Value-Based, Environmentally Sustainable Anterior Cruciate Ligament Surgery.

Orthopedic surgeons are increasingly recognizing the broader societal impact of their clinical decisions, which includes value-based and environmentally sustainable care. Within anterior cruciate ligament reconstruction, value-based care-or most cost-effective care-includes an outpatient surgical setting with regional anesthesia, use of autograft, meniscus repair when indicated, and use of traditional metal implants such as interference screws and staples. Environmentally sustainable care includes slimming down surgical packs and trays to avoid opening unnecessary equipment, avoiding desflurane as an inhaled anesthetic agent, and minimizing waste in the operating room-a priority that addresses both cost and environmental impact.

Higher odds of meniscectomy compared with meniscus repair in a young patient population with increased neighbourhood disadvantage.

OBJECTIVES: To investigate the impact of demographic and socioeconomic factors on the management of isolated meniscus tears in young patients and to identify trends in surgical management of meniscus tears based on surgeon volume. METHODS: Data from a large healthcare system on patients aged 14-44 years who underwent isolated meniscus surgery between 2016 and 2022 were analysed. Patient demographics, socioeconomic factors and surgeon volume were recorded. Patient age was categorised as 14-29 years and 30-44 years old. Area Deprivation Index (ADI), a measure of neighbourhood disadvantage with increased ADI corresponding to more disadvantage, was grouped as <25th, 25-75th and >75th percentile. Multivariate comparisons were made between procedure groups while univariate comparisons were made between surgeon groups. RESULTS: The study included 1552 patients treated by 84 orthopaedic surgeons. Older age and higher ADI were associated with higher odds of undergoing meniscectomy. Patients of older age and with non-private insurance were more likely to undergo treatment by a lower-volume knee surgeon. Apart from the year 2022, higher-volume knee surgeons performed significantly higher rates of meniscus repair compared with lower-volume knee surgeons. When controlling for surgeon volume, higher ADI remained a significant predictor of undergoing meniscectomy over meniscus repair. CONCLUSION: Significant associations exist between patient factors and surgical choices for isolated meniscus tears in younger patients. Patients of older age and with increased neighbourhood disadvantage were more likely to undergo meniscectomy versus meniscus repair. While higher-volume knee surgeons favoured meniscus repair, a growing trend of meniscus repair rates was observed among lower-volume knee surgeons. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction.

BACKGROUND: Different fixation methods in anterior cruciate ligament reconstruction (ACLR) have been associated with different revision rates, specifically in the early postoperative period. However, most previous research has either grouped together different fixation types or evaluated femoral-sided fixation or tibial-sided fixation separately. Therefore, the purpose of this study was to determine ACL revision rates for specific combinations of femoral and tibial fixation methods within 2 years of primary hamstring tendon autograft ACLR based on data from the Swedish National Knee Ligament Registry (SNKLR). METHODS: Patients that underwent primary hamstring tendon autograft ACLR between 2005 and 2018 in the SNKLR were included. The collected data included patient characteristics (age, sex, body mass index [BMI]), activity at time of injury, surgical information (concomitant injuries, time from injury to surgery, fixation types at the femur and tibia), and subsequent revision ACLR. Revision rate within 2 years of the index procedure was chosen, as ACLR fixation is most likely to contribute to ACLR revision within the first 2 years, during graft maturation. RESULTS: Of the 23,238 included patients undergoing primary hamstring ACLR, 581 (2.5%) underwent revision ACLR within 2 years of the index procedure. Among the combinations used for > 300 patients, the femoral metal interference screw/tibial metal interference screw fixation combination had the highest revision rate followed by metal interference screw/resorbable screw and Endobutton/AO screw fixation combinations, with respective revision rates of 4.0, 3.0, and 3.0%. The lowest revision rate within 2 years of ACLR was found in the Endobutton/metal interference screw with backup Osteosuture fixation combination, used in 433 cases, with a failure rate of 0.9%. CONCLUSION: Different early ACL revision rates were found across different combinations of femoral and tibial fixation devices within 2 years of primary hamstring tendon autograft ACLR. Metal interference screw fixation, particularly when performed on both the femoral and tibial sides, most frequently resulted in revision ACLR. These findings may be helpful for surgeons in selecting appropriate fixation devices for hamstring ACLR. LEVEL OF EVIDENCE: IV.

