Tibial Tubercle Osteotomy: Indications, Outcomes, and Complications.

PURPOSE OF REVIEW: The tibial tubercle osteotomy (TTO) is a versatile surgical technique used to treat a range of patellofemoral disorders, including patellar instability, painful malalignment, focal chondral defects, and patellar maltracking that have failed conservative therapies. TTO is a personalized procedure that can be tailored to the pathoanatomy of the patient based on physical examination and imaging. The complication rate associated with TTO strongly depends on the indication for surgery, the severity of the patient's condition, and the surgical approach. Despite the literature on TTO, to our knowledge, no single source has addressed the indications, techniques, outcomes, and complications of this procedure. The purpose of this article is to serve as such a valuable resource. RECENT FINDINGS: Highlights from recent studies we would like to emphasize are two-fold. First, maintaining a distal cortical hinge yields lower complication rates than osteotomies involving complete tubercle detachment with classic or standard techniques. Second, based on current evidence, TTO consistently provides symptomatic relief, and most patients can return to work or sport at their pre-operative level within 3 and 6 months, respectively. TTO is a personalizable surgical technique that may be utilized for multiple patellofemoral disorders and is associated with good outcomes.

Mid-Term Outcomes of the All-Soft Quadriceps Tendon Autograft Are Noninferior to Hamstring Autograft in Primary Anterior Cruciate Ligament Reconstruction: Comparison With Minimum 5-Year Follow-Up.

PURPOSE: To compare the 5-year clinical and functional outcomes of the soft-tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft. METHODS: A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft-tissue QT or double-tendon HT autograft with at least 5 years of follow-up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications. RESULTS: A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2-years' postoperatively. At 5 years' postoperatively, the QT group demonstrated significantly greater IKDC (P = .018) and Lysholm (P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years' postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications. CONCLUSIONS: Although the QT autograft demonstrated increased patient-reported outcome scores when compared with the HT at 5 years' postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years' postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid-term follow-up. LEVEL OF EVIDENCE: III, retrospective comparison study.

Arthroscopic Remplissage Using Knotless, All-Suture Anchors.

Glenohumeral bone loss is a significant risk factor for recurrent instability after shoulder dislocation. The Hill-Sachs lesion is an osseous defect of the posterior humeral head that is commonly recognized after anterior shoulder dislocation. Several procedures exist to address humeral-sided bone loss, including soft tissue filling procedures, osteoarticular allografts, bone plugs, rotation osteotomies, and humeral head replacements. However, among the most common of these procedures is the arthroscopic remplissage. This technique involves capsulotenodesis of the posterior shoulder capsule and infraspinatus tendon into a Hill-Sachs lesion. Previously described techniques use knotted suture anchors. In this report, we describe a modified technique for remplissage using knotless, all-suture anchors to perform capsulotenodesis of a Hill-Sachs lesion. Benefits of this technique include a single skin incision, improved bone preservation, and easier facilitation of revision surgery if required.

Getting paid less for more: shoulder arthroplasty incidence and reimbursement within Medicare from 2000 to 2019.

BACKGROUND: Shoulder arthroplasty has grown in popularity in the past 2 decades, especially following US Food and Drug Administration approval of reverse total shoulder arthroplasty (TSA) in 2003. Studies have shown that Medicare reimbursement for a variety of orthopedic procedures has decreased significantly over the past 2 decades. No study has evaluated this trend in the setting of shoulder arthroplasty, however. The purpose of this study was to assess true reimbursement trends in primary and revision shoulder arthroplasty since 2000. METHODS: Information was collected from the publicly available Medicare Part B National Summary Data Files for the period of 2000 to 2019. Data from Current Procedural Terminology codes 23470 (shoulder hemiarthroplasty), 23472 (TSA), 23473 (single-component revision shoulder arthroplasty), and 23474 (both-component revision shoulder arthroplasty) were analyzed. Reimbursement amounts were adjusted for inflation to May 2021 dollars. RESULTS: From 2000 to 2019, the number of shoulder hemiarthroplasty procedures billed to Medicare decreased 70% (from 5847 to 1750) whereas the number of TSA procedures increased 1527% (from 4044 to 65,477). During the same period, per-procedure Medicare reimbursement for hemiarthroplasty decreased 35% (from $1545.71 to $1003.43) after adjustment for inflation to 2021 dollars. Similarly, TSA reimbursement decreased 22% (from $1600.98 to $1248.76) after adjustment for inflation. For revision procedures, the number of single- and both-component revisions billed to Medicare increased 381% (from 344 to 1655) and 1331% (from 220 to 3147), respectively. Adjusted reimbursement per procedure decreased 36% (from $1931.62 to $1244.49) and 37% (from $2293.08 to $1449.43), respectively. CONCLUSION: This study shows an increase in the annual volume of primary and revision shoulder arthroplasty procedures from 2000 to 2019. During the same period (2000-2019), true Medicare reimbursement to physicians for TSA decreased when adjusted for inflation. This study provides data that may be useful for surgeons, hospitals, and policy makers to maintain access to quality shoulder arthroplasty care moving forward.

