Acromioclavicular Joint Reconstruction with Double-Bundle Constructs Provide Improved Maintenance of Reduction but Comparable Clinical Outcomes Versus Single-Bundle Constructs.

Treatment of acute acromioclavicular (AC) joint separations is dependent on a variety of factors including severity, acuity, patient demographics, activity level, and surgeon preferences. For more severe or unstable separations (Rockwood types IIIB, IV, V, and VI), surgical intervention is typically recommended. Over 160 surgical techniques have been described, but none have emerged as a gold standard. Arthroscopic-assisted or all-arthroscopic fixation of the coracoclavicular (CC) ligaments with suture buttons has become increasingly popular due to lower complication rates compared to more rigid fixation. Configurations include single-bundle (SB) constructs and double-bundle (DB) configurations that more anatomically reconstruct the conoid and trapezoid ligaments but with longer operative times. Clinical studies with short-term follow-up have demonstrated improved maintenance of fixation for DB compared to SB constructs, but no significant differences in clinical outcomes. In our experience, single bundle suture-button-only constructs lead to unacceptable failures due to loss of reduction. We recommend either a single suture-button construct augmented with allograft or double bundle suture-button constructs for the treatment of acute AC joint separations.

Variations in Treatment and Costs for Distal Radius Fractures in Patients Over 55 Years of Age: A Population-Based Study.

Objective To evaluate the rate of surgery for symptomatic malunion after nonoperatively treated distal radius fractures in patients aged 55 and above, and to secondarily report differences in demographics, geographical variation, and utilization costs of patients requiring subsequent malunion correction. Methods We identified patients aged 55 and above who underwent nonoperative treatment for a distal radius fracture between 2007 and 2016 using the IBM MarketScan database. In the nonoperative cohort, we identified patients who underwent malunion correction between 3 months and 1 year after distal radius fracture. The primary outcome was rate of malunion correction. Multivariable logistic regression controlling for sex, region, and Elixhauser Comorbidity Index (ECI) was used. We also report patient demographics, geographical variation, and utilization cost. Results The rate of subsequent malunion surgery after nonoperative treatment was 0.58%. The cohort undergoing malunion surgery was younger and had a lower ECI. For every 1-year increase in age, there was a 6.4% decrease in odds of undergoing surgery for malunion, controlling for sex, region, and ECI (odds ratio = 0.94 [0.93-0.95]; p < 0.01). The southern United States had the highest percentage of patients initially managed operatively (30.7%), the Northeast had the lowest (22.0%). Patients who required a malunion procedure incurred higher costs compared with patients who did not ($7,272 ± 8,090 vs. $2,209 ± 5,940; p < 0.01). Conclusion The rate of surgery for symptomatic malunion after initial nonoperative treatment for distal radius fractures in patients aged 55 and above is low. As younger and healthier patients are more likely to undergo malunion correction with higher associated costs, surgeons may consider offering this cohort surgical treatment initially.

No significant difference in risk of prolonged opioid use following outpatient versus inpatient total shoulder arthroplasty: A propensity matched analysis.

Background: The purpose of this investigation was to compare rates of filled opioid prescriptions and prolonged opioid use in opioid naïve patients undergoing total shoulder arthroplasty (TSA) in inpatient versus outpatient settings. Methods: A retrospective cohort study was conducted using a national insurance claims database. Inpatient and outpatient cohorts were created by identifying continuously enrolled, opioid naïve TSA patients. A greedy nearest-neighbor algorithm was used to match baseline demographic characteristics between cohorts with a 1:1 inpatient to outpatient ratio to compare the primary outcomes of filled opioid prescriptions and prolonged opioid use following surgery between cohorts. Results: A total of 11,703 opioid naïve patients (mean age 72.5 ± 8.5 years, 54.5% female, 87.6% inpatient) were included for analysis. After propensity score matching (n = 1447 inpatients; n = 1447 outpatients), outpatient TSA patients were significantly more likely to fill an opioid prescription in the perioperative window compared to inpatients (82.9% versus 71.5%, p < 0.001). No significant differences in prolonged opioid use were detected (5.74% inpatient versus 6.77% outpatient; p = 0.25). Conclusions: Outpatient TSA patients were more likely to fill opioid prescriptions compared to inpatient TSA patients. The quantity of opioids prescribed and rates of prolonged opioid use were similar between the cohorts. Level of evidence: Therapeutic Level III.

