An accurate method of measuring shoulder sling compliance: a validation study.

BACKGROUND: The effect of postoperative shoulder sling compliance on surgical outcomes is unknown. The goal was to determine an accurate method to measure sling compliance. We compared volunteer recorded sling wear time with temperature-based sensors to monitor sling compliance. METHODS: Data loggers sutured at three locations measured heat generated in 15-minute intervals. Slings wearers logged sling wear to accurately cross-reference with temperature sensors. Secondary experiments analyzed whether surrounding ambient temperature can be discerned from actual sling wear. We created an algorithm to describe actual sling wear time as a function of heat recorded and calculated percent wear accuracy. RESULTS: The modified sling was worn for 172 h. The algorithm modeled sling on/off times by analyzing cutoff temperatures. Diagnostic accuracy was >99 % for the three locations, with no statistically significant differences among them. Compared with sling wear, ambient temperature took longer to reach critical temperature values determined by the algorithm, helping distinguish compliance from false positives. CONCLUSIONS: The described algorithm can effectively quantify shoulder sling wear time based on heat-generated sensor readings. False positives from ambient temperature are minimal. This measurement method could be used to study the relationship between postoperative sling use and functional outcomes after shoulder surgery.

Impact of pre-operative recreational marijuana use on outcomes two years after orthopaedic surgery.

PURPOSE: The purpose of this study was to investigate the relationship between recreational marijuana use and patient-reported outcomes two years after orthopaedic surgery. We hypothesized that pre-operative recreational marijuana use would be associated with less pain, better function, and better mental health measures two years after orthopaedic surgery. METHODS: Patients were retrospectively analyzed from a prospective orthopaedic registry at a single urban institution. A total of 1710 patients completed the pre-operative assessment and 1103 patients (64.5%) completed the two-year follow-up questionnaires. The cohort was then divided into two groups based on reported preoperative recreational marijuana usage, and statistical analysis was performed to determine if marijuana use was associated with two-year outcomes. Multivariable analysis was used to control for confounding variables. RESULTS: Marijuana use was reported by 47 (4.3%) patients. Significantly worse scores for two-year PROMIS Anxiety (53.2 vs. 49.2, p = 0.005), PROMIS Depression (51.1 vs. 46.5, p = 0.001), Met Expectations (63.1 vs. 74.4, p = 0.024), Surgical Satisfaction Questionnaire-8 (71.7 vs. 80.4, p = 0.005), and Numeric Satisfaction Scale (75.6 vs. 83.1, p = 0.041) were associated with marijuana use. Marijuana users also had less improvement of Numeric Pain Scores at the operative site (- 1.8 vs. - 2.7, p = 0.037) and greater decrease in Marx activity scores for lower extremities (- 12.3 vs. - 3.9, p = 0.024). Marijuana use was not an independent predictor of any outcome measure in the multivariable analysis. CONCLUSION: Marijuana use was associated with worse mental health scores, lower activity level, less pain relief, and worse satisfaction two years after orthopaedic surgery. However, after controlling for confounding variables, marijuana use was not predictive of any two-year outcome measure. STUDY DESIGN: Cross-sectional study.

Outcomes of Anterior Cruciate Ligament Reconstruction in Obese and Overweight Patients: A Systematic Review.

OBJECTIVE: To evaluate the mechanism of injury, outcomes, and complications of anterior cruciate ligament (ACL) reconstruction in overweight and obese patients. DATA SOURCES: MEDLINE, EMBASE, and OVID electronic libraries were systematically searched from inception to December, 2017 for any eligible articles using a combination of the phrases "anterior cruciate ligament," "ACL," "overweight," "obese," and "BMI." RESULTS: Studies that evaluated patients with primary ACL reconstruction, classified patients as overweight or obese, and reported a minimum of 1-year follow-up data were included. Eight cohorts from 9 studies fulfilled the inclusion criteria. There were no significant differences for mechanism of injury, Lysholm scores, Knee injury and Osteoarthritis Outcome Scores values, or return to sports with a body mass index (BMI) above or below 25 kg/m. A significant difference was described in International Knee Documentation Committee (IKDC) scores when comparing obese patients (BMI >30 kg/m) to patients with BMI <25 kg/m (P <0.01). In patients with BMI >25 kg/m, the risk for arthritis was significantly higher but the risk for revision surgery or contralateral ACL tear was lower (P <0.05). There was no significant difference in complication rates (P = 0.77). CONCLUSION: Patient-reported outcome measures were similar for patients with BMI above and below 25 kg/m, but there is evidence that obese patients have lower IKDC scores. There is a consistent association between overweight status and developing arthritis among patients having an ACL reconstruction. Overweight and obese patients have a lower risk of revision ACL reconstruction and contralateral ACL tear. There is insufficient data to make any conclusions regarding mechanism of injury or complications. More research is needed to better understand what is the appropriate counsel and treatment for overweight or obese patients with ACL tears. PROSPERO REGISTRATION NUMBER: CRD42017055594.

