Return to Sport After Ulnar Collateral Ligament Tears Treated with Platelet-Rich Plasma Injections is Influenced by Length of Rehabilitation and Leukocyte Content of Injections: A Systematic Review.

PURPOSE: To analyze the current literature assessing return to sport (RTS) outcomes after platelet-rich plasma (PRP) injections for the nonoperative treatment of ulnar collateral ligament (UCL) injuries. METHODS: A systematic review of PubMed, Embase, and Web of Science databases was conducted in June 2023 to identify studies assessing RTS after PRP injections for UCL injuries. Tear severity, leukocyte content of PRP, rehabilitation protocol, and RTS outcomes were collected. Heterogeneity was assessed through proportional random-effects models for RTS and return to preinjury level of play (RTLP) with subgroup analysis by rehabilitation length, leukocyte content of PRP, and tear severity. RESULTS: Eight studies with 278 partial-thickness and 44 full-thickness tears were identified. The mean age of patients ranged from 17.3 to 26 years. The mean RTS time after injection ranged from 5.2 to 25.4 weeks. High heterogeneity was observed among studies, with RTS rates ranging from 46% to 100% (I2 = 83%) and RTLP rates ranging from 34% to 100% (I2 = 83%). Studies with the longest rehabilitation programs (12-14 weeks) had RTS rates of 87% to 100% (I2 = 0%). RTS rates among athletes treated with leukocyte-poor and leukocyte-rich PRP ranged from 73% to 100% (I2 = 30%) and 52% to 88% (I2 = 84%), respectively. Subanalysis of RTS by tear severity demonstrated high variability, with partial-thickness rates ranging from 59% to 100% (I2 = 55%) and full-thickness rates ranging from 27% to 100% (I2 = 63.2%). CONCLUSIONS: Studies assessing RTS after PRP injections are highly heterogeneous; however, current data suggest nonoperative RTS and RTLP rates ranging from 46% to 100% and 34% to 100%, respectively. Studies with at least 12 weeks of rehabilitation and studies using leukocyte-poor PRP demonstrated low heterogeneity and greater RTS rates. Alternatively, high heterogeneity was observed among both partial- and full-thickness tears. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Effect of Antibiotic Administration Before Joint Aspiration on Synovial Fluid White Blood Cell Count in Native Joint Septic Arthritis.

Background: This study was performed to assess the impact of preaspiration antibiotics on synovial fluid analysis and timing of operative treatment in native-joint septic arthritis. Methods: We performed a retrospective record review of adult patients from an urban level 1 trauma center with native joint septic arthritis in 2015-2019, identified by means of codes from the International Classification of Diseases (Ninth Revision and Tenth Revision). Univariate and multivariate analyses were performed to determine whether antibiotics were associated with lower synovial fluid white blood cell counts (WBCs), the percentage of polymorphonuclear neutrophil (PMNs), and rate of culture positivity. Secondary analysis included time elapsed from aspiration to surgery. Results: Of the 126 patients with septic joints included, nearly two-thirds (n = 80 [63.5%]) received antibiotics before joint aspiration. The synovial fluid WBC count, percentage of PMNs, and rate of culture positivity were significantly lower in patients who received preaspiration antibiotics than in those who did not (mean WBC count, 51 379.1/µL [standard deviation, 52 576.3/µL] vs 92 162.7/µL [59 330.6/µL], respectively [P < .001]; PMN percentage, 83.6% [20.5%] vs 91.9% [6.0%; P = .01]; and culture positivity, 32.5% vs 59.1% [P = .008]). Multivariable analyses revealed that these associations remained after controlling for potential confounders (change in PMNs, -42 784.60/µL [95% confidence interval, -65 355/µL to -20 213.90/µL [P < .001]; change in PMNs, -7.8% [-13.7% to -1.8%] [P = .01]; odds ratio, 0.39 [.18-.87; P = .02). Patients with a synovial fluid WBC count ≤50 000/µL experienced significant delay in time from joint aspiration to operative intervention (mean [standard deviation], 10.5 [11.3] vs 17.9 [17.2] hours; P = .02). Conclusions: The administration of antibiotics before joint aspiration for suspected septic arthritis appears to decrease the synovial fluid WBC count, the percentage of PMNs, and the rate of culture positivity. Efforts to limit antibiotic administration before joint aspiration are important to minimize diagnostic dilemmas and circumvent treatment delays.

