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Background: Demand for total knee arthroplasty (TKA) is increasing as it remains the gold-standard treatment for end-stage osteoarthritis (OA) of the knee. Magnetic resonance imaging (MRI) scans of the knee are not indicated for diagnosing knee OA and represent a possible delay to orthopaedic surgeon referral and unnecessary expenditure. The purpose of this study was to determine the proportion of patients who underwent an MRI in the two years prior to their primary TKA for OA and determine patient and physician associations with increased MRI usage. Methods: This is a population-based cohort study using administrative data from Ontario, Canada. All patients over 40 years old who underwent their first primary TKA between April 1, 2008, and March 31, 2019, were included. Statistical analyses were performed using SAS and included the Cochran–Armitage test for trend of MRI prior to surgery. A predictive multivariable regression model was used to determine features correlated to receiving an MRI. Results: There were 194,989 eligible first-time TKA recipients, of which 38,244 (19.6%) received an MRI in the two years prior to their surgery. The majority of these (69.6%) were ordered by primary care physicians. Patients who received an MRI were younger, had fewer comorbidities and were more affluent than patients who did not (p < 0.001). MRI use prior to TKA increased from 2008 to 2018 (p < 0.001). Conclusion: Despite MRIs rarely being indicated for the work-up of end-stage OA, nearly one in five patients have an MRI in the two years prior to their TKA. This may be increasing healthcare expenditure and surgical wait-times. [ABSTRACT FROM AUTHOR]

Background: Clinical practice guidelines (CPGs) are published by several sports medicine institutions. A systematic evaluation can help identify the highest quality CPGs for clinical use and identify any deficiencies that remain. Purpose: To identify and appraise CPGs relevant to clinical sports medicine professionals. Study Design: Systematic review. Methods: Predetermined selection criteria were utilized by 2 reviewers who independently identified published CPGs before January 1, 2014. CPGs were excluded if they focused on injured workers, radiological criteria, medical pathology, or the axial skeleton (back/neck). The remaining guidelines were scored by 6 reviewers with different clinical backgrounds using the Appraisal of Guidelines for Research and Evaluation II (AGREE II). Scores lower than 50% indicated deficiency. Scores were also stratified by the publishing institution and anatomic location and compared using Kruskal-Wallis tests. The Spearman correlation coefficient was used to assess the range of interobserver agreement between the evaluators. Results: Seventeen CPGs met the inclusion criteria. The majority of guidelines pertained to the knee, ankle, or shoulder. Interobserver agreement was strong (r = 0.548-0.740), and mean total scores between nonsurgical (107.8) and surgical evaluators (109.3) were not statistically different. Overall guideline quality was variable but not deficient for 16 of 17 guidelines (>50%), except regarding clinical “applicability” and “editorial independence.” No difference was found between CPGs of the knee, shoulder, foot/ankle, or chronic conditions. However, CPG publishing institutions had significantly different scores; the American Academy of Orthopaedic Surgeons (AAOS) guidelines scored significantly higher (141.4) than the total mean score (108.0). Conclusion: The overall quality of sports medicine CPGs was variable but generally not deficient, except regarding applicability and editorial independence. Bias through poor editorial independence is a concern. To improve future guideline quality, authors should pay particular attention to these areas and use existing highest quality guidelines, or the AGREE II instrument, as templates. CPGs dedicated to anatomic areas other than the knee, ankle, and shoulder are needed. [ABSTRACT FROM AUTHOR]