Orthopaedic surgery patients who use recreational marijuana have less pre-operative pain.

AIMS: To determine the baseline clinical characteristics of recreational marijuana users undergoing outpatient orthopaedic surgery. We hypothesized that patients who report marijuana use would have worse pain, function, and general health status. PATIENTS AND METHODS: Nine-hundred and thirty-seven patients undergoing outpatient orthopaedic surgery were asked to fill out patient-reported outcome (PRO) tools. These PROs included the Patient-Reported Outcomes Measurement Information Systems (PROMIS) computer adaptive tests and legacy PROs unique to each patients' surgical site. RESULTS: Forty patients (4.2%) reported marijuana use. Marijuana use was associated with younger age (33 vs. 43 years, p < 0.001), having a history of fewer operations (1.8 vs. 3.2, p < 0.05), single marital status (68 vs. 38%, p < 0.01), and having a history of smoking cigarettes (63 vs. 31%, p < 0.0001). Marijuana use was found to be significantly associated with greater Marx lower extremity activity rating scale scores (8.5 points vs. 6.1 points, p < 0.05) and decreased pain intensity in the operative site (3.7 points vs. 5.0 points, p < 0.05). Multivariable analysis found that marijuana use was an independent factor associated with less pain intensity in the operative site (p < 0.05). CONCLUSION: Our studies support other national studies that report increased marijuana use among younger patients and those who smoke cigarettes. The results do not support our hypothesis, as marijuana use was associated with less pain and better lower extremity activity rating scale scores when compared to non-users. Further research is warranted to analyze the effects of marijuana use on orthopaedic surgery patients. STUDY DESIGN: Cross-sectional study.

Ibuprofen impairs capsulolabral healing in a rat model of anterior glenohumeral instability.

BACKGROUND: Failure of glenoid labrum and capsular healing after glenohumeral dislocation can lead to persistent shoulder instability. The purpose of this study was to determine the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on the healing glenoid labrum and capsule after glenohumeral dislocation in a rat model. METHODS: Sixty-six rats had surgically induced anterior-inferior labral tears and anterior glenohumeral dislocation. Postoperatively, the animals were assigned to either normal (n = 32) or ibuprofen drinking water (n = 31). Animals were euthanized at 2 and 4 weeks postoperatively for biomechanical testing and histologic analysis. RESULTS: The maximum load increased from 2 to 4 weeks after injury in the NSAID groups but not in the control groups. At 2 weeks, the maximum load was lower in the NSAID group compared with the control group. In a matched comparison between injured and uninjured limbs, the maximum load was significantly decreased in the injured limb of the 2-week NSAID group. At 4 weeks, the NSAID group had decreased stiffness compared with the 4-week control group. CONCLUSIONS: In a new rat model of glenohumeral instability, the postinjury administration of ibuprofen resulted in decreased capsulolabral healing. A matched pair analysis of injured to uninjured limbs supported the findings of impaired healing in the NSAID-treated animals. These findings demonstrate that the use of NSAIDs after glenohumeral dislocation may impair capsulolabral healing and should be limited or avoided to optimize glenohumeral stability.

Designing Biomimetic 3D-Printed Osteochondral Scaffolds for Enhanced Load-Bearing Capacity.