Are Patient-Reported Outcome Measures for Distal Radius Fractures Validated for Spanish and Culture? A Systematic Review.

PURPOSE: Patient-reported outcome measures (PROMs) are used commonly to assess function to direct treatment and evaluate outcomes for patients with distal radius fractures. Most PROMs have been developed and validated in English with minimal report of the demographics of patients studied. The validity of applying these PROMs among Spanish-speaking patients is unknown. The purpose of this study was to evaluate the quality and psychometric properties of Spanish-language adaptations of PROMs for distal radius fractures. METHODS: We conducted a systematic review to identify published studies of adaptations of Spanish-language PROMs evaluating patients with distal radius fractures. We evaluated the methodologic quality of the adaptation and validation using Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures, Quality Criteria for Psychometric Properties of Health Status Questionnaire, and the Consensus-based Standards for the Selection of Health Measurement Instruments Checklist for Cross-Cultural Validity. The level of evidence was evaluated based upon prior methodology. RESULTS: Five instruments reported in eight studies were included: the Patient-Rated Wrist Evaluation (PRWE), Disability of Arm Shoulder and Hand, Upper Limb Functional Index, Lawton Instrumental Activities of Daily Living Scale, and Short Musculoskeletal Function Assessment. The PRWE was the most frequently included PROM. No study followed all six processes for adaptation or assessed all measurement properties. No study demonstrated the completion of more than eight of the 14 aspects of cross-cultural validity. The PRWE had moderate evidence to support half of the domains of measurement properties evaluating the level of evidence. CONCLUSIONS: None of the five instruments identified received a good rating on all three checklists. Only the PWRE demonstrated moderate evidence on half of the measurement domains. CLINICAL RELEVANCE: Given the lack of strong evidence to support the quality of these instruments, we recommend adaptation and testing of PROMs for this population before use. Currently, PROMs in Spanish-speaking patients should be used with caution so as not to perpetuate health care disparities.

Patients Who Return to Sport After Primary Anterior Cruciate Ligament Reconstruction Have Significantly Higher Psychological Readiness: A Systematic Review and Meta-analysis of 3744 Patients.

BACKGROUND: Although objective outcomes assessing knee function are essential measurements for return to sport, psychological factors have become increasingly recognized as equally important parameters for determining an athlete's ability to return to sport after surgery. PURPOSE: To systematically review the literature to determine whether patients who returned to sport after anterior cruciate ligament (ACL) reconstruction had improved psychological scores (as measured with validated questionnaires) compared with patients who did not return to sport. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 3. METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was preregistered on PROSPERO. Four databases were searched for level 1 to 3 studies that compared at least 1 psychological outcome measured by a validated questionnaire for patients who did and did not return to sport after primary ACL reconstruction. The following data were recorded: study and patient characteristics; psychological metrics (ACL-Return to Sport Injury [ACL-RSI] scale, Knee Self-Efficacy Scale [K-SES], and Tampa Scale of Kinesiophobia [TSK/TSK-11]); International Knee Documentation Committee (IKDC) score; and clinical metrics. Study methodological quality was analyzed using the methodological index for non-randomized studies (MINORS), and the mean difference (MD) and 95% CI were calculated for each psychological outcome score using the inverse variance method. RESULTS: We included and analyzed 16 articles (3744 patients; 38.9% female; mean age range, 17-28.7 years; mean MINORS score, 19.9 ± 1.4). Overall, 61.8% of athletes returned to sport (66.8% of male patients; 55.4% of female patients). Patients who returned scored significantly higher on the ACL-RSI scale (MD, 20.8; 95% CI, 15.9 to 25.7; P < .001), significantly higher on the K-SES (MD, 1.3; 95% CI, 0.2 to 2.3; P = .036), and significantly lower on the TSK/TSK-11 (MD, 10.1%; 95% CI, -12.1% to -8.2%; P = .004). Those returning to sport did not exceed the minimal clinically important difference for IKDC score versus those not returning to sport. CONCLUSION: Patients who returned to sport after primary ACL reconstruction had significantly higher psychological readiness, higher self-efficacy, and lower kinesiophobia compared with those who did not return to sport, despite having clinically similar knee function scores. Evaluation of psychological readiness, in combination with other objective measurements, is a critical component of return-to-sport evaluation in athletes after primary ACL reconstruction. REGISTRATION: CRD42021284735 (PROSPERO).

