and in the literature. Even so, the vast majority of OA research has focused on OA in individual joints, particularly the knees, hips or hands. In many “joint-specific” studies, the presence of multijoint symptoms are either ignored or peripherally considered in descriptive and analytical work. The implicit assumption is often that OA is OA, irrespective of whether a single joint or several joints are involved. Objectives To document the occurrence of multijoint symptoms in a clinical sample of individuals with knee and hip OA scheduled for orthopaedic surgery. To examine the joint sites involved and investigate whether the extent of joint involvement is related to demographic and health characteristics. Methods Patients scheduled for total knee or hip replacement for end-stage OA were consecutively recruited from an academic hospital in Toronto, Canada. A health questionnaire completed prior to surgery captured demographic characteristics (age, sex), symptomatic joints other than the surgical joint (right and left shoulders, elbows, wrists, hands, hips, knees, feet, ankle, neck and back), body mass index (BMI), comorbidities (hypertension, depression, diabetes, migraine headaches, cancer, respiratory disease, heart disease, stomach/bowel disease, stroke) and WOMAC hip- and knee-specific pain and function. Results Study questionnaires were completed by 366 hip and 407 knee patients. The mean age of the sample was 65 years (SD=9.2; range 38–89 years), 57% were female. The most frequently reported symptomatic joints among knee patients were the contralateral knee (53.2%), one or both hands (32.1%), and the upper-, mid- or lower-back (31.0%), and among hip patients were one or both knees (49.4%), the back (36.6%), and the contralateral hip (21.3%). The overall mean number of symptomatic joints other than the surgical joint was 3.0 (SD=3.2; range 0–17). Only 19.0% reported the surgical joint as the only symptomatic joint; 23.0% reported 5 or more additional symptomatic joints. Mean hip/knee-specific pain and function scores were significantly worse with increasing symptomatic joint count (p Conclusions In this clinical OA sample, the “average” patient reported multiple symptomatic joints. Increasing age was not associated with increasing frequency of symptomatic joints. Irrespective of age and obesity, multiple symptomatic joints were the rule, not the exception. It was notable that the frequency of co-occurring conditions increased with increasing symptomatic joint count. This may suggest a need to re-examine how OA is characterized and perhaps its underlying etiology as it relates to single vs. multi-joint involvement. Disclosure of Interest None declared

