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Objectives: COVID-19 altered National Football League (NFL) player and team training during the 2020 offseason. All preseason games were cancelled resulting in absence of game play before the first week of the regular season. Thus, concerns exist regarding injury susceptibility of players during regular season games. The purpose of this study was to evaluate and compare injury rates during the 2020 NFL season versus injury rates from the unaffected 2017-2019 seasons. We hypothesized there would be an increased injury rate and an increased rate of season ending injuries during the modified 2020 season., Methods: The NFL's public injury database was queried to identify players placed on the injury lists throughout the 2017-2020 seasons. All players listed as "out" and on the injured reserve due to physical injury were included in the data set. For further stratification, injury incidence was separated based on position. Time missed due to COVID-19 illness was not included. Injury rates were expressed as injuries per 1000 athlete exposures (AE)., Results: Overall, 893 individual players missed games due to injury during the 2020 NFL regular season compared to an average of 743 over the 2017-2019 seasons. Defensive players at all positions had a statistically significant increase in injury incidence from an average of 7.54 to 10.20 injuries per 1000 AE. Defensive backs were most affected with a 46% increase in players injured. There was no statistically significant difference in season ending injuries for any position., Conclusions: The COVID-19 stricken 2020 NFL regular season saw an increased rate and incidence of injuries. Specifically, defensive players had a higher incidence of injury overall with defensive backs experiencing the greatest increase in injury rates.

Hypothesis: The purpose of this study was to perform a systematic review of the available literature evaluating surgical outcomes after chronic distal biceps tendon rupture. Surgical techniques, including primary repair, autograft reconstruction, and allograft reconstruction, were compared, as well as subjective and objective clinical outcomes and complication rates., Methods: A systematic literature search of Level I-IV studies reporting outcomes of surgically treated chronic distal biceps tendon ruptures were performed via PubMed, Cochrane Collaboration, Science Direct, and Google Scholar databases. Twenty-two papers were identified in the review, with 236 patients. A Modified Coleman Methodological Score (CMS) was determined for every article to assess study quality. Patient-reported outcomes, postoperative range of motion, flexion and supination strength, and postoperative complications were recorded. MAYO elbow scores (MEPS) were reported more consistently than the other outcome tools., Results: No Level I or level II studies were identified in our search, and the heterogeneity of outcome measures precluded meta-analysis. Studies demonstrated mean MEPS scores ranging between 86 and 100, regardless of the surgical technique utilized. All studies reported a mean flexion-extension arc equal to or greater than 5-130°. The reported mean postoperative flexion strength was within 10% of the unaffected contralateral side. The most common complication for both direct repair and reconstruction groups was paresthesia of the lateral antebrachial cutaneous nerve [direct repair: 18-16.8%; reconstruction: 8-6.2% (allograft: 4-6%; autograft: 4-7%)]. Rerupture was uncommon and occurred in three patients who had undergone direct repair and in one patient after autograft reconstruction., Conclusions: Surgical treatment of chronic distal biceps injuries yields favorable objective and subjective outcomes. Currently, available evidence suggests that direct repair, autograft reconstruction, or allograft reconstruction are all viable treatment options with similar outcomes.

Purpose: To examine acute postoperative opioid consumption in patients undergoing hip arthroscopy and randomized to either receive a preoperative lateral quadratus lumborum block or sham injection., Methods: This trial randomized 46 subjects undergoing hip arthroscopy with a single surgeon to receive a preoperative lateral quadratus lumborum block (40 mL, ropivacaine 0.25%) or sham injection. The primary outcome was postoperative opioid consumption in patients with and without a block. All opioid medications were converted to morphine milligram equivalents for comparisons. Categorical data were compared with χ 2 tests and Fisher exact tests where appropriate. Continuous data were compared with 2-sided t-test and Wilcoxon rank-sum tests., Results: Forty-six subjects scheduled for elective hip arthroscopy were successfully consented and randomized. Demographic and clinical characteristics did not differ. Postoperative opioid consumption decreased 28.3% in patients who received a preoperative lateral quadratus lumborum block (P = .04). Total perioperative opioid consumption (intraoperative and postoperative combined) was reduced 20% in the block group; however, this did not achieve statistical significance (P = .05). Three subjects in the sham group (12.5%) required unblinding for a rescue block in the postoperative anesthetic care unit (PACU) for uncontrolled pain despite systemic analgesics. While cold sensation was decreased postoperatively over the abdomen (P < .001) and anterior thigh (P = .03) in the block group, other PACU variables did not differ, including VAS pain scores, motor function, side effects, PACU duration, and patient satisfaction., Conclusions: Opioid consumption was reduced in patients who received a preoperative lateral quadratus lumborum block combined with a standardized, multimodal protocol as compared with patients who did not receive a block. Our findings support the growing evidence that quadratus lumborum blocks are an effective component of multimodal analgesia options for patients undergoing elective hip arthroscopy., Level of Evidence: Level I, randomized controlled trial., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Compare postoperative opioid consumption following hip arthroscopy in patients who received a preoperative, lateral quadratus lumborum block versus those who did not. Patients were retrospectively identified. The primary outcome was postoperative opioid consumption (IV morphine milligram equivalents) in patients with and without a block. Comparisons between groups were conducted with Chi-square tests and Fisher Exact Tests where appropriate. Continuous data were compared with two-sided t-tests and Wilcoxon rank-sum tests. Data were collected on 100 patients. Mean (95% confidence interval) postoperative opioid consumption was reduced in patients with a quadratus lumborum block compared to those without a block (6.6 [5.2 - 8.1] vs 11.8 [10.2 - 13.4]; p < 0.0001; respectively). Eleven percent of patients with a preoperative quadratus lumborum block did not consume any opioids in the post anesthesia care unit. Opioid consumption in the immediate postoperative period was significantly reduced in patients that received a preoperative quadratus lumborum block. Level of Evidence: Level III - Retrospective Cohort Study. (Journal of Surgical Orthopaedic Advances 31(1):017-021, 2022).

