Ultrasound and patient-reported outcomes of rotator cuff repair with new acellular human allograft at 6 months and 1 year post surgery.

Background: Determine the effect of a novel acellular cannulated dermal allograft on tendon-to-bone healing, retear rates, and clinical outcomes over a 12-month period. Methods: This was a single surgeon prospective nonrandomized case series. Patients with medium sized full-thickness superior and posterosuperior rotator cuff tears, as confirmed by magnetic resonance imaging, were consented. Patients were excluded if they had fatty atrophy indicative of Goutallier grade III or IV. The allograft is a cannulated rectangular prism that has a 5-year shelf life, does not require prehydration, and does not need to be trimmed to size. Outcome metrics included ultrasound assessment at 1-year as well as 6-month patient-reported outcomes (PROs) scores. Results: 31 patients consented and enrolled in this consecutive cohort series. 9 patients were excluded, and statistical analysis was performed on the remaining 22 patients. There were 9 females and 13 males. The average age was 59.27 ± 7.48 year old. The average supraspinatus short axis measurement in males was 0.56 ± 0.12 cm and 0.52 ± 0.09 cm in females (P = .44). The average supraspinatus long axis measurement in males was 0.61 ± 0.18 cm and 0.55 ± 0.14 cm in females (P = .46). The average infraspinatus short axis measurement in males was 0.48 ± 0.10 cm and 0.50 ± 0.13 in females (P = .74). The average infraspinatus long axis measurement in males was 0.44 ± 0.12 cm and 0.43 ± 0.08 cm in females (P = .84). Of the 19 patients who completed baseline and 6-month PRO's, 17 achieved the minimal clinical important difference for American Shoulder and Elbow Surgeons and Patient-Reported Outcomes Measurement Information SystemUE 7a. Retear occurred in 2 cases. The remaining 20 cases have all demonstrated healing or fully healed repairs at their most recent clinical visits with no additional cases of retears. Conclusion: This study is the first to report the results of a novel acellular dermal allograft for rotator cuff repair augmentation. Satisfactory PRO measures and robust tendon healing at 1 year, as measured by ultrasound, demonstrate the utility of a cannulated human acellular dermal allograft as a viable biologic augmentation device for rotator cuff repair.

Functional and Symptomatic Improvements Based on the Femoral Tunnel Drilling Technique in Anterior Cruciate Ligament (ACL) Reconstruction.

BACKGROUND: The current literature comparing femoral tunnel techniques often reports on short-term outcomes after anterior cruciate ligament reconstruction (ACLR), but only a few studies have analyzed long-term outcomes. In addition, many studies have compared transtibial to anteromedial portal techniques without differentiating whether rigid or flexible reaming is used, making it difficult to infer how the techniques truly compare to one another. PURPOSE: This study aimed to detect differences in patient-reported outcome scores in those treated with three different femoral tunnel drilling techniques. STUDY DESIGN: This study is a prospective cohort study. METHODS: Of 650 patients treated for anterior cruciate ligament (ACL) injuries with ACLR, 350 were 5+ years out from surgery. Of these patients, 111 completed patient-reported outcome surveys (PROs). The Kruskal-Wallis H test was used to detect differences between patients treated with either of the three femoral tunnel drilling techniques: transtibial (TT), anteromedial portal with rigid reaming (AMP-RR), or anteromedial portal with flexible reaming (AMP-FR). Bonferroni correction was applied to the p-values to reduce the risk of making a type 1 error. RESULTS: No differences were found between the three groups in demographics or postoperative PROs. However, there was a significant change between pre-surgery and post-surgery PROs. TT, when compared to AMP-RR, had a greater increase in satisfaction and greater improvement in a patient's ability to go up and down the stairs from pre-surgery to post-surgery. AMP-FR, when compared to TT, had greater improvement of the patient's knee stiffness/swelling. AMP-FR, when compared to AMP-RR, had greater improvement in knee pain during stairs and the ability to go down the stairs. No differences in return to sport, additional procedures on the affected knee (meniscal surgeries or cyclops lesion excisions), or revision surgery rates were found. CONCLUSION: Overall, postoperative PROs did not show statistically significant differences between the three femoral tunnel drilling techniques. Differences, however, were identified in the responses to specific questions on PRO surveys, which may have otherwise been overlooked. It is important to recognize the differences between TT, AMP-RR, and AMP-FR in the improvement of stair climbing and swelling/stiffness as these likely directly affect a patient's satisfaction from pre-ACLR to post-ACLR.

