Comparison of total elbow arthroplasty complications between various surgical indications at 90-day and 1-year follow-up in 1600 elbows.

BACKGROUND: Total elbow arthroplasty (TEA) was traditionally a mainstay of treatment for patients with severe inflammatory arthritis. Recently, the indications for TEA have expanded, and TEA has grown into a versatile procedure that can be used to treat several pathologies of the elbow. The objective of this study was to compare complication rates between TEAs performed for rheumatoid arthritis (RA), fracture (FX), or osteoarthritis (degenerative joint disease [DJD]). METHODS: A retrospective analysis of the MUExtr data set of the PearlDiver national database was performed. International Classification of Diseases, Tenth Revision codes were used to identify patients who underwent TEA from 2010-2020 and to separate them into RA, FX, and DJD cohorts. Demographic characteristics, comorbidities, and hospital data were identified and compared using analysis of variance. Systemic complications at 90 days and surgical complications at both 90 days and 1 year were compared using multivariable logistic regression. Surgical complications included wound dehiscence, hematoma, deep infection, periprosthetic FX, stiffness, instability, triceps injury, nerve injury, and need for revision. RESULTS: We identified 1600 patients (DJD, 38.9%; FX, 48.8%; and RA, 12.3%). The majority of patients in all 3 cohorts were female patients, with the RA group having a significantly higher percentage of female patients than the FX and DJD groups (87.3% vs. 81.4% and 76.9%, respectively; P = .003). No significant differences in systemic complications and surgical complications were noted between all 3 groups at 90 days postoperatively. After controlling for patient factors, FX patients were more likely to have elbow stiffness (odds ratio, 1.53; P = .006) and less likely to have a triceps injury (odds ratio, 0.26; P < .001) at 1 year than were RA or DJD patients. CONCLUSION: The indications for TEA have expanded over the past 10 years, with nearly half of all cases being performed for FX. At 1 year postoperatively, TEAs performed for FX have a significantly lower rate of triceps injury and higher rate of elbow stiffness than TEAs performed for other indications. This finding is important to consider when preoperatively planning, as well as when discussing expected outcomes with patients prior to surgery, especially with the expanded incidence of TEA for FX being performed over the past decade.

Renal Transplant Patients Have a Lower Risk of Complications and Mortalities After Total Knee Arthroplasty Compared to Those on Hemodialysis: A Large National Database Study.

BACKGROUND: Total knee arthroplasty (TKA) in end-stage renal disease is associated with complications. Controversy exists whether elective TKA should be performed while patients are on hemodialysis (HD) or following renal transplant (RT). This study compares TKA outcomes in HD versus RT patients. METHODS: A national database was retrospectively reviewed using International Classification of Diseases codes to identify HD and RT patients who underwent primary TKA from 2010 to 2018. Demographics, comorbidities, and hospital factors were compared using Wald and Chi-squared tests. The primary outcome was in-hospital mortalities while secondary outcomes included quality outcomes and medical/surgical complications. Multivariate regressions were used to determine independent associations. Significance was determined with a 2-tailed P value of .05. There were 13,611 patients who underwent TKA (61.1 HD and 38.9% RT). Patients who had RT were younger, had fewer comorbidities, and more likely to have private insurance. RESULTS: The RT patients had a lower rate of mortality (odds ratio (OR) 0.23, P < .01)), complications (OR 0.63, P < .01), cardiopulmonary complications (OR 0.44, P = .02), sepsis (OR 0.22, P < .001), and blood transfusion (OR 0.35, P < .001) during the index hospitalization. This cohort was also found to have decreased length of stay (-2.0 days, P < .001), non-home discharge (OR 0.57, P < .001), and hospital cost (-$5,300, P < .001). Patients who had RT had a lower rate of readmission (OR 0.54, P < .001), periprosthetic joint infection (OR 0.50, P < .01), and surgical site infection (OR 0.37, P < .001) within 90 days. CONCLUSION: These findings suggest that HD patients are a high-risk population in TKA compared to RT patients and warrant stringent perioperative monitoring.

