CCN1 expression is regulated by mechanical stimuli in tendons.

Tendon overuse injuries are common, but the processes that govern tendon response to mechanical load are not fully understood. A series of experiments of in vitro and in vivo experiments was devised to study to the relationship between mechanical stimuli and the matricellular protein Cellular Communication Network Factor 1 (CCN1) in tenocytes and tendons. First, human and murine tenocytes were subjected to cyclic uniaxial loading in order to evaluate changes in CCN1 gene expression as a response to mechanical stimuli. Then, baseline Ccn1 gene expression in different murine tendons (Achilles, patellar, forearm, and tail) was examined. Finally, changes in Ccn1 expression after in vivo unloading experiments were examined. It was found that CCN1 expression significantly increased in both human and murine tenocytes at 5 and 10% cyclical uniaxial strain, while 2.5% strain did not have any effect on CCN1 expression. At baseline, the Achilles, patellar, and forearm tendons had higher expression levels of Ccn1 as compared to tail tendons. Twenty-four hours of immobilization of the hind-limb resulted in a significant decrease in Ccn1 expression in both the Achilles and patellar tendons. In summary, CCN1 expression is up-regulated in tenocytes subjected to mechanical load and down-regulated by loss of mechanical load in tendons. These results show that CCN1 expression in tendons is at least partially regulated by mechanical stimuli.

Glenoid bony morphology of osteoarthritis prior to shoulder arthroplasty: what the surgeon wants to know and why.

Shoulder arthroplasty is performed with increasing frequency, and osteoarthritis is the most common indication for this procedure. However, the glenoid side of the joint is widely recognized as a limiting factor in the long-term durability of shoulder replacement, and osteoarthritis leads to characteristic bony changes at the glenoid which can exacerbate this challenge by reducing the already limited glenoid bone stock, by altering biomechanics, and by interfering with operative exposure. This article reviews the Walch classification system for glenoid morphology. Several typical findings of osteoarthritis at the glenoid are discussed including central bone loss, posterior bone loss, retroversion, biconcavity, inclination, osteophyte formation, subchondral bone quality, and bone density. The three primary types of shoulder arthroplasty are reviewed, along with several techniques for addressing glenoid deformity, including eccentric reaming, bone grafting, and the use of augmented glenoid components. Ultimately, a primary objective at shoulder arthroplasty is to correct glenoid deformity while preserving bone stock, which depends critically on characterizing the glenoid at pre-operative imaging. Understanding the surgical techniques and the implications of glenoid morphology on surgical decision-making enables the radiologist to provide the morphologic information needed by the surgeon.

Hip Arthroscopy for Femoroacetabular Impingement Improves Sleep Quality Postoperatively.

PURPOSE: To describe the prevalence of abnormal sleep quality in patients with femoroacetabular impingement syndrome and to determine whether arthroscopic hip preservation surgery with cam/pincer correction, labral preservation, and capsular plication can improve sleep quality postoperatively. METHODS: All patients undergoing primary hip arthroscopy for cam/pincer correction who failed nonoperative management between March 1, 2017, and July 1, 2017, were administered a validated sleep quality questionnaire-the Pittsburgh Sleep Quality Index (PSQI)-preoperatively and at 3, 6, 12, and 24 weeks postoperatively. Exclusion criteria included patients undergoing revision arthroscopy, gluteus medius repair, or a contralateral procedure during the follow-up period and those with known sleep disorders. A global (total) PSQI score >5 indicates poor sleep quality. The Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific Subscale, modified Harris Hip Score, and International Hip Outcome Tool-12 were used to assess functional outcomes. A repeated measures analysis of variance with post hoc Greenhouse-Geisser and Bonferroni corrections was conducted to determine statistically significant changes in sleep patterns. RESULTS: A total of 52 patients (94.6%) were included in the final analysis. The mean (± standard error) patient age was 37.8 ± 1.9 years, and body mass index was 27.6 ± 0.7. Preoperatively, 49 (94.2%) of patients experienced poor sleep quality, defined as a global PSQI score >5, with a mean PSQI score of 9.8 ± 0.6. At 24 weeks postoperatively, 10 (21.7%) of patients experienced poor sleep quality with a mean PSQI score of 2.2 ± 0.2. All patients had significant improvements in all hip outcome instruments at 24 weeks postoperatively (P < .001). CONCLUSIONS: Preoperatively, patients with femoroacetabular impingement syndrome have a high prevalence of sleep disturbance. These patients experience subsequent improvement in sleep disturbance after arthroscopic hip surgery early in the postoperative period. LEVEL OF EVIDENCE: Level IV, case series.