Background: Reoperation rates following open reduction and internal fixation (ORIF) of midshaft clavicle fractures have been described, but reported rates of nonunion, malunion, infection, and implant removal have varied. We sought to establish baseline rates of, and risk factors for, reoperations following clavicle ORIF in a large population cohort. Methods: Administrative databases were used to identify patients sixteen to sixty years of age who had undergone an ORIF of a closed, midshaft clavicle fracture from April 2002 to April 2010. The primary outcome was a reoperation within two years (isolated implant removal, irrigation and debridement [deep infection], pseudarthrosis reconstruction [nonunion], or clavicle osteotomy [malunion]). The secondary outcome was rare perioperative complications, including pneumothorax, subclavian vasculature injury, and brachial plexus injury. A multivariable logistic regression analysis was performed to determine the influence of patient and provider factors on these outcomes. Results: We identified 1350 patients who underwent midshaft clavicle ORIF (median age, thirty-two years [interquartile range, twenty-one to forty-four years]; 81.3% male). One in four patients (24.6%) underwent at least one clavicle reoperation. The most common procedure was isolated implant removal (18.8%), and females were at highest risk (odds ratio [OR], 1.7; p = 0.002). The median time to implant removal was twelve months. A reoperation secondary to nonunion, deep infection, and malunion occurred in 2.6%, 2.6%, and 1.1% of the patients after a median of six, five, and fourteen months, respectively. Risk factors for clavicle nonunion included female sex (OR, 2.2; p = 0.04) and a high comorbidity score (OR, 2.8; p = 0.009). For surgeons, fewer years in practice was associated with a small risk of the patient developing an infection (OR, 1.1; p < 0.001). Sixteen pneumothoraces (1.2%) were identified; however, brachial plexus and subclavian vessel injuries were each found in five or fewer patients. Conclusions: Following clavicle ORIF, one in four patients underwent a reoperation. The most common procedure was implant removal, and although the rates of reoperations secondary to nonunion, malunion, and infection were low they were higher than previously reported. Pneumothoraces and neurovascular injuries were infrequent and should continue to be considered rare complications of clavicle ORIF. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purpose To assess orthopaedic trainees performing diagnostic knee arthroscopies and evaluate procedural competence using a novel statistical method, the Cumulative Summation Test for Learning Curve (LC-CUSUM). Methods Twenty orthopaedic trainees in postgraduate year (PGY) 1 through 5 performed diagnostic knee arthroscopy and were evaluated intraoperatively with a validated 10-point knee task-specific checklist (TSCL) and 50-point global rating scale (GRS). A score of 40 points or greater (of 50 points) for the GRS and 8 points or greater (of 10 points) for the knee TSCL was considered to indicate a successful procedure. For the LC-CUSUM analysis, adequate performance was defined as a 10% failure rate, inadequate performance was defined as a 30% failure rate, and an acceptable deviation from adequate performance was defined as 10%. A limit h equal to 1.6 was selected to give a true-discovery rate of 90% and a false-discovery rate of 10% over 50 procedures. Results A total of 340 consecutive procedures were performed by 20 trainees during the 12-month study period. The cumulative number of arthroscopic procedures performed by trainees before study start increased with increasing PGY. The median number of arthroscopic procedures performed per trainee was 16.5 (interquartile range, 14 to 21.75). Competency in knee arthroscopy for the TSCL was achieved by 8 trainees (40%), after a median of 16 procedures (interquartile range, 13 to 20), and for the GRS by only a single trainee (5%), after 14 procedures. Threshold-adjusted curves stratified by PGY level enabled multiple trainees to achieve competency for both the TSCL and GRS. Conclusions The LC-CUSUM can be successfully applied to knee arthroscopy to provide an individualized assessment of performance and quantitatively demonstrate competency for basic arthroscopic tasks. Clinical Relevance The LC-CUSUM is an effective method to evaluate procedure competence in arthroscopic training and can provide objective feedback and benchmarks in the learning phase.

Background Knowledge of the factors that influence the willingness of patients considering elective orthopaedic surgery is essential for patient-centered care. To date, however, these factors remain undefined in the orthopaedic population with shoulder and elbow disorders.

Background:There is a lack of high-quality population-based literature describing the epidemiology of primary anterior shoulder dislocation.Purpose:To (1) calculate the incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR; “index event”) in the general population and demographic subgroups, and (2) determine the rate of and risk factors for repeat shoulder CR.Study Design:Cohort study (prognosis); Level of evidence, 2.Methods:All patients who underwent shoulder CR by a physician in Ontario between April 2002 and September 2010 were identified with administrative databases. Exclusion criteria included age 70 years, posterior dislocation, and prior shoulder dislocation or surgery. Index event IDR was calculated for all populations/subgroups, and IDR comparisons were made. Repeat shoulder CR was sought until September 2012. Risk factors for repeat shoulder CR were identified with a Prentice, Williams, and Peterson proportional hazards model.Results:There were 20,719 persons (median age, 35 years; 74.3% male) who underwent a shoulder CR after a primary anterior shoulder dislocation (23.1/100,000 person-years). The IDR was highest among young males (98.3/100,000 person-years). A total of 3940 (19%) patients underwent repeat shoulder CR after a median of 0.9 years, of which 41.7% were ≤20 years of age. Less than two-thirds of all first repeat shoulder CR events occurred within 2 years; in fact, 95% occurred within 5 years. The risk of repeat shoulder CR was lowest if the primary reduction had been performed by an orthopaedic surgeon (hazard ratio [HR], 0.76; 95% CI: 0.64, 0.90; P = .002) or was associated with a humeral tuberosity fracture (HR, 0.71; CI, 0.53, 0.95; P = .02). Older age (HR, 0.97; CI, 0.97, 0.98; P < .0001) and higher medical comorbidity score (HR, 0.92; CI, 0.87, 0.98; P = .009) were also protective. Risk was highest among males (HR, 1.26; CI, 1.16, 1.36; P < .0001) and patients from low-income neighborhoods (HR, 1.23; CI, 1.13, 1.34; P < .0001).Conclusion:Young male patients have the highest incidence of primary anterior shoulder dislocation requiring CR and the greatest risk of repeat shoulder CR. Patient, provider, and injury factors all influence repeat shoulder CR risk. A comprehensive understanding of the epidemiology of primary anterior shoulder dislocation will aid management decisions and injury prevention initiatives.

