The Relationship Between Surgeon Volume and Major Surgical Complications After Total Shoulder Arthroplasty: An Evaluation of 3177 US Orthopedic Surgeons.

BACKGROUND: Total shoulder arthroplasty (TSA), which includes anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), is a technically demanding procedure and limited data exist on the relationship between case volume and complications. We sought to identify volume thresholds for TSA, aTSA, and rTSA at which risk of a major surgical complication decreased and to compare complications of patients treated by high-volume surgeons with those of patients treated by low-volume surgeons. MATERIALS AND METHODS: Primary, elective TSAs (aTSA and rTSA) from January 1, 2016, to December 31, 2019, were identified in the Premier Healthcare Database. Multivariable logistic regression with restricted cubic splines modeled the relationship between annual TSA, aTSA, and rTSA surgeon volume and 90-day risk of major surgical complications. The 90-day complications of patients treated by high- and low-volume surgeons were compared. RESULTS: From 2016 to 2019, 3177 surgeons performed 78,639 TSAs. Increasing annual volume was associated with decreasing major surgical complication risk (thresholds: 50 TSAs, 25 aTSAs, and 36 rTSAs). High- and low-volume surgeons performed 24,595 and 54,044 TSAs, respectively. Patients of high-volume surgeons had lower risk of major surgical complications (adjusted odds ratio [aOR], 0.69; 95% CI, 0.56-0.84), myocardial infarction (aOR, 0.59; 95% CI, 0.36-0.97), and readmission (aOR, 0.71; 95% CI, 0.62-0.81). Importantly, 74.9% of high-volume and 93.0% of low-volume surgeon-year units had major surgical complication rates below the mean of all recorded surgeons. CONCLUSION: While most high- and low-volume surgeons had major surgical complication rates below the cohort average, increasing TSA volume was associated with a decreased risk of complications. [Orthopedics. 202x;4x(x):xx-xx.].

Preoperative Mental Health Disorders Affect Opioid Consumption and Perioperative Complications After Total Shoulder Arthroplasty.

BACKGROUND: Limited evidence exists regarding the influence of mental health disorders (MHDs) on opioid use and complications after total shoulder arthroplasty (TSA). We aimed to identify the prevalence of common MHDs among patients undergoing anatomic TSA (aTSA) and reverse TSA (rTSA). MATERIALS AND METHODS: The Premier Healthcare Database was queried for patients undergoing primary aTSA and rTSA from 2016 to 2020. International Classification of Diseases, Tenth Revision, diagnosis codes were used to identify MHDs. Primary outcomes included the prevalence of MHDs, perioperative opioid consumption, and 90-day risk of postoperative complications, revision, and readmission. Bivariate and multivariate regression analyses were performed to assess 90-day risk of primary endpoints while controlling for potential confounders. Statistical significance was defined as P<.05. RESULTS: From 2016 to 2020, 49,997 of 144,725 (34.55%) patients undergoing primary TSA had at least one diagnosed MHD. The most prevalent were depression (17.03%), anxiety (16.75%), and substance use disorder (10.20%). Patients with a MHD had higher mean hospital costs ($75,984±$43,129 vs $73,316±$39,046, P<.0001), longer mean length of stay (1.95±2.25 days vs 1.61±1.51 days, P<.0001), and higher mean total postoperative opioid use (72.00±231.55 morphine milligram equivalents [MMEs] vs 59.32±127.31 MMEs, P<.0001). Periprosthetic fractures (odds ratio, 1.20; P=.041), dislocation (odds ratio, 1.12; P=.042), and 90-day readmission rates (odds ratio, 1.26; P<.001) were significantly higher among patients with a MHD. CONCLUSION: This study found that MHDs are associated with significantly increased perioperative opioid consumption, medical and surgical complication rates, and risk of readmission after TSA. Recognition and optimization of MHDs is critical to minimizing complications and opioid consumption after TSA. [Orthopedics. 202x;4x(x):xx-xx.].

Commercial Insurance Coverage Criteria for Autologous Chondrocyte Implantation Poorly Reflect Current Research.