Osteoarthritis is a debilitating chronic joint disorder that affects millions of people worldwide. Since palliative and surgical treatments cannot completely regenerate hyaline cartilage within the articulating joint, osteochondral (OC) tissue engineering has been explored to heal OC defects. Utilizing computational simulations and three-dimensional (3D) printing, we aimed to build rationale around fabricating OC scaffolds with enhanced biomechanics. First, computational simulations revealed that interfacial fibrils within a bilayer alter OC scaffold deformation patterns by redirecting load-induced stresses toward the top of the cartilage layer. Principal component analysis revealed that scaffolds with 800 µm long fibrils (scaffolds 8A-8H) possessed optimal biomechanical properties to withstand compression and shear forces. While compression testing indicated that OC scaffolds with 800 µm fibrils did not have greater compressive moduli than other scaffolds, interfacial shear tests indicated that scaffold 8H possessed the greatest shear strength. Lastly, failure analysis demonstrated that yielding or buckling models describe interfacial fibril failure depending on fibril slenderness S. Specifically for scaffolds with packing density n = 6 and n = 8, the yielding failure model fits experimental loads with S < 10, while the buckling model fitted scaffolds with S < 10 slenderness. The research presented provides critical insights into designing 3D printed interfacial scaffolds with refined biomechanics toward improving OC tissue engineering outcomes.

Strategies for the Codelivery of Osteoclasts and Mesenchymal Stem Cells in 3D-Printable Osteochondral Scaffolds.

Osteochondral defects, characterized by structural compromises to articular cartilage and subchondral bone, can cause pain and lead to progressive cartilage damage and eventual osteoarthritis. Unfortunately, repairing these defects remains difficult because of the poor regenerative properties of cartilage and complex mechanical demands of the joint. As such, the field of tissue engineering aims to develop multiphasic implants that replace pathological cartilage and bone tissue and restore mechanical functionality to the joint. Recent bone physiology investigations have demonstrated that osteoclast (OC) lineage cells are inextricably involved in osteoblastic bone formation through an extensive network of anabolic signaling pathways, and so the codelivery OC and osteoblast (OB) lineage cells within scaffolds is being actively explored for bone tissue engineering purposes. However, it remains unclear how these cells can be incorporated into the design of multiphasic osteochondral scaffolds to potentially enhance subchondral bone formation and subsequent implant osseointegration. To explore this question, we examined direct surface seeding and hydrogel encapsulation as potential scaffold cellularization strategies. First, we examined how OC precursor cells and peripheral blood monocytes (PBMCs) influence early-stage bone matrix development and osteogenesis in 2D coculture. Then, we evaluated the osteogenic potential of mesenchymal stem cells (MSCs) and PBMCs cocultures encapsulated within a gelatin methacrylate (GelMA) hydrogel system. Our findings demonstrate that coculturing PBMCs with MSCs in 2D cultures significantly enhanced cell proliferation, early bone matrix deposition, and the formation of cell clusters by Day 28. However, we observed no significant difference in type I collagen deposition between GelMA hydrogel scaffolds cultured in basal and OC conditions during the same period. In addition, we found that the GelMA hydrogel system with MSC/PBMC cocultures in OC conditions exhibited decreased osteogenic activity by Day 28. Collectively, our findings support the osteogenic potential of OC-lineage cells in 2D culture conditions, and the potential benefits of surface-seeding for the codelivery of OC-lineage cells and MSCs in osteo-scaffolds for enhanced osteochondral regeneration and broader bone tissue engineering purposes.

Biomechanical Comparison of Four- versus Six-Strand Transosseous Suture Repair for Patellar Tendon Rupture.

BACKGROUND: Surgical repair is indicated for patellar tendon ruptures that result in loss of knee extensor mechanism function. However, biomechanical studies report conflicting results when comparing transosseous suture versus suture anchor repair techniques. This discrepancy may be due to inconsistencies in experimental design as these studies use various numbers of suture strands. Therefore, the main objective of this study is to compare the ultimate load of four- versus six-strand transosseous suture repair. Secondary objectives are to compare gap formation after cyclical loading and mode of failure. METHODS: Six pairs of fresh-frozen cadaveric specimen were randomly allocated to either four- or six-strand transosseous suture repair. Specimen underwent preconditioning cyclical loading and then load to failure. RESULTS: The six-strand repair had a significantly higher maximum load to failure compared with the four-strand repair (mean difference = 319.3 N [57.9%], p = 0.03). There was no significant difference in gap length after cyclical loading or at max load. There were no significant differences in mode of failure. CONCLUSION: Utilizing a six-stand transosseous patella tendon repair construct with one additional suture increases overall construct strength by over 50% compared with a four-strand construct.