A biomechanical comparison of two arthroscopic suture techniques in biceps tenodesis: whip-stitch vs. simple suture techniques.

BACKGROUND: The aim of this study was to compare the biomechanical performance of whip-stitch (WS) and simple suture techniques (SST) of the long head of the biceps tendon in suprapectoral intraosseous tenodesis with interference screw fixation. METHODS: A total of 10 paired cadavers (61.1 ± 4.6 years) were randomized to receive WS or SST biceps tenodesis beginning at the musculotendinous junction. Both groups implemented a No. 2 FiberLoop wire and underwent suprapectoral fixation with a polyetheretherketone interference screw at the bicipital grove. A Materials Testing System performed cyclic testing (500 cycles), followed by load to failure at 1 mm/s. Load, displacement, and time were recorded during cyclic and failure testing. A 2-tailed Student's t-test and χ2 analysis were performed for failure load and mode of failure, respectively. RESULTS: Two SST specimens and 1 WS specimen failed during cyclic loading via tendon rupture at the screw-tendon interface. There was no significant statistical difference in the cyclic displacement after 500 cycles between the WS (12.9 mm ± 4.4 mm) and SST groups (14.0 mm ± 3.8 mm, P = .2); cyclic strain, defined as the peak displacement at the 500th cycle divided by the initial gauge length, between the WS (0.4 ± 0.2) and SST groups (0.7 ± 0.7, P = .3); maximal load (162.7 N ± 56.8 N vs. 153.1 N ± 39.3 N, respectively, P = .6); and stiffness (50.5 N/mm ± 17.7 N/mm vs. 43.3 N/mm ± 10.9 N/mm, respectively, P = .3). All specimens ruptured at the screw-tendon interface. CONCLUSION: The WS technique can provide equivalent biomechanical performance to the SST in suprapectoral intraosseous biceps tenodesis with interference screw fixation.

The Influence of Pain in Other Major Joints and the Spine on 2-Year Outcomes After Hip Arthroscopy.

PURPOSE: To determine whether patients who have pain in other major joints or the spine have poorer postsurgical outcomes than patients without comorbid orthopaedic pain. METHODS: We performed a review of a prospectively maintained institutional surgical registry of patients who underwent hip arthroscopy between January 1, 2012, and July 16, 2015, by a single surgeon, with a minimum of 2 years of postoperative follow-up. A musculoskeletal morbidity (MSM) score was assigned to each patient preoperatively based on the presence of pain in other joints and the spine (grade 1, hip only; grade 2, hip and other major joints without spine; grade 3, hip with spine; and grade 4, hip and other major joints with spine). Preoperatively and at 2 years postoperatively, functional outcomes were measured using the Hip Outcome Score-Activities of Daily Living (HOS-ADL), and the percentages of patients achieving a minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) were calculated. RESULTS: In total, 821 patients were identified, of whom 700 (85.3%) completed 2-year follow-up. Preoperatively, MSM grade 1 patients had a higher HOS-ADL than grade 2 patients (P = .02), but there was no difference between grade 1 and grade 3 patients (P = .63) or between grade 1 and grade 4 patients (P = .14). Likewise, there was no difference in the preoperative HOS-ADL among grades 2, 3, and 4. Patients with MSM grades 1 and 2 were younger than those with grades 3 and 4. At 2 years postoperatively, MSM grade 1 patients had higher HOS-ADL values than grade 3 (P = .01) and grade 4 (P = .02) but not grade 2 (P = .07) patients. Overall, 84% of patients showed an MCID and 72% of patients achieved a PASS with regard to the HOS-ADL. There were no statistically significant differences among MSM grades in terms of the MCID or PASS. CONCLUSIONS: Overall, 84% of patients improved with hip arthroscopy by MCID criteria for the HOS-ADL. Patients with no pain in other joints (MSM grade 1) had better 2-year postoperative HOS-ADL values after hip arthroscopy than patients with spine pain (grades 3 and 4). However, there were no significant differences in the MCID or PASS among patients with regard to MSM grade. A total of 40.5% of patients who underwent hip arthroscopy had pain in another joint. A limitation, however, is that there is potential for a type II error, in that there may not have been a sufficient number of patients studied to detect a significant difference in outcome among patients with different grades of musculoskeletal comorbidity. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Demographic Trends and Complication Rates in Arthroscopic Elbow Surgery.

