Prescribing Fewer Opioids After Rotator Cuff Repair and Anterior Cruciate Ligament Reconstruction Lowers Opioid Consumption Without Impacting Patient-Reported Pain Scores.

Purpose: To develop a standardized opioid prescribing schedule (SOPS) following anterior cruciate ligament reconstruction (ACLR) and rotator cuff repair (RCR) and evaluate postoperative opioid consumption alongside Patient-Reported Outcome Measurement Information System (PROMIS) pain interference scores. Methods: A prospective observational study was performed on all patients undergoing primary ACLR and RCR from March 2019 to October 2021. Patients taking opioids preoperatively and revision ACLR and RCR were excluded. PROMIS 6B questionnaires were administered before and after implantation of the SOPS initiated on December 15, 2019. Opioid consumption was determined by email surveys. Hypothesis testing was performed with Mann-Whitney U test. Results: A total of 599 patients met inclusion criteria with 188 patients (71 ACLR and 117 RCR) completing surveys. Before the initiation of SOPS, the average number of oxycodone 5-mg tablets prescribed for ACLR was 44.6 (95% confidence interval [CI] 42.4-46.9) and for RCR was 44.7 (95% CI 42.7-46.8). The average usage was 23.1 (95% CI 16.9-29.2) and 22.1 (95% CI 16.2-28.0), respectively. Following SOPS of 30 tablets of oxycodone 5 mg for ACLR and 40 tablets for RCR, the average number of tablets prescribed significantly decreased for both procedures (P < .01 for ACLR and RCR), and the average consumption decreased to 20.5 (95% CI 16.6-24.4) and 18.6 (95% CI 14.6-22.5), respectively. PROMIS 6B responses did not demonstrate statistically significant changes following SOPS. Conclusions: The results of the present study demonstrate that the implementation of a SOPS reduced postoperative opioid prescribing amounts and consumption without significant impacting PROMIS pain interference scores for ACLR and RCR, supporting the possibility to decrease and standardize opioid prescribing following common sports medicine procedures. Level of Evidence: III: Retrospective, comparative, therapeutic study.

Computational Metrics Can Provide Quantitative Values to Characterize Arthroscopic Field of View.

Purpose: The purpose of this study was to determine the inter-rater reliability of arthroscopic video quality, determine correlation between surgeon rating and computational image metrics, and facilitate a quantitative methodology for assessing video quality. Methods: Five orthopaedic surgeons reviewed 60 clips from deidentified arthroscopic shoulder videos and rated each on a four-point Likert scale from poor to excellent view. The videos were randomized, and the process was completed a total of three times. Each user rating was averaged to provide a user rating per clip. Each video frame was processed to calculate brightness, local contrast, redness (used to represent bleeding), and image entropy. Each metric was then averaged over each frame per video clip, providing four image quality metrics per clip. Results: Inter-rater reliability for grading video quality had an intraclass correlation of .974. Improved image quality rating was positively correlated with increased entropy (.8142; P < .001), contrast (.8013; P < .001), and brightness (.6120; P < .001), and negatively correlated with redness (-.8626; P < .001). A multiple linear regression model was calculated with the image metrics used as predictors for the image quality ranking, with an R-squared value of .775 and root mean square error of .42. Conclusions: Our study demonstrates strong inter-rater reliability between surgeons when describing image quality and strong correlations between image quality and the computed image metrics. A model based on these metrics enables automatic quantification of image quality. Clinical Relevance: Video quality during arthroscopic cases can impact the ease and duration of the case which could contribute to swelling and complication risk. This pilot study provides a quantitative method to assess video quality. Future works can objectively determine factors that affect visualization during arthroscopy and identify options for improvement.

Bone bruising severity after anterior cruciate ligament rupture predicts elevation of chemokine MCP-1 associated with osteoarthritis.