OBJECTIVE: The aim of this study is to both quantify and qualify the way insurance companies justify their coverage policies for autologous chondrocyte implantation (ACI) and determine whether these policies align with recent research on the subject. DESIGN: The top 11 national commercial health insurance payers for ACI were identified. Coverage policy documents were recovered for 8 payers. These documents were examined, and the type of reference and the level of evidence (LOE) were recorded for each applicable reference. Specific coverage criteria for each individual payer were then extracted and assessed for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria. RESULTS: This study found that the majority of cited references were primary journal articles (86, 58.1%) and that only 30 (20.2%) references were level I or level II evidence. This study also found significant homogeneity among payer coverage criteria. Cited sources inconsistently mentioned specific payer coverage criteria. In addition, payer criteria tended to be poorly supported by current evidence on ACI. CONCLUSIONS: This study demonstrates that commercial insurance payers' coverage policies for ACI poorly cite references, cite a majority of references with low LOE, and cite references which infrequently mention their specific coverage criteria. In addition, payer coverage policies have a high degree of homogeneity and many of their specific criteria are poorly supported by current research on ACI.

Studies With Direct Industry Affiliation Are More Likely to Report Positive Results in Randomized Controlled Trials for Platelet-Rich Plasma Use in Rotator Cuff Tears: A Systematic Review.

PURPOSE: To perform a systematic review to evaluate the effect of industry affiliation on the outcomes of randomized controlled trials for platelet-rich plasma (PRP) injections in rotator cuff tears METHODS: The PubMed, SPORTDiscus, and Scopus databases were searched from 2010 to the present for the terms "rotator cuff" and "platelet-rich plasma." The inclusion criteria were randomized controlled trials comparing PRP with controls for the treatment of rotator cuff tears, and the exclusion criteria were systematic reviews, meta-analyses, case reports, cohort studies, basic science studies, studies of Level III or below, and studies not in English. Degree of industry affiliation was categorized into 3 groups: directly, indirectly, and not affiliated. Direct affiliation required the study or its authors to receive financial support from the company manufacturing the devices used in the study to prepare or administer PRP. Indirect affiliation required financial association with a different company that produces or administers PRP than the company in the study. Studies were classified as favorable if study outcomes achieved significance (P < .05) of PRP over controls or as analogous if there was no statistical significance between PRP and controls. Data were analyzed using the χ2 test and Fisher exact test. RESULTS: Of the 47 studies selected for analysis, 8 (17.0%) had no direct industry affiliation; 9 (19.1%) had indirect affiliation; and 30 (63.8%) had no industry affiliation. Of the studies, 22 (46.8%) reported favorable results with PRP compared with controls and 25 (53.2%) showed analogous results between PRP and controls. Degree of industry affiliation was significantly associated with an increased likelihood of reporting favorable study outcomes (P = .041). Directly affiliated studies had a significantly increased likelihood of reporting favorable results (P = .024) compared with indirectly affiliated studies. CONCLUSIONS: Studies that used PRP produced by companies that directly funded the studies or were financially affiliated with the authors were significantly more likely to report favorable results. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

The Literature that Commercial Insurance Payers Use to Substantiate Knee Osteochondral Allograft Policies Are of a Low Level of Evidence.

OBJECTIVE: The purpose of this study is to analyze how the largest insurance companies support their medical necessity policies regarding osteochondral allograft transplantation (OCA) and to determine whether the literature they cite in their policies is of a high level of evidence (LOE). DESIGN: The 10 largest national health insurance companies were identified. Each payer was contacted via phone or email to obtain their coverage policy regarding OCA. For each policy, the medical necessity criteria were recorded, and all cited references were screened. For all references applicable to OCA, the LOE was recorded, and each reference was screened to determine whether they mentioned the specific criteria reported in the policies. RESULTS: The medical policies for 6 of the 10 national health insurance companies were identified. These 6 policies cited a collective total of 102 applicable references. Most of these studies were an LOE of IV (n = 58, 56.9%) and an LOE of V (n = 18, 17.6%). There were similarities amongst the medical necessity criteria between different commercial payers; however, most criteria were poorly supported by the cited literature. CONCLUSIONS: Our results demonstrate that commercial insurance companies utilize studies that are of a low LOE when justifying their medical necessity criteria. Moreover, these cited studies infrequently support or mention the commercial payers' criteria. Future studies should continue to explore how well-supported insurance policies are with the goal of potentially increasing access and authorization for well-supported treatment modalities.

Industry affiliation does not predict outcomes of randomized controlled trials for mesenchymal stem cells in knee osteoarthritis.