Overhead athletes have comparable intraoperative injury patterns and clinical outcomes to non-overhead athletes following surgical stabilization for first-time anterior shoulder instability at average 6-year follow-up.

BACKGROUND AND HYPOTHESIS: Anterior shoulder instability is a common problem affecting young, athletic populations that results in potential career-altering functional limitations. However, little is known regarding the differences in clinical outcomes after operative management of overhead vs. non-overhead athletes presenting with first-time anterior shoulder instability. We hypothesized that overhead athletes would have milder clinical presentations, similar surgical characteristics, and diminished postoperative outcomes when compared with non-overhead athletes after surgical stabilization following first-time anterior shoulder instability episodes. METHODS: Patients with first-time anterior shoulder instability events (subluxations and dislocations) undergoing operative management between 2013 and 2020 were included. The exclusion criteria included multiple dislocations and multidirectional shoulder instability. Baseline demographic characteristics, imaging data, examination findings, and intraoperative findings were retrospectively collected. Patients were contacted to collect postoperative patient-reported outcomes including American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy activity index score, and Subjective Shoulder Value, in addition to return-to-work and -sport, recurrent dislocation, and revision rates. RESULTS: A total of 256 patients met the inclusion criteria, of whom 178 (70%) were non-overhead athletes. The mean age of the entire population was 23.1 years. There was no significant difference in concomitant shoulder pathology, preoperative range of motion, or preoperative strength between cohorts. A greater proportion of overhead athletes presented with instability events not requiring manual reduction (defined as subluxations; 64.1% vs. 50.6%; P < .001) and underwent arthroscopic surgery (97% vs. 76%, P < .001) compared with non-overhead athletes. A smaller proportion of overhead athletes underwent open soft-tissue stabilization compared with non-overhead athletes (1% vs. 19%, P < .001). Outcome data were available for 60 patients with an average follow-up period of 6.7 years. No significant differences were found between groups with respect to recurrent postoperative instability event rate (13.0% for overhead athletes vs. 16.8% for non-overhead athletes), revision rate (13.0% for overhead athletes vs. 11.1% for non-overhead athletes), American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy score, Subjective Shoulder Value, or rates of return to work or sport. CONCLUSION: Overhead athletes who underwent surgery after an initial instability event were more likely to present with subluxations compared with non-overhead athletes. With limited follow-up subject to biases, this study found no differences in recurrence or revision rates, postoperative patient-reported outcomes, or return-to-work or -sport rates between overhead and non-overhead athletes undergoing shoulder stabilization surgery following first-time instability events. Although larger prospective studies are necessary to draw firmer conclusions, the findings of this study suggest that overhead athletes can be considered in the same treatment pathway for first-time dislocation as non-overhead athletes.

Revision Rates After Primary Allograft ACL Reconstruction by Allograft Tissue Type in Older Patients.

