Racial and Ethnic Disparities in the Incidence of High-Impact Chronic Pain Among Primary Care Patients with Acute Low Back Pain: A Cohort Study.

OBJECTIVE: We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP). METHODS: In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP. RESULTS: We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05-1.87 and aOR = 1.25, 95%CI: 0.83-1.90, respectively). CONCLUSIONS: We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated. CLINICALTRIALS.GOV IDENTIFIER: NCT02647658.

Anterior cruciate ligament reconstruction with all-soft tissue quadriceps tendon versus quadriceps tendon with bone block.

PURPOSE: The purpose of this study was to evaluate whether there was a difference in clinical outcomes between patients who underwent primary ACL reconstruction (ACLR) with all-soft tissue quadriceps tendon (sQT) autograft versus QT with bone block (bQT). METHODS: A retrospective cohort study of 708 patients who underwent QT ACLR was conducted. Primary ACLR patients with at least 1 year of follow-up were identified and those who received sQT were compared to those who received bQT. Data collection entailed patient demographics, surgical variables, patient reported outcomes (PROs), knee stability testing, and complications. The primary outcome of interest was International Knee Documentation Committee (IKDC) score, reported as mean score, pre- and postoperative difference, and number who met minimum clinically important difference (MCID). Secondary outcomes included Lachman and pivot shift grade, other patient reported outcomes (PROs), complication rates, and return to sport (RTS). RESULTS: A total of 195 patients (147 sQT, 48 bQT) who underwent primary QT ACLR met criteria for analysis, with mean follow-up of 17.0 ± 7.9 months. No difference was detected between cohorts with respect to postoperative IKDC score (sQT: n = 120, 81.0 ± 18.9, bQT: n = 10, 80.9 ± 20.4, n.s.), proportion of patients who met MCID (sQT: 68/78 [87%], bQT: 6/7 [86%], n.s.), or results of stability testing. In the sQT cohort, 86% (106/123) of athletes achieved full RTS, compared to 85% (34/40) in the bQT cohort (n.s.). Time to RTS was less than a year in both cohorts (sQT: 10.5 ± 3.8 months [n = 106], bQT: 11.1 ± 3.9 months [n = 31], n.s.). Graft rupture occurred in 7 (5%) sQT patients and 3 (6%) bQT patients (n.s.), and all clinical failures were due to graft rupture (n.s.). No differences were detected for rates of postoperative complications. CONCLUSION: No differences in clinical outcomes were detected between patients who underwent primary ACLR with sQT autograft versus bQT autograft. Currently, the decision to employ sQT or bQT is largely determined by surgeon preference. This study demonstrates excellent outcomes with both preparations and supports the use of either graft type at the discretion of the treating surgeon. LEVEL OF EVIDENCE: III.

Traumatic rotator cuff tears with concomitant shoulder dislocation: tear characteristics and postsurgical outcomes.

