Prior Patellectomy: A Systematic Review and Meta-Analysis Comparing Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty Survivorship and Reported Outcomes.

BACKGROUND: In the setting of total knee arthroplasty (TKA), prior patellectomy historically prompted the use of increased constraint implants, specifically posterior-stabilized (PS) designs. However, modern case series have reported similar outcomes utilizing cruciate-retaining (CR) implants. The primary outcome of this study was to compare implant retention rates between these 2 implant designs in prior patellectomy patients. Secondary outcomes included a comparison of patient-reported outcome scores and cause for revision. METHODS: A comprehensive systematic review was performed using Web of Science, PubMed, and Scopus databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Boolean operator search terms included "patellectomy AND (arthroplasty) OR (replacement)." Case reports, review articles, < 2 years of follow-up, and studies in which the implant design could not be ascertained were excluded. An initial screening of titles and abstracts for inclusion was performed, followed by a full manuscript review of eligible articles. Single-data extraction was performed, followed by subsequent statistical analysis. RESULTS: A total of 9 studies (209 knees) met the inclusion criteria. The average time from patellectomy to TKA was 16.1 years. While all patients had significant improvement in functional outcomes, CR implants displayed proportionally greater improvement in Knee Society Scores compared to PS implants (+108 versus +98%, P ≤ .001). However, there was a significantly greater rate of revision in the CR cohort compared to PS (18.6 versus 2.6%, P = .002). CONCLUSIONS: Prior patellectomy patients undergoing TKA have significant improvements in patient-reported functional outcomes and high midterm retention rates. While CR implant designs portend a potentially greater improvement in functional outcomes, they also have a greater risk for revision than their PS implant counterparts. However, contemporary implant designs and operative techniques likely render revision rates equivocal between CR and PS implants in postpatellectomy patients.

Inflammation and DKK1-induced AKT activation contribute to endothelial dysfunction following NR2F2 loss.

NR2F2 is expressed in endothelial cells (ECs) and Nr2f2 knockout produces lethal cardiovascular defects. In humans, reduced NR2F2 expression is associated with cardiovascular diseases including congenital heart disease and atherosclerosis. Here, NR2F2 silencing in human primary ECs led to inflammation, endothelial-to-mesenchymal transition (EndMT), proliferation, hypermigration, apoptosis-resistance, and increased production of reactive oxygen species. These changes were associated with STAT and AKT activation along with increased production of DKK1. Co-silencing DKK1 and NR2F2 prevented NR2F2-loss-induced STAT and AKT activation and reversed EndMT. Serum DKK1 concentrations were elevated in patients with pulmonary arterial hypertension (PAH) and DKK1 was secreted by ECs in response to in vitro loss of either BMPR2 or CAV1, which are genetic defects associated with the development of PAH. In human primary ECs, NR2F2 suppressed DKK1, whereas its loss conversely induced DKK1 and disrupted endothelial homeostasis, promoting phenotypic abnormalities associated with pathologic vascular remodeling. Activating NR2F2 or blocking DKK1 may be useful therapeutic targets for treating chronic vascular diseases associated with EC dysfunction.NEW & NOTEWORTHY NR2F2 loss in the endothelial lining of blood vessels is associated with cardiovascular disease. Here, NR2F2-silenced human endothelial cells were inflammatory, proliferative, hypermigratory, and apoptosis-resistant with increased oxidant stress and endothelial-to-mesenchymal transition. DKK1 was induced in NR2F2-silenced endothelial cells, while co-silencing NR2F2 and DKK1 prevented NR2F2-loss-associated abnormalities in endothelial signaling and phenotype. Activating NR2F2 or blocking DKK1 may be useful therapeutic targets for treating vascular diseases associated with endothelial dysfunction.

Orthopaedic Injuries from All-Terrain Vehicles: An Epidemiological Account and Review of Legislation.

