Effect of Spinopelvic Parameters on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

BACKGROUND: Spinopelvic parameters, including pelvic tilt (PT), sacral slope (SS), and pelvic incidence, have been developed to characterize the relationship between lumbar spine and hip motion, but a paucity of literature is available characterizing differences in spinopelvic parameters among patients with femoroacetabular impingement syndrome (FAIS) versus patients without FAIS, as well as the effect of these parameters on outcomes of arthroscopic treatment of FAIS. PURPOSE: To (1) identify differences in spinopelvic parameters between patients with FAIS versus controls without FAIS; (2) identify associations between spinopelvic parameters and preoperative patient-reported outcomes (PROs); and (3) identify differences in PROs between patients with stiff spines (standing-sitting ΔSS ≤10°) versus those without. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The study enrolled patients ≥18 years of age who underwent primary hip arthroscopy for treatment of FAIS with cam, pincer, or mixed (cam and pincer) morphology. Participants underwent preoperative standing-sitting imaging with a low-dose 3-dimensional radiography system and were matched on age and body mass index (BMI) to controls without FAIS who also underwent EOS imaging. Spinopelvic parameters measured on EOS films were compared between the FAIS and control groups. Patients with FAIS completed the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) before surgery and at 1-year follow-up. Outcome scores were compared between patients with stiff spines versus those without. Associations between spinopelvic parameters and baseline outcome scores were assessed with Pearson correlations. Continuous variables were compared with Student t test and/or Mann-Whitney U test, and categorical variables were compared with Fisher exact test. RESULTS: A total of 50 patients with FAIS (26 men; 24 women; mean age, 36.1 ± 10.7 years; mean BMI, 25.6 ± 4.2) were matched to 30 controls without FAIS (13 men; 17 women; mean age, 36.6 ± 9.5 years; mean BMI, 26.7 ± 3.6). Age, sex, and BMI were not significantly different between the FAIS and control groups (P > .05). Standing PT was not significantly different between stiff and non-stiff cohorts (P = .73), but sitting PT in the FAIS group was more than double that of the control group (36.5° vs 15.0°; P < .001). Incidence of stiff spine was significantly higher in the FAIS group (62.0% vs 3.3%; P < .001). Among FAIS patients, those with stiff spines had a significantly higher prevalence of cam impingement, whereas those with non-stiff spines had a higher prevalence of mixed impingement (P = .04). No significant differences were seen in preoperative mHHS or NAHS scores or pre- to postoperative improvement in scores between FAIS patients with stiff spines versus those without (P > .05), but a greater sitting SS was found to be positively correlated with a higher baseline mHHS (r = 0.36; P = .02). CONCLUSION: Patients with FAIS were more likely to have a stiff spine (standing-sitting ΔSS ≤10°) compared with control participants without FAIS. FAIS patients with stiff spines were more likely to have isolated cam morphology than patient without stiff spines. Although sitting SS was positively correlated with baseline mHHS, no significant differences were seen in 1-year postoperative outcomes between FAIS patients with versus without stiff spine.

Segond fracture: an indicator for increased risk of lateral meniscus injury in patients with acute anterior cruciate ligament ruptures.

PURPOSE: The purpose of this study was to investigate the incidence and anatomic distribution of meniscus injury in patients who have sustained acute ACL injuries with and without concomitant Segond fracture. We hypothesized that patients who have sustained a torn ACL with a concomitant Segond fracture would have a higher incidence of lateral meniscal injuries than patients with an isolated ACL injury. METHODS: Patients who underwent ACL reconstruction from 2012 to 2022 were retrospectively reviewed. Segond fractures were identified on knee radiographs. Inclusion criteria were age 18-40, injury during sports activity, and reconstruction within 90 days of injury. Sports activity, anatomic location of meniscus injury, and meniscus treatment were documented. Multivariable regression was used to identify predictors of meniscus injury/treatment. RESULTS: There were 25 of 603 (4.1%) patients who had an ACL tear with concomitant Segond fracture. The incidence of lateral meniscus injury in the Segond group (72%) was significantly higher than in the non-Segond cohort (49%; p = 0.024). A significantly smaller proportion of medial meniscus injuries among patients with Segond fractures were repaired (23.1%) compared to the non-Segond group (54.2%; p = 0.043). Multivariate analysis found patients with Segond fractures to have increased odds of lateral meniscus injury (OR 2.68; [1.09, 6.60], p = 0.032) and were less likely to have medial meniscus injuries repaired (OR 0.35; [0.15, 0.81], p = 0.014). Additionally, males had increased odds of lateral meniscus injury (OR 1.54; [1.08 - 2.91], p = 0.017), which were more likely to require repair (OR 1.48; [1.02, 2.14], p = 0.038). CONCLUSIONS: Among acute ACL injuries, the incidence of lateral meniscus injury is greater among patients with Segond fractures. Patients with Segond fracture were less likely to undergo repair of medial meniscal injuries.

