Point-of-care radiology service at the US Open Tennis Championships.

Professional tennis tournaments have onsite sports medicine physicians who oversee the athletes' overall health during competition, including musculoskeletal injury and general illnesses. The medical team is composed of orthopedic and non-operative sports medicine physicians. Frequently, the tournament doctors require imaging to localize and grade musculoskeletal injuries and to make decisions regarding treatment, safe training, and return to match play. The most versatile and readily available imaging modality to evaluate for acute musculoskeletal injury is point-of-care ultrasonography. In 2015, a dedicated radiology service was created at the US Open by bringing in a musculoskeletal radiologist who would perform ultrasounds in a formal and consistent manner. In addition, the radiologist was tasked with onsite radiography as well as review of all MRI examinations done at the imaging center. This article describes how this radiology service was implemented, what types of studies were performed and the advantages of having an onsite musculoskeletal radiologist at the tournament. This service allowed the medical team to provide the comprehensive and efficient medical care required in a major professional tennis event. It also showed the value of having the in-person expertise of the musculoskeletal radiologist in the sports medicine team. This same model could be applied to other professional sporting events.

Shoulder Arthroscopy in Adults 60 or Older: Risk Factors That Correlate With Postoperative Complications in the First 30 Days.

PURPOSE: To investigate the 30-day postoperative adverse event (AE) rates of adults 60 years or older after shoulder arthroscopy and identify risk factors for complications in this patient population. METHODS: Patients aged 60 or more who underwent shoulder arthroscopy were identified in the American College of Surgeons National Surgery Quality Improvement Program database from 2006 to 2013 using 12 Current Procedural Terminology codes related to shoulder arthroscopy. Complications were categorized as severe AEs, minor AEs, and infectious AEs for separate analyses. Pearson's χ2 tests were used to identify associations between patient characteristics and AE occurrence and binary logistic regression for multivariate analysis of independent risk factors. RESULTS: In total, 7,867 patients were included for analysis. Overall, 1.6% (n = 127) of the older adults experienced at least one AE with 1.1% (n = 90) severe AEs, 0.6% (n = 46) minor AEs, and 0.4% (n = 28) infectious complications. Multivariate analysis revealed that age 80 years or older (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.2-2.7, P = .01), body mass index greater than 35 (OR = 1.8, 95% CI = 1.1-2.7, P = .01), functionally dependent status (OR = 2.9, 95% CI = 1.3-6.8, P = .01), American Society of Anesthesiologists class greater than 2 (OR = 1.5, 95% CI = 1.0-2.2, P = .04), congestive heart failure (OR = 6.1, 95% CI = 1.8-21.2, P = .03), disseminated cancer (OR = 7.9, 95% CI = 1.4-43.9, P = .02), and existence of an open wound at the time of surgery (OR = 4.0, 95% CI = 1.1-14.6, P = .03) were independently associated with the occurrence of an AE. Nineteen of the patients included in the study required readmission to the hospital within the 30-day period for an overall readmission rate of 0.2%. CONCLUSIONS: Patients 60 years or older who underwent shoulder arthroscopy for a variety of indications have a low overall 30-day postoperative complication rate of 1.6%. Although low, this is a higher rate than previously reported for the overall shoulder arthroscopy population. Independent patient characteristics associated with increased risk of AE occurrence included age 80 years or older, body mass index greater than 35, functional dependent status, American Society of Anesthesiologists score of 3 or 4, congestive heart failure, disseminated cancer, and existence of an open wound. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Ambulatory Surgery Centers Significantly Decrease Total Health Care Expenditures in Primary Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described. PURPOSE: To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017. STUDY DESIGN: Descriptive epidemiology study. METHODS: For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement. RESULTS: There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all). CONCLUSION: Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.

