Medial quadriceps tendon femoral ligament reconstruction and medial patellofemoral ligament reconstruction have no significant differences in clinical outcomes for treatment of lateral patellar instability: a matched-cohort study.

OBJECTIVES: The purpose of this study was to compare clinical outcomes of medial quadriceps tendon-femoral ligament reconstruction (MQTFLR) and medial patellofemoral ligament reconstruction (MPFLR) among patients with recurrent lateral patellar instability. METHODS: A retrospective matched-cohort study was conducted involving patients who underwent MQTFLR or MPFLR with or without tibial tubercle osteotomy (TTO) from 2019 to 2021. Subjects were matched 1:1 on age, concomitant osteochondral allograft (OCA), concomitant TTO, and follow-up time. Measured outcomes included 90-day complications, Visual Analog Scale (VAS) knee pain, return to sport/work, Kujala score, Tegner score, and MPFL-Return to Sport after Injury (MPFL-RSI) score. Outcomes were compared between groups using Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. P-values <0.05 were considered significant. RESULTS: Ten MQTFLR patients (mean age 28.7 years, 80% female, mean follow-up 19.7 months) and ten MPFLR patients (mean age 29.1 years, 90% female, mean follow-up 28.3 months) were included in the study. One MQTFLR patient (10%) and three MPFLR patients (30%) underwent reoperation for postoperative arthrofibrosis. Postoperative VAS resting pain was not significantly different between the groups (MQTFLR mean 1.1, MPFLR mean 0.6, p â€‹= â€‹0.31). There were no significant differences in rates of recurrent subluxations (MQTFLR 20%, MPFLR 0%, p â€‹= â€‹0.47), return to sport (MQTFLR 50%, MPFLR 75%, p â€‹= â€‹0.61), return to work (MQTFLR 100%, MPFLR 88%, p â€‹= â€‹1.00), or MPFL-RSI pass rate (MQTFLR 75% vs. MPFLR 38%, p â€‹= â€‹0.31). CONCLUSION: There were no significant differences in knee pain and function, return to work, and rates of recurrent patellar instability between patients who underwent MQTFLR versus MPFLR, though these results should be interpreted with caution given the small sample size and potential selection bias. LEVEL OF EVIDENCE: III.

Increased kinesiophobia leads to lower return to sport rate and clinical outcomes following osteochondral allograft transplantation of the knee.

PURPOSE: The purpose of this study is to describe the postoperative psychological state of patients following osteochondral allograft (OCA) transplantation in the knee and to determine whether patient-perceived kinesiophobia is associated with the rate of return to sport (RTS). METHODS: A retrospective review of the electronic medical record at a single institution was conducted for all patients that underwent OCA transplantation from January 2010 to 2020. Patient-reported outcomes including the visual analog scale (VAS), knee injury and osteoarthritis outcome score (KOOS) and the Tampa scale of kinesiophobia-11 (TSK-11) were collected. Patients were surveyed regarding their postoperative RTS status. RESULTS: A total of 38 patients (52.6% female) were included in our analysis. Overall, 24 patients (63.2%) returned to sport with 12 (50%) of these patients returning at a lower level of play. When comparing patients that return to sport to those that did not, patients that return had significantly superior KOOS pain (p = 0.019) and KOOS QOL (p = 0.011). Measures of kinesiophobia (TSK-11) were significantly higher among patients that did not return to sport (p = 0.014), while satisfaction (n.s.) and pain intensity (n.s.) were comparable between groups. Logistic regression models controlling for demographic factors, VAS pain scores and lesion size showed that for every one-point increase in TSK-11 kinesiophobia score, patients were 1.33 times more likely to return to sport at a lower level (p = 0.009). For every one-point increase in TSK-11 scores KOOS QOL decreased by 2.4 points (p < 0.001). CONCLUSION: Fear of reinjury decreases the likelihood that patients will return to their preoperative level of sport after OCA transplantation. Patients that do not return to sport report significantly greater fear of reinjury and inferior clinical outcomes, despite similar levels of satisfaction and pain compared to those that return. LEVEL OF EVIDENCE: Level III.

Patient-reported hip pain and function are worse among elite Nordic ski athletes competing in ski jumping versus Nordic combined: a cross-sectional analysis.