BACKGROUND: This research aims to determine the influence of industry on the outcomes of randomized controlled trials (RCTs) for Mesenchymal Stem Cell (MSC) treatments in knee osteoarthritis (OA). METHODS: PubMed, Scopus, and Web of Science were searched from 2010 onwards using the terms "knee osteoarthritis" and "mesenchymal stem cells". After identifying relevant RCTs, studies were categorized as industry-affiliated or non-industry-affiliated. They were also classified as favorable if they achieved statistically significant (p < 0.05) results with MSC injections compared to control. Chi-squared tests were employed to analyze the relationship between industry affiliation and study outcome. RESULTS: Post exclusion criteria, 38 studies were analyzed. Of these, there were 20 (52.6%) industry affiliated (IA) and 18 (47.4%) non-industry affiliated (NIA) studies. Among the 20 IA studies, 17 (85.0%) reported favorable outcomes for MSC treatment arm, with the remaining 3 (15.0%) showing analogous (no difference between treatment arms) results. For the 18 NIA studies, 15 (83.3%) were favorable, and 3 (16.6%) were analogous. No significant difference in outcomes was observed between IA and NIA studies (p = 0.888). Analysis of patient reported outcomes also revealed no significant difference. Of note, studies using allogeneic MSCs were more likely to be IA than studies using autologous MSCs (p = 0.005) CONCLUSION: This study demonstrated no strong association between industry affiliation and the outcomes of RCTs for MSC treatments in knee OA. Despite this, the potential influence of industry ties should always be considered when applying study findings to new treatment modalities for patient care.

Results of Randomized Controlled Trials of Platelet-Rich Plasma in Lower-Extremity Tendinopathy Are Not Influenced by Industry Sponsorship.

PURPOSE: To determine whether industry affiliation influences the results of randomized controlled trials (RCTs) studying the use of platelet-rich plasma (PRP) for the treatment of patellar or Achilles tendinopathy. METHODS: The PubMed, Scopus, Cochrane, and MEDLINE databases were searched in July 2023 for RCTs investigating PRP for the treatment of patellar or Achilles tendinopathy published between 2009 and July 2023. Industry affiliation was determined by analyzing each study's funding or conflict-of-interest section. Author disclosures were searched in the American Academy of Orthopaedic Surgeons disclosure database and the Centers for Medicare & Medicaid Services open payments database. An industry-affiliated (IA) designation was given if an author had a relevant disclosure or if the company that funded the study manufactured PRP. Otherwise, a non-industry-affiliated (NIA) designation was given. Fisher exact analysis was used to determine whether PRP had a favorable effect, no significant effect, or an unfavorable effect on outcome. RESULTS: Analysis was performed on 22 studies (10 IA and 12 NIA), with 17 studies (77.3%) reporting a conflict of interest or funding for the research, 4 (18.2%) reporting no conflict of interest, and 1 (4.5%) with no reporting. Of the 22 included studies, 8 (36.4%) reported favorable outcomes regarding PRP use and 14 (63.6%) reported no significant effect. Favorable outcomes were found in 4 of the 10 IA studies (40.0%), whereas no significant effect was reported in 6 (60.0%). The 12 NIA studies included 4 (33.3%) with favorable results and 8 (66.7%) with no significant effect. The comparison between industry affiliation and results reported was not statistically significant (P > .999). CONCLUSIONS: The results of RCTs evaluating the use of PRP in lower-extremity tendinopathy were not influenced by industry sponsorship. CLINICAL RELEVANCE: Most biomedical research is funded through industry sponsorship. Although this relation is necessary as technologies are developed, it is important to scrutinize studies for evidence of industry bias to understand how this bias may be affecting study results published in the literature.

Most Major Hospitals Fail to Comply With Federal Price Transparency Regulations.

PURPOSE: To present hospital compliance with federal price transparency regulations for sports medicine procedures. METHODS: Online price estimator and machine-readable files were recovered for U.S. News and World Report's top 100 orthopaedic hospitals. From June to November 2023, compliance and monetary values were recorded for each of Centers for Medicare and Medicaid Services price transparency regulations. Price estimator data were assessed on the basis of hospital placement in the bottom and top 50 of the 100 institutions under review, as well as by region (Northeast, South, Midwest, West). Statistical analyses included 2-sample t tests and Kruskal-Wallis tests. RESULTS: In total, 95% of hospitals had a price estimator tool for both subacromial decompression (Current Procedural Terminology [CPT] code 29826) and meniscectomy (CPT code 29881). Only 38% were compliant with all regulations for subacromial decompression and 39% for meniscectomy; the remaining did not list minimum or maximum procedure charges. Higher-ranked hospitals were significantly more likely to charge a greater cash price for subacromial decompression and meniscectomy (P = .040 and P = .009, respectively). Compliance with machine-readable file reporting was poor, with less than 20% meeting requirements for each CPT code. Reported prices varied greatly by hospital. CONCLUSIONS: This study demonstrates that U.S. News and World Report's top 100 orthopaedic hospitals exhibit poor overall compliance with federal price transparency regulations for sports medicine procedures. Most often they lack full compliance by not reporting minimum or maximum charges as part of their price estimator tool or do not report procedure prices in their machine-readable files. Hospitals also exhibit wide variation in prices reported for specific procedures. CLINICAL RELEVANCE: Consumer price transparency continues to be an important goal in health care, as it allows patients to make informed decisions when selecting appropriate treatment options and providers. To realize the full benefits of price transparency, hospitals should address areas of improvement.