How Is Scaphoid Malunion Defined: A Systematic Review.

BACKGROUND: Abnormal scaphoid alignment after fracture is used as an indication for fixation. Acceptable alignment after reduction and fixation of scaphoid fractures is not well defined. We systematically reviewed the literature to identify how scaphoid malunion is currently defined and by what parameters. METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple databases were searched for studies published in the English language that reported on outcomes after scaphoid malunion and included measurements to define malunions. Radiographic scaphoid measurement parameters were collected. Clinical outcome measures recorded included grip strength, wrist range of motion, and patient-reported outcome measures. Study quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Descriptive summaries of the studies are presented. RESULTS: The initial search yielded 1600 articles. Ten articles (161 participants, 93% males, mean age = 28.3 + 6.3 years, mean MINORS score = 10.2 + 1.6) were included and analyzed. Scaphoid malunion was defined if the lateral intrascaphoid angle (LISA) was >45° (3 articles), LISA >35° (1 article), and height to length ratio >0.6 (3 articles). Four out of 5 studies found no significant associations between patient outcomes and degree of scaphoid malunion measured on imaging. CONCLUSIONS: There is a lack of consensus for defining scaphoid malunion on imaging and absence of correlation between findings on imaging and patient outcomes. Future studies defining scaphoid malunion should be appropriately powered, incorporate measures of intrarater and interrater reliabilities for all reported imaging measurements, and utilize validated patient-reported outcome measures to reflect that malunion is associated with inferior outcomes meaningful to patients.

Analysis of Website Accessibility and Content for All 92 Accredited Hand Surgery Fellowship Programs in the United States: An Update.

Purpose: The internet is an important information source for hand surgery fellowship applicants. A previous analysis of hand fellowship websites in 2014 demonstrated they were often inaccessible and incomplete. Given the increased importance of virtual information, we performed an updated assessment of the accessibility and content of hand fellowship program websites. Methods: Websites of 92 accredited hand surgery fellowship programs were evaluated for the following: (1) accessibility; and (2) the presence of 13 fellow recruitment and 13 fellow education criteria, as defined in prior studies. We used Mann-Whitney U and Kruskal-Wallis tests to assess whether the geographic region, number of fellows, or affiliation with a top orthopedic hospital or medical school were associated with website content. Results: Functional website links that redirect to the appropriate fellowship program website are provided for 47 (51.1%) of 92 programs on the American Society for Surgery of the Hand fellowship directory. All missing websites were accessible via independent Google searches. Fellowship program websites contained an average of 13.9 ± 4.4 total criteria (range, 3-23). Of the 15 criteria examined in both 2014 and 2021, there were significant (P < .05) increases in the prevalences of 4: current fellow(s), salary, social media links, and operative experience. Conclusions: Despite a slight increase in accessibility since 2014, nearly half of hand surgery fellowship program websites remain inaccessible from the American Society for Surgery of the Hand directory. Program websites averaged approximately half of the criteria analyzed, with many websites failing to provide information deemed important by applicants. Clinical relevance: Our study provides an impetus for improving the accessibility and content of hand surgery fellowship websites. A website that incorporates criteria examined in this study can serve as an effective recruitment tool by providing consistent baseline information that may help applicants decide which programs align with personal values and future career goals.

Increased Risk of ACL Injury for Female but Not Male Soccer Players on Artificial Turf Versus Natural Grass: A Systematic Review and Meta-Analysis.

Background: Both natural grass (NG) and artificial turf (AT) are popular playing surfaces for soccer. Biomechanical studies have found increased frictional forces on AT that may lead to anterior cruciate ligament (ACL) injury. The increased risk of ACL injury during soccer in female participants may amplify this effect. Purpose: To systematically review the literature for studies comparing ACL injury risk in soccer players on AT versus NG and to specifically determine whether there were differences in injury risk in male versus female players when considering the playing surface. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Three databases were searched for studies with evidence level 1 to 3 that compared the incidence of ACL injuries on AT versus NG in soccer players. Data recorded included study characteristics, sex, competition level, exposure setting (games or practices), turf type, and ACL injury information. Study methodological quality was analyzed using the methodological index for non-randomized studies (MINORS) score, and incidence rate ratios (IRRs) were calculated. Results: Included were 7 articles (3 studying professional soccer, 3 collegiate soccer, 1 youth-level soccer; 4 male cohorts, 2 female cohorts, and 1 male and female cohort; mean MINORS score, 20 ± 0.8). Pooled ACL injury IRRs demonstrated no significant differences in overall ACL injury risk when playing soccer on AT compared with NG (IRR = 0.57 [95% CI, 0.21-1.53]; P = .31). A significantly increased risk of ACL injury in games played on AT compared with NG was detected for female (IRR = 1.18 [95% CI, 1.05-1.31]; P = .004) but not for male players (IRR = 1.18 [95% CI, 0.97-1.42]; P = .09). Subgroup analyses showed no significant differences in injury risk for games (IRR = 1.07 [95% CI, 0.97-1.18]; P = .20) or practices (IRR = 0.21 [95% CI, 0.04-1.23]; P = .09). Conclusion: Findings indicated that female soccer players had a significantly higher risk of ACL injury when playing games on AT versus NG, whereas no significant difference was seen in male players. No differences were found for the combined male/female cohort or for soccer games or training sessions played on AT compared with NG.