OBJECTIVES: Nordic ski athletes are at increased risk of developing hip pain and dysfunction secondary to femoroacetabular impingement syndrome (FAIS), but it is unclear whether hip symptomatology differs between ski jumping (SJ) and Nordic combined (NC) athletes. The purpose of this study was to compare patient-reported hip pain and dysfunction between elite Nordic ski athletes participating in SJ versus NC. METHODS: A cross-sectional study was conducted involving SJ and NC athletes who competed at the international and U.S. national levels during the 2021-2022 season. Subjects were excluded if they had hip surgery within two years prior to enrollment. Subjects were asked to undergo diagnostic workups for FAIS, including physical examination and plain radiographic imaging. Subjects were asked to complete a survey that collected information on athletic and training history and to complete the hip disability and osteoarthritis outcome score (HOOS). Demographics, athletic/training history, and HOOS sub-scores were compared between the SJ and NC groups using the Student's t-test, Wilcoxon rank-sum test, or Fisher's exact test, as appropriate. p-values < 0.05 were considered significant. RESULTS: Twenty-four athletes (13 SJ, 11 NC) were included in the study. There were no statistically significant differences in age, sex, BMI, or age of menarche between the two groups (all p â€‹> â€‹0.05). There were also no statistically significant differences in the number of prior sports participated in, total hours of participation in prior sports, or total hours of training in Nordic specialization (all p â€‹> â€‹0.05). Among the 18 athletes who underwent physical examination (9 SJ, 9 NC), there were no statistically significant inter-group differences in hip range of motion or incidence of positive impingement tests (all p â€‹> â€‹0.05). Among the 19 athletes who underwent imaging (9 SJ, 10 NC), there were no statistically significant inter-group differences in the incidence of cam or pincer morphology in at least one hip (all p â€‹> â€‹0.05). SJ athletes had statistically significantly worse HOOS sub-scores for hip symptoms and stiffness, hip function in sports/recreational activities, and hip-related quality of life compared to NC athletes (all p â€‹< â€‹0.05). CONCLUSION: Elite SJ athletes have worse self-reported hip function compared to elite NC athletes, despite comparable demographics, athletic history, and duration of ski training. LEVEL OF EVIDENCE: IV.

Cannabis Use Disorder Not Associated With Opioid Analgesic Use or Patient-Reported Outcomes After ACL Reconstruction: A Retrospective Matched-Cohort Analysis.

BACKGROUND: The purpose of this study was to compare opioid analgesic use and patient-reported outcomes (PROs) after anterior cruciate ligament reconstruction (ACLR) between patients with and without cannabis use disorder (CUD). HYPOTHESIS: We hypothesized that patients with CUD would have greater postoperative opioid usage with comparable improvement in PROs. STUDY DESIGN: Retrospective matched-cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: We identified patients with CUD who underwent primary ACLR at a single center and had minimum 3-month follow-up. Patients with CUD were propensity score matched 1:1 to non-CUD controls with respect to age, sex, and follow-up time. Total refills, days supply, and morphine milligram equivalents (MMEs) of opioid analgesics prescribed were calculated for up to 1 year postoperatively. Patient-Reported Outcome Information System (PROMIS) instruments were used to assess PROs. Opioid use and outcomes were compared between CUD and control groups using Mann-Whitney U test and Fisher's exact test. P values <0.05 were considered significant. RESULTS: A total of 104 patients with CUD were matched to 104 controls. Both groups were majority male (65.4% male, 34.6% female). The CUD group had a mean age of 29.9 years and mean follow-up time of 16.1 months. There was no significant intergroup difference in opioid prescription rates (CUD 82.7% vs control 83.7%, P ≥ 0.99). Among patients prescribed opioids, there were no significant intergroup differences in total days supply (P = 0.67), total MMEs (P = 0.71), or MMEs per day (P = 0.65). There were no significant differences in pre- to postoperative improvement in PROMIS Pain Intensity (P = 0.51), Pain Interference (P = 0.81), Mobility (P = 0.90), Mental Health (P = 0.74), or Physical Health (P = 0.94). CONCLUSION: There were no significant differences detected in opioid usage or PRO improvement after ACLR between patients with CUD and those without. However, because a sample size was not determined a priori, a larger sample may show a difference. CLINICAL RELEVANCE: CUD does not appear to correlate with inferior outcomes after ACLR.

Sex differences in acute telestroke care: more to the story.