PURPOSE: Anterior cruciate ligament rupture is associated with characteristic bone contusions in approximately 80% of patients, and these have been correlated with higher pain scores. Bone bruising may indicate joint damage that increases inflammation and the likelihood of posttraumatic osteoarthritis. We sought to characterize the severity of bone bruising following acute anterior cruciate ligament injury and determine if it correlates with synovial fluid and serum levels of the proinflammatory chemokine monocyte chemoattractant protein-1 associated with posttraumatic osteoarthritis. METHODS: This was a retrospective analysis of data collected prospectively from January 2014 through December 2016. All patients who sustained an acute ligament rupture were evaluated within 15 days of injury, obtained a magnetic resonance imaging study, and underwent bone-patellar-tendon-bone autograft reconstruction were offered enrollment. The overall severity of bone bruising on magnetic resonance imaging was graded (sum of 0-3 grades in 13 sectors of the articular surfaces). Serum and synovial fluid levels of monocyte chemoattractant protein-1 were measured within 14 days of injury, and serum levels were again measured 6 and 12 months following surgery. Separate univariate linear regression models were constructed to determine the association between monocyte chemoattractant protein-1 and bone bruising severity at each time point. RESULTS: Forty-eight subjects were included in this study. They had a mean age of 21.4 years and were 48% female. Median overall bone bruising severity was 5 (range 0-14). Severity of bone bruising correlated with higher synovial fluid concentrations of monocyte chemoattractant protein-1 preoperatively (R2 = 0.18, p = 0.009) and with serum concentrations at 12 months post-reconstruction (R2 = 0.12, p = 0.04). CONCLUSIONS: The severity of bone bruising following anterior cruciate ligament rupture is associated with higher levels of the proinflammatory cytokine monocyte chemoattractant protein-1 in synovial fluid acutely post-injury and in serum 12-months following anterior cruciate ligament reconstruction. This suggests that severe bone bruising on magnetic resonance imaging after ligament rupture may indicate increased risk for persistent joint inflammation and posttraumatic osteoarthritis. LEVEL OF EVIDENCE: III - retrospective cohort study.

Recurrent Hemarthrosis following Resections of Benign Bone Tumors: A Case Report of Two Pediatric Cases.

Introduction/Cases. Two pediatric patients presenting with benign bone tumors of the distal femur at the level of the suprapatellar fat pad developed late onset recurrent knee hemarthrosis following surgical treatment of the lesions. A sinus tract from the intramedullary bone to the knee capsule was discovered in both patients during surgical exploration. Resection of the sinus tract and full closure of the knee capsule resulted in no further recurrence. Conclusion. Postoperative knee effusions in patients following resection near the distal femur could represent hemarthrosis that require additional workup and treatment. Resection of the sinus tract successfully treats the hemarthrosis.

Editorial Commentary: Fluoroscopy Is Seldom Required During Knee Posterolateral Reconstruction.

Identifying the structures of the lateral knee is critical during knee posterolateral corner reconstruction. Several methods exist that can help estimate the femoral insertions of these structures on lateral radiographs. However, it is important to recognize the limitations of these methods and that anatomic visualization is often more practical and more accurate. Until percutaneous or more minimally invasive techniques become standardized, intraoperative fluoroscopy is seldom needed or used for posterolateral corner reconstruction, whereas radiographic analysis of lateral knee structures could be of benefit in cases of failed reconstruction to assess tunnel placement.

Unmet Patient Expectations for Interventions Decrease Provider Satisfaction Scores.

As health care reimbursement evolves, physicians will continue to be evaluated based on the quality of care that they provide. One measure of quality is based on patient satisfaction as reported through the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS). Although previous studies have explored expectations and their role in patient satisfaction, no studies have investigated the role of patient expectations for interventions in surgical specialty clinics. Patients (N=126) were given 2 surveys, a pre-visit and a post-visit questionnaire, with options based on the CAHPS survey. Patients were asked to select common orthopedic services that they expected to receive from their appointments, rate their physicians on Likert scales, and report the services that were actually provided. Patients who left with unmet expectations for interventions (45%) rated their physicians lower than patients who had all of their expectations met (9.0±1.4 vs 9.5± 0.8; P<.05). For most individual interventions, there was no difference in satisfaction between patients with met and unmet expectations. However, patients who expected surgery and did not have their expectations met rated their physician lower than patients whose expectations for surgery were met (9.0±1.3 vs 9.7±0.6; P<.05). No statistically significant difference was found in physician rating with increased numbers of unmet expectations, individual surgeon rating, perceptions of their providers, and wait time. This study reports that patient expectations for interventions, and particularly a recommendation for surgery, may alter a patient's reported satisfaction, particularly when surgical expectations are unmet. [Orthopedics. 2020;43(5):e378-e382.].