End-stage renal disease patients have comparable results to renal transplant patients after shoulder arthroplasty.

Background: End-stage renal disease (ESRD) and renal transplant (RT) patients are known to have more perioperative and postoperative complications after arthroplasty surgeries when compared to patients without. We hypothesize that RT patients undergoing shoulder arthroplasty (SA) have fewer systemic and surgical complications when compared to ESRD patients undergoing SA. Methods: This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone primary total and reverse shoulder arthroplasty, respectively, and subsequent surgical revisions. Unadjusted univariate analysis of patient demographics, Charlson Cormorbidty Index, and surgical complications at 90 days, 1 year, and 2 years after was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for systemic complications and prosthesis outcomes at all time points. Results: Of 1191 patients with ESRD or previous RT and who underwent either total shoulder arthroplasty or reverse total shoulder arthroplasty, 1042 (87.5%) had ESRD and 149 (12.5%) had a previous RT. ESRD SA patients were more likely to have hypertension, liver disease, coronary artery disease, and hypothyroidism. Interestingly no statistical significance was found in multivariate analysis for systemic complications at 90 days, nor for surgical complications at the 90-day, 1-year, or 2-year mark between ESRD and RT cohorts. Conclusion: SAs have comparable outcomes in ESRD and RT patients. The differing conclusions among studies might be partially accounted for by the demographic differences and comorbidities between these 2 patient populations. Providers should continue to provide appropriate counseling concerning risks, benefits, and timing of SA for these patients.

Comparison of total hip arthroplasty outcomes between haemodyalisis and renal transplant patients.

INTRODUCTION: Total hip arthroplasty (THA) in end-stage renal disease (ESRD) patients is associated with increased complications. Controversy exists whether elective THA should be performed while these patients are on haemodialysis (HD) or following renal transplant (RT). This study seeks to compare THA outcomes in HD versus RT patients. METHODS: A national database was retrospectively reviewed using ICD codes to identify all HD and RT patients who underwent primary THA from 2010 to 2018. Demographics, comorbidities, and hospital factors were compared between cohorts using Wald and chi-square tests. The primary outcome was in-hospital mortality, while secondary outcomes included length of stay (LOS), non-home discharge, cost, readmission, and medical/surgical complications. Multivariate regression was used to determine independent associations. Significance was determined with a 2-tailed p-value of 0.05. RESULTS: 11,133 patients underwent THA, 61.6% HD and 39.4% RT patients. RT patients were younger, had fewer comorbidities, and more likely to have private insurance. After adjusting for these differences, RT patients had a lower rate of mortality (OR 0.31, p = 0.01), complications (OR 0.54, p < 0.01), cardiopulmonary complications (OR 0.54, p = 0.04), sepsis (OR 0.43, p < 0.01), and blood transfusion (OR 0.39, p < 0.001) during the index hospitalisation. RT was associated with decreased LOS (-2.0 days, p < 0.001), non-home discharge (OR 0.35, p < 0.001), and hospital cost (-$6,000, p < 0.001). RT had a lower rate of readmission (OR 0.60, p < 0.001) and revision surgery (OR 0.24, p = 0.01) within 90 days. CONCLUSIONS: These findings suggest HD patients are a high-risk population in THA compared to RT patients and warrant stringent perioperative monitoring.

Cementless Compared to Cemented Total Knee Arthroplasty is Associated With More Revisions Within 1 Year of Index Surgery.