Background: Previous studies have shown sex differences in stroke care. Female patients have both lower thrombolytic treatment rates with OR reported as low as 0.57 and worse outcomes. With updated standards of care and improved access to care through telestroke, there is potential to reduce or alleviate these disparities. Methods: Acute stroke consultations seen by TeleSpecialists, LLC physicians in the emergency department in 203 facilities (23 states) from January 1, 2021 to April 30, 2021 were extracted from the Telecare by TeleSpecialists™ database. The encounters were reviewed for demographics, stroke time metrics, thrombolytics candidate, premorbid modified Rankin Score, NIHSS score, stroke risk factors, antithrombotic use, admitting diagnosis of suspected stroke, and reason not treated with thrombolytic. The treatment rates, door to needle (DTN) times, stroke metric times, and variables of treatment were compared for females and males. Results: There were 18,783 (10,073 female and 8,710 male) total patients included. Of the total, 6.9% of females received thrombolytics compared to 7.9% of males (OR 0.86, 95% CI 0.75-0.97, p = 0.006). Median DTN times were shorter for males than females (38 vs. 41 min, p < 0.001). Male patients were more likely to have an admitting diagnosis of suspected stroke, p < 0.001. Analysis by age showed the only decade with significant difference in thrombolytics treatment rate was 50-59 with increased treatment of males, p = 0.047. When multivariant logistic regression analysis was performed with stroke risk factors, NIHSS score, age, and admitting diagnosis of suspected stroke, the adjusted odds ratio for females was 0.9 (95% CI 0.8, 1.01), p = 0.064. Conclusion: While treatment differences between sexes existed in the data and were apparent in univariate analysis, no significant difference was seen in multivariate analysis once stroke risk factors, age, NIHSS score and admitting diagnosis were taken into consideration in the telestroke setting. Differences in rates of thrombolysis between sexes may therefore be reflective of differences in risk factors and symptomatology rather than a healthcare disparity.

Home ownership, full-time employment, and other markers of higher socioeconomic status are predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction.

BACKGROUND: The purpose of this study was to identify socioeconomic predictors of time to initial evaluation, time to surgery, and postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction (MPFLR). METHODS: We conducted a retrospective review of patients at our institution who underwent primary MPFLR with allograft from 2011 to 2019 and had minimum 12-month follow-up. Patients were administered an email survey in January 2022 to assess symptom history, socioeconomic status, and postoperative outcomes including VAS satisfaction and Kujala score. Predictors of time to initial evaluation, time to surgery, and postoperative outcomes were identified using multivariable linear and logistic regression with stepwise selection. RESULTS: Seventy patients were included in the cohort (mean age 24.8 years, 72.9% female, mean follow-up time 45.7 months). Mean time to evaluation was 6.4 months (range 0-221) and mean time to surgery was 73.6 months (range 0-444). Having a general health check-up in the year prior to surgery was predictive of shorter time to initial evaluation (ß = - 100.5 [- 174.5, - 26.5], p = 0.008). Home ownership was predictive of shorter time to surgery (ß = - 56.5 [- 104.7, 8.3], p = 0.02). Full-time employment was predictive of higher VAS satisfaction (ß = 14.1 [4.3, 23.9], p = 0.006) and higher Kujala score (ß = 8.7 [0.9, 16.5], p = 0.03). CONCLUSION: Markers of higher socioeconomic status including having a general check-up in the year prior to surgery, home ownership, and full-time employment were predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes. LEVEL OF EVIDENCE:  IV, retrospective case series.

What Are the Trends in Women's Representation Among Lead Investigators of Orthopaedic Clinical Trials?

BACKGROUND: Serving as a principal investigator for a clinical trial can bring national visibility and recognition to physicians, and it can have a substantial impact on their promotion and tenure. In the field of orthopaedics, there is a well-known gender gap in terms of representation and leadership. Examining the representation of women in clinical trial leadership may help to inform and enable the design of targeted interventions and policies to foster a more inclusive and diverse environment in clinical trial leadership. QUESTIONS/PURPOSES: (1) What is the proportion of women principal investigators in orthopaedic clinical trials, and has this changed over time? (2) Are there trial characteristics (trial phase, status, funding source, and intervention) associated with women principal investigators? (3) What is the geographic distribution globally and regionally within the United States of clinical trials led by women principal investigators? METHODS: A cross-sectional survey of clinical trials using the ClinialTrials.gov registry and results database provided by the NIH was performed on August 22, 2022. Trial characteristics included principal investigator names and gender, trial phase, type, funding source, intervention, and location (defined by continent and US Census region). Our primary outcome was the overall proportion of women orthopaedic principal investigators over time. We assessed this by comparing the proportion of women principal investigators from 2007 to 2022. Our secondary outcomes were trial characteristics (trial phase, status, funding source, and intervention) and geographic distribution (globally and within the United States) associated with women principal investigators. Baseline characteristics of the clinical trials were calculated using frequencies and percentages for categorical variables. Fisher exact tests were conducted to evaluate differences in gender proportions based on the included clinical trial characteristics. Univariate linear regression was applied to analyze trends in the annual proportion of women principal investigators over time. RESULTS: The overall proportion of women principal investigators was 18% (592 of 3246), and this proportion increased over the study period. Specifically, the proportion of women leading clinical trials was 13% (16 of 121) in 2007 and 22% (53 of 242) in 2022 (r2 = 0.68; p < 0.001). This trend was also observed when evaluating only US women principal investigators (r2 = 0.47; p = 0.003) and non-US women principal investigators over the study period (r2 = 0.298; p = 0.03). There was no difference in the distribution of trial phases between men and women principal investigators. Most men and women were involved in "not applicable" or Phase IV trials. Similarly, there was no difference in trial status or funding source. However, women principal investigators had a higher proportion of studies involving behavioral interventions (11% [67 of 592]) compared with men principal investigators (3% [74 of 2654]; p = 0.03). The proportion of women principal investigators over the study period by world region revealed a higher proportion of women principal investigators in Asia (23% [88 of 391]), followed by South America (24% [12 of 49]), North America (18% [306 of 1746]), and Europe (16% [136 of 833]). Among all US trials over the study period, the proportion of women principal investigators across the US Census region was Northeast (19% [62 of 329]), South (18% [90 of 488]), West (20% [97 of 492]), and Midwest (13% [22 of 168]). CONCLUSION: Although there has been a notable increase in the proportion of women principal investigators over time, the overall representation remains relatively low. The disparities observed in trial characteristics and geographic distribution of women principal investigators further emphasize the need for targeted interventions and policies to foster a more inclusive and diverse environment in clinical trial leadership. CLINICAL RELEVANCE: These results underscore the importance of adopting practices and strategies that foster gender equity in the leadership of orthopaedic clinical trials. By establishing mentorship and sponsorship programs, early-career women surgeons can be connected with experienced leaders, cultivating a supportive network and offering valuable career guidance. Additionally, addressing geographic disparities in the representation of women principal investigators can involve the implementation of mentorship and sponsorship programs in regions with lower representation.