Patient-Reported Outcome Measurement Information System Depression and Anxiety in Elective Knee Surgery Patients.

Mental health has been shown to play an important role in patient-reported outcomes (PRO); however, there is a general lack of literature describing patient-reported outcome measurement information system (PROMIS) depression and anxiety computer adaptive tests in elective knee surgery patients. The purpose of our study was to assess the prevalence of depression and anxiety symptoms before and after elective knee surgery and to determine whether these symptoms influence postoperative functional outcomes. An institutional review board-approved prospective orthopaedic registry was retrospectively queried for patients undergoing elective knee surgery from June 2015 to November 2018. Electronic surveys collecting patient demographic information and PROs were administered pre- and postoperatively. Of the 663 patients that completed baseline questionnaires, 466 completed 2-year follow-up (70.3%). PROs included PROMIS depression, PROMIS anxiety, International Knee Documentation Committee Subjective Knee Form (IKDC), and PROMIS physical function (PF). Wilcoxon rank sum and Spearman's rank order correlation were utilized to determine associations between variables. Multivariable analysis was used to control for confounding variables. Average PROMIS depression and anxiety scores significantly improved 2 years after surgery. PROMIS depression and anxiety scores significantly correlated with each other. PROMIS depression and anxiety scores significantly correlated with PROMIS PF and IKDC scores. After controlling for confounders on multivariable analysis, worse 2-year PROMIS anxiety was predictive of less functional improvement and worse 2-year PF and IKDC, while worse 2-year PROMIS depression was predictive of less improvement in IKDC. This study confirms the important relationship between mental health and functional outcomes. Given that psychiatric comorbidities are potentially modifiable with treatment, proper recognition could potentially lead to better orthopaedic outcomes. In addition, the prevalence of depression and anxiety symptoms postoperatively, as documented by PROMIS computer adaptive tests, may act as a barrier to achieving optimal functional outcomes after elective knee surgery. LEVEL OF EVIDENCE: Level III.

Development of a patient specific cartilage graft using magnetic resonance imaging and 3D printing.

OBJECTIVES: The goal of this project was to develop and validate a patient-specific, anatomically correct graft for cartilage restoration using magnetic resonance imaging (MRI) data and 3-dimensional (3D) printing technology. The specific aim was to test the accuracy of a novel method for 3D printing and implanting individualized, anatomically shaped bio-scaffolds to treat cartilage defects in a human cadaveric model. We hypothesized that an individualized, anatomic 3D-printed scaffold designed from MRI data would provide a more optimal fill for a large cartilage defect compared to a generic flat scaffold. METHODS: Four focal cartilage defects (FCDs) were created in paired human cadaver knees, age <40 years, in the weight-bearing surfaces of the medial femoral condyle (MFC), lateral femoral condyle (LFC), patella, and trochlea of each knee. MRIs were obtained, anatomic grafts were designed and 3D printed for the left knee as an experimental group, and generic flat grafts for the right knee as a control group. Grafts were implanted into corresponding defects and fixed using tissue adhesive. Repeat post-implant MRIs were obtained. Graft step-off was measured as the distance in mm between the surface of the graft and the native cartilage surface in a direction perpendicular to the subchondral bone. Graft contour was measured as the gap between the undersurface of the graft and the subchondral bone in a direction perpendicular to the joint surface. RESULTS: Graft step-off was statistically significantly better for the anatomic grafts compared to the generic grafts in the MFC (0.0 â€‹± â€‹0.2 â€‹mm vs. 0.7 â€‹± â€‹0.5 â€‹mm, p â€‹< â€‹0.001), LFC (0.1 â€‹± â€‹0.3 â€‹mm vs. 1.0 â€‹± â€‹0.2 â€‹mm, p â€‹< â€‹0.001), patella (-0.2 â€‹± â€‹0.3 â€‹mm vs. -1.2 â€‹± â€‹0.4 â€‹mm, p â€‹< â€‹0.001), and trochlea (-0.4 â€‹± â€‹0.3 vs. 0.4 â€‹± â€‹0.7, p â€‹= â€‹0.003). Graft contour was statistically significantly better for the anatomic grafts in the LFC (0.0 â€‹± â€‹0.0 â€‹mm vs. 0.2 â€‹± â€‹0.4 â€‹mm, p â€‹= â€‹0.022) and trochlea (0.0 â€‹± â€‹0.0 â€‹mm vs. 1.4 â€‹± â€‹0.7 â€‹mm, p â€‹< â€‹0.001). The anatomic grafts had an observed maximum step-off of -0.9 â€‹mm and a maximum contour mismatch of 0.8 â€‹mm. CONCLUSION: This study validates a process designed to fabricate anatomically accurate cartilage grafts using MRI and 3D printing technology. Anatomic grafts demonstrated superior fit compared to generic flat grafts. LEVEL OF EVIDENCE: Level IV.