All-terrain vehicles (ATVs) are an ongoing source of orthopaedic trauma in the United States. The National Electronic Injury Surveillance System (NEISS) database was queried for ATV-related extremity trauma from 2010 to 2019. An estimated 31,979 ATV-related injuries present to emergency departments annually without significant variability between years. Patients were predominantly white (63.5%), male (72.2%), and aged 18 - 44 (49.9%). Injury sites frequently included the shoulder (24%), wrist (12.8%), and ankle (11.2%). Fractures were most common followed by strains and sprains. Only 15.5% of injuries occurred on public land. Alcohol use was rarely implicated. Orthopaedic surgeons should be aware that rates of ATV-related musculoskeletal injuries have not changed significantly over the last ten years despite legislative efforts to improve ATV safety. Additionally, safety laws are inconsistent across the US, and many apply to the use of ATVs on public land when a minority of injuries occur on non-public land. (Journal of Surgical Orthopaedic Advances 32(4):225-231, 2023).

The Epidemiology of Hand and Finger Lacerations in United States Emergency Departments.

BACKGROUND: Hand and finger lacerations presenting to U.S. emergency departments (EDs) are common, although the burden of these injuries is not well understood. OBJECTIVE: Our aim is to describe the epidemiology and causes of hand and finger lacerations in U.S. EDs. METHODS: This National Electronic Injury Surveillance System database review investigates hand and finger lacerations presenting to EDs in the United States from 2015 to 2019. RESULTS: Annually, hand and finger lacerations account for 243,844 and 587,451 ED visits, respectively. Affected patients are frequently White (70.5%), male (63.4%), and aged 18 through 44 years (46.3%). The top three products linked to hand and finger lacerations are knives (30.5%), metal containers (4.2%), and drinkware (3.8%), and men are less likely to have injuries from these products than women, especially knives (odds ratio 0.76; 95% confidence interval 0.60-0.96; p < 0.02). Although a minority of hand and finger lacerations involve alcohol (1.2%), men have greater rates of alcohol involvement than women (χ21 = 11.7; p < 0.001). Lacerations frequently occur in the home (61.3%). Many patients (44.2%) present to very large hospitals, and nearly one-half of patients younger than 5 years and one-third of patients aged 5 through 17 years present to pediatric hospitals. Most patients (97.4%) are treated and released without admission and 0.2% are transferred to another hospital. Patients with alcohol, drug, or medication involvement are more likely to leave against medical advice, be admitted, or held for observation (p < 0.001). CONCLUSIONS: Hand and finger lacerations result in a significant number of ED visits. A better understanding of injury trends and presentations can guide injury prevention in manufacturing, education, and public health.

The transition to outpatient shoulder arthroplasty: a systematic review.

BACKGROUND AND HYPOTHESIS: Transitioning shoulder arthroplasty (SA) from an inpatient to outpatient procedure is associated with increased patient satisfaction and potentially decreased costs; however, concerns exist about complications following same-day discharge. We hypothesized that outpatient SA would be associated with low rates of failed discharges, readmissions, and complications, rendering it a safe and effective option for SA. METHODS: A systematic review of the outpatient SA literature identified 16 of 447 studies with level III and IV evidence that met the inclusion criteria with at least 90 days of follow-up. Data on patient demographic characteristics, preoperative and postoperative protocols, surgery characteristics, failed discharges, complications, and readmissions were collected and pooled for analysis. RESULTS: A total of 990 patients were included in our analysis. Many studies identified specific institutional protocols for determining eligibility for outpatient SA, including preoperative clearance from an anesthesiologist; identification of a perioperative caretaker; and exclusion of patients based on cardiac, pulmonary, or hematologic risk factors. Failed same-day discharge occurred in only 0.9% of patients (7 of 788), and 2.1% of patients (9 of 418) and 0.79% of patients (2 of 252) presented to an emergency department or urgent care facility for a perioperative concern. The readmission rate for periprosthetic fracture, arthrofibrosis, infection, subscapularis rupture, and anterior subluxation was 1.3% (7 of 529 patients). Complications occurred in 7.0% of patients (70 of 990), with 5.4% of patients (53 of 990) experiencing a surgical complication and 1.7% (17 of 990) having a medical complication. There were 28 total reoperations (2.9%, 28 of 955 patients). DISCUSSION AND CONCLUSION: Outpatient SA is associated with low rates of failed discharges, readmissions, and complications. Additionally, the medical and surgical complications that occur after outpatient SA are unlikely to be prevented by the short inpatient stay characteristic of traditional SA. With careful screening measures to identify appropriate candidates for same-day discharge, outpatient SA represents a safe approach to prevent unnecessary hospitalizations and to decrease costs associated with SA.