Editorial Commentary: Artificial Intelligence Models Show Impressive Results for Musculoskeletal Pathology Detection.

An important domain of artificial intelligence is deep learning, which comprises computed vision tasks used for recognizing complex patterns in orthopaedic imaging, thus automating the identification of pathology. Purported benefits include an expedited clinical workflow; improved performance and consistency in diagnostic tasks; decreased time allocation burden; augmentation of diagnostic performance, decreased inter-reader discrepancies in measurements and diagnosis as a function of reducing subjectivity in the setting of differences in imaging quality, resolution, penetrance, or orientation; and the ability to function autonomously without rest (unlike human observers). Detection may include the presence or absence of an entity or identification of a specific landmark. Within the field of musculoskeletal health, such capabilities have been shown across a wide range of tasks such as detecting the presence or absence of a rotator cuff tear or automatically identifying the center of the hip joint. The clinical relevance and success of these research endeavors have led to a plethora of novel algorithms. However, few of these algorithms have been externally validated, and evidence remains inconclusive as to whether they provide a diagnostic benefit when compared with the current, human gold standard.

Five-Year Outcomes of Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Among Female Patients: Higher Body Mass Index Is Associated With Reduced Clinically Significant Outcomes.

PURPOSE: To evaluate the impact of age, body mass index (BMI), and symptom duration on 5-year clinical outcomes among females following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: We conducted a retrospective review of a prospectively collected database of hip arthroscopy patients with a minimum 5-year follow-up. Patients were stratified by age (<30, 30-45, ≥45 years), BMI (<25.0, 25.0-29.9, ≥30.0), and preoperative symptom duration (<1 vs ≥1 year). Patient-reported outcomes were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Pre- to postoperative improvement in mHHS and NAHS was compared between groups using the Mann-Whitney U test or Kruskal-Wallis test. Hip survivorship rates and minimum clinically important difference (MCID) achievement rates were compared with Fisher exact test. Predictors of outcomes were identified using multivariable linear and logistic regression. P values <.05 were considered significant. RESULTS: In total, 103 patients were included in the analysis with a mean age of 42.0 ± 12.6 years (range, 16-75) and mean BMI of 24.9 ± 4.8 (range, 17.2-38.9). Most patients had symptoms of duration ≥1 year (60.2%). Six patients (5.8%) had arthroscopic revisions, and 2 patients (1.9%) converted to total hip arthroplasty by 5-year follow-up. Patients with BMI ≥30.0 had significantly lower postoperative mHHS (P = .03) and NAHS (P = .04) than those with BMI <25.0. Higher BMI was associated with reduced improvement in mHHS (ß = -1.14, P = .02) and NAHS (ß = -1.34, P < .001) and lower odds of achieving the mHHS MCID (odds ratio [OR] = 0.82, P = .02) and NAHS MCID (OR = 0.88, P = .04). Older age was predictive of reduced improvement in NAHS (ß = -0.31, P = .046). Symptom duration ≥1 year was predictive of higher odds of achieving the NAHS MCID (OR = 3.98, P = .02). CONCLUSIONS: Female patients across a wide range of ages, BMIs, and symptom durations experience satisfactory 5-year outcomes following primary hip arthroscopy, but higher BMI is associated with reduced improvement in patient-reported outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

The 50 Most Cited Publications in Adipose-Derived "Stem Cell Therapies" with Application in Orthopaedic Surgery.