Limited Biomechanical Evidence Behind Single Row Versus Double Row Repair of Subscapularis Tears: A Systematic Review.

Purpose: To systematically review the literature for studies investigating the biomechanical properties of constructs used to repair isolated subscapularis tears in time zero human cadaveric studies. Methods: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three electronic databases were searched for studies that reported on the construct technique and biomechanical outcomes for the repair of isolated subscapularis tears in human cadaveric specimens. Ultimate load, gap formation, stiffness, and failure mode were documented. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS) scale. Results: Six articles qualified (104 shoulders [72 single-row, 26 double-row, 6 transosseous]; mean QUACS score 10.5 ± 1) and were analyzed. Studies varied in the number and type of anchors and construct technique (1-2 anchors single-row; 3-4 anchors double-row; bioabsorbable or titanium anchors) and suture(s) used (no. 2 FiberWire or FiberTape), subscapularis tear type (25%, 33%, 50%, or 100% tear), and whether a knotless or knotted fixation was used. In studies that created full-thickness, upper subscapularis tears (Fox-Romeo II/III or Lafosse II), no significant differences were seen in ultimate load, gap formation, and stiffness for knotted versus knotless single-row repair (2 studies) and single-row versus double-row repair (1 study). Double-row repair of complete subscapularis tears demonstrated higher ultimate load, stiffness, and lower gap formation in 1 study. Ultimate load differed between the studies and constructs (single-row: range, 244 N to 678 N; double-row: range 332 N to 508 N, transosseous: 453 N). Suture cutout was the most common mode of failure (59%). Conclusion: Because of the limited number of studies and varying study designs in examining the biomechanical properties of repair constructs used for subscapularis tears, there is inconclusive evidence to determine which construct type is superior for repairing subscapularis tears. Clinical Relevance: Results from biomechanical studies of clinically relevant subscapularis repair constructs are important to guide decision-making for choosing the optimal construct for patients with subscapularis tears.

How do orthopaedic surgery residency program websites feature diversity? An analysis of 187 orthopaedic surgery programs in the United States.

Background: The orthopaedic surgery residency program website represents a recruitment tool that can be used to demonstrate a program's commitment to diversity and inclusion to prospective applicants. The authors assessed how orthopaedic surgery residency programs demonstrated diversity and inclusion on their program websites and whether this varied based on National Institutes of Health (NIH) funding, top-40 medical school affiliation, university affiliation, program size, or geographic region. Methods: The authors evaluated 187 orthopaedic surgery residency program websites for the presence of 12 elements that represented program commitment to diversity and inclusion values, based on prior work and ACGME recommendations. Mann-Whitney U and Kruskal-Wallis tests were used to assess whether NIH funding and other program characteristics were associated with commitment to diversity and inclusion on affiliated residency websites. Results: Orthopaedic surgery residency websites included a mean of 4.9 ± 2.1 diversity and inclusion elements, with 21% (40/187) featuring a majority (7+) of elements. Top 40 NIH funded programs (5.4 ± 2.0) did not have significantly higher website diversity scores when compared with nontop-40 programs (4.8 ± 2.1) (P = 0.250). University-based or affiliated programs (5.2 ± 2.0) had higher diversity scores when compared with community-based programs (3.6 ± 2.2) (P = 0.003). Conclusions: Most orthopaedic surgery residency websites contained fewer than half of the diversity and inclusion elements studied, suggesting opportunities for further commitment to diversity and inclusion. Inclusion of diversity initiatives on program websites may attract more diverse applicants and help address gender and racial or ethnic disparities in orthopaedic surgery. Level of Evidence: Level V.

