Glenoid augmentation for subcritical bone loss: a narrative review.

Background and Objective: Anterior shoulder instability can be debilitating for young, active individuals, and increasing magnitudes of glenoid bone loss (GBL) predisposes patients to recurrent instability and increases the likelihood of failure of soft-tissue only repairs. It is widely accepted that GBL >25% should be treated with a glenoid bone grafting procedure. However, consensus is lacking on the optimal management in the setting of subcritical GBL, typically classified as >13.5%. This article reviews the pathoanatomy relevant to anterior shoulder instability and subcritical GBL, while highlighting existing evidence regarding open augmentation procedures in comparison to other treatment options for this subpopulation. Methods: A narrative review of the current literature was conducted focusing on subcritical GBL in anterior glenoid stabilization procedures, including review of forward citation and reference lists of selected articles. Key Content and Findings: Computed tomography (CT) is the modality of choice for obtaining precise measurements of subcritical GBL, defined as <13.5%, using the best-fit circle method. There is debate surrounding the optimal surgical management of subcritical GBL. Arthroscopic Bankart repair (ABR) remains the predominate surgery performed for primary anterior shoulder instability, while glenoid augmentation and open Bankart repair continue to be used sparingly in the United States. Historically, the Latarjet procedure was considered for substantial glenoid defects, but the illumination of subcritical GBL has expanded its indications. Arthroscopic, soft tissue-only repairs with the addition of remplissage, has been shown to have similar 2-year outcomes to the Latarjet in patients with >15% GBL, which has been limited in the study of subcritical GBL. Additionally, utilization of distal tibial allograft and local autograft is becoming increasingly prevalent. However, again, with limited prospective studies in the subcritical GBL population. Conclusions: There is no consensus regarding the optimal treatment approach to recurrent shoulder instability in the setting of subcritical GBL. Conversely, there is a growing agreement that isolated ABR is likely inadequate and subcritical GBL should prompt consideration of a more robust operation. To this end, interest in glenoid bone augmentation continues to grow as a reliable technique for recreating the native architecture and restoring glenohumeral stability are developed.

Minimal Important Clinical Difference Values Are Not Uniformly Valid in the Active Duty Military Population Recovering from Shoulder Surgery.

BACKGROUND: There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of two different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operator curve (ROC) -based MCIDs and baseline-adjusted ROC MCIDs. METHODS: All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROMs battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons score (ASES), Patient Reported Outcome Management Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and the Warfighter Readiness survey. Standard anchor-based and baseline-adjusted ROC MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval either completely negative or positive). RESULTS: There were 117 patients (136 operations) identified, comprised of 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7. CONCLUSION: When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC method was more effective at discerning changes across a battery of PROMs among the same cohort.

Arthroscopic Management of Arthrofibrosis After Hemiarthroplasty for Proximal Humerus Fracture Dislocation.

Poor functional outcomes after hemiarthroplasty for proximal humerus fractures are common, yet revision surgery is relatively rare. Arthroscopic treatment for postoperative stiffness can be considered in the setting of functional limits to glenohumeral range of motion impacting activities of daily living after adequate conservative treatment with physical therapy and in the setting of healed, well-positioned tuberosities and humeral components. This Technical Note illustrates a stepwise approach to an arthroscopic lysis of adhesions and capsular release for the treatment of arthrofibrosis of the shoulder. The advantages of this technique include an alternative approach to entering the glenohumeral joint under direct subacromial visualization and a 2-posterior portal approach to the inferior and anteroinferior capsule, which can be challenging to achieve in the setting of severe postsurgical arthrofibrosis.

Novel 3D MRI-Based Volumetric Assessment of Rotator Cuff Musculature Demonstrates Stronger Correlation with Preoperative Functional Status When Compared to the Goutallier Grading Scheme.