Trends in Health Care Expenditures and Patient Out-of-Pocket Expenses in Primary Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed orthopaedic procedures in the United States, and the number of procedures is increasing annually, as is the cost. Patients are expected to shoulder a larger out-of-pocket expenditure. PURPOSE: To answer the following questions: (1) How is reimbursement changing for ACLR, and how is this affecting patients' out-of-pocket expenditures? (2) How are reimbursements from payers and patients' out-of-pocket expenses for ACLR distributed, and how is this changing? (3) Does performing ACLR in an ambulatory surgery center (ASC) result in lower costs for payers and patients? STUDY DESIGN: Economic and decision analysis study; Level of evidence, 4. METHODS: A total of 37,763 patients who underwent outpatient primary arthroscopic ACLR in the United States between 2013 and 2017 were identified using the IBM MarketScan Commercial Claims and Encounters Database. Patients with concomitant procedures and revision ACLR were excluded. Recorded outcomes were total patient payments and reimbursed claim totals in US dollars. RESULTS: Day-of-surgery reimbursement decreased 4.3% from $11,536 in 2013 to $11,044 in 2017, while patient out-of-pocket expenses increased 36% from $1085 in 2013 to $1480 in 2017. Day-of-surgery charges were the highest expense for patients, followed by physical therapy and magnetic resonance imaging (MRI) costs. Total reimbursement for MRI decreased 22.5%, while patient out-of-pocket expenses for MRI increased 166%. ACLR performed in an outpatient hospital resulted in 61% greater day-of-surgery expenditure for payers compared with ACLR performed in an ASC; however, the median total patient out-of-pocket savings for ACLRs performed in an ASC versus outpatient hospital was only $11. CONCLUSION: Out-of-pocket expenses for patients are increasing as they are forced to cover a larger percentage of their health care costs despite overall payer reimbursement decreasing. High-deductible health plans reimbursed the least out of all insurance types while having the highest patient out-of-pocket expenditure.

Can the change in center-edge angle during pincer trimming be reliably predicted?

BACKGROUND: Femoroacetabular impingement is recognized as a cause of hip pain in young adults and as a precursor to osteoarthritis although many questions persist regarding its management. One in particular is when to resect a pincer lesion and how much to resect. Instability can result from overresection and persistent impingement can result from underresection. QUESTIONS/PURPOSES: We therefore determined the correlation between the change in center-edge (CE) angle and the amount of acetabular rim resection. METHODS: We performed open acetabular rim trimming on 10 cadaveric hips. Radiographs were performed before and after rim resection every millimeter from 1 to 5 mm and we determined the CE angle. We performed linear regression to establish any correlation of the CE angle with the amount of resection. RESULTS: The CE angle could be predicted by -1.3X + 1.5 (R(2) = 0.99), in which X = the amount of resection for 1 to 3 mm of resection. The average CE angle before resection was 35° ± 8.8° (range, 19°-58°). CONCLUSIONS: The CE angle changes in a predictable way with acetabular rim trimming with larger amounts of resection resulting in greater changes in the CE angle. CLINICAL RELEVANCE: The ability to accurately plan the amount of acetabular rim resection in hip arthroscopy by knowing the exact change in CE angle with amount of rim removal may help prevent overresection or underresection in pincer trimming.

Examining the Association of Knee Pain With Modifiable Cardiometabolic Risk Factors.

OBJECTIVE: A well-established link exists between obesity and knee osteoarthritis, and recent research has implicated diabetes mellitus as a potential cause of cartilage degeneration. The objective of this study was to use the National Health and Nutrition Examination Survey (NHANES) database to examine the association between knee pain and various metabolic factors. METHODS: A retrospective cross-sectional study of the NHANES database from 1999 to 2004 was performed. The main outcome was any knee pain and bilateral knee pain. The main effects of interest were body mass index (BMI) and glycohemoglobin A1c . We additionally assessed various patient factors, including age, race, poverty, sex, and smoking status. Multivariable logistic regression models and interaction terms were analyzed. RESULTS: Data on 12,900 patients were included. In the main adjusted analysis, the modifiable risk factors associated with any knee pain were overweight (odds ratio [OR] 0.91 [95% confidence interval (95% CI) 0.85-0.97), obesity (OR 1.54 [95% CI 1.42-1.66]), glycemic control (OR 1.20 [95% CI 1.03-1.38]), and current smoking (OR 1.15 [95% CI 1.05-1.27]) (all P < 0.05). These same factors remain significant for bilateral knee pain. Subgroup analysis showed that patients age <65 years have a 5% increase in the risk of any knee pain as their BMI increases, but patients age ≥65 years have a 10% increase in risk. CONCLUSION: This study confirms the association of knee pain with increased weight, glycemic control, current smoking, and age. Most of these risk factors can be modified in patients with knee pain and should be discussed when providing conservative treatment options.

