Testosterone: A Review for Orthopaedic Surgeons.

¼ Testosterone replacement treatment (TRT) and anabolic androgenic steroid (AAS) use is common and possibly increasing.¼ Diagnosing and treating hypogonadism in men is controversial.¼ Hypogonadism and the use of AASs seem to have a detrimental effect on the musculoskeletal system. The current literature on TRT and the musculoskeletal system shows an increased risk of tendon injury.¼ There may be a role for testosterone supplementation in the postoperative period.

Testosterone Replacement Therapy and Associated Rates of Trigger Finger, de Quervain Tenosynovitis, and Their Subsequent Management.

PURPOSE: Anabolic steroid therapy has been associated with tendon injury, but there is a paucity of evidence associating physiologic testosterone replacement therapy (TRT) with tenosynovitis of the hand, specifically trigger finger and de Quervain tenosynovitis. The purpose of this study was to evaluate the relationship between TRT and tenosynovitis of the hand. METHODS: This was a one-to-one exact matched retrospective cohort study using a large nationwide claims database. Records were queried between 2010 and 2019 for adult patients who filled a prescription for TRT for 3 consecutive months. Rates of new onset trigger finger and de Quervain tenosynovitis and subsequent steroid injection or surgery were identified using ICD-9, ICD-10, and Current Procedural Terminology billing codes. Single-variable chi-square analyses and multivariable logistic regression were used to compare rates in the TRT and control cohorts while controlling for potential confounding variables. Both unadjusted and adjusted odds ratios (OR) are reported for each comparison. RESULTS: In the adjusted analysis, patients undergoing TRT were more than twice as likely to develop trigger finger compared to their matched controls. TRT was also associated with an increased likelihood of experiencing de Quervain tenosynovitis. Of the patients diagnosed with either trigger finger or de Quervain tenosynovitis over the 2-year period, patients with prior TRT were roughly twice as likely to undergo steroid injections or surgical release for both trigger finger and de Quervain tenosynovitis compared to the controls. CONCLUSIONS: TRT is associated with an increased likelihood of both trigger finger and de Quervain tenosynovitis, and an increased likelihood of requiring surgical release for both conditions. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Decreased prevalence of new-onset adhesive capsulitis in patients prescribed angiotensin receptor blockers.

BACKGROUND: Angiotensin receptor blockers (ARBs) are commonly prescribed antihypertensive agents that have well-known antifibrotic properties. The purpose of this study was to examine the association between ARB use and the rates of new-onset adhesive capsulitis as well as adhesive capsulitis requiring operative treatment. METHODS: Using a large national insurance database, a randomly generated cohort of patients with at least 3 continuous months of ARB use between January 2010 and December 2019 (n = 1,000,000) was compared to a separate randomly generated cohort without ARB use (n = 3,000,000). Rates of newly diagnosed adhesive capsulitis and associated manipulation under anesthesia (MUA) and/or arthroscopic capsulotomy were calculated over a 1- and 2-year period following the completion of at least 3 continuous months of ARB therapy. Rates were compared using multivariable logistic regression to control for demographics and comorbidities. Both unadjusted and adjusted odds ratios and 95% confidence intervals were calculated and reported for each comparison. Statistical significance was set at P <.05. RESULTS: The mean age in the ARB cohort was 61.8 years (standard deviation [SD] = 10.0), whereas in the control cohort, it was 54.8 years (SD = 12.3) (P < .001). The ARB cohort had significantly lower rates of newly diagnosed adhesive capsulitis compared with the control cohort at both 1 year (0.15% vs. 0.55%, P < .001) and 2 years (0.3% vs. 0.78%, P < .001). Similar findings were observed for the arthroscopic capsular release/MUA cohort associated with adhesive capsulitis. After adjusting for confounding factors, the lower rates of adhesive capsulitis and arthroscopic capsular release/MUA associated with adhesive capsulitis in the ARB cohort remained statistically significant (P < .001). CONCLUSION: Patients prescribed ARBs experienced a decreased rate of newly diagnosed adhesive capsulitis, as well as adhesive capsulitis requiring surgical intervention when compared to a control cohort. These findings suggest a potential protective effect of ARBs against the development of adhesive capsulitis. Further investigations are warranted to elucidate the underlying mechanisms and establish a causal relationship.