Purpose: The purpose of this study was to (1) report on the incidence of concurrent surgical pathology at the time of adolescent ACL reconstruction, (2) evaluate patient risk factors for concurrent pathology, and (3) measure the effect of BMI on operating room (OR) time., Methods: A retrospective analysis of the NSQIP database for the years 2005-2017 was conducted. Nine-hundred and seventeen patients 18 years of age and younger who underwent ACL reconstruction (ACLR) were identified using CPT code 29888 and patients undergoing surgery for multi-ligamentous knee injuries were excluded. The mean patient age was 17.6 years (range 14-18, standard deviation 0.52) and consisted of 546 males (59.5%) and 371 females (40.5%). Logistic regression was used to assess the relationship between BMI and additional CPT codes for internal derangement at the time of surgery. Internal derangement was defined as any procedure for the treatment of a meniscal tear, chondral lesion, or loose body removal. Linear regression analysis was then performed to evaluate the effect of BMI on operative time., Results: 43.7% of patients undergoing ACLR required an associated procedure for internal derangement. Additionally, the risk of requiring additional procedures for internal derangement increased by 3.1% per BMI point. BMI was also predictive of operative time, independent of the number of additional procedures. Specifically, the operative time increased by nearly one minute for every point increase in BMI (58.0 s)., Conclusions: Adolescent patients with an elevated BMI were much more likely to require additional surgical procedures for internal derangement at the time of ACL reconstruction. Additionally, BMI was a significant predictor for longer operative times., Level of Evidence: Level III., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Case: A 20-year-old woman presented with recurrent bilateral shoulder instability concurrent with severe, treatment-refractory epilepsy. Imaging revealed glenoid bone loss of 25% to 28% and large Hill-Sachs defects bilaterally. Bone graft augmentation of the glenoid and infill of the Hill-Sachs defects was performed bilaterally. Perioperative neuromuscular paralysis of shoulder girdle muscles with botulinum toxin was performed to facilitate recovery. Both shoulders at 2.5 and 4 years, respectively, demonstrate excellent stability and radiographic union despite continued seizure activity., Conclusion: Perioperative neuromuscular paralysis with botulinum toxin may provide early graft protection after the surgical treatment of glenohumeral instability because of seizures., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B707)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

While prior studies have demonstrated that insulin-dependence is an independent risk factor for postoperative complications, morbidity, and mortality following spine and shoulder, hip, and knee arthroplasty, it has not been evaluated in the setting of knee arthroscopy. Therefore, the purpose of this study is to compare the risk of postoperative complications among patients with insulin-dependent diabetes mellitus and noninsulin-dependent diabetes mellitus (IDDM and NIDDM respectively) with the general population following knee arthroscopy. A retrospective analysis of the National Surgical Quality Improvement Program's database for the years 2005 to 2016 was conducted. Logistic regression analyses were used to assess the relationship between diabetic status and outcomes. Multivariate models were established to adjust for age, sex, body mass index, hypertension, congestive heart failure, chronic obstructive pulmonary disease, smoking status, American Society of Anesthesiology classification, and functional status. A total of 86,023 patients were identified. Patients with IDDM were at a much higher risk of surgical complications (odds ratio [OR]: 2.186, 95% confidence interval [CI]: 1.226-1.157), including deep infections (OR: 3.082, 95% CI: 1.753-5.419) and return to operating room [OR] (OR: 1.933, 95% CI: 1.280-2.919), as well as unplanned hospital admission (OR: 1.770, 95% CI: 1.289-2.431). However, NIDDM was not an independent risk factor for subsequent medical or surgical complications, unplanned hospital admission, or 30-day mortality. Patients with IDDM were much more likely to have surgical complications, including deep infection and return to OR, as well as unplanned hospital admission following knee arthroscopy. These risks diminished among those with NIDDM, with their adjusted risk profiles comparable to those without diabetes. Since diabetes occurs in a heterogenous state, more weight should be given to those with insulin-dependence when risk-stratifying patients for surgery. This is a Level III, retrospective comparison study., Competing Interests: None declared., (Thieme. All rights reserved.)