Arthroscopic Meniscus Repair Using an All-Inside, All-Suture, Knotless Device.

With an increased appreciation of the importance an intact meniscus has on normal knee kinematics and function, more meniscal tears are being treated with a repair rather than partial meniscectomy. There are several techniques for repairing torn meniscal tissue, including the outside-in, inside-out, and all-inside repairs. Each technique comes with its advantages and drawbacks. The inside-out and outside-in techniques allow for greater control of the repair using knots outside the joint capsule; however, they pose a risk for neurovascular injury and require additional incisions. Arthroscopic all-inside repairs have seen increasing popularity, but with current techniques, fixation is achieved either with intra-articular knots or extra-articular implants, leading to variable outcomes and the potential for postoperative complications. This technical note describes the use of SuperBall, an all-inside meniscus repair device that provides an all-arthroscopic approach, no intraarticular knots or implants, and surgeon-guided tensioning of the meniscus repair.

Gender Differences in Reimbursement Among Orthopaedic Surgeons: A Cross-sectional Analysis of Medicare Claims.

INTRODUCTION: Inequalities involving women across orthopaedic subspecialties continue to be highlighted in the literature. Previous analyses exploring reimbursement differences between sexes have not controlled for confounding factors or have been limited by small sample sizes. Our study used Medicare data on a national sample of orthopaedic surgeons to better evaluate these disparities. METHODS: This cross-sectional analysis used publicly available data from the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use File. Using each provider's National Provider Identifier number, this data set was linked to the National Plan and Provider Enumeration System downloadable file and the 2019 National Provider Compare Database. Mean differences were calculated using the Welch t -test. Multivariate linear regression analysis was conducted to determine the effect of sex on total Medicare payments per physician, controlling for years in practice, practice diversity, clinical productivity, and subspecialty. RESULTS: Nineteen thousand six orthopaedic surgeons were included in our analysis. Of these providers, 1,058 were female (5.6%) and 17,948 were male (94.4%). Male orthopaedic surgeons billed an average of 19.40 unique billing codes per provider and female orthopaedic surgeons billed 14.4 per provider ( P < 0.001). Female orthopaedic surgeons billed an average of 1,245.5 services per physician while male orthopaedic surgeons billed 2,360.7 services per physician. The mean difference in payment between male and female orthopaedic surgeons was $59,748.7 ( P < 0.001). Multivariate linear regression showed that female sex was a significant predictor of lower total yearly Medicare reimbursement ( P < 0.001). DISCUSSION: These findings emphasize the need for additional efforts to help ensure reimbursement differences do not deter women from pursuing orthopaedics. Healthcare organizations should use this information to ensure equal salary negotiating power among their employees while additionally addressing potential biases and misconceptions related to referrals and surgeon aptitude, respectively.

The impact of race and ethnicity on acute telestroke care: A multistate experience.