Testosterone replacement therapy is associated with increased odds of Achilles tendon injury and subsequent surgery: a matched retrospective analysis.

BACKGROUND: Prescription of testosterone replacement therapy (TRT) has increased in the United States in recent years, and though anabolic steroids have been associated with tendon rupture, there is a paucity of literature evaluating the risk of Achilles tendon injury with TRT. This study aims to evaluate the associative relationship between consistent TRT, Achilles tendon injury, and subsequent surgery. METHODS: This is a one-to-one matched retrospective cohort study utilizing the PearlDiver database. Records were queried for patients aged 35-75 who were prescribed at least 3 consecutive months of TRT between January 1, 2010 and December 31, 2019. Achilles tendon injuries and subsequent surgeries were identified using ICD-9, ICD-10, and CPT billing codes. Multivariable logistic regression was used to compare odds of Achilles tendon injury, Achilles tendon surgery, and revision surgery, with a p-value < 0.05 representing statistical significance. RESULTS: A sample of 423,278 patients who filled a TRT prescription for a minimum of 3 consecutive months was analyzed. The 2-year incidence of Achilles tendon injury was 377.8 (95% CI, 364.8-391.0) per 100,000 person-years in the TRT cohort, compared to 245.8 (95% CI, 235.4-256.6) in the control (p < 0.001). The adjusted analysis demonstrated TRT to be associated with a significantly increased likelihood of being diagnosed with Achilles tendon injury (aOR = 1.24, 95% CI, 1.15-1.33, p < 0.001). Of those diagnosed with Achilles tendon injury, 287/3,198 (9.0%) of the TRT cohort subsequently underwent surgery for their injury, compared to 134/2,081 (6.4%) in the control cohort (aOR = 1.54, 95% CI, 1.19-1.99, p < 0.001). CONCLUSIONS: There is a significant association between Achilles tendon injury and prescription TRT, with a concomitantly increased rate of undergoing surgical management. These results provide insight into the risk profile of TRT and further research into the science of tendon pathology in the setting of TRT is an area of continued interest.

Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury.

BACKGROUND: Anabolic steroid use at supraphysiologic doses has been associated with an increased risk of tendon injury. However, the musculoskeletal effects of testosterone therapy in the clinical setting are not well understood. QUESTIONS/PURPOSES: (1) Is prescription testosterone associated with a higher odds of subsequent quadriceps muscle or tendon injury? (2) Is prescription testosterone associated with a higher odds of surgical repair of the quadriceps tendon? METHODS: The PearlDiver Database, which contains data on Medicaid, Medicare, and commercially insured patients, allows for a large representative sample of the US population including both publicly and privately insured patients. The database was queried for all patients between 2011 and 2018 who filled a testosterone prescription. Additionally, all quadriceps injuries using ICD-9 and ICD-10 codes between 2011 and 2018 were queried. Propensity score matching based on age, sex, Charlson comorbidity index, and specific comorbidities allowed us to create matched control groups. We used the t-test and chi-square analysis to compare the unmatched and matched cohorts. A total of 151,797 patients (123,627 male patients and 28,170 female patients) with a history of filled testosterone prescriptions were included in the study after matching with the control group, which was of equal size and representation of age, male-female proportions, and comorbidities. Chi-square and logistic regression analyses were performed to compare odds of quadriceps injury and quadriceps tendon repair among the testosterone groups to that of their respective control groups by age and sex. RESULTS: Within 1 year of filling prescriptions for testosterone, 0.06% (97 of 151,797) of patients experienced a quadriceps injury compared with less than 0.01% (18 of 151,797) of patients in the control group (OR 5.4 [95% CI 3.4 to 9.2]; p < 0.001). Within the sex-specific matched groups, filling a testosterone prescription was associated with an increase in the odds of quadriceps injury in male patients within 1 year of the prescription (OR 5.8 [95% CI 3.5 to 10.3]; p < 0.001). Additionally, patients who filled a testosterone prescription were at increased risk of having quadriceps tendon repair within a year of the injury than were patients in the matched control group (OR 4.7 [95% CI 2.0 to 13.8]; p = 0.001). CONCLUSION: Considering these findings, it is important for physicians to counsel patients receiving testosterone replacement therapy of the substantially increased odds of quadriceps tendon injury. Future investigations into the mechanisms of influence of exogenous anabolic steroids on tendon injury remains of interest. LEVEL OF EVIDENCE: Level III, therapeutic study.