Background: Cementless total knee arthroplasties (TKAs) have gained renewed interest due to improved implant designs and lower rates of revision than its cemented counterparts. The purpose of this study was to compare revision rates between cemented vs cementless TKAs within 1 year of primary arthroplasty. Methods: This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone cemented and cementless TKAs and subsequent surgical revisions. An unadjusted univariate analysis of patient demographics, Charlson Comorbidity Index score, and surgical revisions at 90 days and 1 year after TKA was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for 1-year surgical complications requiring revision. Results: Of 324,508 patients, 312,988 (96.45%) underwent cemented TKAs, and 11,520 (3.55%) underwent cementless TKAs. Patients undergoing cementless TKA tended to be younger than patients undergoing cemented TKA (63.67 ± 9.15 cementless vs 66.22 ± 8.85 cemented, P < .001). Univariate chi-squared testing showed that cementless patients were more likely to require 1-component femoral or tibial revision at 90 days and 1 year, irrigation and debridement at 90 days and 1 year, and arthroscopy with lysis of adhesions at 1 year only. Similar findings were observed for these 3 revision procedures at 1 year after correcting for age, gender, and Charlson Comorbidity Index score using multivariate logistic regression analysis as cementless TKA patients had higher odds ratios for each of the revisions. Conclusions: Small but significant differences were found in surgical revisions among cementless TKAs when compared to cemented TKAs within 1 year of the index procedure.

Platelet-rich plasma use for hip and knee osteoarthritis in the United States.

BACKGROUND: Hip and knee osteoarthritis (OA) are rising in prevalence and increasingly affecting younger patients. There is a rising demand for therapeutics to address its growing disease burden. Platelet-rich plasma (PRP) therapy has been used to treat various musculoskeletal conditions, but its role in OA treatment is not well understood. Even still, there is significant interest in this biologic for treatment of OA. The purpose of this study was to determine the PRP utilization trends in the United States for hip and knee OA. METHODS: This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had received PRP injections for hip and knee OA from 2010 to 2018. Injection incidence was evaluated on an annual basis and by patient demographics, geographic distribution, and medical specialty under which the treatment was administered. RESULTS: A total of 3,884 PRP injections were administered over the study period, 15% for hip OA and 85% for knee OA. PRP injections per 100,000 patient cases increased by an average year-over-year percentage of 53% and 12% for hip and knee OA, respectively. The highest injection incidences were observed in patients younger than 44 years of age. 58% of both hip and knee PRP injections were administered in general orthopaedic practices. CONCLUSION: These findings show that PRP is increasingly being used as a treatment modality for hip and knee OA. There is a need for further research on its long term outcomes.

Regular-Season Injury Rates in the National Football League After an Attenuated Preseason Due to COVID-19.

Background: The preseason is a crucial time period for professional athletes to prepare for the upcoming season. However, due to the coronavirus 2019 (COVID-19) pandemic, the 2020 National Football League (NFL) preseason was canceled. As the regular season progressed, an increased number of injuries became apparent. Purpose/Hypothesis: The purpose of this study was to compare injury rates between the 2019 and 2020 NFL regular seasons after the canceled 2020 preseason. It was hypothesized that injury rates in the 2020 season would be the same or higher compared with 2019. Study Design: Descriptive epidemiology study. Methods: A public database of all 32 NFL teams was used to examine the movement of all players to injured reserve status as well as every player who missed a regular-season game due to injury for both the 2019 and the 2020 NFL regular seasons. Data collection consisted of tallying the total number of reported musculoskeletal injuries for each team. Comparisons of injury rates between the 2 seasons were made using a Wilcoxon signed-rank statistical analysis. Results: The total number of musculoskeletal injuries was 632 for the 2019 regular season and 765 for the 2020 regular season (P = .0324). Compared with 2019, statistically significant increases in injury rates in 2020 were seen for calf or Achilles tendon strain (17 vs 39; P = .009), groin injury (25 vs 46; P = .018), and anterior cruciate ligament tear (14 vs 29; P = .016). There were several other increased trends in soft tissue injury rates in the 2020 season (eg, hamstring injury [87 vs 114; P = .085]); however, these did not reach statistical significance. Conclusion: This study showed a significant increase in total injuries during the 2020 COVID-19-affected NFL regular season compared with 2019. Several major soft tissue injuries reached statistical significance in their increase from 2019 to 2020 after the cancellation of the 2020 preseason due to COVID-19. These findings suggest that organized team preseason training and conditioning could have an effect on the prevention of sport-related injury at the highest level.