BACKGROUND: Arthroscopic rotator cuff repair has been shown to have favorable outcomes following traumatic rotator cuff tear with concomitant shoulder dislocation. The aim of this study was to compare outcomes and tear characteristics between patients who underwent arthroscopic rotator cuff repair following traumatic tear with shoulder dislocation to those without dislocation. METHODS: A retrospective review of 226 consecutive patients with traumatic rotator cuff tears who underwent arthroscopic repair between 2013 and 2017 with a minimum of 1-year follow-up was performed. Patients with traumatic dislocations and concomitant rotator cuff tears were placed in the Dislocation & Tear cohort (DT cohort) and were matched 1:2 with a second cohort sustaining traumatic cuff tears without dislocation (T cohort). Primary outcomes were injury characteristics including tendon involvement and atrophy and tear size and thickness. Secondary outcomes were postoperative strength and range of motion (ROM) in forward flexion (FF), external rotation (ER), and internal rotation (IR); patient-reported outcomes including Subjective Shoulder Value, visual analog scale, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; complications including repair failure (defined as symptomatic retear confirmed on postoperative magnetic resonance imaging), infection, adhesive capsulitis, and impingement; and rates of revision surgery. RESULTS: There were 18 patients in the DT Cohort and 36 patients in the T Cohort with no significant differences in time to final follow-up (50.4 ± 24.5 months vs. 49.0 ± 30.4 months, P = .73). The DT cohort displayed a larger mean tear size (34 ± 12 mm vs. 19 ± 12 mm, P = .01) and had greater infraspinatus involvement (78% vs. 36%, P = .004) and subscapularis involvement (72% vs. 39%, P = .02) than the T cohort. With regard to strength, postoperative ER strength was less likely to be 5/5 in the DT Cohort (53% vs. 94% of patients with 5/5 strength, P = .002) compared with the T cohort. With regard to ROM, the DT cohort had significantly lower preoperative FF (90° ± 55° vs. 149° ± 33°, P < .001), ER (36 ± 21° vs. 52° ± 14°, P = .02), and IR (5.4 ± 2.1 vs. 7.5 ± 1.2, P = .002) compared with the T cohort but had similar FF, ER, and IR outcomes postoperatively. There were no differences between the groups for complications and postoperative patient-reported outcomes. CONCLUSION: Traumatic rotator cuff tears with concomitant dislocations are associated with larger tear size and greater infraspinatus and subscapularis involvement than traumatic tears without dislocation. Arthroscopic repair of this injury is associated with lower preoperative ROM in FF, ER, and IR, as well as lower postoperative ER strength compared with traumatic tears without dislocation. Nonetheless, excellent patient-reported outcomes can be achieved following arthroscopic repair similar to patients without dislocation.

External fixation increases complications following surgical treatment of multiple ligament knee injuries.

PURPOSE: The purpose of this study was to review post-operative complications after surgical intervention of MLKIs within the first 6 months to be better able to counsel patients before surgical intervention. METHODS: All patients who underwent surgical reconstruction for a MLKI at one institution from 2009 to 2018 were included in this study. A retrospective review was performed of all patients and post-operative complications were recorded, including motion loss (which included > 10 degree flexion loss or > 3 degree extension loss), hematoma formation, infection, iatrogenic vascular or nerve injury, deep vein thrombosis (DVT), pulmonary embolism (PE), skin lesions, symptomatic hardware, recurrent ligamentous laxity, and need for additional surgery. Knee ligament injuries were classified based on the Schenck Knee Dislocation (KD) Classification. RESULTS: A total of 136 patients were included in this study, 83 with KD I injuries, 40 with KD III injuries, 9 with KD IV injuries, and 4 with KD V injuries. Of these total patients, 48 (35.5%) sustained a post-operative complication: 11 out of 133 (8.3%) from 0 to 1 week, 46 out of 132 (34.8%) from 1 week to 1 month, 28 out of 124 (22.6%) from 1 to 3 months, and 26 out of 121 (21.5%) from 3 to 6 months. Out of the total complications, 99 (78.5%) occurred at 1 week-3 months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common complication was motion loss in 39 (28.6%) patients. There was a significant difference in mean number of complications between the KD I and KD III groups, as well as the KD III and KD IV-V groups. There was no significant difference in the overall prevalence of post-operative complications or occurrence of motion loss with KD grade. CONCLUSION: The main finding of this study was 48 (35.5%) patients sustained a complication after surgical treatment of MLKIs, with 99 (78.5% of all complications) complications occurring at 1 week-3 months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common post-operative complication was motion loss in 39 (28.6%) patients. The KD grade was not associated with post-operative development of motion loss, but KD III had a significantly greater mean number of complications than KD I or KD IV-V grades. LEVEL OF EVIDENCE: IV.

Risk Stratification and Pain Outcomes Following Revision Total Hip Arthroplasty for Adverse Local Tissue Reactions.