BACKGROUND: The Goutallier classification (GC) is used to assess fatty atrophy in rotator cuff (RC) tears, yet limitations exist. A battery of 3D-magnetic resonance imaging (MRI) volumetric scores (VS) was developed to provide comprehensive characterization of RC pathology. The purposes of this study were to: (1) Describe the correlation between GC and VS for supraspinatus changes in RC tears, (2) Characterize the chronicity of RC tears using the battery of 12 VS measurements, and (3) Compare GC and VS to determine which method most closely corresponds with preoperative patient reported outcome measures (PROMs). METHODS: Preoperative shoulder MRIs were reviewed after arthroscopic RC repair. Preoperative GC stage and Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores were collected. The battery of VS included fat infiltration (FIS), muscle size (MSS) and relative volume contribution (RCS) for each RC muscle. Backwards linear regression was performed to compare GC stage with preoperative PROMIS PF/PI to determine which VS measurement most closely correlated with preoperative PROMs. RESULTS: Eighty-two patients underwent RC repair (mean age 55±8.2 years, 63% male, 68% GC stage ≤1). In evaluation of the supraspinatus, there was a moderate positive correlation between GC and FIS (r = 0.459, p < 0.001); strong negative correlations were observed between MSS (r = -0.800, p < 0.001) and RCS (r = -0.745, p < 0.001) when compared to GC. A negligible linear correlation was observed between GC and preoperative PROMIS PF (r = -0.106, p = 0.343) and PI (r = -0.071, p = 0.528). On multivariate analysis, subscapularis MSS (beta > 0, p = 0.064) was a positive predictor, and subscapularis FIS (beta < 0, p = 0.137), teres minor MSS (beta < 0, p = 0.141) and FIS (beta < 0, p = 0.070) were negative predictors of preoperative PF (r = 0.343, p = 0.044); while supraspinatus MSS (beta > 0, p = 0.009) and FIS (beta > 0, p = 0.073), teres minor FIS (beta > 0, p = 0.072) and subscapularis FIS (beta > 0, p = 0.065) were positive predictors of preoperative PI (r = 0.410, p = 0.006). CONCLUSION: Although gold standard in evaluation of RC pathology, GC demonstrated negligible correlation with preoperative functional disability. Alternatively, a battery of 3D VS showed strong correlation with GC through a quantitative, comprehensive evaluation of the RC unit including several moderate predictors of preoperative functional disability.

Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist.

Purpose: To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery. Methods: A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. Results: Nine articles (level II-IV studies) were included in the final analysis. A total of 887 patients (54% male, average age 45 years) underwent arthroscopic surgery, including general knee (n = 3 studies), ACLR-only knee (n = 1 study), rotator cuff repair (n = 4 studies), and hip (n = 1 study). The Brief Resilience Scale was the most common instrument measuring resilience in 7 of 9 studies (78%). Five of 9 studies (56%) stratified patients based on high, normal, or low resilience cohorts, and these stratification threshold values differed between studies. Only 4 of 9 studies (44%) measured PROs both before and after surgery. Three of 9 studies (33%) reported rates of return to activity, with 2 studies (22%) noting high resilience to be associated with a higher likelihood of return to sport/duty, specifically after knee arthroscopy. However, significant associations between resilience and functional outcomes were not consistently observed, nor was resilience consistently observed to be predictive of subjects' capacity to return to a preinjury level of function. Conclusions: Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn. Level of Evidence: Level IV, systematic review of level II-IV studies.

Editorial Commentary: Biocomposite Implant Combined With Local Human Recombinant Parathyroid Hormone Enhances the Histological Quality and Biomechanical Strength of Rotator Cuff Repairs.

Rates of rotator cuff repair retear remain unacceptably high and are frequently the source of diminished shoulder function and patient dissatisfaction. Endocrinopathies have been implicated in these processes. Parathyroid hormone (PTH) activates chondrogenesis and angiogenesis at the enthesis and prevents fatty infiltration and atrophy in rotator cuff musculature. These facts have spurred interest in the therapeutic benefits of PTH as a means to enhance tendon healing and strengthen the bone in and around tendon repairs. New research demonstrates that recombinant human PTH delivered locally through a process of coupling it to a bioengineered scaffold "sheath" may be beneficial. The growth factor, encased within polycaprolactone (PCL), is slowly released as the PCL degrades to extend drug delivery time. The augmentation of rotator cuff repairs with this biocomposite material improves short-term structural tissue integrity and promotes the formation of more organized and stronger tendon-to-bone interface in a rabbit model.