Stem cell therapies have become widely popular in orthopaedic surgery, with a recent interest in adipose-derived therapeutics. Adipose-derived mesenchymal signaling cells (ADSCs) and micronized adipose tissue (MAT) are unique therapies derived from different processing methods. Characterizing the most influential studies in lipoaspirate research can help clarify controversies in definitions, identify core literature, and further collective knowledge for educational purposes. The Science Citation Index Expanded subsection of the Web of Science Core Collection was systematically searched to identify the top 50 most cited publications (based on citation/year) on orthopaedic ADSCs or MAT research. Publication and study characteristics were extracted and reported using descriptive statistics. Level of evidence was assessed for applicable studies, and Spearman correlations were calculated to assess the relationship between citation data and level of evidence. The top 50 articles were published between the years 2003 and 2020, with 78% published in the year 2010 or later. The mean number of citations was 103.1 ± 81.1. The mean citation rate was 12.4 ± 6.0 citations per year. Of the 21 studies for which level of evidence was assessed, the majority were level III (10, 47.6%). The single study design most common among the top 50 cited articles was in vitro basic science studies (17 studies, 34%). Twenty-nine articles (58%) were classified as basic science or translational. Application to treat knee osteoarthritis was the most common focus of studies (14 studies, 28%), followed by in vitro analysis of growth factor and cell signaling markers (11 studies, 22%). No correlation was found between rank, citation rate, or year of publication and level of evidence. This study provides a current landscape on the most cited articles in lipoaspirates in orthopaedic surgery. With the expansion of ADSCs and MAT in the past two decades, this study provides the first historical landmark of the literature and a launching point for future research. Studies should explicitly state their processing methodology and whether their study investigates ADSCs or MAT to avoid misinformation.

Patient-reported allergies are associated with increased rate of postoperative stiffness after arthroscopic rotator cuff repair.

BACKGROUND: Several risk factors have been identified for the development of postoperative shoulder stiffness, and there has been increasing interest in orthopedic literature regarding patient-reported allergy (PRA) as an identifiable risk factor for adverse outcomes. The purpose of this study is to determine whether PRAs are associated with subsequent rates of diagnosis of adhesive capsulitis (AC) or return to the operating room for postoperative shoulder stiffness within 2 years after arthroscopic rotator cuff repair (ARCR). METHODS: Current Procedural Terminology surgical billing codes were used to retrospectively identify patients who underwent ARCR at a single urban academic institution from January 2012 to December 2020 with minimum 2-year follow-up. Lysis of adhesions (LOA), manipulation under anesthesia (MUA), and AC of the shoulder were further queried within 2 years postoperatively for the ipsilateral shoulder. Patients were excluded if they had undergone ipsilateral MUA/LOA or received a diagnosis of AC before the index procedure. Demographic characteristics and medical comorbidities (hypertension, diabetes, hyperlipidemia, and hypothyroidism) were extracted from electronic medical records. Baseline characteristics were compared between patients with and without PRAs. Multivariate logistic regression analyses were performed to determine the association of the presence of PRAs overall, as well as the presence of 1, 2, or 3 or more PRAs, with subsequent MUA/LOA or diagnosis of AC within 2 years postoperatively. RESULTS: Of 7057 patients identified in the study period, 6583 were eligible for the final analysis. The mean age was 56.6 ± 11.7 years, and the mean body mass index was 29.1 ± 5.6. Overall, 19.3% of patients (n = 1271) reported at least 1 allergy, and 7.1% (n = 469) had >1 PRA. A total of 44 patients (0.7%) underwent subsequent ipsilateral MUA/LOA within 2 years postoperatively, whereas 93 patients (1.4%) received a diagnosis of ipsilateral AC in the same time frame. PRAs were significantly associated with subsequent diagnosis of AC (odds ratio [OR]: 2.39; 95% confidence interval [CI]: 1.45-3.92; P < .001), but not MUA/LOA (OR: 1.97, 95% CI: 1.26-3.61; P = .133). Patients with 2 PRAs had greater odds of being diagnosed with AC than patients with 1 PRA (OR: 2.74; 95% CI: 1.14-5.99; P = .012). Although this association was nonsignificant for MUA/LOA, patients with 2 PRAs (OR: 2.67; 95% CI: 0.96-8.80; P = .059) demonstrated a similar statistical trend. CONCLUSION: PRAs are associated with increased odds of receiving a diagnosis of AC within 2 years after ARCR but were not found to be associated with return to the operating room for postoperative stiffness.

