Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX).

BACKGROUND: Perceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement. METHODS: A prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units. RESULTS: Compared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts. CONCLUSIONS: Revision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

Determining health information-seeking behavior of shoulder patients.

BACKGROUND: Patients today have access to an increasing number of health resources to guide medical decision making, including specialist health care providers, the Internet, friends, and family members. No prior studies, to our knowledge, have comprehensively explored health information-seeking behavior (HISB) for patients being managed for shoulder pain. OBJECTIVE: Our primary objective is to identify which health resources patients use and find helpful in a cohort of patients being either evaluated or managed for shoulder pain. With increased access to the Internet and its use, we also hope to quantify the extent of use of Internet resources and identify predictors of patient use. METHODS: We interviewed a cohort of new and follow-up patients being surgically or nonoperatively managed for shoulder pain by a single fellowship-trained orthopedic surgeon. All patients were administered a questionnaire to determine HISB, which evaluated the types of resources used and those deemed most helpful in guiding medical decision making. For patients using the Internet, specific websites were documented. Additional variables that were collected included age, gender, ethnicity, and highest education attained. Multivariable logistic regression was used to evaluate predictors of Internet use. RESULTS: This study included 242 patients. A discussion with an orthopedic surgeon was reported to be the most informative for nonoperatively treated patients, first postoperative patients, and operative follow-up patients. Patients at the first postoperative visit reported YouTube as their preferred resource almost 4 times more than new patients (odds ratio [OR] 3.9, P = .015). Search engine use was significantly higher in patients at the first postoperative visit (OR 5.8, P = .004) and patients at subsequent surgical follow-up (OR 8.3, P = .001) compared with new patients. Having an undergraduate (OR 0.1, P = .037) or graduate degree (OR 0.03, P = .01) had a significant inverse association with difficulty of using Internet resources. Patients of Black race reported significantly higher rates of distrust for Internet resources than those of White race (OR 5.8, P < .001). CONCLUSION: This study highlights the patterns of HISB among patients with shoulder conditions. A face-to-face discussion with a physician or a shoulder surgeon was the most crucial resource for information compared to other resources. This study has also defined the preferred Internet resources for patients at different time points of care and the reasons for refraining from seeking health information on the Internet. Such findings can aid shoulder surgeons in understanding the optimal methods for delivering health information for different patient demographics and different phases of their care.

Adjusting Implant Size and Position Can Improve Internal Rotation After Reverse Total Shoulder Arthroplasty in a Three-dimensional Computational Model.

BACKGROUND: Efforts during reverse total shoulder arthroplasty (RSA) have typically focused on maximizing ROM in elevation and external rotation and avoiding scapular notching. Improving internal rotation (IR) is often overlooked, despite its importance for functional outcomes in terms of patient self-care and hygiene. Although determinants of IR are multifactorial, it is unable to surpass limits of bony impingement of the implant. Identifying implant configurations that can reduce bony impingement in a computer model will help surgeons during preoperative planning and also direct implant design and clinical research going forward. QUESTIONS/PURPOSES: In a CT-modeling study, we asked: What reverse total shoulder arthroplasty implant position improves the range of impingement free internal rotation without compromising other motions (external rotation and extension)? METHODS: CT images stored in a deidentified teaching database from 25 consecutive patients with Walch A1 glenoids underwent three-dimensional templating for RSA. Each template used the same implant and configuration, which consisted of an onlay humeral design and a 36-mm standard glenosphere. The resulting constructs were virtually taken through ROM until bony impingement was found. Variations were made in the RSA parameters of baseplate lateralization, glenosphere size, glenosphere overhang, humeral version, and humeral neck-shaft angle. Simulated ROM was repeated after each parameter was changed individually and then again after combining multiple changes into a single configuration. The impingement-free IR was calculated and compared between groups. We also evaluated the effect on other ROM including external rotation and extension to ensure that configurations with improvements in IR were not associated with losses in other areas. RESULTS: Combining lateralization, inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion resulted in a greater improvement in internal rotation than any single parameter change did (median baseline IR: 85° [interquartile range 73° to 90°]; combined changes: 119° [IQR 113° to 121°], median difference: 37° [IQR 32° to 43°]; p < 0.001). CONCLUSION: Increased glenosphere overhang, varus neck-shaft angle, and humeral anteversion improved internal rotation in a computational model, while glenoid lateralization alone did not. Combining these techniques led to the greatest improvement in IR. CLINICAL RELEVANCE: This computer model study showed that various implant changes including inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion can be combined to increase impingement-free IR. Surgeons can employ these currently available implant configurations to improve IR when planning and performing RSA. These findings support the need for further clinical studies validating the effect of implant configuration on resultant IR.