Editorial Commentary: Decreased Superior Capsular Reconstruction Postoperative Graft Volume Is More Common in Patients With Advanced Rotator Cuff Arthropathy and Is Associated With Inferior Outcome: Cause or Effect?

Recent research has investigated the impact of graft condition on the outcomes of shoulder superior capsular reconstruction for irreparable rotator cuff tears. A decreased lateral graft volume compared with the medial graft volume is more common in patients with rotator cuff arthropathy and is associated with inferior clinical outcomes. This would suggest that aside from simply failing at the suture-graft junction, grafts with thinner lateral segments may exhibit diminished biomechanical strength over time. This may explain, in part, the discrepancy in outcomes between thinned grafts and grafts with preservation of tissue thickness. However, a significant association is also shown between grafts with lateral thinning and factors that portend worse clinical outcomes, including a higher Hamada grade, larger anteroposterior distance of the graft spanning the greater tuberosity, increased fatty infiltration in the infraspinatus and subscapularis muscles, and higher rate of subscapularis retears postoperatively. This would suggest that reductions in graft volume may be a product of worse initial pathology, which in and of itself may explain the worse postoperative outcomes. Thus, it remains unclear whether the findings represent cause or effect.

Predictors of Return to Activity at 2 Years After Anterior Cruciate Ligament Reconstruction Among Patients With High Preinjury Marx Activity Scores: A MOON Prospective Cohort Study.

BACKGROUND: Predictors of return to activity after anterior cruciate ligament reconstruction (ACLR) among patients with relatively high preinjury activity levels remain poorly understood. PURPOSE/HYPOTHESIS: The purpose of this study was to identify predictors of return to preinjury levels of activity after ACLR, defined as achieving a Marx activity score within 2 points of the preinjury value, among patients with Marx activity scores of 12 to 16 who had been prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) cohort. We hypothesized that age, sex, preinjury activity level, meniscal injuries and/or procedures, and concurrent articular cartilage injuries would predict return to preinjury activity levels at 2 years after ACLR. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: All unilateral ACLR procedures from 2002 to 2008 performed in patients enrolled in the MOON, with preinjury Marx activity scores ranging from 12 to 16, were evaluated with a specific focus on return to preinjury activity levels at 2 years postoperatively. Return to activity was defined as a Marx activity score within 2 points of the preinjury value. The proportion of patients able to return to preinjury activity levels was calculated, and multivariable modeling was performed to identify risk factors for patients' inability to return to preinjury activity levels. RESULTS: A total of 1188 patients were included in the final analysis. The median preinjury Marx activity score was 16 (interquartile range, 12-16). Overall, 466 patients (39.2%) were able to return to preinjury levels of activity, and 722 patients (60.8%) were not able to return to preinjury levels of activity. Female sex, smoking at the time of ACLR, fewer years of education, lower 36-Item Short Form Health Survey Mental Component Summary scores, and higher preinjury Marx activity scores were predictive of patients' inability to return to preinjury activity levels. Graft type, revision ACLR, the presence of medial and/or lateral meniscal injuries, a history of meniscal surgery, the presence of articular cartilage injuries, a history of articular cartilage treatment, and the presence of high-grade knee laxity were not predictive of a patient's ability to return to preinjury activity level. CONCLUSION: At 2 years after ACLR, most patients with high preinjury Marx activity scores did not return to their preinjury level of activity. The higher the preinjury Marx activity score that a patient reported at the time of enrollment, the less likely he/she was able to return to preinjury activity level. Smoking and lower mental health at the time of ACLR were the only modifiable risk factors in this cohort that predicted an inability to return to preinjury activity levels. Continued effort and investigation are required to maximize functional recovery after ACLR in patients with high preinjury levels of activity.

Editorial Commentary: A Biphasic (Calcified and Demineralized), Cancellous, Interpositional Allograft Augmenting Rotator Cuff Repair in an Ovine Model Does Not Show Harmful Inflammation or Foreign Body Reaction.