Effect of body mass index on complications following total shoulder arthroplasty: a population-wide analysis.

BACKGROUND: Evidence regarding the effect of body mass index (BMI) on complications following anatomic shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA) remains controversial. This high-powered study examines the effect of BMI on surgical and medical complications following aTSA and rTSA. METHODS: This retrospective cohort study was conducted using the Premier Healthcare Database to query all adult patients who underwent primary, elective TSA (aTSA, rTSA) from 2016 to 2020. Patients eligible for inclusion were identified using International Classification of Diseases -10 and CPT codes for primary TSA. Patients were stratified into 3 subgroups based on BMI (BMI <30 kg/m2, BMI 30-35 kg/m2, BMI >35 kg/m2). The primary endpoints assessed were 90-day risks of postoperative complications, revisions, and readmissions among the 3 BMI groups undergoing primary TSA. RESULTS: A total of 32,645 patients were analyzed; 10,951 patients underwent aTSA and 21,694 patients underwent rTSA. Patient populations for aTSA and rTSA differed significantly across all BMI categories in terms of age, sex, cost of care, and insurance status. After multivariate regression analysis, there was no increased risk of surgical complications in the aTSA and rTSA cohorts with BMI 30-35 kg/m2 and BMI >35 kg/m2. In the aTSA cohort, rates of acute respiratory failure (adjusted Odds Ratio [aOR] 2.65) was all significantly higher in the BMI >35 kg/m2 group. As for rTSA cohort, acute respiratory failure (aOR 1.67) and acute renal failure (aOR 1.53) were significantly higher in the BMI >35 kg/m2 group. CONCLUSION: While we found no increased risk of immediate postoperative surgical risks, patients with a BMI >35 kg/m2 demonstrated greater risk of medical complications after rTSA. Given this trend, providers should exercise caution in patient selection for TSA and counsel obese patients as to these increased risks. Future studies should aim to provide a more comprehensive picture of the effect of BMI on functional outcomes after TSA.

Perioperative intravenous dexamethasone use is not associated with periprosthetic joint infection or wound healing complications following shoulder arthroplasty.

BACKGROUND: Perioperative intravenous (IV) dexamethasone is commonly used in lower extremity total joint arthroplasty to manage postoperative pain and nausea/vomiting, and recent studies have demonstrated that its use may lower rates of acute postoperative medical complications. However, there is limited information regarding the safety and efficacy of IV dexamethasone in patients undergoing total shoulder arthroplasty (TSA). Additionally, there is concern surrounding corticosteroid use prior to surgery as preoperative corticosteroid injections have been associated with adverse outcomes after TSA, including periprosthetic joint infection (PJI) and revision surgery. Thus, the purpose of this study was to evaluate the effect of perioperative IV dexamethasone on 90-day rates of PJI, wound complications, and medical complications after TSA. METHODS: The Premiere national hospital database was used to identify adult patients undergoing elective TSA between 2016 and 2020; patients were excluded if they were under 18 years old, were undergoing revision TSA, or had a prior proximal humerus open reduction internal fixation procedure. Patients who did and did not receive perioperative IV dexamethasone were then compared in both univariate and multivariate analyses. A Bonferroni correction was utilized to adjust for multiple comparisons. The primary end point was risk of acute infectious complications within 90 days of surgery, including PJI and wound infection/dehiscence. Secondary end points included acute pulmonary, renal, and thromboembolic complications. RESULTS: A total of 135,333 patients underwent TSA during the study period; 61.2% underwent reverse total shoulder arthroplasty, 33.8% underwent anatomic total shoulder arthroplasty, and 5.0% underwent hemiarthroplasty. From 2016 to 2020, perioperative IV dexamethasone use increased by 135%. Multivariate analysis revealed that patients who received perioperative IV dexamethasone did not have increased odds of PJI, superficial wound infection, or wound dehiscence (P = .15-.47) but did have decreased odds of sepsis (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.55-0.81) and other medical complications such as urinary tract infection and acute kidney injury. Additionally, there was a trend towards decreased 90-day hospital readmission (OR 0.88, 95% CI 0.81-0.96, P = .003). CONCLUSIONS: Perioperative IV dexamethasone was not associated with increased risk of acute infectious and wound healing complications. Moreover, patients who received perioperative IV dexamethasone had decreased odds of medical complications and trended toward lower rates of 90-day hospital readmission. The results of this study support the safety of perioperative IV dexamethasone use in patients undergoing elective TSA.

