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Background: Recent animal studies have demonstrated that hyperlipidemia is associated with poor tendon-bone healing after rotator cuff repair; however, these findings have not been substantiated in human studies. Purpose: To examine any association between hyperlipidemia and the failure of arthroscopic rotator cuff repair requiring revision surgery and to investigate whether the use of statin lipid-lowering agents had any influence on observed associations. Study Design: Cohort study; Level of evidence, 3. Methods: From a national insurance database, patients who underwent arthroscopic rotator cuff repair with perioperative lipid levels (total cholesterol, low-density lipoprotein [LDL], and triglycerides) recorded were reviewed. For each lipid test, patients were stratified into normal, moderate, and high groups based on published standards. For the total cholesterol and LDL cohorts, a subgroup analysis of patients stratified by statin use was performed. The primary outcome measure was ipsilateral revision rotator cuff surgery, including revision repair or debridement. A logistic regression analysis controlling for patient demographics and comorbidities was utilized for comparison. Results: There were 30,638 patients included in the study. The rate of revision rotator cuff surgery was significantly increased in patients with moderate (odds ratio [OR], 1.20; 95% CI, 1.03-1.40; P = .022) and high total cholesterol levels (OR, 1.36; 95% CI, 1.10-1.55; P = .006) compared with patients with normal total cholesterol levels perioperatively. Within each of these groups, patients without statin use had significantly higher rates of revision surgery, while those with statin prescriptions did not. The absolute risk reduction for statin use ranged from 0.24% to 1.87% when stratified by the total cholesterol level, yielding a number needed to treat from 54 to 408 patients. The rate of revision surgery was significantly increased in patients with moderate (OR, 1.24; 95% CI, 1.10-1.41; P = .001) and high LDL levels (OR, 1.46; 95% CI, 1.08-1.99; P = .014) compared with patients with normal LDL levels perioperatively. Again, patients without statin prescriptions had significantly increased rates of revision surgery, whereas patients with statin use did not. The absolute risk reduction for statin use ranged from 0.26% to 1.89% when stratified by the LDL level, yielding a number needed to treat from 53 to 387 patients. There were no significant differences in the rates of revision rotator cuff surgery between patients with moderate and high triglyceride levels compared with patients with normal triglyceride levels. Conclusion: The present study found a significant association between moderate and high perioperative total cholesterol and LDL levels and the rate of revision surgery after primary arthroscopic rotator cuff repair. Furthermore, the use of statin agents appeared to mitigate the need for revision rotator cuff repair. Further prospective studies are necessary to validate these preliminary findings and determine if better perioperative lipid control can improve clinical outcomes after arthroscopic rotator cuff repair. [ABSTRACT FROM AUTHOR]

Background: Tenodesis of the long head of the biceps tendon has become a popular surgical treatment option for patients with pain or instability attributed to a diseased or unstable biceps tendon. No previous studies have characterized the practice patterns of surgeons performing biceps tenodesis in the United States. Purpose: To investigate current trends in both arthroscopic and open biceps tenodesis across time, sex, age, and region of the United States as well as associated charges. Study Design: Descriptive epidemiology study. Methods: Patients who underwent biceps tenodesis (Current Procedural Terminology [CPT] codes 23430 and 29828) for the years 2008 through 2011 were identified using the PearlDiver Patient Record Database, including both private-payer and Medicare data. These cohorts were then assessed for associated diagnoses using International Classification of Diseases, 9th Revision, codes and concomitant procedures using CPT codes. These searches yielded procedural volumes, sex and age distribution, regional volumes, and average per-patient charges. A χ2 linear-by-linear association analysis, Student t test, and linear regression were used for comparisons, with P\.05 considered significant. Results: A total of 44,932 biceps tenodesis procedures were identified from 2008-2011. The incidence of biceps tenodesis procedures per 100,000 database patients increased 1.7-fold over the study period, from 8178 in 2008 to 14,014 in 2011 (P < .0001). An increase in the overall percentage volume was noted in patients aged 60-69 years (P = .039) and 20-29 years (P = .016). The overall charges for arthroscopic tenodesis increased at a rate significantly greater than that of open tenodesis (P<.0001). Rotator cuff tear or sprain, bicipital tenosynovitis, biceps tendon rupture, superior labral lesion, and osteoarthritis were the most common diagnoses associated with biceps tenodesis procedures. A significant increase in isolated biceps tenodesis was also observed over the study period, from 1967 patients in 2008 to 3565 patients in 2011, representing a 1.8-fold increase. Conclusion: The incidence of biceps tenodesis has increased yearly from 2008-2011. Arthroscopic tenodesis has emerged as a more popular technique. Charges associated with the procedure have increased significantly. Significant regional variations in procedural incidences exist. [ABSTRACT FROM AUTHOR]