Trends in open shoulder surgery among early career orthopedic surgeons: who is doing what?

BACKGROUND: The incidence of various open shoulder procedures has changed over time. In addition, various fellowships provide overlapping training in open shoulder surgery. There is a lack of information regarding the relationship between surgeon training and open shoulder procedure type and incidence in early career orthopedic surgeons. METHODS: The American Board of Orthopaedic Surgery Part-II database was queried from 2002 to 2016 for reported open shoulder procedures. The procedures were categorized as follows: arthroplasty, revision arthroplasty, open instability, trauma, and open rotator cuff. We evaluated procedure trends as well as their relationship to surgeon fellowship categorized by Sports, Shoulder/Elbow, Hand, Trauma, and "Other" fellowship as well as no fellowship training. We additionally evaluated complication data as it related to procedure, fellowship category, and volume. RESULTS: Over the 2002-2016 study period, there were increasing cases of arthroplasty, revision arthroplasty, and trauma (P < .001). There were decreasing cases in open instability and open rotator cuff (P < .001). Those with Sports training reported the largest overall share of open shoulder cases. Those with Shoulder/Elbow training reported an increasing overall share of arthroplasty cases and higher per candidate case numbers. The percentage of early career orthopedic surgeons reporting 5 or more arthroplasty cases was highest among Shoulder/Elbow candidates (P < .001). Across all procedures, those without fellowship training were least likely to report a complication (odds ratio [OR], 0.76; 95% confidence interval, 0.67-0.86; P < .001). Shoulder/Elbow candidates were least likely to report an arthroplasty complication (OR, 0.84, P = .03) as was any surgeon reporting 5 or more arthroplasty cases (OR, 0.81; 95% confidence interval, 0.70-0.94; P = .006). CONCLUSION: The type and incidence of open shoulder surgery procedures continues to change. Among early career surgeons, those with more specific shoulder training are now performing the majority of arthroplasty-related procedures, and early career volume inversely correlates with complications.

Age matters when comparing hemiarthroplasty and total hip arthroplasty for femoral neck fractures in Medicare patients.

INTRODUCTION: The optimal treatment of patients with a displaced intracapsular femoral neck fracture remains controversial. We utilised a national database of Medicare patients to determine if there was any difference in complications and reoperation rate of patients undergoing total hip arthroplasty (THA) or hemiarthroplasty (HA) for femoral neck fractures. METHODS: This study utilised the PearlDiver Patient Records Database, a national for-fee database of Medicare patient procedure and diagnosis records from 2005 to 2012. Outcome procedures and diagnoses including revision, dislocation, infection, and cardiovascular events that occurred during the study time period were also identified over the entire study period as well as 90 days and 2 years. RESULTS: We identified 275,439 patients with femoral neck fractures who underwent HA and 26,017 patients who underwent THA, respectively. Patients undergoing HA had significantly lower rates (p < 0.0001) of revision 2.48% versus 3.85% (OR = 0.633; 95% CI, 0.592-0.678), dislocation 1.76% versus 3.39% (0.512; 0.476-0.551), infection 3.44% versus 4.87% (0.694; 0.657-0.737). There was no statistical significant difference in 2-year cardiac morbidity (p = 0.252). However, when controlling for age, patients 65-69 years showed no significant difference in infection or revision over the study period or at 2 years. CONCLUSIONS: In this study, patients who underwent THA for femoral neck fractures had a higher rate of dislocations, infections and increased rates of repeat surgery than those who underwent HA but this difference was not significant in patients 65-69 years. Hemiarthroplasty may result in fewer complications in older Medicare patients although this difference may not be present in younger Medicare patients.