Anchorless Arthroscopic Transosseous and Anchored Arthroscopic Transosseous Equivalent Rotator Cuff Repair Show No Differences in Structural Integrity or Patient-reported Outcomes in a Matched Cohort.

BACKGROUND: Anchored transosseous equivalent suture-bridge technique (TOE) is widely used for arthroscopic rotator cuff repair. It is unknown how patient outcomes scores, ROM, and integrity of the rotator cuff after repair using this anchored technique compare with those after repair using an anchorless transosseous technique (TO). QUESTIONS/PURPOSES: (1) What are the differences in patient-reported outcomes (American Shoulder and Elbow Surgeons [ASES] score) and shoulder ROM between TO and TOE rotator cuff repair techniques at 1 and 2 years after surgery? (2) What is the difference in repair integrity as measured by the re-tear rate, assessed ultrasonographically at 1 year, between these two techniques? (3) What is the difference in procedure duration between the two techniques when performed by a surgeon familiar with each? METHODS: We reviewed 331 arthroscopic rotator cuff repairs performed by one surgeon from December 2011 to July 2016 in this retrospective, matched-pair study. Of these patients, 63% (208 of 331) underwent repair with standard anchored technique (anchors placed in a double-row, TOE manner) and 37% (123 of 331) underwent anchorless TO repair, with the same indications for surgery between groups. Forty-four percent (91 of 208) of patients in the TOE group and 61% (75 of 123) of patients in the TO group met the inclusion criteria. Eighty percent (73 of 91) of patients in the TOE group and 88% (66 of 75) in the TO group had minimum 2-year follow-up. We matched each group to a cohort of 50 patients by sex, age, smoking status, and tear size (by Cofield classification: small, < 1 cm; medium, 1-3 cm; large, > 3-5 cm; or massive, > 5 cm). The resulting cohorts did not differ in mean age (TO, 62 years [range 53-65 years]; TOE, 58 years [range 53-65 years]; p = 0.79), mean BMI value (TO, 30 [range 27-33]; TOE, 29 [range 27-35]; p = 0.97), or dominant arm involvement (TO, 80%; TOE, 78%; p = 0.81). The cohorts were followed for at least 2 years (median, 3.2 years [interquartile range (IQR) 2.2-4.3] for TO and 2.9 years [IQR 2.0-3.5 years] for TOE). ASES scores and ROM were evaluated before surgery and at follow-up visits and were recorded in a longitudinally maintained institutional database. Repair integrity was assessed using ultrasonography at 1 year, as is standard in our practice. For each tear-size group, we calculated the proportion of intact tendon repairs versus the proportion of re-tears. Duration of surgery was recorded for each patient. RESULTS: At 1 year, we observed no difference in median ASES scores (90 [IQR 92-98] for TO and 88 [IQR 72-98] for TOE; p = 0.44); external rotation (50° [IQR 45°-60°) for TO and 50° [IQR: 40°-60°] for TOE; p = 0.58); forward flexion (165° [IQR 160°-170°] for both groups; p = 0.91); or abduction (100° [IQR 90°-100°] for TO and 90° [IQR 90°-100°] for TOE; p = 0.06). Fourteen percent of shoulders (seven of 50) in each treatment group had evidence of re-tear at 1 year (p > 0.99): 0 of 2 small tears in each group, 0 of 7 medium tears in each group, five of 32 large tears in each group, and two of 9 massive tears in each group (all, p > 0.99). At 2 years, we found no differences in median ASES scores (92 [IQR 74-98)] for TO and 90 [IQR 80-100] for TOE; p = 0.84); external rotation (60° [IQR 50°-60°] for both groups; p = 0.74); forward flexion (170° [IQR 160°-170°] for both groups; p = 0.69); or abduction (100° [IQR 90°-100°] for both groups; p = 0.95). We found no differences between groups in mean ± SD procedure time, which was 103 ± 20 minutes for TO repair and 99 ± 20 minutes for TOE repair (p = 0.45). CONCLUSIONS: TO and TOE techniques for arthroscopic rotator cuff repair results in no differences in ROM, ASES scores, re-tear rates, and surgical time. Randomized control trials are needed to confirm these similarities or determine a superior method of repair. Future cost analyses may also help to determine the relative value of each technique. LEVEL OF EVIDENCE: Level III, therapeutic study.