Functional somatic syndromes are associated with inferior outcomes and increased complications after hip and knee arthroplasty: a systematic review.

BACKGROUND: Functional somatic syndromes (FSSs), defined as chronic physical symptoms with no identifiable organic cause, may impact results after hip and knee arthroplasty. The purpose of this study was to perform a systematic review assessing the relationship between FSSs and clinical outcomes after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). METHODS: The PubMed and Web of Science databases were queried from January 1955 through December 2021 for studies investigating the impact of at least one FSS (fibromyalgia, irritable bowel syndrome (IBS), chronic headaches, and chronic low back pain) on outcomes after primary THA/TKA/UKA. Outcomes of interest included patient-reported outcome measures (PROMs), postoperative opioid use, complications, revisions, and costs of care. RESULTS: There were twenty-eight studies, including 768,909 patients, of which 378,384 had an FSS. Five studies reported preoperative PROMs prior to THA/TKA, all of which showed worse PROMs among patients with at least 1 FSS diagnosis. Thirteen studies reported postoperative PROMs after THA/TKA, all of which demonstrated worse PROMs among patients with at least 1 FSS diagnosis. Patients with FSS diagnoses were more likely to continue using opioids at 3, 6, and 12 months following TKA, THA, and UKA. Medical and surgical complications, as well as revision rates, were higher among patients with FSSs. CONCLUSION: Patients with FSSs have inferior PROMs and are at increased risk for prolonged postoperative opioid use, medical and surgical complications, and revision after hip and knee arthroplasty. Improved understanding of the factors influencing the success of hip and knee arthroplasty is critical. Future studies should address the biopsychosocial determinants of health that can impact outcomes after total joint arthroplasty.

Incidence of Complications and Revision Surgery After High Tibial Osteotomy: A Systematic Review.

BACKGROUND: High tibial osteotomy (HTO) is a well-recognized procedure for its effectiveness in treating symptomatic early knee arthritis and malalignment. Although there are numerous systematic reviews evaluating the management and outcomes after HTO, there are few investigations on complications of this procedure. PURPOSE: To systematically review the literature to determine the incidence of intraoperative and postoperative complications associated with medial opening wedge and lateral closing wedge HTOs. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: The Cochrane Database of Systematic Reviews, PubMed, Embase, and MEDLINE databases were queried for studies reporting complications associated with HTO with or without concomitant procedures. Data including patient characteristics, procedure type, concomitant procedures, follow-up time, and postoperative imaging were extracted. Rates of intra- and postoperative complications, reoperations, and conversion to arthroplasty were recorded. RESULTS: A total of 71 studies were included for analysis, comprising 7836 patients. The overall intraoperative complication rate during HTO was 5.5% (range, 0%-29.3%), and the overall postoperative complication rate was 6.9% (range, 0%-26.6%). The most common intraoperative complication was lateral hinge fracture (incidence, 9.1%; range, 0%-30.4%) in medially based HTOs and peroneal nerve injury in laterally based HTOs (incidence, 3.2%; range, 0%-8.7%). The overall incidence of neurovascular injury after medially or laterally based HTOs was 1.1% (range, 0%-18.9%). The most common postoperative complication was superficial infection (incidence, 2.2%; range, 0%-13%). Of the included studies, 62 included postoperative radiographic analysis, and among those, the incidence of nonunion was 1.9% (range, 0%-15.5%), loss of correction was 1.2% (range, 0%-34.3%), and implant failure was 1.0% (range, 0%-10.2%). Among studies reporting revision surgeries, the overall reoperation rate was 15.5% (range, 0%-70.7%), with the most common type of reoperation being hardware removal (incidence, 10.0%; range, 0%-60%). CONCLUSION: Intraoperatively, medially based HTOs are associated with a 1 in 11 risk of lateral hinge fracture and laterally based HTOs with a 1 in 30 risk of peroneal nerve injury. Postoperative complication rates in the range of 10% to 15% can be expected, including infection (2.9%), loss of correction (1.2%), and nonunion (1.9%). Patients should also be counseled that the reoperation rate is approximately 15%, with hardware removal being the most common procedure.

Arthroscopic Treatment Is a Safe and Effective Alternative to Open Treatment for Acute Septic Arthritis of the Native Knee: A Systematic Review.