BACKGROUND: Revision total hip arthroplasty (THA) for adverse local tissue reactions (ALTRs) secondary to head-neck taper corrosion is associated with a high complication rate. Diagnosis of ALTR is based on risk stratification using the patient's history and examination, implant risk, serum metal ion levels, and imaging. The purpose of this study was to determine if stratification using similar risk factors is predictive of outcomes following revision THA for metal-on-polyethylene (MoP) ALTR. METHODS: We performed a retrospective review on 141 patients revised for ALTR due to head-neck taper corrosion. Pain outcomes following surgery were analyzed using a generalized linear mixed model. Complications were defined as instability/dislocation, infection, fracture, nerve palsy, leg-length discrepancy, or reoperation. RESULTS: The overall complication rate was 17.7%. The odds of having pain decreased by 44% after revision surgery (Odds Ratio = 0.56, 95% Confidence Interval: 0.324 to 0.952). There was no significant difference in instability/dislocation based on either increased or decreased head-neck offset (P = .67) or magnetic resonance imaging findings of abductor loss, effusion size, and degree of ALTR (P = .73). Increased serum cobalt (P = .31) and chromium (P = .08) levels did not predict complications; however, a decreased cobalt-chromium ratio was associated with postoperative complications (2.8 versus 3.5; P = .002). CONCLUSION: These findings are the first to suggest that patients who have ALTR after MoP THA undergoing revision surgery demonstrated major pain relief. Increasing femoral head offset did not change rates of instability/dislocation. In clinical scenarios where preoperative cobalt-chromium femoral head offsets were greater than available ceramic head offsets, a mandatory decrease in femoral head offset did not increase rates of instability/dislocation.

High Mortality After Total Knee Arthroplasty Periprosthetic Joint Infection is Related to Preoperative Morbidity and the Disease Process but Not Treatment.

BACKGROUND: Periprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself. METHODS: A multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints. RESULTS: The septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119). CONCLUSION: Compared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.

Short- to Intermediate-Term Radiographic Outcomes Following Cotton Osteotomy.

The cotton osteotomy or the medial cuneiform opening wedge osteotomy has been a common adjunct procedure in flatfoot reconstruction to correct for forefoot varus or a dorsiflexed first ray. The main goal of the study is to retrospectively review outcomes specifically in the short-intermediate term for the cotton osteotomy. The medical records of a single foot and ankle surgeon (PRB) were reviewed for patients who met inclusion and exclusion criteria. The study period was from January 2006 to October 2018. The analysis was performed using information obtained from chart-review to examine union and complication rates, as well as changes in the cuneiform articular angle based on graft size and type. A total of 71 feet in 61 patients underwent cotton osteotomies for flatfoot reconstruction. Overall complication rate was 5.6% (4/71) with 2 nonunions (2/47) in those that had radiographic follow-up of greater than 9 months. Change in cuneiform articular angle (CAA) showed 0.91° of correction per 1-millimeter increase in graft wedge size from preoperative to 3 weeks. Change for anterior-posterior medial cuneiform bisection dorsal length (AP length) was 0.70 mm per 1 mm of graft used from preoperative to 3 weeks. 6 weeks to 10 weeks showed statistically significant changes in the CAA (p = .01) and the AP length (p = .002). The cotton osteotomy showed statistically significant radiographic loss of correction between the 6- and 10-week time points when patients were allowed to begin weightbearing. Metal grafts may provide maintenance of correction which warrants future studies on their efficacy.

Comparison of Asymptomatic and Symptomatic Adverse Local Tissue Reaction in Patients With Head-Neck Taper Corrosion.

BACKGROUND: Diagnosis of adverse local tissue reaction (ALTR) in metal-on-polyethylene (MoP) total hip arthroplasty (THA) secondary to head-neck taper corrosion is challenging. The purpose of this study is to compare differences between asymptomatic and symptomatic ALTR in an observational cohort, including presentation, metal ion differences, and metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) findings. METHODS: We performed a retrospective review of an observational cohort of 492 MoP THA patients at increased risk of developing ALTR. Ninety-four patients underwent revision arthroplasty for ALTR. Patients were stratified into symptomatic and asymptomatic ALTR groups. Presentation, metal ion levels, and imaging findings were compared. RESULTS: For patients with confirmed ALTR, 41% were asymptomatic. There was a statistically significant difference in the serum chromium levels between symptomatic and asymptomatic ALTR patients (2.2 µg/L vs 3.1 µg/L, P = .05). There was no statistically significant difference between the serum cobalt levels or MRI findings in these 2 groups. We observed that extracapsular disease associated with ALTR could be misinterpreted as trochanteric bursitis. CONCLUSION: Almost half of the MoP THA ALTR cases identified were asymptomatic. Cobalt levels could not differentiate between symptomatic and asymptomatic pseudotumor formation. Symptomatic and asymptomatic MoP ALTRs have similar MARS MRI characteristics. Our findings suggest that it is essential to risk stratify patients who could potentially have ALTR based on implant type, symptoms, ion levels, and MARS MRI.