Eponyms for the Description and Classification of Calcaneus Fractures.

There are several eponyms used in the assessment and management of calcaneus fractures. However, the origin of these eponyms is no longer widely known. Named for orthopaedic surgeons who made substantial contributions to the management of calcaneus fractures as well as the field of orthopaedic surgery, understanding the context of how these descriptors were derived helps give context to their use in the present day. The purpose of this review is to provide a historical perspective and comprehensive collection of the most common eponyms related to calcaneus fractures.

Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors Have No Significant Relationship With Postoperative Arthrofibrosis After Shoulder Arthroscopy.

Purpose: To determine the effect of perioperative angiotensin II receptor blocker (ARB) or angiotensin-converting enzyme inhibitors (ACEi) on postoperative arthrofibrosis, as defined by requiring manipulation under anesthesia (MUA) or new diagnosis of adhesive capsulitis (AC) following arthroscopic shoulder procedures. Methods: Patients were retrospectively identified using Current Procedural Terminology surgical billing codes to identify patients who underwent any shoulder arthroscopic procedure at a single urban academic institution from 2012 to 2020 with a minimum 2-year follow-up. Patients were excluded if <30 years old at time of surgery, as these patients rarely use ARB and ACEi medications, or if they had pre-existing AC. Demographics, active medication prescriptions at the time of surgery, and medical comorbidities were recorded. Multivariable logistic regression was performed to determine the effect of ARB/ACEi on subsequent MUA or AC by 90 days, 1 year, and 2 years. Results: In total, 5,559 patients were included in the final analysis. A majority of the cohort (53.4%) underwent arthroscopic surgery between the ages of 50 to 69 years. Most patients were male (61.8%) and without obesity (67.3%). In total, 18.9% and 15.0% were taking an ARB or ACEi medication perioperatively, respectively. Within 2 years' postoperatively, 51 patients (0.9%) underwent subsequent ipsilateral MUA, and 174 patients (3.1%) developed AC. Patients taking ARBs had a 17.5% rate of postoperative arthrofibrosis within 2-years compared with 19.1% in those not on ARBs, although this difference was not significant (P = .58). Likewise, no significant difference was found between those taking ACEi versus not (15.0% vs 15.0%, P = .99). Individual generic ARB/ACEi subgroup analysis did not demonstrate any significant associations with rate of postoperative arthrofibrosis (P > .05). Conclusions: ARBs or ACEi did not significantly affect the rate of postoperative arthrofibrosis following shoulder arthroscopy, however female sex, diabetes mellitus, and Black/African American race were associated with an increased rate of necessitating MUA or developing AC within 2 years postoperatively. Level of Evidence: Level III, retrospective cohort study.

Reprint of: Class I Obesity Delays Achievement of Patient-Acceptable Symptom State but Not Minimum Clinically Important Difference or Substantial Clinical Benefit After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: To identify differences in the time taken to achieve the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) among patients of different body mass index (BMI) categories. METHODS: We conducted a retrospective comparative study of hip arthroscopy patients with minimum 2-year follow-up. BMI categories were defined as normal (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI <30.0), or class I obese (30.0≤BMI<35.0). All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6 months, 1 year, and 2 years postoperative. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥8.2 and ≥19.8, respectively. PASS cutoff was set at postoperative mHHS ≥74. Time to achievement of each milestone was compared using the interval-censored EMICM algorithm. The effect of BMI was adjusted for age and sex using an interval-censored proportional hazards model. RESULTS: 285 patients were included in the analysis: 150 (52.6%) normal BMI, 99 (34.7%) overweight, and 36 (12.6%) obese. Obese patients had lower mHHS at baseline (P = .006) and at 2-year follow-up (P = .008). There were no significant intergroup differences in time to achievement for MCID (P = .92) or SCB (P = .69), but obese patients had longer time to PASS than normal BMI patients (P = .047). Multivariable analysis found obesity to be predictive of longer time to PASS (HR = .55; P = .007) but not MCID (HR = 0.91; P = .68) or SCB (HR = 1.06; P = .30). CONCLUSIONS: Class I obesity is associated with delays in achieving a literature-defined PASS threshold after primary hip arthroscopy for FAIS. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Treatment options for acute Rockwood type III-V acromioclavicular dislocations: a network meta-analysis of randomized controlled trials.