Purpose The objective of our study was to summarize the available clinical evidence pertaining to the combined arthroscopic Bankart repair and remplissage procedure (BRR) for the management of recurrent anterior glenohumeral instability. Methods We searched Medline (1946 to the third week of November, 2012), the Cochrane Central Register of Controlled Trials, Embase (1947 to the 50th week of 2012), and PubMed for studies that reported clinical outcome data at a minimum of 1 year after BRR. Two independent reviewers selected studies for inclusion, assessed methodological quality, and extracted relevant data. Clinical outcome data were pooled and summarized. Results Seven clinical studies with a total of 220 patients met the inclusion criteria. Mean patient age was 29 years and mean follow-up was 26 months. Among all studies, the pooled rate of recurrent dislocation after BRR was 3.4%. Compared with preoperative range of motion (ROM) and ROM after Bankart repair (BR) for similar pathologic conditions, there were no clinically significant losses in glenohumeral motion after BRR. Moreover, BRR resulted in favorable functional outcome scores and high patient satisfaction. Four studies reported on postoperative imaging and found high rates of healing and tissue fill-in at the site of infraspinatus tenodesis. Conclusions After BRR, the rate of recurrent dislocation is low and there are no clinically significant losses in glenohumeral ROM. Moreover, functional outcome scores are good and there is a high rate of patient satisfaction. Going forward, there is a need for high-level clinical studies to support the findings of this systematic review and to develop an evidence-based approach to the management of patients with recurrent glenohumeral instability in the setting of a Hill-Sachs defect (HSD). Level of Evidence Level IV, systematic review of Level II, III, and IV studies.

Purpose Failed anterior shoulder stabilization procedures have traditionally been treated with open procedures. Recent advances in arthroscopic techniques have allowed for certain failed stabilization procedures to be treated by arthroscopic surgery. The aim of this systematic review was to determine the outcomes of revision arthroscopic Bankart repair. Methods We searched Medline, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) for articles on revision arthroscopic Bankart repairs. Key words included shoulder dislocation, anterior shoulder instability, revision surgery, and arthroscopic Bankart repair. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Results We included 16 studies comprising 349 patients. All studies were retrospective (1 Level II study and 15 Level IV studies). The mean incidence of recurrent instability after revision arthroscopic Bankart repair was 12.7%, and the mean follow-up period was 35.4 months. The most common cause for failure of the primary surgeries was a traumatic injury (62.1%), and 85.1% of patients returned to playing sports. The reasons for failure of revision cases included glenohumeral bone loss, hyperlaxity, and return to contact sports. Conclusions With proper patient selection, the outcomes of revision arthroscopic Bankart repair appear similar to those of revision open Bankart repair. Prospective, randomized clinical trials are required to confirm these findings. Level of Evidence Level IV, systematic review of Level II and Level IV studies.