Trends in Surgical Management and Costs for Operative Treatment of Proximal Humerus Fractures in the Elderly.

Proximal humerus fractures in the elderly are increasing in frequency as the population ages. The purpose of this study was to investigate surgical and cost trends in the Medicare population. The PearlDiver database was queried using diagnosis codes to identify Medicare recipients with proximal humerus fractures from 2005 to 2012. Surgical trends, demographics, and charge/reimbursement data were analyzed. There were 750,426 proximal humerus fractures in Medicare recipients during the 8-year period. Eighty-five percent of the fractures were treated nonoperatively; however, the percentage of operative vs nonoperative management increased significantly over time for all fractures, isolated fractures, and fracture dislocations. Open reduction and internal fixation (ORIF) was the most common surgical treatment and remained constant. Reverse total shoulder arthroplasty (RTSA) increased by 406% and hemiarthroplasty (HEMI) decreased by 47%. Compared with younger patients, older patients were more likely to undergo HEMI or RTSA than to undergo ORIF for isolated fractures and fracture dislocations. Charges and reimbursements from Medicare increased over time. The charge to reimbursement gap increased from 87% in 2005 to 104% in 2012. Charges were higher for RTSA than for ORIF or HEMI. Nonoperative management was the treatment of choice for 85% of proximal humerus fractures in the elderly; however, there was a trend toward higher rates of surgery. The RTSA rate increased and the HEMI rate decreased, while ORIF remained constant. There was an increasing charge to reimbursement ratio for all procedure types. [Orthopedics. 2017; 40(4):e641-e647.].

Initial medical management of rotator cuff tears: a demographic analysis of surgical and nonsurgical treatment in the United States Medicare population.

BACKGROUND: Rotator cuff tears have a lifetime incidence between 25% and 40% in the United States, but optimum treatment strategies and protocol have not yet been widely accepted. This study evaluated the proportions of patients treated with nonoperative and operative modalities and how this proportion has changed during an 8-year period (2005-2012) among patients with Medicare. METHODS: Using the PearlDiver patient record database, we identified Medicare patients having been diagnosed with a rotator cuff tear. These patients were then stratified on the basis of treatment with physical therapy, subacromial/glenohumeral injection, or rotator cuff repair. We analyzed the data in regard to standard demographic information, comorbidities, and the Charlson Comorbidity Index. RESULTS: During the study period, 878,049 patients were identified and 397,116 patients had rotator cuff repair. The proportion of patients treated initially with physical therapy dropped from 30.0% in 2005 to 13.2% in 2012, and the subacromial/glenohumeral injection proportion decreased from 6.00% to 4.19% (P < .001). The proportion of patients who had rotator cuff repair increased from 33.8% to 40.4% from 2005 to 2012 (P < .001). Charlson Comorbidity Indexes were significantly lower in operative patients compared with each nonoperative treatment examined. DISCUSSION: This analysis demonstrates a significant decrease in the initial trial of nonoperative treatment and an increase in the rate of surgery. Patients undergoing rotator cuff repair had fewer comorbidities than those undergoing nonoperative treatments. It also demonstrates that patients who had a trial of injection had a higher incidence of eventual rotator cuff repair compared with the patients with an initial trial of physical therapy.

Risk Factors for Infection After Knee Arthroscopy: Analysis of 595,083 Cases From 3 United States Databases.