Importance: High-grade posterior cruciate ligament (PCL) tears can be a significant cause of patient morbidity and knee instability. The graft of choice for operative repair remains controversial, although recently there has been increased interest in quadriceps tendon (QT) as an autologous graft option., Objective: The purpose of this study was to perform a systematic review to assess reported clinical outcomes of PCL reconstructions using QT autografts., Evidence Review: A comprehensive review of clinical studies was performed evaluating PCL reconstruction with QT autograft including a systematic search of PubMed, Scopus, Cochrane and Google Scholar databases, and reference lists of relevant papers. Clinical results, stability results, functional outcomes, range-of-motion outcomes, complications and morbidity, and the conclusions of each study were evaluated., Findings: Seven studies were included in the review of clinical results, including 145 subjects undergoing PCL reconstructions with QT autograft. All studies evaluated quadriceps tendon bone (QT-B) grafts. Among these seven studies, two included isolated PCL reconstruction while five included multiligamentous knee injury reconstruction. These studies suggest that QT-B autograft offers a viable graft option for primary PCL reconstruction with generally favourable patient-reported outcomes, knee stability and range of motion reported along with relatively low complication rates., Conclusions and Relevance: Use of the QT-B autograft may be a reasonable graft option for PCL reconstruction. However, high-quality prospective studies are required to evaluate the long-term safety, efficacy and functional outcomes., Level of Evidence: Level IV (Systematic review of Level IV studies)., Competing Interests: Competing interests: None declared., (© International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To (1) determine the rate of surgical complications and venous thromboembolism (VTE) in patients undergoing arthroscopic Bankart repair, open Bankart repair, or Latarjet-Bristow; and (2) assess potential risk factors for surgical complications and VTE in patients undergoing shoulder stabilization procedures., Methods: The NSQIP database was used to identify patients undergoing isolated surgery for shoulder instability from 2005 to 2017. Demographic data were collected and compared. Logistic regression was used to assess the risk factors for developing a postoperative complication, and regression analyses were used to evaluate the odds of postoperative complications between types of surgery., Results: We identified 7,233 patients for inclusion. Patients undergoing Latarjet-Bristow were more likely to be male and Black and to report current tobacco use. Overall, there was a low rate of surgical complications (0.4%) and VTE (0.2%). However, patients undergoing Latarjet-Bristow had nearly a 10-fold increase in the risk of surgical complications compared with an arthroscopic or open Bankart repair (1.9% versus 0.2%, P < .001), including deep surgical site infections, return to operating room within 30 days, and symptomatic VTE (deep venous thrombosis rate: arthroscopic Bankart repair, 0.1%; Latarjet-Bristow, 0.8%; P < .001). There were no differences in the odds of developing a surgical complication or VTE between patients undergoing arthroscopic or open Bankart repair., Conclusion: This study used a nationally representative, widely validated, peer-reviewed database to demonstrate that patients undergoing a Latarjet-Bristow procedure are at significantly higher risk for short-term postoperative complications, including deep surgical site infections, return to the operating room, and symptomatic VTE, than those undergoing Bankart repair. These findings should not discourage surgeons from proceeding with a coracoid transfer procedure when indicated for glenoid deficiencies, but should inform preoperative counseling and help guide perioperative care to optimize patient outcomes., Level of Evidence: III, retrospective comparative trial., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To use the Truven MarketScan database to (1) report the incidence of venous thromboembolism (VTE), including deep vein thromboses (DVTs) and pulmonary embolism (PE), in patients undergoing simple knee arthroscopy and anterior cruciate ligament (ACL) reconstruction, and (2) evaluate combined oral contraceptive (COCP) use as a potential risk factor for VTE in patients undergoing knee arthroscopy., Methods: All female patients between the ages of 16 and 40 years undergoing knee arthroscopy and ACL reconstruction between 2010 and 2015 were identified in the MarketScan database. Patients were stratified by whether they had a documented pharmaceutical claim for COCP therapy, and the primary outcome was the risk of DVT and or PE within 90 postoperative days., Results: In total, 64,165 patients were identified for inclusion. While the overall incidence of VTE was low, patients taking COCPs had an increased risk of a DVT or PE compared with those not on COCPs (odds ratio [OR] 2.1, P < .001). When patients were analyzed by procedural subgroup (ACL reconstruction and simple knee arthroscopy), similar results held true. Furthermore, smoking and obesity had a synergistic effect when combined with COCPs use on the risk of VTE. Specifically, 3.1% of patients with obesity on COCPs (OR 3.1, P < .001) and 4.0% of smokers on COCPs (OR 4.3, P < .001) developed a postoperative VTE., Conclusions: This study demonstrates that COCP use is associated with an increased risk for a symptomatic DVT or PE (1.70% and 0.27%, respectively) after knee arthroscopy and an increased risk for DVT, but not PE (1.80% and 0.23%, respectively), after ACL reconstruction. In addition, patients with multiple risk factors present such as tobacco use, obesity, and COCP use had odds ratios greater than the sum of the individual risk factors alone., Level of Evidence: level III prognostic cohort study., (Copyright © 2021. Published by Elsevier Inc.)

Introduction: The purpose of this study was to evaluate nationwide trends and regional variability in opioid prescriptions after common orthopaedic procedures., Methods: A retrospective analysis of privately insured subjects from the MarketScan database between 2015 and 2016 was conducted. Median oral morphine equivalents and interquartile ranges were analyzed by region for the initial post-op prescriptions and 90-day total prescriptions for opioid-naive patients undergoing the following: carpal tunnel release; anterior cruciate ligament reconstruction; arthroscopic meniscectomy; bimalleolar ankle fracture open reduction and internal fixation; distal radius fracture open reduction and internal fixation; arthroscopic rotator cuff repair; single-level anterior cervical discectomy and fusion; and total shoulder, hip, and knee arthroplasties. We hypothesized that notable regional variability exists with postoperative narcotic prescribing habits., Results: Seventy three thousand nine hundred twenty-one opioid-naive patients were identified. A notable regional variability was observed across the United States in the prescriptions given for all procedures, except total joint arthroplasty. Furthermore, although patients undergoing soft-tissue-only procedures required the fewest refills, patients undergoing total joint arthroplasty required the most., Discussion: Notable regional variability exisits in opioid prescribing patterns for many common orthopaedic procedures. Furthermore, prescriptions were smallest in the region most affected by the opioid epidemic. This information can be used to re-evaluate recommendations, serve as a benchmark for surgeons, and develop institutional and quality improvement guidelines to reduce excess postoperative opioid prescriptions., Level of Evidence: Level III observational cohort study., (Copyright © 2020 by the American Academy of Orthopaedic Surgeons.)