Evidence Guiding Commercial Payer Coverage Criteria for Total Ankle Arthroplasty.

Background: Total ankle arthroplasty (TAA), first developed as an alternative to ankle arthrodesis, has become an increasingly popular management option for end-stage ankle arthritis. Prior studies have shown commercial insurance payers base their coverage criteria on limited and low level of evidence research. This study aims to quantify and describe the evidence insurance companies use to support TAA coverage policies. Methods: The top 11 national commercial health insurance payers for TAA were identified. A google search was performed to identify payer coverage policies. Policy documents were examined and cited references were classified by type of reference as well as reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted. Criteria were compared to assess for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria. Results: Six of the 11 payers had accessible coverage policies. The majority of cited references were primary journal articles (145, 60.9%) and the majority of references cited (179, 75.2%) were level III or level IV evidence. We found significant homogeneity in coverage criteria among payers. In addition, cited sources inconsistently mentioned specific payer coverage criteria. Conclusion: This study demonstrates that commercial insurance payers rely on the relatively low level of currently available scientific evidence when formulating coverage policies for TAA use and adopt criteria that have not been thoroughly analyzed in the literature. More high level of evidence research is needed to help clinicians and insurance companies further refine indications for TAA so that patients who might benefit from the procedure are adequately covered. Level of Evidence: Level IV, review.

Subjective Causes for Failure to Return to Sport After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

CONTEXT: While current literature has explored the outcomes of athletes who return to sport (RTS) after anterior cruciate ligament (ACL) injuries, less is known about the outcomes of those who are unsuccessful in returning to sport. OBJECTIVE: To determine the rate of athletes who did not RTS after primary ACL reconstruction (ACLR) and to identify the specific subjective reasons for failure to RTS. DATA SOURCES: A comprehensive search of the PubMed/MEDLINE, Scopus, and Web of Science databases was conducted through April 2021. STUDY SELECTION: Eligible studies included those explicitly reporting the rate of failure for RTS after ACLR as well as providing details on reasons for athletes' inability to return; 31 studies met the inclusion criteria. STUDY DESIGN: Systematic review and meta-analysis. LEVEL OF EVIDENCE: Level 2 to 4. DATA EXTRACTION: The reasons for failure to RTS referred to in our study are derived from those established previously in the studies included. Data were collected on the number of athletes, mean age, mean follow-up time, type of sport played, failure to RTS rate, and specific reasons for failure to return. RESULTS: The weighted rate of failure to RTS after ACLR was 25.5% (95% CI, 19.88-31.66). The estimated proportion of psychosocial-related reasons cited for failure to RTS was significantly greater than knee-related reasons for failure RTS (55.4% vs 44.6%, P < 0.01). The most cited reason for failure to RTS was fear of reinjury (33.0%). CONCLUSION: This study estimates the rate of failure to RTS after ACLR to be 25.5%, with the majority of athletes citing fear of reinjury as the major deterrent for returning to sports. We highlight how factors independent of surgical outcomes may impact an athlete's ability to return to play given that the predominant reason for no RTS after ACLR was unrelated to the knee.

NCAA football players are at higher risk of upper extremity injury after first-time concussion.

BACKGROUND: Previous research has demonstrated that concussions increase the risk of subsequent lower extremity musculoskeletal injury in athletes. However, the risk of upper extremity injury in athletes' post-concussion is poorly understood. METHODS: All concussed football players within a National Collegiate Athletic Association (NCAA) Division I conference athletic database were identified between 2017 and 2021. After exclusions, each athlete experiencing their first concussion was then retrospectively reviewed for upper extremity injuries in the year prior to their concussion and in the year beginning at 90 days after their concussion. All upper extremity injuries were identified and the odds ratio, 95% confidence interval, and statistical significance between groups were calculated in Microsoft Excel. RESULTS: 160 de-identified football players from a single conference who were first diagnosed with concussions in the seasons from 2017 through 2021 met inclusion criteria. In these athletes the odds of upper extremity injury in year following first diagnosed concussion were 2.36 times higher than in the year prior (95% CI 1.13-4.95, p = 0.02). Shoulder was the most common site of injury with 57.7% of injuries compared to 19.2% in the hand, 15.4% in the elbow, 7.7% in the forearm, and 0% in the wrist. CONCLUSION: This study demonstrates that collegiate football players are at a 2.36 times greater risk of upper extremity injury in the year following their first diagnosed concussion compared to the year preceding it. The most common site of upper extremity injury after concussion was the shoulder. LEVEL OF EVIDENCE: III.