Resident Selection: An Orthopaedic Program Director Survey.

As the competitiveness of orthopaedic surgery residency increases, we sought to determine whether program and Program Director (PD) characteristics influence candidate selection. This novel 19-question survey reviews PDs' opinions and practices in resident selection. Response rate was 31% (63/203). Performance during orthopaedic rotations, United States Medical Licensing Examination (USMLE) scores, and clerkship honors were the top three ranked criteria, with USMLE scores used to screen candidates for interviews (70%) and rotations (43%). PDs practicing < 10 years felt USMLE scores reflect resident quality, while those practicing >10 years felt they reflect ability to pass the American Board of Orthopaedic Surgery exam. Most (81%) accept applicants with low scores. PDs > 66 years old emphasized academic honors and Dean's letters, PDs 46-55 emphasized conscientiousness, and PDs practicing >21 years emphasized dexterity. PD demographics such as age, time in practice, and geographic location affect how they approach candidate selection. (Journal of Surgical Orthopaedic Advances 31(1):042-047, 2022).

Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations.

BACKGROUND: The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration. OBJECTIVE: This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations. METHODS/DESIGN: We conducted a retrospective review of video recordings of pediatric patients who required critical care ("resuscitation") in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained. RESULTS: Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50 seconds [IQR 30,74] and 108 seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR. CONCLUSION: Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.

Process conformance is associated with successful first intubation attempt and lower odds of adverse events in a paediatric emergency setting.

BACKGROUND: Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes. METHODS: An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence. RESULTS: We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99). CONCLUSIONS: Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.

Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children.

BACKGROUND: Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes. METHODS: A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests. RESULTS: One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75). CONCLUSIONS: Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery. LEVEL OF EVIDENCE: III STUDY TYPE: Case series.

Subacromial Balloon Placement Demonstrates No Advantage Over Debridement in the Treatment of Massive Irreparable Rotator Cuff Tears: A Dual-Armed Systematic Review and Meta-analysis of Over 1000 Patients.

BACKGROUND: In recent years, the placement of a subacromial balloon (SAB) spacer has emerged as a treatment option for massive irreparable rotator cuff tears (MIRCTs); however, there is significant controversy regarding its utility in comparison with other surgical interventions. PURPOSE: To compare outcomes after SAB spacer placement versus arthroscopic debridement for MIRCTs. STUDY DESIGN: Dual-armed systematic review and meta-analysis (level IV evidence). METHODS: A literature search of PubMed (MEDLINE), Scopus, and CINAHL Complete databases for articles published before May 7, 2022, was conducted to identify patients with MIRCTs undergoing the 2 procedures. For the SAB arm, 14 of 449 studies were considered eligible for inclusion, while 14 of 272 studies were considered eligible for inclusion in the debridement arm. RESULTS: In total, 528 patients were eligible for inclusion in the SAB arm and 479 patients in the debridement arm, and 69.9% of patients undergoing SAB placement also underwent concomitant debridement. Decreases in the visual analog scale (VAS) pain score and increases in the Constant score were found to be significantly larger after debridement (-0.7 points [P < .001] and +5.5 points [P < .001], respectively), although the Patient Acceptable Symptom State for the VAS was not achieved after either procedure. Both SAB placement and debridement significantly improved range of motion in forward flexion/forward elevation, internal and external rotation, and abduction (P < .001). Rates of general complication were higher after debridement versus SAB placement (5.2% ± 5.6% vs 3.5% ± 6.3%, respectively; P < .001); however, there were no significant differences between SAB placement and debridement in rates of persistent symptoms requiring a reintervention (3.3% ± 6.2% vs 3.8% ± 7.3%, respectively; P = .252) or reoperation rates (5.1% ± 7.6% vs 4.8% ± 8.4%, respectively; P = .552). The mean time to conversion to reverse total shoulder arthroplasty was 11.0 versus 25.4 months, respectively, for the SAB versus debridement arm. CONCLUSION: While SAB placement was associated with acceptable postoperative outcomes in the treatment of MIRCTs, there was no clear benefit over debridement alone. Shorter operative times coupled with better postoperative outcomes and longer times to conversion to reverse total shoulder arthroplasty rendered debridement a more attractive option. While there may be a role for SAB placement in poor surgical candidates, there is burgeoning evidence to support debridement alone without SAB placement for the treatment of MIRCTs.

