An Opioid-Sparing Pain Protocol of Intravenous and Oral Ketorolac Reduces Opioid Consumption and Pain Levels after Arthroscopic Meniscus Surgery: A Prospective, Randomized Controlled Trial.

BACKGROUND: The primary purpose was to compare ketorolac to oxycodone-acetaminophen with respect to pain and opioid consumption after arthroscopic meniscus surgery. The secondary purpose was to compare short-term functional outcomes between the two protocols. METHODS: A power analysis demonstrated that 43 patients were required. In this randomized control trial, patients with meniscal pathology undergoing arthroscopic meniscus surgery were included. Group 1 received oxycodone-acetaminophen alone. Group 2 received one dose of intravenous ketorolac intraoperatively, oral ketorolac upon discharge, and "rescue" oxycodone-acetaminophen. Patients recorded the number of opioid tablets consumed and visual analog pain scale (VAS) scores three times per day for five days postoperatively. Opioids were converted to morphine milligram equivalents (MME). VAS, Lysholm Knee Scoring Scale (LKSS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) were obtained. RESULTS: Forty-eight patients were randomized. There were 25 patients in the control group and 23 patients in the ketorolac group. The mean age was 47.9 (±14.3) years. Fifty-two percent (n=25) of the population were female. Three patients (6.3%) underwent meniscal repair. During the first five days postoperatively, the mean VAS score (ß= -13.2, SE=5.97, p=0.029) and the MME consumed were significantly lower (ß=-4.7, SE=1.93, p=0.015) per time point in the ketorolac group relative to the control group. The control group had better LKSS (80.6 [SD 18.5] versus 65 [SD 21.5], p=0.016) and KOOS (74.1 [SD 16.7] versus 61.9 [SD 18.6], p=0.029) scores at 6 weeks. There were no significant differences in the rates of side effects. CONCLUSIONS: An opioid-sparing pain protocol of intravenous and oral ketorolac is associated with significant reductions in VAS scores and MME consumption in the first five days after arthroscopic meniscus surgery. There were significant differences in patient-reported outcomes at final follow-up, favoring the control group. There were no significant differences in adverse reactions and side effects. LEVEL OF EVIDENCE: Therapeutic Level II, prospective randomized-controlled trial.

ChatGPT Responses to Common Questions About Anterior Cruciate Ligament Reconstruction Are Frequently Satisfactory.

PURPOSE: To evaluate ChatGPT responses to common questions patients have regarding anterior cruciate ligament (ACL) reconstruction. METHODS: Ten frequently asked questions regarding ACL tears and ACL reconstruction were chosen from the frequently asked questions found on the websites of major institutions. These were presented to ChatGPT and responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." RESULTS: Four responses were satisfactory, requiring minimal clarification, 3 were satisfactory, requiring moderate clarification, 2 were unsatisfactory, and 1 was excellent, requiring no clarification. CONCLUSIONS: As hypothesized, ChatGPT provided generally accurate information to common questions around ACL reconstruction. Although clarification often was needed, responses were satisfactory for providing generalized information about ACL tears and ACL reconstruction. CLINICAL RELEVANCE: ChatGPT is a promising avenue for patients to learn about general background information regarding ACL reconstruction, although questions specific to any planned operation need to be addressed directly with an orthopaedic provider.

High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review.