Background: While there is extensive literature on the use of allograft versus autograft in anterior cruciate ligament (ACL) reconstruction, there is limited clinical evidence to guide the surgeon in choice of allograft tissue type. Purpose: To assess the revision rate after primary ACL reconstruction with allograft and to compare revision rates based on allograft tissue type and characteristics. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent primary allograft ACL reconstructions at a single academic institution between 2015 and 2019 and who had minimum 2-year follow-up were included. Exclusion criteria were missing surgical or allograft tissue type data. Demographics, operative details, and subsequent surgical procedures were collected. Allograft details included graft tissue type (Achilles, bone-patellar tendon-bone [BTB], tibialis anterior or posterior, semitendinosus, unspecified soft tissue), allograft category (all-soft tissue vs bone block), donor age, irradiation duration and intensity, and chemical cleansing process. Revision rates were calculated and compared by allograft characteristics. Results: Included were 418 patients (age, 39 ± 12 years; body mass index, 30 ± 9 kg/m2). The revision rate was 3% (11/418) at a mean follow-up of 4.9 ± 1.4 years. There were no differences in revision rate according to allograft tissue type across Achilles tendon (3%; 3/95), BTB (5%; 3/58), tibialis anterior or posterior (3%; 5/162), semitendinosus (0%; 0/46), or unspecified soft tissue (0%; 0/57) (P = .35). There was no difference in revision rate between all-soft tissue versus bone block allograft (6/283 [2%] vs 5/135 [4%], respectively; P = .34). Of the 51% of grafts with irradiation data, all grafts were irradiated, with levels varying from 1.5 to 2.7 Mrad and 82% of grafts having levels of <2.0 Mrad. There was no difference in revision rate between the low-dose and medium-to high-dose irradiation cohorts (4% vs 6%, respectively; P = .64). Conclusion: Similarly low (0%-6%) revision rates after primary ACL reconstruction were seen regardless of allograft tissue type, bone block versus all-soft tissue allograft, and sterilization technique in 418 patients with mean age of 39 years. Surgeons may consider appropriately processed allograft tissue with or without bone block when indicating ACL reconstruction in older patients.

Low-Volume Surgeons Use Allograft in Younger Patients and Show Greater Rates of Revision Following Primary Allograft Anterior Cruciate Ligament Reconstruction Compared With High-Volume Surgeons.

Purpose: To determine whether surgeon volume affects revision rate following primary anterior cruciate ligament reconstruction (ACLR) with allograft and to determine whether surgeon volume impacts allograft tissue type used. Methods: All patients aged 14 years or older who underwent primary allograft ACLR at a large hospital system between January 2015 to December 2019 with minimum 2-year follow-up were included. Patients with double-bundle ACLR, multiligament reconstruction, and absent allograft type data were excluded. Surgeon volume was categorized as 35 or more ACLR/year for high-volume surgeons and less than 35 ACLR/year for low-volume surgeons. Revision was defined as subsequent ipsilateral ACLR. Patient characteristics, operative details, allograft type, and revision ACLR rates were retrospectively collected. Revision rate and allograft type were analyzed based on surgeon volume. Results: A total of 457 primary allograft ACLR cases (mean age: 38.8 ± 12.3 years) were included. Low-volume surgeons experienced greater revision rates (10% vs 5%, P = .04) and used allograft in a younger population (37.6 vs 40.0 years old, P = .03) than high-volume surgeons. Subgroup analysis of the total cohort identified a significantly increased failure rate in patients <25 years old compared with ≥25 years old (30% vs 4%, P < .001). Allograft type selection varied significantly between surgeon volume groups, with low-volume surgeons using more bone-patellar tendon-bone (P < .001) and less semitendinosus allograft (P = .01) than high-volume surgeons. No differences in revision rate were observed based on allograft type (P = .71). Conclusions: There was a greater revision rate following primary allograft ACLR among low-volume surgeons compared with high-volume surgeons. Low-volume surgeons also used allograft in a younger population than did high-volume surgeons. Level of Evidence: Level III, retrospective comparative prognostic trial.

Delayed multiligament PCL reconstruction is associated with a higher prevalence of intraarticular injury and may influence treatment.

