Evaluation of Health Care Disparities in Patients With Anterior Cruciate Ligament Injury: Does Race and Insurance Matter?

Background: It is unknown whether race- or insurance-based disparities in health care exist regarding baseline knee pain, knee function, complete meniscal tear, or articular cartilage damage in patients who undergo anterior cruciate ligament reconstruction (ACLR). Hypothesis: Black patients and patients with Medicaid evaluated for ACLR would have worse baseline knee pain, worse knee function, and greater odds of having a complete meniscal tear. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A cohort of patients (N = 1463; 81% White, 14% Black, 5% Other race; median age, 22 years) who underwent ACLR between February 2015 and December 2018 was selected from an institutional database. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, KOOS Function subscale, and intraoperatively assessed complete meniscal tear (tear that extended through both the superior and the inferior meniscal surfaces) were determined via multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS). Results: The 3 factors most strongly associated with worse KOOS Pain and KOOS Function were lower VR-12 MCS score, increased BMI, and increased age. Except for age, the other two factors had an unequal distribution between Black and White patients. Univariate analysis demonstrated equal baseline median KOOS Pain scores (Black, 72.2; White, 72.2) and KOOS Function scores (Black, 68.2; White, 68.2). After adjusting for confounding variables, there was no significant difference between Black and White patients in KOOS Pain, KOOS Function, or complete meniscal tears. Insurance status was not a significant predictor of KOOS Pain, KOOS Function, or complete meniscal tear. Conclusion: There were clinically significant differences between Black and White patients evaluated for ACLR. After accounting for confounding factors, no difference was observed between Black and White patients in knee pain, knee function, or complete meniscal tear. Insurance was not a clinically significant predictor of knee pain, knee function, or complete meniscal tear.

What Are the Predictors of Poor Patient-Reported Outcomes After Shoulder Instability Surgery?

BACKGROUND: Prospectively collected responses to Patient Acceptable Symptom State (PASS) questions after shoulder instability surgery are limited. Responses to these outcome measures are imperative to understanding their clinical utility. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate which factors predict unfavorable patient-reported outcomes after shoulder instability surgery, including "no" to the PASS question. We hypothesized that poor outcomes would be associated with male adolescents, bone loss, combined labral tears, and articular cartilage injuries. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients aged ≥13 years undergoing shoulder instability surgery were included in point-of-care data collection at a single institution across 12 surgeons between 2015 and 2017. Patients with anterior-inferior labral tears were included, and those with previous ipsilateral shoulder surgery were excluded. Demographics, American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, and surgical findings were obtained at baseline. ASES and SANE scores, PASS responses, and early revision surgery rates were obtained at a minimum of 1 year after the surgical intervention. Regression analyses were performed. RESULTS: A total of 234 patients met inclusion criteria, of which 176 completed follow-up responses (75.2%). Nonresponders had a younger age, greater frequency of glenoid bone loss, fewer combined tears, and more articular cartilage injuries (P < .05). Responders' mean age was 25.1 years, and 22.2% were female. Early revision surgery occurred in 3.4% of these patients, and 76.1% responded yes to the PASS question. A yes response correlated with a mean 25-point improvement in the ASES score and a 40-point improvement in the SANE score. On multivariate analysis, combined labral tears (anterior-inferior plus superior or posterior tears) were associated with greater odds of responding no to the PASS question, while both combined tears and injured capsules were associated with lower ASES and SANE scores (P < .05). Sex, bone loss, and grade 3 to 4 articular cartilage injuries were not associated with variations on any patient-reported outcome measure. CONCLUSION: Patients largely approved of their symptom state at ≥1 year after shoulder instability surgery. A response of yes to the PASS question was given by 76.1% of patients and was correlated with clinically and statistically significant improvements in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across patient-reported outcome measures, whereas sex, bone loss, and cartilage injuries were not.

Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs.

BACKGROUND: Shoulder pain and dysfunction are common indications for rotator cuff repair surgery, yet the factors that are associated with these symptoms are not fully understood. PURPOSE/HYPOTHESIS: This study aimed to investigate the associations of patient and disease-specific factors with baseline patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair. We hypothesized that tear size and mental health status, as assessed by the Veterans RAND 12-Item Health Survey mental component score (VR-12 MCS), would be associated with baseline total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscale scores. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We prospectively identified 12 patient factors and 12 disease-specific factors as possible statistical predictors for baseline PROMs in patients undergoing surgical repair of superior-posterior rotator cuff tears at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in baseline PSS and its subscale scores. RESULTS: A total of 1442 patients who had undergone surgery by 23 surgeons met inclusion criteria, with a baseline median total PSS of 38.5 (pain, 12; function, 24.2; satisfaction, 2). Adjusted R2 in multivariable models demonstrated that the 24 general patient and disease-specific factors accounted for 22% to 24% of the variability in total PSS and its pain and function subscale scores. Large/massive tear size was significantly associated with worse PSS total score and function score but not pain or satisfaction scores. Lower VR-12 MCS was significantly associated with worse total PSS and all 3 subscale scores. Among other factors significantly associated with baseline PROMs were sex, race, preoperative opioid use, years of education, employment status, acromion status, and adhesive capsulitis. Lower VR-12 MCS, preoperative opioid use, female sex, and black race were the factors most strongly associated with baseline PROMs. CONCLUSION: Large/massive tear size, lower VR-12 MCS, and several additional patient and disease-specific factors are associated with baseline PROMs in patients undergoing rotator cuff repair. Further studies are needed to investigate whether these factors will also predict poor postoperative PROMs.

