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AimsThis study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA).MethodsData for this study were collected from the National Surgery Quality Improvement Program (NSQIP) database from the year 2018. Patients who received a primary, elective, unilateral TKA with a diagnosis of primary osteoarthritis were included. Demographic, preoperative, and intraoperative variables were analyzed. The ANN model was compared to a logistic regression model, which is a conventional machine-learning algorithm. Variables collected from 28,742 patients were analyzed based on their contribution to hospital length of stay.ResultsThe predictability of the ANN model, area under the curve (AUC) = 0.801, was similar to the logistic regression model (AUC = 0.796) and identified certain variables as important factors to predict same-day discharge. The ten most important factors favouring same-day discharge in the ANN model include preoperative sodium, preoperative international normalized ratio, BMI, age, anaesthesia type, operating time, dyspnoea status, functional status, race, anaemia status, and chronic obstructive pulmonary disease (COPD). Six of these variables were also found to be significant on logistic regression analysis.ConclusionBoth ANN modelling and logistic regression analysis revealed clinically important factors in predicting patients who can undergo safely undergo same-day discharge from an outpatient TKA. The ANN model provides a beneficial approach to help determine which perioperative factors can predict same-day discharge as of 2018 perioperative recovery protocols.Cite this article: Bone Joint J2021;103-B(8):1358–1366.

AimsSurgeons commonly resect additional distal femur during primary total knee arthroplasty (TKA) to correct a flexion contracture, which leads to femoral joint line elevation. There is a paucity of data describing the effect of joint line elevation on mid-flexion stability and knee kinematics. Thus, the goal of this study was to quantify the effect of joint line elevation on mid-flexion laxity.MethodsSix computational knee models with cadaver-specific capsular and collateral ligament properties were implanted with a posterior-stabilized (PS) TKA. A 10° flexion contracture was created in each model to simulate a capsular contracture. Distal femoral resections of + 2 mm and + 4 mm were then simulated for each knee. The knee models were then extended under a standard moment. Subsequently, varus and valgus moments of 10 Nm were applied as the knee was flexed from 0° to 90° at baseline and repeated after each of the two distal resections. Coronal laxity (the sum of varus and valgus angulation with respective maximum moments) was measured throughout flexion.ResultsWith + 2 mm resection at 30° and 45° of flexion, mean coronal laxity increased by a mean of 3.1° (SD 0.18°) (p < 0.001) and 2.7° (SD 0.30°) (p < 0.001), respectively. With + 4 mm resection at 30° and 45° of flexion, mean coronal laxity increased by 6.5° (SD 0.56°) (p < 0.001) and 5.5° (SD 0.72°) (p < 0.001), respectively. Maximum increased coronal laxity for a + 4 mm resection occurred at a mean 15.7° (11° to 33°) of flexion with a mean increase of 7.8° (SD 0.2°) from baseline.ConclusionWith joint line elevation in primary PS TKA, coronal laxity peaks early (about 16°) with a maximum laxity of 8°. Surgeons should restore the joint line if possible; however, if joint line elevation is necessary, we recommend assessment of coronal laxity at 15° to 30° of knee flexion to assess for mid-flexion instability. Further in vivo studies are warranted to understand if this mid-flexion coronal laxity has negative clinical implications.Cite this article: Bone Joint J2021;103-B(6 Supple A):87–93.

AimsMany patients undergoing total knee arthroplasty (TKA) have severe osteoarthritis (OA) in both knees and may consider either simultaneous or staged bilateral TKA. The implications of simultaneous versus staged bilateral TKA for return to work are not well understood. We hypothesized that employed patients who underwent simultaneous bilateral TKA would have significantly fewer days missed from work compared with the sum of days missed from each operation for patients who underwent staged bilateral TKA.MethodsThe prospective arthroplasty registry at the Hospital for Special Surgery was used. Baseline characteristics and patient-reported outcome scores were evaluated. We used a linear regression model, adjusting for potential confounding variables including age, sex, preoperative BMI, and type of work (sedentary, moderate, high activity, or strenuous), to analyze time lost from work after simultaneous compared with staged bilateral TKA.ResultsWe identified 152 employed patients who had undergone simultaneous bilateral TKA and 61 who had undergone staged bilateral TKA, and had completed the registry’s return to work questionnaire. The simultaneous group missed a mean of 46.2 days (SD 29.1) compared with the staged group who missed a mean total of 68.0 days of work (SD 46.1) when combining both operations. This difference was statistically significant (p < 0.001). In multivariate mixed regression analysis adjusted for age, sex, BMI, American Society of Anesthesiologists status, and type of work, the simultaneous group missed a mean of 16.9 (SD 5.7) fewer days of work compared with the staged group (95% confidence interval 5.8 to 28.1; p = 0.003).ConclusionEmployed patients undergoing simultaneous bilateral TKA missed a mean of 17 fewer days of work as a result of their surgical treatment and rehabilitation compared with those undergoing staged bilateral TKA. This information may be useful to surgeons counselling employed patients with bilateral OA of the knee who are considering surgical treatment.Cite this article: Bone Joint J2021;103-B(6 Supple A):108–112.

