A Brief Mind-body Intervention Is Feasible and May Prevent Persistent Pain After Acute Orthopaedic Traumas: A Randomized Controlled Trial.

BACKGROUND: Approximately 20% to 50% of patients develop persistent pain after traumatic orthopaedic injuries. Psychosocial factors are an important predictor of persistent pain; however, there are no evidence-based, mind-body interventions to prevent persistent pain for this patient population. QUESTIONS/PURPOSES: (1) Does the Toolkit for Optimal Recovery after Injury (TOR) achieve a priori feasibility benchmarks in a multisite randomized control trial (RCT)? (2) Does TOR demonstrate a preliminary effect in improving pain, as well as physical and emotional function? METHODS: This pilot RCT of TOR versus a minimally enhanced usual care comparison group (MEUC) was conducted among 195 adults with an acute orthopaedic traumatic injury at risk for persistent pain at four geographically diverse Level 1 trauma centers between October 2021 to August 2023. Fifty percent (97 of 195) of participants were randomized to TOR (mean age 43 ± 17 years; 67% [65 of 97] women) and 50% (98) to MEUC (mean age 45 ± 16 years; 67% [66 of 98] women). In TOR, 24% (23 of 97) of patients were lost to follow-up, whereas in the MEUC, 17% (17 of 98) were lost. At 4 weeks, 78% (76 of 97) of patients in TOR and 95% (93 of 98) in the MEUC completed the assessments; by 12 weeks, 76% (74 of 97) of patients in TOR and 83% (81 of 98) in the MEUC completed the assessments (all participants were still included in the analysis consistent with an intention-to-treat approach). The TOR has four weekly video-administered sessions that teach pain coping skills. The MEUC is an educational pamphlet. Both were delivered in addition to usual care. Primary outcomes were feasibility of recruitment (the percentage of patients who met study criteria and enrolled) and data collection, appropriateness of treatment (the percent of participants in TOR who score above the midpoint on the Credibility and Expectancy Scale), acceptability (the percentage of patients in TOR who attend at least three of four sessions), and treatment satisfaction (the percent of participants in TOR who score above the midpoint on the Client Satisfaction Scale). Secondary outcomes included additional feasibility (including collecting data on narcotics and rescue medications and adverse events), fidelity (whether the intervention was delivered as planned) and acceptability metrics (patients and staff), pain (numeric rating scale), physical function (Short Musculoskeletal Function Assessment questionnaire [SMFA], PROMIS), emotional function (PTSD [PTSD Checklist], depression [Center for Epidemiologic Study of Depression]), and intervention targets (pain catastrophizing, pain anxiety, coping, and mindfulness). Assessments occurred at baseline, 4 and 12 weeks. RESULTS: Several outcomes exceeded a priori benchmarks: feasibility of recruitment (89% [210 of 235] of eligible participants consented), appropriateness (TOR: 73% [66 of 90] scored > midpoint on the Credibility and Expectancy Scale), data collection (79% [154 of 195] completed all surveys), satisfaction (TOR: 99% [75 of 76] > midpoint on the Client Satisfaction Scale), and acceptability (TOR: 73% [71 of 97] attended all four sessions). Participation in TOR, compared with the MEUC, was associated with improvement from baseline to postintervention and from baseline to follow-up in physical function (SMFA, baseline to post: -7 [95% CI -11 to -4]; p < 0.001; baseline to follow-up: -6 [95% CI -11 to -1]; p = 0.02), PROMIS (PROMIS-PF, baseline to follow-up: 2 [95% CI 0 to 4]; p = 0.045), pain at rest (baseline to post: -1.2 [95% CI -1.7 to -0.6]; p < 0.001; baseline to follow-up: -1 [95% CI -1.7 to -0.3]; p = 0.003), activity (baseline to post: -0.7 [95% CI -1.3 to -0.1]; p = 0.03; baseline to follow-up: -0.8 [95% CI -1.6 to -0.1]; p = 0.04), depressive symptoms (baseline to post: -6 [95% CI -9 to -3]; p < 0.001; baseline to follow-up: -5 [95% CI -9 to -2]; p < 0.002), and posttraumatic symptoms (baseline to post: -4 [95% CI -7 to 0]; p = 0.03; baseline to follow-up: -5 [95% CI -9 to -1]; p = 0.01). Improvements were generally clinically important and sustained or continued through the 3 months of follow-up (that is, above the minimum clinically important different [MCID] of 7 for the SMFA, the MCID of 3.6 for PROMIS, the MCID of 2 for pain at rest and pain during activity, the MCID of more than 10% change in depressive symptoms, and the MCID of 10 for posttraumatic symptoms). There were treatment-dependent improvements in pain catastrophizing, pain anxiety, coping, and mindfulness. CONCLUSION: TOR was feasible and potentially efficacious in preventing persistent pain among patients with an acute orthopaedic traumatic injury. Using TOR in clinical practice may prevent persistent pain after orthopaedic traumatic injury. LEVEL OF EVIDENCE: Level I, therapeutic study.

Editorial Commentary: Routine Use of Suture Tape Augmentation for Primary Anterior Cruciate Ligament Reconstruction Surgery Is Not Justified.