PURPOSE: To identify and quantify patient- and procedure-related risk factors for post-arthroscopic knee infections using a large dataset. METHODS: An administrative health care database including 8 years of records from 2 large commercial insurers and Medicare (a 5% random sample) was queried to identify all knee arthroscopies performed on patients aged at least 15 years using Current Procedural Terminology (CPT) codes. Each CPT code was designated as a high- or low-complexity procedure, with the former typically requiring accessory incisions or increased operative time. Deep infections were identified by a CPT code for incision and drainage within 90 days of surgery. Superficial infections were identified by International Classification of Diseases, Ninth Revision infection codes without any record of incision and drainage. Patients were compared based on age, sex, body mass index, tobacco use, presence of diabetes, and Charlson Comorbidity Index. RESULTS: A total of 526,537 patients underwent 595,083 arthroscopic knee procedures. Deep postoperative infections occurred at a rate of 0.22%. Superficial infections occurred at a rate of 0.29%. Tobacco use and morbid obesity were the largest risk factors for deep and superficial infections, respectively (P < .001; relative risk of 1.90 and 2.19, respectively). There were also higher infection rates among patients undergoing relatively high-complexity arthroscopies, men, obese patients, diabetic patients, and younger patients (in order of decreasing relative risk). Increased Charlson Comorbidity Index was associated with superficial and total infections (P < .001). CONCLUSIONS: Post-arthroscopic knee infections were more frequent among morbidly obese patients, tobacco users, patients undergoing relatively complex procedures, men, obese patients, diabetic patients, relatively young patients, and patients with increased comorbidity burdens in this study population. This knowledge may allow more informed preoperative counseling, aid surgeons in patient selection, and facilitate infection prevention by targeting individuals with higher inherent risk. LEVEL OF EVIDENCE: Level IV, cross-sectional study.

Effects of Hand Fellowship Training on Rates of Endoscopic and Open Carpal Tunnel Release.

PURPOSE: To investigate rates, trends, and complications for carpal tunnel release (CTR) related to fellowship training using the American Board of Orthopaedic Surgery Part II Database. METHODS: We searched the American Board of Orthopaedic Surgery database for patients with carpal tunnel syndrome who underwent either open carpal tunnel release (OCTR) or endoscopic (ECTR) from 2003 to 2013. Cases with multiple treatment codes were excluded. Data were gathered on geographic location, fellowship, and surgical outcomes. Data were then divided into 2 cohorts: hand fellowship trained versus non-hand fellowship trained. We performed analysis with chi-square tests of independence and for trend. RESULTS: Overall, 12.4% of all CTRs were done endoscopically. Hand fellowship-trained orthopedists performed about 4.5 times the number of ECTR than did non-hand fellowship-trained surgeons. An increasing trend over time of ECTR was seen only among the hand fellowship cohort. The northwest region of the United States had the highest incidence (23.1%) of ECTR, and the Southwest the lowest incidence (5.9%). The complication incidence associated with CTR overall was 3.6%, without a significant difference between ECTR and OCTR. Within the hand fellowship cohort the complication incidence for ECTR was significantly less than for OCTR. There was no difference in overall complication rates with ECTR and OCTR between the 2 cohorts. Wound complications were higher with OCTR (1.2% vs 0.25%) and nerve palsy with ECTR (0.66% vs 0.27%); with postoperative pain equivalent between techniques independent of fellowship training. CONCLUSIONS: Within the United States from 2003 to 2013, the rate of ECTR increased, as did complications. However, complication rates remained low in the first 2 years of practice. Hand fellowship-trained surgeons performed more ECTR than did non-hand fellowship-trained orthopedic surgeons, and both groups had similar complication rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A regional assessment of medicaid access to outpatient orthopaedic care: the influence of population density and proximity to academic medical centers on patient access.