Biomechanical comparison of pectoralis major repair techniques: A systematic review and meta-regression.

Background: There are many surgical techniques when repairing pectoralis major tears. However, there is no clear consensus on which repair technique is biomechanically superior. Our purpose was to perform a systematic review and meta-regression to evaluate the most biomechanically superior pectoralis major repair technique. Methods: We performed a systematic review and meta-regression of six human cadaveric biomechanical studies evaluating fixation techniques for pectoralis major repairs. The primary outcome was the ultimate failure load. Covariates included cadaveric age, bone mineral density, implants, suture, and stitch method. Meta-regression accounted for differences in variables. Results: Compared with Krackow/Bunnell stitch method, the modified Mason-Allen stitch demonstrated a decrease in ultimate failure load by 220.6 N (95% CI, -273.0 to -168.2; p = <0.001). No differences were found between Krackow/Bunnell and whipstitch. There was an increase in ultimate failure load when utilizing suture tape by 206.6 N (95% CI, 139.5-273.7, p < 0.001). Suture anchors had a decrease in ultimate failure load by 88.1 N (95% CI, -153.4 to -22.8, p = 0.008) when compared to transosseous sutures. No differences were found between transosseous sutures and unicortical buttons. Discussion: We found the combination of suture tape in a whipstitch or Krackow/Bunnell stitch utilizing transosseous sutures or unicortical buttons is the most biomechanically superior construct for pectoralis major repairs.

Outcomes of platelet rich plasma injections in the adhesive capsulitis of the shoulder.

Background: Platelet rich plasma (PRP) injections have been utilized in an attempt to provide improved pain and functional outcomes to patients with a variety of orthopaedic ailments. Adhesive capsulitis, also known as frozen shoulder is a common debilitating condition that carries significant morbidity due to the painful and prolonged course. Various studies have investigated intra-articular PRP administration with different methodologies and outcomes. Hypothesis/purpose: We sought to perform a meta-analysis on outcomes of adhesive capsulitis after PRP injection, determine effectiveness compared to corticosteroid, and compare adverse events. Study design: Meta analysis. Methods: EMBASE, EBSCO, Pubmed and Google Scholar were used to extract titles and abstracts using keywords "adhesive capsulitis", "frozen shoulder", "PRP", "platelet rich plasma". 41 articles were found and after duplicates removed and full-text review, 7 studies investigating 385 patients undergoing PRP or corticosteroid injections were found. Age, gender, body mass index (BMI), and ASA scores were obtained. Patient reported outcomes (PROs) were obtained and all reported range of motion (ROM) were recorded and compared after PRP and steroid injections using random effects meta-regression pre-injection and post-injection. Results: Both intra-articular PRP and steroid injections resulted in improved outcomes for treatment of adhesive capsulitis at 3 months. PRP injections had significantly better range of motion in passive forward flexion (151° vs 144.1°, p = 0.024) and had improved Shoulder Pain and Disability Index (SPADI) scores (14.6° vs 18.6°, p = 0.009) compared to steroid, however these may not reach minimum clinical thresholds. PRP had significantly better active (60° vs 43. 5°, p = 0.038) and passive internal rotation (69.6° vs 52.7°, p = 0.017) compared to steroid which did reach minimum clinical thresholds. There were no differences detected between VAS pain, active forward flexion, extension, abduction, external rotation nor difference in adverse events. Discussion: Both injections decreased pain and improved range of motion in patients. Intra-articular PRP injections may result in improved internal rotation compared to corticosteroid. Improvement in SPADI and passive forward flexion may be statistically significantly but may not be clinically relevant. Level of evidence: 3, Therapeutic.

Ten-Year Outcomes of Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion : A Systematic Review With Meta-Analysis.