The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair.

BACKGROUND: In the United States, the use of testosterone therapy has increased over recent years. Anabolic steroid use has been associated with tendon rupture, although there is a paucity of evidence evaluating the risk of biceps tendon injury (BTI) with testosterone therapy. The aim of this study was to quantify the risk of BTI after the initiation of testosterone therapy. METHODS: This was a retrospective cohort study using the PearlDiver database. Records between 2011 and 2018 were queried to identify patients aged 35-75 years who filled a testosterone prescription for a minimum of 3 months. A control group was created, comprising patients aged 35-75 years who had never filled a prescription for exogenous testosterone. International Classification of Diseases, Ninth Revision, International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes were used to identify patients with distal biceps injuries and those undergoing surgical repair. Three matching processes were completed: one for the overall cohort, one for the cohort comprising only male patients, and one for the cohort comprising only female patients. Each cohort was matched to its control on age, sex, Charlson Comorbidity Index, diabetes, tobacco use, and osteoporosis. Multivariate logistic regression was used to compare rates of distal BTI and subsequent surgical repair in the testosterone groups with their control groups. RESULTS: A total of 776,974 patients had filled a prescription for testosterone for a minimum of 3 consecutive months. In the overall matched analysis between the testosterone and control groups (n = 291,610 in both), the mean age of the patients was 53.9 years and 23.1% were women. Within 1 year of filling exogenous testosterone prescriptions for a minimum of 3 consecutive months, 650 patients experienced a distal BTI compared with 159 patients in the control group (odds ratio [OR], 4.10; 95% confidence interval [CI], 3.45-4.89; P < .001). At any time after testosterone therapy, patients with testosterone use were more than twice as likely to experience a distal BTI as their matched controls (OR, 2.07; 95% CI, 1.94-2.38). Patients who filled prescriptions for testosterone were more likely to undergo surgical repair within a year of the injury compared with the control group. A similar trend was seen in the cohort comprising male patients (OR, 1.63; 95% CI, 1.29-2.07). CONCLUSION: Patients with prior prescription testosterone exposure have an increased rate of BTI and biceps tendon repair compared with patients without such exposure. This finding provides insight into the risk profile of testosterone therapy, and doctors should consider counseling patients about this risk, particularly male patients.

The Relationship Between Testosterone Therapy and Rotator Cuff Tears, Repairs, and Revision Repairs.

INTRODUCTION: The purpose of this study was to evaluate rates of rotator cuff tears (RCTs), repairs (RCRs), and revision RCR in patients who were prescribed testosterone replacement therapy (TRT) and compare these patients with a control group. METHODS: The PearlDiver database was queried for patients who were prescribed testosterone for at least 90 days between 2011 and 2018 to evaluate the incidence of RCTs in this population. A second analysis evaluated patients who sustained RCTs using International Classification of Diseases, 9th/10th codes to evaluate these patients for rates of RCR and revision RCR. Chi square analysis and multivariate regression analyses were used to compare rates of RCTs, RCR, and subsequent or revision RCR between the testosterone and control groups, with a P -value of 0.05 representing statistical significance. RESULTS: A total of 673,862 patients with RCT were included for analysis, and 9,168 of these patients were prescribed testosterone for at least 90 days before their RCT. The TRT group had a 3.6 times greater risk of sustaining an RCT (1.14% versus 0.19%; adjusted odds ratio (OR) 3.57; 95% confidence interval (CI) 3.57 to 3.96). A 1.6 times greater rate of RCR was observed in the TRT cohort (TRT, 46.4% RCR rate and control, 34.0% RCR rate; adjusted OR 1.60; 95% CI 1.54 to 1.67). The TRT cohort had a 26.7 times greater risk of undergoing a subsequent RCR, irrespective of laterality, within 1 year of undergoing a primary RCR when compared with the control group (TRT, 47.1% and control, 4.0%; adjusted OR 26.4; 95% CI 25.0 to 27.9, P < 0.001). CONCLUSIONS: There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. This finding may represent a musculoskeletal consequence of TRT and is important for patients and clinicians to understand. Additional research into the science of tendon injury in the setting of exogenous anabolic steroids remains of interest. LEVEL OF EVIDENCE: Level Ⅲ, retrospective cohort study.