Bicondylar tibial plateau fracture after posterior cruciate ligament reconstruction.

The authors present a report of a bicondylar tibial plateau fracture in an adolescent athlete after posterior cruciate ligament (PCL) reconstruction. The procedure was performed via arthroscopic transtibial PCL reconstruction with quadrupled semi-tendinosus and gracilis autograft. The patient recovered uneventfully postoperatively and was able to participate in high-level sports activity, such as baseball and track, with no limitations, no subjective complaints, and no episodes of instability. He continued to be asymptomatic up to 3.5 years postoperatively. Almost 4 years postoperatively, the patient reinjured the left knee during recreational noncontact football and was seen emergently. Plain radiographs, magnetic resonance image scan, and computed tomography scan at the time of injury showed a bicondylar tibial plateau fracture with intra-articular involvement. Operative intervention was undertaken for open reduction and internal fixation of the bicondylar tibial plateau fracture. A plate was placed along the medial aspect of the tibia with locking and nonlocking screws, and the joint line was restored appropriately. The patient recovered uneventfully and at the most recent follow-up had full active and passive range of motion, had no subjective or objective evidence of instability, and had returned to full activity with no restrictions. The patient had no history of multiple fractures or any medical or pharmacologic history that predisposed him to decreased bone density. This case shows a unique possible complication after transtibial PCL reconstruction in an adolescent patient.

Femoral component rotation in total knee arthroplasty: an MRI-based evaluation of our options.

Proper femoral component rotation is crucial in successful total knee arthroplasty. Rotation using anatomic landmarks has traditionally referenced the transepicondylar axis (TEA), Whiteside's Line (WSL), or posterior condylar axis (PCA). TEA is thought to best approximate the flexion-axis of the knee, however WSL or PCA are common surrogates in the operating room. This study evaluated 560 knees using MRI-based planning software to assess the relationship of WSL and PCA to the TEA and determine if the relationships were influenced by pre-operative coronal deformity. Results showed the WSL-TEA relationship has more variability than PCA-TEA and that the PCA is more internally rotated in females and valgus knees. Axis options and historical assumptions about axis relationships may need to be reassessed as imaging technology advances.

Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review.

BACKGROUND: Various methods of bony stabilization, including modifications of Bristow and Latarjet procedures, are considered gold-standard treatment for recurrent anterior shoulder instability but are associated with unique complications and risk of reoperation. The purpose of this study was to identify the prevalence of these complications. We hypothesized that the Bristow-Latarjet procedure would be a successful technique for treatment of shoulder instability but associated with a risk of recurrent postoperative instability, reoperation, and other complications. METHODS: A systematic review of multiple medical databases included studies reporting outcomes with complication and reoperation rates following original or modified versions of the Bristow or Latarjet shoulder stabilization surgeries. RESULTS: Forty-five studies were analyzed (1,904 shoulders) (all Level IV evidence). Most subjects were male (82%). The dominant shoulder was the operative shoulder in 64% of cases. Mean subject age was 25.8 years. Mean clinical follow-up was 6.8 years. Ninety percent of surgeries were done open; 9.3% were all-arthroscopic. Total complication rate was 30%. Recurrent anterior dislocation and subluxation rates were 2.9% and 5.8%, respectively. When reported, most dislocations occurred within the first year postoperatively (73%). Nearly 7% of patients required an unplanned reoperation following surgery. CONCLUSION: Osseous stabilization shoulder surgery using original or modified Bristow and Latarjet procedures has a 30% complication rate. Rates of recurrent dislocation and reoperation were 2.9% and 7%, respectively. Mild loss of external rotation is common. Reoperation rates were lower following all-arthroscopic techniques. There was a greater loss of postoperative external rotation with all-arthroscopic surgery.

The strength of achilles tendon repair: a comparison of three suture techniques in human cadaver tendons.

BACKGROUND: A previous study suggests the double Krackow suture (locking-loop) weave technique is nearly twice as strong as the single Bunnell or single Kessler suture repair techniques. Our hypothesis was that the strength of different repair techniques would be comparable if a similar number of suture strands cross the repair site. MATERIALS AND METHODS: Twenty-four fresh-frozen human cadaver Achilles tendons were used to test maximum strength of three suture techniques (double Bunnell, double Kessler, and double Krackow). The simulated ruptures were created in the midsubstance of the Achilles tendon, five centimeters proximal to its calcaneal insertion. All repairs were performed with No. 2 polyester (Mersilene, Ethicon, Sommerville, NJ) nonabsorbable suture in standard fashion for each technique, with four strands crossing the repair site. The tendons were then anchored to a materials testing machine (Instron, Canton, MA) through a calcaneal pin distally and a modified soft tissue clamp proximally. Tendons were loaded with continuous tension at a head speed of 0.85 cm/s. RESULTS: All repairs failed at the site of the suture knots, none pulling out through the substance of the tendon. A one-way analysis of variance was performed on the maximum force at failure of each repair technique. No statistically significant difference was noted between the double Krackow weave (199.9 +/- 20 N), the double Bunnell weave (196.2 +/- 45 N), and the double Kessler weave (166.9 +/- 51 N). CONCLUSION: We found that in a laboratory model of cadaveric Achilles tendon repairs there was no significant difference in strength between the Krackow, Bunnell, and Kessler suture techniques, when each was performed with a double suture weave. CLINICAL RELEVANCE: This is a cadaveric study that attempts to simulate the clinical parameters of Achilles tendon ruptures, repairs, and repair failures to examine the strength of different repair techniques.