In response to recent concerns about the accuracy of suture passage during arthroscopic remplissage, this study was conducted to determine whether a previously described “safe zone” technique can improve the accuracy of suture passage. A recommended safe zone technique was used for arthroscopic remplissage on 6 cadaveric specimens. The safe zone was described as a region at least 1 cm lateral and no greater than 3 cm distal to the posterolateral acromion. Results were compared with a control group of 6 specimens for which the safe zone technique was not used. For each group, 24 suture passes were performed. In the safe zone group, 83.3% (20 of 24) of sutures passed through the infraspinatus tendon. This was a significant improvement compared with the control group, in which only 25% (6 of 24) of sutures pierced the infraspinatus tendon (In response to recent concerns about the accuracy of suture passage during arthroscopic remplissage, this study was conducted to determine whether a previously described “safe zone” technique can improve the accuracy of suture passage. A recommended safe zone technique was used for arthroscopic remplissage on 6 cadaveric specimens. The safe zone was described as a region at least 1 cm lateral and no greater than 3 cm distal to the posterolateral acromion. Results were compared with a control group of 6 specimens for which the safe zone technique was not used. For each group, 24 suture passes were performed. In the safe zone group, 83.3% (20 of 24) of sutures passed through the infraspinatus tendon. This was a significant improvement compared with the control group, in which only 25% (6 of 24) of sutures pierced the infraspinatus tendon (P<.01). In the safe zone group, 4.2% (1 of 24) of attempted suture passes were placed through the muscle or musculotendinous junction compared with 75% (18 of 24) in the control group (P<.01). Prevention of overmedialization improved significantly with the safe zone technique. In the safe zone group, both anchors had significantly more lateral (6 to 10 mm) suture passage compared with the control group (P<.01). The safe zone technique also showed greater precision of suture passes, and overall precision (SD) improved in 75% of passes. The safe zone technique significantly improved the accuracy of suture penetration into the infraspinatus tendon during arthroscopic remplissage. This reproducible method may help to prevent the reported complications of remplissage. [Orthopedics.2017; 40(4):e598–e603.]

Orthopedic studies are occasionally published in high-impact general medical journals; these studies are often given high visibility and have significant potential to impact health care policy and inform clinical decision-making. The purpose of this review was to investigate the characteristics of operative orthopedic studies published in high-impact medical journals. The number of orthopedic studies published in high-impact medical journals is relatively low; however, these studies demonstrate methodological characteristics that may bias toward nonoperative treatment. Careful analysis and interpretation of orthopedic studies published in these journals is warranted. [Orthopedic studies are occasionally published in high-impact general medical journals; these studies are often given high visibility and have significant potential to impact health care policy and inform clinical decision-making. The purpose of this review was to investigate the characteristics of operative orthopedic studies published in high-impact medical journals. The number of orthopedic studies published in high-impact medical journals is relatively low; however, these studies demonstrate methodological characteristics that may bias toward nonoperative treatment. Careful analysis and interpretation of orthopedic studies published in these journals is warranted. [Orthopedics.2017; 40(3):e405–e412.]