Validity and Responsiveness of Floor Sitting-Rising Test in Post-Total Knee Arthroplasty: A Cohort Study.

OBJECTIVES: To assess the construct validity and responsiveness of the floor sitting-rising test (SRT) in individuals with total knee arthroplasty (TKA). DESIGN: Cohort study with 6-month follow-up. Secondary analysis using data from a randomized controlled trial. SETTING: An outpatient rehabilitation research center. PARTICIPANTS: Participants (N=240) enrolled in the parent study who had unilateral primary TKA. INTERVENTION: Participants in the parent study underwent 12 weeks of exercise programs. MAIN OUTCOME MEASURES: Validity analysis correlated baseline data of participants who completed the SRT and measures of knee motion, muscle strength, performance-based tests, and patient-reported outcomes of physical and psychosocial function. Responsiveness analysis used the 3- and 6-month follow-up data. Effect sizes were calculated using changes from baseline. Areas under the receiving operating characteristics curve were calculated using a global rating of change as the external anchor. RESULTS: Of the 240 participants (148 women; age, 70±7y), 180 (75%) were able to perform the SRT at baseline. Performers scored significantly better in all physical function tests (P<.0001) than nonperformers. SRT scores generally converged with measures of knee impairment and performance-based tests (associations ranged from small [r=0.15; P=.0516] to moderate [r=0.52; P<.0001]). SRT scores associated with self-efficacy for function (r=0.34; P<.0001) and fear of falls (r=-0.25; P=.001). At 3 (n=174) and 6 months (n=160), SRT effect sizes were 0.38 (95% confidence interval, 0.25-0.52) and 0.42 (95% confidence interval, 0.25-0.60), and areas under the curve were 0.59 (95% confidence interval, 0.49-0.69) and 0.62 (95% confidence interval, 0.52-0.73), respectively. CONCLUSIONS: The results add evidence to the validity of the SRT in patients after TKA. The strength of the associations suggests that the SRT measures a physical function construct not captured by the other tests. The magnitude of indices of responsiveness for the SRT were similar to other performance-based tests, indicating comparable responsiveness to more widespread tests of functional performance.

Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty.

BACKGROUND: Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events. METHODS: A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon. RESULTS: TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77). CONCLUSION: Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA. LEVEL OF EVIDENCE: Level III, Observational Cohort Study.

A Portable System for Remote Rehabilitation Following a Total Knee Replacement: A Pilot Randomized Controlled Clinical Study.

Rehabilitation has been shown to improve functional outcomes following total knee replacement (TKR). However, its delivery and associated costs are highly variable. The authors have developed and previously validated the accuracy of a remote (wearable) rehabilitation monitoring platform (interACTION). The present study's objective was to assess the feasibility of utilizing interACTION for the remote management of rehabilitation after TKR and to determine a preliminary estimate of the effects of the interACTION system on the value of rehabilitation. Specifically, we tested post-operative outpatient rehabilitation supplemented with interACTION (n = 13) by comparing it to a standard post-operative outpatient rehabilitation program (n = 12) using a randomized design. Attrition rates were relatively low and not significantly different between groups, indicating that participants found both interventions acceptable. A small (not statistically significant) decrease in the number of physical therapy visits was observed in the interACTION Group, therefore no significant difference in total cost could be observed. All patients and physical therapists in the interACTION Group indicated that they would use the system again in the future. Therefore, the next steps are to address the concerns identified in this pilot study and to expand the platform to include behavioral change strategies prior to conducting a full-scale randomized controlled trial. Trial registration: ClinicalTrials.gov NCT02646761 "interACTION: A Portable Joint Function Monitoring and Training System for Remote Rehabilitation Following TKA" 6 January 2016.

Talectomy as Part of Chronic Foot and Ankle Deformity Correction Procedure: A Retrospective Study.