Based on short-term (1 year or less) followup, primary fixation of displaced midshaft clavicle fractures reportedly results in better function compared with that reported for nonoperative methods. Whether better function persists beyond 1 year is unclear.For displaced midshaft clavicle fractures, do the better mean Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley Shoulder (CSS) scores for operative versus nonoperative treatment at 1 year change between 1- and 2-year followup?We previously reported 132 patients in a randomized prospective trial at 1 year, and here we report a further followup of 95 of the 132 patients (72%) at 2 years after injury. We evaluated all patients with the DASH and CSS scores.The mean DASH and CSS scores were similar at 2 years compared with 1 year postinjury for both the nonoperated and operated patients. The mean scores for the operated patients remained higher than those in the nonoperative group (DASH operative 4.1 ± 7.0 versus DASH nonoperative 11.4 ± 19.7, CSS operative 97.1 ± 4.5 versus CSS nonoperative 91.6 ± 14.1) at 2 years postinjury.The improvement in DASH and CSS scores seen with primary fixation of displaced clavicle fractures persists at 2 years but does not differ from values seen after 1 year of followup, suggesting a clinical steady state has been reached whereby outcome is unlikely to change with time.Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Loosening of the humeral component is rarely a cause for revision. This study was conducted to determine long-term survivorship of humeral components and investigate the risk factors associated with humeral component removal or revision. Materials and methods From 1984 to 2004, 1423 patients underwent 1584 primary Neer and Cofield shoulder arthroplasties. The Kaplan-Meier method was used to estimate implant survival. Cox proportional hazards regression was used to assess the effects of age, gender, etiology of the disease, surgery type (hemi vs total), fixation (cemented vs noncemented), and the humeral component design (Neer II, Cofield 1 or 2) with survival free of revision or removal of the humeral component. Results There were 108 revisions and 17 removals of the humeral component. Estimates of survivorship free of revision or removal of the humeral component for any reason was 94.8% (95% confidence interval [CI], 93.6-96.0) at 5 years, 92.0% (95% CI, 90.4-93.6) at 10 years, 86.7% (95% CI, 84.2-89.4) at 15 years, and 82.8% (95% CI, 78.5-87.5) at 20 years. Younger age, male gender, replacement due to posttraumatic arthritis, an uncemented component, and use of a metal-backed glenoid component increased the likelihood of humeral component failure. Conclusions The need for revision of the humeral component is commonly related to glenoid or glenoid component issues. Patient and diagnostic factors play a role in implant survival; implant type and method of fixation are less important. Level of evidence Level 4; Case series, treatment study.

Between 1976 and 2004, 38 revision arthroplasties (35 patients) were performed for aseptic loosening of the humeral component. The mean interval from primary arthroplasty to revision was 7.1 years (0.4 to 16.6). A total of 35 shoulders (32 patients) were available for review at a mean follow-up of seven years (2 to 19.3). Pre-operatively, 34 patients (97%) had moderate or severe pain; at final follow-up, 29 (83%) had no or only mild pain (p < 0.0001). The mean active abduction improved from 88° to 107° (p < 0.01); and the mean external rotation from 37° to 46° (p = 0.27). Excellent or satisfactory results were achieved in 25 patients (71%) according to the modified Neer rating system. Humeral components were cemented in 29, with ingrowth implants used in nine cases. There were 19 of standard length and 17 were longer (two were custom replacements and are not included). Bone grafting was required for defects in 11 humeri. Only two glenoid components were left unrevised. Intra-operative complications included cement extrusion in eight cases, fracture of the shaft of the humerus is two and of the tuberosity in four. There were four re-operations, one for recurrent humeral loosening, with 89% survival free of re-operations at ten years. Revision surgery for aseptic loosening of the humeral component provides reliable pain relief and modest improvement of movement, although there is a substantial risk of intra-operative complications. Revision to a total shoulder replacement gives better results than to a hemiarthroplasty.

Among hand injuries, exor tendon lacerations remain a challenge for hand surgeons. There are presently no therapeutic agents available for the prevention of tendon adhesions. It is already known that TGF-1 plays a role in tendon healing as well as in adhesion formation. Anti-TGF-1 therapies are not eective in preventing adhesion formation. The goal of the present study was to identify possible genes that are aected by TGF-1 in human Flexor Digitorum Profundus (FDP) tendon cells (tenocytes) in vitro. Tenocytes were isolated from human FDP tendons and treated with TGF-1 in low-serum cell culture medium. Gene expression was assessed at 6h and 24h using RTPCR. TGF-1 caused upregulation of several genes (SERPINE1, PLAU, ACTA2, CTGF, FN1, COL1A1, COL3A1, LOX, COMP, MMP13, TIMP1, TIMP3, BGN, SCX, POSTN, SMAD7, IL6, IGF1), downregulation of MMP9, DCN and ACAN, and had no eect on MMP2 and TIMP2. Targeting TGF-1-aected genes may be an alternative therapeutic approach in controlling adhesion formation that may lead to optimal healing of injured FDP tendon or FDP tendon graft.

