Suture Anchor Fixation Has Less Gap Formation and No Difference in Complications or Revisions for Patellar Tendon Repair: A Systematic Review.

PURPOSE: To evaluate the literature on suture anchor (SA) usage for patellar tendon repair, summarize the overall biomechanical and clinical outcomes, and assess whether the cumulative research supports the adoption of this technique compared with transosseous (TO) repair. METHODS: A systematic literature review using the Preferred Reporting Items for Systematic and Meta-Analyses guidelines was performed. Multiple electronic databases were searched to identify studies focusing on surgical outcomes of patellar tendon repair with suture anchor usage. Cadaver and animal biomechanical studies, technical studies, and clinical studies were included. RESULTS: A total of 29 studies met the inclusion criteria: 6 cadaver, 3 animal, 9 technical, and 11 clinical reports. Four of the 6 cadaver studies and 1 of the 2 animal studies found significantly less gap formation from SA than from TO repair. Average gap formation in human studies ranged from 0.9 to 4.1 mm in the SA group compared with 2.9 to 10.3 mm in TO groups. Load to failure was significantly stronger in 1 of 5 cadaver studies and 2 of 3 animal studies, with human studies SA load to failure ranging from 258 to 868 N and TO load to failure ranging from 287 to 763 N. There were 11 clinical studies that included 133 knees repaired using SA. Nine studies showed no difference between complication rate or risk for reoperation, where one study reported a significantly lower re-rupture rate after SA repair compared with TO repair. CONCLUSIONS: SA repair is a viable option for patellar tendon repair and could have several advantages over TO repair. Multiple studies indicate that SA repair has less gap formation during biomechanical testing compared with TO repair in human cadaver and animal models. No differences in complications or revisions were found in the majority of clinical studies. CLINICAL RELEVANCE: Both animal and human models suggest SA fixation has potential biomechanical benefits when compared with TO tunnels for patellar tendon repair, whereas clinical studies show no difference in complications and revisions postoperatively.

Upper-Extremity Injuries Have the Poorest Return to Play and Most Time Lost in Professional Baseball: A Systematic Review of Injuries in Major League Baseball.

PURPOSE: To summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature. METHODS: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across 3 databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active Major League Baseball (MLB) athletes and studies published in the English language. Exclusion criteria were non-MLB players, case series and case report studies with a cohort of ≤3 players, and/or review articles. RESULTS: A total of 477 articles were identified from the initial search of 3 databases, with 105 studies meeting inclusion criteria. Among these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the greatest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament (UCL) tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40%-72.5%), rotator cuff tears (33.3%-87%), and UCL tears (51%-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated nonoperatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days), and anterior cruciate ligament (ACL) tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement requiring arthroscopy, athletes had a significantly lower workloads compared with before injury upon return to play. CONCLUSIONS: Most published investigations focus on elbow injuries of the UCL, with variable return to play and mixed performance following surgery. UCL tears, shoulder labral tears, and ACL tears result in the most missed time. Upper-extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest return to play rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for femoroacetabular impingement. LEVEL OF EVIDENCE: Level IV, systematic review of level II-IV studies.

Race and Socioeconomic Status Are Associated With Inferior Patient-Reported Outcome Measures Following Rotator Cuff Repair.

PURPOSE: To investigate the impact social determinants of health (SDOH) have on National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test scores and postoperative health care use in patients who undergo rotator cuff repair (RCR). METHODS: All patients who underwent RCR surgery by 3 shoulder and/or sports medicine fellowship-trained orthopaedic surgeons between July 2017 and January 2020 were included. The electronic medical record (EMR) was used to identify SDOH for each patient. PROMIS computer adaptive test measures of Upper Extremity function, Pain Interference, and Depression were completed preoperatively and postoperatively (6 months and 1 year). Postoperative health care use (clinical visits, virtual encounters, imaging encounters, and physical therapy visits) were recorded as well. Univariate associations, multiple linear regressions, and Wilcoxon rank-sum tests were used to analyze mean differences between patient groups based on SDOH. RESULTS: Three hundred thirty-eight patients who underwent RCR were included. Patients who were Black, in lower median household income quartiles, had public insurance, and female reported lower PROMIS scores compared with their counterparts. Smokers and White patients attended fewer postoperative office visits whereas Black patients had more physical therapy and nonvisit encounters compared with their respective counterparts. CONCLUSIONS: Black race and lower socioeconomic status are associated with worse function and pain outcomes post-RCR compared with White race. Similarly, Black race and positive smoking status are associated with differential use of health care following RCR. Further attention may be required for these patients to address health care disparities. LEVEL OF EVIDENCE: III, retrospective cohort study.