BACKGROUND: The Centers for Disease Control defines work-related musculoskeletal disorders as disorders of the nerves, muscles, tendons, joints, spinal discs, and cartilage that are caused or exacerbated by the environment or nature of work. Previous meta-analyses have characterized work-related musculoskeletal disorders among interventionists, general surgeons, and other surgical subspecialties, but prevalence estimates, prognosis, and ergonomic considerations vary by study and surgical specialty. QUESTIONS/PURPOSES: (1) What is the career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons? (2) What is the treatment prevalence associated with work-related musculoskeletal disorders in orthopaedic surgeons? (3) What is the disability burden of work-related musculoskeletal disorders in orthopaedic surgeons? (4) What is the scope of orthopaedic surgical ergonomic assessments and interventions? METHODS: A systematic review of English-language studies from PubMed, MEDLINE, Embase, and Scopus was performed in December 2022 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that presented prevalence estimates of work-related musculoskeletal disorders or assessed surgical ergonomics in orthopaedic surgery were included. Reviews, case reports, gray literature (conference abstracts and preprints), and studies with mixed-surgeon (nonorthopaedic) populations were excluded. The search yielded 5603 abstracts; 24 survey-based studies with 4876 orthopaedic surgeons (mean age 48 years; 79% of surgeons were men) were included for an analysis of work-related musculoskeletal disorders, and 18 articles were included for a descriptive synthesis of ergonomic assessment. Quality assessment using the Joanna Briggs Institute Tool revealed that studies had a low to moderate risk of bias, largely because of self-reporting survey-based methodology. Because of considerable heterogeneity and risk of bias, prevalence outcomes were not pooled and instead are presented as ranges (mean I 2 = 91.3%). RESULTS: The career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons ranged from 37% to 97%. By anatomic location, the prevalence of work-related musculoskeletal disorders in the head and neck ranged from 4% to 74%; back ranged from 9% to 77%; forearm, wrist, and hand ranged from 12% to 54%; elbow ranged from 3% to 28%; shoulder ranged from 3% to 34%; hip and thigh ranged from 1% to 10%; knee and lower leg ranged from 1% to 31%; and foot and ankle ranged from 4% to 25%. Of orthopaedic surgeons reporting work-related musculoskeletal disorders, 9% to 33% had a leave of absence, practice restriction or modification, or early retirement, and 27% to 83% received some form of treatment. Orthopaedic surgeons experienced biomechanical, cardiovascular, neuromuscular, and metabolic stress during procedures. Interventions to improve orthopaedic surgical ergonomics have been limited, but have included robotic assistance, proper visualization aids, appropriate use of power tools, and safely minimizing lead apron use. In hip and knee arthroplasty, robotic assistance was the most effective in improving posture and reducing caloric expenditure. In spine surgery, proper use of surgical loupes was the most effective in improving posture. CONCLUSION: Although the reported ranges of our main findings were wide, even on the low end of the reported ranges, work-related musculoskeletal disability among orthopaedic surgeons appears to be a substantial concern. We recommend that orthopaedic residency training programs incorporate surgical ergonomics or work injury lectures, workshops, and film review (alongside existing film review of surgical skills) into their curricula. We suggest hospitals engage in shared decision-making with surgeons through anonymous needs assessment surveys to implement wellness programs specific to surgeons' musculoskeletal needs. We urge institutions to assess surgeon ergonomics during routine quality assessment of novel surgical instruments and workflows. LEVEL OF EVIDENCE: Level III, prognostic study.

Risk Factors of Emergency Department Utilization After Outpatient Surgery for Sports-Related Injuries.

INTRODUCTION: The purpose of this study was to identify the most common reasons for and risk factors associated with postoperative emergency department (ED) utilization after orthopaedic procedures for sports-related injuries. METHODS: Using the 2014 to 2016 New York and Florida State Databases from the Healthcare Cost and Utilization Project, outpatient procedures for sports-related injuries were identified. Patient records were tracked across care settings within each state to determine the rate and reasons of postoperative ED utilization within 90 days after the index surgery. Multiple logistic regression models were used to identify risk factors associated with ED visits at 0 to 7 days, 8 to 30 days, 31 to 90 days postoperatively. RESULTS: A total of 28,192 surgery visits for sports-related injuries were identified, with knee arthroscopy with partial meniscectomy (18.48%) and arthroscopic anterior cruciate ligament reconstruction (17.04%) as the two most common procedures treating sports injuries. The overall postoperative ED utilization rates were 1.6% (0 to 7 days postoperative), 1.3% (8 to 30 days) and 2.1% (31 to 90 days). The main cause of ED visits was markedly different during each postoperative period: mainly musculoskeletal pain (36.3%) during 0 to 7 days, either musculoskeletal pain (17%) or injury (16.6%) during 8 to 30 days, and injury (24.2%) during 31 to 90 days. Sports with the highest ED utilization in descending order were basketball, football, ice/snow sports, walking/running, cycling, and soccer. Relative to open procedures, arthroscopic procedures were 0.71 times as likely to result in a postoperative ED visit. Independent predictors of ED utilization up to 90 days postoperatively included renal failure, chronic pulmonary disease, psychosis, diabetes, and alcohol abuse. DISCUSSION: Rate of ED utilization after outpatient surgery for sports-related injuries is low (<2.2%), with postoperative musculoskeletal pain and reinjury as the two most common causes, highlighting the importance of postoperative pain management and injury prevention. Arthroscopic procedures showed markedly lower ED utilization compared with open surgery, although not indicative of overall superiority. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Common characteristics of shoulder injury related to vaccine administration following COVID-19 vaccination: a comprehensive systematic review.