PURPOSE: To compare complication rates, reoperation rates, and subjective outcomes after arthroscopic and open irrigation and debridement for treatment of native knee septic arthritis. METHODS: Following The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the Embase, Cochrane, and PubMed databases was performed. Comparative studies reporting clinical outcomes after arthroscopic versus open treatment for septic arthritis of the native knee in human adults were included. Excluded were case series with <10 patients, inclusion of patients <18 years old, studies on non-native joints, abstract-only publications, and studies without stratification of the involved joint. Two reviewers in duplicate independently performed search and data extraction. The quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies instrument. The mean score among the included studies was 18.2 (range 16-23). RESULTS: Eleven studies were included, comprising 2,343 knees treated arthroscopically, and 1,595 treated with arthrotomy. Studies reported no differences in erythrocyte sedimentation rate, C-reactive protein, peripheral white blood cells, or symptom chronicity between groups. Nine studies (81.8%) attempted to control for potentially confounding variables in their analyses, and 4 studies (36.4%) reported significant differences in patient characteristics. Reoperation rates ranged from 0% to 50% for arthroscopy and 6% to 71% for arthrotomy. Complication rates ranged from 0% to 39.4% arthroscopically and 0% to 49% for arthrotomy. Superior patient-reported outcomes were achieved after arthroscopy in 2 studies that analyzed subjective outcomes. CONCLUSIONS: Arthroscopic management of native knee septic arthritis is a safe and effective alternative to open treatment and is associated with comparable complication rates, reoperation rates, hospitalization lengths, readmission rates, and superior patient-reported outcomes compared with open irrigation and debridement. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, III, and IV studies.

Reverse Fragility Index Comparing Rates of Rerupture After Open Achilles Tendon Repair Versus Early Functional Rehabilitation: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Despite similar published rates of rerupture among patients treated with early functional rehabilitation and open repair for acute Achilles tendon rupture, uncertainty still exists regarding the optimal treatment modality. The reverse fragility index (RFI) is a statistical tool that provides an objective measure of the study's neutrality by determining the number of events that need to change for a nonsignificant result to be significant. PURPOSE: The purpose was to utilize the RFI to appraise the strength of neutrality of randomized controlled trials (RCTs) comparing the rerupture rates of acute Achilles tendon ruptures treated with open repair versus early functional rehabilitation. STUDY DESIGN: Systematic review; Level of evidence, 1. METHODS: A systematic review was performed including all RCTs comparing the rerupture rates after operative repair and early functional rehabilitation for acute Achilles tendon ruptures. Studies were included that explicitly used early functional rehabilitation, defined as weightbearing and exercise-based interventions initiated within 2 weeks, as compared with open repair and reported a nonsignificant difference in rerupture rates. The RFI, with rerupture as the primary outcome, was calculated for each study (significance threshold, P < .05). The RFI quantifies a study's strength of neutrality and is defined as the minimum number of event reversals necessary to change a nonsignificant result to statistically significant. RESULTS: Nine RCTs were included, with 713 patients and 46 reruptures. The median (interquartile range) rerupture rate was 7.69% (6.38%-9.64%) overall, 4.00% (2.33%-7.14%) in the operative group, and 10.00% (5.26%-12.20%) in the nonoperative group. The median RFI was 3, indicating that an outcome reversal of 3 patients was necessary to change the results from nonsignificant to statistically significant. The median number of patients lost to follow-up was 6 (3-7). Of 9 studies, 7 (77.8%) had a loss to follow-up greater than or equal to its RFI. CONCLUSION: The statistical nonsignificance of studies reporting equivalent rerupture rates in the management of acute Achilles tendon ruptures with open repair versus nonoperative management with early functional rehabilitation can be reversed by changing the outcome status of only a few patients.