Background: Clinical outcomes after revision anterior cruciate ligament reconstruction (ACLR) are not well understood. Hypothesis: Patients undergoing revision ACLR would demonstrate worse patient-reported outcomes and worse limb symmetry compared with a cohort undergoing primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: 672 participants (373 with primary ACLR, 111 with revision ACLR, and 188 uninjured) completed functional testing at a single academic medical center. Descriptive information, operative variables, and patient-reported outcomes (International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Tegner Activity Scale score) were assessed for each patient. Quadriceps and hamstring strength tests were conducted using a Biodex System 3 Dynamometer. Single-leg hop for distance, triple hop test, and the 6-m timed hop test were also assessed. Limb symmetry index (LSI) between the ACLR limb and contralateral limb was calculated for strength and hop testing. Normalized peak torque (N·m/kg) was calculated for strength testing. Results: No differences were found in group characteristics, excluding body mass (P <.001), or in patient-reported outcomes. There were no interactions between revision status, graft type, and sex. Knee extension LSI was inferior (P <.001) in participants who had undergone primary (73.0% ± 15.0%) and revision (77.2% ± 19.1%) ACLR compared with healthy, uninjured participants (98.8% ± 10.4%). Knee flexion LSI was inferior (P =.04) in the primary group (97.4% ± 18.4%) compared with the revision group (101.9% ± 18.5%). Difference in knee flexion LSI between the uninjured and primary groups, as well as between the uninjured and revision groups, did not reach statistical significance. Hop LSI outcomes were significantly different across all groups (P <.001). Between-group differences in extension in the involved limb (P <.001) were noted, as the uninjured group exhibited stronger knee extension (2.16 ± 0.46 N·m/kg) than the primary group (1.67 ± 0.47 N·m/kg) and the revision group (1.78 ± 0.48 N·m/kg). As well, differences in flexion in the involved limb (P =.01) were found, as the revision group exhibited stronger knee flexion (1.06 ± 0.25 N·m/kg) than the primary group (0.97 ± 0.29 N·m/kg) and the uninjured group (0.98 ± 0.24 N·m/kg). Conclusion: At 7 months postoperatively, patients who had undergone revision ACLR did not demonstrate inferior patient-reported outcomes, limb symmetry, strength, or functional performance compared with patients who had undergone primary ACLR. Patients who had undergone revision ACLR exhibited greater strength and LSI than their counterparts with primary ACLR, but these parameters were still inferior to those of uninjured controls. [ABSTRACT FROM AUTHOR]

Background: Performance on strength and functional tests is often used to guide postoperative rehabilitation progress and return to activity decisions after anterior cruciate ligament reconstruction (ACLR). Clinicians may have difficulty in determining which criteria to follow if there is disagreement in performance outcomes among the tests. Purpose/Hypothesis: The purpose of this study was to compare pass rates between strength tests and single-leg hop (SLHOP) tests among men and women and between patients with lower and higher preinjury activity levels recovering from ACLR. We hypothesized that pass rates would be nonuniformly distributed among test types, sex, and activity level and that more participants would pass hop tests than strength tests. Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 299 participants (146 men; 153 women)—at a mean of 6.8 ± 1.4 months after primary, unilateral, and uncomplicated ACLR (mean age, 23 ± 9.7 years; mean height, 172 ± 10.5 cm; mean mass, 75.8 ± 18.4 kg)—completed testing. Quadri.tif strength was evaluated using peak torque during isokinetic knee extension at 90 deg/s and 180 deg/s. Jump distance during the SLHOP and triple hop tests was measured (in cm). Strength and hop test measures were evaluated based on the limb symmetry index ((LSI) = (ACLR / contralateral side) × 100). We operationally defined "pass" as > 90% on the LSI. Results: Pass rates were nonuniformly distributed between isokinetic knee extension at 90 deg/s and the SLHOP test (χ 2 = 18.64; P <.001). Disagreements between isokinetic testing at 90 deg/s and the SLHOP test occurred in 36.5% (109/299) of the participants. Among those who failed strength testing and passed hop testing, a greater portion reported higher activity levels before their injury (χ 2 = 6.90; P =.01); however, there was no difference in pass rates between men and women. Similar patterns of disagreement were observed between all strength test and hop test outcomes. Conclusion: ACLR patients with higher activity levels may be more likely to pass hop testing despite failing quadri.tif strength testing. This may be an indicator of movement compensations to achieve jump symmetry in the presence of quadri.tif weakness. [ABSTRACT FROM AUTHOR]