PURPOSE: To investigate demographic trends in elbow arthroscopy over time, as well as to query complication rates requiring reoperation associated with these procedures. METHODS: The Current Procedural Terminology (CPT) billing codes of patients undergoing elbow arthroscopy were searched using a national insurance database. From the years 2007 to 2011, over 20 million orthopaedic patient records were present in the database with an orthopaedic International Classification of Diseases, Ninth Revision diagnosis code or CPT code. Our search for procedures and the corresponding CPT codes for the elbow included diagnostic arthroscopy, loose body removal, synovectomy, and debridement. The type of procedure, date, gender, and region of the country were identified for each patient. In addition, the incidence of reoperation for infection, stiffness, and nerve injury was examined. RESULTS: There was a significant increase in arthroscopic elbow procedures over the study period. Male patients accounted for 71% of patients undergoing these procedures. Of the elbow arthroscopy patients, 22% were aged younger than 20 years, 25% were aged 20 to 39 years, 47% were aged 40 to 59 years, and 6% were aged 60 years or older. Other than synovectomy, there were regional variations in the incidence of each procedure type. The overall rate of reoperation was 2.2%, with specific rates of 0.26% for infection, 0.63% for stiffness, and 1.26% for nerve injury. It should be noted that because only the complications requiring reoperation are recorded in the database, these numbers are lower than the overall complication rate. CONCLUSIONS: Overall, the incidence of elbow arthroscopy in this patient population is relatively low and appears to be increasing slightly over time. In the database used in this study, elbow arthroscopy procedures were most commonly performed in male patients and in patients aged 40 to 59 years, with regional variation in the incidence of the different procedures. Furthermore, the rate of complications requiring reoperation was low, with a nerve operation being the most common reoperation performed. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Social Media Influence and Gender Are Correlated with Industry Payments to Orthopaedic Sports Surgeons.

Social media, specifically Twitter, has become an increasingly used tool in academic orthopaedic surgery to help surgeons connect with patients and peers. This study seeks to understand correlations among social medial influence, academic influence, and gender among academic orthopaedic sport surgeons. A list of all orthopaedic sports surgeons serving as faculty of sports fellowships in the United States was compiled, along with publicly available demographic information. Their Hirsh indices (h-indices) were obtained using the Scopus database. The Physician Payments Sunshine Act Web site was used to determine their industry payments from 2014 through 2020. The number of Twitter followers was used as a measure of social media influence. Multivariable linear regression models were employed to explore the associations between these parameters and industry payments. Of the 633 surgeons, 33% had a Twitter account. Surgeons with > 1,000 followers (7.3%) were awarded 186% more in nonresearch funding (p = 0.01) and had a higher probability of receiving industry research funding compared with those with no followers (p = 0.03). Sports surgeons had an average h-index of 16, with 44% having ≤ 20 publications and 21% having ≥ 100 publications. Surgeons with ≥ 100 publications were awarded 453% more in nonresearch funding (p = 0.001) and had a 32% higher probability of receiving industry research funding (p < 0.001) when compared with their colleagues with ≤ 20 publications. Female sports surgeons accounted for only 7.9% of surgeons included in the study, and were awarded 65% less in industry nonresearch funding compared with their male colleagues (p = 0.004) when controlling for other factors. Both number of publications and a high level of Twitter activity (> 1,000 followers) had the strongest associations with the quantity of industry nonresearch funding and the highest probability of industry research funding. Female sports surgeons received significantly less industry nonresearch funding compared with their male colleagues. Future studies further exploring gender disparities in industry funding for orthopaedic surgeons may be warranted. LEVEL OF EVIDENCE: Prognostic, Level III.

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.

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.

Pdgfrß+ lineage cells transiently increase at the site of Achilles tendon healing.

The purpose of this study was to track platelet-derived growth factor receptor-ß (Pdgfr-ß) lineage cells at the site of Achilles tendon injury over time. Pdgfr-ß-CreERT2 :Ai9 mice were generated to track Pdgfr-ß lineage cells in adult mice. A surgical Achilles transection injury model was employed to examine the presence of Pdgfr-ß lineage cells in the healing tendon over time, with five mice per time point at 3, 7, 14, 28, and 56 days postoperatively. Histology and immunohistochemistry for tdTomato (Pdgfr-ß lineage cells), PCNA (proliferating cell nuclear antigen, cell proliferation), and α-SMA (α-smooth muscle actin, myofibroblasts) were performed. The percentage of cells at the healing tendon site staining positive for tdTomato and PCNA were quantified. Over 75% of cells at the injury site were Pdgfr-ß lineage cells at Days 3, 7, and 14, and this percentage decreased significantly by Days 28 and 56 postinjury. Cell proliferation at the injury site peaked on Day 7 and decreased thereafter. Immunohistochemistry for α-SMA demonstrated minimal colocalization of myofibroblasts with Pdgfr-ß lineage cells. This study demonstrates that in a mouse model of Achilles tendon injury, Pdgfr-ß lineage cells' presence at the injury site is transient. Thus, we conclude that they are unlikely to be the cells that differentiate into myofibroblasts and directly contribute to tendon fibrous scar formation. Clinical Significance: This study provides some insight into the presence of Pdgfr-ß lineage cells (including pericytes) following Achilles injury, furthering our understanding of tendon healing.