Comparison of Total Knee Arthroplasty Outcomes Between Renal Transplant and End Stage Renal Disease Patients.

INTRODUCTION: Patients with end-stage renal disease (ESRD) have increased risk for periprosthetic joint infection (PJI) due to their predisposition for bacteremia and subsequent implant inoculation secondary to dialysis. PJI risk is also elevated in transplant patients secondary to chronic immunosuppressive therapy. The purpose of this study was to compare medical and surgical complications after primary total knee arthroplasty (TKA) in patients with ESRD or renal transplant (RT). METHODS: This was a retrospective review from the PearlDiver database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients with ESRD or RT who underwent primary TKA for osteoarthritis from 2015 to 2019. Univariate and multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. RESULTS: Within 90 days of TKA, patients with RT were less likely to develop pneumonia (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.23 to 0.84, P = 0.018) and wound dehiscence (OR 0.46, 95% CI 0.21 to 0.90, P = 0.015). Patients with RT had a lower risk for PJI at 1 year (OR 0.61, 95% CI 0.36 to 0.99, P = 0.017) and at 2 years (OR 0.56, 95% CI 0.34 to 0.88, P = 0.017) after primary TKA. DISCUSSION: Consideration should be given to delaying TKA in patients with ESRD who are RT candidates.

Cemented Versus Noncemented Total Knee Arthroplasty Outcomes.

INTRODUCTION: Aseptic loosening remains one of the most common indications for revision total knee arthroplasty (TKA). Given the demographic shift to a younger and more active TKA patient population, some surgeons have revisited noncemented fixation given its potential for lower rates of long-term aseptic loosening. The purpose of this study was to compare the demographics and complications between patients undergoing noncemented and cemented TKA. METHODS: Using the MKnee subset of the PearlDiver database, diagnosis and procedure codes were used to identify patients who had undergone cemented or noncemented TKA for osteoarthritis with a minimum 2-year follow-up. Propensity score matching was done to compare risk-adjusted medical and surgical complication profiles at 90 days, 1 year, and 2 years. RESULTS: Of 203,574 patients identified, 3.2% underwent noncemented TKA and 96.8% underwent cemented TKA. Using propensity-matched analysis, there was no difference in 90-day medical complications. Noncemented TKA was associated with a greater risk of periprosthetic joint infection throughout the study (90-day odds ratio [OR] 1.34, 1-year OR 1.27, 2-year OR 1.27, P < 0.05). Noncemented TKA was associated with a greater risk of periprosthetic fracture at 1 year and 2 years (1 year OR 2.19, 2 years OR 1.89, P < 0.05). No notable difference was observed in risk of aseptic loosening between the two groups. DISCUSSION: Noncemented TKA is associated with a higher rate of periprosthetic joint infection and periprosthetic fracture. Additional studies are needed to compare long-term rates of aseptic loosening between noncemented and cemented TKA. LEVEL OF EVIDENCE: Level III.

Revision total knee arthroplasty outcomes in solid organ transplant Patients, a matched cohort study of aseptic and infected revisions.

BACKGROUND: Previous studies have demonstrated that solid organ transplant (SOT) patients undergoing primary total knee arthroplasty (TKA) are at an increased risk of postoperative complications. The purpose of this study is to utilize a large, national database to investigate revision TKA (rTKA) outcomes in SOT patients. METHODS: This was a retrospective review utilizing the Nationwide Readmissions Database (NRD) and ICD-9 codes to identify patients who underwent rTKA from 2010-2014 with a history of at least one SOT. Propensity-score-matching (PSM) was used to compare rTKA outcomes in SOT patients compared to matched patients without SOT. RESULTS: A total of 303,867 rTKAs, with 464 of those being performed in SOT patients, were included in the study. Of these, 71,903 and 182 were performed for PJI in non-SOT and SOT patients, respectively. rTKA was performed most frequently in kidney transplant patients (53.0%) followed by liver transplant patients (34.3%). For non-PJI patients, SOT patients had a higher 90-day readmission rate than matched non-SOT rTKA patients (23.2% vs 12.6%, p = 0.006). However, there were no differences in 90-day readmission rates for specific rTKA complications, subsequent revision rTKA, or mortality. Among patients undergoing rTKA for PJI, there was no difference in overall 90-day readmission rate, readmission for specific rTKA complications, subsequent revision rTKA, or mortality. CONCLUSIONS: While the increased medical comorbidities associated with SOT place patients at increased risk for complications following rTKA, it appears that SOT alone does not do so when patients are matched based on overall medical comorbidity.