BACKGROUND: Access to care is limited for patients with Medicaid with many conditions, but data investigating this relationship in the orthopaedic literature are limited. The purpose of this study was to investigate the relationship between health insurance status and access to care for a diverse group of adult orthopaedic patients, specifically if access to orthopaedic care is influenced by population density or distance from academic teaching hospitals. METHODS: Two hundred and three orthopaedic practices within the state of North Carolina were randomly selected and were contacted on two different occasions separated by three weeks. An appointment was requested for a fictitious adult orthopaedic patient with a potential surgical problem. Injury scenarios included patients with acute rotator cuff tears, zone-II flexor tendon lacerations, and acute lumbar disc herniations. Insurance status was reported as Medicaid at the time of the first request and private insurance at the time of the second request. County population density and the distance from each practice to the nearest academic hospital were recorded. RESULTS: Of the 203 practices, 119 (59%) offered the patient with Medicaid an appointment within two weeks, and 160 (79%) offered the patient with private insurance an appointment within this time period (p < 0.001). Practices in rural counties were more likely to offer patients with Medicaid an appointment as compared with practices in urban counties (odds ratio, 2.25 [95% confidence interval, 1.16 to 4.34]; p = 0.016). Practices more than sixty miles from academic hospitals were more likely to accept patients with Medicaid than practices closer to academic hospitals (odds ratio, 3.35 [95% confidence interval, 1.44 to 7.83]; p = 0.005). CONCLUSIONS: Access to orthopaedic care was significantly decreased for patients with Medicaid. Practices in less populous areas were more likely to offer an appointment to patients with Medicaid than practices in more populous areas. Practices that were farther from academic hospitals were more likely to offer an appointment to patients with Medicaid than practices closer to academic hospitals. CLINICAL RELEVANCE: This study illustrates the barriers to timely outpatient orthopaedic care that patients with Medicaid face. The findings from our study imply that patients with Medicaid in more populous areas and in areas closer to academic medical centers are less likely to obtain an outpatient orthopaedic appointment than patients with Medicaid in less populous areas and in areas more distant from academic medical centers. A shift in policy to enhance access to orthopaedic care for patients with Medicaid, especially those in urban areas and areas close to academic medical centers, will become increasingly important as more patients become eligible for Medicaid through the Patient Protection and Affordable Care Act of 2010.

Anterior Cruciate Ligament Injury, Return to Play, and Reinjury in the Elite Collegiate Athlete: Analysis of an NCAA Division I Cohort.

BACKGROUND: Graft survivorship, reinjury rates, and career length are poorly understood after anterior cruciate ligament (ACL) reconstruction in the elite collegiate athlete. The purpose of this study was to examine the outcomes of ACL reconstruction in a National Collegiate Athletic Association (NCAA) Division I athlete cohort. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective chart review was performed of all Division I athletes at a single public university from 2000 to 2009 until completion of eligibility. Athletes were separated into 2 cohorts: those who underwent precollegiate ACL reconstruction (PC group) and those who underwent intracollegiate reconstruction (IC group). Graft survivorship, reoperation rates, and career length information were collected. RESULTS: Thirty-five athletes were identified with precollegiate reconstruction and 54 with intracollegiate reconstruction. The PC group had a 17.1% injury rate with the original graft, with a 20.0% rate of a contralateral ACL injury. For the IC group, the reinjury rates were 1.9% with an ACL graft, with an 11.1% rate of a contralateral ACL injury after intracollegiate ACL reconstruction. The athletes in the PC group used 78% of their total eligibility (average, 3.11 years). The athletes in the IC group used an average of 77% of their remaining NCAA eligibility; 88.3% of those in the IC group played an additional non-redshirt year after their injury. The reoperation rate for the PC group was 51.4% and was 20.4% for the IC group. CONCLUSION: Reoperation and reinjury rates are high after ACL reconstruction in the Division I athlete. Precollegiate ACL reconstruction is associated with a very high (37.1%) rate of repeat ACL reinjuries to the graft or opposite knee. The majority of athletes are able to return to play after successful reconstruction.

Surgical Trends in the Treatment of Superior Labrum Anterior and Posterior Lesions of the Shoulder: Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database.