Machine Learning Model Identifies Preoperative Opioid Use, Male Sex, and Elevated Body Mass Index as Predictive Factors for Prolonged Opioid Consumption Following Arthroscopic Meniscal Surgery.

PURPOSE: To develop a predictive machine learning model to identify prognostic factors for continued opioid prescriptions after arthroscopic meniscus surgery. METHODS: Patients undergoing arthroscopic meniscal surgery, such as meniscus debridement, repair, or revision at a single institution from 2013 to 2017 were retrospectively followed up to 1 year postoperatively. Procedural details were recorded, including concomitant procedures, primary versus revision, and whether a partial debridement or a repair was performed. Intraoperative arthritis severity was measured using the Outerbridge Classification. The number of opioid prescriptions in each month was recorded. Primary analysis used was the multivariate Cox-Regression model. We then created a naïve Bayesian model, a machine learning classifier that uses Bayes' theorem with an assumption of independence between variables. RESULTS: A total of 581 patients were reviewed. Postoperative opioid refills occurred in 98 patients (16.9%). Multivariate logistic modeling was used; independent risk factors for opioid refills included male sex, larger body mass index, and chronic preoperative opioid use, while meniscus resection demonstrated decreased likelihood of refills. Concomitant procedures, revision procedures, and presence of arthritis graded by the Outerbridge classification were not significant predictors of postoperative opioid refills. The naïve Bayesian model for extended postoperative opioid use demonstrated good fit with our cohort with an area under the curve of 0.79, sensitivity of 94.5%, positive predictive value (PPV) of 83%, and a detection rate of 78.2%. The two most important features in the model were preoperative opioid use and male sex. CONCLUSION: After arthroscopic meniscus surgery, preoperative opioid consumption and male sex were the most significant predictors for sustained opioid use beyond 1 month postoperatively. Intraoperative arthritis was not an independent risk factor for continued refills. A machine learning algorithm performed with high accuracy, although with a high false positive rate, to function as a screening tool to identify patients filling additional narcotic prescriptions after surgery. LEVEL OF EVIDENCE: III, retrospective comparative study.

What are patients asking and reading online? An analysis of online patient searches for rotator cuff repair.

BACKGROUND: Patients undergoing rotator cuff surgery often search the internet for information regarding the procedure. One popular source, Google, compiles frequently asked questions and links to websites that may provide answers. This study provides an analysis of the most frequently searched questions associated with rotator cuff surgery. We hypothesize that there will be distinct search patterns associated with online queries about rotator cuff surgery that could provide unique insights into patient concerns. METHODS: A set of search terms were entered into Google Web Search using a clean-install Google Chrome browser. Frequently associated questions and their webpages were extracted to a database via a data mining extension. Questions were categorized by topics relevant for rotator cuff arthroscopy. Websites were categorized by source and scored for quality using the JAMA Benchmark Criteria. Pearson's χ2 tests were used to analyze nominal data. Student t tests were performed to compare JAMA Benchmark Scores. RESULTS: Of the 595 questions generated from the initial search, 372 unique questions associated with 293 websites were extracted and categorized. The most popular question topics were activities/restrictions (20.7%), pain (18.8%), and indications/management (13.2%). The 2 most common websites searched were academic (35.2%) and medical practice (27.4%). Commercial websites were significantly more likely to be associated with questions about cost (57.1% of all cost questions, P = .01), anatomy/function (62.5%, P = .001), and evaluation of surgery (47.6%, P < .001). Academic websites were more likely to be associated with questions about technical details of surgery (58.1%, P < .001). Medical practice and social media websites were more likely associated with activities/restrictions (48.1%, P < .001, and 15.6%, P < .001, respectively). Government websites were more likely associated with timeline of recovery (12.8%, P = .01). On a scale of 0-4, commercial and academic websites had the highest JAMA scores (3.06 and 2.39, respectively). CONCLUSION: Patients seeking information regarding rotator cuff repair primarily use the Google search engine to ask questions regarding postoperative activity and restrictions, followed by pain, indications, and management. Academic websites, which were associated with technical details of surgery, and medical practice websites, which were associated with activities/restrictions, were the 2 most commonly searched resources. These results emphasize the need for orthopedic surgeons to provide detailed and informative instructions to patients undergoing rotator cuff repair, especially in the postoperative setting.