Over 20 years of declining Medicare reimbursement for spine surgeons: a temporal and geographic analysis from 2000 to 2021.

OBJECTIVE: Procedural reimbursement for spine surgery has changed drastically over the past 20 years. A comprehensive understanding of these trends is important as major changes in reimbursement models of spine surgery continue to evolve within various spine specialties as well as broader national healthcare policy. In this study the authors evaluated the monetary trends in Medicare reimbursement rates for the 15 most common spinal surgery procedures from 2000 to 2021. METHODS: The National Surgery Quality Improvement Project database (2019) was queried to determine the 15 most commonly performed spine surgery procedures. The Current Procedural Terminology (CPT) codes for each of these procedures were obtained from the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services, and comprehensive reimbursement data for each code were extracted. Changes in Medicare reimbursement rates were calculated and averaged for each procedure as both raw percent changes and percent changes adjusted for inflation to 2021 US dollars (USD) based on the consumer price index (CPI). The adjusted R2 value, the compound annual growth rate (CAGR), and both the average annual and the total percent change in reimbursement were calculated based on these adjusted trends for all included procedures. RESULTS: After adjustment for inflation, average reimbursement for all procedures decreased by 33.8% from 2000 to 2021. The greatest mean decrease was seen in anterior cervical arthrodesis (-38.7%), while the smallest mean decrease was in vertebral body excision (-17.1%). From 2000 to 2021, the adjusted reimbursement rate for all included procedures decreased by an average of 1.9% each year, with an average R2 value of 0.69. CONCLUSIONS: This is the first study to evaluate monetary trends in Medicare reimbursement for spine surgery procedures. After adjusting for inflation, Medicare reimbursement for the 15 most commonly performed spine procedures has steadily decreased from 2000 to 2021. Increased awareness of these trends and the forces driving them will be critical in the coming years as negotiations regarding reimbursement models continue to unfold. Greater understanding of spine surgery reimbursement among policy makers, hospitals, and surgeons will be important to ensure continued access to quality surgical spine care in the United States.

Robotic-Assisted Total Knee Arthroplasty Allows for Trainee Involvement and Teaching Without Lengthening Operative Time.

BACKGROUND: Robot-assisted total knee arthroplasty (RA-TKA) is more accurate than mechanical total knee arthroplasty (M-TKA) and can provide real-time feedback about alignment and soft-tissue balancing that may be helpful in trainee education. However, both robotic-assist and trainee involvement potentially increase the surgical time. This study sought to evaluate whether RA-TKA procedures were longer than M-TKA procedures and whether trainee participation added additional surgical time. METHODS: This retrospective cohort study reviewed 220 consecutive primary TKAs (110 M-TKA and 110 RA-TKA) performed by an orthopedic trainee under supervision or performed by the consultant surgeon with an assistant present. For M-TKAs, a measured resection technique was used. For all RA-TKAs, the MAKO robotic system (Stryker, USA) was used. Tourniquet time was measured from inflation immediately prior to skin incision to deflation after placement of the final polyethylene insert. Procedures performed by a consulting surgeon with a surgical assist were used as controls for procedures performed by the trainee. In trainee-conducted procedures, the trainee is responsible for performing all critical aspects of the procedure while the consulting surgeon provides supervision and acts as first assist. RESULTS: 103 M-TKA and 96 RA-TKA were included. Tourniquet time was significantly longer for RA-TKAs vs M-TKAs (100 vs 89 minutes, P < .0001). However, there were no significant differences in tourniquet times between surgery performed by a trainee vs the consulting surgeon with surgical assist for either M-TKA (P = .3452) or RA-TKA (P = .6724). CONCLUSIONS: While RA-TKA takes longer, orthopedic trainees do not add additional time. Trainees at all stages of postgraduate learning can be educated in the use of robotic technology and potentially benefit from real-time feedback without further compromising surgical efficiency or increasing patient risk.