Objectives: The existing medial meniscectomy (MMx) procedure in rodents involves transection of MCL and wide opening of the knee capsule followed by meniscus transection that results into articular cartilage degeneration and causes significant changes in subchondral bone at specific post-MMx period. These animals serve as experimental osteoarthritis (OA) models. Structurally, knee is very complex. There may be a need to uncouple articular cartilage degenerative changes from subchondral bone degenerative changes in experimental OA models. Therapeutical drugs/agents, designed to treat articular cartilage degenerative changes of OA knee, may not be effective to treat subchondral bone degenerative changes or vice versa. The purpose of the study was to modify the existing MMx procedure to a less invasive procedure so that it causes only articular cartilage degenerative OA changes and no subchondral bone changes. This will serve as an early OA model to target degenerative changes in articular cartilage in human. Methods: Ten 8-9 weeks old male athymic nude rats underwent less invasive MMx on right knee; the left knee served as unoperated control. The surgery involved no transection of MCL and opening of knee capsule wide. The medial meniscus was pulled out from a slit made on the medial aspect of the knee capsule, and was transected. At 10 weeks post-MMx, animals were sacrificed and knees were assessed. Results: There was no significant alteration in bone strength parameters (BV/TV, Tb.Th, Tb.Sp, Tb.N, Tb.Pf, cortical wall thickness) in subchondral bone in the less invasive MMx knee as analyzed by μCT. X-ray radiography did not indicate the presence of any osteophyte at the knee margins. On the other hand, the less invasive MMx caused degenerative changes in articular cartilage as follows: fibrillation and thinning in the medial tibia; narrowing of medial knee joint; reduced proteoglycans shown by safranin-O staining; decreased metachromasia by PSR staining; alteration in collagen fibril thickness under cross-polarization light. Immunohistochemical expression was reduced (COL-II, aggrecan), increased (NITEGE, Col2-3/4m, COL-X, and MMP13) or imbalanced (lubricin) in articular cartilage thickness of less invasive MMx knee. Conclusion: The less invasive MMx procedure, in rat, can be a model for early or less severe human OA due to articular cartilage degenerative changes only and with no subchondral bone degenerative changes in the knee synovial joint. The therapeutical drugs/agents designed to repair articular cartilage may be suitable for this model and may lead to treatment of early or less severe human OA.

Common standard practice after complex arthroscopic elbow surgery includes hospital admission for 72 h. The authors hypothesized that an expedited care pathway, with 24 h of hospital admission and ambulatory brachial plexus analgesia and continuous passive motion at home, results in equivalent elbow range of motion (ROM) 2 weeks after surgery compared with standard 72-h hospital admission.A randomized, single-blinded study was conducted after obtaining approval from the research ethics board. Forty patients were randomized in a 1:1 ratio using a computer-generated list of random numbers into an expedited care pathway group (24-h admission) and a control group (72-h admission). They were treated equally aside from the predetermined hospital length of stay.Patients in the control (n = 19) and expedited care pathway (n = 19) groups achieved similar elbow ROM 2 weeks (119 ± 18 degrees and 121 ± 15 degrees, P = 0.627) and 3 months (130 ± 18 vs. 130 ± 11 degrees, P = 0.897) postoperatively. The mean difference in elbow ROM at 2 weeks was 2.6 degrees (95% CI, -8.3 to 13.5). There were no differences in analgesic outcomes, physical function scores, and patient satisfaction up to 3 months postoperatively. Total hospital cost of care was 15% lower in the expedited care pathway group.The results suggest that an expedited care pathway with early hospital discharge followed by ambulatory brachial plexus analgesia and continuous passive motion at home is a cost-effective alternative to 72 h of hospital admission after complex arthroscopic elbow surgery.