Background: Femoral nerve block (FNB) is a popular technique for reducing postoperative pain in patients with anterior cruciate ligament reconstruction (ACLR), but it is also linked to a number of adverse effects, such as quadriceps weakness, antalgic ambulation, and increased fall risk. Adductor canal block (ACB) has been offered as a motor nerve-sparing alternative to FNB., Purpose: To evaluate available literature that compares the effects of ACB and FNB on functional outcomes after arthroscopic ACLR., Study Design: Systematic review., Methods: Following the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a search of PubMed (Ovid), CINAHL, Scopus, Cochrane, and Google Scholar databases was conducted. Search terms were designed to capture studies comparing the effects of ACB and FNB in patients undergoing arthroscopic ACLR. Data were evaluated regarding study and patient characteristics, functional measures, opioid consumption, pain scores, and complications., Results: Eight randomized controlled trials (N = 655 patients) comparing the efficacy of ACB versus FNB in arthroscopic ACLR were included. The heterogeneity of outcome measures precluded meta-analysis. Seven studies reported functional measures, which included isokinetic strength, straight-leg raise, and other various measures. Follow-up periods varied between 1 hour and 6 months. In 3 trials, ACB was found to preserve quadriceps strength as measured using straight-leg raise for the first 12 to 24 hours after surgery, while 3 other trials found no difference between the groups. No differences were reported in isokinetic strength at 6 months. In other functional measures, ACB either outperformed or was equivalent to FNB. The majority of studies reporting opioid consumption, pain scores, and complications found no differences between the blocks., Conclusion: This systematic review suggests that when compared with FNB, ACB preserves quadriceps function in the early postoperative period after ACLR while providing a similar level of analgesia. Limitations of this study include the use of various functional measures and limited long-term follow-up. More research evaluating long-term functional outcomes with standardized measures is needed to draw adequate conclusions regarding the effects of ACB and FNB on function after ACLR.

Background: Opioid use disorder (OUD) will touch the careers of future generations of nurses no matter their chosen setting of work. It is critical to incorporate OUD education into the nursing school curriculum to prepare these future nurses., Method: Research has shown that the unfolding case study is a beneficial pedagogical modality. It allows for the building of new information and the expansion of critical thinking by encouraging the student to assess and ask questions to receive further information., Results: An unfolding case study was created that centered on a person who develops OUD and their family. It includes simulations, activities, and discussion topics., Conclusion: The unfolding case study can be integrated throughout the undergraduate curriculum from assessment to critical care. The unfolding case study can continue into the graduate program, which allows for interdisciplinary use. [J Nurs Educ. 2020;59(4):235-238.]., (Copyright 2020, SLACK Incorporated.)

Hypothesis: The purpose of this study was to evaluate the association between smoking and postoperative complications following total shoulder arthroplasty. We hypothesized that active smokers would have significantly greater postoperative medical and surgical complications., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent total shoulder arthroplasties from 2005 through 2016. Patients were stratified based on tobacco use within the past year. Logistic regression was used to assess the relationship between smoking status and postoperative medical and surgical complications. Multivariate logistic regression was used to adjust for demographic and comorbid factors., Results: We identified 14,465 patients, of whom 10.5% were active smokers. Smokers were more likely to be younger, to be female patients, and to have a lower body mass index compared with nonsmokers (P < .001). Univariate analysis demonstrated that smoking was not associated with postoperative medical complications (P > .05) but was associated with an increased risk of overall surgical complications (odds ratio [OR], 3.259; 95% confidence interval [CI], 1.861-5.709; P < .001). Multivariate modeling showed that smoking increased the risk of wound complications (adjusted OR, 7.564; 95% CI, 2.128-26.889; P = .002) and surgical-site infections (adjusted OR, 1.927; 95% CI, 1.023-3.630; P = .042)., Discussion and Conclusion: This study demonstrates that smoking is associated with an increased risk of surgical complications following total shoulder arthroplasty. On the basis of our available data, medical complications are not significantly increased. This information can help risk stratify patients prior to their procedures., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study is to evaluate the utility of the modified frailty index-5 (mFI-5) as a predictor for postoperative complications in patients undergoing arthroscopic rotator cuff repair (RCR)., Methods: The National Surgical Quality Improvement Program database was queried for patients undergoing arthroscopic RCR between 2006 and 2016. The mFI-5, a 5-factor score comprising comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status limiting independence, was calculated for each patient. Multivariate logistic regression models were used to evaluate the mFI-5 score as a predictor for complications including medical complications, surgical-site infections, hospital admission, discharge to a facility, and mortality., Results: In total, 24,477 patients met criteria for inclusion. The mFI-5 was a strong predictor for medical complications (P < .001), hospital admission (P < .001), length of stay (P = .007), and discharge to a facility (P = .001) but not surgical-site infections (P = .153). For each point increase in mFI-5 score, the risk for a medical complication increased by 66%, readmission by 52%, and adverse discharge by 45%. However, of all the measured complications, the mFI-5 was the strongest predictor for mortality, with the risk more than doubling for each increase in mFI-5 point (odds ratio 2.66, P = .025)., Conclusions: The mFI-5 is a sensitive tool for predicting life-threatening medical complications, hospital admission, increased length of stay, adverse discharge, and mortality following arthroscopic RCR. The 5 comorbidities comprising the mFI-5 are easily obtained through the patient history, making it a practical clinical tool for identifying high-risk patients, informing preoperative counseling, and improving value-based health care., Level of Evidence: Level III, prognostic., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Cutibacterium (formerly called Propionibacterium) acnes is a human skin flora often implicated in orthopedic infections. The unique characteristics of this microorganism make the diagnosis of infection difficult. The diagnosis often is made based on clinical evidence, radiographic signs, and laboratory and/or surgical findings combined. Treatment often involves both pharmacologic and surgical methods. In addition, formation of biofilms and increased resistance to drugs exhibited by the microorganism can require combined antimicrobial therapy. Prophylactic measures are particularly important, but no single method has been shown to fully eliminate the risk of C acnes infections. Previous reports have focused on C acnes infections involving surgical implants or after certain orthopedic procedures, particularly in the shoulder and spine. This article reviews current clinical, diagnostic, and treatment principles for C acnes in orthopedics in general. [Orthopedics. 2020; 43(1):52-61.]., (Copyright 2020, SLACK Incorporated.)