Editorial Commentary: Soaking Anterior Cruciate Ligament Grafts in Vancomycin Solution Lowers Infection Rates Without Lowering Functional Outcomes.

Soaking anterior cruciate ligament grafts in vancomycin solution is done by many surgeons. Research has indicated decreased infection rates and similar anterior cruciate ligament retear rates between grafts soaked in vancomycin solution before implantation versus those without. In addition, there has been basic science evidence for tenocyte survival and viability even when exposed to vancomycin solution. The next frontier, investigating the maturation of vancomycin-soaked grafts with advanced imaging, may cause some surgeons to reconsider the practice but should not stop it, based on the available literature.

Arthroscopic Single and Double Row Repair of Isolated and Combined Subscapularis Tears Result in Similar Improvements in Outcomes: A Systematic Review.

PURPOSE: To systematically review the literature to (1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and (2) compare outcomes after single- and double-row subscapularis repair in both of these settings. METHODS: A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis retears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis. RESULTS: The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 ± 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs used single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in 5 studies comparing isolated to combined tears. Subscapularis retear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and retear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (P > .05 for all). CONCLUSION: Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless of whether tears were isolated or combined or if repairs were single or double row. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Outcomes after resection arthroplasty versus permanent antibiotic spacer for salvage treatment of shoulder periprosthetic joint infections: a systematic review and meta-analysis.

BACKGROUND: Although revision to new components is favored after shoulder periprosthetic joint infections (PJIs), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the I2 statistic. A P value of .05 was set as significant. RESULTS: The initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37-78.5 years, mean Methodological Index for Non-Randomized Studies score 9.6 ± 0.7) were included and analyzed. The pooled infection eradication rate was 82% (72%-89%) after resection arthroplasty and 85% (79%-90%) after permanent antibiotic spacer. The pooled mean forward flexion (71.5° vs. 48.7°; P < .001) and mean American Shoulder and Elbow Surgeons score (53.5 vs. 31.0; P < .001) were significantly higher for patients treated with a permanent antibiotic spacer compared with resection arthroplasty. No significant differences were found for mean external rotation (13.5° vs. 20.5°; P = .07), abduction (58.2° vs. 50.3°; P = .27), or visual analog scale pain (3.7 vs. 3.4; P = .24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 vs. 30.0; P < .001). CONCLUSION: When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. Although both can decrease pain levels, the permanent antibiotic spacer may result in better functional outcomes compared with resection arthroplasty.

Cost minimization analysis of the treatment of olecranon fracture in elderly patients: a retrospective analysis.

Background: Operative treatment of olecranon fractures in the elderly can lead to greater complications with similar outcomes to nonoperative treatment. The purpose of this study was to analyze cost differences between operative and nonoperative management of isolated closed olecranon fractures in elderly patients. Methods: Using a United States Medicare claims database, the authors identified 570 operative and 1,863 nonoperative olecranon fractures between 2005 and 2014. The authors retrospectively determined cost of treatment from the payer perspective for a 1-year period after initial injury, including any surgical procedure, emergency room care, follow-up care, physical therapy, and management of complications. Results: One year after diagnosis, mean costs per patient were higher for operative treatment (United States dollars [US$]10,694 vs US$2,544). 31.05% of operative cases were associated with a significant complication compared with 4.35% of nonoperative cases. When excluding complications, mean costs per patient were still higher for operative treatment ($7,068 vs $2,320). Conclusions: These findings show that nonoperative management for olecranon fractures in the elderly population leads to fewer complications and is less costly. Nonoperative management may be a higher-value management option for this patient population. These results will help inform management of olecranon fractures as payers shift toward value-based reimbursement models in which quality of care and cost influence surgical decision making. Level of Evidence: Level IV.

Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions.

BACKGROUND: There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery. METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported. RESULTS: The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome. CONCLUSIONS: There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores. CLINICAL RELEVANCE: Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.

Increased Lower Extremity Injury Risk Associated With Player Load and Distance in Collegiate Women's Soccer.