Background: For early stages of osteonecrosis, preservation of the femoral head is the primary objective; however, there has not been a consensus on how best to achieve this goal. Core decompression alone is associated with a lack of structural support with inconsistent outcomes, whereas vascularized fibular grafting requires an extensive surgical procedure with high donor-site morbidity and prolonged rehabilitation. The adjunctive use of a porous tantalum implant offers the advantages of core decompression, structural support, minimally invasive surgery, and no donor-site morbidity. The purpose of this study was to assess the survivorship and to evaluate the clinical results and radiographic outcomes of hips in which osteonecrosis of the femoral head was treated with core decompression and a porous tantalum implant. Methods: We evaluated fifty-four patients (sixty consecutive hips) in whom osteonecrosis of the femoral head was treated with core decompression and insertion of a porous tantalum implant. Fifty-two patients (fifty-eight hips) were available for follow-up at a mean of twenty-four months. All patients were sixty-five years of age or younger (mean age, thirty-five years). According to the classification system of Steinberg et al., one hip (2%) had stage-I disease, forty-nine hips (84%) had stage-II disease, and eight hips (14%) had stage-III disease. Outcome measures that were used included a limb-specific score (Harris hip score), radiographic outcome measures, and survivorship analysis with revision to total hip arthroplasty as the end point. Results: Overall, nine hips (15.5%) were converted to total hip arthroplasty, including six with stage-II disease and three with stage-III disease. The overall survival rates were 91.8% (95% confidence interval, 87.8% to 95.8%) at twelve months, 81.7% (95% confidence interval, 75.8% to 87.6%) at twenty-four months, and 68.1% (95% confidence interval, 54.7% to 81.5%) at forty-eight months. The absence of chronic systemic diseases resulted in a survival rate of 92% at forty-eight months (95% confidence interval, 87.4% to 96.4%). Conclusions: Treatment of early stage osteonecrosis of the femoral head with core decompression and a porous tantalum implant can be accomplished with a minimally invasive technique and no donor-site morbidity. The early clinical results show encouraging survival rates in patients who do not have chronic systemic disease, especially in association with early stage disease. Level of Evidence: Therapeutic Level IV. See Instructions to Authors on [jbjs.org][1] for a complete description of levels of evidence. [1]: http://jbjs.org

Endothelin-1 (ET-1) is implicated in the signaling between vascular endothelial cells (VECs) and osteoblasts during bone development, remodeling and repair. Vascular endothelial growth factor (VEGF) also plays an important role in these intercellular interactions. Our objectives were to identify which specific VEGF isoforms were produced during osteoblastic proliferation and differentiation and to determine the effects of ET-1 on VEGF mRNA and protein production by osteoblastic cells. Semiquantitative reverse transcription polymerase chain reaction (RT-PCR) and ELISA were used to evaluate VEGF mRNA isoform expression and protein synthesis at different stages of ET-1-induced osteoblastic differentiation in fetal rat calvaria (FRC) osteoblastic cells. Three VEGF mRNA isoforms were identified corresponding to VEGF 120 , VEGF 164 and VEGF 188 . Predominant isoforms VEGF 120 and VEGF 164 had a bimodal expression that increased in the early proliferation and late mineralization phases. ET-1 stimulated osteoblastic proliferation and differentiation, but surprisingly, ET-1 down-regulated VEGF mRNA and protein expression and sustained the down-regulation over time in long-term cultures. Time course studies showed that ET-1 inhibited VEGF mRNA expression after incubation for 3 h in 7- and 14-day FRC cell cultures. Similarly, ET-1 inhibited VEGF protein secretion by 5.8- and 2.8-fold in 7- and 14-day FRC cells, respectively. VEGF-A protein secretion was inhibited by ET-1 in a dose-dependent manner with a maximal effect at 10 −7 M. This study supports a novel inhibitory role for ET-1 on VEGF synthesis in osteoblastic cells as a feedback mechanism in the temporal and spatial coupling of angiogenesis to bone formation and resorption.