INTRODUCTION: Previous analyses suggest that ethnic and racial differences exist in acute stroke care including thrombolytic treatment rates. The current study evaluates ethnic or racial differences in acute stroke treatment within a multi-state telestroke program. METHODS: Acute telestroke consultations seen in the Emergency Department in 203 facilities and 23 states were extracted from the Telecare by TeleSpecialistsTM database. Cases were reviewed for age, race, ethnicity, sex, last known normal time, arrival time, treatment with thrombolytic therapy, door-to-needle (DTN) time, and baseline National Institutes of Health Stroke Scale score. Race was defined as Black, White, or Other; ethnicity was defined as Hispanic or non-Hispanic. RESULTS: The current study included 13,221 acute telestroke consultations consisting of 9890 White, 2048 Black, and 1283 patients classified as Other. A total of 934 patients were Hispanic and 12,287 patients were non-Hispanic. There were no statistically significant differences noted in thrombolytic treatment rates when comparing White (7.9%) patients with non-White patients (7.4%), p = 0.36, or comparing Black (8.1%) with non-Black patients (7.8%), p = 0.59. In addition, there were no statistically significant differences in treatment rates comparing Hispanic (6.3%) with non-Hispanic (7.9%) patients, p = 0.072. We noted no measurable differences in DTN times by race or ethnicity. CONCLUSIONS: Contrary to previous reports, we failed to detect any significant differences in thrombolytic treatment rates and DTN times by race or ethnicity among stroke patients in a multistate telestroke program. These findings support the hypothesis that telestroke may mitigate racial and ethnic disparities which may be attributable to local variability in stroke procedures or access to healthcare.

Acceptable clinical outcomes despite high reoperation rate at minimum 12-month follow-up after concomitant arthroscopically assisted anterior cruciate ligament reconstruction and medial meniscal allograft transplantation.

BACKGROUND: Single-stage medial meniscus allograft transplantation (MAT) with concomitant anterior cruciate ligament reconstruction (ACLR) is a technically challenging procedure for management of knee pain and instability in younger patients, but clinical and functional outcomes data are sparse. The purpose of this study was to assess surgical and patient-reported outcomes following concomitant ACLR and medial MAT. METHODS: We conducted a retrospective case series of patients who underwent medial MAT with concomitant primary or revision ACLR at our institution from 2010 to 2021 and had minimum 12-month follow-up. Complications, reoperations, visual analog scale (VAS) pain, satisfaction, Lysholm score, return to sport, and return to work outcomes were assessed. Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference, Pain Intensity, and Physical Function Scores were used to measure patients' functional status relative to the US population. P-values < 0.05 were considered significant. RESULTS: The cohort consisted of 17 knees of 16 individual patients. The cohort was majority male (82.4%) with mean age of 31.9 years (range 19-49 years) and mean body mass index (BMI) of 27.9 kg/m2 (range 22.5-53.3 kg/m2). Mean follow-up time was 56.8 months (range 13-106 months). Most patients underwent revision ACLR (64.7%). The 1-year reoperation rate was high (23.5%), with two patients (11.8%) tearing their meniscus graft. Patient-reported outcomes indicated low VAS pain (mean 2.2), high satisfaction (mean 77.9%), and fair Lysholm score (mean 81.1). Return to work rate was high (92.9%), while return to sport rate was low (42.9%). Postoperative PROMIS scores were comparable or superior to the national average and correlated significantly with patient satisfaction (p < 0.05). CONCLUSIONS: The concomitant ACLR and MAT procedure is associated with excellent knee pain and functional outcomes and high rate of return to work after surgery, though the 1-year reoperation rate is high and rate of return to sport is low. LEVEL OF EVIDENCE: IV.

Postoperative flares and peri-arthroscopic management of immunosuppressive medications in patients with rheumatic disease.

PURPOSE: To determine the rate and characteristics of postoperative flares in rheumatic disease patients undergoing arthroscopic surgery, and the role of perioperative immunosuppression (IS) management in preventing or provoking these exacerbations. METHODS: We conducted a retrospective review of arthroscopic surgeries in patients with rheumatologic disease over 11 years. Patients taking IS at baseline and those without were matched 1:1 using propensity scores on age, sex, rheumatic disease type, and procedure complexity. Patients taking IS at baseline were sub-divided into those remaining on IS perioperatively versus those who held IS before surgery. Multivariable logistic regression identified risk factors for postoperative flares for the three IS groups, and survival analysis was used to compare the probability of remaining flare-free up to 12 weeks postoperatively. RESULTS: After matching, 428 patients (214 on various types of baseline IS, 214 not on baseline IS) were included, with 110 on baseline IS remaining on it perioperatively. Rates of postoperative flares were similar for those staying on vs holding their baseline IS (9.1% vs 9.6%) but flares were less frequent in patients not on baseline IS (1.9%). Patients who remained on perioperative IS did not have significantly less flares compared to patients taken off perioperative IS (OR 0.764 [0.267, 2.181]; p = 0.61). Patients not on baseline IS had a significantly higher probability ofremaining flare-free up to 12 weeks (p = 0.004). CONCLUSION: Rheumatic disease patients who hold IS medication before undergoing arthroscopy, out of concern for potential infection or complications, do not significantly increase their risk of flaring their autoimmune disease whether they had been taking csDMARDs or biologic agents. Those not taking any IS at baseline have a much lower risk of post-arthroscopic flaring, though as a group they likely harbor less of an autoimmune burden.