Randomized controlled trials in the shoulder arthroplasty literature rarely include key demographic and socioeconomic patient data.

BACKGROUND: It is well known that socioeconomic and demographic variables can greatly affect health outcomes. Previous studies across medical and surgical subspecialties have demonstrated that these variables are frequently under-reported in randomized controlled trials (RCTs). No such study currently exists that examines rates of reporting of sociodemographic variables in shoulder arthroplasty RCTs. This study aims to present these rates and explore the impact of failing to report socioeconomic variables in shoulder arthroplasty RCTs. METHODS: The PubMed database was queried for the term shoulder arthroplasty. Sixty-five RCTs from the past 10 years were identified for inclusion from 5 high-impact orthopedic surgery journals. Each RCT was analyzed for patient age and sex or gender as well as the following sociodemographic variables: race, ethnicity, insurance status, income, work status, and education. It was also noted whether each of the above variable was mentioned in the results section of the article. Data were presented in a descriptive fashion as well as analyzed using χ2 and Fisher exact tests where appropriate. RESULTS: From 2014 to 2023, the 65 shoulder arthroplasty RCTs published reported age in 40 of 65 (61.5%) in their results sections and 61 of 65 (93.8%) in any section. Sex or gender was reported in 27 of 65 (41.5%) in their results sections and 61 of 65 (93.8%) in any section. No articles included any sociodemographic variables in the results section. Reporting rates for sociodemographic variables in any section were as follows: race, 6 of 65 (9.2%); ethnicity, 5 of 65 (7.7%); work status, 4 of 65 (6.2%); and insurance status, 1 of 65 (1.5%). No studies included income or education of the enrolled patients. There was no difference in reporting sociodemographic variables by journal (P = .45) or by year of publication (P = .57). However, no study prior to 2020 included any sociodemographic variable (0 of 27, 0%), whereas from 2020 onward 6 studies included at least 1 (6 of 38, 15.8%). Sociodemographic variables were reported significantly less frequently than age and sex or gender (P = .001). DISCUSSION: Our study found sociodemographic variables are rarely reported in shoulder arthroplasty RCTs, whereas age and sex or gender are reported with great frequency. In order to understand the results of shoulder arthroplasty RCTs, apply their findings to the care of our patients, and address health disparities, we must ensure these studies include patient sociodemographic data.

Demographic and Socioeconomic Patient Data Are Rarely Included in Randomized Controlled Trials for Femoral Acetabular Impingement and Hip Arthroscopy: A Systematic Review.

Purpose: To determine the rate of reporting for sociodemographic variables in randomized controlled trials (RCTs) investigating femoral acetabular impingement (FAI) and hip arthroscopy. Methods: PubMed, Scopus, and Web of Science were queried for articles relating to FAI and hip arthroscopy. Articles included in final analysis were RCTs investigating operative management of FAI. Included RCTs were analyzed for reporting of age and sex or gender as well as the following sociodemographic variables: race, ethnicity, insurance status, income, housing status, work status, and education level in the results section or any section of the paper. Data was analyzed using χ2 and Fisher exact tests with significance defined as P < .05. Results: Forty-eight RCTs were identified from 2011 to 2023. Age was reported in 48 of 48 (100%) of included papers; sex or gender was reported in 47 of 48 (97.9%). Reporting of sociodemographic variables in any section respectively was: race (7/48, 14.6%), ethnicity (4/48, 8.33%), insurance status (0/48, 0%), income (1/48, 2.08%), housing status (0/48, 0%), work status (3/48, 6.25%), and education (2/48, 4.17%). There was no significant difference for reporting demographic variables with respect to journal or year of publication (P = .666 and P = .761, respectively). Sociodemographic variables (9/48) were reported significantly less frequently than age and sex or gender (48/48) (P < .001). Conclusions: This study found that sociodemographic variables in FAI and hip arthroscopy RCTs are reported with much lower frequency than age and sex or gender. These findings may demonstrate the need to include patient sociodemographic data in RCTs so that their results can be better generalized and applied to the appropriate patient population. Level of Evidence: Level II, systematic review of level I and II evidence.

Reporting Bias is Highly Prevalent in Systematic Reviews and Meta-Analyses of Platelet Rich Plasma Injections for Hip Osteoarthritis.