Inflammatory and Proliferative Pathway Activation in Human Esophageal Myofibroblasts Treated with Acidic Bile Salts.

Subepithelial human esophageal myofibroblasts (HEMFs) in gastroesophageal reflux disease (GERD) are exposed to luminal contents via impaired squamous epithelium barrier integrity. The supernatant of HEMFs treated with acidic bile salts reflective of in vivo reflux increases squamous epithelial thickness. We aimed to identify the involved mechanisms using an unbiased approach. Acidic-bile-salt-treated primary HEMF cultures (n = 4) were submitted for RNA-Seq and analyzed with Partek Flow followed by Ingenuity Pathway Analysis (IPA). A total of 1165 molecules (579 downregulated, 586 upregulated) were differentially expressed, with most top regulated molecules either extracellular or in the plasma membrane. Increases in HEMF CXCL-8, IL-6, AREG, and EREG mRNA, and protein secretion were confirmed. Top identified canonical pathways were agranulocyte and granulocyte adhesion and diapedesis, PI3K/AKT signaling, CCR5 signaling in macrophages, and the STAT3 pathway. Top diseases and biological functions were cellular growth and development, hematopoiesis, immune cell trafficking, and cell-mediated response. The targets of the top upstream regulator ErbB2 included CXCL-8, IL-6, and AREG and the inhibition of CXCL-8 in the HEMF supernatant decreased squamous epithelial proliferation. Our work shows an inflammatory/immune cell and proliferative pathways activation in HEMFs in the GERD environment and identifies CXCL-8 as a HEMF-derived chemokine with paracrine proliferative effects on squamous epithelium.

Arthroscopic Case Volumes Among Orthopaedic Surgery Residents and Orthopaedic Sports Medicine Fellows: An Analysis of ACGME Case Log Data.

Arthroscopic procedures are used to treat a multitude of disorders, but they can be technically demanding. These procedures are a fundamental aspect of orthopaedic surgery residency and surgical sports medicine fellowship. The goal of this study was to analyze the variability in arthroscopic case experience to better understand the disparities between various training programs and the opportunity for increased surgical case volume of an orthopaedic sports medicine fellowship. Resident and fellow case log reports were gathered from the Accreditation Council for Graduate Medical Education. Fellows reported 286% more arthroscopic cases in one year of fellowship than residents reported in five years of residency (554 cases vs. 193 cases, p < 0.0001). Fellows also performed 770% more arthroscopic hip procedures than residents (57 cases vs. 7 cases, p < 0.0001). There is a significant difference in arthroscopic case volume between residents and fellows. An orthopaedic sports medicine fellowship dramatically increases the arthroscopic experience of trainees. (Journal of Surgical Orthopaedic Advances 31(1):022-025, 2022).

Risk Factors for Greater Than 24-Hour Length of Stay After Primary Total Knee Arthroplasty.

BACKGROUND: Recently, the Center for Medicare Services removed total knee arthroplasty (TKA) from the inpatient-only procedure list. The purpose of this study is to assess the role of demographics, medical comorbidities, and postsurgical complications in predicting safe discharge to home within 24 hours after TKA. METHODS: Patients undergoing primary TKA between 2011 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped into those whose length of stay (LOS) was less than 24 hours after surgery vs those greater than 24 hours. Demographics, preoperative comorbidities, operative variables, and postoperative adverse events were studied as risk factors for LOS greater than 24 hours. RESULTS: A total of 210,075 patients undergoing primary TKA met the inclusion criteria, and of those, 18,134 (8.6%) patients were discharged within 24 hours postoperatively. In a risk-adjusted multivariate analysis, patients with increasing age, obesity, preoperative comorbidities of smoking, diabetes, dyspnea, chronic obstructive pulmonary disease, hypertension, bleeding disorder, corticosteroid use preoperatively, and dependent functional status conferred a greater risk for discharge greater than 24 hours. Male gender, spinal anesthesia, and monitored anesthesia care were protective against LOS greater than 24 hours. CONCLUSION: This study suggests that dependent functional status, preoperative comorbidities, and postoperative complications are all associated with a LOS greater than 24 hours after TKA. Surgeons and patients should be aware of the clinical and demographic variables associated with risk for LOS greater than 24 hours when considering outpatient status for patients undergoing TKA.