Functional Somatic Syndromes Are Associated With Varied Postoperative Outcomes and Increased Opioid Use After Spine Surgery: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVE: To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and clinical outcomes after spine surgery. METHODS: A systematic review of online databases (PubMed and Web of Science) through December 2021 was conducted via PRISMA guidelines to identify all studies investigating the impact of at least one FSS (fibromyalgia, irritable bowel syndrome (IBS), chronic headaches/migraines, interstitial cystitis, chronic fatigue syndrome, multiple chemical sensitivity) on outcomes after spine surgery. Outcomes of interest included patient reported outcome measures (PROMs), postoperative opioid use, cost of care, complications, and readmission rates. RESULTS: A total of 207 records were identified. Seven studies (n = 40,011 patients) met inclusion criteria with a mean MINORS score of 16.6 out of 24. Four studies (n = 21,086) reported postoperative opioid use; fibromyalgia was a strong risk factor for long-term opioid use after surgery whereas the association with chronic migraines remains unclear. Two studies (n = 233) reported postoperative patient reported outcome measures (PROMs) with mixed results suggesting a possible association between fibromyalgia and less favorable PROMs. One study (n = 18,692) reported higher postoperative complications in patients with fibromyalgia. CONCLUSION: Patients with fibromyalgia and possibly migraines are at higher risk for prolonged postoperative opioid use and less favorable PROMs after spine surgery. There is limited research on the relationship between other Functional somatic syndromes (FSSs) and outcomes following spine surgery. Growing evidence suggests the variation in outcomes after spine procedures may be attributed to non-identifiable organic patient factors such as FSSs.

Predictors of Hardware Removal in Orthopaedic Trauma Patients Undergoing Syndesmotic Ankle Fixation With Screws.

Background: Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal. Methods: Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal. Results: Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P < .001) and have a lower ASA score (2 ± 0.8 vs 2.1 ± 0.7, P = .003) by bivariate analysis. Of patients who underwent screw removal, 21.7% (13/60) had a broken screw at the time of removal. Whether the screw was placed at the physeal scar was not significantly associated with patient decision for hardware removal (P = .80). Conclusion: Younger and healthier patients were more likely to undergo elective removal of syndesmotic hardware. Screw distance from joint and screw placement at the physeal scar were not significantly associated with hardware removal. Level of Evidence: Level III, retrospective cohort study.

Comparing Orthopaedic Randomized Control Trials Published in High-Impact Medical and Orthopaedic Journals.

INTRODUCTION: Orthopaedic studies published in high-impact medical journals are often believed to have a high prevalence of negative or neutral results and possess methodological characteristics that may bias toward nonsurgical treatments. The purpose of this study was to compare study characteristics, methodologic quality, exposure, and outcome direction among orthopaedic randomized control trials (RCTs) published in high-impact medical and orthopaedic journals and to identify study attributes associated with greater impact. METHODS: RCTs published between January 2010 and December 2020 in the five medical journals and 10 orthopaedic journals with the highest 5-year impact factors were analyzed. Inclusion criteria were RCTs reporting on orthopaedic surgical intervention compared with nonsurgical or less-invasive surgical procedures. Study characteristics, methodologic quality (Jadad scale), outcomes, and altmetric data were collected. Primary outcomes were categorized as positive (favoring surgical/more-extensive surgery), negative (favoring nonsurgical/less-extensive surgery), or neutral. RESULTS: One hundred twenty-eight RCTs were analyzed; 26 from medical and 102 from orthopaedic journals. Studies published in medical journals included more authors ( P < 0.001), larger sample sizes ( P < 0.001), more institutions ( P < 0.001), and more often received funding ( P < 0.001). The average Jadad scale did not significantly differ between journals ( P = 0.14). The direction of the primary study outcome did not differ between journals ( P = 0.22). Average AAS and annual citation rates were higher in RCTs published in medical journals ( P < 0.001). Publication in a medical journal was the only covariate associated with higher annual citation rates ( P < 0.001) and AAS ( P < 0.001) on multivariable analyses. DISCUSSION: High-impact medical journals do not publish orthopaedic RCTs with negative or neutral findings at a rate that significantly differs from orthopaedic journals. However, the higher impact and digital coverage of the studies published in medical journals may disproportionally influence the practices of nonorthopaedic providers. Raising awareness of critical findings published in orthopaedic journals may be particularly important for improving healthcare policies and orthopaedic referral patterns for musculoskeletal problems.

Subjective Outcomes After Allograft Reconstruction and Nonoperative Treatment of Anterior Cruciate Ligament Ruptures Are Similar in Patients Aged 40 Years and Older: A 2:1 Propensity Score-Matched Analysis.