High rates of graft failure after primary anterior cruciate ligament reconstruction (ACLR) and the need for revision ACLR continue to be a challenge. Multiple studies demonstrate graft failure rates and the need for revision ACLR in 10% to 15% of young patients participating in pivot sporting activities. Currently, a wide range of strategies to mitigate this is problem being investigated, including extra-articular augmentation (with modified lateral extra-articular tenodesis or anterolateral ligament reconstruction) and intra-articular fixation (that aim for primary anterior cruciate ligament healing or augmentation of an ACLR with suture tape). While the early data on suture tape augmentation of primary ACLR seem optimistic, it does not justify its routine use.

Orthopaedic Sports Medicine Randomized Controlled Trials Infrequently Report on the Social Determinants of Health Factors of Their Patient Cohorts.

PURPOSE: To describe the prevalence of randomized controlled trials (RCTs) in orthopaedic sports medicine-related journals reporting on the social determinants of health (SDOH) of their patient cohorts, including factors receiving less attention, such as education level, employment status, insurance status, and socioeconomic status. METHODS: The PubMed/MEDLINE database was used to search for RCTs between 2020 and 2022 from 3 high-impact orthopaedic sports medicine-related journals: American Journal of Sports Medicine, Arthroscopy, and Journal of Shoulder and Elbow Surgery. The following information was extracted from each article: age, sex/gender, body mass index, year published, corresponding author country, and self-reported SDOH factors (race, ethnicity, education level, employment status, insurance status, and socioeconomic status). RESULTS: A total of 189 articles were analyzed. Articles originated from 34 different countries, with the United States (n = 66) producing the greatest number of articles. Overall, age (n = 186; 98.4%) and sex/gender (n = 184; 97.4%) were the factors most commonly reported, followed by body mass index (n = 112; 59.3%), race (n = 17; 9.0%), ethnicity (n = 10; 5.3%), employment status (n = 9; 4.8%), insurance status (n = 7; 3.7%), and education level (n = 5; 2.6%). Socioeconomic status was not reported in any of the articles analyzed. Articles from the United States report on SDOH factors more frequently than international articles, most notably race (24.2% vs 0.8%, respectively) and ethnicity (15.2% and 0%, respectively). CONCLUSIONS: RCTs from 3 high-impact orthopaedic sports medicine journals infrequently report on SDOH. CLINICAL RELEVANCE: Better understanding patient SDOH factors in RCTs is important to help orthopaedic surgeons and other practitioners best apply study results to their patients, as well as help researchers and our field ensure that research is being done transparently with relevance to as many patients as possible.

Is Next-day Discharge Safe After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis?

OBJECTIVE: While the implementation of enhanced recovery after surgery protocols and improvements in pain control have decreased the length of stay (LOS) after scoliosis surgery, adolescents are typically hospitalized for several days after posterior spinal instrumented fusion (PSF). The purpose of this study was to determine whether next-day discharge after PSF for adolescent idiopathic scoliosis (AIS) had an equivalent safety profile compared with longer LOS. The secondary purpose was to examine perioperative factors associated with next-day discharge. METHODS: We performed a retrospective study of all patients who underwent PSF for AIS at a single institution from 2017 to 2022. We compared patients based on postoperative LOS with an early discharge group consisting of those who were discharged on the first postoperative day 1 (POD1; n = 40) and a standard discharge group consisting of those who were discharged after POD1 (n = 71). We documented preoperative variables, including patient demographics and curve characteristics, intraoperative variables, including levels fused, implant density, operative time, and blood loss, and postoperative variables, including emergency department (ED) visits within 30 days and hospital readmissions within 90 days. RESULTS: One hundred eleven patients were included with a mean curve magnitude of 67 degrees. Forty patients (36%) were discharged on POD1. There were one (3%) ED visit and 2 (5%) readmissions in the early discharge group and 3 (4%) ED visits and 2 (3%) readmissions in the standard discharge group (P = 0.64 and 0.55, respectively). Patients in whom intravenous methadone was used intraoperatively were more likely to discharge POD1 (P = 0.02). There were no other significant differences in perioperative variables between the two groups including: BMI, distance from home to hospital, magnitude of main curve, curve flexibility, number of levels fused, estimated blood loss, implant density, operative time, or postoperative pain scores. CONCLUSIONS: Next-day discharge after PSF for AIS has an equivalent safety profile compared with longer LOS. Over one-third of patients were discharged on POD1, and there was no statistically significant difference in ED visits or hospital readmissions between the groups. Patients in whom intravenous methadone was used intraoperatively were more likely to discharge POD1. CLINICAL RELEVANCE: In a retrospective study of posterior spinal fusions for AIS, we found no increase in ED visits or hospital readmissions for those discharged the next day. LEVEL OF EVIDENCE: Level III.

Periostin regulation and cartilage degradation early after anterior cruciate ligament reconstruction.