Severe foot and ankle deformities can be associated with high complication rates and impaired quality of life in patients. Surgical correction using a talectomy procedure has previously been described in many lower extremity pathologies and is a powerful tool for the correction of severe foot and ankle deformity. This study aimed to describe the role of talectomy and the outcomes of this procedure in patients presenting with severe foot and ankle deformity. A review of 45 patients undergoing talectomy by a single surgeon was completed. Data extracted included the cause of deformity, history of infection, body mass index, and relevant comorbidities. Outcome measures of interest were minor or major complications and limb functionality at final follow-up. Statistical analysis was performed by using a Wilcoxon rank sum test and a Fisher exact test looking at variables affecting selected outcome measures. Limb salvage occurred in 38 of 45 patients (84.4%). Patients with an infection history had 89% lower odds of a functional limb at final follow-up (p = .0389). Six of 7 patients (85.7%) who ultimately underwent amputation had a history of prior infection. Women had 8.25 times higher odds of having a functional limb compared with men (p = .047). All 13 patients with major complications had neuropathy (p = .024). Patients with chronic lower extremity deformities can successfully be treated with a talectomy as a part of the reconstructive procedure. This is a challenging patient population that is associated with a high complication rate. Patients with a history of infection should be counseled on the possibility of requiring major amputation.

Verification of a Portable Motion Tracking System for Remote Management of Physical Rehabilitation of the Knee.

Rehabilitation following knee injury or surgery is critical for recovery of function and independence. However, patient non-adherence remains a significant barrier to success. Remote rehabilitation using mobile health (mHealth) technologies have potential for improving adherence to and execution of home exercise. We developed a remote rehabilitation management system combining two wireless inertial measurement units (IMUs) with an interactive mobile application and a web-based clinician portal (interACTION). However, in order to translate interACTION into the clinical setting, it was first necessary to verify the efficacy of measuring knee motion during rehabilitation exercises for physical therapy and determine if visual feedback significantly improves the participant's ability to perform the exercises correctly. Therefore, the aim of this study was to verify the accuracy of the IMU-based knee angle measurement system during three common physical therapy exercises, quantify the effect of visual feedback on exercise performance, and understand the qualitative experience of the user interface through survey data. A convenience sample of ten healthy control participants were recruited for an IRB-approved protocol. Using the interACTION application in a controlled laboratory environment, participants performed ten repetitions of three knee rehabilitation exercises: heel slides, short arc quadriceps contractions, and sit-to-stand. The heel slide exercise was completed without feedback from the mobile application, then all exercises were performed with visual feedback. Exercises were recorded simultaneously by the IMU motion tracking sensors and a video-based motion tracking system. Validation showed moderate to good agreement between the two systems for all exercises and accuracy was within three degrees. Based on custom usability survey results, interACTION was well received. Overall, this study demonstrated the potential of interACTION to measure range of motion during rehabilitation exercises for physical therapy and visual feedback significantly improved the participant's ability to perform the exercises correctly.

Plantar Approach for Midfoot Wedge Resection to Reconstruct the Rocker Bottom Foot.

Chronic deformity of the foot can lead to ulceration, infection, and amputation. Midfoot wedge osteotomy for deformity correction has been described in the literature; however, most reports are case review or small series. Wedge osteotomy can be performed from a medial or plantar approach, but there are limited data on outcomes regarding these relatively uncommon procedures. This study aims to review a population of patients with a rocker bottom foot deformity that underwent a midfoot wedge resection performed from the plantar surface for deformity correction, wound healing, and limb salvage. A review of medical records from a single foot and ankle surgeon was undertaken. Patients who had a midfoot wedge performed from the plantar surface to address rocker bottom deformity resulting from Charcot neuroarthropathy or severe flatfoot were included. Thirty patients met inclusion criteria. The outcome measures evaluated were minor and major complications, wound healing, and functional limb status. Statistical analysis was performed to evaluate factors that influenced outcomes. At time of final follow up, 17 of 20 (85%) preoperative wounds had healed. Mean preoperative talo-first metatarsal angle was -25° and improved to -5° postoperatively. An 87% limb salvage rate (26/30) was demonstrated. Body mass index was the only statistically significant factor that influenced functional limb status. Maintaining a functional limb can have profound effects on a patient's quality of life. Generally, patients with this severe rocker bottom foot deformity have multiple comorbidities and are at an increased risk of major amputation and early death. The current study has shown that patients with a rocker bottom foot deformity can benefit from midfoot wedge resection from a plantar approach to achieve a plantigrade foot.