BACKGROUND: There is limited research regarding the impact of workload on injury risk specific to women's soccer. Wearable global positioning system (GPS) units can track workload metrics such as total distance traveled and player load during games and training sessions. These metrics can be useful in predicting injury risk. PURPOSE: To examine the relationship between injury risk and player workload as collected from wearable GPS units in National Collegiate Athletic Association (NCAA) Division I women's soccer players. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Lower extremity injury incidence and GPS workload data (player load, total distance, and high-speed distance) for 65 NCAA Division I women's soccer players were collected over 3 seasons. Accumulated 1-, 2-, 3-, and 4-week loads and acute-to-chronic workload ratios (ACWR) were classified into discrete ranges by z-scores. ACWR was calculated using rolling averages and exponentially weighted moving averages (EWMA) models. Binary logistic regression models were used to compare the 7:28 rolling average and EWMA ACWRs between injured and noninjured players for all GPS/accelerometer variables. The prior 1-, 2-, 3-, and 4-week accumulated loads for all GPS/accelerometer variables were compared between the injured and uninjured cohorts using 2-sample t tests. RESULTS: There were a total of 53 lower extremity injuries that resulted in lost time recorded (5.76/1000 hours "on-legs" exposure time; 34 noncontact and 19 contact injuries). The prior 2-week (7242 vs 6613 m/s2; P = .02), 3-week (10,533 vs 9718 m/s2; P = .02), and 4-week (13,819 vs 12,892 m/s2; P = .04) accumulated player loads and 2-week (62.40 vs 57.25 km; P = .04), 3-week (90.97 vs 84.10 km; P = .03), and 4-week (119.31 vs 111.38 km; P = .05) accumulated total distances were significantly higher for injured players compared with noninjured players during the same time frames. There were no significant differences in player load, total distance, or high-speed distance ACWR between injured and noninjured players for both the rolling averages and EWMA calculations. CONCLUSION: Higher accumulated player load and total distance, but not ACWR, were associated with injury in women's soccer players.

SARS-CoV-2 Impairs Dendritic Cells and Regulates DC-SIGN Gene Expression in Tissues.

The current spreading coronavirus SARS-CoV-2 is highly infectious and pathogenic. In this study, we screened the gene expression of three host receptors (ACE2, DC-SIGN and L-SIGN) of SARS coronaviruses and dendritic cells (DCs) status in bulk and single cell transcriptomic datasets of upper airway, lung or blood of COVID-19 patients and healthy controls. In COVID-19 patients, DC-SIGN gene expression was interestingly decreased in lung DCs but increased in blood DCs. Within DCs, conventional DCs (cDCs) were depleted while plasmacytoid DCs (pDCs) were augmented in the lungs of mild COVID-19. In severe cases, we identified augmented types of immature DCs (CD22+ or ANXA1+ DCs) with MHCII downregulation. In this study, our observation indicates that DCs in severe cases stimulate innate immune responses but fail to specifically present SARS-CoV-2. It provides insights into the profound modulation of DC function in severe COVID-19.

Tendon-Derived Progenitor Cells With Multilineage Potential Are Present Within Human Patellar Tendon.

BACKGROUND: Progenitor cells serve as a promising source of regenerative potential in a variety of tissue types yet remain underutilized in tendinopathy. Tendon-derived progenitor cells (TDPCs) have previously been isolated from hamstring tendon but only as part of a concomitant medical procedure. Determining the presence of TDPCs in patellar tendon may facilitate clinical utilization of these cells because of the relative accessibility of this location for tissue harvest. PURPOSE: To characterize TDPCs in human patellar tendon samples. STUDY DESIGN: Descriptive laboratory study. METHODS: Human patellar tendon samples were obtained during elective knee surgery. TDPCs were isolated and seeded at an optimal low cell density and subcultured to confluence for up to 2 passages. Flow cytometry was used to analyze for the expression of CD90+, CD105+, CD44+, and CD31-, CD34-, and CD45- markers. The multilineage differentiation potential of TDPCs was tested in vitro via adipogenic, osteogenic, and chondrogenic culture with subsequent cytochemical staining for Oil Red O, Alizarin Red, and Alcian Blue, respectively. Enzyme-linked immunosorbent assay was used to quantify the amount of adiponectin, alkaline phosphatase, and SRY-box transcription factor 9 secreted into cell culture supernatant for further confirmation of lineage differentiation. Results were analyzed statistically using the 2-tailed Student t test. RESULTS: TDPCs demonstrated near-uniform expression of CD90, CD105, and CD44 with minimal expression of CD34, CD31, and CD45. Adipogenic, osteogenic, and chondrogenic differentiation of TDPCs was confirmed using qualitative analysis. The expression of adiponectin, alkaline phosphatase, and SRY-box transcription factor 9 were significantly increased in differentiated cells versus undifferentiated TDPCs (P < .05). CONCLUSION: TDPCs can be successfully isolated from human patellar tendon samples, and they exhibit characteristics of multipotent progenitor cells. CLINICAL RELEVANCE: These data demonstrate the promise of patellar tendon tissue as a source of progenitor cells for use in biologic therapies for the treatment of tendinopathy.