To improve the outcomes of arthroscopic rotator cuff (RC) repair, it is important to achieve tendon-to-bone healing at the repair site. Healed repairs are more likely to restore shoulder strength and lead to higher magnitudes of satisfaction. Patches or grafts that can be either secured to the bursal surface of the RC or interposed between the RC tendon and greater tuberosity at the time of repair have been described as adjuncts to RC repair. A cancellous, biphasic allograft tissue composed of 2 layers (calcified to promote osseointegration and demineralized to support soft-tissue ingrowth) has been shown to be safe in an ovine model, without a harmful inflammatory or foreign body response. Human trials may be a reasonable next step.

Psychological Readiness to Return to Sport: Fear of Reinjury Is the Leading Reason for Failure to Return to Competitive Sport and Is Modifiable.

Many of our patients are athletes, and an ultimate goal is to help these athletes return to their preinjury level of activity or sport. Generally, we focus on patients' injuries and treatments, but there are modifiable factors that can improve patient outcomes independent of surgical technique. A factor frequently ignored is psychological readiness to return to sport. In patients including athletes, particularly teenagers, chronic, clinical depression is a prevalent and pathologic condition. In addition, in nondepressed patients (or in patients who are situationally depressed because of injury), the ability to deal with stressors may still govern clinical outcomes. Specific psychological traits of significance have been identified and defined, including self-efficacy; locus of control; resilience; catastrophizing; kinesiophobia; and fear of reinjury. (Fear of reinjury is the leading reason for failure to return to competitive sport, reduced activity levels after sports injury, and greater reinjury rates.) The traits may overlap and may be modifiable. Thus, like strength and functional testing, we should evaluate for signs or symptoms of depression, and we should measure psychological readiness to return to sport. With awareness, we can intervene or refer as indicated. Psychological readiness to return to sport represents an underexamined domain in which we can help our patients achieve best outcomes.

Documented Contact Allergy Impacts Risk for Surgical Adhesive-Associated Contact Dermatitis after Shoulder Arthroplasty.

Purpose: The purpose of this study is to report on the incidence and risk factors for allergic contact dermatitis (ACD) in patients who received Prineo after total shoulder arthroplasty (SA). Methods: A retrospective case-control study was conducted to investigate patients who experienced ACD after having SA by a single surgeon during a defined period when Prineo was routinely used as an adjunct to wound closure. Known risk factors for ACD (e.g., history of contact dermatitis, smoking) were analyzed for association development of Prineo-associated ACD using Fisher exact and Wilcoxon rank sum tests. Results: From June 2019 through July 2021, 236 consecutive patients were identified as having Prineo applied after SA. Nine cases of Prineo-ACD (3.8%) were documented, whereas 227 patients were unaffected. In all 9 affected patients, the complication was identified and treated without compromising the outcome of the SA. Previous allergy to medical adhesives was a statistically significant risk factor for Prineo-associated ACD in this series (P = .01). The odds of having Prineo-associated ACD among those with adhesive or contact allergy was 38.5 times that of their nonallergic counterparts in a multivariate model. Conclusions: Prineo adhesive ACD had an incidence of 3.8% in this study, and a history of adhesive or contact allergy was highly associated with its development. Level of Evidence: Level III, case-control study.

Quadriceps Dysfunction Following Joint Preservation Surgery: A Review of the Pathophysiologic Basis and Mitigation Strategies.

PURPOSE OF REVIEW: To characterize quadriceps muscle dysfunction associated with knee joint preservation surgery, with a focus on its pathophysiology and promising approaches to mitigate its impact on clinical outcomes. RECENT FINDINGS: Quadriceps dysfunction (QD) associated with knee joint preservation surgery results from a complex interplay of signaling, related to changes within the joint and from those involving the overlying muscular envelope. Despite intensive rehabilitation regimens, QD may persist for many months postoperatively and negatively impact clinical outcomes associated with various surgical procedures. These facts underscore the need for continued investigation into the potential detrimental effects of regional anesthetic and intraoperative tourniquet use on postoperative quadriceps function, with an outward focus on innovation within the field of postoperative rehabilitation. Neuromuscular stimulation, nutritional supplementation, cryotherapy, blood flow restriction (BFR), and open-chain exercises are all potential additions to postoperative regimens. There is compelling literature to suggest that these modalities are efficacious and may diminish the magnitude and duration of postoperative QD. A clear understanding of QD, with respect to its pathophysiology, should guide perioperative treatment and rehabilitation strategies and influence ongoing rehabilitation-based research and innovation. Moreover, clinicians must appreciate the magnitude of QD's effect on diminished clinical outcomes, risk for re-injury and patients' ability (or inability) to return to pre-injury level of activity following knee joint preservation procedures.