BACKGROUND: Acute Rockwood type III-V acromioclavicular (AC) dislocations have been treated with numerous surgical techniques over the years. The purpose of this study was to perform a network meta-analysis (NMA) of randomized controlled trials to quantitatively define the optimal treatment for AC dislocations requiring operative treatment. METHODS: A literature search of 3 databases was performed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Randomized controlled trials comparing 1 of 10 treatments for acute Rockwood type III-V AC dislocations-nonoperative treatment, Kirschner wire fixation (KW), coracoclavicular screw fixation (Scr), hook plate (HP), open coracoclavicular cortical button (CBO), arthroscopic coracoclavicular cortical button (CBA), ≥2 coracoclavicular cortical buttons (CB2), isolated graft reconstruction (GR), cortical button with graft augmentation (CB-GR), and coracoclavicular and acromioclavicular fixation (AC)-were included. Clinical outcomes were compared using a frequentist approach to NMA, with statistical analysis performed using the R program. Treatment options were ranked using the P-score, which estimates the likelihood that the investigated treatment is the ideal method for an optimal result in each outcome measure on a scale from 0 to 1. RESULTS: Of 5362 reviewed studies, 26 met the inclusion criteria, with a total of 1581 patients included in the NMA. AC, CB-GR, GR, CB2, CBA, and CBO demonstrated superiority over HP, Scr, KW, and nonoperative treatment at final follow-up for the Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score, with AC and CB-GR showing the highest P-scores for the Constant-Murley score (0.957 and 0.781, respectively) and GR and CBO showing the highest P-scores for the Disabilities of the Arm, Shoulder and Hand score (0.896 and 0.750, respectively). GR had the highest P-score for the visual analog scale score (0.986). HP, CB2, CB-GR, AC, CBA, and CBO demonstrated superiority in the coracoclavicular distance (CCD) and recurrence at final follow-up, with HP and CB2 having the highest P-scores for the CCD (0.798 and 0.757, respectively) and with GR and CB-GR having the highest P-scores for recurrence (0.880 and 0.855, respectively). KW and Scr showed the shortest operative times (P-scores of 0.917 and 0.810, respectively), whereas GR and CBA showed the longest operative times (P-scores of 0.120 and 0.097, respectively). CONCLUSIONS: Although there are multiple fixation options for acute Rockwood type III-V AC dislocations, adding AC fixation or graft augmentation likely improves functional outcomes and decreases the CCD and recurrence rate at final follow-up-at the expense of longer operative times.

A history of eponym usage in hip and pelvis radiography part 2: the adult hip.

Eponyms, while inherently flawed, remain a constant in medical vernacular, especially in orthopaedic surgery. It is essential to understand how these eponyms came to be named and for whom they were named after in order to understand their correct usage and definitions. In this second part of a 2-part review, we describe the history of eponym usage in the radiography of the adult hip; who, when, what, where, and how. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to adult hip radiography.

A history of eponym usage in hip and pelvis radiography part 1: the paediatric hip.

Eponyms, while inherently flawed, remain a constant in medical vernacular, especially in orthopaedic surgery. It is essential to understand how these eponyms came to be named and for whom they were named after in order to know the correct usage and definition of these eponyms. In this first part, we describe the history of eponym usage in paediatric hip radiography; who, when, what, where, and how. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to paediatric hip radiography.

Psychiatric Disorders Are Predictive of Worse Pain Severity and Functional Outcomes After Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg.

OBJECTIVE: To determine whether concomitant psychiatric diagnoses and medication use were associated with postfasciotomy outcomes in patients with chronic exertional compartment syndrome (CECS). DESIGN: Retrospective comparative cohort study. SETTING: Single academic medical center from 2010 to 2020. PATIENTS: All patients above 18 years old who underwent fasciotomy for CECS. ASSESSMENT OF RISK FACTORS/INDEPENDENT VARIABLES: Psychiatric history was recorded from electronic health records including disease diagnosis and medications. MAIN OUTCOME MEASURES: The 3 main outcome measures were postoperative pain using the Visual Analog Scale, functional outcomes using the Tegner Activity Scale, and return to sport. RESULTS: Eighty one subjects (legs), 54% male, with an average age of 30 years and follow-up of 52 months were included. 24 subjects (30%) had at least one psychiatric diagnosis at the time of surgery. Regression analysis found psychiatric history to be an independent predictor of worse postoperative pain severity and postoperative Tegner scores (P < 0.05). Furthermore, subjects with psychiatric disorders not on medication had worse pain severity (P < 0.001) and Tegner scores (P < 0.01) versus controls, whereas subjects with a psychiatric disorder on medication had better pain severity (P < 0.05) versus controls. CONCLUSIONS: History of psychiatric disorder was predictive of worse postoperative pain and activity outcomes after fasciotomy for CECS. Use of psychiatric medication was associated with improvement in pain severity in some domains.