Preoperative Patient Education May Decrease Postoperative Opioid Use After Meniscectomy.

PURPOSE: To identify the current opioid prescribing and use practices after arthroscopic meniscectomy and to evaluate the role of preoperative patient education in decreasing postoperative opioid consumption. METHODS: Patients undergoing arthroscopic meniscectomy were prospectively identified for inclusion. They were placed into 1 of 2 groups: Group 1 received no education regarding opioid use after surgery, whereas group 2 received a standardized overview on postoperative opioid use. Patients were assigned to the groups consecutively: Patients treated at the beginning of the study were assigned to group 1, and patients treated at the end of the study were assigned to group 2. Data from group 1 were used to identify "normal" opioid prescribing and use practices and to guide patients in group 2 regarding normal postoperative opioid use. Patients were surveyed weekly for 4 weeks after surgery to determine the number of opioids taken. Postoperative opioid consumption was analyzed and compared between the 2 groups. RESULTS: A total of 62 patients completed the study (32 in group 1 and 30 in group 2). Patients in group 1 were prescribed an average of 42.0 opioid pills (95% confidence interval [CI], 34.0-51.0 pills) and used an average of 15.84 pills (95% CI, 9.26-22.4 pills) after surgery, whereas patients in group 2 used an average of 4.00 pills (95% CI, 2.12-5.88 pills) after surgery. Patients in group 2 used 11.84 fewer opioid pills (P = .001), a 296% decrease in postoperative opioid consumption. The number of patients who continued to take opioid pills 4 weeks after surgery was 7 patients (21.9%) in group 1 and 1 patient (3.3%) in group 2. CONCLUSIONS: Preoperative patient education regarding opioids may decrease postoperative opioid consumption and the duration for which patients take opioid pills after arthroscopic meniscectomy. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Return to sports following operatively treated ankle fractures.

BACKGROUND: This study investigated which variables influence patients' return to sports after operative fixation of an unstable ankle fracture. MATERIALS AND METHODS: Over a 5-year period, 488 patients underwent surgical repair of an unstable ankle fracture. 243 patients preoperatively identified themselves as participating in vigorous activity. Clinical evaluation, functional outcome scores, and radiographic findings were reviewed retrospectively. RESULTS: At 3 months postoperatively, only 3% of all patients had returned to full sports. At 6 months, 14% of patients had returned, while at one year, only 24% of patients had returned. Younger age was predictive of return to sports by 3 months (p = 0.02), 6 months (p = 0.02) and 12 months (p = 0.0001). Males were more likely to return to sports at 6 (p = 0.001) and 12 months (p = 0.040). At 1 year, 88% of recreational athletes had returned to sports, while only 11.6% of competitive athletes had returned to sports (p = 0.043). At 12 months, bimalleolar injuries were more likely to return to sports than unimalleolar ankle fractures (p = 0.042). Furthermore, patients without an associated syndesmotic injury were more likely to return to athletic activities at 12 months (p = 0.011). A patient with an ASA of one or two was ten times more likely to return to sports versus a patient with an ASA of three or four (odds ratio > 10, p = 0.010). CONCLUSION: Predictors of return to sporting activities at one year include younger age, male gender, no or mild systemic disease, and a less severe ankle fracture. Negative predictors include older age, female gender, and the presence of severe medical comorbidities.

Withdrawals and Retirements in Professional Tennis Players.