STUDY DESIGN: A systematic review with meta-analysis of randomized controlled trials and comparative retrospective cohort studies. OBJECTIVE: The purpose of this study is to compare the 10-year outcomes of cervical disc arthroplasty (CDA) with those of anterior cervical discectomy and fusion (ACDF) for the treatment of cervical degenerative disc disease (CDDD). SUMMARY OF BACKGROUND DATA: ACDF is the gold standard for the treatment of CDDD. However, the loss of motion at the operative level may accelerate adjacent segment disease (ASD). The preservation of motion with CDA attempts to prevent this complication of cervical fusion. Short-term and mid-term data reveal comparable results for CDA versus ACDF; however, long-term results are unknown. MATERIALS AND METHODS: A systematic review with meta-analysis was performed to determine if CDA had improved outcomes compared with ACDF at 10-year follow-up. PubMed and Web of Science database searches through 2023 were performed to identify randomized controlled trials and comparative retrospective cohort studies involving treatment of one-level or two-level CDDD. RESULTS: Six studies were eligible for analysis. CDA had significantly improved neck disability index and visual analog scale scores but lower Japanese Orthopaedic Association scores compared to ACDF at 10-year follow-up ( P < 0.05). None of these results met minimal clinically important differences. CDA had significantly fewer secondary surgeries and adverse events compared to ACDF ( P <0.05). There were no significant differences in neurological success. CONCLUSIONS: The authors found that significantly fewer secondary surgeries and adverse events were seen after CDA than after ACDF at 10-year follow-up. CDA had statistically, but not clinically, improved neck disability index and visual analog scale scores but lower Japanese Orthopaedic Association scores in comparison to ACDF. CDA was not significantly different from ACDF in terms of a successful neurological outcome.

Does playing surface affect the risk of anterior cruciate ligament injuries in the National Football League? A look at the 2017 - 2021 NFL seasons.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are devastating injuries for athletes. Prior studies have shown increased ACL injury rates on non-natural surfaces versus natural grass in several sports. The purpose of this study is to calculate the prevalence of ACL injuries in the NFL on natural versus non-natural surfaces to determine if there is a significant increase on non-natural surfaces. METHODS: Accessing publicly available data for NFL seasons beginning with the 2017-2018 season through 2021-2022 seasons, all ACL injuries with publicly available data concerning timing and playing surface were recorded and categorized according to playing surface. Practice injuries or those without an identifiable playing surface were excluded. Incidence rates, defined as ACL ruptures per game, were calculated. ACL injuries were recorded for each playing surface, as well as the combined category of non-natural grass surface. Odds ratio was calculated to compare the risk of ACL rupture on non-natural surfaces vs natural grass. RESULTS: During the 2017-2021 NFL seasons, 173 ACL ruptures were identified with known surfaces. Injury rate for non-natural surfaces was 0.134 compared to 0.097 for grass. Injury rate ratio for non-natural vs natural grass surfaces was 1.211, a 21.1% increased risk of ACL injury in the NFL on non-natural surfaces vs natural grass. OR for non-natural surfaces 1.239 (95% CI 0.900-1.704). Based on these findings there is a trend toward increased risk of ACL injury on non natural grass surfaces, however this did not reach statistical significance. CONCLUSION: Numerous published studies show trends toward increasing rates of ACL injuries on non-natural playing surfaces vs natural grass. Based on our findings the difference is not statistically significant, however it does trend toward increased risk of ACL injury with non-natural surfaces. Further studies should be performed with larger sample sizes in order to further determine the risk of non-natural surfaces.

Effects of vancomycin and tobramycin on compressive and tensile strengths of antibiotic bone cement: A biomechanical study.

Purpose: This study aims to compare the compressive and tensile strengths of bone cement mixed with various concentrations of vancomycin, tobramycin, and combinations of the two. Methods: 12 mm × 6 mm antibiotic bone cement samples were created by vacuum mixing 0-4 g of vancomycin, tobramycin, and combinations of the two in 0.5 g increments per one pouch (40 g) of Palacos LV cement. An Instron 3369 Universal Testing System was used to determine the compressive and tensile strengths. Results: Compressive and tensile strengths of the bone cement without antibiotics were 118 ± 4 MPa and 30.3 ± 12 MPa, respectively. 4 g of vancomycin alone decreased the compressive strength to 108 ± 4 MPa (p-value 0.001) and decreased the tensile strength beginning at 2 g which yielded a strength of 28.1 ± 12 MPa (p-value 0.016). Tobramycin alone decreased the tensile strength beginning at 1.5 g yielding a strength of 27.7 ± 7 MPa (p-value 0.003). Although it decreased compressive strength at 1 g to 117 ± 7 MPa (p-value 0.002), it demonstrated variable effects with increasing concentrations. A combination of vancomycin and tobramycin decreased both the compressive (111 ± 5 MPa, p-value 0.014) and tensile (27.9 ± 8 MPa, p-value 0.007) strengths beginning at 1 g each. Conclusions: Various combinations of vancomycin and tobramycin affect the compressive and tensile strengths of bone cement. Clinicians should be diligent when mixing these antibiotics in bone cement to prevent possible failure of the constructs.