BACKGROUND: After failure of nonoperative treatment, repair has long been the primary treatment option for symptomatic superior labrum anterior and posterior (SLAP) lesions of the shoulder. There is growing evidence to support both biceps tenotomy and tenodesis as effective alternative treatments for SLAP lesions. HYPOTHESES: For patients with isolated SLAP lesions, the frequency of SLAP repair has decreased, while treatment with biceps tenodesis and tenotomy has increased. Similar trends are expected in patients with SLAP lesions undergoing concomitant rotator cuff repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A query of the American Board of Orthopaedic Surgery part II database was performed from 2002 to 2011. The database was searched for patients with isolated SLAP lesions undergoing SLAP repair, open biceps tenodesis, arthroscopic biceps tenodesis, or biceps tenotomy. The database was then queried a second time for patients undergoing arthroscopic rotator cuff repair with concomitant SLAP repair, biceps tenodesis, or biceps tenotomy. RESULTS: From 2002 to 2011, there were 8963 cases reported for the treatment of an isolated SLAP lesion and 1540 cases reported for the treatment of SLAP lesions with concomitant rotator cuff repair. For patients with isolated SLAP lesions, the proportion of SLAP repairs decreased from 69.3% to 44.8% (P < .0001), while biceps tenodesis increased from 1.9% to 18.8% (P < .0001), and biceps tenotomy increased from 0.4% to 1.7% (P = .018). For patients undergoing concomitant rotator cuff repair, SLAP repair decreased from 60.2% to 15.3% (P < .0001), while biceps tenodesis or tenotomy increased from 6.0% to 28.0% (P < .0001). There was a significant difference in the mean age of patients undergoing SLAP repair (37.1 years) versus biceps tenodesis (47.2 years) versus biceps tenotomy (55.7 years) (P < .0001). CONCLUSION: Practice trends for orthopaedic board candidates indicate that the proportion of SLAP repairs has decreased over time, with an increase in biceps tenodesis and tenotomy. Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair.

Access to outpatient care for adult rotator cuff patients with private insurance versus Medicaid in North Carolina.

BACKGROUND: Access to orthopaedic care for pediatric patients has been shown in previous studies to be decreased for patients with Medicaid compared with those with private insurance. The relationship between type of insurance and access to care for adult patients with acute rotator cuff tears has not yet been examined. This study aimed to determine if type of health insurance would have an impact on access to care for an adult patient with an acute rotator cuff tear. METHODS: Seventy-one orthopaedic surgery practices within the state of North Carolina were randomly selected and contacted on 2 different occasions separated by 3 weeks. The practices were presented with an appointment request for a fictitious 42-year-old man with an acute rotator cuff tear. Insurance status was reported as Medicaid for the first call and as private insurance during the second call. RESULTS: Of the 71 practices contacted, 51 (72%) offered the patient with Medicaid an appointment, whereas 68 (96%) offered the patient with private insurance an appointment. The difference in these rates was statistically significant (P < .001). The likelihood of patients with private insurance obtaining an appointment was 8.8 times higher than that of patients with Medicaid (95% CI: 2.5, 31.5). CONCLUSION: For patients with acute rotator cuff tears, access to care is decreased for those with Medicaid compared with those with private insurance. Patients with private insurance are 8.8 times more likely than those with Medicaid to obtain an appointment. LEVEL OF EVIDENCE: Basic science, survey study.

Comparison of fixation methods after anteromedialization osteotomy of the tibial tubercle for patellar instability.

PURPOSE: The aim of this study was to evaluate the biomechanical strength of two 4.5-mm screws and three 3.5-mm screws for fixation of the tibial tubercle after anteromedialization osteotomy. METHODS: Anteromedialization of the tibial tubercle was performed on 5 pairs of fresh-frozen cadaveric lower extremities. One leg from each pair was randomized to fixation with two 4.5-mm screws and the contralateral leg to fixation with three 3.5-mm screws. Each specimen was loaded cyclically to simulate an active straight-leg raise and then to failure while displacement of the tubercle fragment was recorded. RESULTS: There was no difference in mean tubercle fragment displacement under cyclic loading at any cycle number (P > .352). Maximum failure load for osteotomies secured with two 4.5-mm screws was 1,459 ± 540 N, and for three 3.5-mm screws it was 1,360 ± 707 N. This was not a statistically significant difference (P = .723). Tubercle migration of 7 mm was chosen as clinical failure. At this amount of displacement, mean load was 1,085 ± 398 N and 764 ± 313 N in the 4.5-mm and 3.5-mm groups, respectively, which was also not significantly different (P = .146). CONCLUSIONS: Both 2 × 4.5-mm and 3 × 3.5-mm screw constructs after tibial tubercle anteromedialization are equally capable of withstanding physiologic forces like those encountered during an active straight-leg raise and have similar failure strength. CLINICAL RELEVANCE: Although both configurations are comparable, the use of the smaller 3.5-mm screws may reduce the need for hardware removal related to prominence and soft tissue irritation.