Preoperative opioid use is associated with worse preoperative patient-reported outcomes in hip arthroscopy patients.

OBJECTIVES: The purpose of this study was to define the rate of preoperative opioid use among patients undergoing hip arthroscopy, ascertain which clinical factors are associated with opioid use, and assess the effect of preoperative opioid usage on preoperative patient-reported outcome (PRO) measures. METHODS: A single institution orthopedic registry was retrospectively analyzed for patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) syndrome with or without labral tear between 2015 and 2022. Patients completed Patient-Reported Outcomes Measurement Information System (PROMIS) in six domains, Numeric Pain Scores (NPS), and Musculoskeletal Outcomes Data Evaluation and Management System expectations domain preoperatively. Patients' charts were reviewed to determine demographic factors and identify any active opioid prescription within 6 weeks before surgery. Bivariate analysis was used to determine associations between preoperative opioid use and baseline PROs. Statistically significant bivariate associations were further tested by multivariate analysis to determine independent predictors. RESULTS: A total of 123 patients were included (age 39.7 â€‹± â€‹12.0 years; 87 females; body mass index 27.4 â€‹± â€‹5.7 kg/m2). There were 21 patients (17%) using opioids preoperatively. Prior orthopedic or other surgery and lower education level were associated with preoperative opioid use. Patients with preoperative opioid use scored statistically significantly worse compared with those without preoperative opioid use on baseline PROMIS Physical Function (38.6 vs 40.5, p â€‹= â€‹0.01), Pain Interference (65.9 vs 60.2, p â€‹= â€‹0.001), Fatigue (60.7 vs 51.6, p â€‹= â€‹0.005), Social Satisfaction (38.2 vs 43.2, p â€‹= â€‹0.007), and Depression (54.2 vs 48.8, p â€‹= â€‹0.01). Preoperative opioid use was also associated with statistically significantly worse preoperative NPS for both the operative hip (6.3 vs 4.6, p â€‹= â€‹0.003) and whole body (3.0 vs 1.4, p â€‹= â€‹0.008). Preoperative opioid use was an independent predictor of worse baseline PROMIS Pain Interference, Fatigue, Social Satisfaction, and NPS for the operative hip. CONCLUSION: Patients using opioids preoperatively had worse baseline PROs for physical function, pain, social satisfaction, and depression than those not using opioids preoperatively. When controlling for confounding variables, preoperative opioid use was independently predictive of worse baseline pain, fatigue, and social satisfaction. LEVEL OF EVIDENCE: Level III, prognostic study.

Shoulder and elbow arthroplasty in younger patients.

Joint arthroplasty is common in elderly patients with arthritis. The success of joint arthroplasty in the elderly population has increased the indications for joint arthroplasty in younger patients. The success and increased indications are due to advances in technology and joint arthroplasty design and materials, as well as to bone-conserving approaches that are more applicable to younger patients. Although most joint arthroplasty procedures are for the hip and knee, the upper extremity (shoulder and elbow) is the fastest-growing segment of joint arthroplasty procedures. This article presents innovative approaches to shoulder and elbow arthroplasty that are designed to treat younger patients with arthritis of the shoulder and elbow.

PROMIS cluster analysis predicts two-year outcomes in knee surgery patients.