This review evaluated the quality of patient satisfaction reporting after total hip arthroplasty. The initial search of the MEDLINE database yielded 755 studies. Twenty-four met the inclusion criteria. Most studies provided level III or IV evidence (n=15, 62.5%). The most common method used to assess satisfaction was the 10-point visual analog scale (7 studies, 29.2%), followed by an ordinal satisfaction scale (6 studies, 25.0%). The quality of evidence was poor, and the methods used to assess satisfaction were not standardized. Further research is needed to define the factors that affect patient satisfaction after total hip arthroplasty and how satisfaction is best measured. [This review evaluated the quality of patient satisfaction reporting after total hip arthroplasty. The initial search of the MEDLINE database yielded 755 studies. Twenty-four met the inclusion criteria. Most studies provided level III or IV evidence (n=15, 62.5%). The most common method used to assess satisfaction was the 10-point visual analog scale (7 studies, 29.2%), followed by an ordinal satisfaction scale (6 studies, 25.0%). The quality of evidence was poor, and the methods used to assess satisfaction were not standardized. Further research is needed to define the factors that affect patient satisfaction after total hip arthroplasty and how satisfaction is best measured. [Orthopedics.2017; 40(3):e400–e404.]

ABSTRACTObjectives: Minimal clinically important difference (MCID) and other measures of minimum clinical importance are increasingly recognized as important clinical considerations for evaluating the efficacy of an intervention. As our interpretation of clinical outcome evolves beyond statistical significance, psychometric properties such as MCID will be increasingly important to various stakeholders in the orthopaedic community. The purpose of this study was to: 1) describe the state of clinically important outcome reporting and 2) describe the methods used to derive these psychometric values for sports medicine patients undergoing operative treatments.Methods: A review of the MEDLINE database was performed. Studies primarily deriving and reporting clinically important outcome measures for operative interventions in sports medicine were included. Demographic, methodological and psychometric properties of included studies were extracted. Level of Evidence and the Newcastle Ottawa Scale (NOS) were used to assess study quality. Statistical analysis was primarily descriptive.Results: Fifteen studies met inclusion criteria; 10 of the 15 studies were Level II evidence and mean NOS score was 5.3/9. Minimal detectable change (MDC) was the most commonly derived measure of clinical importance, calculated in 53.3% of studies, followed by MCID, calculated in 40.0% of studies. A combination of distribution and anchor-based methods was the most commonly used method to determine clinical importance (N = 7, 46.7%) followed by distribution only (N = 5, 33.3%). Predictors of clinically important change were reported in four studies and were most commonly related to pre-operative functional score.Conclusions: MDC and the MCID are the most commonly reported measures of clinically important outcome after operative treatment in sports medicine. A combination of both distribution and anchor-based methods is commonly used to derive these values. More attention should be paid to reporting outcomes that are clinically important and developing guidelines for reporting clinical meaningful outcome.

ABSTRACTObjectives: Youth participation in competitive athletics has significantly increased in the past two decades. There has also been a recent rise in the number of sports injuries that physicians are seeing in young athletes. The objective of this study was to assess the likelihood of sports injuries based on several risk factors in a general sample of athletes at a suburban-area high school.Methods: This was a cross-sectional study. An online survey was distributed to 2,200 student-athletes at a local high school with a mean age of 15.9 years. Four hundred eighty four (22%) complete responses were received. Data collected in the survey included demographics, frequency of sports participation, level of participation, types of sports played, participation in cross-training, injuries incurred, use of non-steroidal anti-inflammatory drugs, and treatment for sports injuries.Results: Athletes played an average of 1.6 different sports. The average number of hours of participation in sports annually was 504.3 ± 371.6 hours. The average total number of sports injuries experienced by athletes in our study was 1.7 per participant. 80.8% of respondents reported having sustained at least one sports injury.A higher total number of hours per year of sports participation and playing a contact sport were significantly associated with more reported lifetime sports injuries. Older age, playing a contact sport, and playing on a travel/club team were associated with students using NSAIDs for sports injuries. Older age, playing a contact sport, and doing cross training are also associated with having had surgery for a sports injury.Conclusions: Although more hours of participation and playing a contact sport may lead to an increased number of injuries, this risk must be weighed against the myriad of benefits that sports provide for young athletes.

The article focuses on operating room (OR) cancellations and their effect in the cost and expenditures of outpatient surgical facility. It says that prior missed medical appointments, history of alcoholism, and central nervous system impairment are among the predictors of patient's OR cancellation. It mentions that many fixed costs will not be recovered when a patient cancels their OR schedule including OR staff, surgeon time, and equipment and medication costs.