OBJECTIVE AND DESIGN: The purpose of this study was to explore pathological processes during the first 4 weeks after anterior cruciate ligament reconstruction (ACLR). SUBJECTS: Sixteen ACL-injured patients (8 females/8 males, mean age = 19.1, mean BMI = 28.6). METHODS: Arthrocentesis was performed 1 and 4 weeks after ACLR. Proteins in the synovial fluid were identified using nanoLC-ESI-MS/MS. Differentially up- or down-regulated proteins were identified and quantified, and a pathway analysis was performed. All identified proteins were mapped into a protein-protein interaction (PPI) network, and networks of PPIs with a combined score > 0.9 were then visualized. RESULTS: Seven pathways were upregulated after ACLR: PI3K-AKT signaling pathway, extracellular matrix (ECM)-receptor interaction, focal adhesion, protein digestion and absorption, ameobiasis, and platelet activation. Network analyses identified 8 proteins that were differentially upregulated with strong PPI interactions (periostin and 7 collagen-related proteins). Increases in periostin moderately correlated with increases in a synovial fluid biomarker of type II cartilage degradation (ρ = 0.51, p = 0.06). CONCLUSION: Pro-inflammatory pathways and periostin were upregulated after ACLR. Periostin demonstrated strong network connections with markers of collagen breakdown, and future work is needed to determine whether periostin may offer a biomarker of early cartilage degradation after ACLR and/or play an active role in early post-traumatic osteoarthritis (PTOA) progression.

Epidemiological analysis of pediatric baseball and softball concussions in United States emergency departments.

PURPOSE: To evaluate the epidemiology of concussions in pediatric baseball and softball players. We hypothesized that head-to-ball injuries would be the most common cause of concussions. METHODS: The National Electronic Injury Surveillance System (NEISS) database was used to gather data. Concussions occurring during baseball and softball participation in pediatric patients (4-17 years old) from 2012 to 2021 was gathered. Concussion mechanisms were grouped into 5 categories: head-to-player, head-to-ball, head-to-surface (ground, walls, railings), head-to-bat, and unknown. Linear regression models were used to assess changes in yearly concussion rates over the study period. Results from these models were reported using parameter estimates and the estimated Pearson correlation coefficient. RESULTS: A weighted total of 54,978 baseball and softball related concussion injuries were analyzed. The average weighted age of our cohort at the time of injury was 13.1 years, with 54.1% (n = 29,761) of concussions occurring in males. The national estimated incidence of concussion injuries decreased non-significantly over the study period (slope estimate = -311 concussions/year, r = -0.625, p-value = 0.054). The majority of weighted national estimate concussions were due to head-to-ball injuries (n = 34,650; 63.0%), followed by head-to-player (n = 8501; 15.5%), head-to-surface (n = 5347; 9.7%), and head-to-bat (n = 5089; 9.3%). On sub-analysis, individuals were grouped into 3 age brackets: 4-8, 9-13, and 14-17 years. The most common mechanism of concussions in children of all ages was head-to-ball. The incidence of head-to-player and head-to-surface injuries increased throughout each age group, while head-to-bat decreased. CONCLUSION: The incidence of concussions in pediatric baseball and softball athletes has been decreasing non-significantly over our 10-year study period. The most common mechanism of concussions in our study was head-to-ball injuries.

Patients With Depression and/or Anxiety Having Arthroscopic Rotator Cuff Repair Show Decreased Number of Prescriptions and Number of Psychotherapy Sessions in the Year After Surgery.

PURPOSE: To determine whether the utilization of psychological treatments changes after arthroscopic rotator cuff repair (RCR) for patients with preoperative depression and/or anxiety. METHODS: The Truven Healthcare Marketscan database was used to identify patients who underwent arthroscopic RCR between January 2009 and December 2016. We included all patients with diagnosis codes associated with either depression or anxiety before RCR. Patients were excluded if they did not have complete insurance coverage for 1 year before or after surgery, or if they had arthroscopic RCR in the year before the index surgical procedure. We compared the proportion of patients with preoperative depression or anxiety who filled a prescription and had psychotherapy procedural codes in the year before and the year after arthroscopic RCR. RESULTS: A total of 170,406 patients who underwent RCR were identified, of which depression and/or anxiety was found in 46,737 patients (43.7% male). Of the 46,737 patients, 19.6% filled a prescription for a depression/anxiety medication at least once in the year before surgery. Of this subset of patients, 41.5% did not fill a prescription for depression or anxiety medication after surgery, whereas 32.6% continued medication use but demonstrated a median 30-day reduction in the number of days' worth of medication. Similarly, 13.1% of patients were attending psychotherapy sessions preoperatively, but 76.6% of those patients either stopped or reduced the amount of psychotherapy sessions in the year following RCR. CONCLUSIONS: The number of prescriptions and psychotherapy sessions decreased in the year after RCR for patients with preoperative diagnoses of depression and/or anxiety. LEVEL OF EVIDENCE: Level IV, case series.

Preliminary Evaluation of a Novel Point of Care Diagnostic Device for Sports-Related Concussion.

OBJECTIVE: Visinin-like protein 1 (VILIP-1) is a neuron-specific calcium sensor protein rapidly released into blood after mild traumatic brain injury (mTBI) and may be a suitable biomarker for identification of sports-related concussion (SRC). The objective of the study is to test if quantification of a specific post-translationally modified (ubiquitinated) form of VILIP-1 (ubVILIP-1) from a fingerstick blood sample using a point of care (POC) lateral flow device (LFD) can be used to rapidly identify athletes with SRC. DESIGN: Prospective cohort study. SETTING: Side-line blood collection at football, soccer, and volleyball games/practices. PARTICIPANTS: Division I athletes with/without SRC. MAIN OUTCOME MEASURES: Blood ubVILIP-1 concentrations. RESULTS: Data collected over 2 athletic seasons from non-SRC athletes (controls) show a small but statistically significant elevation of ubVILIP-1 over an individual season for male athletes (P = 0.02) dependent on sport (P = 0.014) and no significant changes in ubVILIP-1 levels between seasons. For SRC athletes, the data show ubVILIP-1 levels substantially increase above baseline as soon as 30 minutes postdiagnosis with peak concentrations and times postinjury that vary based on injury severity. CONCLUSION: Results of the study suggest quantification of blood ubVILIP-1 levels measured using an LFD may provide an objective identification of athletes with SRC, setting the stage for further study with a larger number of SRC patients.