How do pre-operative intra-articular injections impact periprosthetic joint infection risk following primary total hip arthroplasty? A systematic review and meta-analysis.

INTRODUCTION: Although intra-articular injections (IAIs) serve as the first-line non-surgical management for severe osteoarthritis (OA), recent analyses have suggested they are associated with an increased infection risk following primary total hip arthroplasty (THA). Therefore, our systematic review and meta-analysis explored the relationship between IAIs and periprosthetic joint infection (PJI) following THA reported in the current literature. METHODS: Five online databases were queried for analyses published from January 1st, 2000-May 1st, 2021 reporting on PJI rates between patients undergoing primary THA who did and did not preoperatively receive an IAI. The overall pooled effect of injection status on PJI incidence was determined using Mantel-Haenszel (M-H) models. This was similarly conducted for segregated preoperative intervals: 0-3 months, > 3-6 months, > 6 + months. RESULTS: A total of 11 articles were included in our analysis reporting on 278,782 THAs (IAI: n = 41,138; no IAI: n = 237,644). Patients receiving pre-operative injections had a significantly higher risk of PJI (OR: 1.31, 95% CI 1.07-1.62; p = 0.009). However, this finding was not robust. IAI receipt within 3-months of THA was associated with significantly higher PJI rates (OR: 1.68, 95% CI 1.48-1.90; p < 0.001). However, no significant difference was demonstrated in the > 3-6 month (OR: 1.19, 95% CI 0.94-1.52; p = 0.16) and > 6 + month sub-analyses (OR: 1.20, 95% CI 0.96-1.50; p = 0.11). The results of all sub-analyses remained were robust. DISCUSSION: Our findings suggest that patients requiring THA should wait at least 3-months following IAI to reduce post-operative infection risk. This information can help inform patients considering OA management options, as well as adult reconstruction surgeons during preoperative optimization.

Concentration of synovial fluid biomarkers on the day of anterior cruciate ligament (ACL)-reconstruction predict size and depth of cartilage lesions on 5-year follow-up.

PURPOSE: The current investigation evaluated the relationship between the synovial fluid cytokine microenvironment at the time of isolated anterior cruciate ligament (ACL) reconstruction and the presence of subsequent chondral wear and radiologic evidence of osteoarthritis (OA) on cartilage-specific MRI sequences at a minimum of 5-year follow-up. METHODS: Patients who underwent primary ACL reconstruction with no baseline concomitant cartilage or meniscal defects and had synovial fluid samples obtained at the time of surgery were retrospectively identified. Patients with a minimum of 5 years of postoperative follow-up were contacted and asked to complete patient-reported outcome (PRO) measures including Visual Analog Scale (VAS) for pain, Lysholm Scale, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Tegner Activity Scale, along with postoperative magnetic resonance imaging (MRI). The concentration of ten biomarkers that have previously been suggested to play a role in cartilage degradation and inflammation in the joint space was measured. Linear regression controlling for age, sex, and body mass index (BMI) was performed to create a model using the synovial fluid concentrations at the time of surgery to predict postoperative semiquantitative cartilage lesion size and depth on MRI at a minimum of 5 years follow up. RESULTS: The patients were comprised of eight males (44.4%) and ten females (55.6%) with a mean age at the time of surgery of 30.8 ± 8.7 years (range 18.2-44.5 years). The mean follow-up time was 7.8 ± 1.5 years post-operatively (range 5.7-9.7 years). MCP-1, VEGF, and IL-1Ra were found to have significant associations with the presence of postoperative cartilage wear (p < 0.05). No correlations were demonstrated among the biomarker concentrations at the time of injury with PRO scores at final follow-up (NS). CONCLUSION: Synovial fluid inflammatory biomarker concentrations at the time of injury can predict progression of early-stage post-traumatic osteoarthritis at a mean of almost 8 years post-operatively. Findings from this study may help identify treatment targets to alter the natural history of cartilage loss following anterior cruciate ligament injury. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

RANTES Concentration at the Time of Surgery Is Associated With Postoperative Stiffness in Patients Undergoing ACL Reconstruction.