Strength symmetry after autograft anterior cruciate ligament reconstruction.

OBJECTIVE: To compare postoperative isometric quadriceps strength indices (QI%) and hamstring strength limb symmetry indices (HI%) between partial thickness quadriceps tendon (pQT), full thickness quadriceps tendon (fQT), and bone-patellar-tendon bone (BPTB) autograft anterior cruciate ligament reconstruction (ACLR). METHODS: Patients with primary ACLR with pQT, fQT, or BPTB autograft with the documentation of quantitative postoperative strength assessments between 2016 and 2021 were included. Isometric Biodex data, including QI% and HI% (calculated as the percentage of involved to uninvolved limb strength) were collected between 5 and 8 months and between 9 and 15 months postoperatively. RESULTS: In total, 124 and 51 patients had 5-8- and 9-15-month follow-up strength data, respectively. No significant difference was detected between groups for sex. However, patients undergoing fQT were found to be older than those undergoing BPTB (24.6±7 vs 20.2±5; â€‹p = 0.01). There were no significant differences in the number of concomitant meniscus repairs between the groups (pQT vs. fQT vs. BPTB). No significant differences were detected in median (min-max) QI% between pQT, fQT, and BPTB 5-8 months [87 â€‹% (44%-130 â€‹%), 84 â€‹% (44%-110 â€‹%), 82 â€‹% (37%-110 â€‹%) or 9-15 months [89 â€‹% (50%-110 â€‹%), 89 â€‹% (67%-110 â€‹%), and 90 â€‹% (74%-140 â€‹%)] postoperatively. Similarly, no differences were detected in median HI% between the groups 5-8 months or 9-15 months postoperatively. CONCLUSION: The study was unable to detect differences in the recovery of quadriceps strength between patients undergoing ACLR with pQT, fQT, and BPTB autografts at 5-8 months and 9-15-months postoperatively. LEVEL OF EVIDENCE: III.

A Cluster Analysis of Initial Primary Care Orders for Patients with Acute Low Back Pain.

PURPOSE: Primary care physicians (PCPs) often face a complex intersection of patient expectations, evidence, and policy that influences their care recommendations for acute low back pain (aLBP). The purpose of this study was to elucidate patterns of PCP orders for patients with aLBP, identify the most common patterns, and describe patient clinical and demographic characteristics associated with patterns of aLBP care. METHODS: This prospective cohort study included 9574 aLBP patients presenting to 1 of 77 primary care practices in 4 geographic locations in the United States. We performed a cluster analysis of PCP orders extracted from electronic health records within the first 21 days of an initial visit for aLBP. RESULTS: 1401 (15%) patients did not receive a PCP order related to back pain within the first 21 days of their initial visit. These patients predominantly had aLBP without leg pain, less back-related disability, and were at low-risk for persistent disability. Of the remaining 8146 patients, we found 4 distinct order patterns: combined nonpharmacologic and first-line medication (44%); second-line medication (39%); imaging (10%); and specialty referral (7%). Among all patients, 29% received solely 1 order from their PCP. PCPs more often combined different guideline concordant and discordant orders. Patients with higher self-reported disability and psychological distress were more likely to receive guideline discordant care. CONCLUSION: Guideline discordant orders such as steroids and NSAIDS are often combined with guideline recommended orders such as physical therapy. Further defining patient, clinician, and health care setting characteristics associated with discordant care would inform targeted efforts for deimplementation initiatives.

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

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

Effects of simulated aging on cushion performance measured using standardized laboratory test methods.