Establishing the Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptomatic State After Arthroscopic Posterior Labral Repair for Posterior Glenohumeral Instability.

BACKGROUND: Posterior glenohumeral instability is an increasingly recognized cause of shoulder pain and dysfunction among young, active populations. Outcomes after posterior stabilization procedures are commonly assessed using patient-reported outcome measures including the Single Assessment Numeric Evaluation (SANE), the Rowe instability score, the American Shoulder and Elbow Surgeons (ASES) score, and the visual analog scale (VAS) for pain. The clinical significance thresholds for these measures after arthroscopic posterior labral repair (aPLR), however, remain undefined. PURPOSE: We aimed to define the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for the SANE, Rowe score, and ASES score as well as the VAS pain after aPLR. Additionally, we sought to determine preoperative factors predictive of reaching, as well as failing to reach, clinical significance. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study was a retrospective analysis of patient-reported outcome scores collected from patients who underwent aPLR between January 2011 and December 2018. To determine the clinically significant threshold that corresponded to achieving a meaningful outcome, the MCID, SCB, and PASS were calculated for the SANE, Rowe score, ASES score, and VAS pain utilizing either an anchor- or distribution-based method. Additionally, univariate and multivariate logistic regression analyses were performed to determine the factors associated with achieving, or not achieving, the MCID, SCB, and PASS. RESULTS: A total of 73 patients with a mean follow-up of 82.55 ± 24.20 months were available for final analysis. MCID, SCB, and PASS values for the VAS pain were 1.10, 6, and 3, respectively; for the ASES score were 7.8, 34, and 80, respectively; for the SANE were 10.15, 33, and 85, respectively; and for the Rowe score were 11.3, 60, and 90, respectively. To meet the MCID, male sex (odds ratio [OR], 1.1639; P = .0293) was found to be a positive predictor for the VAS pain, and a lower preoperative SANE score (OR, 0.9939; P = .0003) was found to be a negative predictor for the SANE. Dominant arm involvement was associated with lower odds of achieving the PASS for the ASES score (OR, 0.7834; P = .0259) and VAS pain (OR, 0.7887; P = .0436). Patients who reported a history of shoulder trauma were more likely to reach the PASS for the SANE (OR, 1.3501; P = .0089), Rowe score (OR, 1.3938; P = .0052), and VAS pain (OR, 1.3507; P = .0104) as well as the SCB for the ASES score (OR, 1.2642; P = .0469) and SANE (OR, 1.2554; P = .0444). A higher preoperative VAS pain score was associated with higher odds of achieving the SCB for both the VAS pain (OR, 1.1653; P = .0110) and Rowe score (OR, 1.1282; P = .0175). Lastly, concomitant biceps tenodesis was associated with greater odds of achieving the SCB for the ASES score (OR, 1.3490; P = .0130) and reaching the PASS for the SANE (OR, 1.3825; P = .0038) and Rowe score (OR, 1.4040; P = .0035). CONCLUSION: To our knowledge, this study is the first to define the MCID, SCB, and PASS for the ASES score, Rowe score, SANE, and VAS pain in patients undergoing aPLR. Furthermore, we found that patients who reported a history of shoulder trauma and those who underwent concomitant biceps tenodesis demonstrated a greater likelihood of achieving clinical significance. Dominant arm involvement was associated with lower odds of achieving clinical significance.

The Influence of Obesity on Outcomes Following Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-Analysis of 118,331 Patients Internationally.