BACKGROUND: The pathogenesis of shoulder injury related to vaccine administration (SIRVA) is incompletely understood, but it is postulated to be an immune-mediated inflammatory response to a vaccine antigen, leading to shoulder pain and dysfunction. The purpose of this investigation is to systematically review the literature related to SIRVA specifically after the COVID-19 vaccination by describing the diagnostic and clinical characteristics, diagnoses associated with SIRVA, and incidence between vaccine types. METHODS: A systematic review was performed to identify level I to IV studies and case descriptions of shoulder pain occurring after COVID-19 vaccination. To confirm that no studies were missing from the systematic review, references of studies from the initial search were scanned for additional relevant studies. RESULTS: A total of 22 studies, comprised of 81 patients, were identified meeting the inclusion/exclusion criteria. Reports were most commonly published from countries in Asia (53.1%; n = 43/81). The most commonly described vaccines were Oxford-AstraZeneca at 37.0% (n = 30/81) and Pfizer-BioNTech at 33.3% (n = 27/81). Symptoms occurred most commonly after at least 72 hours of administration (30.9%, n = 25/81). One hundred percent of patients (n = 81/81) described pain as an associated symptom and 90.1% of patients (n = 73/81) described multiple symptoms. The diagnostic modalities utilized to identify a specific pathology consisted of magnetic resonance imaging (55.6%; n = 45/81), ultrasound (28.4; n = 23/81), radiograph (25.9%; n = 21/81), and computed tomography (4.9%; 4/81). Nearly a third of patients (32.1%; n = 26/81) were diagnosed with bursitis, while 22 (27.2%) were diagnosed with adhesive capsulitis, 17 (21.0%) with either rotator cuff tear or tendinopathy, and 14 (17.3%) with polymyalgia rheumatica or polymyalgia rheumatica-like syndrome. The 2 most common treatment options were physical therapy (34.6%; n = 28/81) and nonsteroidal anti-inflammatory medications (33.3%; 27/81). The majority of SIRVA cases (52.1%; n = 38/73) completely resolved within a few weeks to months. CONCLUSION: Despite the limited quality and lack of large-scale studies, it is important for providers to recognize SIRVA as a potential risk factor as the number of patients receiving COVID-19 vaccinations and boosters continues to rise.

Effects of Opioid-Limiting Legislation in the State of Ohio on Opioid Prescriptions After Shoulder Arthroscopy.

Background: Recent studies have shown that legislation regulating opioid prescriptions in the United States has been successful in reducing the morphine milligram equivalent (MME) prescribed after certain orthopaedic procedures. Purpose: To (1) determine the effect of Ohio's legislation limiting opioid prescriptions after shoulder arthroscopy and (2) identify risk factors associated with prolonged opioid use and increased postoperative opioid dosing. Study Design: Cohort study; Level of evidence, 3. Methods: We reviewed the data of patients who underwent shoulder arthroscopy between January 1, 2016, and March 31, 2020. Patients were classified according to the date of legislation passage (August 31, 2017) as before legislation (PRE) or on/after legislation (POST). Patients were also classified based on the number of opioid prescriptions filled within 30 days of surgery as opioid-tolerant (at least 1 prescription) or opioid-naïve (zero prescriptions). We recorded patient characteristics, medical comorbidities, and surgical details, as well as the number of opioid prescriptions, MME per prescription from 30 days preoperatively to 90 days postoperatively, and the number of gamma-aminobutyric acid (GABA) analogues and benzodiazepine prescriptions from 30 days preoperatively to the date of surgery. Differences between cohorts were compared with the Fisher exact test and Wilcoxon test. A covariate-adjusted regression analysis was used to evaluate risk factors associated with increased postoperative opioid dosing. Results: Overall, 279 patients (n = 97 PRE; n = 182 POST; n = 42 opioid-tolerant; n = 237 opioid-naïve) were included in the final analysis. There was a significant reduction in the cumulative MME prescribed in the immediate (0-7 days) postoperative period (PRE, 450 MME vs POST, 315 MME), the first 30 postoperative days (PRE, 590 MME vs POST, 375 MME), and the first 90 postoperative days (PRE, 600 MME vs POST, 420 MME) (P < .001 for all). The opioid-tolerant cohort had higher MME at every time point in the postoperative period (P < .001). Consumption of preoperative opioid (ß = 1682.5; P < .001), benzodiazepine (ß = 468.09; P < .001), and GABA analogue (ß = 251.37; P = .04) was associated with an increase in the cumulative MME prescribed. Conclusion: Opioid prescription-limiting legislation in Ohio significantly reduced the cumulative MME prescribed in the first 30 days postoperatively for both opioid-naïve and opioid-tolerant patients after shoulder arthroscopy. Consumption of opioids, benzodiazepines, and GABA analogues preoperatively was associated with increased postoperative opioid dosage.