Negative Pain Thoughts Questionnaire Short Form (NPTQ-SF) Scores and Outcomes After Arthroscopic Meniscectomy.

BACKGROUND: Pain is multifactorial, and pain intensity has been shown to be influenced by patients' thoughts. The Negative Pain Thoughts Questionnaire Short Form (NPTQ-SF) can be used to quantify unhelpful negative cognitive biases about pain, but the relationship between negative pain thoughts and orthopaedic surgery outcomes is not known. PURPOSE: To evaluate the prevalence of negative pain thoughts in patients undergoing arthroscopic meniscectomy using the NPTQ-SF survey and assess the relationship these thoughts have to knee function, general health, pain, and satisfaction before and after surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In total, 146 patients undergoing arthroscopic meniscectomy were administered the 4-item NPTQ-SF, 12-item Short Form Survey (SF-12), International Knee Documentation Committee (IKDC) questionnaire, and visual analog scale pain survey preoperatively between July 2021 and August 2022. The same surveys were completed at a minimum of 3 months and no later than 1 year postoperatively by 92 patients confirmed to have undergone meniscectomy. RESULTS: NPTQ-SF scores were correlated with IKDC, SF-12, and satisfaction score preoperatively and at least 3 months postoperatively (mean, 108.5 ± 43.7 days). Preoperative NPTQ-SF scores were significantly negatively correlated with postoperative IKDC (R = -0.284), SF-12 (R = -0.266 and -0.328), and visual analog scale pain (R = 0.294) scores, while a relationship with postoperative satisfaction did not reach statistical significance (P = .067). Patients with a preoperative NPTQ-SF score >8 were less likely to achieve a Patient Acceptable Symptom State on the postoperative IKDC questionnaire (39% vs 63%; P = .03). Patients with a history of a psychiatric or chronic pain diagnoses have worse NPTQ-SF, SF-12, and IKDC scores pre- and postoperatively. CONCLUSION: The level of negative pain thoughts in patients undergoing meniscectomy is related to knee function, general health, and pain. Patients with a high level of negative pain thoughts are less likely to achieve a favorable outcome from meniscectomy, with a score ≥8 representing a clinically significant threshold for preoperative screening.

Preoperative Rank of Expectations for Shoulder Surgery (PRESS): a novel survey.

BACKGROUND: Patient expectations for orthopedic surgeries, and elective shoulder surgery in particular, have been shown to be important for patient outcomes and satisfaction. Current surveys assessing patient expectations lack clinical applicability and allow patients to list multiple expectations at the highest level of importance. The purpose of this study was to develop and evaluate the use of a novel, rank-based survey assessing the relative importance of patient expectations for shoulder surgery. METHODS: The Preoperative Rank of Expectations for Shoulder Surgery (PRESS) survey was developed by polling 100 patients regarding their expectations for surgery. The PRESS survey consisted of 8 common expectations for elective shoulder surgery by importance and a 0%-100% scale of expected pain relief and range of motion improvement. After initial development of the PRESS survey, it was administered preoperatively to 316 patients undergoing surgery for shoulder arthritis, rotator cuff tear, subacromial pain syndrome, or glenohumeral instability between August 2020 and April 2021. Patients also completed preoperative outcome measures such as the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Physical Function 7a version 1.0 (PROMIS PF), and PROMIS Pain Interference short form 8a version 2.0 (PROMIS PI) surveys. Patient-reported outcome measure (PROM) surveys were administered 6 months postoperatively. RESULTS: Improvement in range of motion was the expectation most often ranked first for the entire study group (18%), arthritis subgroup (23%), and rotator cuff tear subgroup (19%). Subacromial pain syndrome patients most often ranked improving ability to complete activities of daily living and relieving daytime pain first (19%). Shoulder instability patients most often ranked improving ability to participate in sports first (31%). Patients who ranked improving range of motion or sports highly had better PROMs. Those who ranked relieving pain highly had worse PROMs. Patients with high (>90%) expectations of pain relief had better PROMIS PI scores. Patients with high pain relief expectations in the arthritis and subacromial pain syndrome groups had better PROMs, whereas patients with instability were less satisfied. CONCLUSION: The novel PRESS survey assesses patient expectations for shoulder surgery in a new, more clinically applicable rank-based format. The responses provided by patients provide actionable information to clinicians and are related to postoperative outcomes. Therefore, the PRESS survey represents a useful tool for guiding discussions between patients and surgeons, as well as aiding in overall patient-centered clinical decision making.