Aims & objectives: Meaningful clinical interpretation of orthopaedic patient-reported outcome scores remains challenging. Grouping scores may be more meaningful than individual score analysis. The purpose of this study was to determine if grouping knee surgery patients into four preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) clusters would have prognostic value for two-year postoperative outcomes. Materials & methods: 488 of 697 (70%) patients undergoing elective knee surgery at a single urban institution were enrolled in an orthopaedic registry and completed two-year follow up. Patients were administered questionnaires for PROMIS, International Knee Documentation Committee Score (IKDC), Marx Activity Rating Scale (MARS), and Surgical Satisfaction (SSQ-8). A k-means cluster analysis was performed to identify preoperative PROMIS clusters. Chi-square or Kruskal-Wallis tests were conducted for bivariate analyses. Least-squares multiple linear regression models were performed to identify if cluster group was an independent predictor. Results: Cluster analysis revealed four clusters of patients. Psychological distress was most significant in determining classification. More impaired clusters were associated with higher rates of arthroplasty, African American race, preoperative opioid use, lower income, higher comorbidity index, and other sociodemographic and operative factors. Worse preoperative cluster status was associated with higher chance of achieving minimally clinically important change (MCID) on all metrics except PROMIS Pain Interference (PI), IKDC, and MARS. Multivariable analysis confirmed better preoperative cluster as predictive of better PROMIS Physical Function (PF), PI, IKDC scores, and satisfaction. Worse preoperative cluster was predictive of greater improvement on PF and PI but not IKDC. Conclusion: Preoperative PROMIS clusters have prognostic value in predicting outcomes for knee surgery patients. Better preoperative cluster function predicts superior outcomes. While worse preoperative cluster predicts worse outcome, all clusters still significantly improve, so worse preoperative cluster is not a contraindication to surgery.

Preoperative Factors Associated with Press Ganey Patient Satisfaction Scores after Anterior Cruciate Ligament Reconstruction.

Patient satisfaction is increasingly used as a metric to evaluate the quality of healthcare services and to determine hospital and physician compensation. The aim of this study was to identify preoperative factors associated with Press Ganey Ambulatory Surgery (PGAS) satisfaction scores, and to evaluate the effect of each PGAS domain score on the total PGAS score variability in patients undergoing anterior cruciate ligament reconstruction (ACLR). A review of a Press Ganey (PG) database at a single center was performed for patients undergoing ACLR between 2015 and 2019. Ninety-nine patients completed the PGAS survey and 54 also completed preoperative demographic and patient-reported outcome measures (PROMs) for an orthopaedic registry. PGAS scores were calculated and bivariate analysis was performed. Multivariable linear regression determined the effect of each of the six PGAS domains on the total PGAS score variability. In the total cohort of 99 patients, no factors were significantly associated with the total PGAS score or any domain scores. For the 54 patients who also participated in the orthopaedic registry, none of the preoperative PROMs were significantly correlated with total PGAS score. However, having a college degree (89 vs. 95 or 97 points; p = 0.02) and continuous femoral nerve catheter (92 vs. 100 points; p = 0.04) was associated with lower personal issue domain scores, while patients with a greater number of prior surgeries had worse registration domain scores (ρ = -0.27; p = 0.049). For the entire cohort, the registration and facility domains contributed the most variability to the total PGAS score, while the physician domain contributed the least. Few preoperative factors are associated with PGAS scores, and total PGAS scores do not significantly correlate with baseline PROMs. Surgeons may have limited ability to improve their PGAS scores given most of the variability in total scores stems from systemic aspects of the patient experience.

Perioperative Opioid Use in Anterior Cruciate Ligament Reconstruction Patients.

Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed outpatient orthopaedic procedures, yet there is little data about perioperative opioid prescribing practices. The purposes of this study were to quantify the perioperative opioid prescriptions filled by patients who underwent ACLR and to identify factors associated with greater postoperative opioid use. Patients who underwent ACLR at a single institution between June 2015 and May 2017 were studied using a regional prescription monitoring database to identify all preoperative and postoperative outpatient opioid prescriptions up to 2 years postoperatively. The number of morphine milligram equivalents of each opioid was calculated to determine total morphine milligram equivalents (TMEs) filled preoperatively, at discharge, and refilled postoperatively. Patients who refilled an opioid prescription postoperatively were compared with those who did not. Ninety-nine of 269 (36.8%) total patients refilled an opioid prescription postoperatively. Thirty-three patients (12.3%) required a refill after 2 weeks postoperatively, and no patients refilled after 21 months postoperatively. Fifty-seven patients (21%) received an opioid prescription in the 2 years following surgery that was unrelated to their ACL reconstruction. Increased age, higher body mass index (BMI), government insurance, current or prior tobacco use history, preoperative opioid use, and greater number of medical comorbidities were significantly associated with refilling a prescription opioid. Higher BMI and government insurance were independent predictors of refilling. Higher preoperative TMEs and surgeon were independent predictor of greater refill TMEs. In the opioid-naïve subgroup of 177 patients, only higher BMI was a predictor of refilling, and only greater comorbidities was a predictor of greater refill TMEs. The results demonstrate that preoperative opioid use was associated with postoperative opioid refills and higher refill TMEs in a dose-dependent fashion. A higher percentage of patients received an opioid prescription for reasons unrelated to the ACL reconstruction than refilled a prescription after the first 2 weeks postoperatively.