Return-to-activity (RTA) assessments are commonly administered after anterior cruciate ligament reconstruction (ACLR) to manage the patient's postoperative progressions back to activity. To date, few data are available on the clinical utility of these assessments to predict patient outcomes such as secondary anterior cruciate ligament (ACL) injury once the athlete has returned to activity. To identify the measures of patient function at 6 months post-ACLR that best predict RTA and second ACL injury at a minimum of 2 years after ACLR. Prospective cohort study. Laboratory. A total of 234 patients with primary, unilateral ACLR completed functional assessments at approximately 6 months post-ACLR. Of these, 192 (82.1%) completed follow-up at ≥2 years post-ACLR. The 6-month functional assessments consisted of patient-reported outcomes, isokinetic knee-flexor and -extensor strength, and single-legged hopping. We collected RTA and secondary ACL injury data at ≥2 years after ACLR. Of the patients who were able to RTA (n = 155), 44 (28.4%) had a subsequent ACL injury, 24 (15.5%) to the ipsilateral graft ACL and 20 (12.9%) to the contralateral ACL. A greater proportion of females had a secondary injury to the contralateral ACL (15/24, 62.5%), whereas a greater proportion of males reinjured the ipsilateral ACL graft (15/20, 75.0%; P =.017). Greater knee-extension symmetry at 6 months increased the probability of reinjury (B = 0.016, P =.048). Among patients with RTA at < 8 months, every 1% increase in quadriceps strength symmetry at 6 months increased the risk of reinjury by 2.1% (B = 0.021, P =.05). Among patients with RTA at >8 months, every month that RTA was delayed reduced the risk of reinjury by 28.4% (B = –0.284, P =.042). Descriptive statistics of patient function stratified between the early and delayed RTA groups can be found in the Supplemental Table (available online at http://dx.doi.org/10.4085/1062-6050-0407.20.S1). Patients with more symmetric quadriceps strength at 6 months post-ACLR were more likely to experience another ACL rupture, especially those who returned to sport at < 8 months after the index surgery. Clinicians should be cognizant that returning high-functioning patients to activity at < 8 months post-ACLR may place them at an increased risk for reinjury. [ABSTRACT FROM AUTHOR]

Background: Pass rates for return-to-play evaluations are alarmingly low for patients after anterior cruciate ligament reconstruction (ACLR). Since timing of return to play is a complicated decision, it is important that patients be given optimal time to realize meaningful improvements in strength that warrant additional testing. Purpose: To (1) compare outcomes among patients assessed at different time points after ACLR, (2) determine strength gains indicative of improvements in subjective function, and (3) determine the amount of time necessary to achieve meaningful strength gains. Study Design: Cross-sectional/case-control study; Level of evidence, 3. Methods: A total of 293 patients participated in the study after ACLR (mean ± SD, 23.2 ± 10.1 years old; n = 142 female participants; 6.4 ± 0.9 months after ACLR). Participants were stratified on the month of their evaluation after ACLR: 5 to 6 months (n = 122), 6 to 7 months (n = 102), 7 to 8 months (n = 43), and 8 to 9 months (n = 26). The International Knee Documentation Committee (IKDC) subjective form and knee extensor and flexor torque and symmetry, as assessed through an isokinetic dynamometer, were compared among groups. Forty patients (20 female participants, 20.4 ± 7.1 years old) were referred for subsequent testing (2.14 ± 0.78 months after initial visit). Subjective improvement between visits was defined as a ≥9-point change of the IKDC score. Thresholds of knee extensor torque and symmetry indicative of subjective improvement and the time between assessments needed to achieve these strength improvements were determined. Results: Patients between 5 and 6 months (IKDC, 79.7; interquartile range [IQR], 70.1-88.5) had lower subjective function compared to patients between 6 and 7 months (IKDC, 83.9; IQR, 74.5-92.0; P =.019) and 8 and 9 months after ACLR (IKDC, 89.1; IQR 75.8-92.3; P =.026). Patients between 5 and 6 months (1.41 N·m/kg; IQR, 1.16-1.73 N·m/kg]) had lower knee extensor torque compared to patients 6 and 7 months (1.59 N·m/kg; IQR, 1.23-1.95 N·m/kg; P =.013) and 7 and 8 months after ACLR (1.62 N·m/kg; IQR, 1.30-1.86 N·m/kg; P =.046). Patients between 5 and 6 months (66.4%; IQR, 54.2-78.6) had lower symmetry compared to patients between 6 and 7 months (71.8%; IQR,61.1-82.9; P =.019) and 8 and 9 months afterACLR (75.2%; IQR, 66.6-87.7; P =.014). Of the 40 patients that completed follow-up assessments, an increase in knee extensor torque of 0.22 N·m/kg and symmetry of 5.75% discriminated patients that achieved subjective improvement. A period of 1.97 months between assessments discriminated those that achieved the established symmetry threshold. Conclusion: Patients demonstrate increasing subjective and quadriceps function when tested at later time points from surgery; however, the observed values are low, suggesting that at 9 months patients are demonstrating deficits that may be improving. Approximately 2 months is needed to observe clinically meaningful improvements. [ABSTRACT FROM AUTHOR]