Purpose: To perform a systematic review with quantitative and qualitative analysis of publications to date focusing on the use of quadriceps tendon (QT) autografts in anterior cruciate ligament (ACL) reconstruction and to define the regional variability, type of publication, level of evidence, journal of publication, and type of QT graft used., Methods: The PubMed, Scopus, and Google Scholar databases were systematically queried for journal articles relating to QT autografts used for ACL reconstruction through 2018. These publications were filtered for relevance and then analyzed and differentiated by publication characteristics., Results: Most articles were published in the United States and Europe, and most articles evaluating clinical outcomes were Level of Evidence III. Over 60% of the publications (115 of 187) focusing on QT for ACL reconstruction were published within the past 10 years, and 30% (56 of 187) were published within the past 3 years. The results not only showed a recent increase in the number of publications regarding QT as a choice for the autograft harvest site in ACL reconstruction over time, but also yielded informative data regarding the publication journal, country or region, and level of evidence., Conclusions: This evaluation shows the increasing interest in the scientific evaluation of QT as a source of autograft tissue for ACL reconstruction., Clinical Relevance: Increased production of high-quality research will allow surgeons to feel more confident in their use of the QT as an autograft option in ACL reconstruction., (© 2019 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Hypothesis: The purpose of this study was to evaluate the 5-factor modified frailty index (mFI-5) as a predictor of postoperative complications in patients undergoing total shoulder arthroplasty (TSA)., Methods: We conducted a retrospective analysis of the National Surgical Quality Improvement Program database for patients undergoing TSA between the years 2005 and 2017. The mFI-5 score, which includes the presence of comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and postoperative complications., Results: A total of 18,957 patients undergoing TSA were identified. The mFI-5 was a strong predictor of serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), discharge to a facility, and readmission (odds ratio ≥ 1.309, P ≤ .001). Length of stay also increased as the mFI-5 score increased (P < .001). However, among all the measured complications, the mFI-5 was the strongest predictor of mortality, with the risk more than doubling for each point increase in the mFI-5 score (odds ratio, 2.113; 95% confidence interval, 1.447-3.086; P < .001)., Conclusion: The mFI-5 predicts serious medical complications, increased length of stay, discharge to a facility, hospital readmission, and mortality in patients undergoing TSA. All of the variables within the mFI-5 are easily obtained through the patient history, allowing for a practical clinical tool that hospitals and surgeons can use to identify high-risk surgical candidates, inform preoperative counseling, and guide perioperative care to optimize patient outcomes., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare complications after shoulder arthroscopy in patients with insulin-dependent diabetes mellitus (IDDM), patients with non-insulin-dependent diabetes mellitus (NIDDM), and nondiabetic patients., Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005 to 2016 was conducted. Logistic regression analyses were used to assess the relation between diabetic status (nondiabetic patients, n = 50,626; NIDDM patients, n = 5,332; and IDDM patients, n = 2,484) and outcomes. Multivariate models were established to adjust for age, sex, body mass index, hypertension, congestive heart failure, chronic obstructive pulmonary disease, smoking status, American Society of Anesthesiologists classification, and functional status., Results: Patients with IDDM were at a higher risk of medical complications, with an adjusted odds ratio (AOR) of 1.524 (95% confidence interval [CI], 1.082-2.147), including pulmonary complications (AOR, 2.078; 95% CI, 1.089-3.964) and urinary tract infections (AOR, 2.129; 95% CI, 1.027-4.415). Patients with IDDM also had a higher risk of 30-day hospital admission (AOR, 1.581; 95% CI, 1.153-2.169) and 30-day mortality (AOR, 3.821; 95% CI, 1.243-11.750). Conversely, patients with NIDDM had comparable risks of medical and surgical complications, unplanned hospital admission, and death to nondiabetic patients., Conclusions: Medical complications, 30-day hospital admission, and death after shoulder arthroscopy were more likely in patients with IDDM. These risks diminished among patients with NIDDM, with their risks being comparable with those of nondiabetic patients., Level of Evidence: Level III, retrospective comparison study., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Quadriceps tendon (QT) autografts are being increasingly used for anterior cruciate ligament reconstruction (ACLR). A paucity of studies exist that compare QT autografts with alternative graft options. Additionally, concerns exist regarding quadriceps recovery after graft harvest insult to the quadriceps muscle-tendon unit., Purpose/hypothesis: The purpose of this study was to compare quadriceps recovery and functional outcomes in patients with QT versus bone-patellar tendon-bone (BPTB) autografts. The hypothesis was that those with QT autografts would demonstrate superior outcomes., Study Design: Cohort study; Level of evidence, 3., Methods: Active patients with a history of primary, unilateral ACLR with soft tissue QT or BPTB autografts participated. Quadriceps recovery was quantified using variables of strength, muscle size, and activation. Knee extensor isometric and isokinetic strength was measured bilaterally with an isokinetic dynamometer and normalized to body weight. Quadriceps activation was measured with the superimposed burst technique. The maximal cross-sectional area of each quadriceps muscle was measured bilaterally using magnetic resonance imaging. Assessors of muscle size were blinded to the graft type and side of ACLR. Functional tests included hop tests and step length symmetry during walking, measured via spatiotemporal gait analysis. Self-reported function was determined with the International Knee Documentation Committee (IKDC) questionnaire. Neuromuscular and functional outcomes were expressed as limb symmetry indices (LSIs: [surgical limb/nonsurgical limb]*100%). Wilcoxon rank-sum tests were used to compare the LSIs and IKDC scores between groups., Results: There were 30 study participants (19 male, 11 female; median age, 22 years [range, 14-41 years]; median time since surgery, 8 months [range, 6-23 months]), with 15 patients in each group. There were no significant between-group differences in demographic variables or outcomes. LSIs were not significantly different between the QT versus BPTB group, respectively: knee extensor isokinetic strength at 60 deg/s (median, 70 [range, 41-120] vs 68 [range, 37-83]; P = .285), activation (median, 95 [range, 85-111] vs 92 [range, 82-105]; P = .148), cross-sectional area of the vastus medialis (median, 79 [range, 62-104] vs 77 [range, 62-95]; P = .425), single-leg hop test (median, 88 [range, 35-114] vs 77 [range, 49-100]; P = .156), and step length symmetry (median, 99 [range, 93-104] vs 98 [range, 92-103]; P = .653). The median IKDC scores between the QT and BPTB groups were also not significantly different: 82 (range, 67-94) versus 83 (range, 54-94); respectively ( P = .683)., Conclusion: Patients with QT autografts demonstrated similar short-term quadriceps recovery and postsurgical outcomes compared with patients with BPTB autografts., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported by the South Carolina Clinical & Translational Research Institute, at the Medical University of South Carolina, through National Institutes of Health grants TL1 TR001451 and UL1 TR001450. This project was also supported by the National Athletic Trainers’ Association Foundation Award (1617DGP005). S.K.W. has received educational support from Arthrex, MTF, Smith & Nephew, and Stryker; honoraria and hospitality fees from MTF; and consulting fees from MicroAire. H.S.S. has received educational support from Arthrex and Smith & Nephew and speaking fees from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Objectives: There are numerous benefits of organized athletics, but there is an inherent risk with competitive participation. The need for proper care for high school and community athletes can be met with comprehensive community sports medicine programs, and the employment of certified athletic trainers (AT-Cs). The benefit of clinic-based AT-C has been clearly demonstrated, but there has been little published on the economics of outreach AT-C serving directly in the community. Our hypothesis was that outreach AT-Cs are economically sustainable to an academic health system., Methods: Evaluation of clinical business generated from the outreach Sports Medicine AT-C program at our institution was performed from fiscal years 2012 to 2015 to determine new referrals, billable patient encounters (bpe), and corresponding revenue generated. Data were retrieved from an existing aggregate business analysis, including both professional billing and hospital billing; data were restricted to the fiscal year of the initial referral. Both new patients and patients with established care were identified. Total revenue was determined, as well as the distribution across clinical departments within our health system., Results: 8570 bpe resulted from 843 patients referred into the system, yielding $2286,733 in total revenue. Of these, 187 were new patients, yielding 1602 bpe. Each patient generated an average of 10.17 bpe, by combining revenue across services; this yielded an average of $2712 per patient generated through the AT-C program., Conclusion: Affiliation between a health system and community sports teams through an outreach AT-C program is an economically sustainable, symbiotic relationship. Additionally, there is not only a positive economic impact for sports medicine and orthopaedic providers but also a distinct benefit to the entire health system. This is the first study to demonstrate that an outreach AT-C program is financially sustainable and directly benefits the entire health system across many subspecialties.