Purpose: To compare subjective outcomes and rates of subsequent operations for patients aged 40 years and older with anterior cruciate ligament (ACL) ruptures who elected nonoperative management or allograft ACL reconstruction (ACLR). Methods: This was a retrospective study comparing 2-year minimum results of nonoperative treatment and primary allograft ACLR among patients aged 40 years and older presenting to a single institution between the years 2005 and 2016. Patients who elected nonoperative management were 2:1 propensity score (PS)-matched to patients who elected ACLR based on age, sex, body mass index, sports-related mechanism of injury, Outerbridge grade III or IV chondral lesions, and medial or lateral meniscus tears. Univariate analysis was performed to compare subjective outcome measures of International Knee Documentation Committee and Marx activity level scores, subsequent operations, and satisfaction rates. Results: After 2:1 PS matching, 40 ACLR and 20 nonoperative patients with mean ages of 52.2 years and 54.5 years, respectively, were included with a mean follow-up of 5.7 years (SD 2.1 years, range 2.3-10.6 years). There were no significant differences between the groups in any of the matching variables. There were no significant differences in International Knee Documentation Committee scores (81.9 ± 14.1, CI 77.4-86.5 vs 84.3 ± 12.8, CI 78.3-90.3, P = .53), Marx activity level scores (5.8 ± 4.8, CI 4.2-7.3 vs 5.7 ± 5.1, CI 3.3-8.1, P = .96), or satisfaction rates (100% vs 90%, P = .11) between the ACLR and nonoperative groups. Four (10%) patients who underwent ACLR sustained a graft treated with revision ACLR. 7 (17.5%) ACLR and 0 nonoperative patients subsequently received further ipsilateral knee surgeries (P = .08), including 2 total knee arthroplasties. Conclusions: In this PS-matched analysis of patients aged 40 years and older with ACL ruptures, patients who elected nonoperative management had similar subjective outcomes compared with those who elected allograft ACLR. Patients who elected allograft ACLR did not have fewer subsequent operations than those who elected nonoperative treatment. Level of Evidence: Level III, retrospective cohort study.

The reverse fragility index: RCTs reporting non-significant differences in failure rates between hamstring and bone-patellar tendon-bone autografts have fragile results.

PURPOSE: The reverse fragility index (RFI) is a novel metric to appraise the results of studies reporting statistically non-significant results. The purpose of this study was to determine the statistical robustness of randomized controlled trials (RCTs) reporting non-significant differences in anterior cruciate ligament reconstruction (ACLR) graft failure rates, defined as re-rupture/revision ACLR rate, between hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts by calculating RFIs. METHODS: A systematic review was performed to identify RCTs that compared HT to BTB grafts for ACLR through January 2022. Studies reporting non-significant differences in graft re-rupture and revision ACLR rate (n.s.) were included. The RFI, defined as the fewest number of event reversals needed to change the non-significant graft re-rupture/revision outcome to statistically significant (P < 0.05), was recorded for each study. In addition, the number of studies in which the loss to follow-up exceeded the RFI was recorded. RESULTS: Among the 16 included RCTs, the median (interquartile range [IQR]) sample size was 71 (64-114), and the median (IQR) total number of graft re-rupture/revision ACLR events was 4 (4-6). The median (IQR) graft re-rupture/revision ACLR rate was 4.3% (3.0-6.4) overall, 4.1% (2.6-6.7) in the BTB group, and 5.4% (3.0-6.3) in the HT group. The median (IQR) RFI was 3 (3-4), signifying that a reversal of the outcome in 3 patients in one arm was needed to flip the studies' result from non-significant to statistically significant (P < 0.05). The median (IQR) number of participants lost to follow-up was 11 (3-13), and 13 (81.3%) of the included studies had a loss to follow-up greater than the studies' RFI. CONCLUSION: The results of RCTs reporting statistically non-significant re-rupture/revision ACLR rates between HT and BTB autografts would become significant if the outcome were reversed in a small number of patients-a number that was less than the loss to follow-up in the majority of studies. Thus, the neutrality of these studies is fragile, and a true statistically significant difference in re-rupture/revision rates may have been undetected. LEVEL OF EVIDENCE: Level I.

Is Patellar Instability a Contraindication to Semiextended Tibial Nailing?: A Case Report.

CASE: We report a 40-year-old woman with undiagnosed patellofemoral instability that worsened 8 months after intramedullary nailing of a distal left tibia fracture in the semiextended position through a partial medial parapatellar approach. Patella stability and asymptomatic knee function were restored after IM nail removal, medial patellofemoral ligament repair, and left tibial tubercle transposition. CONCLUSION: The optimal surgical approach for tibial IM nailing in patients with chronic patellar instability has not been described. Clinicians should be cognizant of the potential for worsening patellofemoral instability in these patients when using the medial parapatellar approach in the semiextended position.