Patient Preferences and Perceptions of Provider Diversity in Orthopaedic Surgery.

BACKGROUND: Orthopaedic surgery in the U.S. historically has been among the least demographically diverse specialties in medicine. Currently, limited data exist on how patients perceive diversity within the field and what patients look for when choosing an orthopaedic surgeon. The purpose of this study was to identify specific patient preferences for surgeon demographics and understand patient perceptions of racial and gender diversity in orthopaedic surgery. METHODS: Nonconsecutive patients from orthopaedic clinics affiliated with a U.S. academic health system voluntarily completed a 39-item questionnaire that surveyed basic demographic information, perception of diversity, racial and gender preferences during surgeon selection, and perception of health-care inequalities. Bivariate analyses were used to test the association between patient-surgeon demographic variables and ratings of diversity. Multiple regression models were used to identify independent predictors of overall perceived diversity ratings. RESULTS: A total of 349 patients (80.6% White, 17.9% Black, and 1.5% other) were analyzed. Black patients were more likely to experience difficulty relating to their surgeon than White patients (11.48% versus 2.29%; odds ratio [OR], 5.62; 95% confidence interval [CI], 1.55 to 21.1; p = 0.004). Moreover, Black patients were more likely to perceive racial bias from their surgeon than White patients (5.17% versus 0.37%; OR, 14.44; 95% CI, 1.14 to 766.29; p = 0.02). While the level of racial diversity perceived by White patients (2.57 of 10) was significantly higher than that perceived by Black patients (2.10 of 10) (p = 0.001), the absolute difference between these 2 figures was small, suggesting that both groups perceived racial diversity in orthopaedics to be low. White and Black patients differed in their importance ranking of a surgeon's race (p < 0.0001): Black patients ranked a surgeon's race with higher importance (mean, 3.49 of 10) when selecting a surgeon compared with White patients (1.45 of 10). Both male and female patients gave relatively low importance rankings for a surgeon's gender (mean, 1.58 of 10 and 2.15 of 10, respectively, p = 0.02). CONCLUSIONS: Patients in this study did not perceive orthopaedic surgery as a diverse field (overall diversity rating, <3 of 10). There were significant racial and gender differences in patients' preferences for specific physician characteristics when choosing an orthopaedic surgeon, which may help explain some instances of perceived racial bias and difficulty relating to their orthopaedic surgeon.

Common Sports Infectious Disease.

There is growing concern about the impact of infectious diseases in athletes, especially as they relate to exposures in athletic training facilities. This article reviews common pathogens encountered in athletic training facilities, while offering an evidence-based overview of practical preventative measures that can be implemented to reduce the incidence of infectious diseases in close-contact sports such as American football and wrestling.

Increase in Deltoid Compartment Pressures Immediately After Arthroscopic Rotator Cuff Repair Does Not Significantly Affect Postoperative Opioid Consumption.