Tetracycline use in treating osteoarthritis: a systematic review.

BACKGROUND AND AIMS: The purpose of the review was to synthesize the current literature regarding tetracyclines in the treatment of osteoarthritis. METHODS: Using multiple databases, a systematic review was performed with customized search terms crafted to identify studies examining doxycycline or minocycline in the treatment of osteoarthritis. Results were classified into basic science mechanistic studies, in vivo animal studies, and human clinical trials. A total of 1446 potentially relevant studies were reviewed, and after exclusion criteria were applied, 23 investigations were included in the final analysis. RESULTS: From 12 basic science mechanistic studies, we report on three main mechanisms by which tetracyclines may exert benefit in osteoarthritis progression: matrix metalloproteinase inhibition, immunomodulation, and nitric oxide synthase inhibition. Seven animal studies showed generally encouraging results. Four articles reported human clinical studies, showing mixed results in the treatment of osteoarthritis, potentially related to the choice of patient population, primary outcomes, and timing of treatment. CONCLUSION: Tetracyclines have the potential to benefit osteoarthritis patients via multiple mechanisms. Further study is warranted to examine the optimal dose and timing of tetracycline treatment in osteoarthritis.

Pitch break and performance metrics remain unchanged in pitchers who returned to the same level of play after ulnar collateral ligament reconstruction in Major League Baseball pitchers.

BACKGROUND: The ulnar collateral ligament is commonly injured in overhead-throwing athletes, particularly baseball pitchers. Pitch movement (break) is a critical aspect to pitching performance. The primary purpose of this study was to determine the changes in pitch velocity, pitch break, angle of break, and pitch performance metrics before and after ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers. The secondary purpose was to determine changes in pitch performance metrics before and after UCLR. We hypothesized that pitch break and pitch performance metrics would be unchanged following UCLR. MATERIALS AND METHODS: This was a retrospective case-series study of pitchers who had undergone primary UCLR between 2008 and 2014. Velocity, horizontal movement (Hmov), and vertical movement (Vmov) of each pitch were collected from the PITCHf/x system for each pitcher 12-24 months before surgery, 12-24 months after surgery, and 24-36 months after surgery. Overall break was calculated by taking the Pythagorean sum of Hmov and Vmov. Angle of break was determined by taking the inverse tangent of Vmov divided by Hmov. Repeated-measures analysis of covariance was performed to determine differences in pitch velocity, movement, angle of movement, and performance metrics between preoperative and postoperative time frames. Performance metrics included balls, strikes, swings, fouls, swings and misses, ground balls, line drives, pop-ups, fly balls, and home runs. Covariates included age at surgery, time from MLB debut to surgery, innings pitched as a starter, innings pitched as a reliever, and total pitches thrown. RESULTS: In a cohort of 46 pitchers who underwent UCLR between 2008 and 2014, pitch velocity, movement, and angle were not significantly changed with respect to preoperative or postoperative time frames. In addition, postoperative time frames had clinically insignificant differences in pitch performance metrics. CONCLUSION: Pitch break and performance metrics are not significantly affected in pitchers who return after UCLR.

Depression and Anxiety Are Associated With Increased Health Care Costs and Opioid Use for Patients With Femoroacetabular Impingement Undergoing Hip Arthroscopy: Analysis of a Claims Database.

PURPOSE: To determine if opioid use and health care costs in the year before and following hip arthroscopy for femoroacetabular impingement (FAI) differ between those with or without depression or anxiety. METHODS: Using the Truven Health Marketscan database, FAI patients who underwent hip arthroscopy between October 2010 and December 2015 were identified (Current Procedural Terminology codes 29914 [femoroplasty], 29915 [acetabuloplasty], and/or 29916 [labral repair]). Patients were excluded if they had incomplete coverage for 1 year either before or following surgery. The number of patients with 1 or more claims related to depression or anxiety during the year before surgery was quantified (International Statistical Classification Diseases and Related Health-9 codes 296, 298, 300, 309, 311). Health care costs in the year before and following hip arthroscopy were compared between those with or without depression or anxiety. We also compared the number of patients in each group who filled a narcotic pain prescription within 180 days before surgery as well as >60 or >90 days after hip arthroscopy. RESULTS: Depression or anxiety claims were seen in 5,208/14,830 patients (35.1%) before surgery. A significantly greater proportion of those with preoperative depression or anxiety filled opioid-related prescriptions in the 6 months before surgery (36.2% vs 25.6%, P < .0001) and both >60 days (31.3% vs 24.7%, P < .0001) and >90 days after surgery (29.5% vs 23.4%, P < .0001). The group with preoperative depression or anxiety had significantly greater health care costs both before ($8,775 vs $5,674, P < .0001) and following surgery ($5,287 vs $3,908, P < .0001). CONCLUSIONS: Both before and following hip arthroscopy, opioid use and health care costs were significantly greater for FAI patients with comorbid depression or anxiety. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic study.