Massive rotator cuff tears: algorithmic approach to surgical treatment.

The management of massive rotator cuff tears (MRCT) presents a unique challenge to many orthopedic specialists. Unlike tears that are predicted to do well with primary, complete repair, MRCT are affected by tissue retraction, in-elasticity, bursal scarring, muscle atrophy, and fatty degeneration; operative repair thus portends worse healing rates than smaller tears and is associated with recurrent tear rates of up to 91% based on ultrasonography and magnetic resonance imaging (MRI). Rotator cuff tears are a common condition in patients over the age of 50. Thus, multiple advances in treatment strategies have been made to combat the limited efficacy of complete or partial rotator cuff repair in the setting of a massive or irreparable rotator cuff tears. It is of utmost importance that the operating orthopedic surgeon be familiar with these various treatment modalities to best serve the patient and that they harbor these skills within their armamentarium. This article details a review of the current literature including nonoperative and operative treatments for the management of massive and irreparable rotator cuff tears. The primary objective is to propose a literature-based algorithm for the treatment of massive and often irreparable rotator cuff tears to allow for informed ease in the decision-making process.

Factors affecting biomechanical strength of Latarjet constructs: A systematic review and meta-regression.

BACKGROUND: The Latarjet procedure reduces recurrent glenohumeral instability but has potential hardware and graft complications. The procedure has been modified to use various screw types as well as suture buttons. Biomechanical studies have evaluated the effect of these implants on construct strength. With varying results it is unclear whether there is an optimal implant to use. METHODS: We conducted a systematic review of human cadaveric biomechanical studies evaluating Latarjet ultimate failure load. Two independent reviewers screened articles and included them after full text review. Additional factors including implants used, graft orientation, cortices engaged, drill diameter, and screw characteristics were recorded. Meta-regression was performed on the 145 specimens from eight studies that met inclusion criteria. RESULTS: Screw fixation resulted in a 396.8 N (95% CI, 149.8-643.7) N higher ultimate failure load against shear stresses than suture buttons (p = 0.002). There were no differences between implants for ultimate failure load against tensile forces. Tensile strength was significantly affected by drill diameter with each millimeter of increase reducing the mean ultimate failure load by 127.4 N (95% CI, 41.2-213.6) N (p = 0.004). CONCLUSIONS: These results suggest that using screw fixation and minimizing drill diameter can obtain the maximum ultimate failure load against both shear and tensile forces in a Latarjet construct.

Biomechanical Effects of Combined Anterior Cruciate Ligament Reconstruction and Anterolateral Ligament Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: Combined anterior cruciate ligament (ACL) reconstruction (ACLR) and anterolateral ligament reconstruction (ALLR) are performed with the intention to restore native knee kinematics after ACL tears. There continue to be varying results as to the difference in kinematics between combined and isolated procedures, including anterior tibial translation (ATT) and internal tibial rotation (IR). PURPOSE: To perform a systematic review and meta-analysis to evaluate the kinematic changes of a combined ACLR/ALLR versus isolated ACLR and to assess the effects of different fixation techniques. STUDY DESIGN: Systematic review. METHODS: We conducted a systematic review and meta-analysis of 15 human cadaveric biomechanical studies evaluating combined ACLR/ALLR versus isolated ACLR and their effects on ATT and IR in 149 specimens. The primary outcomes were ATT and IR. Secondary outcomes included graft type and size as well as fixation methods such as type, angle, tension, and position of fixation. Meta-regression was used to examine the effect of various cofactors on the resulting measures. RESULTS: Compared with isolated ACLR, combined ACLR/ALLR decreased ATT and IR by 0.01 mm (95% CI, -0.059 to 0.079 mm; P = .777) and 1.64° (95% CI, 1.30°-1.98°; P < .001), respectively. Regarding ACLR/ALLR, increasing the knee flexion angle and applied IR force led to a significant reduction in IR (P < .001 and P = .044, respectively). There was also a significant reduction in IR in combined procedures with semitendinosus ALL graft, higher flexion fixation angles, and tension but no change in IR with differing femoral fixation points (P < .001, P < .001, and P = .268, respectively). Multivariate meta-regression showed that the use of tibial-sided suture anchor fixation significantly reduced IR (P < .001). CONCLUSION: These results suggest that a combined ACLR/ALLR procedure significantly decreases IR compared with isolated ACLR, especially at higher knee flexion angles. Semitendinosus ALL graft, fixation at higher knee flexion, increased tensioning, and tibial-sided interference screw fixation in ALLR may help to further reduce IR.