High Levels of Satisfaction and Adequate Patient-Reported Outcomes After Operative Reconstruction of Multiligament Knee Injury With Allograft Among Patients Aged 40 Years and Older.

Purpose: To describe injury characteristics and patient-reported outcomes (PROs) among patients aged 40 years and older who underwent allograft reconstruction for multiligament knee injury (MLKI). Methods: Records of patients aged 40 years and older who underwent allograft multiligament knee reconstruction at a single institution between 2007 and 2017 with a minimum of 2 years of follow-up were retrospectively reviewed. Demographic information, concomitant injuries, patient satisfaction, and PROs including International Knee Documentation Committee and Marx activity scores were obtained. Results: Twelve patients were included with a minimum follow-up time of 2.3 years (mean, 6.1; range, 2.3-10.1 years) and a mean age at surgery of 49.8 years. Seven patients were male, and the most common mechanism of injury was sport-related. The most frequently reconstructed MLKIs were anterior cruciate ligament and medial collateral ligament (4), anterior cruciate ligament and posterolateral corner (2), and posterior cruciate ligament and posterolateral corner (2). The majority of patients reported satisfaction with their treatment (11). Median International Knee Documentation Committee and Marx scores were 73 (interquartile range, 45.5-88.0) and 3 (interquartile range 0-5), respectively. Conclusions: Patients aged 40 years and older can expect a high level of satisfaction and adequate PROs at 2-years follow-up after operative reconstruction for a MLKI with allograft. This demonstrates that allograft reconstruction for a MLKI in older patients may have clinical utility. Level of Evidence: IV, therapeutic case series.

The Majority of Sports Medicine and Arthroscopy-Related Randomized Controlled Trials Reporting Nonsignificant Results Are Statistically Fragile.

PURPOSE: To evaluate the robustness of sports medicine and arthroscopy related randomized controlled trials (RCTs) reporting nonsignificant results by calculating the reverse fragility index (RFI) and reverse fragility quotient (RFQ). METHODS: All sports medicine and arthroscopic-related RCTs from January 1, 2010, through August 3, 2021, were identified. Randomized-controlled trials comparing dichotomous variables with a reported P value ≥ .05 were included. Study characteristics, such as publication year and sample size, as well as loss to follow-up and number of outcome events were recorded. The RFI at a threshold of P < .05 and respective RFQ were calculated for each study. Coefficients of determination were calculated to determine the relationships between RFI and the number of outcome events, sample size, and number of patients lost to follow-up. The number of RCTs in which the loss to follow-up was greater than the RFI was determined. RESULTS: Fifty-four studies and 4,638 patients were included in this analysis. The mean sample size and loss to follow-up were 85.9 patients and 12.5 patients, respectively. The mean RFI was 3.7, signifying that a change of 3.7 events in one arm was needed to flip the results of the study from non-significant to significant (P < .05). Of the 54 studies investigated, 33 (61%) had a loss to follow-up greater than their calculated RFI. The mean RFQ was 0.05. A significant correlation between RFI with sample size (R2 = 0.10, P = .02) and the total number of observed events (R2 = 0.13, P < .01) was found. No significant correlation existed between RFI and loss to follow-up in the lesser arm (R2 = 0.01, P = .41). CONCLUSIONS: The RFI and RFQ are statistical tools that allow the fragility of studies reporting nonsignificant results to be appraised. Using this methodology, we found that the majority of sports medicine and arthroscopy-related RCTs reporting nonsignificant results are fragile. CLINICAL RELEVANCE: RFI and RFQ serve as tools that can be used to assess the validity of RCT results and provide additional context for appropriate conclusions.

Intrasubstance Patellar Tendon Repair with the Addition of a Bio-inductive Implant.

Intrasubstance patellar tendon ruptures are an uncommon injury that can have devastating long-term effects for patients. Operative intervention to repair the ruptured tendon is the gold standard treatment for these injuries and can be performed using a variety of techniques. Unlike the more common patellar tendon ruptures at the level of the patella, repairs of intrasubstance ruptures are often challenging because of the poor quality of the remaining tendon fibers. Tendon repair with augmentation via bio-inductive implants has gained popularity in upper extremity literature, as it has demonstrated improved tendon strength and patient outcomes. However, there remains a sparsity of reports regarding tendon augmentation in the lower extremity literature. Here, we describe repair of an intrasubstance patellar tendon rupture using a modified SpeedBridge repair and augmentation with a bio-inductive implant.