Editorial Commentary: High Variability Exists Among Different Techniques for Measuring Glenoid Bone Loss.

Glenoid bone loss is a predominant factor in determining proper surgical management for glenohumeral instability. Precise measurements of glenoid (and humeral) bone defects are fundamental, and millimeters matter. Three-dimensional computed tomography scans may provide the highest interobserver reliability for making these measurements. Yet, because imprecision in the range of millimeters is observed with even the most precise glenoid bone loss measurement techniques, it could be a mistake to over-rely, let alone solely rely, on glenoid bone loss measurement as the primary determinant for selecting one surgical procedure over another. Surgeons must measure glenoid bone loss but also thoughtfully consider patient age, associated soft-tissue injuries, and activity level, including throwing and participation in collision sports. When choosing the proper surgical procedure for a shoulder instability patient, we should not focus on only one variably measured parameter but, instead, on a comprehensive assessment of the patient.

Does Surgery for Cruciate Ligament and Meniscus Injury Increase the Risk of Comorbidities at 2 Years in the Military System?

This study aims to determine whether surgery for cruciate ligament (anterior or posterior) or meniscus injury increased risks of subsequent comorbidities in beneficiaries of the Military Health System. The study was a retrospective case-control design in which individuals with cruciate or meniscus injuries were divided into two groups (surgery or none). Data were pulled 12 months prior and 24 months following each respective event and presence of comorbidities were compared between the two groups. Bivariate analyses and logistic regression were used to determine if surgery increased the odds of comorbidities. Participants included 1,686 with a cruciate ligament injury (30.1% treated surgically) and 13,146 with a meniscus injury (44.4% treated surgically). Bivariate comparisons of surgery versus nonsurgical treatment found multiple significant differences. After adjusting for covariates, a significant (p < 0.05) protective effect was seen only for meniscus surgery for concussion, insomnia, other mental health disorders, depression, and substance abuse. Surgery had no increased/decreased risk of comorbidities for cruciate ligament injuries. For meniscus injuries, surgery demonstrated a protective effect for six of the comorbidities we assessed. The treatment approach (surgery vs. nonsurgical) did not change the risk of comorbidities in those with a cruciate ligament injury. It is noteworthy that three of the six comorbidities involved mental health disorders. Although the study design does not allow for determination of causation, these findings should compel future prospective study designs that could confirm these findings.

What to Do When It Is Anterior Cruciate Ligament Reconstruction Number Two.

Several factors contribute to the greater complexity of revision anterior cruciate ligament reconstruction compared with primary anterior cruciate ligament reconstructive surgery. Prior tunnels and hardware may compromise revision tunnel placement and secure fixation. This may necessitate two-stage revision or specific techniques to achieve anatomic revision tunnels. Prior autograft use may limit graft options. Individuals with a failed anterior cruciate ligament reconstruction are more likely to have risk factors for further failure. These may include malalignment, occult instability, knee hyperextension, or increased tibial slope. There are also higher rates of meniscus and cartilage injuries in revision anterior cruciate ligament reconstruction that may require intervention. Successful revision anterior cruciate ligament reconstruction requires thoughtful preoperative planning along with multiple potential intraoperative plans depending on the pathology encountered. It is important to provide the orthopaedic surgeon with an up-to-date, evidence-based overview of how to approach and execute a successful revision anterior cruciate ligament reconstruction.

Surgical Management of Patellar Tendinopathy Results in Improved Outcomes and High Rates of Return to Sport: A Systematic Review.