Revision Total Hip Arthroplasty in Solid Organ Transplant Patients: A Propensity Score-Matched Cohort Study for Aseptic and Infected Revisions.

BACKGROUND: Previous studies have demonstrated that solid organ transplant (SOT) patients undergoing primary total hip arthroplasty (THA) are at an increased risk of postoperative complications. The purpose of this study is to use a large, national database to investigate revision THA (rTHA) outcomes in SOT patients. METHODS: Nationwide Readmissions Database (NRD) from 2010-2018 was used, and ICD-9 and ICD-10 codes were used to identify all patients who underwent rTHA, including those with history of SOT. Propensity score matching (PSM) was used to analyze rTHA outcomes in SOT patients comparted to matched controls. Separate analysis performed for patients undergoing rTHA for prosthetic joint infection (PJI) vs other causes. RESULTS: A total of 414,756 rTHA, with 1837 of those being performed in SOT patients, were identified. Of these, 65,961 and 276 were performed for PJI in non-SOT and SOT patients, respectively. For non-PJI patients, SOT patients had higher 90-day all-cause readmission rates (24.0% vs 19.4%, P = .03) but lower rate for readmission related to rTHA (6.0% vs 9.2%, P = .03), but no difference readmission for specific rTHA complications, mortality (0.6% vs 1.3%, P = .20), or revision rTHA. Of PJI patients, SOT patients had no difference in overall 90-day readmission (38.6 vs 31.3%, P = .280), readmission for specific rTHA complications, re-revision, or mortality (4.7% vs 6.0%, P = .63). CONCLUSIONS: SOT patients undergoing rTHA for aseptic reasons are higher risk of overall readmission but lower risk of readmission related to rTHA than appropriately matched controls. SOT PJI patients undergoing had similar rates of readmission, mortality, and revision surgery compared to matched non-SOT PJI patients.

Reduced Costs, Complications, and Length of Stay After Arthroscopic Versus Open Irrigation and Débridement for Knee Septic Arthritis.

BACKGROUND: In the treatment of native knee bacterial septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival, complications, and resource utilization between these approaches. METHODS: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D), if any, were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: A total of 14,365 patients with native knee septic arthritis undergoing I&D were identified, 8,063 arthroscopic (56.1%) and 6,302 open (43.9%). The mean follow-up was 148 days (interquartile range 53 to 259). A total of 2,156 patients (15.0%) underwent revision I&D. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $5,674 and length of stay of 1.46 days (P < 0.001 for both). Arthroscopic I&D was associated with lower overall complications (odds ratio [OR] 0.63, P < 0.001), need for blood transfusion (OR 0.58, P < 0.001), and wound complications (OR 0.32, P < 0.001). Revision-free survival after index I&D was 95.3% at 3 days, 91.0% at 10 days, 88.3% at 30 days, 86.0% at 90 days, and 84.5% at 180 days. No statistically significant difference was observed between surgical approaches on Cox modeling. DISCUSSION: Risk of revision I&D did not differ between arthroscopic and open I&D; however, arthroscopy was associated with decreased costs, length of stay, and complications. Additional study is necessary to confirm these findings and characterize which patients require an open I&D. LEVEL OF EVIDENCE: III.

Renal disease is a risk factor for complications and mortality after open reduction internal fixation of proximal humerus fractures.