Smoking as a Risk Factor for Readmission in Arthroscopic Surgery: A Propensity Matched Analysis.

The objective of this study was to perform a propensity matched analysis exploring smoking as a risk factor for readmission following hip, knee and shoulder arthroscopy. Patients undergoing knee, shoulder or hip arthroscopy between 2006-2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Patient's smoking was analyzed for its effect on 30-day readmission using multivariate regression adjusting for demographics and comorbidities. A propensity matched analysis control identified 19,732 non-smokers to serve as the control group. The readmission rate for the non-smoking cohort was 0.9% and 1.3% in the smoking group (p = 0.01). In a multivariate analysis adjusting for baseline characteristics and medical comorbidities, smoking status was associated with increased risk readmission (Odds Ratio: 1.37 [95% Confidence Interval: 1.133-1.657] p = 0.0012). This study suggests that smoking increases chances of readmission in all arthroscopic surgery. (Journal of Surgical Orthopaedic Advances 28(4):272-276, 2019).

Preoperative coagulation abnormalities as a risk factor for adverse events after pancreas surgery.

OBJECTIVE: To determine whether elevated INR or PTT values predicted 30-day postoperative adverse events following elective pancreatectomy. METHODS: The American college of surgeons national surgical quality improvement program (ACS-NSQIP) database was used to identify 14 747 patients undergoing elective pancreatectomy from 2005 to 2013. The association of elevated INR or PTT with 30-day postoperative outcomes of morbidity and mortality was examined using multivariate logistic regression analysis. RESULTS: The overall 30-day mortality rate increased from 1.8% to 3.3% from the control to the high INR or PTT group (P = <0.001). An elevated INR/PTT increased the odds for bleeding requiring transfusion, superficial SSI, sepsis, unplanned intubation or >48 h on a ventilator, cardiac arrest or myocardial infarction, acute renal failure, return to the OR, and prolonged length of stay. With the exception of superficial SSI, multivariate logistic regression models revealed that these same events remained statistically significant after controlling for potential confounders. CONCLUSION: Prolonged bleeding times (high INR/PTT) is associated with increased mortality and adverse outcomes after pancreas surgery. A patient's coagulation profile may serve as a risk stratification tool to identify higher risk patients that require more resources.

The association of length of hospital stay with readmission after elective pancreatic resection.

OBJECTIVE: The aim of this study was to identify if prolonged length of hospital stay was protective for certain post-discharge complications requiring readmission after pancreatectomy. METHODS: Patients undergoing elective pancreatectomy from 2012 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Multivariate regression analyses were conducted to elucidate the association of length of hospital stay (LOS), in-hospital complications, and post-discharge complications with 30-day hospital readmission. RESULTS: Mean LOS for the readmitted versus not readmitted cohort was 9.01 and 10.36, respectively (P < 0.001). Approximately half of hospital readmissions occur within 7 days of discharge from the hospital. The readmission rate (after hospital discharge) for patients with any in-hospital complication was 13.2%. On the other hand, the readmission rate for patients with any post-discharge complication was 70.8%. Readmission rates were above 85% for patients with the following post-discharge complications: organ/space surgical site infection (SSI), pneumonia, ventilator dependence greater than 48 h, progressive renal insufficiency, sepsis, and septic shock. In a multivariate logistic regression model, prolonged LOS reduced the odds of any post-discharge complication requiring readmission (OR = 0.68, P = 0.01). Specifically, prolonged LOS reduced the odds of a post-discharge organ/space SSI requiring readmission (OR = 0.72, P = 0.02). CONCLUSION: Readmission after pancreatectomy primarily occurs due to a new post-discharge event. Furthermore, increased LOS is protective for readmission for post-pancreatectomy complications, particularly those due to post-discharge organ space SSIs. Our findings suggest that solely focusing on reducing LOS in pancreatectomy may lead to the unintended consequence of increasing readmission rates.

Intraoperative neurophysiological monitoring team's communiqué with anesthesia professionals.