Implications of positive urine toxicology screening in trauma patients.

BACKGROUND: Pain management in trauma patients can be difficult due to their varied injuries and presence or absence of illicit substances in their systems. Additionally, trauma patients have variable lengths of stay. Limiting length of stay to what is medically necessary and preventing long-term dependence on narcotic medications are important in trauma patient care. METHODS: We performed a retrospective review of 385 consecutive trauma activations at a Level II trauma center with urine toxicology screens from 2015. Main outcome measures recorded were urine toxicology results, average daily morphine milligram equivalents (MME), length of stay (LOS), injury severity score (ISS). We also recorded patient demographic information. Statistical analysis compared outcomes and demographics between trauma patients with positive urine toxicology screens to those with negative screens. Significance was set at p < 0.05. RESULTS: Positive urine toxicology screens were present in 230/385 (59.7%) patients. The median (interquartile range (IQR)) daily MME usage in the positive urine toxicology group was 25.2 (12.0-48.6) versus 12.4 (2.5-27.5) for those with a negative drug screen (p < 0.001). Median LOS was 3 (1-6) days versus 2 (1-4) days for the positive and negative groups, respectively (p = 0.004). There were no differences in age, gender distribution, or ISS between the two groups. Subgroup analysis showed urine toxicology positive for opiates, benzodiazepines, and tetrahydrocannabinol (THC) were associated with increased daily MME. Benzodiazepines and amphetamines were associated with increased LOS. CONCLUSION: This study identifies a positive toxicology screening as a risk factor for increased narcotic demands and longer length of stay in trauma patients. These findings may assist in developing treatment plans and setting expectations in this population. This information can also lead to proactive interventions aimed at minimizing narcotic use and shortening LOS in this population.

Predictors of Long-term Opioid Use After Elective Primary Total Shoulder Arthroplasty.

Opioids are prescribed routinely for pain after total shoulder arthroplasty (TSA). This study was designed to characterize opioid use after elective primary TSA and identify predictors of long-term postoperative opioid use. The authors used the MarketScan administrative claims database to identify 5676 adults who underwent elective primary TSA between 2010 and 2015 and had 1 year or more of continuous insurance enrollment, including prescription drug coverage, postoperatively. Long-term postoperative opioid use was defined as filling prescriptions totaling a 120-day or greater supply during the 3- to 12-month postoperative period. The authors performed univariate regression analysis with age, sex, US region, anatomic or reverse TSA, anxiety, chronic obstructive pulmonary disease, congestive heart failure, depression, diabetes, history of drug abuse, hypertension, obesity, osteoporosis, history of myocardial infarction, and current tobacco use. Variables that were significant at P<.05 were included in multivariate logistic regression. Overall, 16% of patients had long-term postoperative opioid use, which was strongly predicted by the multivariate model (area under the curve, 0.77; P<.001). The strongest predictors in the multivariate analysis were preoperative opioid use (odds ratio [OR], 4.7; 95% CI, 4.0-5.5), history of drug abuse (OR, 2.5; 95% CI, 1.3-4.9), depression (OR, 1.9; 95% CI, 1.6-2.3), anxiety (OR, 1.4; 95% CI, 1.2-1.7), surgery performed in the Western United States (OR, 1.8; 95% CI, 1.3-2.4), and reverse TSA (OR, 1.5; 95% CI, 1.2-1.8). Most patients do not have long-term opioid use after elective primary TSA. Strong predictors of long-term postoperative opioid use are preoperative opioid use, history of drug abuse, depression, anxiety, reverse TSA, and surgery performed in the Western United States. [Orthopedics. 2021;44(1):58-63.].

Detection of Surgical Wrap Defects in the Operating Room Setting.

Surgical site infection is a challenging complication that places a significant burden on the patient and the health care system. Emphasis is being placed on the prevention and treatment of surgical site infections. We evaluated the accuracy of identifying surgical wrap defects based on defect size, location, and operating room staff experience. Forty sterilization wraps were divided into 4 separate groups based on the size of the puncture defects created. Defects measuring 1.2 mm, 3.7 mm, and 6.8 mm were compared with a control group of surgical wraps with no defects. Defects were randomly placed on an inner or outer line with circumference of 7 cm or 14 cm, respectively. Twenty operating room staff of varying levels of experience evaluated each wrap for defects. The detection rates for the 1.2-mm, 3.7-mm, and 6.8-mm wraps and the wraps with no defects were 3%, 73%, 80%, and 99%, respectively. A significant difference was seen between the detection rates for the small defects vs all other size defects. No significant difference was seen in detection rate based on the location of defects. The detection rate was higher among staff members with greater than 1 year of experience vs those with less than 1 year of experience. Sterilization wrap defects of all sizes went undetected at very high rates. Small defects of 1.2 mm, which have been shown to allow bacterial contamination, were missed 97% of the time. Operating room staff with more experience detected more defects than those with less than 1 year of experience. Wrap defects may be a source of bacterial contamination that may frequently go unnoticed. [Orthopedics. 2021;44(6):735-e738.].