Pain management in shoulder arthroplasty: a systematic review and network meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Given the variety of pain management options available, the purpose of this investigation was to systematically review the literature for randomized controlled trials reporting on pain control after shoulder arthroplasty. We sought to determine which modalities are most effective in managing postoperative pain and reducing postoperative opioid use. METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched for Level I-II randomized controlled trials that compared interventions for postoperative pain control after TSA. Pain control measures included nerve blocks and nerve block adjuncts, local injections, patient-controlled analgesia, oral medications, and other modalities. The 2 primary outcome measures were pain level measured on a 0-10 visual analog scale and opioid use. The risk of study bias and methodologic quality were analyzed using The Cochrane Collaboration's Risk of Bias 2 (RoB 2) tool. Network meta-analyses were performed for visual analog scale pain scores at postsurgical time points and opioid use using a frequentist approach and random-effects model, with heterogeneity quantified using the I2 statistic. Treatments were ranked using the P score, and statistical significance was set at P < .05. RESULTS: The initial search yielded 2391 articles (695 duplicates, 1696 screened, 53 undergoing full-text review). Eighteen articles (1358 shoulders; 51% female patients; mean age range, 65-73.7 years; 4 studies with low risk of bias, 12 with some risk, and 2 with high risk) were included and analyzed. At 4 and 8 hours postoperatively, patients receiving local liposomal bupivacaine (LB) injection (P < .001 for 4 and 8 hours) or local ropivacaine injection (P < .001 for 4 hours and P = .019 for 8 hours) had significantly more pain compared with patients who received either a continuous interscalene block (cISB) or single-shot interscalene block (ssISB). No differences in opioid use (at P < .05) were detected between modalities. The P scores of treatments demonstrated that ssISBs were most favorable at time points < 24 hours, whereas pain at 24 and 48 hours after surgery was best managed with cISBs or a combination of an ssISB with a local LB injection. CONCLUSION: Interscalene blocks are superior to local injections alone at managing pain after TSA. Single-shot interscalene blocks are optimal for reducing early postoperative pain (< 24 hours), whereas pain at 24-48 hours after surgery may be best managed with cISBs or a combination of an ssISB with a local LB injection.

Google Trends Analysis Shows Increasing Public Interest in Platelet-Rich Plasma Injections for Hip and Knee Osteoarthritis.

BACKGROUND: Osteoarthritis is a chronic musculoskeletal condition that frequently affects the hip and knee joints. Given the burden associated with surgical intervention for hip and knee osteoarthritis, patients continue to search for potential nonoperative treatments. One biologic therapy with mixed clinical and basic science evidence for treating osteoarthritis is platelet-rich plasma injections into the affected joint. We used the Google Trends tool to provide a quantitative analysis of national interest in platelet-rich plasma injections for hip and knee osteoarthritis. METHODS: Google Trends parameters were selected to obtain search data from January 2009 to December 2019. Various combinations of "arthritis," "osteoarthritis," "PRP," "platelet-rich plasma," "knee," and "hip" were entered into the Google Trends tool and trend analyses were performed. RESULTS: Three linear models were generated to display search volume trends in the United States for platelet-rich plasma and osteoarthritis, hip osteoarthritis, and knee osteoarthritis, respectively. All models showed increased Google queries as time progressed (P < .001), with R2 ranging from 0.837 to 0.940. Seasonal, income-related, and geographic variations in public interest in platelet-rich plasma for osteoarthritis were noted. CONCLUSION: Our results demonstrate a significant rise in Google queries related to platelet-rich plasma injections for osteoarthritis of the hip and knee since 2009. Surgeons treating hip and knee osteoarthritis patients can expect continued interest in platelet-rich plasma, despite inconclusive clinical and basic science data. Trends in public interest may inform patient counseling, shared decision-making, and directions for future clinical research.