BACKGROUND: Patients undergoing anterior cruciate ligament (ACL) reconstruction have been shown to be at risk for postoperative arthrofibrosis. Diagnostic biomarkers associated with the development of postoperative stiffness are unknown. HYPOTHESIS: Biomarkers found in the synovial fluid at the time of surgery are associated with the development of postoperative arthrofibrosis in a cohort of patients undergoing ACL reconstruction. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients undergoing ACL reconstruction were prospectively enrolled. Synovial fluid was collected before surgical incision. A cohort of patients with postoperative stiffness requiring manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) was retrospectively identified. Matching of cases to controls was performed using a 1:2 pair matching algorithm. Risk factor-adjusted single-biomarker and multivariable models were used to assess the association of synovial fluid biomarkers with postoperative stiffness requiring MUA/LOA. Stepwise logistic regression controlling for clinical risk factors was used to identify biomarkers that are possible predictors of postoperative stiffness. RESULTS: A total of 11 cases (3 male, 8 female) were identified and matched with 21 controls (6 male, 15 female) with no significant differences in age, sex, smoking history, or days from injury to surgery. Concentrations of the biomarker regulated upon activation, normal T-cell expressed and presumably secreted (RANTES) were significantly higher in patients requiring MUA/LOA versus controls (694.20 pg/mL [interquartile range, 214.75-3428.79] vs 113.04 pg/mL [interquartile range, 32.81-517.91], respectively; P = .034). On single-biomarker models, RANTES (odds ratio, 2.28; 95% CI, 1.29-5.37; P = .019) and basic fibroblast growth factor (bFGF) (odds ratio, 1.91; 95% CI, 1.07-3.99; P = .047) were associated with increased risk of postoperative stiffness requiring MUA/LOA after ACL reconstruction. Stepwise logistic regression identified 3 biomarkers that are possible predictors of postoperative stiffness, which were included in the final model: Interleukin 1 receptor antagonist (IL-1RA) (P = .198), bFGF (P = .157), and RANTES (P = .046). CONCLUSION: Higher concentrations of synovial fluid biomarkers bFGF and RANTES were associated with increased risk for stiffness requiring intervention after ACL reconstruction. Interleukin 6 (IL-6), vascular endothelial growth factor A (VEGF-A), tissue inhibitor of metalloproteinases 1 (TIMP-1), interleukin 1 receptor antagonist (IL-1RA), matrix metalloproteinase 3 (MMP-3), monocyte chemotactic protein 1 (MCP-1), and macrophage inflammatory protein 1B (MIP-1B) were not associated with the development of postoperative arthrofibrosis.

Current Controversies in Arthroscopic Partial Meniscectomy.

PURPOSE OF REVIEW: Given the continued controversy among orthopedic surgeons regarding the indications and benefits of arthroscopic partial meniscectomy (APM), this review summarizes the current literature, indications, and outcomes of partial meniscectomy to treat symptomatic meniscal tears. RECENT FINDINGS: In patients with symptomatic meniscal tears, the location and tear pattern play a vital role in clinical management. Tears in the central white-white zone are less amenable to repair due to poor vascularity. Patients may be indicated for APM or non-surgical intervention depending on the tear pattern and symptoms. Non-surgical management for meniscal pathology includes non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), and intraarticular injections to reduce inflammation and relieve symptoms. There have been several landmark multicenter randomized controlled trials (RCTs) studying the outcomes of APM compared to PT or sham surgery in symptomatic degenerative meniscal tears. These most notably include the 2013 Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial, the 2018 ESCAPE trial, and the sham surgery-controlled Finnish Degenerative Meniscal Lesion Study (FIDELITY), which failed to identify substantial benefits of APM over nonoperative treatment or even placebo surgery. Despite an abundance of literature exploring outcomes of APM for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following APM. It is often difficult to determine if the presenting symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant OA. A central tenet of managing meniscal pathology is to preserve tissue whenever possible. Most RCTs show that exercise therapy may be non-inferior to APM in degenerative tears if repair is not possible. Given this evidence, patients who fail nonoperative treatment should be counseled regarding the risks of APM before proceeding to surgical management.

Acute Well-Leg Compartment Syndrome After Meniscal Allograft Transplantation and Revision ACL Reconstruction: A Case Report.

CASE: A 17-year-old adolescent boy presented with continued knee pain, swelling, and mechanical symptoms after anterior cruciate ligament (ACL) reconstruction with partial meniscectomy. The patient eventually underwent ACL revision surgery that was without complications. Postoperatively, the well leg grew firm with associated neurological deficits, and physical examination confirmed compartment syndrome of the lower leg compartments that resolved with emergency fasciotomy. The patient proceeded on normal postoperative course. CONCLUSION: Compartment syndrome of the well leg is a rare complication in the field of sports medicine, owing to the relatively healthy and young demographic, but providers should nonetheless be vigilant to prevent disastrous sequalae.

Intra-articular injection receipt within 3 months prior to primary total knee arthroplasty is associated with increased periprosthetic joint infection risk.