Standardized test methods providing wheelchair cushion performance characteristics can aid cushion design and selection. Assessment of the changes in performance that occur with aging provides additional information. Test methods published by the International Organization for Standardization were applied to a cohort of 21 cushions of varying design and construct to assess changes in performance due to simulated aging. Performance tests measured immersion, envelopment, stiffness, impact response, and pressure distribution properties. Means of test outcome metrics pre- and post-aging are presented, and changes in the metrics due to aging are analyzed using linear mixed models. Statistically significant changes were found for outcome measures for each performance test. The minimum aging method simulating 18-24 months use had a significant effect on cushion performance. Changes to loaded contour depth, envelopment, pressure mapping, hysteresis, horizontal stiffness, and 10% force deflection characterization test metrics indicated decreased cushion performance. The simulated aging method resulted in cushion stiffening and reduced immersion, pressure distribution, and stability performance. Together, these changes may increase a user's risk for pressure injuries.

Weight Changes in Young Service Members After Lower Limb Amputation: Insights From Group-Based Trajectory Modeling.

INTRODUCTION: Weight gain can contribute to osteoarthritis, cardiovascular disease, low back pain, and poor health-related quality of life. Weight trajectory patterns have been described in older veterans with limb loss; however, there is limited evidence of changes in weight in younger veterans with limb loss. MATERIALS AND METHODS: Service members with unilateral or bilateral lower limb amputations (LLAs) (and without an upper limb amputation) were included in this retrospective cohort analysis (n = 931). The mean postamputation baseline weight was 78.0 ± 14.1 kg. Bodyweight and sociodemographic data were extracted from clinical encounters within electronic health records. Group-based trajectory modeling assessed weight change patterns 2 years postamputation. RESULTS: Three weight change trajectory groups were identified: 58% (542 of 931) of the cohort had stable weight, 38% (352 of 931) had weight gain (mean gain = 19.1 kg), and 4% (31 of 931) had weight loss (mean loss = 14.5 kg). Individuals with bilateral amputations were more frequently noted in the weight loss group compared with those with unilateral amputations. Individuals with LLAs because of trauma other than blasts were more frequently found in the stable weight group compared with those with amputations because of disease or a blast. Younger individuals (<20 years old) with amputations were more likely to be in the weight gain group compared with older individuals. CONCLUSIONS: More than half the cohort maintained a stable weight for two years after amputation, and more than a third experienced weight gain during the same time frame. Knowledge of underlying factors that were associated with weight gain could inform preventative strategies for young individuals with LLAs.

Low-Volume Surgeons Use Allograft in Younger Patients and Show Greater Rates of Revision Following Primary Allograft Anterior Cruciate Ligament Reconstruction Compared With High-Volume Surgeons.

Purpose: To determine whether surgeon volume affects revision rate following primary anterior cruciate ligament reconstruction (ACLR) with allograft and to determine whether surgeon volume impacts allograft tissue type used. Methods: All patients aged 14 years or older who underwent primary allograft ACLR at a large hospital system between January 2015 to December 2019 with minimum 2-year follow-up were included. Patients with double-bundle ACLR, multiligament reconstruction, and absent allograft type data were excluded. Surgeon volume was categorized as 35 or more ACLR/year for high-volume surgeons and less than 35 ACLR/year for low-volume surgeons. Revision was defined as subsequent ipsilateral ACLR. Patient characteristics, operative details, allograft type, and revision ACLR rates were retrospectively collected. Revision rate and allograft type were analyzed based on surgeon volume. Results: A total of 457 primary allograft ACLR cases (mean age: 38.8 ± 12.3 years) were included. Low-volume surgeons experienced greater revision rates (10% vs 5%, P = .04) and used allograft in a younger population (37.6 vs 40.0 years old, P = .03) than high-volume surgeons. Subgroup analysis of the total cohort identified a significantly increased failure rate in patients <25 years old compared with ≥25 years old (30% vs 4%, P < .001). Allograft type selection varied significantly between surgeon volume groups, with low-volume surgeons using more bone-patellar tendon-bone (P < .001) and less semitendinosus allograft (P = .01) than high-volume surgeons. No differences in revision rate were observed based on allograft type (P = .71). Conclusions: There was a greater revision rate following primary allograft ACLR among low-volume surgeons compared with high-volume surgeons. Low-volume surgeons also used allograft in a younger population than did high-volume surgeons. Level of Evidence: Level III, retrospective comparative prognostic trial.