Proximal Humeral Replacement With Osteoarticular Allograft Prosthetic Composite in Failed Revision Total Elbow Arthroplasty With Marked Bone Loss.

Total elbow arthroplasty (TEA) procedures are becoming more prevalent with an associated increase in revision procedures. Revision TEA in the setting of marked bone loss poses a challenge for the treating surgeon. We present a viable surgical option for patients with extensive proximal humeral bone loss treated with proximal humerus osteoarticular allograft prosthetic composites prepared with intact rotator cuff, pectoralis, and deltoid soft tissue attachments along with a rehabilitative protocol and follow up. Revision techniques involving the use of strut allografts and allograft prosthetic composites have previously been described in the distal humerus, but none to our knowledge have been published regarding composite allograft replacement of the proximal humerus in in combination with a TEA.

Hospital outcomes in pediatric patients with Prader-Willi syndrome (PWS) undergoing orthopedic surgery: A 12-year analysis of national trends in surgical management and inpatient hospital outcomes.

BACKGROUND: The incidence of orthopedic disorders amongst patients with Prader-Willi Syndrome (PWS) is high when compared to the general pediatric population. The purpose of this retrospective study was to define the most commonly performed orthopedic procedures in pediatric patients with PWS and to characterize the peri-operative outcomes of these patients. METHODS: The Kids Inpatient Database (KID) was queried to collect data and identify all pediatric patients with PWS who underwent orthopedic procedures from 2001 to 2012. A total of 3684 patients with PWS were identified, 334 of who underwent an orthopedic procedure. Population demographics, comorbidities, and specific procedures undergone were defined. The incidences of postoperative complications and length of associated hospital stay were additionally evaluated. RESULTS: Mean age of patients in this sample was 10.33 years (SD 4.5). The most common comorbidities included obesity (18.1%), chronic pulmonary disease (14.1%), hypothyroidism (5.1%), hypertension (5.1%), and uncomplicated diabetes (4%). Common procedures were spinal fusion (165/334, 49%) and lower extremity procedures (50/334, 15%). Complications included acute blood loss anemia, device related complications, pneumonia, sepsis, and urinary tract infections. The overall complication rate was 35.6%. Average hospital lengths of stay for patients undergoing spinal fusion was 6.68 days (SD 4.13), lower extremity orthopedic procedure was 5.65 days (SD 7.4), and all other orthopedic procedures was 7.74 days (SD 16.3). CONCLUSIONS: Orthopedic disorders are common in patients with PWS. Consequently, spinal fusions and lower extremity procedures are commonly performed in this patient population. Associated comorbid conditions may negatively impact surgical outcomes in these patients. This information should prove useful in the peri-operative management of patients with PWS undergoing orthopedic surgery and for shared decision making with families.

Epidemiology of Spine Injuries in National Collegiate Athletic Association Men's Wrestling Athletes.

BACKGROUND: Spine injuries are common in collegiate wrestlers and can lead to reinjury, persistent pain, and time lost from participation. PURPOSE: To describe the epidemiology of spine injuries in National Collegiate Athletic Association (NCAA) wrestlers between academic years 2009 to 2010 and 2013 to 2014. STUDY DESIGN: Descriptive epidemiology study. METHODS: The incidence and characteristics of spine injuries were identified utilizing the NCAA-Injury Surveillance Program database. Spine injuries were assessed for injury type, injury mechanism, time of season, event type, recurrence, participation restriction, and time lost from participation. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). Injury rate ratios (IRRs) were calculated for event type and time of season, and results with 95% confidence intervals that did not include 1.0 were considered statistically significant. RESULTS: There were an estimated 2040 spine injuries reported in the database over the 4-year period, resulting in an injury rate of 0.71 per 1000 AEs.  Spine injuries were over twice as likely to occur in competitions as in practices (IRR, 2.02; 95% confidence interval, 1.10-3.69). More injuries occurred in both the preseason (0.94 per 1000 AEs) and the postseason (1.12 per 1000 AEs) compared with the regular season (0.55 per 1000 AEs). Contact injuries (42%) were the most common mechanism of injury, and brachial plexus injury (20%) was the most common diagnosis. Only 1.3% of injuries required surgery, and athletes most commonly returned to sport within 24 hours (33%) or within 6 days (25%). CONCLUSION: This investigation found an overall injury rate of 0.71 per 1000 AEs in wrestling athletes between academic years 2009 to 2010 and 2013 to 2014. The majority of these injuries were new, and athletes most commonly returned to sport within 24 hours. The injury rate was highest in competition, and both the preseason and the postseason showed a higher injury rate than that in season. Efforts to improve injury prevention and management should be informed by these findings.

