Factors Associated With Knee Extension Strength Symmetry After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft.

Background: Diminished postoperative knee extension strength may occur after anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) autograft. Factors influencing the restoration of knee extensor strength after ACLR with QT autograft remain undefined. Purpose: To identify factors that influence knee extensor strength after ACLR with QT autograft. Study Design: Case-control study; Level of evidence, 3. Methods: The authors performed a retrospective review of patients who underwent primary ACLR with QT autograft at a single institution between 2010 and 2021. Patients were included if they completed electromechanical dynamometer testing at least 6 months after surgery. Exclusion criteria consisted of revision ACLR, <6 months of follow-up, concomitant procedure (osteotomy, cartilage restoration), and concomitant ligamentous injury requiring surgery. Knee extension limb symmetry index (LSI) was obtained by comparing the peak torque of the operated and nonoperated extremities. Univariable and multivariable analyses were performed to identify factors associated with knee extension LSI in the patient, injury, rehabilitation, and preoperative patient-reported outcomes score domains. Results: A total of 107 patients (58 male; mean age, 22.8 years) were included. Mean knee extension LSI of the overall cohort was 0.82 ± 0.18 at 7.5 ± 2.0 months; 35 patients (33%) had a value of ≥0.90. Multivariable analysis demonstrated significant negative associations between knee extension LSI and female sex (-0.12; P < .001), increased age at the time of surgery (-0.01; P = .018), and larger QT graft width (-0.049; P = .053). Conclusion: Factors influencing knee extensor LSI after ACLR with QT autograft in this study population spanned patient and surgical factors, including female sex, older age at the time of surgery, and wider graft harvest. Surgeons should consider the association between these factors and lower postoperative knee extensor LSI to optimize patient outcomes.

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.

Barriers to Bariatric Surgery: a Mixed Methods Study Investigating Obstacles Between Clinic Contact and Surgery.

PURPOSE: Populations most affected by obesity are not reflected in the patients who undergo bariatric surgery. Gaps in the referral system have been studied, but there is a lack of literature investigating obstacles patients encounter after first contact with bariatric surgery clinics. We aim to identify patient populations at risk for attrition during bariatric surgery evaluation and determine patient reported barriers to bariatric surgical care. MATERIALS AND METHODS: This study was a single institution, retrospective, mixed methods study from 2012 to 2021 comparing patients who underwent bariatric surgery to those that withdrew. Surveys were performed of patients who withdrew, collecting information on patient knowledge, expectations, and barriers. RESULTS: This study included 5982 patients evaluated in bariatric surgery clinic. Those who attained bariatric surgery (38.8%) were more likely to be White (81.2 vs. 75.6%, p<0.001), married (48.5 vs. 44.1%, p=0.004), and employed full time (48.2 vs. 43.8%, p=0.01). They were less likely to live in an area with low income (37.1 vs. 40.7%, p=0.01) or poverty (poverty rate 15.8 vs. 17.4, p<0.001). Of the 280 survey respondents, fear of complications, length of insurance approval process, and wait time between evaluation and surgery were the most reported barriers. CONCLUSION: Patients who undergo bariatric surgery were more likely to be White, married, employed full time, and reside in more resourced environments which is not reflective of communities most affected by obesity. The complexity of insurance coverage requirements was a major barrier to bariatric surgery and should be a focus of future healthcare reform.

Criteria-based return-to-sport testing helps identify functional deficits in young athletes following posterior labral repair but may not reduce recurrence or increase return to play.

Background: The purpose of this study was to compare recurrent instability and return to play (RTP) in young athletes who underwent clearance to full activity based on a validated return-to-sport (RTS) test to those who underwent time-based clearance following primary posterior labral repair. Methods: This was a retrospective review of athletes with posterior shoulder instability who underwent primary arthroscopic posterior labral repair from 2012 to 2021 with minimum 1-year follow-up. Patients who underwent RTS testing at a minimum of 5 months postoperatively were compared to a historic control cohort of patients who underwent time-based clearance. Results: There were 30 patients in the RTS cohort and 67 patients in the control cohort (mean follow-up 32.1 and 38.6 months, respectively). Of the 30 patients who underwent RTS testing, 11 passed without failing any sections, 10 passed while failing 1 section, and 9 failed the RTS test by failing 2+ sections. No differences were found between the RTS and control cohort in the incidence of recurrent instability (6.7% vs. 9.0%), overall RTP (94.7% vs. 94.3%), RTP at the same level as before injury (84.2% vs. 80.0%), recurrent pain/weakness (23.3% vs. 25.4%), or revision surgery (0% vs. 3.0%), respectively. Discussion: While RTS testing in young athletes after posterior labral repair did not reduce recurrence or improve return to play compared to time-based clearance, two-thirds of athletes who underwent testing failed at least 1 section, indicating some functional deficit. Thus, RTS testing may help guide postoperative rehabilitation following posterior stabilization.