Background: Renal osteodystrophy predisposes renal disease patients to fracture. Proximal humerus fractures (PHFs) frequently undergo open reduction internal fixation (ORIF); however, the effect of renal disease on outcomes is unknown. Methods: A retrospective review of the Nationwide Readmissions Database used International Classification of Diseases, 9th Revision, codes to identify patients who underwent ORIF for closed PHF from 2010 to 2014 with no renal disease, predialysis chronic renal disease (CRD), and end-stage renal disease (ESRD). Results: A total of 85,433 patients were identified, including 5498 (6.4%) CRD and 636 (0.7%) ESRD. CRD and ESRD patients had increased age, comorbidities, and rates of Medicare insurance. After adjusting for differences, CRD and ESRD patients were at increased risk of any complication (odds ratio [OR] 2.48, 1.66), blood transfusion (OR 1.85, 3.31), respiratory complications (OR 1.14, 1.59), acute renal failure (OR 4.80, 1.67), systemic infection (OR 2.00, 3.14), surgical site infection (OR 1.52, 3.87), longer length of stay (7.1 and 12.9 days vs. 5.9 days), and higher cost ($21,669 and $35,413 vs. $20,394) during index hospitalization, as well as surgical site infection (OR 1.43, 3.03) and readmission (OR 1.61, 3.69) within 90 days of discharge, respectively, compared with no renal disease patients. During index hospitalization, CRD patients also had increased risk for periprosthetic fracture (OR 4.97) and cardiac complications (OR 1.47), whereas ESRD patients had increased risk of mortality (OR 5.79), wound complication (2.67), and deep vein thrombosis (OR 16.70). Conclusion: These findings suggest renal patients are at increased risk for complications after PHF ORIF, highlighting the importance of close perioperative monitoring and appropriate patient selection in this population, including strong consideration of nonoperative management.

Lower Risk of Revision Surgery After Arthroscopic Versus Open Irrigation and Débridement for Shoulder Septic Arthritis.

BACKGROUND: In the treatment of native shoulder septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival (RFS), complications, and resource utilization between these approaches. METHODS: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D) were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: A total of 4,113 patients with native shoulder septic arthritis undergoing I&D were identified, 2,775 arthroscopic (67.5%) and 1,338 open (32.5%). The median follow-up was 170 days (interquartile range 79 to 265). A total of 341 patients (8.3%) underwent revision I&D at a median of 9 days. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $4,154 ( P < 0.001) and length of stay of 0.78 days ( P = 0.030). Arthroscopic I&D was associated with reduced blood transfusions (odds ratio 0.69, P = 0.001) and wound complications (odds ratio 0.30, P < 0.001). RFS was 96.4%, 94.9%, 93.3%, and 92.6% for arthroscopic I&D and 94.1%, 92.6%, 90.4%, and 89.0% for open I&D at 10, 30, 90 and 180 days, respectively ( P = 0.00043). On multivariate Cox modeling, arthroscopic I&D was associated with improved survival (hazard ratio 0.67, P = 0.00035). On stratified analysis, arthroscopic I&D was associated with improved RFS in patients aged 65 years or older ( P < 0.001), but RFS was similar in those younger than 65 years ( P = 0.17). CONCLUSION: Risk of revision I&D was markedly lower after arthroscopic I&D compared with open, although the protective benefit was limited to patients aged 65 years or older. Arthroscopy was also associated with decreased costs, length of stay, and complications. Although surgeons must consider specific patient factors, our results suggest that arthroscopic I&D is superior to open I&D. LEVEL OF EVIDENCE: III.

Analysis of the Digital Footprint of Orthopaedic Surgeons.