The Top 50 Most-Cited Knee Arthroscopy Studies.

PURPOSE: To objectively identify the 50 most influential studies in knee arthroscopy and provide an analysis of their key characteristics. METHODS: The Clarivate Analytics Web of Knowledge database was used to gather data and metrics of knee arthroscopy research. The search list was sorted by the number of citations, and articles were included or excluded based on relevance to knee arthroscopy. The information extracted for each article included author name, publication year, country of origin, journal name, article type, and the level of evidence. RESULTS: For these 50 studies, the total number of citations was calculated to be 12,168, with an average of 243.4 citations per paper. The most-cited article was cited 1,220 times. The 50 studies included in this analysis were published between 1972 and 2013. All 50 articles were published in English and came from 10 different orthopaedic journals. The United States was responsible for the majority of articles (n = 26); however, many other countries were represented. The most prevalent study designs were case series (n = 20). CONCLUSIONS: The 50 most influential articles in knee arthroscopy were cited a total of 12,168 times. The study designs most commonly used were case series and cohort studies. This article serves as a reference to direct orthopaedic practitioners to the 50 most influential studies in knee arthroscopy. We hope that these 50 studies and the analysis we provide help health care professionals efficiently assess consensus, trends, and needs within the field. CLINICAL RELEVANCE: This analysis of the 50 most influential studies in knee arthroscopy will provide medical students, residents, fellows, and attending physicians with a comprehensive inventory and citation analysis of the most impactful academic contributions to one of the most important fields within orthopaedic surgery.

Hospital outcomes of scoliosis surgery in children with Prader-Willi Syndrome: comparison with adolescent idiopathic scoliosis.

PURPOSE: The purpose of this study was to evaluate the peri-operative outcomes of patients with Prader-Willi Syndrome (PWS) undergoing spinal deformity correction and compare the outcomes to patients with adolescent idiopathic scoliosis (AIS). METHODS: A retrospective review of the Kid's Inpatient Database was performed from 2000 to 2012 to identify all pediatric patients with scoliosis undergoing spinal fusion. Cohorts were created on the basis of PWS diagnosis and adolescent idiopathic scoliosis. Statistical analysis was performed for differences in post-operative outcomes between these two patient cohorts. RESULTS: Between 2000 and 2012, the number of spinal fusions performed increased by 24.6 and 32.2% in the PWS and adolescent idiopathic scoliosis populations, respectively. There was no difference between the incidence of major complications in PWS patients when compared to AIS (1.7% vs. 1.0% in idiopathic scoliosis; p = 0.362). Although there was no significant difference in the rate of overall minor complications, PWS patients were demonstrated to be more likely to experience post-operative pneumonia (p < 0.0001) and implant complications (p < 0.001). CONCLUSION: Patients with scoliosis associated with PWS do not have any increased risk of major complications following spinal deformity correction when compared to patients with adolescent idiopathic scoliosis. Two important minor complications to keep in mind when surgically treating scoliosis in PWS patients include pulmonary and implant-related complications. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Surgical Ergonomics and Musculoskeletal Pain in Orthopaedic Surgery Residents: A Multicenter Survey Study.

PURPOSE: Owing to the nature of orthopaedic surgery, occupational hazards and musculoskeletal pain (MSP) are inherent. These hazards have been well-documented among practicing orthopaedic surgeons, but there remains a paucity of data regarding MSP among orthopaedic surgery residents. The purpose of this study was to identify the prevalence and quantify the extent of work-related MSP among orthopaedic surgical residents. We also sought to analyze resident attitudes, beliefs, and behaviors regarding surgical ergonomics. METHODS: An online survey was sent to 78 orthopaedic surgery resident program directors to be distributed to residents within their programs. The survey included three main sections: symptoms by body part, attitudes/beliefs/behaviors regarding surgical ergonomics, and finally demographics. Pain was reported as using the 0 to 10 Numeric Rating Scale, with 0 = no pain and 10 = maximum pain. Several questions about resident well-being were assessed using the Maslach Burnout Inventory. RESULTS: Seventy-six orthopaedic surgery residents completed the survey, 72% men and 28% women. Most residents (97%) experience procedural-related MSP. Average pain scores of all residents was 3.52/10. Notable levels of MSP (≥4/10) were most common in the lower back (35%), neck (29.7%), and feet (25.7%). A positive association exists between higher MSP and lower work satisfaction (P = 0.005), burnout (P = 0.04), and callousness toward others (P < 0.0001). MSP has notable impact on resident behaviors including over-the-counter medication use, stamina, concentration, and degree of irritability. CONCLUSION: The prevalence of MSP among orthopaedic surgical residents is extremely high. Our study demonstrates that MSP has a notable impact on resident concentration, degree of irritability, and other burnout symptoms. The results of this study highlight the importance of limiting compromising procedural positions, ergonomic optimization, and increasing the awareness of the importance of ergonomics among residents. This could have future implications on productivity and career longevity.