Although the majority of patients with patellar tendinopathy (PT) can be treated nonoperatively, operative management may be indicated for recalcitrant cases. While several surgical techniques have been described, there is limited understanding of postoperative outcomes and expectations regarding return to activity and sport. The purpose of this study was to characterize the clinical outcomes associated with the surgical management of PT with an emphasis on return to sport (RTS) rates. We hypothesized that surgical management would lead to clinically important improvements in patient-reported outcomes (PROs) with high rates of RTS and RTS at the same level. A comprehensive search of the PubMed, Medline, and Embase databases was performed in December 2020. Level of evidence studies I through IV, investigating results of surgical management for PT (PRO, functional outcomes, pain, and/or RTS), were included. The search was performed in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Forty clinical studies reporting on surgery for PT satisfied inclusion criteria, with 1,238 total knees undergoing surgery for PT. A comparison of pre- and postoperative Victorian Institute of Sport Assessment, patellar tendon (VISA-P) scores (mean difference: 41.89, p < 0.00001), Lysholm scores (mean difference: 41.52, p < 0.00001), and visual analogue scale (VAS) pain scores (mean difference: 5, p < 0.00001) demonstrated clinically and statistically significant improvements after surgery. The overall RTS rate following operative management was 89.8% (95% confidence interval [CI]: 86.4-92.8, I 2 = 56.5%) with 76.1% (95% CI: 69.7.5-81.9, I 2 = 76.4%) of athletes returning to the same level of activity. Surgery for PT provides meaningful improvement in patient reported outcomes and pain while allowing athletes to RTS at high rates with levels of participation similar to that of preinjury. Comparative studies of open and/or arthroscopic surgery are still limited but current evidence suggests better rates of RTS for arthroscopic surgery compared with open surgery. This is a systematic review of level-I to -IV studies.

Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in management over this time as well as an appreciation of the preoperative factors associated with both the chosen surgical modality and short-term complications will help inform future surgical considerations. QUESTIONS/PURPOSES: In this study, we sought to: (1) characterize trends in the surgical management of PHFs over time, including usage rates of various surgical modalities and changes in complication rates; (2) identify preoperative variables associated with the selection of surgical modality; and (3) assess the independent covariates of acute 30-day complications, including demographic variables, injury characteristics, and treatment type. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology and ICD-9 and ICD-10 codes to identify individuals with PHF undergoing open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA) from 2007 to 2018. The NSQIP database was utilized because of its collection of detailed preoperative demographic information and large repository of clinically derived data, which is felt to be more accurate than claims or administrative data. In total, 5889 patients with PHFs met the inclusion criteria. Patients 17 years or older were included. Patients with isolated greater tuberosity, humeral shaft, and distal humerus fractures; nonunions; malunions; and those undergoing revision procedures were excluded. A Cochran-Armitage test was used to evaluate surgical trends over time. Multivariable logistic regression models were created to identify covariates associated with surgical modality and complications. Although complications were either classified as major or minor, specific complications were also individually analyzed to avoid potentially misleading conclusions associated with pooling. RESULTS: The proportion of patients with PHFs undergoing RTSA (4% in 2007 and 34% in 2018; p < 0.001) and ORIF (46% in 2007 and 57% in 2018; p < 0.001) increased over time, and the proportion of those undergoing HA (50% in 2007 and 9% in 2018; p < 0.001) decreased. Across each surgical modality, minor complication rates decreased over time (RTSA: 10% in 2018; p < 0.001; ORIF: 5% in 2018; p = 0.01; and HA: 6% in 2018; p = 0.01). After controlling for confounding variables like diabetes, chronic obstructive pulmonary disease, congestive heart failure, dialysis, and preoperative blood transfusion, the following factors were independently associated with an increased odds of a patient undergoing RTSA rather than HA: older age, higher BMI, independent functional status, and smoking. The following factors were independently associated with a decreased odds of a patient undergoing ORIF rather than RTSA and HA: older age, higher BMI, higher American Society of Anesthesiologists (ASA) classification, smoking, steroid/immunosuppressant use, as well as three- and four-part fractures. After controlling for age, ASA classification, functional status, and preoperative blood transfusion, we also found that in the latter part of the study period, arthroplasty (RTSA and HA) was no longer independently associated with 30-day major or minor complications compared with ORIF. CONCLUSION: The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. Quantifying demographics, injury characteristics, and comorbidities associated with both the choice of surgical modality and complications serves as the groundwork for decision support tools, which can inform patients and surgeons of the probability of a particular surgical modality being chosen and the risk of complications, based on national benchmarks. Future studies should investigate longer term complication rates, as many differences between the approaches being compared might occur beyond the perioperative period and our study had no means to address questions about complications beyond that period, but obviously those must be considered when choosing a treatment for patients with these injuries. Future work might also investigate the mechanisms behind the decreasing rates of short-term complications. LEVEL OF EVIDENCE: Level III, therapeutic study.