BACKGROUND: The aim of this study was to investigate differences in concomitant injury patterns and their treatment in patients undergoing early (≤ 12 weeks) and delayed (> 12 weeks) primary multiligament posterior cruciate ligament (PCL) reconstruction (PCL-R). METHODS: This study was a retrospective chart review of patients undergoing primary multiligament PCL-R at a single institution between 2008 and 2020. Multiligament PCL-R was defined as PCL-R and concurrent surgical treatment of one or more additional knee ligament(s). Exclusion criteria included isolated PCL-R, PCL repair, and missing data for any variable. Patients were dichotomized into early (≤ 12 weeks) and delayed (> 12 weeks) PCL-R groups based on the time elapsed between injury and surgery. Between-group comparison of variables were conducted with the Chi-square, Fisher's exact, and independent samples t-tests. RESULTS: A total of 148 patients were eligible for analysis, with 57 (38.5%) patients in the early and 91 (61.1%) patients in the delayed multiligament PCL-R groups. Concomitant LCL/PLC reconstruction (LCL-R/PLC-R) was performed in 55 (60%) of delayed multiligament PCL-Rs and 23 (40%) of early PCL-Rs (p = 0.02). Despite similar rates of meniscus injury, concomitant meniscus surgery was significantly more prevalent in the early (n = 25, 44%) versus delayed (n = 19, 21%) multiligament PCL-R group (p = 0.003), with a significantly greater proportion of medial meniscus surgeries performed in the early (n = 16, 28%) compared to delayed (n = 13, 14%) PCL-R group (p = 0.04). The prevalence of knee cartilage injury was significantly different between the early (n = 12, 24%) and delayed (n = 41, 46%) multiligament PCL-R groups (p = 0.01), with more frequent involvement of the lateral (n = 17, 19% vs. n = 3, 5%, respectively; p = 0.04) and medial (n = 31, 34% vs. n = 6, 11%, respectively; p = 0.005) femoral condyles in the delayed compared to the early PCL-R group. CONCLUSIONS: Given higher rates of chondral pathology and medial meniscus surgery seen in delayed multiligament PCL-R, early management of PCL-based multiligament knee injury is recommended to restore knee stability and potentially prevent the development of further intraarticular injury. LEVEL OF EVIDENCE: Level III.

Single-Stage Correction of Genu Valgum Recurvatum by Distal Femoral and High Tibial Opening Wedge Osteotomies: A Case Report.

CASE: A 32-year-old woman with genu valgum recurvatum presented to clinic complaining of long-standing anterior knee pain. Radiographs demonstrated a 13° anterior tibial slope and 15° valgus malalignment. She underwent a single-stage 2-level osteotomy at the distal femur and proximal tibia to simultaneously correct genu valgum and recurvatum. This procedure achieved precise correction in both planes. At 1 year, the patient was pain-free and ambulated without restriction. CONCLUSION: This procedure should be considered among the available surgical options when treating genu valgum recurvatum because it produced excellent results for the studied patient.

First-time traumatic anterior shoulder dislocation: current concepts.

The management of first-time traumatic anterior shoulder dislocations has been a topic of extensive study yet remains controversial. Development of a treatment plan requires an understanding of patient-specific considerations, including demographics, functional demands, and extent of pathology. Each of these can influence rates of recurrence and return to activity. The purpose of this review is to provide a framework for decision-making following a first-time anterior shoulder dislocation, with particular focus on the high-risk young and athletic population. A summary of surgical treatment options and their outcomes is outlined, along with future biomechanical and clinical perspectives.

What to Do When It Is Anterior Cruciate Ligament Reconstruction Number Two.

Several factors contribute to the greater complexity of revision anterior cruciate ligament reconstruction compared with primary anterior cruciate ligament reconstructive surgery. Prior tunnels and hardware may compromise revision tunnel placement and secure fixation. This may necessitate two-stage revision or specific techniques to achieve anatomic revision tunnels. Prior autograft use may limit graft options. Individuals with a failed anterior cruciate ligament reconstruction are more likely to have risk factors for further failure. These may include malalignment, occult instability, knee hyperextension, or increased tibial slope. There are also higher rates of meniscus and cartilage injuries in revision anterior cruciate ligament reconstruction that may require intervention. Successful revision anterior cruciate ligament reconstruction requires thoughtful preoperative planning along with multiple potential intraoperative plans depending on the pathology encountered. It is important to provide the orthopaedic surgeon with an up-to-date, evidence-based overview of how to approach and execute a successful revision anterior cruciate ligament reconstruction.