INTRODUCTION: Patients increasingly rely on Google search to guide their choice of healthcare providers. Despite this trend, there is limited literature systematically characterizing the online presence of orthopaedic surgeons. The goal of this study was to identify the information patients see after queries of Google search when selecting orthopaedic surgeon providers. METHODS: The Physician Comparable downloadable file from the Centers for Medicare and Medicaid Services was deduplicated and filtered. A list of orthopaedic surgeons within the United States was generated, of which a randomized sample was taken and queried using a Google Custom Search. The results for each surgeon's first page were classified into the following categories: (1) hospital-controlled content website, (2) third-party health website, (3) social media website, (4) primary academic journals, or (5) other. RESULTS: The most frequently returned website was third-party health websites (43.3%). Statistically significant differences were observed in the categories across multiple comparisons, including academic and nonacademic orthopaedic surgeons, male and female providers, and surgeons from different graduation years. DISCUSSION: Most of the results were attributed to third-party websites demonstrating that orthopaedic surgeons do not have notable control over their digital footprint. Increased patient visibility of physician-controlled websites and an objective rating system for patients remain potential areas of growth.

Public Interest in Sports Medicine and Surgery (Anterior Cruciate Ligament, Meniscus, Rotator Cuff) Topics Declined Following the COVID-19 Outbreak.

PURPOSE: To quantify the coronavirus disease 2019 (COVID-19) pandemic's impact on public interest in sports medicine and surgery topics. METHODS: The Google Trends analysis tool (Google Search Volume Indices [GSVI]) was used to collect search information regarding orthopaedic sports medicine terms ("ACL," "meniscus," "rotator cuff") and sports surgery terms ("ACL surgery," "meniscus surgery," "rotator cuff surgery") from May 2015 to May 2020. A time series analysis was performed for these GSVIs and compared to the timing of the pandemic. RESULTS: Interest in both sports medicine and surgery declined following the COVID-19 outbreak. Following the World Health Organization's statement on COVID-19's pandemic status on March 11, 2020, searches for "ACL," "meniscus" and "rotator cuff" declined by 34.78%, 43.95%, and 31.37%, and search for "ACL surgery," "meniscus surgery" and "rotator cuff surgery" declined by 42.70%, 51.88%, and 53.32%, respectively. CONCLUSION: The COVID-19 outbreak correlated with a decline in public interest in sports medicine and sports surgery topics, as measured by Google searches. CLINICAL RELEVANCE: Orthopaedic sports medicine and arthroscopy patient and surgical case volumes were negatively affected by various factors after the onset of the pandemic. One factor associated with the volume decrease is a decline in public interest.

Biomechanical Evaluation of a Modified Internal Brace Construct for the Treatment of Ulnar Collateral Ligament Injuries.

BACKGROUND: Ulnar collateral ligament (UCL) repair augmented with the "internal brace" construct for the management of acute UCL injuries has recently garnered increasing interest from the sports medicine community. One concern with this technique is excessive bone loss at the sublime tubercle, should revision UCL reconstruction be required. In an effort to preserve the bony architecture of the sublime tubercle, an alternative internal brace construct is proposed and biomechanically compared with the gold standard UCL reconstruction. HYPOTHESIS: The internal brace repair construct will restore valgus laxity and rotation to its native state and demonstrate comparable load-to-failure characteristics with the 3-strand reconstruction technique. STUDY DESIGN: Controlled laboratory study. METHODS: For this study, 8 matched pairs of fresh-frozen cadaveric elbows were randomized to undergo either UCL reconstruction with the 3-ply docking technique or UCL repair with a novel internal brace construct focused on augmenting the posterior band of the anterior bundle of the ligament (modified repair-IB technique). Valgus laxity and rotation measurements were quantified through use of a MicroScribe 3DLX digitizer at various flexion angles of the native ligament, transected ligament, and repaired or reconstructed ligament. Laxity testing was performed from maximum extension to 120° of flexion. Each specimen was then loaded to failure, and the method of failure was recorded. RESULTS: Valgus laxity was restored to the intact state at all degrees of elbow flexion with the modified repair-IB technique, and rotation was restored to the intact state at both full extension and 30°. In the reconstruction group, valgus laxity was not restored to the intact state at either full extension or 30° of flexion (P < .001 and P = .004, respectively). Laxity was restored at 60° of flexion, but the elbow was overconstrained at 90° and 120° of flexion (P = .027 and P = .003, respectively). In load-to-failure testing, the reconstruction group demonstrated significantly greater yield torque (19.1 vs 9.0 N·m; P < .005), yield angle (10.2° vs 5.4°; P = .007), and ultimate torque (23.9 vs 17.6 N·m; P = .039). CONCLUSION: UCL repair with posterior band internal bracing was able to restore valgus laxity and rotation to the native state. The construct exhibited lower load-to-failure characteristics when compared with the reconstruction technique. CLINICAL RELEVANCE: In selected patients with acute, avulsion-type UCL injuries, ligament repair with posterior band internal bracing is a viable alternative surgical option that, by preserving bone at the sublime tubercle, may decrease the complexity of future revision procedures.