Background: Given the rising prevalence of obesity, the number of patients with obesity undergoing arthroscopic rotator cuff repair (RCR) will likely increase; however, there have been mixed results in the existing literature with regard to the effect of elevated body mass index (BMI) on functional outcomes and complications. Methods: The patient-reported outcome measures included the visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, range of motion, and adverse events. Results: Fourteen studies (118,331 patients) were included. There were significant decreases in VAS pain scores for both patients with obesity (mean difference, -3.8 [95% confidence interval (CI), -3.9 to -3.7]; p < 0.001) and patients without obesity (mean difference, -3.2 [95% CI, -3.3 to -3.1]; p < 0.001). There were also significant increases in ASES scores for both patients with obesity (mean difference, 24.3 [95% CI, 22.5 to 26.1]; p < 0.001) and patients without obesity (mean difference, 24.3 [95% CI, 21.4 to 26.0]; p < 0.001). There were also significant increases in ASES scores for both patients with obesity (mean difference, 24.3 [95% CI, 22.5 to 26.1]; p < 0.001) and patients without obesity (mean difference, 24.3 [95% CI, 21.4 to 26.0]; p < 0.001). However, there were no significant differences in final VAS pain scores, ASES scores, or range of motion between the groups. The mean rates of complications were higher among patients with obesity (1.2% ± 1.7%) than among patients without obesity (0.59% ± 0.11%) (p < 0.0001), and the mean rates of postoperative admissions were also higher among patients with obesity (5.9%) than patients without obesity (3.7%) (p < 0.0001). Although the mean rates of reoperation were similar between groups (5.2% ± 2.8% compared with 5.2% ± 4.2%), the meta-analysis revealed lower odds of reoperation in patients without obesity (odds ratio [OR], 0.76 [95% CI, 0.71 to 0.82]). Conclusions: No significant or clinically important differences in postoperative pain, ASES scores, or range of motion were found between patients with and without obesity following arthroscopic RCR. However, populations with obesity had higher rates of complications, postoperative admissions, and reoperation following arthroscopic RCR. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Concomitant Glenohumeral Stabilization After Arthroscopic Rotator Cuff Repair in Military Patients Younger Than 40 Years.

Background: While concomitant rotator cuff and inferior labral tears are relatively uncommon in young civilians, military populations represent a unique opportunity to study this injury pattern. Purpose: To (1) evaluate the long-term outcomes after combined arthroscopic rotator cuff and inferior labral repair in military patients <40 years and (2) compare functional outcomes with those after isolated arthroscopic rotator cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: Military patients who underwent arthroscopic rotator cuff repair between January 2011 and December 2016 and had a minimum of 5-year follow-up data were included in this study. The patients were categorized into those who had undergone combined arthroscopic rotator cuff and inferior labral repair (RCIL cohort) and those who had isolated arthroscopic rotator cuff repair (ARCR cohort). Pre- and postoperative outcome measures-visual analog scale for pain, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons shoulder score, Rowe Instability Score, and range of motion-were compared between the groups. Results: A total of 50 shoulders (27 in the RCIL cohort and 23 in the ARCR cohort) were assessed. The RCIL and ARCR groups were similar in terms of age (mean, 33.19 years [range, 21-39 years] vs 35.39 years [range, 26-39 years], respectively) and sex (% male, 88.46% vs 82.61%, respectively). All patients were active-duty military at the time of surgery. The mean final follow-up was at 106.93 ± 16.66 months for the RCIL group and 105.70 ± 7.52 months for the ARCR group (P = .75). There were no differences in preoperative outcome scores between groups. Postoperatively, both groups experienced statistically significant improvements in all outcome scores (P < .0001 for all), and there were no significant group differences in any final postoperative outcome measures. At the final follow-up, 26 (96.30%) patients in the RCIL cohort and 20 (86.96%) in the ARCR cohort had returned to unrestricted active-duty military service (P = .3223). Conclusion: The study findings indicate that concomitant glenohumeral stabilization does not prevent worse outcomes after arthroscopic rotator cuff repair in this military cohort. Combined repair produced statistically and clinically significant improvements in outcome scores at the long-term follow-up, indicating that simultaneous repair of combined lesions was an appropriate treatment option in this patient population.

Epidemiologic investigation of pediatric distal humerus fractures: An American insurance claims database study.

BACKGROUND: Distal humerus elbow fractures are one of the most common traumatic fractures seen in pediatric patients and present as three main types: Supracondylar (SC), lateral condyle (LC), and medial epicondyle (ME) fractures. AIM: To evaluate the epidemiology of pediatric distal humerus fractures (SC, LC, and ME) from an American insurance claims database. METHODS: A retrospective review was performed on patients 17 years and younger with the ICD 9 and 10 codes for SC, LC and ME fractures based on the IBM Truven MarketScan® Commercial and IBM Truven MarketScan Medicare Supplemental databases. Patients from 2015 to 2020 were queried for treatments, patient age, sex, length of hospitalization, and comorbidities. RESULTS: A total of 1133 SC, 154 LC, and 124 ME fractures were identified. SC fractures had the highest percentage of operation at 83%, followed by LC (78%) and ME fractures (41%). Male patients were, on average, older than female patients for both SC and ME fractures. CONCLUSION: In the insurance claims databases used, SC fractures were the most reported, followed by LC fractures, and finally ME fractures. Age was identified to be a factor for how a pediatric distal humerus fractures, with patients with SC and LC fractures being younger than those with ME fractures. The peak age per injury per sex was similar to reported historic central tendencies, despite reported trends for younger physiologic development.