Impingement and perforation of the anterior femoral cortex in cephalomedullary nailing: Systematic review and surgical techniques.

BACKGROUND: Anterior femoral cortical impingement and perforation are known risks of cephalomedullary nailing. The incidence of and risk factors for these findings have not been fully established in the literature. The purpose of this review was to answer: (1) What is the incidence of anterior femoral cortical impingement and perforation associated with cephalomedullary nailing of proximal femur fractures? (2) How does incidence vary by nail radius of curvature (ROC)? (3) What populations are at increased risk of impingement and perforation? (4) What surgical techniques prevent their occurrence? HYPOTHESIS: Our hypothesis was that impingement would be a relatively common finding following cephalomedullary nailing, and perforation would be much less frequent but still an appreciable risk. Secondarily, nails with a larger ROC would have a higher rate of impingement. PATIENTS AND METHODS: In this systematic review, PubMed, MEDLINE, and Cochrane databases were searched for articles from 1990-2020 written in English using the terms "cephalomedullary nail" or "femoral nail" and "perforation" or "impingement", and similar words. Inclusion criteria were studies discussing the complication of anterior femoral cortical impingement or perforation associated with the use of a cephalomedullary nail. Fourteen studies met inclusion criteria. Rates of anterior femoral cortical impingement or perforation, patient demographics, nail type, and ROC were extracted. Surgical techniques to prevent perforation were qualitatively reviewed. RESULTS: The rate of anterior cortical impingement with long cephalomedullary nails was 17.2% (192/1117 patients) and with short nails was 29.2% (176/602). The rate of anterior cortical perforation with long nails was 1.0% (11/1116) and with short nails was 0% (0/234). Long nails with ROC>150cm showed an impingement rate of 10.9% (62/567) and perforation rate of 1.1% (7/617 patients). Nails with ROC 150cm or 100cm had an impingement rate of 1.1% (1/93) and perforation rate of 0% (0/93). DISCUSSION: Impingement and perforation of the anterior femoral cortex during cephalomedullary nailing are appreciable risks that surgeons should anticipate and avoid, especially in certain populations and with nails with larger ROC. Surgeons may consider use of long nails with ROC 150cm and below, given a nearly 10-fold lower incidence of impingement and no reported perforations. LEVEL OF EVIDENCE: Therapeutic, level IV.

Periacetabular osteotomy after failed hip arthroscopy demonstrates improved outcomes in a heterogenous patient population: a systematic review.

PURPOSE: To evaluate the literature on patients undergoing periacetabular osteotomy after failed hip arthroscopy (PAO-FHA) for (1) patient demographics and hip morphology, (2) changes in preoperative to postoperative patient-reported outcomes (PROs), and (3) PROs in comparison to primary periacetabular osteotomy (PAO) patients. METHODS: A systematic literature search of Pubmed, CINAHL/Medline, and cochrane databases was performed in accordance with PRISMA guidelines. The search phrase was "(periacetabular osteotomy or PAO or rotational osteotomy) and (hip arthroscopy or arthroscopic)". The titles, abstracts, and full texts were screened for studies on PAO-FHA. Study quality was assessed, and relevant data were collected. A meta-analysis was not performed due to study heterogeneity. RESULTS: The search identified 7 studies, including 151 hips (148 patients, 93.9% female) undergoing PAO-FHA, out of an initial 593 studies, with three Level IV and four Level III studies. Mean time from hip arthroscopy to PAO ranged from 17.0 to 29.6 months. Heterogenous hip morphologies and radiologic findings prior to PAO were observed, though patients most frequently demonstrated moderate-to-severe dysplasia (mean or median lateral center edge angle < 20°) and minimal osteoarthritis (Tönnis grade 0 or 1). In all 5 studies that reported concomitant procedures with PAO, femoral and/or acetabular osteoplasty was performed via arthroscopy or arthrotomy. Following PAO-FHA, radiographic acetabular coverage and PROs improved in all 6 studies that reported postoperative outcomes. All four comparative studies of primary PAO vs. PAO-FHA included patients with mean or median LCEAs < 20°, reporting mixed outcomes for the optimal treatment approach. CONCLUSION: PAO-FHA is reported in a heterogenous patient population that frequently includes hips with moderate-to-severe dysplasia and minimal osteoarthritis. Regardless of hip morphology or concomitant procedures, all studies that reported postoperative outcomes demonstrated improved PROs following PAO-FHA. LEVEL OF EVIDENCE: Level IV.