Multi-potentiality of a new immortalized epithelial stem cell line derived from human hair follicles.

We previously demonstrated that keratin 15 expressing cells present in the bulge region of hair follicles exhibit properties of adult stem cells. We have now established and characterized an immortalized adult epithelial stem cell line derived from cells isolated from the human hair follicle bulge region. Telogen hair follicles from human skin were microdissected to obtain an enriched population of keratin 15 positive skin stem cells. By expressing human papillomavirus 16 E6/E7 genes in these stem cells, we have been able to culture the cells for >30 passages and maintain a stable phenotype after 12 mo of continuous passage. The cell line was compared to primary stem cells for expression of stem cell specific proteins, for in vitro stem cell properties, and for their capacity to differentiate into different cell lineages. This new cell line, named Tel-E6E7 showed similar expression patterns to normal skin stem cells and maintained in vitro properties of stem cells. The cells can differentiate into epidermal, sebaceous gland, and hair follicle lineages. Intact beta-catenin dependent signaling, which is known to control in vivo hair differentiation in rodents, is maintained in this cell line. The Tel-E6E7 cell line may provide the basis for valid, reproducible in vitro models for studies on stem cell lineage determination and differentiation.

Ulnar Collateral Ligament Repair With Suture Bridge Augmentation.

The gold standard for management of elbow ulnar collateral ligament (UCL) injuries in elite athletes is reconstruction of the UCL with a tendon graft. Over the past several years, UCL repair for acute tears, as well as partial tears, in young athletes has gained increasing popularity, with studies reporting good outcomes and high rates of return to sports. Additionally, there is increased interest in ligament augmentation using the InternalBrace concept. A recent technique paper describes a direct repair of the UCL augmented with a spanning suture bridge. Although clinical outcomes for this method are promising, one possible concern when using this technique is bone loss at the ulnar origin of the UCL should revision reconstruction be required. We propose an alternative augmentation method that allows for stress shielding of the healing native ligament while minimizing bone compromise in the face of UCL reconstruction at a later time point.

Return to Golfing Activity After Joint Arthroplasty.

BACKGROUND: Many patients who are considering total joint arthroplasty, including hip, knee, and shoulder replacement, are concerned with their likelihood of returning to golf postoperatively as well as the effect that surgery will have on their game. PURPOSE: To review the existing literature on patients who have undergone major joint arthroplasty (hip, knee, and shoulder), to examine the effects of surgery on performance in golf, and to provide surgeon recommendations as related to participation in golf after surgery. A brief review of the history and biomechanics of the golf swing is also provided. STUDY DESIGN: Systematic review. METHODS: We performed a systematic review of the literature in the online Medline database, evaluating articles that contained the terms "golf" and "arthroplasty." Additionally, a web-based search evaluating clinical practice recommendations after joint arthroplasty was performed. The research was reviewed, and objective and anecdotal guidelines were formulated. RESULTS: Total joint arthroplasty provided an improvement in pain during golfing activity, and most patients were able to return to sport with variable improvements in sport-specific outcomes. CONCLUSION: In counseling patients regarding the return to golf after joint arthroplasty, it is our opinion, on the basis of our experience and those reported from others in the literature, that golfers undergoing total hip, knee, and shoulder arthroplasty can safely return to sport.