Os acromiale is a failure of fusion between 1 or more ossification centers of the scapula and the acromion process. Pain can be caused by motion and impingement of the unfused segment. Several methods for the management of os acromiale have been described. Internal fixation is the most common surgical technique, followed by excision and acromioplasty. We present a novel technique for treatment of symptomatic os acromiale using arthroscopically-guided headless compression screws. This is a viable technique in the management of symptomatic os acromiale due to preservation of the periosteal blood supply and less concern for symptomatic hardware., Competing Interests: Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Perioperative bleeding and postsurgical hemorrhage are common in invasive surgical procedures, including orthopedic surgery. Tranexamic acid (TXA) is a pharmacologic agent that acts through an antifibrinolytic mechanism to stabilize formed clots and reduce active bleeding. It has been used successfully in orthopedics to reduce perioperative blood loss, particularly in total hip and knee arthroplasty and spine surgery. Numerous research studies have reported favorable safety and efficacy in orthopedic cases, although there is no universal standard on its administration and its use has not yet become the standard of practice. Reported administration methods often depend on the surgeon's preference, with both topical and intravenous routes showing efficacy. The type and anatomic site of the surgery seem to influence the decision making but also result in conflicting opinions. Reported complication rates with TXA use are low. The incidence of both arterial and venous thromboembolic events, particularly deep venous thrombosis and pulmonary embolism, has not been found to be significantly different with TXA use for healthy patients. The route of administration and dosage do not appear to affect complication rates either. However, data on patients with higher-risk conditions are deficient. In addition, TXA has shown potential to reduce blood loss, transfusion rates and volumes, perioperative hemoglobin change, and hospital-related costs at various degrees among the published studies. Conservation of blood products, reduced laboratory costs, and shorter hospital stays are likely the major factors driving the cost savings associated with TXA use. This article reviews current data supporting the safety, efficacy, and cost-effectiveness of TXA in orthopedic surgery., (Copyright 2016, SLACK Incorporated.)