Postoperative Negative Pain Thoughts and Their Correlation With Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair: An Observational Cohort Study.

BACKGROUND: Pain and pain perception are influenced by patients' thoughts. The short form Negative Pain Thoughts Questionnaire (NPTQ-SF) can be used to quantify unhelpful negative cognitive biases about pain, but the relationship between NPTQ-SF scores and orthopaedic surgery outcomes is not known. PURPOSE/HYPOTHESIS: The purpose was to assess the relationship between negative pain thoughts, as measured by the NPTQ-SF, and patient-reported outcomes in patients undergoing arthroscopic rotator cuff repair, as well as to compare NPTQ-SF scores and outcomes between patients with and without a history of chronic pain and psychiatric history. It was hypothesized that patients with worse negative pain thoughts would have worse patient-reported outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In total, 109 patients undergoing arthroscopic rotator cuff repair were administered the 4-item NPTQ-SF, 12-item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons (ASES) Shoulder Evaluation Form, and visual analog scale pain survey preoperatively between July 2021 and August 2022. The same surveys were completed ≥6 months postoperatively by 74 patients confirmed to have undergone arthroscopic rotator cuff repair. RESULTS: Preoperative NPTQ-SF scores did not show any correlation with the postoperative patient-reported outcomes measured in this study. Postoperative NPTQ-SF scores were statistically significantly negatively correlated with postoperative SF-12 Physical Health Score, SF-12 Mental Health Score, ASES, and satisfaction scores (P < .05). Postoperative NPTQ-SF scores were statistically significantly positively correlated with postoperative visual analog scale scores (P < .001). Moreover, postoperative NPTQ-SF scores were statistically significantly negatively correlated with achieving a Patient Acceptable Symptom State and the minimal clinically important difference on the postoperative ASES form (P < .001 and P = .009, respectively). CONCLUSION: Postoperative patient thought patterns and their perception of pain are correlated with postoperative outcomes after rotator cuff repair. This correlation suggests a role for counseling and expectation management in the postoperative setting. Conversely, preoperative thought patterns regarding pain, as measured by the NPTQ-SF, do not correlate with postoperative patient-reported outcome measures. Therefore, the NPTQ-SF should not be used as a preoperative tool to aid the prediction of outcomes after rotator cuff repair.

Effects of Surgeon-Preferred Staff and Staff Turnover on Operating Time and Complication Rates in Reverse and Anatomic Total Shoulder Arthroplasty.