Class I Obesity Delays Achievement of Patient-Acceptable Symptom State but Not Minimum Clinically Important Difference or Substantial Clinical Benefit After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: To identify differences in the time taken to achieve the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) among patients of different body mass index (BMI) categories. METHODS: We conducted a retrospective comparative study of hip arthroscopy patients with minimum 2-year follow-up. BMI categories were defined as normal (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI <30.0), or class I obese (30.0≤BMI<35.0). All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6 months, 1 year, and 2 years postoperative. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥8.2 and ≥19.8, respectively. PASS cutoff was set at postoperative mHHS ≥74. Time to achievement of each milestone was compared using the interval-censored EMICM algorithm. The effect of BMI was adjusted for age and sex using an interval-censored proportional hazards model. RESULTS: 285 patients were included in the analysis: 150 (52.6%) normal BMI, 99 (34.7%) overweight, and 36 (12.6%) obese. Obese patients had lower mHHS at baseline (P = .006) and at 2-year follow-up (P = .008). There were no significant intergroup differences in time to achievement for MCID (P = .92) or SCB (P = .69), but obese patients had longer time to PASS than normal BMI patients (P = .047). Multivariable analysis found obesity to be predictive of longer time to PASS (HR = .55; P = .007) but not MCID (HR = 0.91; P = .68) or SCB (HR = 1.06; P = .30). CONCLUSIONS: Class I obesity is associated with delays in achieving a literature-defined PASS threshold after primary hip arthroscopy for FAIS. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Increased incidence of acute achilles tendon ruptures in the peri-pandemic COVID era with parallels to the 2021-22 NFL season.

PURPOSE: Acute Achilles tendon ruptures (AATRs) are a common sporting injury, whether for recreational athletes or elite athletes. Prior research has shown returning to physical activity after extended periods of inactivity leads to increased rates of musculoskeletal injuries. The purpose of this study was to investigate rates of acute Achilles' tendon ruptures at a single academic institute in the peri-COVID era, with corollary to the recent NFL season. METHODS: A retrospective search was conducted using current procedural terminology to identify the total number of Achilles acute primary repair surgeries performed from years 2017 to 2021. Non-operatively managed AATRs were identified from the same electronic medical record using ICD-10 codes. NFL data were obtained from publicly available sites according to previously validated studies. RESULTS: A total of 588 patients who sustained AATRs and underwent primary surgical repair were identified, primarily men (75.7%, n = 445), with an average age of 43.22 ± 14.4 years. The number and corresponding incidence of AATR repairs per year was: 2017: n = 124 (21.1%), 2018: n = 110 (18.7%), 2019: n = 130 (22.1%), 2020: n = 86 (14.6%), 2021: n = 138 (23.5%), indicating a 7.5% decrease in rate of AATRs from 2019 to 2020, followed by an 8.9% increase in incidence from 2020 to 2021. Within the NFL, the number of AATRs resulting in an injured reserve stint increased every regular season from 2019 to 2020: n = 11 (21.2%), to 2020-2021: n = 17 (32.7%), to this past 2021-2022 season: n = 24 (46.2%). CONCLUSION: AATR surgeries seem to have increased in 2021 following a 2020 COVID pandemic-induced quarantine for recreational athletes at a single academic institution and for professional athletes in the NFL, although these results are of questionable clinical significance. This provides prognostic information when counseling patients and athletes on return to activity or sport. LEVEL OF EVIDENCE: Level IV.

Can we predict size, Haraguchi type and preoperative displacement of posterior malleolar fractures in association with tibial shaft fractures?