Background: Anatomic studies have demonstrated that bipolar glenoid and humeral bone loss have a cumulative effect on shoulder instability and that these defects may engage in functional positions depending on their size and location, potentially resulting in failure of stabilization procedures. Determining which lesions pose a risk for engagement remains challenging, with arthroscopic assessments and a 3-dimensional computed tomography (CT)–based glenoid track method being accepted approaches at this time. Purpose: The purpose was to investigate the interaction of humeral and glenoid bone defects on shoulder engagement in a cadaveric model. Two alternative approaches to predicting engagement were evaluated: (1) CT of the shoulder in abduction and external rotation (ABER) and (2) measurement of the glenoid lesion width and measurement of a novel parameter, the intact anterior articular angle (IAAA), on conventional 2-dimensional multiplane reformats. Study Design: Controlled laboratory study. Methods: Hill-Sachs and glenoid defects of varying sizes were created in 12 cadaveric upper limbs, producing 45 bipolar defect combinations. The defect characteristics were assessed using CT with the shoulder in a neutral position. ABER CT was performed with the shoulder positioned in 60° of glenohumeral abduction (corresponding to 90° of abduction relative to the trunk) and 90° of external rotation. The IAAA was measured as the cartilage arc angle anterior to the Hill-Sachs defect on the axial slice bisecting the humeral head. The performance of the ABER CT and IAAA approaches to predicting engagement were compared with the glenoid track method. Results: Of the 45 defect combinations, 24 (53%) were classified as engaging using the glenoid track method. ABER CT predicted engagement accurately in 43 of 45 (96%), with a sensitivity and specificity of 92% and 100%, respectively. A logistic model based on the glenoid defect width and IAAA provided a prediction accuracy of 87%, with a sensitivity and specificity of 92% and 81%, respectively. Conclusion/Clinical Relevance: Bipolar lesions at risk for engagement can be identified accurately using an ABER CT scan or by performing 2-dimensional measurements of the glenoid defect width and IAAA on conventional CT multiplane reformats. This information will be useful for surgical planning in the setting of bipolar bone defects before shoulder stabilization. [ABSTRACT FROM AUTHOR]

Objective Therapeutic intraarticular injections are used in the management of hip osteoarthritis (OA). Some studies suggest that their use increases the risk of infection and subsequent revision surgery after primary total hip arthroplasty (THA), while others do not. We undertook this study to clarify the relationship between prior intraarticular injection and the risk of complication in a subsequent primary THA. Methods In a cohort of patients with hip OA who underwent a primary elective THA between 2002 and 2009, we identified those who received ≥1 intraarticular injection performed by a radiologist in the 5 years preceding their THA. Multivariable Cox proportional hazards models were used to determine the relationship between receipt of a presurgical injection (no injection, 1-5 years prior to THA, or <1 year prior to THA) and the occurrence of postsurgical joint infection and revision THA in the following 2 years, while controlling for confounders. Results Of 37,881 eligible THA recipients, 2,468 (6.5%) received an intraarticular injection performed by a radiologist within 5 years of their THA (1,691 at <1 year, 777 at 1-5 years). Controlling for age, sex, comorbidity, frailty, income, and provider volume, those who had an injection in the year preceding surgery were at increased risk of infection (adjusted hazard ratio [HR] 1.37, P = 0.03) and revision THA (adjusted HR 1.53, P = 0.03) within 2 years of the primary THA, relative to patients who did not. The association between prior injection and revision arthroplasty was attenuated and became nonsignificant (adjusted HR 1.41, P = 0.13) after occurrence of postoperative infection was controlled for in the regression model. No effect was found for injection 1-5 years prior to surgery. Conclusion Intraarticular injection in the year preceding THA independently predicted increased risk of infection leading to early revision surgery. Further studies are warranted to elucidate explanations for these findings. [ABSTRACT FROM AUTHOR]

The article presents research which discussed the rate and risk factors for patients who underwent revision anterior cruciate ligament reconstruction in Ontario. Topics covered include the number of participants who have been readmitted after the surgery as well as survival rate among those who had re-revision of the approach. Also mentioned is the rarity of patients who had total knee arthroplasty.

The article discusses a study which calculated the incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction in the general population and demographic subgroups in Ontario. Results showed that young male patients have the highest incidence of primary anterior shoulder dislocation requiring CR and the greatest risk of repeat shoulder CR. The study also found that patient, provider, and injury factors all influence repeat shoulder CR risk.