Purpose: To investigate the association between changes in individual (anterior, lateral, and posterior) and overall deltoid compartment pressures and postoperative opioid consumption up to 14 days after primary double-row arthroscopic rotator cuff repair (ARCR). Methods: In 113 consecutive patients undergoing primary double-row ARCR, anterior, lateral, and posterior deltoid compartment pressures were measured prior to incision and immediately after closure with a manometer. Postoperatively, all patients were provided with an identical rehabilitation protocol, quantity and dose of opioid tablets, and pain journal in which to record daily opioid consumption and visual analog scale pain scores for 14 days after surgery. The pain journals were collected at the first postoperative visit, and opioid consumption was calculated based on morphine equivalents. Statistical analysis was performed to determine the association between deltoid compartment pressures and opioid consumption postoperatively. Results: Sixty-nine percent of patients who met the inclusion criteria (74 of 107) returned the pain journals. The mean age at the time of surgery was 57.4 ± 8.8 years (range, 30-75 years), with female patients being significantly older (P = .03). The mean length of surgery was 71.7 ± 16.3 minutes. No significant association between increase in individual (anterior, lateral, or posterior) or mean overall compartment pressures and morphine equivalents of opioid consumption was appreciated on any postoperative day. Conclusions: No significant correlation between increase in individual or overall deltoid compartment pressures after ARCR and postoperative opioid consumption in the immediate postoperative period was found in this study. Level of Evidence: Level II, prospective cohort study.

Management of Bone Loss and Tunnel Widening in Revision ACL Reconstruction.

➤ Both mechanical and biological factors can contribute to bone loss and tunnel widening following primary anterior cruciate ligament (ACL) reconstruction.➤ Revision ACL surgery success is dependent on graft position, fixation, and biological incorporation.➤ Both 1-stage and 2-stage revision ACL reconstructions can be successful in correctly indicated patients.➤ Potential future solutions may involve the incorporation of biological agents to enhance revision ACL surgery, including the use of bone marrow aspirate concentrate, platelet-rich plasma, and bone morphogenetic protein-2.

Smaller diameter femoral tunnel biocomposite interference screws provide adequate fixation strength in anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to evaluate the effect of bioabsorbable interference screw diameter on the pullout strength and failure mode for femoral tunnel fixation in primary anterior cruciate ligament reconstruction (ACLR) at time zero fixation using bone-patellar tendon-bone (BTB) autograft in a cadaveric model. METHODS: Twenty-four fresh-frozen cadaveric knees were obtained from 17 different donors. Specimens were allocated to three different treatment groups (n = 8 per group) based on interference screw diameter: 6 mm, 7 mm, or 8 mm biocomposite interference screw. All specimens underwent dual energy X-ray absorptiometry (DEXA) scanning prior to allocation to ensure no difference in bone mineral density among groups (n.s.). All specimens underwent femoral-sided ACLR with BTB autograft. Specimens subsequently underwent mechanical testing under monotonic loading conditions to failure. The load to failure and failure mechanism were recorded. RESULTS: The mean pullout force (N) at time zero for each group was 309 ± 213 N, 518 ± 313 N, and 541 ± 267 N for 6 mm, 7 mm, and 8 mm biocomposite interference screw diameter, respectively (n.s.). One specimen in the 6 mm group, two specimens in the 7 mm group, and one specimen in the 8 mm group failed by screw pullout. The remainder in each group failed by graft failure (n.s.). CONCLUSION: Biocomposite interference screw diameter did not have a significant influence on fixation pullout strength or failure mode following femoral tunnel fixation using BTB autograft at time zero. A 6 mm interference screw can improve preservation of native bone stock, increase potential for biologic healing, and decrease the risk of damage to the graft during insertion without significantly compromising fixation strength. This study supports the use of smaller 6 mm interference screw diameter options for femoral tunnel fixation in ACLR.

Trends in Orthopedic Device Innovation: An Analysis of 510(k) Clearances and Premarket Approvals From 2000 to 2019.

The objective of this study was to characterize recent trends in orthopedic device development across different subspecialty areas. Orthopedic 510(k) clearances, premarket approvals (PMAs; together, "authorizations"), and new market entrants from 2000 to 2019 were analyzed as markers of research and development activity. Data were extracted from the US Food and Drug Administration website and stratified into one of 9 "subspecialty" groups: spine, trauma, hip arthroplasty, knee arthroplasty, shoulder, hand/elbow, foot/ankle, cement/filler/graft, and other. Descriptive statistics were used to analyze the data. Growth rates were calculated from trailing 3-year averages. During the study period, there were 9906 orthopedic 510(k) clearances and 1409 PMAs, of which 61 were for original PMA submissions. The preponderance of 510(k) clearances were for devices used in spine (36%) and trauma (30%) surgery, followed by hip (11%) and knee (8%) arthroplasty. Annual 510(k) clearances for spine and trauma devices grew by 232% and 44%, respectively, whereas annual hip and knee arthroplasty clearances declined. Paralleling these findings, the influx of new manufacturers of orthopedic devices was greatest for the trauma surgery (438), spine surgery (383), and cement/filler/graft (181) markets. Spinal surgery and orthopedic trauma have become leading priorities in orthopedic product development during the past two decades. Meanwhile, hip and knee arthroplasty products have proportionally become a smaller category of new devices over time. These findings demonstrate changing priorities within orthopedic innovation. [Orthopedics. 2023;46(2):e98-e104.].