Response Bias for Press Ganey Ambulatory Surgery Surveys after Knee Surgery.

The Press Ganey Ambulatory Surgery (PGAS) survey is an emerging tool used to capture patient satisfaction after elective surgery. Evaluating patient satisfaction is important; however, quality improvement (QI) surveys used to capture the patient experience may be subject to nonresponse bias. An orthopaedic registry was used to retrospectively identify patients who underwent ambulatory knee surgery from June 2015 to December 2019. Multivariable logistic regression was performed to identify independent predictors of PGAS survey nonresponse and response. In the cohort of 1,161 patients, 142 (12.2%) completed the PGAS survey. Multiple logistic regression demonstrated that male sex, Black race, not living with a caretaker, student or unemployment status, and worse preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) fatigue were predictors of nonresponse. The results of this study highlight the presence of nonresponse bias in the PGAS survey after elective knee surgery.

Early LQT2 nonsense mutation generates N-terminally truncated hERG channels with altered gating properties by the reinitiation of translation.

Mutations in the human ether-a-go-go-related gene (hERG) result in long QT syndrome type 2 (LQT2). The hERG gene encodes a K(+) channel that contributes to the repolarization of the cardiac action potential. We have previously shown that hERG mRNA transcripts that contain premature termination codon mutations are rapidly degraded by nonsense-mediated mRNA decay (NMD). In this study, we identified a LQT2 nonsense mutation, Q81X, which escapes degradation by the reinitiation of translation and generates N-terminally truncated channels. RNA analysis of hERG minigenes revealed equivalent levels of wild-type and Q81X mRNA while the mRNA expressed from minigenes containing the LQT2 frameshift mutation, P141fs+2X, was significantly reduced by NMD. Western blot analysis revealed that Q81X minigenes expressed truncated channels. Q81X channels exhibited decreased tail current levels and increased deactivation kinetics compared to wild-type channels. These results are consistent with the disruption of the N-terminus, which is known to regulate hERG deactivation. Site-specific mutagenesis studies showed that translation of the Q81X transcript is reinitiated at Met124 following premature termination. Q81X co-assembled with hERG to form heteromeric channels that exhibited increased deactivation rates compared to wild-type channels. Mutant channels also generated less outward current and transferred less charge at late phases of repolarization during ventricular action potential clamp. These results provide new mechanistic insight into the prolongation of the QT interval in LQT2 patients. Our findings indicate that the reinitiation of translation may be an important pathogenic mechanism in patients with nonsense and frameshift LQT2 mutations near the 5' end of the hERG gene.

Biomechanical Aspects of Osteochondral Regeneration: Implications and Strategies for Three-Dimensional Bioprinting.

Osteoarthritis is among the most prevalent of musculoskeletal disorders in the world that causes joint pain, deformity, and limited range of movement. The resulting osteochondral defect can significantly decrease the patient's quality of life, but current treatment options have not demonstrated the capacity to fully regenerate the entire osteochondral microenvironment. Structurally, the osteochondral unit is a composite system composed of three layers-articular cartilage, calcified cartilage, and subchondral bone. Collectively these distinct layers contribute to the distinct biomechanical properties that maintain the health and aid in load transfer during joint articulation. The purpose of this review was to examine the role of the osteochondral interface in tissue engineering. Topics of discussion include the biomechanics of the osteochondral unit and an overview of various strategies for osteochondral interface tissue engineering, with a specific focus on three-dimensional bioprinting. The goal of this review was to elucidate the importance of the osteochondral interface and overview some strategies of developing an interface layer within tissue engineered scaffolds. Impact Statement This review provides an overview of interface tissue engineering for osteochondral regeneration. It offers a detailed investigation into the biomechanics of the osteochondral unit as it relates to tissue engineering, and highlights the strategies that have been utilized to develop the osteochondral interface within tissue engineering scaffolds.