Lysholm and KOOS QoL Demonstrate High Responsiveness in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

BACKGROUND: There have been a large number of patient-reported outcome measures (PROMs) used to assess outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR). PURPOSE/HYPOTHESIS: The purpose was to determine which PROMs are being commonly used in randomized clinical trials (RCTs) to assess patients undergoing ACLR and to compare the responsiveness between them. It was hypothesized that the International Knee Documentation Committee (IKDC) score would be the most commonly used and responsive PROM among patients undergoing ACLR. STUDY DESIGN: Meta-analysis. Level of evidence, 2. METHODS: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and relevant studies were extracted from the PubMed/MEDLINE and Web of Science databases. The inclusion criteria were English-language RCTs reporting on PROMs after ACLR. For articles meeting our inclusion criteria for responsiveness analysis (≥2 PROMs reported, 1 year minimum follow-up, and reported pre- and postoperative PROM means and standard deviations), the responsiveness between PROMs was compared using effect size (ES) and relative efficiency (RE). RESULTS: A total of 108 articles met the inclusion criteria, comprising 9034 patients (mean age, 29.9 years; mean body mass index, 24.3; mean follow-up time, 36.1 months). There were 34 PROMs identified. The top 3 most commonly reported PROMs were the IKDC (n = 68; 63.0%), Lysholm (n = 65; 60.2%), and Tegner (n = 47; 43.5%) scores. The 2 PROMs with the highest ES were the ACL-Quality of Life (QoL) (3.37) and Knee Injury and Osteoarthritis Outcome Score (KOOS) QoL (2.07) scores. Compared with other PROMs, Lysholm and KOOS QoL scores had the greatest RE values. The Lysholm score had a greater RE than the KOOS Pain (RE, 1.17), KOOS Symptoms (RE, 1.22), KOOS Activities of Daily Living (ADL) (RE, 1.42), KOOS Sport/Recreation (RE, 1.55), KOOS QoL (RE, 1.41), and Tegner (RE, 2.89) scores. KOOS QoL had a greater RE than the IKDC (RE, 1.32), KOOS Pain (RE, 1.60), KOOS Symptoms (RE, 2.12), KOOS ADL (RE, 3.03), KOOS Sport/Recreation (RE, 1.27), and Tegner (RE, 2.06) scores. CONCLUSION: The IKDC score is the most commonly reported PROM in RCTs after ACLR; however, the Lysholm and KOOS QoL scores demonstrated the highest responsiveness in patients undergoing ACLR compared with other PROMs.

Responsiveness of Patient-Reported Outcome Measures After Large Knee Articular Cartilage Transplantation: A Systematic Review and Meta-analysis.

BACKGROUND: Cartilage transplantation is commonly used to treat large (>4 cm2) articular cartilage defects of the knee. The 2 most common transplants are osteochondral allograft transplantation and autologous chondrocyte implantation. Several patient-reported outcome measures (PROMs) have been used to determine the efficacy of treatment, but it is unknown which measures are the most effective. PURPOSE: To report the multiple PROMs used after large knee articular cartilage transplantation surgery and to compare the responsiveness between them. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of the PubMed/MEDLINE and Web of Science databases was performed. A total of 181 articles met inclusion criteria. Patient and study characteristics were extracted, including pre- and postoperative means for PROMs. From the articles that met inclusion criteria for responsiveness analysis (2+ PROMs reported, 1-year minimum follow-up, reported pre- and postoperative means and standard deviations; n = 131), the authors compared the responsiveness between PROM instruments using effect size and relative efficiency (RE) if a PROM could be compared with another in ≥10 articles. RESULTS: A total of 10,015 patients (10,093 knees; mean age, 34.8 years; mean body mass index, 26.1) were included in this study. The mean follow-up time was 58.3 months (range, 1.5-247.2 months), imaging findings were reported in 80 articles (44.2%), patient satisfaction was reported in 39 articles (21.5%), and range of motion was reported in 10 articles (5.5%). There were 58 unique PROM instruments identified, with the most used being the International Knee Documentation Committee (IKDC) score (n = 118; 65.2%), followed by Knee injury and Osteoarthritis Outcome Score (KOOS) Pain (n = 58; 32.0%), KOOS Sport and Recreation (n = 58; 32.0%), KOOS Quality of Life (n = 57; 31.5%), KOOS Activities of Daily Living (n = 57; 31.5%), and KOOS Symptoms (n = 57; 31.5%). Overall, IKDC was found to have the greatest effect size (1.68) and the best responsiveness of the other PROMs, which include KOOS Pain (RE, 1.38), KOOS Symptoms (RE, 3.06), KOOS Activities of Daily Living (RE, 1.65), KOOS Sport and Recreation (RE, 1.44), Lysholm (RE, 1.76), and Tegner (RE, 1.56). CONCLUSION: The IKDC is the most responsive PROM after large knee articular cartilage transplantation surgery. The IKDC score is recommended for assessing outcomes after cartilage transplantation surgery.