Background: Anterior cruciate ligament reconstruction (ACLR) is routinely performed for symptomatic instability. Although it isa common procedure, there remain differences in surgical technique. Hospital administrative records in a public health care systemwere used to investigate the effect of patient, provider, and surgical factors on the risk of revision ACLR.Purpose: To define the rate and risk factors for ACL reoperation in Ontario, Canada, including both ipsilateral revision and contralateralprimary procedures.Study Design: Cohort study; Level of evidence, 3.Methods: All primary elective ACLR procedures performed in Ontario (July 2003 to March 2008) in patients aged 15 to 60 yearswere identified via physician billing and hospital databases. Revision and contralateral ACLR were sought until January 2012.Patient factors (age, sex, comorbidity, income quintile, length of index hospital admission), provider factors (surgeon volume, academichospital status), and surgical factors (allograft vs autograft; fixation type [screw, button, staple]; concomitant operative procedures)were used as covariates in a Cox proportional hazards survivorship model to generate hazard ratios (HRs) withconfidence intervals (CIs) (α = .05). Kaplan-Meier survivorship curves with ACL revision as the end point were generated.Results: A total of 12,967 ACLR procedures with a mean follow-up of 5.2 years were eligible for study using preset criteria. The revisionrate was 2.6% (mean ± SD, 2.91 ± 1.71 years to revision). The rate of primary contralateral ACLR was 4.6% (mean, 2.95 ± 1.81years). In the Cox model, younger age (15-19 years) (HR, 2.1; 95% CI, 1.5-2.9; P<.001), ACLR performed at an academic hospital(HR, 1.6; 95% CI, 1.2-2.1; P<.001), and the use of allograft (HR, 1.7; 95% CI, 1.1-2.6; P = .02) significantly increased the risk of revisionACLR. Only younger age (HR, 2.1; 95% CI, 1.6-2.7; P<.001) was associated with an increased risk of contralateral ACLR.Conclusion: Contralateral ACLR was more frequent than revision ACLR in this population, while both surgical procedures weremost common in patients younger than 20 years. Academic hospital status, but not surgeon volume, as well as the use of allograftalso increased the risk for revision ACLR. [ABSTRACT FROM AUTHOR]

Background: Factors contributing to recurrent dislocation, revision stabilization, and complications requiring reoperation after aninitial shoulder stabilization procedure for instability have not been evaluated on a population level.Purpose: (1) To define the rate of ipsilateral revision stabilization, contralateral primary stabilization, postoperative dislocation,and complications after primary shoulder stabilization in a population cohort. (2) To understand which risk factors among patient,surgical, and provider factors influence these outcomes.Study Design: Cohort study; Level of evidence, 3.Methods: All residents of Ontario, Canada, aged 16 to 60 years undergoing primary shoulder stabilization between July 2003 andDecember 2008 were identified from billing and hospital databases. Separate Cox proportional hazards survivorship models werebuilt for the outcomes revision stabilization and postoperative physician-documented shoulder relocation (minimum 2-yearfollow-up). Model covariates included patient demographics (age, sex, preoperative dislocations), provider characteristics (surgeonvolume, hospital academic status), and type of surgery (open, arthroscopic). The frequency and risk factors for contralateralstabilization were identified.Results: A total of 5904 patients (80.6% male; median age, 29 years) were identified. Arthroscopic stabilization was used in ~60% ofcases in 2003, increasing to ~80% in 2008. The rates of postoperative dislocation were 6.9%, revision stabilization 4%, and contralateralprimary stabilization 3.9%. Patients aged younger than 20 years had a 7.7% revision rate (hazard ratio [HR], 2.7; 95% confidenceinterval [CI], 1.7-4.2; P < .0001) and a 12.6% rate of postoperative physician-documented dislocation (HR, 2.4; 95% CI,1.8-3.4; P < .0001), compared with 2.8% and 5.5%, respectively, in patients 29 years old (median cohort age). Patients with 3 ormore preoperative dislocations in Ontario had an increased risk of revision (HR, 2.1; 95% CI, 1.5-3.0; P<.0001) and postoperativedislocation (HR, 10.6; 95% CI, 8.1-14.0; P < .0001). Revision was more common after arthroscopic (4.3%) compared with open(3.5%) stabilization (HR, 1.4; 95% CI, 1.02-1.98; P = .04). No provider factor was predictive, including surgeon volume. Reoperationrate for complications not related to recurrent instability was 0.23% (infection, 0.07%; manipulation under anesthesia, 0.15%).Conclusion: The risks of revision stabilization and postoperative (either shoulder) dislocation were most influenced by young age(<20 years) and having had 3 or more preoperative dislocations. Complications requiring surgery are rare. [ABSTRACT FROM AUTHOR]