Purpose: To describe the incidence and types of spin in systematic reviews of platelet-rich plasma (PRP) injections for hip osteoarthritis (OA) and to determine whether patterns in study characteristics could be identified among studies with identifiable spin. Methods: The PubMed, Scopus, and SPORTDiscus databases were queried. Inclusion criteria were systematic reviews or meta-analyses that included an assessment of intra-articular PRP injections as a stand-alone treatment for hip OA. Two authors independently assessed the presence of spin in the included studies and recorded general study characteristics. The prevalence of the 15 different categories of spin was quantified using descriptive statistics. Results: Fifteen studies met inclusion criteria for this study. All studies contained at least two types of spin (range 2-9), with a median of 2. The most common type of spin was type 14 ("Failure to report a wide confidence interval of estimates"), which was observed in 10 studies. The second most common type of spin was type 13 ("Failure to specify the direction of the effect when it favors the control intervention"), found in 6 studies. Conclusions: Spin is highly prevalent in abstracts of systematic reviews of PRP in the treatment of hip OA. Several associations were found between spin types and the study characteristics of AMSTAR 2 rating, Scopus CiteScore, journal impact factor, and PROSPERO preregistration. When present, spin in the abstracts of reviewed studies tended to favor the use of PRP in hip osteoarthritis. Clinical Relevance: It is important to understand the prevalence of spin in published abstracts, especially in areas of great impact or interest, so authors and readers can have a greater awareness of this potential form of bias.

Reporting Bias in the Form of Positive Spin Is Highly Prevalent in Abstracts of Systematic Reviews on Primary Repair of the Anterior Cruciate Ligament.

PURPOSE: To analyze reporting bias in the form of spin present in systematic reviews and meta-analyses on the topic of primary anterior cruciate ligament (ACL) repair. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed throughout this study. Peer-reviewed systematic reviews were collected from 3 databases (PubMed, Scopus, and SPORTDiscus), and their abstracts were assessed for the 15 most common types of spin. Articles were excluded if they were not published in English, had no evidence, were retracted, were published without an abstract, did not have full text available, or included cadaveric or nonhuman subjects. Full text quality was assessed using AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews Version 2). Fisher exact tests were used to examine associations between the different types of spin and other study characteristics such as AMSTAR 2 confidence rating, study design, and level of evidence. RESULTS: Spin was present in the abstracts of 13 of 15 articles (86.7%). There were significant associations between PRISMA adherence and lower incidences of spin types 3, 6, and 8 (P = .029 for each). A critically low AMSTAR 2 confidence rating was significantly associated with an increased incidence of spin type 9 (P = .01), and a higher AMSTAR 2 score was significantly associated with decreased spin type 4 and type 5 (P = .039 and P = .048, respectively). A more recent year of publication was correlated with a lower incidence of spin type 14 (P = .044). CONCLUSIONS: Spin is present in most systematic reviews and meta-analyses regarding primary repair of the ACL, with two-thirds of abstracts spinning evidence in favor of ACL repair. Standardized guidelines including the PRISMA guidelines and the AMSTAR 2 assessment tool were negatively correlated with spin. More recently published articles were found to contain significantly less spin, as were articles published in journals with higher Clarivate Impact Factors and Scopus CiteScores. LEVEL OF EVIDENCE: Level V, systematic review of Level III through V studies.

Harms reporting in randomized controlled trials underpinning the American Academy of Orthopaedic Surgeons clinical practice guidelines for glenohumeral osteoarthritis.

BACKGROUND: Glenohumeral osteoarthritis is one of the most common causes of shoulder pain. As such, the American Academy of Orthopaedic Surgeons (AAOS) has developed clinical practice guidelines (CPGs) to address the management of glenohumeral osteoarthritis. These CPG recommendations stem from the findings of randomized controlled trials (RCTs), which have been shown to influence clinical decision making and health policy. Therefore, it is essential that trial outcomes, including harms data (ie, adverse events), are adequately reported. We intend to evaluate the reporting quality of harms-related data in orthopedic literature specifically relating to AAOS CPG recommendations on the management of glenohumeral osteoarthritis. METHODS: We adhered to the Preferred Reporting Items for Systematic Reviews (PRISMA) as well as guidance for reporting meta-research. The AAOS CPGs for glenohumeral osteoarthritis were obtained from orthoguidelines.org, and 2 authors independently screened the guidelines for the RCTs referenced. A total of 14 studies were identified. Data were extracted from the 14 included studies independently by the same 2 authors. Adherence to the Consolidated Standards of Reporting Trials (CONSORT) Extension for Harms Checklist was assessed using an 18-item scoring chart, with 1 point being awarded for meeting a checklist item and 0 points being awarded for not meeting a checklist item. Descriptive statistics, such as frequencies, percentages, and 95% confidence intervals were used to summarize RCT adherence to the CONSORT checklist. RESULTS: The average score among the studies included was 7.36/18 items (39% adherence). No study adhered to all criteria, with the highest-performing study meeting 11 of 18 items (58%) and the lowest meeting 3 of 18 items (16%). A positive correlation between checklist score and year of publication was observed, with studies published more recently receiving a higher score on the CONSORT checklist (P < .05). Studies that disclosed funding information received a higher score than those that did not (P < .05), but there was no significant difference when the different funding sources were compared. Finally, double-blinded studies scored higher on the checklist than those with lower levels of blinding (single or no blinding, P < .05). CONCLUSION: Adverse events are poorly reported amongst RCTs cited as supporting evidence for AAOS Management of Glenohumeral Osteoarthritis CPGs, evidenced by a CONSORT checklist compliance rate of only 41% in this study. We recommend the development of an updated checklist with information that makes it easier for authors to recognize, evaluate, and report on harms data. Additionally, we encourage authors to include information about adverse events or negative outcomes in the abstract.