Incidence of Osteoarthritis Diagnosis Within 5 Years of Surgery Was Greater Following Partial Meniscectomy Than Meniscus Repair and/or Anterior Cruciate Ligament Reconstruction.

Purpose: To compare knee osteoarthritis (OA) incidence within 5 years of surgery between 5 common sports medicine procedures: isolated anterior cruciate ligament (ACL) reconstruction, isolated meniscus repair (MR), isolated arthroscopic partial meniscectomy (APM), ACL reconstruction with MR (ACL + MR), and ACL reconstruction with APM (ACL + APM). Methods: The PearlDiver Mariner M157Ortho database was searched. Five cohorts were identified using Current Procedural Terminology (CPT) codes and included those 16 to 60 years old who underwent isolated ACL reconstruction, isolated MR, ACL + MR, isolated APM, or ACL + APM repair. Groups were matched by age, sex, and presence of diagnosis codes for obesity. The incidence of knee OA diagnosis within 5 years of the index procedure was determined for each group, and odds ratios (ORs) were calculated and compared against isolated ACL reconstruction. Results: Each group consisted of 7,672 patients (3,450 females, 4,222 males). A significantly greater proportion of the APM group was diagnosed with knee OA within 5 years of surgery compared to isolated ACL reconstruction (APM = 1,032/7,672 [13.5%] vs ACL = 745/7,672 [9.7%]; P ≤ .001; OR, 1.45; 95% confidence interval [CI], 1.31-1.60). Similarly, a greater proportion of the MR group was diagnosed with OA compared to isolated ACL reconstruction (MR = 826/7,672 [10.7%]; P = .030; OR, 1.12; 95% CI, 1.01-1.25). No differences in OA incidence were noted between the ACL + APM group when compared to isolated ACL reconstruction (P = .81). Patients undergoing ACL + MR demonstrated the lowest OA incidence with reduced odds when compared to isolated ACL reconstruction (ACL + MR = 575/7,672 [7.5%]; P < .001; OR, 0.75; 95% CI, 0.67-0.84). Conclusions: In this analysis using CPT codes, APM was associated with the highest knee OA incidence, and ACL + MR was associated with the lowest OA incidence within 5 years of surgery. Level of Evidence: Level III, retrospective cohort study.

ASES and UCLA Are Responsive Patient-Reported Outcome Measures After Rotator Cuff Repair: A Systematic Review and Meta-analysis.

BACKGROUND: Multiple patient-reported outcome measures (PROMs) have been used to assess shoulder function, but it is unknown which are the most effective. PURPOSE/HYPOTHESIS: The purpose of this study was to report the multiple PROMs used after rotator cuff repair (RCR) and to compare the responsiveness between them. It was hypothesized that the Western Ontario Rotator Cuff PROM would be the most responsive and commonly used in patients undergoing RCR. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PRISMA-Searching extension guidelines via PubMed/MEDLINE, Embase (Elsevier), and Web of Science (Clarivate). Patient and study characteristics were extracted. From the studies that met inclusion criteria for responsiveness analysis (≥2 PROMs reported, 1-year minimum follow-up, and pre- and postoperative PROM means and standard deviations reported), the authors compared the responsiveness between PROM instruments using effect size and relative efficiency (RE) if a PROM could be compared with another in ≥10 articles. RESULTS: A total of 252 studies met inclusion criteria (32,072 patients; mean age, 59.6 years; mean body mass index, 28.7; mean follow-up time, 27.8 months). Range of motion was reported in 131 (52%) studies and imaging findings were reported in 123 (49%) studies. There were 67 PROM instruments identified; the most commonly used were the American Shoulder and Elbow Surgeon (ASES) (n = 183; 73%), Visual Analog Scale (VAS) (n = 163; 65%), and Constant (n = 118; 47%) scores. The 3 PROMs with the highest effect sizes were the University of California, Los Angeles (UCLA) (2.51), Western Ontario Rotator Cuff (2.42), and ASES (2.00) scores. Overall, UCLA and ASES scores were the most responsive PROMs. The ASES PROM was more responsive than the VAS (RE, 1.70), Constant (RE, 2.76), Simple Shoulder Test (RE, 1.67), and Single Assessment Numeric Evaluation (RE, 2.14) scores. The UCLA PROM was more responsive than the ASES (RE, 1.03), VAS (RE, 3.66), Constant (RE, 1.72), and Simple Shoulder Test (RE, 1.66) scores. CONCLUSION: ASES and UCLA scores were the most responsive PROMs after RCR. The authors recommend widespread adoption of ASES and UCLA scores for clinical and research standardization; however, the UCLA PROM requires in-person range of motion and strength testing, which is a practical limitation and barrier to long-term follow-up.

Randomized Controlled Trial of Irrigation-Coupled Bipolar Electrocautery Versus Tourniquet in Total Knee Arthroplasty.