Biologics, Stem Cells, Growth Factors, Platelet-Rich Plasma, Hemarthrosis, and Scaffolds May Enhance Anterior Cruciate Ligament Surgical Treatment.

Biologics including mesenchymal stem cells (MSCs), growth factors, and platelet-rich plasma may enhance anterior cruciate ligament (ACL) reconstruction and even ACL primary repair. In addition, hemarthrosis after acute ACL injury represents a source of biologic factors. MSCs can differentiate into both fibroblasts and osteoblasts, potentially providing a transition between the ligament or graft and bone. MSCs also produce cytokines and growth factors necessary for cartilage, bone, ligament, and tendon regeneration. MSC sources including bone marrow, synovium, adipose tissue, ACL-remnant, patellar tendon, and umbilical cord. Also, scaffolds may represent a tool for ACL tissue engineering. A scaffold should be porous, which allows cell growth and flow of nutrients and waste, should be biocompatible, and might have mechanical properties that match the native ACL. Scaffolds have the potential to deliver bioactive molecules or stem cells. Synthetic and biologically derived scaffolds are widely available. ACL reconstruction with improved outcome, ACL repair, and ACL tissue engineering are promising goals. LEVEL OF EVIDENCE: Level V, expert opinion.

Which Application Factors Are Associated With Outstanding Performance in Orthopaedic Surgery Residency?

BACKGROUND: Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice. QUESTIONS/PURPOSES: We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance. METHODS: Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program, were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p < 0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values < 0.05 were considered significant. RESULTS: The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ 2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ 2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ 2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study. CONCLUSION: Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought. LEVEL OF EVIDENCE: Level III, therapeutic study.

Achilles Tendon Repairs: Identification of Risk Factors for and Economic Impact of Complications and Reoperation.

BACKGROUND: Compared with nonoperative management, Achilles tendon repair is associated with increased rates of complications and increased initial healthcare cost. However, data are currently lacking on the risk factors for these complications and the added healthcare cost associated with common preoperative comorbidities. HYPOTHESIS: Identify the independent risk factors for complications and reoperation after acute Achilles tendon repair and calculate the added cost of care associated with having each preoperative risk factor. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: A retrospective review of a large commercial claims database was performed to identify patients who underwent primary operative management for Achilles tendon rupture between 2007 and 2016. The primary outcome measures of the study were risk factors for (1) postoperative complications, (2) revision surgery, and (3) increased healthcare resource utilization. RESULTS: A total of 50,279 patients were included. The overall complication rate was 2.7%. The most common 30-day complication was venous thromboembolism (1.2%). The rate of revision surgery was 2.5% at 30 days and 4.3% at 2 years. Independent risk factors for 30-day complications in our cohort included increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Independent risk factors for revision surgery within 2 years included female sex, tobacco use, hypertension, obesity, and the presence of any postoperative complication. The average 5-year cost of operative intervention was $17,307. The need for revision surgery had the largest effect on 5-year overall cost, increasing it by $6776.40. This was followed by the presence of a postoperative complication ($3780), female sex ($3207.70), and diabetes ($3105). CONCLUSION: Achilles tendon repair is a relatively low-risk operation. Factors associated with postoperative complications include increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Factors associated with the need for revision surgery include female sex, hypertension, obesity, and the presence of any postoperative complication. Female sex, diabetes, the presence of any complication, and the need for revision surgery had the largest added costs associated with them. CLINICAL RELEVANCE: Surgeons can use this information for preoperative decision-making and during the informed consent process.

Oral Ketorolac as an Adjuvant Agent for Postoperative Pain Control After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study.