BACKGROUND AND AIMS: Intraoperative neurophysiological monitoring (IONM) is the standard of care during many spinal, vascular, and intracranial surgeries. High-quality perioperative care requires the communication and cooperation of several multidisciplinary teams. One of these multidisciplinary services is intraoperative neuromonitoring (IONM), while other teams represent anesthesia and surgery. Few studies have investigated the IONM team's objective communication with anesthesia providers. We conducted a retrospective review of IONM-related quality assurance data to identify how changes in the evoked potentials observed during the surgery were communicated within our IONM-anesthesia team and determined the resulting qualitative outcomes. MATERIAL AND METHODS: Quality assurance records of 3,112 patients who underwent surgical procedures with IONM (from 2010 to 2015) were reviewed. We examined communications regarding perioperative evoked potential or electroencephalography (EEG) fluctuations that prompted neurophysiologists to alert/notify the anesthesia team to consider alteration of anesthetic depth/drug regimen or patient positioning and analyzed the outcomes of these interventions. RESULTS: Of the total of 1280 (41.13%) communications issued, there were 347 notifications and 11 alerts made by the neurophysiologist to the anesthesia team for various types of neuro/orthopedic surgeries. Prompt communication led to resolution of 90% of alerts and 80% of notifications after corrective measures were executed by the anesthesiologists. Notifications mainly related to limb malpositioning and extravasation of intravenous fluid. CONCLUSION: Based on our institutions' protocol and algorithm for intervention during IONM-supported surgeries, our findings of resolution in alerts and notifications indicate that successful communications between the two teams could potentially lead to improved anesthetic care and patient safety.

Lysholm and KOOS QoL Demonstrate High Responsiveness in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

BACKGROUND: There have been a large number of patient-reported outcome measures (PROMs) used to assess outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR). PURPOSE/HYPOTHESIS: The purpose was to determine which PROMs are being commonly used in randomized clinical trials (RCTs) to assess patients undergoing ACLR and to compare the responsiveness between them. It was hypothesized that the International Knee Documentation Committee (IKDC) score would be the most commonly used and responsive PROM among patients undergoing ACLR. STUDY DESIGN: Meta-analysis. Level of evidence, 2. METHODS: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and relevant studies were extracted from the PubMed/MEDLINE and Web of Science databases. The inclusion criteria were English-language RCTs reporting on PROMs after ACLR. For articles meeting our inclusion criteria for responsiveness analysis (≥2 PROMs reported, 1 year minimum follow-up, and reported pre- and postoperative PROM means and standard deviations), the responsiveness between PROMs was compared using effect size (ES) and relative efficiency (RE). RESULTS: A total of 108 articles met the inclusion criteria, comprising 9034 patients (mean age, 29.9 years; mean body mass index, 24.3; mean follow-up time, 36.1 months). There were 34 PROMs identified. The top 3 most commonly reported PROMs were the IKDC (n = 68; 63.0%), Lysholm (n = 65; 60.2%), and Tegner (n = 47; 43.5%) scores. The 2 PROMs with the highest ES were the ACL-Quality of Life (QoL) (3.37) and Knee Injury and Osteoarthritis Outcome Score (KOOS) QoL (2.07) scores. Compared with other PROMs, Lysholm and KOOS QoL scores had the greatest RE values. The Lysholm score had a greater RE than the KOOS Pain (RE, 1.17), KOOS Symptoms (RE, 1.22), KOOS Activities of Daily Living (ADL) (RE, 1.42), KOOS Sport/Recreation (RE, 1.55), KOOS QoL (RE, 1.41), and Tegner (RE, 2.89) scores. KOOS QoL had a greater RE than the IKDC (RE, 1.32), KOOS Pain (RE, 1.60), KOOS Symptoms (RE, 2.12), KOOS ADL (RE, 3.03), KOOS Sport/Recreation (RE, 1.27), and Tegner (RE, 2.06) scores. CONCLUSION: The IKDC score is the most commonly reported PROM in RCTs after ACLR; however, the Lysholm and KOOS QoL scores demonstrated the highest responsiveness in patients undergoing ACLR compared with other PROMs.

Differential Contributions of Fibroblast Subpopulations to Intercellular Communication in Eosinophilic Esophagitis.