PURPOSE: To (1) determine if any injury characteristics or radiographic parameters of tibial shaft fractures (TSFs) could predict posterior malleolar fracture (PMF) size, and (2) identify characteristics of PMFs that were fixed versus those that were not in a cohort of ipsilateral TSFs that underwent intramedullary nailing. METHODS: A cross-sectional radiographic study was performed at a single academic institution. Demographic and radiographic parameters of TSFs were recorded, including fracture obliquity angle (FOA) and distance from distal extent of fracture to plafond (DFP). Using CT, the PMFs were evaluated for Haraguchi classification, size measurements, and preoperative displacement. Multivariate regression analysis was used to identify independent predictors of PMF Harachuchi classification, size parameters, and preoperative displacement. Univariate differences between PMF that were fixed and not fixed were identified. RESULTS: 47 (50%) PMF underwent surgical fixation with 47 treated conservatively. There were no demographic differences between groups. Multivariate linear regression demonstrated increasing DFP and high energy injury mechanism as independent variables correlated with plafond surface area involvement, PMF height and width on sagittal CT cuts. Increasing DFP alone was correlated with PMF width on axial CT cuts and extent > 50% into incisura. Haraguchi type II fractures were associated with high energy injury mechanism (OR = 4.2 [95% CI = 1.3-14.5]; p = 0.02). Odds of Haraguchi type 3 fractures increased 9% per increased year of age (OR = 1.09 [95% CI = 1.04-1.16]; p = 0.006) and decreased 13% per 1% increase in relative DFP (OR = 0.87 [95% CI = 0.75-0.98]; p = 0.04). CONCLUSIONS: An increasing DFP of TSFs and high energy injury mechanism were independent predictors of PMF size, and high energy injury mechanism was also correlated with Haraguchi type II fracture patterns. Increasing age and decreasing DFP of TSFs predict Haraguchi type III PMF patterns. These radiographic parameters should prompt surgeons to plan for fixation in scenarios in which CT scan is not available. LEVEL OF EVIDENCE: Diagnostic Level III.

Ambulation on hip fracture postoperative day 1: a marker for better outcomes following hip fracture surgery in patients 55 years or older.

PURPOSE: The purpose of this study was to investigate if early postoperative ambulation metrics affect hospital quality measures and 1-year outcomes in operative hip fracture patients. METHODS: A consecutive series of hip fracture patients [OTA/AO 31A, 31B, 32A-C] who underwent operative treatment were reviewed for demographic and clinical data. Chart review was performed to determine participation with physical therapy [PT] and ambulation distance on postoperative day (POD) 1, 3, and 5. POD1 ambulators and non-ambulators were statistically compared. Outcome correlates of postoperative ambulation distance were investigated by univariate and multivariate linear and logistic regression. RESULTS: 1044 patients were identified with 546 (52.3%) able to ambulate on POD1. Those able to ambulate on POD1 were significantly younger (78.4 ± 10.9 vs. 82.1 ± 10.4, p < 0.001), had fewer co-morbidities (CCI 1.22 ± 1.60 vs. 1.73 ± 1.82, p < 0.001), and were more likely to be preoperative community ambulators (82.2% vs. 68.3%, p < 0.001). Patients unable to ambulate on POD1 had significantly higher rate of inpatient mortality (2.8% vs. 0.5%, p = 0.004), 1-year mortality (14.6% vs. 6.9%, p < 0.001), and a longer length of stay (7.94 ± 4.73 vs. 6.43 ± 4.02 days, p < 0.001). Non-ambulators more often required the intensive care unit postoperatively (18.7% vs. 7.1%, p < 0.001), and had increased rates of major complications (15.5% vs. 5.7%, p < 0.001). Patients with OTA 31B or 32A fractures were 1.63 times more likely to ambulate on POD1 while patients with an assistive device at baseline were 0.51 times less likely to ambulate on POD1. Increasing postoperative ambulation distance correlated with shorter length of stay (p < 0.001 for POD1, 3, and 5) and every foot walked was associated with 0.57% decreased odds of a hospital complication (p = 0.0353). CONCLUSIONS: Failure to ambulate on POD1 following hip fracture surgery in >55 years is associated with an increased risk of in-hospital complications and mortality. Every effort should be made address this modifiable risk factor and mobilise patients on POD1 to improve patient outcomes.