INTRODUCTION: Successful outpatient anterior cruciate ligament (ACL) reconstruction hinges on effective analgesia. Routinely, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents have several known adverse effects and are associated with a potential for abuse. This study evaluates the efficacy of ketorolac, a nonsteroidal anti-inflammatory drug with analgesic properties, as an adjuvant agent for postoperative pain control after ACL reconstruction. METHODS: Adult patients undergoing primary ACL reconstruction were prospectively enrolled. Exclusion criteria involved patients with a history of bleeding diathesis, renal dysfunction, chronic analgesia use, or alcohol abuse. Eligible patients were randomized into one of two groups. The control group received a standard-of-care pain protocol involving oxycodone-acetaminophen 5 to 325 on discharge. The ketorolac group additionally received intravenous ketorolac postoperatively and 3 days of oral ketorolac on discharge. Pain levels and total narcotic utilization were recorded three times per day for the first 5 days after surgery. Pain and functional outcomes were obtained at 2 and 6 weeks postoperatively. RESULTS: The final analysis included 48 patients; the mean age of the cohort was 32 ± 11.6 years, and 60.4% of patients were female. No differences were observed in preoperative demographics, comorbidities, and preoperative functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 45.4% fewer narcotic pills than the control group (P < 0.001). In addition, mean postoperative pain scores were 22.36 points lower for patients in the ketorolac group (P < 0.001). There was no difference in functional outcome scores at up to 6 weeks postoperatively or adverse events between the two groups with no reported cases of gastrointestinal bleeding. DISCUSSION: The use of adjunctive intravenous and short-term oral ketorolac substantially reduces narcotic utilization and pain levels after ACL reconstruction. CLINICALTRIALGOV REGISTRATION NUMBER: NCT04246554.

Complete Isolated Ruptures of the Distal Biceps Brachii During Athletic Activity: A Systematic Review.

Complete, isolated ruptures of the distal biceps brachii sustained during athletic activities are uncommon. A systematic review of the literature was performed to identify complete distal biceps brachii tears experienced during athletic activities to determine injury prevalence, athletic activities/mechanisms responsible for injury and return to activity timing following operative management. A total of 10 studies, comprising 16 athletes undergoing surgery for 18 cases, were identified. Injuries were predominately associated with weightlifting. Injuries were treated utilizing a single incision in 56% of cases and primary repair performed in 89% of cases. Mean time to return to activity was 4.86 ± 1.14months. Athletes undergoing surgery ≤ 10 days following injury and those undergoing primary repair returned to activity significantly quicker. Isolated tears of the distal biceps remain uncommon during athletic activities, occurring primarily during weightlifting. Return to activity timing was not significantly delayed based on surgical approach, steroid use, or athlete age.

Emergency Department Utilization Is Low After Outpatient Elective Rotator Cuff Repair.

INTRODUCTION: The purpose of this study was to establish emergency department (ED) utilization rate and reasons for presentation to the ED after outpatient rotator cuff repair (RCR) and determine preoperative predictors for these ED visits. METHODS: Patients who underwent outpatient RCR between 2014 and 2015 were retrospectively evaluated using the New York and Florida State Databases. The primary outcome was all-cause 7- and 30-day ED utilization rates. Reasons for presentation to the ED were recorded and stratified. Univariate and multivariate analyses were done to identify independent predictors of ED utilization. RESULTS: The 7- and 30-day ED visit rates were 3.2% and 5.0%, respectively. The most common cause for an ED visit after outpatient RCR at 7- and 30-days postoperatively were postoperative pain (29.0%) and GI complaints (16.3%), respectively. African American race (odds ratio [OD], 1.69; P < 0.001), Hispanic race (OD, 1.47; P = 0.005), and comorbid diagnoses of hypertension (OD, 1.51; P < 0.001), diabetes (OD, 1.58; P < 0.001), and/or schizophrenia (OD, 5.14; P < 0.001) were independent risk factors for an ED visit at up to 30 days postoperatively. Those with Medicare (OD, 2.01; P < 0.001) or Medicaid (OD, 2.61; P < 0.001) were more than twice as likely to present to the ED within 30 days than those with private health insurance. DISCUSSION: ED utilization after outpatient RCR is uncommon with postoperative pain as the most common chief concern for ED visits within the first 7 days and GI issues as the most common reason for ED encounters at up to 30 days postoperatively. Hypertension, diabetes, renal failure, liver disease, rheumatologic diseases, schizophrenia, depression, and Medicare and Medicaid insurance were independent predictors of ED encounters at up to 30 days postoperatively. Procedures done at freestanding surgery centers were protective against ED utilization. LEVEL OF EVIDENCE: Level III, Retrospective Cohort.