Shoulder pain and dysfunction is a complex problem frequently encountered by primary care physicians. Common nonarthritic conditions seen in the primary care setting include rotator cuff syndrome, impingement, posttraumatic stiffness, adhesive capsulitis, and instability. A thorough history and physical examination can aid in the diagnosis of many common shoulder complaints. Pain and instability are the most common shoulder complaints. Pain that is sharp or burning is commonly radicular in origin, whereas pain caused by tendinitis is often dull, diffuse, and aching. Instability is frequently found in patients with a history of dislocation, but also may occur with no prior history. Imaging modalities such as magnetic resonance imaging can be helpful for more advanced pathology. However, many common shoulder conditions can be diagnosed without imaging, and may be initially treated with a short course of rest, ice, topical analgesics, nonsteroidal anti-inflammatory drugs, directed and supervised physical therapy, and occasionally subacromial corticosteroid injections. As always, a detailed history and a thorough physical exam by a primary care physician are vital for diagnosis. When conservative measures fail, referral to an orthopaedic surgeon may be necessary for further patient management.

Review of available English literature suggests that combined injuries involving a clavicle shaft fracture and an acromioclavicular (AC) separation are rare. The force dissipation after the occurrence of either a midshaft clavicle fracture or an AC separation typically renders the injuries mutually exclusive. This article presents a review of literature on this combined injury pattern. A variety of treatment approaches have been put forth, including nonoperative, operative, and hybrid management of the two distinct injuries. The most appropriate treatment rendered depends on the degree of AC joint instability. This case report involves a midshaft clavicle fracture associated with a type IV AC separation in a patient ejected during a high-speed motor vehicle collision. Internal fixation of each injury was chosen and the patient had a successful final result. Other reported treatment options and recommendations are reviewed.

This prospective, randomized study compared postoperative pain control with use of a continuous temperature-controlled cryotherapy system versus a traditional ice therapy regimen following outpatient knee arthroscopy. Patients with unilateral knee pathology scheduled for outpatient arthroscopic surgery were included. Patients with major ligament reconstructions were excluded. A specific cold therapy regimen was begun postoperatively and continued for 2 weeks as adjunctive management of postoperative pain. Preoperative and postoperative pain intensity, pain type, functionality, and sleep quality were assessed. Patients were randomly assigned to either an ice or a continuous cryotherapy group. Follow-up questionnaires were completed on 5 postoperative days. Data were analyzed using a chi-square test with a level of significance at P < 0.05. Fifty-three patients completed the study. Pain intensity was similar between groups throughout the course of the study. Among patients who reported experiencing night pain, 36% of those in the continuous cryotherapy group were able to sleep soundly with minimal awakening through postoperative day 2 versus 5.9% among the ice therapy group (P = 0.04). No significant differences existed between groups regarding functional ability, and no differences were noted on other follow-up days. These findings support use of continuous temperature-controlled cold therapy devices for nighttime pain control and improved quality of life in the early period following routine knee arthroscopy.

Background: Autologous chondrocyte implantation (ACI) is an expensive treatment option for focal cartilage defects, and commercial funding of research is associated with a study reaching a positive conclusion. The purpose of this analysis is to compare outcomes (and levels of evidence) between published ACI outcome studies that were commercially funded and studies that were not commercially funded., Hypothesis: Commercially funded ACI literature could be commercially biased., Study Design: Comparative meta-analysis., Methods: MEDLINE was searched for human, knee, ACI, nonmembrane, English language, and clinical outcome studies. Studies were evaluated with regard to funding status (commercially funded or not commercially funded), outcomes, and levels of evidence. Outcomes and levels of evidence were evaluated and compared for commercially funded studies versus those that were not commercially funded., Results: Twenty-three studies were included; 16 (70%) were commercially funded. Pooled clinical outcome measures data were not significantly different (Lysholm, Modified Cincinnati, patient-reported Cincinnati, Tegner, pain Visual Analog Scale) when comparing commercially funded studies with those that were not commercially funded. However, distribution of levels of evidence was significantly lower (P = .045) for commercially funded studies., Conclusion: Reassuringly, commercial funding of ACI studies did not result in a difference in published clinical outcomes versus those that were not commercially funded. However, the lower levels of evidence of commercially funded studies suggests that commercially funded ACI studies may be of less value to surgeons desiring to practice evidence-based medicine, and, in the future, commercial entities funding medical research could selectively fund studies of the highest levels of evidence.