PURPOSE: This systematic review and meta-analysis analyzed the influence of pre-operative intra-articular injections (IAI) on periprosthetic joint infection (PJI) rates after primary total knee arthroplasty (TKA). METHODS: Studies published between January 1st, 2000 and May 1st, 2021 evaluating PJI rates among TKA patients with and without IAI were identified from PubMed, Cochrane Library, MEDLINE, EBSCO Host, and Google Scholar. The pooled effect of IAI on PJI risk was calculated utilizing Mantel-Haenszel (M-H) models. Sub-analysis comparisons were conducted based on the interval from IAI to TKA: 0-3 months; > 3-6 months; > 6-12 months. The Methodological Index for Non-Randomized Studies (MINORS) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool were utilized to evaluate the quality of each included study. RESULTS: The present analysis included 12 studies reporting on 349,605 TKAs (IAI: n = 115,122; No IAI: n = 234,483). Patients receiving an IAI at any point prior to TKA (2850/115,122; 2.48%) had statistically significant increased risk of infection compared to patients not receiving IAIs (4479/234,483; 1.91%; OR: 1.14, 95% CI: 1.08-1.20; p < 0.0001). However, this finding was not demonstrated across sensitivity analyses. Receiving injections within 3 months prior to TKA was associated with increased infection risk (OR: 1.23, 95% CI: 1.14-1.31; p < 0.0001). There were no differences in infection rates when injections were given between > 3 and 6 months (OR: 0.82, 95% CI: 0.47-1.43; p = 0.49) and > 6-12 months prior to TKA (OR: 1.26, 95% CI: 0.89-1.78; p = 0.18). CONCLUSIONS: Based on the current literature, the findings of this analysis suggest that patients receiving IAI should wait at least 3 months before undergoing TKA to mitigate infection risk. Orthopaedic surgeons and patients can utilize this information when undergoing shared decision-making regarding osteoarthritis management options and timing. LEVEL OF EVIDENCE: Level III.

Telestroke: Maintaining Quality Acute Stroke Care During the COVID-19 Pandemic.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted acute stroke care globally. Decreased stroke presentations and concern for delays in acute stroke care have been identified. This study evaluated the impact of COVID-19 on the timely treatment of patients with thrombolytics at hospitals utilizing telestroke acute stroke services. Methods: Acute stroke consultations seen in 171 hospitals (19 states) via telestroke from December 1, 2019, to June 27, 2020, were extracted from the TeleCare™ database. The consults were divided into pre-COVID and COVID groups (March 15, 2020, start of COVID group). The consults were reviewed for age, sex, hospital, state, date seen, last known normal, arrival time, consult call time, needle time, thrombolytic candidate, and National Institutes of Health Stroke Scale (NIHSS) score. The total number of consults, median door to needle (DTN) time for emergency department (ED) patients, and call to needle (CTN) time for inpatients were calculated. Results: Pre-COVID, 15,226 stroke consults were evaluated compared with 11,105 in the COVID group, a 27% decrease. Pre-COVID, 1,071 ED patients (7.9%) received thrombolytics and 66 inpatients (4.0%), while COVID, 813 ED patients (8.2%) and 70 inpatients (5.7%). The median DTN time for ED patients pre-COVID was 42 (32, 55) versus 40 (31, 52) in the COVID group, with no statistically significant difference between groups. CTN time pre-COVID was 53 (35, 67) versus 46 (35, 61) in the COVID group, with no statistically significant difference between groups. Conclusions: Telestroke assessments allowed for uninterrupted acute stroke care and treatment stability despite nursing and other resource realignments triggered by the COVID-19 pandemic.

Effects of enzyme-assisted extraction on the profile and bioaccessibility of isoflavones from soybean flour.

The effects of enzymatic extraction strategies on extractability, bioconversion, and bioaccessibility of biologically active isoflavone aglycones, total phenolic content, and antioxidant activity of aqueous extracts from full-fat soy flour were evaluated. Protease, tannase, and cellulase enzymes were used individually or in combination. Except for the protease treatment, all enzymatic treatments increased the extraction of biologically active isoflavones (daidzein and genistein) compared with the control. The use of a mixture of protease, tannase, and cellulase resulted in increased extractability and/or bioconversion of aglycones from soy flour, indicating a synergistic effect amongst the enzymes. Daidzein and genistein concentrations increased from 29.0 to 158.2 µg/g and from 27.0 to 156.5 µg/g (compared to the control), respectively. Furthermore, enzymatic extraction followed by in vitro gastrointestinal digestion significantly increased the bioaccessibility of isoflavone aglycones, total phenolic content (by 22-45%), and antioxidant activity (by 15-22%) of the extracts. These results demonstrate that enzyme selection is an efficient strategy to maximize the extraction, bioconversion, and bioaccessibility of bioactive isoflavones from soy flour, which could contribute to health benefits associated with the consumption of soy-rich products.