Background: Recovery from total knee arthroplasty remains arduous for some patients, prompting interest in perioperative management. While tourniquet use is not associated with longer-term outcomes, its effect on quadriceps strength in the immediate postoperative window is unknown. Methods: A single-center, double-blind, randomized controlled trial of 66 patients undergoing primary total knee arthroplasty from 2019 to 2022 was performed to compare the use of an irrigation-coupled bipolar device (ICBD) and no tourniquet (ICBD group, N = 34) to tourniquet use with no ICBD (tourniquet group, N = 32). Groups were similar with respect to age, sex, and obesity. The primary outcome was quadriceps strength at 2 weeks, measured using a handheld dynamometer and standardized to the contralateral side. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement was measured with the difference from baseline serving as a secondary outcome. Comparisons were performed using the Student's t-test. Results: Only 28 patients, 14 in each group, had primary outcome data. At 2-weeks, quadriceps strength was higher in the ICBD group compared to the tourniquet group (83% vs 70%), though not statistically significant (P = .16). There was no difference between the ICBD and tourniquet groups in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement changed at 2-weeks (13 vs 10, P = .37) or 6-weeks (16 vs 17, P = .76). Conclusions: Tourniquet use was associated with a small but not statistically significant difference in quadriceps strength at 2 weeks that may justify further study given the loss of power here. There can be limitations to conducting randomized controlled trials that are important for early-career investigators to consider and that were magnified due to COVID-related restrictions in the present study, which we discuss. Level of Evidence: Level II.

Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in the National Women's Soccer League.

Background: The anterior cruciate ligament (ACL) is commonly injured in elite-level female athletes, which usually requires ACL reconstruction (ACLR). Purpose: To analyze return to play (RTP) and changes in performance of players in the National Women's Soccer League (NWSL) after ACLR. Study Design: Descriptive epidemiology study. Methods: NWSL players who sustained an ACL tear and underwent surgery between the 2013 and 2020 seasons were identified by multiple online resources. Players were classified as forwards, defenders, midfielders, and goalkeepers. RTP was assessed according to games played, games started, percentage of minutes played, plus/minus net per 90 minutes (a measure of a player's contribution to their team's performance while on the field), goals scored, and assists. A subanalysis was performed based on the median age at the time of the injury (≤24 vs ≥25 years). Nonparametric testing methods were used throughout the analysis. Results: A total of 30 NWSL athletes were included. Midfielders had the highest percentage of injuries (n = 11; 36.7%), followed by forwards (n = 10; 33.3%). Overall, 27 players returned to the NWSL at a median of 12.1 months (IQR, 10.9-14.3 months), constituting a 90.0% RTP rate. There was a significant decrease in the percentage of minutes played from 1 year before the injury to 1 year after the injury (median, 87.9% [IQR, 80.7%-90.6%] vs 25.1% [IQR, 16.3%-57.2%], respectively; P = .031). Forwards and midfielders had a significant decrease in the number of assists from 1 year before the injury to 1 year after the injury (median, 3.0 [IQR, 1.0-3.0] vs 0.0 [IQR, 0.0-1.0], respectively; P = .037) as well as the number of goals scored when averaging across 2 seasons before the injury to 2 seasons after the injury (median, 3.0 [IQR, 1.5-5.5] vs 1.0 [IQR, 0.5-3.5], respectively; P = .031). On subanalysis, older players started in significantly more games (median, 12.0 [IQR, 3.8-18.5] vs 3.0 [IQR, 0.5-6.0], respectively; P = .048) and had a higher percentage of minutes played (median, 63.0% [IQR, 18.8%-77.3%] vs 14.9% [IQR, 2.0%-21.2%], respectively; P = .046) at 1 year after the injury versus younger players. Conclusion: There was a 90.0% RTP rate after ACLR in the NWSL. Players who returned to the NWSL had a lower percentage of minutes played in their first year after RTP, with older players starting in more games and having a greater percentage of minutes played. Compared with preinjury performance, forwards and midfielders had a significant decrease in the number of assists at 1 year after the injury as well as the number of goals scored at 2 years after the injury.

Older Age, Female Sex, Anxiety, Substance Use Disorder, Osteoarthritis, Tibial Tubercle Osteotomy, and Opioid Familiarity Are Risk Factors for Prolonged Opioid Use Following Medial Patellofemoral Ligament Reconstruction.

Purpose: To determine which preoperative factors are associated with prolonged opioid use after medial patellofemoral ligament reconstruction (MPFLR). Methods: The M151Ortho PearlDiver database was queried for patients who underwent MPFLR between 2010 and 2020. Inclusion criteria included patients who underwent MPFLR using Current Procedural Terminology codes 27420, 27422, and 27427 and had a patellar instability diagnosis. Prolonged opioid use was defined as opioid use greater than 1 month after surgery. Postoperative opioid use from 1 month to 6 months was assessed. Multivariable logistic regression was used to evaluate the association between patient-related risk factors (age, sex, Charlson Comorbidity Index, anxiety, depression, substance use disorder, osteoarthritis, tibial tubercle osteotomy [TTO], and previous opioid use within 3 months to 1 week of surgery) with prolonged postoperative opioid use. Odds ratios (OR) and their associated 95% confidence intervals (CI) were calculated for each risk factor. Results: A total of 23,249 patients were included. There was a higher proportion of female patients compared to male patients (67.8% vs 32.2%) in our cohort, as well as a large proportion of patients who had preoperative opioid use (23.9%). In total, 14.3% of patients had a concomitant TTO. Three months post-MPFLR, male patients were at a decreased risk of opioid usage (OR 0.75; CI 0.67-0.83; P ≤ .001). Older age (OR 1.01, CI 1.00-1.01; P ≤ .001), patients with pre-existing anxiety (OR 1.30, CI 1.15-1.47; P ≤ .001), substance use disorder (OR 2.04, CI 1.80-2.31; P ≤ .001), knee osteoarthritis (OR 1.70, CI 1.49-1.94; P ≤ .001), concomitant TTO (OR 1.91, CI 1.67-2.17; P ≤ .001), and opioid familiarity (OR 7.68, CI 6.93-8.52; P ≤ .001) were at a significantly increased risk of postoperative opioid usage. Conclusions: Older age, female sex, anxiety, substance use disorder, osteoarthritis, tibial tubercle osteotomy, and opioid familiarity are risk factors for prolonged opioid use following MPFLR. Level of Evidence: Level III, retrospective cohort study.