BACKGROUND: Injuries and illnesses for professional tennis athletes disrupt training, competition, and progression in the sport and represent a major reason for athlete withdrawal or retirement from a tournament. Few descriptive epidemiological studies have focused on these trends in elite tennis athletes. PURPOSE: To examine the causes of professional tennis player withdrawal or retirement from United States Tennis Association (USTA) Pro Circuit tournaments during 2013. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: Tournament records from the 2013 USTA Pro Circuit season were retrospectively reviewed for incidences of injury and illness that resulted in athlete withdrawal from the tournament. Data were reported as incidence rates per 1000 match exposures and rate ratios. RESULTS: There were 70 medical conditions over the course of 27 competitions (20,988 match exposures), for an overall incidence rate of 3.34 per 1000 match exposures. Women were more likely to injure themselves on clay courts compared with hard courts (rate ratio, 4.67; 95% confidence interval [CI], 1.41-19.85) and in the first half of the season compared with the second half (rate ratio, 3.95; 95% CI, 1.13-21.17). Men had a higher injury rate than women (rate ratio, 1.88; 95% CI, 1.17-3.63), and muscle-/tendon-related injuries were 6 times more likely than all other injuries (95% CI, 2.81-14.69). CONCLUSION: Women were more likely to experience an injury when playing on clay court surfaces, and they also experienced more injuries during the first half of the season. Injury rates for men often peaked during the months that players could qualify for Grand Slam competitions. There was a predominance of injuries in men compared with women.

Sports-related injuries in the young female athlete.

The number of females participating in sports continues to increase. Adolescent and preadolescent females are at a risk injury to both their open growth plates as well as their joints. The purpose of this article is to review the common injuries seen with the most popular sports with females. Mt Sinai J Med 77:307-314, 2010. (c) 2010 Mount Sinai School of Medicine.

Practice patterns for combined anterior cruciate ligament and meniscal surgery in the United States.

PURPOSE: The purpose of the study was to compare frequency of meniscal repair to partial meniscectomy in patients undergoing anterior cruciate ligament reconstruction using the American Board of Orthopaedic Surgeons (ABOS) database. HYPOTHESES: (1) Practice patterns are similar with respect to geographic region. (2) Surgeons with fellowship training perform more meniscal repairs compared with general orthopaedic practitioners. (3) Younger patients are more likely to be treated with meniscal repair at the time of anterior cruciate ligament reconstruction. (4) The frequency of meniscal repair in conjunction with anterior cruciate ligament reconstruction has increased over time. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Information was extracted from the ABOS database from 2002 orthopaedic surgeons who sat for the part II examination from 2003 to 2007. The database was queried for all patients who underwent anterior cruciate ligament reconstruction (Current Procedural Terminology [CPT] code 29888) without or with meniscectomy (CPT 29881) or meniscal repair (CPT 29882). Factors affecting meniscal surgery that were investigated included patient age, geographic region of practice, fellowship training, and declared subspecialty of the surgeon. RESULTS: On average there were 52,000 cases per year registered in the ABOS database, approximately 1700 of whom underwent anterior cruciate ligament reconstruction. Meniscal repair was most frequently performed in the Southwest region (18.6%, P < .001) and least frequently in the Northwest region (11.3%, P < .001). Combined anterior cruciate ligament reconstruction and meniscal repair was performed significantly more often by fellowship-trained surgeons (17%) than by surgeons with other fellowship training (12%) or no fellowship training (12%, P < .001) and in patients younger than age 25 years (19%) compared with those age 40 years and older (8%, P <.001). Meniscal repair was performed in 13.9% of anterior cruciate ligament reconstructions in 2003 and in 16.4% of anterior cruciate ligament reconstructions in 2007 (P > .05). CONCLUSION: Combined anterior cruciate ligament reconstruction with meniscal repair was more frequent for younger patients and by surgeons with sports fellowship training. Concomitant meniscal repair is performed by fellowship-trained surgeons in this study in only 18% of anterior cruciate ligament reconstructions.

Tendon-derived stem/progenitor cell aging: defective self-renewal and altered fate.

Aging is a major risk factor for tendon injury and impaired tendon healing, but the basis for these relationships remains poorly understood. Here we show that rat tendon- derived stem / progenitor cells (TSPCs) differ in both self-renewal and differentiation capability with age. The frequency of TSPCs in tendon tissues of aged animals is markedly reduced based on colony formation assays. Proliferation rate is decreased, cell cycle progression is delayed and cell fate patterns are also altered in aged TSPCs. In particular, expression of tendon lineage marker genes is reduced while adipocytic differentiation increased. Cited2, a multi-stimuli responsive transactivator involved in cell growth and senescence, is also downregulated in aged TSPCs while CD44, a matrix assembling and organizing protein implicated in tendon healing, is upregulated, suggesting that these genes participate in the control of TSPC function.