Purpose: The superior-medial (SM) shoulder arthroscopic portal (Neviaser portal) is the portal anatomically closest to the suprascapular nerve, and any potential benefits of this portal would be mitigated if risk of suprascapular nerve injury were significant. The purpose of this study is to determine the safety of the SM arthroscopic shoulder portal. We hypothesize that the SM shoulder arthroscopic portal is safe., Methods: Twelve fresh cadaveric shoulders were securely positioned to simulate shoulder arthroscopy in the beach-chair position with the arm at the patient's side in neutral rotation. An SM portal was established 1 cm medial to the acromion and 1 cm posterior to the clavicle, and a 5.5-mm burr sheath was oriented toward the acromioclavicular joint. The skin and trapezius were resected, the supraspinatus was retracted, and the suprascapular nerve was identified. The distance between the sheath and the nerve was measured by 2 independent observers with calipers. A safe distance was defined as 10 mm., Results: The measured distances between the nerve and burr ranged from 18.5 to 35.7 mm, with a mean of 24.2 +/- 5 mm. The distance is significantly greater than the safe distance of 10 mm (P < .0001)., Conclusions: This study shows that the SM portal is safe. The distance between an instrument oriented toward the acromioclavicular joint via the SM portal and the suprascapular nerve was 18.5 mm or greater in all specimens., Clinical Relevance: Our study has clinical relevance because the SM portal is useful for arthroscopic rotator cuff repair, arthroscopic superior labrum repair, and arthroscopic distal clavicle excision.

Trisomy 21 or Down syndrome is the most common chromosomal anomaly and is associated with musculoskeletal abnormalities related to a generalized ligamentous laxity. Approximately 1% to 7% of Down syndrome patients have hip instability. Prior studies on the topic recommend Salter innominate osteotomy, capsular plication, and a varus derotational osteotomy of the proximal femur, which typically is in an anteverted and valgus position. The authors present a previously unreported bilateral finding in two patients noted on three-dimensional reconstruction computed tomography: deficiency of the posterior acetabular wall. Each was treated using a modification of the Pemberton osteotomy in which a wedge of iliac crest graft is placed posteriorly to hinge the posterior wall into a position of better posterior coverage of the femoral head. Both patients' hips have remained stable more than 10 years postoperatively. Follow-up imaging demonstrates well-remodeled osteotomy sites and excellent posterior coverage of the femoral heads.

Investigations dedicated to examining relationships between low back pain (LBP) and factors specific to running and walking are limited. Current literature suggests runners and walkers may have a lower relative risk for significant LBP. The purpose of this study was to investigate the incidence, prevalence, and possible risk factors for LBP among a group of runners and walkers. A survey was administered to participants who registered for either a 10-kilometer run or 4-mile recreational walk. A total of 539 responses were received. Previous history of LBP was reported by 74% of respondents overall. Prevalence of LBP at the time of survey completion was 13.6%. Low back pain was experienced more frequently by obese runners and by those who reported certain patterns of shoe wear. Regular participation in aerobics correlated with a reduced lifetime risk for LBP. We believe these findings warrant further investigation. This knowledge may benefit not only athletes in training, but other fitness enthusiasts, including casual runners and walkers and those who jog or walk to rehabilitate low back injuries.

Since current bone procurement and processing standards have been adopted, published studies have consistently shown that the risk of disease transmission from allograft is small. The purpose of this study was to evaluate allograft use and opinions regarding allograft safety during spinal deformity surgery. A postal survey was sent to 151 pediatric orthopaedists chosen from a cross-referenced listing of active members of both the Scoliosis Research Society and the Pediatric Orthopaedic Society of North America. The survey consisted of six questions covering allograft use during idiopathic and neuromuscular scoliosis cases, concerns about disease transmission, preoperative counseling, concerns about providers, and evaluation of clinical results. The response rate was 80%. Allograft bone use was reported by 96% of those responding for neuromuscular cases and by 62% for idiopathic cases. Infection (68%) and pseudoarthrosis (26%) were the most common topics mentioned among the 41% who addressed potential risks. Variation was found in surgeons' perceptions regarding the safety and efficacy of allograft for scoliosis surgery.

The purpose of this study was to assess the dynamic in vitro and in vivo characteristics of two different bioabsorbable copolymer soft-tissue fixation devices and to determine their efficacy in reattaching soft tissue to bone. Suretac fixators (Smith & Nephew/Acufex MicroSurgical Inc., Northwood, MA), made of polyglyconate (2:1 glycolic acid:trimethylene carbonate), and Pop Rivets (Arthrotek, Warsaw, IN), made of LactoSorb (82% poly L-lactic acid, 18% polyglycolic acid), were anchored into synthetic bone, and their pull-out strengths were evaluated. The devices were also evaluated with the use of an in vivo goat model in which the medial collateral ligament (MCL) was elevated from the tibia and directly reattached. In the in vitro biomechanical study, the Suretac fixators had negligible strength remaining by four weeks, whereas the Pop Rivets retained 50% of their strength at 4 weeks, 20% at 8 weeks, and negligible strength at 12 weeks. The in vivo strength of MCL repairs affected by each implant was not statistically different at any of the time points. Histologically, both implants were absorbed by 52 weeks, and there was no appreciable adverse tissue response. In conclusion, both copolymer fixators were found to be biocompatible. The Pop Rivet fixators demonstrated in vivo performance comparable to the Suretac fixators, although the Pop Rivets retained strength longer in vitro. Our results suggest that both devices provide adequate strength of fixation before degrading to allow the healing soft tissues to reach or surpass their native strength., (Copyright 2001 John Wiley & Sons, Inc.)

The presence of bioabsorbable materials in orthopaedics has grown significantly over the past two decades with applications in fracture fixation, bone replacement, cartilage repair, meniscal repair, fixation of ligaments, and drug delivery. Numerous biocompatible, biodegradable polymers are now available for both experimental and clinical use. Not surprisingly, there have been a wealth of studies investigating the biomechanical properties, biocompatibility, degradation characteristics, osteoconductivity, potential toxicity, and histologic effects of various materials. Promising results have been reported in the areas of fracture fixation, ligament repair, and drug delivery. In this article we review the pre-clinical in vivo testing of bioabsorbable devices with particular emphasis on implants used for these applications.