Effects of opioid-limiting legislation on postoperative opioid use in shoulder arthroplasty in an epidemic epicenter.

BACKGROUND: The current opioid epidemic in the United States has become a public health crisis with an estimated 150 daily deaths and nearly 47,000 opioid-related deaths in the United States in 2017 alone. Sensible prescriber practice changes have been a focus of policymakers to decrease the total number of narcotic pain medications in circulation. In the state of Ohio, opioid prescription limits for acute pain were enacted in August 2017. However, given the association of acute opioid exposure with long-term use and lack of assessment of these policies, there is an unmet need to evaluate the effects of similar legislation in Ohio on postoperative opioid dosing after shoulder arthroplasty. This study evaluates the effects of opioid prescription-limiting legislation in Ohio on postoperative opioid dosing in shoulder arthroplasty and assesses risk factors related to long-term opioid use. METHODS: All patients undergoing primary and revision shoulder arthroplasty over a 5-year period performed by a single surgeon were included. The pre-legislation (PRE) and post-legislation (POST) groups were defined as patients undergoing shoulder arthroplasty before August 31, 2017 and on or after August 31, 2017, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively. Patients were designated as opioid tolerant if they had filled an opioid prescription within 30 days of surgery. A binary logistic regression analysis was applied to assess factors related to long-term opioid use. RESULTS: A total of 334 patients were categorized into 2 cohorts: PRE (n = 99) and POST (n = 235). Accounting for legislative effects, we observed significant reductions in cumulative morphine milligram equivalent (MME) dosing in the opioid-naive patients in the 7-day and 30-day postoperative periods (450.0 MMEs in PRE group vs. 210.0 MMEs in POST group, P < .001) and in the opioid-tolerant patients in the 7-day postoperative period (450.0 MMEs in PRE group vs. 250.0 MMEs in POST group, P = .001). Among the opioid-naive patients, the POST group had a significant MME reduction in the 90-day postoperative period relative to the PRE cohort (P < .001). Preoperative opioid tolerance and benzodiazepine tolerance were independent risk factors for increased MME dosing at 90 days postoperatively (P < .001 and P = .02, respectively). CONCLUSION: Opioid prescription-limiting legislation for acute pain in the state of Ohio is associated with a notable reduction in opioid MME dosing in the 90-day postoperative period after shoulder arthroplasty, particularly in opioid-naive patients in the first 30 days postoperatively. Preoperative opioid tolerance is correlated with significantly higher MME dosing postoperatively after shoulder arthroplasty.

Epidemiology of Tibial Fractures in Professional American Football Athletes From 2013 to 2019.

BACKGROUND: Lower extremity injuries occur with high frequency in National Football League (NFL) athletes and cause high burden to players and teams. Tibial fractures are among the most severe lower extremity injuries sustained in athletes and are associated with prolonged time loss from sport. PURPOSE: To determine the number of tibial fractures in NFL athletes from the 2013 to 2019 NFL seasons and describe athlete demographics, fracture characteristics, and details of injury onset. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of the NFL injury database was performed to identify all NFL athletes sustaining tibial fractures over the 2013 to 2019 NFL seasons. Athlete characteristics, injury characteristics, days missed, and treatment (operative vs nonoperative) were examined. Descriptive statistics were used to calculate means, standard deviations, ranges, and percentages. RESULTS: A total of 64 tibial fractures were identified in 60 athletes, resulting in a median loss of 74 days. Defensive secondary athletes had the highest number of injuries (n = 10; 16%), followed by running backs (n = 9; 14%), while 61% of these injuries occurred during NFL regular-season games, primarily between weeks 13 and 17. The most commonly reported activity during injury was athletes being tackled, with a direct impact to the tibia being the most common mechanism of injury. Lateral tibial plateau fractures were the most frequently reported, while distal tibial fractures resulted in the greatest number of days lost. The median time lost for injuries requiring surgery was 232 days compared with 56 days for injuries treated using conservative management. CONCLUSION: The highest proportion of tibial fractures were injuries to defensive secondary athletes and athletes being tackled while sustaining a direct impact to the leg, primarily to the lateral tibial plateau. Tibial fracture injuries were commonly sustained during NFL regular-season games, primarily during the final 4 weeks of the NFL regular season. Further investigations examining performance and career longevity in athletes sustaining tibial fractures are warranted to help improve the health and safety of NFL athletes.