Preoperative factors associated with failure to reach the patient acceptable symptom state after anterior cruciate ligament reconstruction in patients aged 40 and older.

PURPOSE: To perform a predictive analysis to identify preoperative patient factors associated with failure to achieve a newly defined patient acceptable symptom state (PASS) for the International Knee Documentation Committee (IKDC) Score after anterior cruciate ligament reconstruction (ACLR) in patients aged ≥ 40 years with a minimum of 2-year follow-up. METHODS: This was a secondary analysis of a retrospective review of all patients aged 40 years or older receiving a primary allograft ACLR at a single institution between the years of 2005 and 2016, with 2-year minimum follow-up. Using an updated PASS threshold of 66.7 for the International Knee Documentation Committee (IKDC) score previously established for this patient cohort, a univariate and multivariate analysis was performed to identify preoperative patient characteristics predictive of failure to achieve PASS. RESULTS: A total of 197 patients with a mean follow-up of 6.2 ± 2.1 years (range 2.7 - 11.2) were included in the analysis (48.5 ± 5.6 years, 51.8% female, Body Mass Index (BMI) 25.9 ± 4.4). PASS was achieved by 162 patients (82.2%). Patients who failed to achieve PASS more often had lateral compartment cartilage defects (P = 0.001) and lateral meniscus tears (P = 0.004), higher BMIs (P = 0.004), and Workers' Compensation status (P = 0.043) on univariable analysis. Factors predictive of failure to achieve PASS on multivariable analysis included BMI and lateral compartment cartilage defect (OR 1.12 [1.03-1.23], P = 0.013; OR 5.1 [1.87-13.9], P = 0.001). CONCLUSION: Among patients ≥ 40 years who receive a primary allograft ACLR, patients who fail to achieve PASS more often had lateral compartment cartilage defects and higher BMIs. LEVEL OF EVIDENCE: Level IV.

Patients With Functional Somatic Syndromes-Fibromyalgia, Irritable Bowel Syndrome, Chronic Headaches, and Chronic Low Back Pain-Have Lower Outcomes and Higher Opioid Usage and Cost After Shoulder and Elbow Surgery.

PURPOSE: To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and patient-reported outcome measures (PROMs), postoperative opioid consumption, and hospitalization costs after shoulder and elbow surgery. METHODS: A systematic review of the PubMed and Web of Science databases was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies evaluating the effect of having at least 1 FSS (fibromyalgia, irritable bowel syndrome, chronic headaches, chronic low back pain) on outcomes after shoulder and elbow surgeries. Outcomes of interest included postoperative analgesic use, PROMs, and hospitalization costs. RESULTS: The review identified a total of 320 studies, of which 8 studies met the inclusion criteria. The total number of participants in our 8 included studies was 57,389. Three studies (n = 620) reported PROMs. These studies demonstrated that the presence of at least 1 FSS is predictive of significantly greater pain scores and lower quality of recovery, Disability Arm Shoulder and Hand, American Shoulder and Elbow Surgeons Shoulder Score, and Single Assessment Numeric Evaluation scores postoperatively. Although scores were inferior in among patients with FSS, 2 of the 3 studies showed improvement in PROMs in this group of patients. Seven studies (n = 56,909) reported postoperative opioid use. Of these, 5 reported that a diagnosis of at least 1 FSS was a strong risk factor for long-term opioid use after surgery. One study (n = 480) found that time-driven activity-based costs were significantly greater in patients with FSSs. CONCLUSIONS: Patients with functional somatic syndromes have less-favorable PROMs postoperatively, consume more opioids postoperatively, and have greater health care costs after elective shoulder and elbow procedures. Although PROMs among patients with FSSs are inferior compared with those without FSSs, PROMs still improved compared with baseline. LEVEL OF EVIDENCE: Level III, systematic review of Level II-III studies.

The Reverse Fragility Index: Interpreting the Current Literature on Long-Term Survivorship of Computer-Navigated Versus Conventional TKA: A Systematic Review and Cross-Sectional Study of Randomized Controlled Trials.