Acute Simple Elbow Dislocations in the United States: An Epidemiological Analysis of Trends Including COVID-19.

Background Elbows are one of the most frequently dislocated large joints; however, there is limited epidemiological data, especially during the coronavirus disease 2019 (COVID-19) pandemic. This study characterizes elbow dislocations presenting to Emergency Departments (EDs) over the last decade. Methods This study is a cross-sectional, descriptive, epidemiologic analysis of isolated elbow dislocations presenting to EDs from 2011-2020 using the National Electronic Injury Surveillance System (NEISS) database. Patients under 10, those with radial head subluxation, and those with complex fractures were excluded. Data on incidence ratios, patient demographics, mechanisms of injury, and incident locales were analyzed. Results Approximately 83,996 simple, primary elbow dislocations occurred from 2011-2020 (n=2,328), generating an incidence of 2.98/100,000 person-years. Incidence was higher among males (3.26 versus 2.69/100,000 person-years). Dislocations peaked in patients aged 10-19, with higher rates in males (11.12 versus 5.31/100,000 person-years; injury rate ratio 2.09, CI=2.05-2.14, p<0.001). Rates of elbow dislocations decreased with age in males (age 20-29=11.12, age >80=0.63/100,000) but increased in females over 40 (age 40-49=1.59, age 70-79=2.83/100,000). Athletic activities accounted for 55% of dislocations (n=45,902), with 15% from football and 14% from wrestling. The fewest annual dislocations occurred during COVID-19 (n=6440). Injuries occurring at schools and during contact and indoor sports decreased, while those from soccer increased. Conclusions Elbow dislocations are common, with trends of decreasing incidence with age among men and increasing incidence in women over 40. COVID-19 impacted sports-related and epidemiologic injury patterns. Ultimately, understanding population-level risks for elbow dislocations enables orthopaedic surgeons to predict injury trends and conceive educational preventative measures.

The Perfect-Circle Technique Demonstrates Poor Inter-Rater Reliability in Measuring Posterior Glenoid Bone Loss on Magnetic Resonance Imaging.

Purpose: To evaluate the reliability of the "perfect-circle" methodology for measurement of glenoid bone loss with magnetic resonance imaging (MRI) in patients with posterior glenohumeral instability. Methods: A prospective chart review was performed on patients who underwent isolated arthroscopic posterior labral repairs in our institution's electronic medical records between January 1, 2021, and June 30, 2021. Inclusion criteria included isolated posterior shoulder instability with posterior labral repair and corroborated tears on MRI. A total of 9 raters, either sports or shoulder and elbow fellowship-trained orthopaedic surgeons, each evaluated the affected shoulder MRI scans twice, at over 2 weeks apart. Measurements followed the "perfect-circle" technique and included projected anterior-to-posterior (AP) glenoid diameter, amount of posterior bone loss, and percentage of posterior bone loss. Results: Ten consecutive patients between the ages of 17 and 46 years with diagnosed posterior glenohumeral instability were selected. The average age was 28 ± 10 years, and 60% of patients were male. The patient's dominant arm was affected in 40%, and 50% of cases involved the right shoulder. The average glenoid diameter was 29.62 ± 3.69 mm, and the average measured bone loss was 2.8 ± 1.74 mm. The average percent posterior glenoid bone loss was 9.41 ± 5.78%. The inter-rater reliability was poor for the AP diameter and for the posterior glenoid bone loss with intraclass correlation coefficients at 0.30 (0.12-0.62) and 0.22 (0.07-0.54) respectively. The intrarater reliability was poor for AP diameter and moderate for posterior glenoid bone loss, with intraclass correlation coefficients at 0.41 (0.22-0.57) and 0.50 (0.33-0.64), respectively. Conclusions: Using the "perfect-circle" technique for evaluating posterior glenohumeral bone loss has poor-to-moderate inter- and intrarater reliability from MRI. Level of Evidence: Level IV, prospective diagnostic study.