BACKGROUND: This study focuses on investigating the risk factors of increased operating room time and patient complication rates after total shoulder arthroplasty cases (both reverse and anatomic). We hypothesize that the use of surgeon-preferred staff will improve operating room efficiency and reduce complication rates while increased staff turnover will decrease efficiency and increase complications. METHODS: This is a single-center, retrospective study focused on determining the effects of staffing on operating room time and efficiency in total shoulder arthroplasty. The study included patients who underwent total shoulder arthroplasty by a single fellowship-trained orthopaedic surgeon from 2018 to 2023. RESULTS: Four hundred twenty-three patients were included in the study from August 2018 to April 2023, 264 of which were reverse total shoulder arthroplasty (rTSA) and 159 were anatomic total shoulder arthroplasty (aTSA). In both rTSA and aTSA, the presence of surgeon-preferred staff markedly decreased operating room time. In rTSA, staff turnover increased risk of 90-day complications. CONCLUSION: Because the presence of surgeon-preferred staff affects operating room time and efficiency, orthopaedic surgeons should train multiple surgical teams so that efficiency is not affected by the loss of personnel during a case. To reduce 90-day complication rates in rTSA, staff breaks and turnover should be minimized as much as possible because this has a direct effect on patient outcomes. Effort from hospital administration and management should be put toward reducing turnover to improve patient outcomes.

Opioid use and disposal at 2 weeks post-surgery: Brief communication regarding excess opioids and disposal habits.

OBJECTIVE: To measure the number of unused prescription opioids and disposal habits of patients following orthopedic shoulder surgery. DESIGN: A prospective observational study. SETTING: Academic orthopedic sports medicine department. PATIENTS: Sixty-seven patients undergoing shoulder surgery. INTERVENTIONS: Nine-question opioid use questionnaire. MAIN OUTCOME MEASURES: Responses to an opioid use questionnaire were collected at 2 weeks post-surgery. Outcomes of interest included the amount of initial opioid prescription used and the disposal of excess opioids. RESULTS: Sixty-seven patients completed the opioid use questionnaire. Forty-six (68.7 percent) patients reported having excess opioids at 2 weeks. Of the 46 patients with excess opioids, 57 percent disposed of the excess, and 43 percent planned to keep their opioids. CONCLUSION: Two-thirds of the patients reported having excess opioids, highlighting the issue of an overabundance of unused prescription opioids in America. Utilization of opioid-free pain management strategies and drug disposal kits should be explored to reduce the number of unused and improperly disposed opioids.

Preoperative Predictors of Patient-Reported Outcomes Following Arthroscopic Partial Meniscectomy.

The purpose of this study is to evaluate the effect of patient demographics and injury characteristics on post-arthroscopic partial meniscectomy (post-APM) patient-reported outcomes (PROs). We hypothesize that the presence of high-grade (Kellgren-Lawrence grades 3-4) arthritis at any location of the knee (medial and lateral compartments, patella, trochlea), comorbidities (psychiatric history, chronic pain, diabetes, smoking, body mass index [BMI] ≥ 30), and lower scores on preoperative patient-reported measures (36-Item Short Form Health Survey [SF-36]) would predict poor outcomes after APM. We conducted a single-center prospective study of 92 patients who underwent APM surgery for associated knee pain. General demographic information and PROs were prospectively collected using SF-12, SF-36, and International Knee Documentation Committee (IKDC) surveys presurgery and at 6-month follow-up. Postsurgery outcomes were patient-reported satisfaction (yes/no) and obtaining a patient-acceptable symptom state (PASS) on IKDC. Data were analyzed with odds ratios (ORs), binomial logistic regression, and Mann-Whitney U test using IBM SPSS software. Demographic and injury characteristics that were poor prognostic indicators (had a decreased likelihood of obtaining PASS on IKDC postsurgery) included having Medicaid insurance (OR: 0.056; 0.003-1.00), chronic pain (OR: 0.106; 0.013-0.873), acute injury (OR: 0.387; 0.164-0.914), and high-grade (KL grades 3-4) medial compartment arthritis (OR: 0.412; 0.174-0.980), and preoperative SF-36 physical health score (PHS; p = 0.023) and mental health score (MHS; p = 0.006) values less than 47 and 48, respectively. Additionally, former smoking history (OR: 0.271; 0.079-0.928) showed a lower likelihood of being satisfied postsurgery. Not having psychiatric history (OR: 14.925; p < 0.001; increased likelihood of obtaining PASS on IKDC score postsurgery) and not having patellar arthritis (OR: 4.082; p = 0.025; increased likelihood of PASS on IKDC) were positive prognostic indicators. This study identifies predictive factors of poor outcomes post-APM; particularly, it highlights the usefulness of SF-36 surveys prior to APM surgery. Patients with low SF-36 score preoperatively may not find APM acceptable. Additional attention should be put on patient demographics (such as psychiatric history, chronic pain, and insurance type) and injury characteristics (presence of arthritis and acute injury) prior to performing APM. LEVEL OF EVIDENCE: II.