Fibroblast heterogeneity remains undefined in eosinophilic esophagitis (EoE), an allergic inflammatory disorder complicated by fibrosis. We utilized publicly available single-cell RNA sequencing data (GSE201153) of EoE esophageal biopsies to identify fibroblast sub-populations, related transcriptomes, disease status-specific pathways and cell-cell interactions. IL13-treated fibroblast cultures were used to model active disease. At least 2 fibroblast populations were identified, F_A and F_B. Several genes including ACTA2 were more enriched in F_A. F_B percentage was greater than F_A and epithelial-mesenchymal transition upregulated in F_B vs. F_A in active and remission EoE. Epithelial-mesenchymal transition was also upregulated in F_B in active vs. remission EoE and TNF-α signaling via NFKB was downregulated in F_A. IL-13 treatment upregulated ECM-related genes more profoundly in ACTA2- fibroblasts than ACTA2+ myofibroblasts. After proliferating epithelial cells, F_B and F_A contributed most to cell-cell communication networks. ECM-Receptor interaction strength was stronger than secreted or cell-cell contact signaling in active vs. remission EoE and significant ligand-receptor pairs were driven mostly by F_B. This unbiased analysis identifies at least 2 fibroblast sub-populations in EoE in vivo, distinguished in part by ACTA2. Fibroblasts play a critical role in cell-cell interactions in EoE, most profoundly via ECM-receptor signaling via the F_B sub-group.

Anterior Cruciate Ligament Hybrid Remnant Preservation Reconstruction Demonstrates Equivalent Patient-Reported Outcomes and Complications as Traditional Anterior Cruciate Ligament Reconstruction After 1 Year.

Purpose: To compare the outcomes of anterior cruciate ligament (ACL) Hybrid Remnant Preservation Reconstruction (HRPR) with traditional anterior cruciate ligament reconstruction (ACLR) and determine differences in patient-reported outcomes, range of motion (ROM), and complications after 12 months. Methods: A retrospective cohort study of patients undergoing ACLR by a single surgeon from December 2020 to January 2022 was conducted. Patients undergoing ACL-HRPR were compared with control patients undergoing traditional ACLR with bone-patellar tendon-bone autograft. Preoperative and postoperative Patient-Reported Outcome Measurement Information System scores, International Knee Documentation Committee, and patient acceptable symptom state were recorded over 12 months. Any complications occurring 12 months postoperatively were collected. Results: The final analysis included 104 patients, with 39 undergoing ACL-HRPR compared with 65 ACLR controls. Patients who received HRPR were on average 19.46 ± 5.01 years old, with 51.28% being female, whereas control patients were, on average, 21.92 ± 7.71 years old with 50.77% being female. Total ROM was equivalent between groups, with complete terminal extension at 12 months. No significant differences were found for patient acceptable symptom state; Patient-Reported Outcome Measurement Information System-Physical Function, -Pain Interference, or -Depression; or International Knee Documentation Committee at 6 months and 12 months postoperatively. Total ROM was similar between the HRPR and control groups. No differences were found for timed 6-meter hop test, hop for distance, or KT-1000 side-to-side differences. Over the 12-month period, complication rates were similar between groups (10% vs 12% P = .75) were similar. Conclusions: ACL HRPR is associated with equivalent patient-reported outcomes, full ROM, and no differences in complications rates after 1 year compared with control patients in the present retrospective study. Level of Evidence: Level III, retrospective cohort study.

The Impact of Social Determinants of Health on Outcomes and Complications After Total Knee Arthroplasty: An Analysis of Neighborhood Deprivation Indices.