Do Community-level Disadvantages Account for Racial Disparities in the Safety of Spine Surgery? A Large Database Study Based on Medicare Claims.

BACKGROUND: Racial health disparities across orthopaedic surgery subspecialties, including spine surgery, are well established. However, the underlying causes of these disparities, particularly relating to social determinants of health, are not fully understood. QUESTIONS/PURPOSES: (1) Is there a racial difference in 90-day mortality, readmission, and complication rates ("safety outcomes") among Medicare beneficiaries after spine surgery? (2) To what degree does the Centers for Disease Control and Prevention Social Vulnerability Index (SVI), a community-level marker of social determinants of health, account for racial disparities in safety outcomes? METHODS: To examine racial differences in 90-day mortality, readmission, and complications after spine surgery, we retrospectively identified all 419,533 Medicare beneficiaries aged 65 or older who underwent inpatient spine surgery from 2015 to 2019; we excluded 181,588 patients with endstage renal disease or Social Security disability insurance entitlements, who were on Medicare HMO, or who had missing SVI data. Because of the nearly universal coverage of those age 65 or older, Medicare data offer a large cohort that is broadly generalizable, provides improved precision for relatively rare safety outcomes, and is free of confounding from differential insurance access across races. The Master Beneficiary Summary File includes enrollees' self-reported race based on a restrictive list of mutually exclusive options. Even though this does not fully capture the entirety of racial diversity, it is self-reported by patients. Identification of spine surgery was based on five Diagnosis Related Groups labeled "cervical fusion," "fusion, except cervical," "anterior-posterior combined fusion," "complex fusion," and "back or neck, except fusion." Although heterogeneous, these cohorts do not reflect inherently different biology that would lead us to expect differences in safety outcomes by race. We report specific types of complications that did and did not involve readmission. Although complications vary in severity, we report them as composite measures while being cognizant of the inherent limitations of making inferences based on aggregate measures. The SVI was chosen as the mediating variable because it aggregates important social determinants of health and has been shown to be a marker of high risk of poor public health response to external stressors. Patients were categorized into three groups based on a ranking of the four SVI themes: socioeconomic status, household composition, minority status and language, and housing and transportation. We report the "average race effects" among Black patients compared with White patients using nearest-neighbor Mahalanobis matching by age, gender, comorbidities, and spine surgery type. Mahalanobis matching provided the best balance among propensity-type matching methods. Before matching, Black patients in Medicare undergoing spine surgery were disproportionately younger with more comorbidities and were less likely to undergo cervical fusion. To estimate the contribution of the SVI on racial disparities in safety outcomes, we report the average race effect between models with and without the addition of the four SVI themes. RESULTS: After matching on age, gender, comorbidities, and spine surgery type, Black patients were on average more likely than White patients to be readmitted (difference of 1.5% [95% CI 0.9% to 2.1%]; p < 0.001) and have complications with (difference of 1.2% [95% CI 0.5% to 1.9%]; p = 0.002) or without readmission (difference of 3.6% [95% CI 2.9% to 4.3%]; p < 0.001). Adding the SVI to the model attenuated these differences, explaining 17% to 49% of the racial differences in safety, depending on the outcome. An observed higher rate of 90-day mortality among Black patients was explained entirely by matching using non-SVI patient demographics (difference of 0.00% [95% CI -0.3% to 0.3%]; p = 0.99). However, even after adjusting for the SVI, Black patients had more readmissions and complications. CONCLUSION: Social disadvantage explains up to nearly 50% of the disparities in safety outcomes between Black and White Medicare patients after spine surgery. This argument highlights an important contribution of socioeconomic circumstances and societal barriers to achieving equal outcomes. But even after accounting for the SVI, there remained persistently unequal safety outcomes among Black patients compared with White patients, suggesting that other unmeasured factors contribute to the disparities. This is consistent with evidence documenting Black patients' disadvantages within a system of seemingly equal access and resources. Research on racial health disparities in orthopaedics should account for the SVI to avoid suggesting that race causes any observed differences in complications among patients when other factors related to social deprivation are more likely to be determinative. Focused social policies aiming to rectify structural disadvantages faced by disadvantaged communities may lead to a meaningful reduction in racial health disparities. LEVEL OF EVIDENCE: Level III, therapeutic study.