Culture Negative Pasteurella multocida Confirmed Prosthetic Hip Infection using Next-generation Sequencing.

Introduction: Prosthetic joint infections (PJIs) are a dreaded complication of joint arthroplasty. Zoonotic organisms such as Pasteurella multocida (PM) rarely cause PJIs. Still, these organisms can be challenging to treat due to a low suspicion index and inadequate growth on culture. Next-generation sequencing (NGS) can be used to identify organisms in culture-negative PJIs. This is the first reported case of a PM positive total hip arthroplasty PJI using NGS. Case Report: We report the case of a 70-year-old male presenting with a periprosthetic hip infection. PM was identified in high relative abundance on NGS and grew in culture. Subsequent intraoperative samples were culture negative for Pasteurella, but NGS demonstrated continued presence of Pasteurella. Conclusion: PM is a rare case of PJI, but a high index of suspicion must be maintained in the appropriate clinical context. NGS is a vital tool for the identification of culture-negative organisms like PM.

Understanding overall shoulder function and health: the value of specific quantitative vs. qualitative shoulder range of motion on patient-reported outcome measures.

HYPOTHESIS AND BACKGROUND: It is known that, though widely used, shoulder range of motion (ROM) measurements are not standardized and have a high rate of intra- and interobserver differences. Particularly, the inconsistency in quantitative and qualitative measurements and their relationship to patient-reported outcome measures (PROMs) make shoulder health difficult to determine. METHODS: This was a prospective study of 147 patients who presented with a chief complaint of shoulder pain to the orthopedic sports medicine and shoulder clinic of a single fellowship-trained surgeon. Measured by 1 examiner, quantitative ROM measurements were taken with a goniometer and qualitative ROM measured by the anatomic level that the patient could reach. The following PROMs were used as well: American Shoulder and Elbow Surgeons shoulder score, Single Assessment Numeric Evaluation, Shoulder Pain and Disability Index, Oxford Shoulder Score, Disabilities of the Arm, Shoulder, and Hand questionnaire, 12-Item Short Form Health Survey, and Patient-Reported Outcomes Measurement Information System pain interference short form 6a (PROMIS 6a). Statistical analysis was performed with SPSS using the Pearson correlation and 2-sample t test. The Benjamini-Hochberg correction was used to determine the P value at which statistical significance was reached to correct for multiple comparisons. RESULTS: Qualitative internal rotation (IR) (the hand behind back reach test) and qualitative forward flexion (FF) correlated with all goniometer angle measurements and PROMs (both shoulder and general health scores). These qualitative measures proved to be an appropriate proxy for IR and FF goniometer measurements. Qualitative external rotation (ER) was not a good substitute for quantitative ER measurement. Quantitative ER correlated with all PROMs. As ROM increased when measured by quantitative ER, qualitative IR, and qualitative FF, shoulder and general health PROMs incrementally increased as well. DISCUSSION/CONCLUSIONS: Qualitative IR measurement, the hand-behind-back reach test, is an adequate substitution for IR goniometer angle as well as a strong representation of global shoulder ROM, shoulder health, and general health while factoring in patient age. Qualitative FF measurement is also an appropriate proxy for quantitative FF and represents global shoulder and general health without factoring in age. Quantitative ER, via goniometer angle, is a better assessment of the shoulder than qualitative ER and is a representation of overall shoulder and general health. We recommend the use of quantitative ER, qualitative IR, and qualitative FF measurements to best understand a patient's overall shoulder health and its impact on their overall health.