Editorial Commentary: Bone Marrow Aspirate Concentrate May Accelerate Anterior Cruciate Ligament Allograft Using Bone Patellar Tendon Bone Maturation on Magnetic Resonance Imaging, but Clinical Differences Have Not Been Demonstrated.

Accelerating graft healing in anterior cruciate ligament reconstruction (ACLR) continues to be an elusive proposition. In vivo assessments of graft histology are challenging to perform, especially in human subjects. Multiple authors have reported on the utility of magnetic resonance imaging as a noninvasive modality in characterizing postoperative changes, suggestive of graft maturation. However, previous literature, by and large, has been limited by heterogenous scanning protocols and underpowered comparisons of dissimilar treatment techniques, and these issues complicate efforts to assess the benefits (if any) of adjuncts focused on improving graft healing after ACLR. Particularly in cases of allograft ACLR, where concerns persist regarding the pace and quality of tissue healing and graft integration, the use of orthobiologic adjuncts represents a promising area for ongoing investigation. Although there has been great enthusiasm for the use of bone marrow aspirate concentrate as an adjunct in a variety of applications, high level evidence substantiating its use in ACLR is lacking. Even when significant differences between groups treated with and without such adjuncts may be apparent radiographically, demonstrating a concrete, clinical benefit will continue to be a difficult proposition.

Does Surgery for Concomitant Cruciate and Meniscus Injuries Increase or Decrease Subsequent Comorbidities at 2 Years?

Concomitant cruciate and meniscus injuries of the knee are generally associated with acute trauma and commonly treated with surgical intervention. Comorbidities (simultaneous presence of two or more medical conditions) may be acquired from changes in activity levels and lifestyle after an injury and/or treatment. This study aimed to compare differences in comorbidity proportions between surgical and nonsurgical approaches in Military Health System beneficiaries who had concurrent cruciate and meniscus injuries. The retrospective case control design included 36-month data that were analyzed to reflect 12 months prior to injury/surgery and 24 months after injury/surgery. A comparison of differences within and between groups in surgical and nonsurgical approaches was calculated and logistic regression was used to determine if surgery increased or decreased the odds of comorbidities at 24 months. In our sample of 2,438 individuals with concurrent meniscus and cruciate injury, 79.1% (n = 1,927) received surgical intervention and 20.9% (n = 511) elected for nonoperative management. All comorbidities demonstrated significant within-group differences from pre- to postsurgery for those with a surgical intervention; approximately, half the comorbidities increased (i.e., concussion or traumatic brain injury, insomnia, other sleep disorders, anxiety, posttraumatic stress disorder, and tobacco abuse disorder), whereas the other half decreased (i.e., chronic pain, apnea, cardiovascular disease, metabolic syndrome, mental health other, depression, and substance abuse disorders). The odds of acquiring a comorbid diagnosis after surgery reflected the bivariate comparisons with half increasing and half decreasing in odds. To our knowledge, this is the first study to explore comorbidity changes with a control group for individuals with concurrent meniscus and cruciate injuries.

Treatment of Cartilage Defects of the Knee in Military Tactical Athletes: An Overview of Management and Clinical Outcomes.

Cartilage defects of the knee are a common problem that can be caused by trauma or chronic repetitive overload and result in debilitating functional limitations. These consequences are of particular significance to military service members, who, by in large, are a group of young, active individuals with professional duties requiring full, unrestricted activity and function. The burden of knee chondral-related disease among military tactical athletes is well established, and systematic approach to the evaluation of a military member with suspected knee chondral pathology facilitates the execution of a surgical procedure that maximizes the likelihood of a return to duty. Despite advances in cartilage restoration surgery, chondral pathology of the knee remains a vexing problem and an omnipresent threat to military medical readiness and warfighter lethality.