BACKGROUND: Social determinants of health (SDOH) are important factors in the delivery of orthopaedic care. The purpose of this study was to investigate the relationship between outcomes following total knee arthroplasty (TKA) and both the Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI). METHODS: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was utilized to identify TKA cases for inclusion. Demographic characteristics and medical history were documented. The SVI, its subthemes, and the ADI were analyzed. Outcome data included length of stay, discharge disposition, postoperative change in the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR), 90-day incidences of emergency department (ED) visits, readmission, death, deep venous thrombosis (DVT) and/or pulmonary embolism (PE), periprosthetic fracture, implant failure, periprosthetic joint infection (PJI), and all-cause reoperation. Database cross-referencing was completed to document aseptic and septic revisions beyond 90 days postoperatively. Bivariate quartile-stratified and multivariable analyses were used to associate deprivation metrics with outcomes. RESULTS: A total of 19,321 TKA cases met inclusion criteria. Baseline patient characteristics varied among the SVI and/or ADI quartiles, with patients of non-White race and with a greater number of comorbidities noted in higher deprivation quartiles. Higher SVI and/or ADI quartiles were correlated with an increased rate of discharge to a skilled nursing facility (p < 0.05). A higher SVI and/or ADI quartile was associated with increased incidences of ED visits and readmissions postoperatively (p < 0.05). DVT and/or PE and long-term aseptic revision were the complications most strongly associated with higher deprivation metrics. Upon multivariable analysis, greater length of stay and greater incidences of ED visits, readmissions, DVT and/or PE, and aseptic revision remained significantly associated with greater deprivation based on multiple metrics. CONCLUSIONS: Greater deprivation based on multiple SVI subthemes, the composite SVI, and the ADI was significantly associated with increased length of stay, non-home discharge ED visits, and readmissions. The SVI and the ADI may be important considerations in the perioperative assessment of patients who undergo TKA. LEVEL OF EVIDENCE: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

What Do Patients Encounter When Searching Online About Meniscal Surgery? An Analysis of Internet Trends.

Background: Many patients use the internet to learn about their orthopaedic conditions and find answers to their common questions. However, the sources and quality of information available to patients regarding meniscal surgery have not been fully evaluated. Purpose: To determine the most frequently searched questions associated with meniscal surgery based on question type and topic, as well as to assess the website source type and quality. Study Design: Cross-sectional study. Methods: The following search terms were entered into a web search (www.google.com) using a clean-install browser: "meniscal tear,""meniscus repair,""meniscectomy,""knee scope,""meniscus surgery," and "knee arthroscopy." The Rothwell classification system was used to categorize questions and sort them into 1 of 13 topics relevant to meniscal surgery. Websites were also categorized by source into groups. The Journal of the American Medical Association (JAMA) benchmark criteria (medians and interquartile ranges [IQRs]) were used to measure website quality. Results: A total of 337 unique questions associated with 234 websites were extracted and categorized. The most popular questions were "What is the fastest way to recover from meniscus surgery?" and "What happens if a meniscus tear is left untreated?" Academic websites were associated more commonly with diagnosis questions (41.9%, P < .01). Commercial websites were associated more commonly with cost (71.4%, P = .03) and management (47.6%, P = .02). Government websites addressed a higher proportion of questions regarding timeline of recovery (22.2%, P < .01). Websites associated with medical practices were associated more commonly with risks/complications (43.8%, P = .01) while websites associated with single surgeons were associated more commonly with pain (19.4%, P = .03). Commercial and academic websites had the highest median JAMA benchmark scores (4 [IQR, 3-4] and 3 [IQR, 2-4], respectively) while websites associated with a single surgeon or categorized as "other" had the lowest scores (1 [IQR 1-2] and 1 [IQR 1-1.5], respectively). Conclusion: Our study found that the most common questions regarding meniscal surgery were associated with diagnosis of meniscal injury, followed by activities and restrictions after meniscal surgery. Academic websites were associated significantly with diagnosis questions. The highest quality websites were commercial and academic websites.

ChatGPT-4 Generates More Accurate and Complete Responses to Common Patient Questions About Anterior Cruciate Ligament Reconstruction Than Google's Search Engine.

Purpose: To replicate a patient's internet search to evaluate ChatGPT's appropriateness in answering common patient questions about anterior cruciate ligament reconstruction compared with a Google web search. Methods: A Google web search was performed by searching the term "anterior cruciate ligament reconstruction." The top 20 frequently asked questions and responses were recorded. The prompt "What are the 20 most popular patient questions related to 'anterior cruciate ligament reconstruction?'" was input into ChatGPT and questions and responses were recorded. Questions were classified based on the Rothwell system and responses assessed via Flesch-Kincaid Grade Level, correctness, and completeness were for both Google web search and ChatGPT. Results: Three of 20 (15%) questions were similar between Google web search and ChatGPT. The most common question types among the Google web search were value (8/20, 40%), fact (7/20, 35%), and policy (5/20, 25%). The most common question types amongst the ChatGPT search were fact (12/20, 60%), policy (6/20, 30%), and value (2/20, 10%). Mean Flesch-Kincaid Grade Level for Google web search responses was significantly lower (11.8 ± 3.8 vs 14.3 ± 2.2; P = .003) than for ChatGPT responses. The mean correctness for Google web search question answers was 1.47 ± 0.5, and mean completeness was 1.36 ± 0.5. Mean correctness for ChatGPT answers was 1.8 ± 0.4 and mean completeness was 1.9 ± 0.3, which were both significantly greater than Google web search answers (P = .03 and P = .0003). Conclusions: ChatGPT-4 generated more accurate and complete responses to common patient questions about anterior cruciate ligament reconstruction than Google's search engine. Clinical Relevance: The use of artificial intelligence such as ChatGPT is expanding. It is important to understand the quality of information as well as how the results of ChatGPT queries compare with those from Google web searches.