Pectoralis Major Muscle Belly Rupture in a 17-Year-Old Female Softball Player: A Case Report.

CASE: We report the case of a healthy 17-year-old female softball player with a subacute full-thickness intramuscular tear of the pectoralis major (PM) muscle. A successful muscle repair was obtained using a modified Kessler technique. CONCLUSIONS: Despite initially being a rare injury pattern, the incidence of PM muscle rupture is likely to increase as interest in sports and weight training increases, and although this injury pattern is more common in men, it is becoming more common in women as well. Furthermore, this case presentation provides support for operative treatment of intramuscular ruptures of the PM muscle.

Rotator cuff tear with scapular dyskinesis treated with a pectoralis major transfer and rotator cuff repair: a case report.

We report a 45-year-old man who presented with a rotator cuff tear and scapular dyskinesis of his left shoulder and underwent a pectoralis major split transfer with an allograft to the inferior border of his scapula. The patient reported significant improvement in shoulder function and decreased severity of his scapular dyskinesis. Combined arthroscopic rotator cuff repair and allograft scapula stabilization is a novel technique for the unusual clinical presentation reported in this case report. To the best of our knowledge, this is the first reported surgical management of a patient with rotator cuff repair and non-palsy-related scapular dyskinesis.

Cartilaginous defect of the lateral trochlea following suprapatellar nailing of an open tibial shaft fracture: a case report.

A 34-year-old female sustained a 1.8 cm full-thickness chondral defect of the right lateral trochlear surface as the result of intramedullary tibial nailing via a suprapatellar portal to treat a displaced right sided open comminuted spiral fracture of the distal tibial shaft. An osteochondral allograft was used to treat the chondral defect. Iatrogenic injury to intraarticular structures is a potential complication when inserting a tibial nail via a suprapatellar portal. Using proper technique with cannula systems and guide pins is essential to lowering the risk of damage to intraarticular structures.

Risk factors associated with ACL registry compliance: can we predict who will follow-up?

PURPOSE: The purpose of this study was to determine patient factors that influence patient compliance to fill out anterior cruciate ligament reconstruction (ACLR) registry forms. METHODS: Patients prospectively enrolled in the ACLR registry at a single institution were retrospectively reviewed. Patients who were followed up for at least 6 months were included. Patients who did not fill out initial registry forms were excluded. Patients were asked to fill out forms preoperatively and at 6, 12 and 24 months postoperatively. The impacts of age, race, employment status, medical insurance, smoking status, driving distance to the hospital and importance to return to the same level of sporting activity were analyzed against patient compliance (yes/no) to complete registry forms at the respective follow-ups. Multivariate analysis was performed to analyze variables at 6 and 12 months postoperatively. The numbers of patients who were followed up for more than 24 months were too low to run a multivariate analysis, so only univariate analysis was performed on this cohort. RESULTS: A total of 221 patients filled out the initial preoperative forms at least 6 months before data gathering was commenced and were included. At 6 months postoperatively, none of the variables significantly influenced patient compliance. At 12 months, younger age and longer driving distance to the hospital had a significant negative impact on compliance [OR per year: 0.92 (0.85-0.99), p = 0.0237; OR per mile: 1.01 (1, 1.01), p = 0.0297]. Patients who filled out registry forms at 6 months were significantly more compliant at 12 months postoperatively (p < 0.0001). At 24 months, the influence of age remained significant (p = 0.0262) and, additionally, patients who initially noted that it was important for them to return to the same level of sports were significantly less compliant (p = 0.0367). CONCLUSION: Younger age and longer driving distance to the hospital were significantly associated with less compliance to fill out ACLR registry forms at 12 months postoperatively. Patient perspectives on the importance to return to the same level of sports were inversely related to compliance at 24 months postoperatively. This information can be utilized to improve compliance in future studies as we have potentially identified patients that can be viewed as "at-risk" for registry noncompliance.