Biomechanical analysis of a double-loaded glenoid anchor configuration: can fewer anchors provide equivalent fixation?

BACKGROUND: Bankart repair with multiple anchor holes concentrated in the anterior-inferior glenoid may contribute to glenoid weakening and potentially may induce glenoid failure. PURPOSE: To compare the biomechanical strength of a Bankart repair construct that used 3 single-loaded suture anchors versus a repair construct that used 2 double-loaded suture anchors. STUDY DESIGN: Comparative laboratory study. METHODS: A standard Bankart lesion was created in 18 human cadaveric shoulders (9 matched pairs). Within each matched pair, 1 repair construct used 3 single-loaded anchors, whereas the other used 2 double-loaded suture anchors. Measured outcomes (load, stiffness, and energy absorbed) were recorded at failure and at 2 mm of labral displacement. Constructs were loaded to failure with a materials testing device that had differential variable reluctance transducers for displacement measurements. RESULTS: The double-loaded anchor construct had a significantly higher ultimate tensile load (944 ± 231 vs 784 ± 287 N; P = .03). For the other measures (load at 2 mm of displacement, energy absorbed at failure and at 2 mm of displacement and stiffness), there were no significant differences between tested constructs. CONCLUSION: A Bankart repair construct that used 2 double-loaded anchors was either superior to or equal to a repair construct that used 3 single-loaded anchors in all measured outcomes. CLINICAL RELEVANCE: Using 2 double-loaded suture anchors for a Bankart repair may limit anchor holes in the glenoid and reduce the risk of postsurgical glenoid fracture while providing a stable repair construct.

Revision anterior cruciate ligament reconstruction.

Revision reconstruction of the anterior cruciate ligament (ACL) introduces several diagnostic and technical challenges in comparison with primary ACL reconstruction. With the increasing numbers of original reconstructions combined with the continued expectation of high-level athletic participation, revision ACL reconstruction is likely to become more frequent. The purpose of this article was to summarize the causes of failure and the evaluation of the patient with recurrent instability. A review of the literature regarding results after revision ACL reconstruction was performed to assist in the decision-making process and patient counseling. Good results can be obtained in terms of functional stability after revision reconstruction, but chondral and meniscal injury as well as unrecognized associated pathologic instability may play a role in diminished outcomes. In addition, a wide variety of surgical techniques are reviewed to address problems associated with tunnel malposition, widening, and pre-existing hardware.

Femoral radiographic landmarks for lateral collateral ligament reconstruction and repair: a new method of reference.

BACKGROUND: Little work has been made regarding the use of radiographic landmarks in fibular collateral ligament reconstruction. Radiographic tools can be of use to the surgeon in posterolateral reconstruction as secondary checks in the setting of tissue and bony attrition. HYPOTHESIS: Using standardized radiographic imaging, a zone for femoral tunnel placement in lateral collateral ligament (LCL) reconstruction can be identified. STUDY DESIGN: Descriptive laboratory study. METHODS: Eight fresh-frozen unmatched knees, free of any osseous or articular pathological changes, were selected for dissection (mean age, 61.3 years). Skin and surrounding soft tissues were left intact. Subsequent dissection was carried out to identify the true origin of the LCL. A radiographic marker was applied. True lateral radiographs of the distal femur (posterior condyles overlapping) were taken. Digital radiographic images were obtained and analyzed. RESULTS: The Blumensaat line was found to be closely associated with the LCL origin on lateral radiographic imaging. On average, the LCL ligament was found to be 58% (+ or - 4.7%) across the width of the condyle and 2.3 mm (+ or - 2.3 mm) distal to the Blumensaat line. In all specimens, the anatomical LCL origin was found to have less than 5 mm variance from the mean. CONCLUSION: The LCL origin is located within a specific region that is noted to have a small amount of variance. This is of benefit to the clinician in the traumatic and reconstructive setting where the true origin may not be easily identifiable through dissection. CLINICAL RELEVANCE: Intraoperative fluoroscopic imaging can be used as an adjunctive tool for femoral tunnel placement during posterolateral corner and LCL reconstruction.