Anatomic anterior cruciate ligament reconstruction: Freddie Fu's paradigm.

Anterior cruciate ligament (ACL) reconstruction techniques have evolved over the past four decades. There is evidence that non-anatomic reconstruction techniques, such as traditional transtibial drilling, fail to recreate the native anatomy of the ACL, which can lead to increased rotatory knee instability, revision risk, and post-traumatic osteoarthritis. Anatomic ACL reconstruction has emerged as the gold standard, with the goal of restoring the patient's native anatomy and knee kinematics. This review will summarise the relevant anatomy, modern anatomic ACL reconstruction techniques, and literature supporting anatomic ACL reconstruction as the new paradigm. LEVEL OF EVIDENCE: Level V, review article.

Editorial Commentary: Prophylaxis Against Deep Venous Thrombosis Should Be the Norm After Knee Arthroscopy.

Knee arthroscopy has low complication rates overall, and most complications are not overly disabling. Yet one of the most concerning complications is venous thromboembolism, and pulmonary embolism (PE), in particular. The combination of low rate of venous thromboembolism in knee arthroscopy but high potential cost in the event of PE makes for a challenging risk-benefit analysis in the decision for whether to use thromboprophylaxis. Research is inherently difficult due to the infrequency of deep venous thrombosis and PE, leaving orthopaedic surgeons to fill in the gaps with clinical judgement. Risk stratification based on patient risk factors (e.g., oral contraceptives, renal disease, cardiovascular disease) and specific surgical procedure (e.g., meniscectomy, anterior cruciate ligament reconstruction) are important to define the highest-risk patients that may warrant stronger anticoagulation. Yet even in low-risk patients, given the potential severity of a PE and safety of aspirin, surgeons should consider aspirin as thromboprophylaxis.

Slope-Reducing High Tibial Osteotomy and Over-The-Top Anterior Cruciate Ligament Reconstruction With Achilles Tendon Allograft in Multiple Failed Anterior Cruciate Ligament Reconstruction.

Graft failure is a challenging complication following anterior cruciate ligament reconstruction (ACL-R). Among the multiple anatomic and nonanatomic risk factors contributing to ACL-R failure, there is accumulating evidence that a posterior tibial slope of 12° or greater may predispose patients to graft failure of primary and revision ACL-R. In addition, previously malpositioned or widened tunnels, as well as limited autograft options, pose challenges in the setting of revision ACL-R. This Technical Note describes a technique to correct an increased posterior tibial slope using slope-reducing high tibial osteotomy, and single stage revision ACL-R with Achilles tendon allograft using the over-the-top route, in a single-stage procedure. The surgical technique involves an anterior approach to the proximal tibia, followed by tibial tubercle osteotomy and anterior closing-wedge osteotomy. The posterior cortical osteotomy hinge is left intact below the insertion of the posterior cruciate ligament. Over-the-top revision ACL-R is then performed using an Achilles tendon allograft passed around the posterior aspect of the lateral femoral condyle and fixed onto the lateral femur.