Analysis of Player Performance and Financial Costs Associated With Implementation of an Updated National Hockey League Concussion Protocol: A Retrospective Comparative Study.

Background: An updated National Hockey League (NHL) concussion protocol (NHLCP) was established in the 2016-2017 season to mitigate the negative outcomes of sport-related concussions. However, few studies on the effects of implementing the NHLCP have been performed. Purpose: To define concussion incidence and investigate differences in NHL player performance after a concussion during periods before and after NHLCP implementation and assess the financial impact on NHL teams associated with NHLCP implementation. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective review of NHL players who sustained a concussion before (2000-2001 to 2015-2016 seasons) and after (2016-2017 to 2020-2021 seasons) implementing the NHLCP (pre-NHLCP and post-NHLCP groups). For each group, multiple performance metrics-including 30 days, 1 season, and 3 seasons before and after concussion-were compared for both groups. Return to play, total concussion cost, and association of return to play with cost were investigated using regression analysis. Results: A total of 452 players (423 skaters, 29 goalies) sustained concussions during the study period, including 331 players (315 skaters, 16 goalies) in the pre-NHLCP group and 121 players (108 skaters, 13 goalies) in the post-NHLCP group. For both groups, no significant differences in standard performance were observed during the 30-day and 1-season periods before and after concussion. The mean return to play was significantly higher in the pre-NHLCP group than in the post-NHLCP group (20.1 vs 15.7 days; P = .022). The mean adjusted player salary was not different between groups; nonetheless, the mean adjusted replacement player salary was significantly higher in the post-NHLCP group ($744,505 vs $896,942; P = .032). The mean cost of time missed did not differ between groups. The mean return to play time significantly decreased over the entire study period (R2 = 0.33; P = .005), and the mean return to play time was positively associated with cost R2 = 0.215; P = .030). Conclusion: Concussion incidence did not change after implementation of the updated NHLCP; nonetheless, players had significantly less missed time from injury after protocol implementation. Changes in player performance 30 days and 1 year before and after concussion injury were not different before and after NHLCP implementation. No differences were found in the financial cost of concussions between the pre- and post-NHLCP groups, and missed time was significantly correlated with mean cost from missed time.

Return to Play, Performance, and Earnings Analysis After Lumbar Disc Herniation in National Hockey League Players.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Professional hockey players have a high incidence of lumbar disc herniations (LDH). The purpose of this study was to determine the impact of LDH on the performance and financial earnings of National Hockey League (NHL) players. METHODS: NHL players who sustained a LDH were retrospectively reviewed utilizing an online database and a 2:1 matched control cohort. Player performance and game usage was compared at one- and three-season(s) pre- and post-injury season within the cohorts. Injured and matched players were divided into 3 groups based on the player's adjusted index season salary. RESULTS: A total of 181 players were included, with 62 LDH players matched to 119 healthy controls. Return to play after LDH was 79%. The LDH cohort had fewer seasons played throughout their career compared to the matched group (12.5 ± 4.3 vs 14.2 ± 3.8; P = .031). At 1 season post-index, the LDH cohort had significantly fewer goals per 60 and points per 60 when compared to pre-index. At 3 seasons post-index, the LDH cohort exhibited a significant decline in time-on-ice per game played, goals per 60, and points per 60 compared to pre-index. CONCLUSION: The majority of NHL players who sustained a LDH returned to play (79%) but had shorter careers overall and decreased performance outcomes when compared to matched cohorts at both 1 and 3 seasons post-injury.