Trends in upper extremity injuries presenting to emergency departments during the COVID-19 pandemic.

INTRODUCTION: During the emergence of the SARS-CoV-2 (COVID-19) pandemic, there were substantial changes in United States (U.S.) emergency department (ED) volumes and acuity of patient presentation compared to more recent years. Thus, the purpose of this study was to characterize the incidence of specific upper extremity (UE) injuries presenting to U.S. EDs during the COVID-19 pandemic and analyze trends across age groups and rates of hospital admission compared to years prior. METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried to identify patients who presented to U.S. EDs for an UE orthopaedic injury between 2016 and 2020. Chi-square analysis and logistic regression were used to assess for differences in ED presentation volume and hospital admissions between pre-pandemic (2016 through 2019) and during-pandemic (2020) times. RESULTS: These queries returned 285,583 cases, representing a total estimate of 10,452,166 injuries presenting to EDs across the U.S. The mean incidence of UE orthopaedic injuries was 640.2 (95% CI, 638.2-642.3) injuries per 100,000 person-years, with the greatest year to year decrease in incidence occurring between 2019 and 2020 (20.1%). The largest number of estimated admissions occurred in 2020, with a total 135,018 admissions (95% CI, 131,518-138,517), a 41.6% increase from the average number of admissions between 2016 and 2019. CONCLUSION: There was a 20.1% decrease in the incidence of UE orthopaedic injuries presenting to EDs after the start of the COVID-19 pandemic with a concomitant 41.2% increase in the number of hospital admissions from the ED in 2020 compared to recent pre-pandemic years. We speculate that at least some elective, semi-elective or urgent ambulatory surgeries were canceled or delayed due to the pandemic and were subsequently directed to the ED for admission. Regardless of the cause of increased UE orthopaedic admissions, policy planners and administrators should be aware of the additional stresses placed on already burdened ED and inpatient services. LEVEL OF EVIDENCE: Level III - Retrospective Cohort Study.

Proprioception of the knee before and after anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to determine, first, if there is measurable deficit in proprioception in an anterior cruciate ligament (ACL)-deficient knee, either compared to the contralateral knee or external controls; second, if this deficit, if present, improves after ACL reconstruction; and third, if improvement occurs, what the time course of improvement is. TYPE OF STUDY: Prospective cohort study. METHODS: Patients undergoing ACL reconstruction at the University of Chicago, demonstrating a full and painless range of motion and no other knee ligament injury or history of previous knee surgery, were eligible. Twenty-six patients, with an average age of 25 years (range, 16 to 48) were enrolled. Average time from injury to reconstruction was 8 weeks. The patients' contralateral knee served as an internal control, and 26 age-matched and gender-matched healthy volunteers were enrolled as an external control group. ACL reconstructions were performed using a single-incision technique with either bone-patellar tendon-bone or quadrupled hamstring autograft. They were allowed immediate weightbearing as tolerated and participated in a standardized rehabilitation program, with the goal of returning to sport at approximately 6 months. Proprioception testing was carried out using an electrogoniometer, in a seated position. Joint position sense (JPS) and threshold to detection of passive motion (TDPM) were measured preoperatively and at 3 and 6 weeks and 3 and 6 months postoperatively. RESULTS: Mean KT-2000 values 6 months postoperatively were 1.38 mm (+/-2). Modified Lysholm score improved significantly (P <.01). Calculated r values were 0.65 for JPS and 0.96 for TDPM. No significant differences in postoperative proprioception were found between hamstring and patellar tendon grafts or among patients with meniscus injury, meniscus repair, or chondral injury. Preoperatively, the mean TDPM in both the injured and contralateral knees was significantly higher (worse) than in the external control knees (P =.008; P =.016). Evaluation of changes in proprioception from preoperative to 6 months postoperative showed significant improvement in both injured and contralateral knees (P =.04; P =.01). At 6-month follow-up, there was no significant difference from controls. CONCLUSIONS: TDPM was a more reliable method than JPS for testing proprioception before and after ACL reconstruction in this study. Bilateral deficits in knee joint proprioception (TDPM) were documented after unilateral ACL injury. Reconstruction of a mechanical restraint (ACL graft) was believed to have a significantly positive impact on early and progressive improvement in proprioception.