Understanding the Match: The Effect of Signaling, Demographics, and Applicant Characteristics on Match Success in the Orthopaedic Residency Application Process.

INTRODUCTION: As of the 2022 to 2023 match cycle, orthopaedic residency programs began offering applicants 30 signals as part of a preference signaling program. Many have assumed that signals would become powerful tools in the match process, yet no objective data currently exist analyzing their effect. This study aims to provide such analysis while also offering comparisons with other factors affecting match success. METHODS: Self-reported survey data on applicants and applications from 2017 to 2023 from the Texas Seeking Transparency in Application to Residency database were queried. Variables associated with receiving interviews and match success were analyzed using two-sided Student t -tests, chi-squared tests, variance ratio testing, and receiver operating characteristic analysis. RESULTS: Compared with 2017 to 2022, 2023 applicants submitted fewer applications (61.8 versus 78; P < 0.001), received fewer interview offers (11.6 versus 13.8; P < 0.001), and interview offers were spread more evenly among applicants (SD, 6.82 versus 9.10; P < 0.001). For 2023 applications, odds of securing an interview were increased most by away rotations (odds ratios [OR] 61.8; P < 0.001), use of a signal (OR, 9.61; P < 0.001), and geographic connection (OR, 4.70; P < 0.001). Female applicants received more interview offers from signaled programs than their male counterparts (11.2 versus 8.94; P = 0.003). Applicant variables most predictive of match success in 2023 were interview offers (area under the receiver operating characteristic curve [AUC] = 0.802), step 2 CK score (AUC = 0.673), and step 1 score (AUC = 0.648). DISCUSSION: The preference signaling program seems to be accomplishing its goals of reducing applications and more evenly distributing interviews. Away rotations, signals, and geographic connections represent the strongest predictors of applications resulting in a successful match. Applicants must use their signals carefully to maximize their chance of success. LEVEL OF EVIDENCE: Level III.

SETD2 alterations impair DNA damage recognition and lead to resistance to chemotherapy in leukemia.

Mutations in SETD2, encoding the histone 3 lysine 36 trimethyltransferase, are enriched in relapsed acute lymphoblastic leukemia and MLL-rearranged acute leukemia. We investigated the impact of SETD2 mutations on chemotherapy sensitivity in isogenic leukemia cell lines and in murine leukemia generated from a conditional knockout of Setd2. SETD2 mutations led to resistance to DNA-damaging agents, cytarabine, 6-thioguanine, doxorubicin, and etoposide, but not to a non-DNA damaging agent, l-asparaginase. H3K36me3 localizes components of the DNA damage response (DDR) pathway and SETD2 mutation impaired DDR, blunting apoptosis induced by cytotoxic chemotherapy. Consistent with local recruitment of DDR, genomic regions with higher H3K36me3 had a lower mutation rate, which was increased with SETD2 mutation. Heterozygous conditional inactivation of Setd2 in a murine model decreased the latency of MLL-AF9-induced leukemia and caused resistance to cytarabine treatment in vivo, whereas homozygous loss delayed leukemia formation. Treatment with JIB-04, an inhibitor of the H3K9/36me3 demethylase KDM4A, restored H3K36me3 levels and sensitivity to cytarabine. These findings establish SETD2 alteration as a mechanism of resistance to DNA-damaging chemotherapy, consistent with a local loss of DDR, and identify a potential therapeutic strategy to target SETD2-mutant leukemias.