Computational investigation of interface printing patterns within 3D printed multilayered scaffolds for osteochondral tissue engineering.

Osteoarthritis is a highly prevalent rheumatic musculoskeletal disorder that commonly affects many joints. Repetitive joint overloading perpetuates the damage to the affected cartilage, which undermines the structural integrity of the osteochondral unit. Various tissue engineering strategies have been employed to design multiphasic osteochondral scaffolds that recapitulate layer-specific biomechanical properties, but the inability to fully satisfy mechanical demands within the joint has limited their success. Through computational modeling and extrusion-based bioprinting, we attempted to fabricate a biphasic osteochondral scaffold with improved shear properties and a mechanically strong interface. A 3D stationary solid mechanics model was developed to simulate the effect of lateral shear force on various thermoplastic polymer/hydrogel scaffolds with a patterned interface. Additionally, interfacial shear tests were performed on bioprinted polycaprolactone (PCL)/hydrogel interface scaffolds. The first simulation showed that the PCL/gelatin methacrylate (GelMA) and PCL/polyethylene glycol diacrylate (PEGDA) scaffolds interlocking hydrogel and PCL at interface in a 1:1 ratio possessed the largest average tensile (PCL/GelMA: 80.52 kPa; PCL/PEGDA: 79.75 kPa) and compressive stress (PCL/GelMA: 74.71 kPa; PCL/PEGDA: 73.83 kPa). Although there were significant differences in shear strength between PCL/GelMA and PCL/PEGDA scaffolds, no significant difference was observed among the treatment groups within both scaffold types. Lastly, the hypothetical simulations of potential biphasic 3D printed scaffolds showed that for every order of magnitude decrease in Young's modulus (E) of the soft bioink, all the scaffolds underwent an exponential increase in average displacement at the cartilage and interface layers. The following work provides valuable insights into the biomechanics of 3D printed osteochondral scaffolds, which will help inform future scaffold designs for enhanced regenerative outcomes.

Impact of Postoperative Opioid Use on 2-Year Patient-Reported Outcomes in Knee Surgery Patients.

The purposes of this study were to identify the patient characteristics associated with refilling a postoperative opioid prescription after knee surgery and to determine whether refilling opioids is associated with 2-year patient-reported outcomes. We hypothesized that postoperative refill of opioids would be associated with worse 2-year patient-reported outcomes. We studied 192 patients undergoing knee surgery at a single urban academic institution. Patients completed multiple patient-reported outcome measures preoperatively and 2 years postoperatively, including six Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the International Knee Documentation Committee (IKDC) questionnaire, numeric pain scale scores for the operative knee and the rest of the body, Marx Activity Rating Scale, as well as measures of met expectations, improvement, and satisfaction. Total morphine equivalents (TMEs) were calculated from a regional prescription monitoring program. Patients who refilled a postoperative opioid prescription were compared with those who did not, and TMEs were calculated for those who refilled (Refill TMEs). One hundred twenty-nine patients (67%) refilled at least one postoperative opioid prescription. Black race, older age, higher average body mass index (BMI), smoking, greater medical comorbidities, preoperative opioid use, lower income, government insurance, and knee arthroplasty were associated with refilling opioids. Greater Refill TMEs was associated with black or white race, older age, higher average BMI, smoking, greater medical comorbidities, preoperative opioid use, government insurance, and unemployment. Refilling opioids and greater Refill TMEs were associated with worse postoperative scores on most patient-reported outcome measures 2 years after knee surgery. However, refilling opioids and greater Refill TMEs did not have a significant association with improvement after surgery. Multivariable analysis controlling for potential confounding variables confirmed that greater postoperative Refill TMEs independently predicted worse 2-year PROMIS Physical Function, 2-year PROMIS Pain Interference, and 2-year IKDC knee function scores. Postoperative refill of opioids was associated with worse 2-year patient-reported outcomes in a dose-dependent fashion. These findings reinforce the importance of counseling patients regarding opioid use and optimizing opioid-sparing pain management postoperatively.