Optimizing Fixation for Distal Biceps Tendon Repairs: A Systematic Review and Meta-regression of Cadaveric Biomechanical Testing.

BACKGROUND: Various surgical techniques can be used to repair acute distal biceps tendon (DBT) tears; however, it is unknown which type of repair or implant has the greatest biomechanical strength and presents the lowest risk of type 2 failure. PURPOSE: To identify associations between the type of implant or construct used and the biomechanical performance of DBT repairs in a review of human cadaveric studies. STUDY DESIGN: Systematic review and meta-regression. METHODS: We systematically searched the EMBASE and Medline (PubMed) databases for biomechanical studies that evaluated DBT repair performance in cadaveric specimens. Two independent reviewers extracted data from 14 studies that met our inclusion criteria. The pooled data set was subjected to meta-regression with adjusted failure load (AFL) as the primary outcome variable. Procedural parameters, such as number of sutures, cortices, locking stitches, and whipstitches, served as covariates. Adjusted analysis was performed to determine the differences among implant types. The alpha level was set at .05. RESULTS: When using no implant (bone tunnels) as the referent, no fixation type or procedural parameter was significantly better at predicting AFL. Cortical button fixation had the highest AFL (370 N; 95% CI, -2 to 221). In an implant-to-implant comparison, suture anchor alone was significantly weaker than cortical button (154 N; 95% CI, 30 to 279). Constructs using a cortical button and interference screw were not stronger (as measured by AFL) than those using a cortical button alone. The presence of a locking stitch added 113 N (95% CI, 29 to 196) to the AFL. The use of cortical button instead of interference screws or bone tunnels was associated with lower odds of type 2 failure. Avoiding locking stitches and using more sutures in the construct were also associated with lower odds of type 2 failure. CONCLUSION: Cortical button fixation is associated with greater construct strength than is suture anchor repair and a lower risk of type 2 failure compared with interference screw fixation or fixation without implants. The addition of an interference screw to cortical button fixation was not associated with increased strength. The presence of a locking stitch added 113 N to the failure load but also increased the odds of type 2 failure.

Are Implant Choice and Surgical Approach Associated With Biceps Tenodesis Construct Strength? A Systematic Review and Meta-regression.

BACKGROUND: Despite the increasing use of biceps tenodesis, there is a lack of consensus regarding optimal implant choice (suture anchor vs interference screw) and implant placement (suprapectoral vs subpectoral). PURPOSE/HYPOTHESIS: The purpose was to determine the associations of procedural parameters with the biomechanical performance of biceps tenodesis constructs. The authors hypothesized that ultimate failure load (UFL) would not differ between sub- and suprapectoral repairs or between interference screw and suture anchor constructs and that the number of implants and number of sutures would be positively associated with construct strength. STUDY DESIGN: Meta-analysis. METHODS: The authors conducted a systematic literature search for studies that measured the biomechanical performance of biceps tenodesis repairs in human cadaveric specimens. Two independent reviewers extracted data from studies that met the inclusion criteria. Meta-regression was then performed on the pooled data set. Outcome variables were UFL and mode of failure. Procedural parameters (fixation type, fixation site, implant diameter, and numbers of implants and sutures used) were included as covariates. Twenty-five biomechanical studies, representing 494 cadaveric specimens, met the inclusion criteria. RESULTS: The use of interference screws (vs suture anchors) was associated with a mean 86 N-greater UFL (95% CI, 34-138 N; P = .002). Each additional suture used to attach the tendon to the implant was associated with a mean 53 N-greater UFL (95% CI, 24-81 N; P = .001). Multivariate analysis found no significant association between fixation site and UFL. Finally, the use of suture anchors and fewer number of sutures were both independently associated with lower odds of native tissue failure as opposed to implant pullout. CONCLUSION: These findings suggest that fixation with interference screws, rather than suture anchors, and the use of more sutures are associated with greater biceps tenodesis strength, as well as higher odds of native tissue failure versus implant pullout. Although constructs with suture anchors show inferior UFL compared with those with interference screws, incorporation of additional sutures may increase the strength of suture anchor constructs. Supra- and subpectoral repairs provide equivalent biomechanical strength when controlling for potential confounders.