The article reports a study which was conducted to determine whether meniscal repair (MR) in a presumed stable knee has the same rate of re-operation as MR performed with anterior cruciate ligament reconstruction (ACLR). The results revealed that concomitant ACLR and MR is statistically and clinically significantly protective against re-operations after MR.

STUDY QUESTION Is there a cut point in annual surgeon volume associated with increased risk for complications after primary elective total hip arthroplasty, and, if so, can we quantify this risk? SUMMARY ANSWER In a cohort of first time recipients of total hip arthroplasty, we found that patients operated on by surgeons who had performed 35 or fewer procedures in the year before the index arthroplasty were at increased risk for dislocation and early revision. WHAT IS KNOWN AND WHAT THIS PAPER ADDS Though there is a general consensus that increased surgeon volume is associated with a reduced risk of complications, there is a lack of consensus around what constitutes a “low” annual volume. This study showed that in patients undergoing total hip arthroplasty, the risks for dislocation and early revision increased by about 48% and 44%, respectively, when they were operated on by surgeons with annual volumes ≤35 procedures. [ABSTRACT FROM AUTHOR]

Objective: To characterize and compare the incidence of basketball-related, soccer-related, and hockey-related injuries over a 10-year period. Design: Cohort analysis of sport-related injuries using multiple Ontario healthcare databases. Setting: Emergency department visits in Ontario, Canada. Patients: Any patient who sustained musculoskeletal injuries sustained while playing basketball, soccer, or hockey between 2006 and 2017 were identified. Assessment of Risk Factors: Sport of injury, age, sex, rurality index, marginalization status, and comorbidity score. Main Outcome Measures: Annual Incidence Density Rates of injury were calculated for each sport, and significance of trends was analyzed by assessing overlap of 95% confidence intervals. Results: One lakhs eighty five thousand eighty hundred sixty-eight patients (median age: 16 years, interquartile range 13-26) received treatment for sport-related injuries (basketball = 55 468; soccer = 67 021; and hockey = 63 379). The incidence of basketball-related and soccer-related injuries increased from 3.4 (3.3-3.5) to 5.6 (5.5-5.7) and 4.4 (4.3-4.5) to 4.9 (4.8-5) per 10 000 person years, respectively, whereas the incidence of hockey-related injuries decreased from 4.7 (4.6-4.8) to 3.7 (3.6-3.8). Patients with basketball injuries were more marginalized (3.01 ± 0.74) compared with patients with soccer and hockey injuries (2.90 ± 0.75 and 2.72 ± 0.69, respectively). Conclusions: Accurate regional epidemiologic information regarding sports injuries can be used to guide policy development for municipal planning and sport program development. The trends and demographic patterns described highlight general and sport-specific injury patterns in Ontario. Populations with the highest incidence of injury, most notably adolescents and men older than 50, may represent an appropriate population for injury risk prevention. [ABSTRACT FROM AUTHOR]