Hip Pain in Ballet Dancers: Evaluation and Management.

Hip and groin injuries are common in ballet dancers, who often begin sport-specific training at a young age. The unique demands of ballet include extreme range of motion, with an emphasis on external rotation and abduction. This creates a distinctive constellation of hip symptoms and pathology in this cohort, which may differ from other flexibility sports. When managing hip symptoms in this cohort, orthopaedic surgeons should consider the unique factors associated with ballet, including ballet-specific movements, morphologic adaptations of the hip, and the culture of the sport. Three common etiologies of hip pain in ballet dancers include femoroacetabular impingement syndrome, hip instability, and extra-articular snapping hip syndrome. First-line treatment often consists of focused physical therapy to strengthen the core and periarticular hip musculature, with surgical management reserved for patients who fail to improve with conservative measures.

Over-The-Top Technique for Revision ACL Reconstruction with Achilles Allograft and Associated Lateral Extra-articular Tenodesis.

Revision anterior cruciate ligament reconstruction (ACL-R) is made challenging by the frequent presence of rotatory instability, tunnel malpositioning and widening, and limited autograft options. Lateral extra-articular tenodesis (LET), alternative tunnel routing, and the use of allograft tissue can be used to manage these challenges. This Technical Note describes revision ACL-R using the over-the-top (OTT) technique with Achilles tendon allograft with concomitant LET. The surgical approach involves routing the graft around the posterior aspect of the lateral femoral condyle, and then deep to the iliotibial band to a site just medial to Gerdy's tubercle, with staple fixation on the lateral femur for the ACL-R and anterolateral tibia for the LET. The OTT technique with LET provides a versatile approach for the management of failed ACL-R by circumventing challenges in revision ACL-R and addressing rotatory instability, a contributing factor to prior graft failure.

Single-Stage Revision Anterior Cruciate Ligament Reconstruction Using the Stacked Screws Technique.

Single-stage revision anterior cruciate ligament (ACL) reconstruction is preferable to 2-stage revision, when possible, as it avoids an additional surgery and recovery period. Malpositioned and/or widened bone tunnels are a common cause of ACL reconstruction failure and are challenging to manage in revision reconstructions. The "stacked screws construct" fills the previous malpositioned tunnels and bone voids with an oversized biocomposite screw as graft material. The revised tunnel can then be drilled in an anatomic "primary" location, even partially overlapping the filler screw. This technique simplifies tunnel management in revision ACL reconstruction.

Editorial Commentary: Saving Cost in Orthopaedics While Preserving Patient Experience and Outcomes: We Can Have It All.

Healthcare costs in the United States are the highest in the world and continue to increase unsustainably. As a result, cost-cutting measures are paramount. Bundled payments are a primary method to decrease healthcare use, and they are increasingly prominent in orthopaedic surgical care. Bundled payments require an accurate assessment of the cost of a procedure, which may be determined more reliably and feasibly than previously with time-driven activity-based costing. Time-driven activity-based costing identifies the cost of various stages of care, which allows cost-containment strategies to target the most expensive stages. Amidst the warranted focus on cost reduction, we must maintain a strong focus on the patient experience and patient outcomes. For example, reducing surgeon and staff time with the patient could negatively impact patient care, yet increasing efficiency in the operating room and perioperative setting could decrease the relative cost of staff without harming the patient experience. Other realms, such as implant and administrative costs, are important focuses that are less likely to directly hamper patient care. Controlling cost in the U.S. healthcare system will require a wide-reaching approach with contributions from all parties. As we work toward a more financially sustainable system, we must be sure to preserve excellent patient experience and outcomes.