Smoking is an independent risk factor for complications following open rotator cuff repair.

Objectives: Smoking has been associated with poor cuff healing and worse long-term outcomes in patients undergoing rotator cuff repair. The effects of smoking on short-term complications following open rotator cuff repair are not well defined. The purpose of this study is to analyze the effects of smoking on 30-day outcomes following open rotator cuff repair. Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open rotator cuff repair from 2011 to 2016. Patients who were current smokers (within 1 year prior to surgery) were identified and compared with nonsmokers. Demographic data and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of smoking on complications after surgery. Results: We identified 5,157 patients who underwent open rotator cuff repair, of which 18% (946 patients) were current smokers (within 1 year of surgery). Smokers were younger (54.4 years versus 61.5 years, P < 0.001) and were more likely to be male (60.8% versus 56.9%, P = 0.03). Compared with nonsmokers, smokers had a similar rate of comorbidities (P = 0.35) and similar preoperative functional status (P = 0.53), but had higher mean American Society of Anesthesiologists (ASA) class (P < 0.001). Logistic regression revealed that smoking was an independent predictor for any complication (OR 1.9, P = 0.03), any venous thromboembolic event (OR 4.6, P = 0.01), and pulmonary embolism (OR 6.4, P = 0.02). Conclusion: Patients who smoke are at increased risk for short-term complications after open rotator cuff repair. Smoking is independently associated with increased rate of postoperative venous thromboembolic events such as pulmonary embolism. This further highlights the importance of preoperative smoking cessation in patients undergoing open rotator cuff repair.

Radial axial interosseous load (RAIL) test for essex lopresti type injuries.

BACKGROUND: When approaching radial head and neck fractures, the decision for ORIF, resection, or arthroplasty is often performed intraoperatively. Factors that contribute include ligamentous and bony stability, cartilage injury, mechanical alignment as well as patient factors. Recent data has suggested conventional methods may not be sufficiently sensitive in detecting Essex Lopresti injuries. Here we describe an intraoperative technique that could objectively assess proximal radio-ulnar stability with subsequent disruption of the ligamentous structures. METHODS: Eight cadaveric specimens were used to evaluate amount of radial proximal migration between three groups of forearms. After radial head resection, proximal migration of the radial shaft was measured in three distinct groups. Group A included intact forearms, Group B included forearms with resected interosseous membranes (IOM), and Group C included forearms with resected interosseous membranes and distal radioulnar joint (DRUJ) disruptions. RESULTS: As compared to group A, group B averaged 4 mm of proximal radial migration (p < 0.01), while Group C demonstrated >6 mm of migration (p < 0.01). CONCLUSION: In the setting of a non-repairable radial head, the RAIL test may provide a more objective means of assessing for Essex-Lopresti injuries.

Radiographic Outcomes of Dorsal Distraction Distal Radius Plating for Fractures With Dorsal Marginal Impaction.

Background: The purpose of this study is to compare radiographic outcomes of patients treated with dorsal spanning plates with previously reported normal values of radiographic distal radius anatomy and compare the results with prior publications for both external fixation and internal fixation with volar locked plates. Methods: Patients with complex distal radius fractures including dorsal marginal impaction pattern necessitating dorsal distraction plating at the discretion of the senior authors (M.A.T. and M.A.I.) from May 30, 2013, to December 29, 2015, were identified and included in the study. Retrospective chart and radiograph review was performed on 19 patients, 11 male and 8 female, with mean age of 47.83 years (22-82). No patients were excluded from the study. Results: All fractures united prior to plate removal. The average time the plate was in place was 80.5 days (49-129). Follow-up radiographs showed average radial inclination of 20.5° (13.2°-25.5°), radial height of 10.7 mm (7.5-14 mm), ulnar variance of -0.3 mm (-2.1 to 3.1 mm), and volar tilt of 7.9° (-3° to 15°). One patient had intra-articular step-off greater than 2 mm. Conclusions: Dorsal distraction plating of complex distal radius fractures yields good radiographic results with minimal complications. In cases of complex distal radius fractures including dorsal marginal impaction where volar plating is not considered adequate, a dorsal distraction plate should be considered as an alternative to external fixation due to reduced risk for infection and better control of volar tilt.