BACKGROUND: Despite the most recent American Academy of Orthopaedic Surgeons clinical practice guideline making a "strong" recommendation against the use of intraoperative navigation in total knee arthroplasty (TKA), its use is increasing. We utilized the concept of the reverse fragility index (RFI) to assess the strength of neutrality of the randomized controlled trials (RCTs) comparing the long-term survivorship of computer-navigated and conventional TKA. METHODS: A systematic review was performed including all RCTs through August 3, 2021, comparing the long-term outcomes of computer-navigated and conventional TKA. Randomized trials with mean follow-up of >8 years and survivorship with revision as the end point were included. The RFI quantifies the strength of a study's neutrality by calculating the minimum number of events necessary to flip the result from nonsignificant to significant. The RFI at a threshold of p < 0.05 was calculated for each study reporting nonsignificant results. The reverse fragility quotient (RFQ) was calculated by dividing the RFI by the study sample size. RESULTS: Ten clinical trials with 2,518 patients and 38 all-cause revisions were analyzed. All 10 studies reported nonsignificant results. The median RFI at the p < 0.05 threshold was 4, meaning that a median of 4 events would be needed to change the results from nonsignificant to significant. The median RFQ was 0.029, indicating that the nonsignificance of the results was contingent on only 2.9 events per 100 participants. The median loss to follow-up was 27 patients. In all studies, the number of patients lost to follow-up was greater than the RFI. CONCLUSIONS: The equipoise in long-term survivorship between computer-navigated and conventional TKA rests on fragile studies, as their statistical nonsignificance could be reversed by changing the outcome status of only a handful of patients--a number that was always smaller than the number lost to follow-up. Routine reporting of the RFI in trials with nonsignificant findings may provide readers with a measure of confidence in the neutrality of the results. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Revision Soft-Tissue Allograft Anterior Cruciate Ligament Reconstruction Is Associated With Lower Patient-Reported Outcomes Compared With Primary Anterior Cruciate Ligament Reconstruction in Patients Aged 40 and Older.

PURPOSE: To evaluate patient-reported outcomes (PROs) and graft failure rates in revision allograft anterior cruciate ligament reconstruction (ACLR) in patients aged 40 and older and compare them with primary ACLRs. METHODS: Patients aged 40 and older who underwent arthroscopic soft-tissue allograft ACLR between 2005 and 2016 with a minimum 2-year follow-up were retrospectively reviewed. Patients were grouped based on revision versus primary ACLR. The rate of achieving an International Knee Documentation Committee (IKDC) patient acceptable symptom state (PASS) score was recorded. Patient satisfaction, PROs, and graft failure were compared between groups using the χ2 test, Fisher exact test, and Mann-Whitney U test. RESULTS: We identified 32 patients who underwent revision ACLR and 201 patients who underwent primary ACLR aged 40 and older who met inclusion criteria with a mean follow-up of 6.2 and 6.9 years, respectively (P = .042). There was a lower rate of concomitant meniscal repair in the primary ACLR group (6% vs 21.9%, P = .007) There were no other differences in chondral injuries, mechanism of injury, or meniscal injuries between groups. The median IKDC score was greater in the primary ACLR group as compared with the revision ACLR group (83.9 vs 70.6, P < .001). Patients who underwent revision ACLR were less likely to achieve the IKDC PASS threshold (82.5% vs 56.3%, P = .001) and were less likely to report satisfaction as compared with patients who underwent primary ACLR (90.5% vs 78.1%, P =.038). No difference in graft failure rates was identified between groups (8% vs 15.6%, P = .180). CONCLUSIONS: Revision allograft ACLR in patients aged 40 and older was associated with lower PROs compared with primary ACLR. Patients who underwent revision ACLR failed to meet the IKDC PASS threshold more often and were dissatisfied with procedure results more than twice as often as patients that underwent primary ACLR. LEVEL OF EVIDENCE: III, retrospective cohort study.

Single-Stage Revision Anterior Cruciate Ligament Reconstruction Using the Stacked Screws Technique.

Single-stage revision anterior cruciate ligament (ACL) reconstruction is preferable to 2-stage revision, when possible, as it avoids an additional surgery and recovery period. Malpositioned and/or widened bone tunnels are a common cause of ACL reconstruction failure and are challenging to manage in revision reconstructions. The "stacked screws construct" fills the previous malpositioned tunnels and bone voids with an oversized biocomposite screw as graft material. The revised tunnel can then be drilled in an anatomic "primary" location, even partially overlapping the filler screw. This technique simplifies tunnel management in revision ACL reconstruction.