A Multicenter Study of Radiographic Measures Predicting Failure of Arthroscopy in Borderline Hip Dysplasia: Beware of the Tönnis Angle.

BACKGROUND: Hip arthroscopy has been previously demonstrated to be an effective treatment for adult mild hip dysplasia. There are many radiographic parameters used to classify hip dysplasia, but to date few studies have demonstrated which parameters are of most importance for predicting surgical outcomes. PURPOSE: To identify preoperative radiographic parameters that are associated with poor outcomes in the arthroscopic treatment of adult mild hip dysplasia. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Radiographic analysis was performed in patients with mild hip dysplasia who underwent arthroscopic surgery between 2009 and 2015. Preoperative radiographic measurements included lateral center edge angle, Tönnis angle, neck shaft angle, anterior center edge angle, alpha angle, femoral head extrusion index, and acetabular depth-to-width ratio. Failure was defined as failure to achieve the minimal clinically important difference (MCID) utilizing the modified Harris Hip Score or as the need for secondary operation. The equal variance t test was used to analyze radiographic parameters. Statistical significance was determined using a P value of .05. RESULTS: A total of 373 hips underwent analysis with an average follow-up of 41 months (range, 24-102 months). Of these, 46 hips (12%) required secondary operation, and 95 (25%) failed to meet the MCID. The overall failure rate was 32.4%. There was no single measurement or combination thereof associated with failure to reach the MCID. Higher preoperative Tönnis angles were associated with secondary operation, with a mean of 6.7° (95% CI, 5.3°-8.1°) in the secondary operation group versus 4.8° (95% CI, 4.4°-5.3°) in the nonsecondary operation group (P = .006). The odds ratio was 1.12 (95% CI, 1.0-1.2; P = .05) per degree increase in Tönnis angle for secondary operation. In patients with a Tönnis angle >10°, 84% required secondary operation. CONCLUSION: Higher Tönnis angles portend a higher risk for revision surgery. The probability of secondary operation was increased by a magnitude of 1.12 with each degree increase in the Tönnis angle. In patients with a Tönnis angle >10°, 84% required a secondary operation.

Current Trends in Patient-Reported Outcome Measures in Total Joint Arthroplasty: A Study of 4 Major Orthopaedic Journals.

BACKGROUND: More emphasis is being placed on patient-reported outcome measures (PROMs), but the myriad of PROMs makes standardization and cross-study comparison difficult. As the era of big data and massive total joint registries matures, it will be critical to identify and implement the best PROMs. METHODS: All abstracts published in the years 2004, 2009, 2014, and 2016 in the Journal of Bone and Joint Surgery-American volume, the Bone and Joint Journal, Clinical Orthopedics and Related Research, and the Journal of Arthroplasty were reviewed. A PubMed search was performed with filters limiting results only to total knee, total hip, and unicompartmental knee arthroplasty articles with available abstracts. Each abstract was reviewed to identify all PROMs. Trends over time were evaluated using the Cochran-Armitage test. In the non-trend analysis, Pearson chi-square tests and one-way analysis of variance were performed. RESULTS: A total of 42 unique PROMs were used 1073 times across 644 studies. The number of PROMs in these 4 journals increased from 97 in 2004 to 228 in 2016 (P < .0001). The proportion of articles with more than one PROM increased from 20.6% in 2004 to 47.8% in 2016 (P = .0001). The most common PROMs used in total knee, total hip, and unicompartmental knee arthroplasty studies were the Knee Society Score, the Harris Hip Score, and the Oxford Knee Score, respectively. CONCLUSION: Providers and registries should consider the relative prevalence of published outcome measures when selecting which PROMs to use, to better facilitate future cross-study comparison.