Background: Despite recent advances in the treatment of hepatitis C, it is estimated that nearly 4 million Americans have a chronic form of the disease. Although research in lower-extremity arthroplasty suggests patients with hepatitis C are at risk for increased complications, including postoperative bleeding, acute postoperative infection, and general medical complications, no similar studies have investigated this question in patients undergoing total shoulder arthroplasty (TSA).Questions/purposes: We asked whether there is an increased risk of postoperative complications after TSA among patients who have hepatitis C, and if so, what complications in particular seem more likely to occur in this population?Methods: Patients who underwent TSA, including anatomic or reverse TSA, were identified in the PearlDiver database using ICD-9 procedure codes. This is a for-fee insurance patient-records database that contains more than 100 million individual patient records from 2005 to 2012. The Medicare data in the database are the complete 100% Medicare Standard Analytical File indexed to allow for patient tracking with time. Patients with hepatitis C who underwent shoulder arthroplasty then were identified using ICD-9 codes. Patients with hepatitis B coinfection or HIV were excluded. A control cohort of patients without hepatitis C who underwent TSA was created and matched to the study cohort based on age, sex, obesity, and diabetes mellitus. A total of 1466 patients with hepatitis C and 21,502 control patients were included. The two cohorts were statistically similar in terms of sex (53% females in study and control groups), age (nearly ½ of each cohort younger than 65 years), obesity (approximately 17% of each cohort were obese), diabetes (approximately 40% of each cohort had diabetes), and followup of each cohort occurred throughout the length of the database from 2005 to 2012. Postoperative complications were assessed using ICD-9 and Current Procedural Terminology codes and compared between cohorts.Results: Patients with hepatitis C, when compared with matched control subjects, had greater odds of infection within 3 months (odds ratio [OR], 1.7; 95% CI, 1.1-2.6; p = 0.015), 6 months (OR, 1.7; CI, 1.3-2.4; p = 0.001), and 1 year (OR, 2.1; CI, 1.7-2.7; p < 0.001); revision TSA within 1 year (OR, 1.5; CI, 1.1-2.9; p = 0.008) and 2 years (OR, 1.6; CI, 1.2-2.0; p = 0.001), dislocation within 1 year (OR, 1.6; CI, 1.2-2.2; p < 0.001); postoperative fracture within 1 year (OR, 1.8; CI, 1.2-2.6; p = 0.002); systemic or medical complications within 3 months (OR, 1.3; CI, 1.0-1.6; p = 0.022); and blood transfusion within 3 months (OR, 1.7; CI, 1.4-1.9; p < 0.001).Conclusions: Hepatitis C is associated with an increased risk for complications after TSA, including infection, dislocation, fracture, revision TSA, systemic complications, and blood transfusion compared with matched control subjects. Although this study is able to identify increased odds of complications in patients with hepatitis C, the mechanism by which these occur is likely not solely related to the virus, and is more likely related to a higher degree of case complexity in addition to other postoperative socioeconomic factors.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

The article presents research which compared the two-year clinical outcomes of patients with open subpectoral and arthroscopic suprapectoral biceps tenodesis. Topics covered include the examination of the biomechanical aspects of tenodesis locations of different implants. Also mentioned is the impact of the operations on the functions of the biceps and shoulders of patients.