Return to Play, Performance, and Economic Analysis of National Football League Players After Lisfranc Injury.

Background: A Lisfranc injury can occur to either the ligament or bone, which causes instability when attempting to perform strength and balance maneuvers. Purpose/Hypothesis: The study's aims were to (1) analyze the return-to-play (RTP) rate and performance level of players in the National Football League (NFL) after Lisfranc injury and (2) determine the economic and financial impact of Lisfranc injuries to the NFL. We hypothesized that there would be a low RTP rate following Lisfranc injury in the NFL. Study Design: Case series; Level of evidence, 4. Methods: Multiple online public records were used to identify NFL players with Lisfranc injuries between the 2009 and 2020 seasons. Players were assessed according to their RTP statistics: snap count, approximate value (AV), games played, and games started. Nonparametric methods were used to compare player statistics before and after injury. Also, player salaries while injured were calculated (in 2022 US dollars after adjusting for inflation) to approximate economic loss for those players who returned to play. Results: A total of 33 NFL athletes sustained a Lisfranc injury during the study period. Most Lisfranc injuries were experienced by offensive linemen (n = 8; 24.2%), followed by running backs (n = 7; 21.2%). Overall 27 players (81.8%) returned to play after injury at a median of 11.0 months (IQR, 10.2-11.8 months). There were no significant differences between pre- and postinjury snap counts or number of games played and started. In terms of player performance, there was a statistically significant decrease in AV at 1 year postinjury (median [IQR], 6.0 [4.0-10.0] preinjury vs 5.0 [2.5-7.5] postinjury; P = .022). The overall cost of recovery amounted to $104.7 million, with quarterbacks (n = 4) accounting for the greatest cost at $32.6 million. The next 2 most expensive positions were offensive and defensive linemen (n = 5 each) at $19.4 million each. Conclusion: Our results did not support the hypothesis, as the RTP rate for NFL athletes sustaining Lisfranc injuries was 81.8%. This injury was associated with a significant decrease in AV 1 year postinjury. In terms of economic impact, quarterbacks accounted for almost one-third of expenses while constituting only 14.8% of injuries.

Leveraging Insurance Claims Data to Identify Risk Factors for Posttraumatic Osteoarthritis After Multiligament Knee Reconstruction.

BACKGROUND: The incidence of subsequent posttraumatic osteoarthritis (OA) diagnosis after surgery and the associated risk factors have been well reported after single-ligament anterior cruciate ligament (ACL) reconstruction; however, to date, the incidence of posttraumatic OA for those who have experienced multiligament knee injury (MLKI) has been reported only in relatively small, single-center studies. PURPOSE: To compare the incidence of OA diagnoses between patients with ACL injury versus patients with MLKI and to identify risk factors for OA diagnosis after MLKI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study used the PearlDiver Mariner database, which contains insurance claims information on >151 million orthopaedic patients. We identified 2 cohorts for this study by using Current Procedural Terminology codes. The cohorts included patients between the ages of 16 and 60 who underwent either isolated ACL reconstruction (n = 114,282) or MLKI reconstruction (n = 3325) between July 1, 2010, and August 30, 2016. MLKI reconstruction was operationally defined as ACL reconstruction plus concurrent surgical treatment of ≥1 additional ligaments. Demographic factors, concomitant meniscal and cartilage procedures, and subsequent reoperation to restore motion were recorded, as was the incidence of knee OA diagnosis within 5 years of the index surgical procedure. OA incidence and demographic and surgical factors were compared (1) between ACL and MLKI groups and (2) between patients with MLKI either with or without OA diagnosis. RESULTS: A significantly greater proportion of patients with MLKI were diagnosed with knee OA within 5 years of surgery (MLKI = 299/3325 [9.0%] vs ACL = 6955/114,282 [6.1%]; P < .0001) (odds ratio [OR], 1.52; 95% CI, 1.35-1.72; P < .001). Factors associated with increased odds of OA diagnosis after MLKI included age ≥30 years (OR, 5.90), reoperation to restore motion (OR, 2.54), obesity (OR, 1.96), mood disorder diagnoses (OR, 1.85), partial meniscectomy (OR, 1.85), and tobacco use (OR, 1.72). Concomitant meniscal repair was protective against OA diagnosis (OR, 0.06). CONCLUSION: OA incidence was greater after MLKI reconstruction than after isolated ACL reconstruction. Potentially modifiable risk factors for OA after MLKI were identified and include obesity, tobacco use, depression, and the need for motion-restoring surgery.