Glenoid microfracture in active-duty military patients: minimum 5-year follow-up demonstrates 75% survival.

Background: To present midterm patient-reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid. Methods: All consecutive patients from January 2013 through December 2016 who underwent glenoid microfracture for full-thickness cartilage injuries with complete outcome scores were identified. Twenty patients met the final inclusion criteria for the study, and all were active-duty military at the time of surgery. A separate subgroup analysis was performed to determine if dominant-shoulder involvement portends worse outcomes. Results: The mean follow-up was 81.45 ± 19.43 months (range, 60-108). Of the 20 patients, 5 required a secondary surgical procedure within 5 years of their index procedure, with an average time to failure of 45.6 ± 13.15 months. For the 15 patients who did not fail, there was a statistically significant increase in the mean American Shoulder and Elbow Surgeons score (57.20 vs. 88.27, P < .0001) and Single Assessment Numeric Evaluation (45.00 vs. 86.33, P < .0001). Mean pain decreased significantly as measured by the pain visual analog scale (5.40 vs. 1.37, P < .0001). Range of motion in forward elevation, external rotation, and internal rotation did not change significantly postoperatively (P = .4528, .4810, and .1919, respectively). Concomitant procedures did not predict changes in pain, American Shoulder and Elbow Surgeons, or Single Assessment Numeric Evaluation scores. A majority of patients (13/20, 65%) were able to remain on unrestricted military active-duty service, but 7 (35%) underwent medical discharge, including the 5 patients who had experienced treatment failure, plus 2 additional patients. Conclusion: Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at 5 years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.

Simultaneous Arthroscopic Glenohumeral Stabilization and Glenoid Microfracture in Young, Active-Duty Military Patients: Outcomes at 5-Year Follow-up.

Background: Glenohumeral instability represents a common cause of shoulder pain and disability among active-duty members of the military and is associated with the development of glenoid osteochondral defects. Purpose: To report clinical outcomes and survivorship after combined microfracture of isolated chondral lesions of the glenoid and labral repair among young, active-duty military patients and to compare outcomes with those of patients who underwent isolated shoulder stabilization. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 31 active-duty military patients aged <40 years who underwent simultaneous microfracture of chondral lesions of the glenoid and labral repair for shoulder instability between January 2011 and January 2017 (microfracture group) and 209 patients without chondral defects who underwent shoulder stabilization during the same time period (instability group). Preoperative and 5-year postoperative outcomes (range of motion [ROM], visual analog scale [VAS] for pain, Single Assessment Numeric Evaluation [SANE] score, American Shoulder and Elbow Surgeons [ASES] shoulder score, and Rowe instability score) were compared within and between groups, and separate subgroup analyses were performed to determine whether variant of instability and dominant-shoulder involvement were associated with worse outcomes. Results: The mean follow-up was significantly longer for the microfracture group versus the instability group (95.58 ± 23.12 vs 83.38 ± 25.93 months; P = .014). Age and sex distributions were similar between groups. In both groups, there was significant pre- to postoperative improvement on all outcomes scores (P = .0001 for all). When compared with the instability cohort, microfracture patients had significantly worse postoperative VAS pain (2.65 ± 1.78 vs 1.55 ± 1.92; P = .003), SANE (79.13 ± 14.43 vs 91.23 ± 13.20; P < .0001), and ASES (79.90 ± 13.87 vs 89.03 ± 14.28; P = .001) scores, as well as decreased ROM in forward flexion (151.29° ± 11.76° vs 155.48° ± 10.3°; P = .039) and external rotation (63.65° ± 8.34° vs 65.17° ± 0.64°; P = .010). At latest follow-up, 58% of microfracture patients had returned to active-duty military service compared with 93.78% of isolated instability patients (P < .0001). Conclusion: Combined microfracture and arthroscopic labral repair produced modest, albeit statistically significant, improvements in patient-reported outcome measures and may be a reasonable treatment option for patients with chondral lesions who are not candidates for arthroplasty. However, microfracture patients had significantly worse outcomes than patients who underwent stabilization without concomitant chondral defects.