Rates of Septic Arthritis After ACL Reconstruction: A Single-Center Analysis Highlighting Quadriceps Tendon Grafts.

BACKGROUND: Although the infection rates for bone-patellar tendon-bone autograft (BTB), hamstring tendon autograft (HT), and allograft have been reported previously, there are limited data available for a large cohort of individuals undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) using quadriceps tendon autograft (QT). PURPOSE: The aims of this study are (1) to compare rates of septic arthritis after primary and revision ACLR with QT, BTB, HT, and allograft and (2) to evaluate the association between an infection after ACLR and potential risk factors in a large single-system analysis. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All ACLR cases performed by 10 high-volume sports medicine fellowship-trained ACL surgeons between January 2000 and January 2022 were retrospectively analyzed. Minimum follow-up was 90 days after ACLR, and all multiligament reconstructions were excluded. Demographic information, surgical variables, infection characteristics, and rate of ACL graft retention were collected for all included patients. Independent samples t test, chi-square test, or Fisher exact tests with adjusted Benjamini-Hochberg post hoc procedure were used for group comparisons. RESULTS: In total, 6652 patients were included in this study. The most commonly used graft was allograft (n = 2491; 37.4%), followed by HT (n = 1743; 26.2%), BTB (n = 1478; 22.2%), and QT (n = 940; 14.1%). The overall postoperative rate of septic arthritis was 0.34% (n = 23). Septic arthritis rates based on graft type were 0.74% (n = 13) for HT, 0.24% (n = 6) for allograft, 0.20% (n = 3) for BTB, and 0.10% (n = 1) for QT. While a statistically significant difference with regard to graft type (P = .01) was observed, no significant relationships were found between postoperative septic arthritis and age, sex, revision ACLR, ACLR surgical technique, and accompanying intra-articular procedures for all septic arthritis patients (P > .05). The average time from the onset of the symptoms of infection to surgical irrigation and debridement (I&D) was 2 days (minimum, 0; maximum, 6). ACL grafts were retained during I&D procedures in all patients with postoperative septic arthritis. CONCLUSION: The postoperative rate of septic arthritis was 0.1% after use of the QT autograft. While graft choice may affect rates of septic arthritis after ACLR, patient characteristics, ACLR technique, revision ACLR, and accompanying intra-articular procedures during ACLR were not associated with postoperative septic arthritis with the numbers available for analysis.

Effects of extreme potassium stress on blood pressure and renal tubular sodium transport.

We characterized mouse blood pressure and ion transport in the setting of commonly used rodent diets that drive K+ intake to the extremes of deficiency and excess. Male 129S2/Sv mice were fed either K+-deficient, control, high-K+ basic, or high-KCl diets for 10 days. Mice maintained on a K+-deficient diet exhibited no change in blood pressure, whereas K+-loaded mice developed an ~10-mmHg blood pressure increase. Following challenge with NaCl, K+-deficient mice developed a salt-sensitive 8 mmHg increase in blood pressure, whereas blood pressure was unchanged in mice fed high-K+ diets. Notably, 10 days of K+ depletion induced diabetes insipidus and upregulation of phosphorylated NaCl cotransporter, proximal Na+ transporters, and pendrin, likely contributing to the K+-deficient NaCl sensitivity. While the anionic content with high-K+ diets had distinct effects on transporter expression along the nephron, both K+ basic and KCl diets had a similar increase in blood pressure. The blood pressure elevation on high-K+ diets correlated with increased Na+-K+-2Cl- cotransporter and γ-epithelial Na+ channel expression and increased urinary response to furosemide and amiloride. We conclude that the dietary K+ maneuvers used here did not recapitulate the inverse effects of K+ on blood pressure observed in human epidemiological studies. This may be due to the extreme degree of K+ stress, the low-Na+-to-K+ ratio, the duration of treatment, and the development of other coinciding events, such as diabetes insipidus. These factors must be taken into consideration when studying the physiological effects of dietary K+ loading and depletion.