Shoulder Shoulder osteoarthritis (OA) is common. Primary shoulder OA is the most common form. The most common type of secondary shoulder OA is rotator cuff arthropathy and is believed to be related to a decoupling of forces about the humeral head. Typical presentation is activity-related shoulder pain and loss of shoulder range of motion. Physical exam should include an assessment of the rotator cuff and axillary nerve. Standard radiographs are often sufficient to make diagnosis, but cross-sectional imaging may be indicated to identify bone loss (CT) or soft tissue deficiencies (MRI/ultrasound). Nonoperative care can include physical therapy, pharmacotherapy, and intra-articular injections (cortisone and hyaluronic acid), but evidence for or against these treatments is limited. Surgical management of end-stage shoulder OA includes arthroscopic debridement, interposition arthroplasty (glenoid resurfacing), humeral head resurfacing, hemiarthroplasty, anatomic total shoulder arthroplasty, and, in low demand patients with a deficient rotator cuff, reverse total shoulder arthroplasty. In young patients with end-stage shoulder OA, arthroplasty has high failure rates secondary to either glenoid erosion (hemiarthroplasty) or glenoid component loosening (anatomic total shoulder arthroplasty). For older patients with end-stage shoulder OA and an intact rotator cuff, anatomic total shoulder arthroplasty is recommended.

1. Precision medicine, or what patients and the media often call personalized medicine, aims to utilize molecular profiles of patient biospecimens and increasingly precise outcome metrics from diverse biosensors to more accurately diagnose a disease, tailor the therapy a patient receives, and monitor response. 2. In order to accomplish the goals of precision medicine in osteoarthritis, several key components of biomedical research (target identification, marker identification, molecular mechanisms) and clinical medicine (treatment, diagnosis, health outcomes) must be seamlessly integrated across several data repositories (clinical records, biospecimen, -omics databases) and analyzed using integrative data mining and iterative learning strategies. 3. A clinically meaningful and feasible strategy is required for identifying OA phenotypes for targeted treatment. 4. The OA Data Integration Platform (OADIP) provides comprehensive, expert curated clinical and molecular data repository across OA. Advances in molecular profiling, interoperability, integration, and exchange of data combined with machine learning techniques will enable comprehensive signatures for OA subtypes to be identified and targeted for treatment and discovery. 5. The feasibility and reality of precision medicine for OA are on the horizon as we strive to provide the right care to the right patient at the right time.

Background Simple elbow dislocations are often treated with closed reduction (CR); however, the rate of CR failure and factors that may predict failure have been largely underinvestigated. The objectives of this study were (1) to determine the incidence of elbow dislocations treated by CR in a universal health care system and (2) to identify patient characteristics associated with failed CR, defined as the subsequent need for open reduction. Methods Patients ≥16 years old who underwent elbow CR by a physician between 1994 and 2010 were identified from administrative databases. Concurrent elbow fractures were excluded. The incidence density rate (IDR) of CR per 100,000 eligible person-years among the general population was calculated. Failed CR was defined as subsequent open reduction with or without ligament repair or reconstruction within 90 days. Patient and provider characteristics were modeled in a multivariate logistic regression for failure. Results The cohort consisted of 4878 patients (median age, 41 years) who underwent CR (IDR, 2.65 per 100,000 person-years), and 75 (1.5%) underwent subsequent open reduction with or without ligament repair or reconstruction (median time, 15 days). Young men (≤20 years) had the highest IDR (7.45 per 100,000 person-years), twice that of young women ( P = .005). Patient characteristics associated with failed CR included older age ( P = .001), admission to the hospital ( P 1 attempted CR ( P = .001), and new orthopedic consultation in the 4 weeks after the CR ( P = .02). Conclusion Young men are at highest risk for CR for simple elbow dislocations; however, older patients are more likely to require open intervention, as are those with markers of a difficult reduction signifying potentially greater soft tissue damage. A comprehensive understanding of the epidemiology of simple elbow dislocation will aid management decisions.