Is MRI Overutilized for Evaluation of Knee Pain in Veterans?

MRI is an essential diagnostic imaging modality for many knee conditions; however, it is not indicated in the setting of advanced knee arthritis. Inappropriate MRI imaging adds to health care costs and may delay definitive management for many patients. The primary purpose of this study was to ascertain the frequency of inappropriate MRI scans performed at one Veterans' Administration Medical Center (VAMC). We performed a retrospective chart review of all knee MRIs ordered over a 6-month period. Inappropriate MRI was defined as MRI performed prior to radiographs (XRs), or in the presence of XRs demonstrating severe osteoarthritis, without leading to a nonarthroplasty procedure of the knee. Of the 304 cases reviewed, 36.8% (112) of the MRIs were deemed inappropriate, 33 were ordered by orthopedists, and 79 were ordered by other health care providers. Of the 33 ordered by orthopedists, 25 were ordered by retired/nonsurgical orthopedists. Obtaining an MRI delayed care by an average of 29.2 days. Of the 252 cases that had XR prior to MRI, none included all four views in the standard knee XR series and only four had weightbearing images. Over a third of knee MRIs performed at this VAMC were inappropriate and delayed care. Additionally, no XRs in our study contained all the necessary views to properly assess knee arthritis. These concerning findings signify a potential opportunity for education in diagnostic strategies, to better patient care and resource utilization in the VAMC.

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.

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.

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.

Rehabilitation Principles to Consider for Anterior Cruciate Ligament Repair.

CONTEXT: Injury to the anterior cruciate ligament (ACL) is among the most common orthopaedic injuries, and reconstruction of a ruptured ACL is a common orthopaedic procedure. In general, surgical intervention is necessary to restore stability to the injured knee, and to prevent meniscal damage. Along with surgery, intense postoperative physical therapy is needed to restore function to the injured extremity. ACL reconstruction (ACLR) has been the standard of care in recent decades, and advances in surgical technology have reintroduced the prospect of augmented primary repair of the native ACL via a variety of methods. EVIDENCE ACQUISITION: A search of PubMed database of articles and reviews available in English was performed through 2020. The search terms ACLR, anterior cruciate ligament repair, bridge enhanced acl repair, suture anchor repair, dynamic intraligamentary stabilization, internal bracing, suture ligament augmentation, and internal brace ligament augmentation were used. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: No exact consensus exists on effective rehabilitation protocols after ACL repair techniques, as the variation in published protocols seem even greater than the variation in those for ACLR. For some techniques such as internal bracing and dynamic interligamentary stabilization, it is likely permissible for the patients to progress to full weightbearing and discontinue bracing sooner. However, caution should be applied with regard to earlier return to sport than after ACLR as to minimize risk for retear. CONCLUSION: More research is needed to address how physical therapies must adapt to these innovative repair techniques. Until that is accomplished, we recommend that physical therapists understand the differences among the various ACL surgery techniques discussed here and work with the surgeons to develop a rehabilitation protocol for their mutual patients. STRENGTH OF RECOMMENDATION TAXONOMY (SORT): C.

Patient Perception of Being "Completely Better" After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Contextualizing patient-reported outcomes (PROs) by defining clinically relevant differences is important. Considering that anterior cruciate ligament reconstruction (ACLR) ideally results in the restoration of normal knee function, an assessment of patients' perception of being "completely better" (CB) may be of particular value. PURPOSE: The purpose of this study was to assess the prevalence and characteristics of patients who self-report a CB status after ACLR. Additionally, we aimed to determine whether PROs were associated with a CB status after ACLR as well as to determine CB status thresholds for 2-year and change in values. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We retrospectively analyzed data from an orthopaedic registry at a single institution. Patients were administered the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and International Knee Documentation Committee (IKDC) Subjective Knee Form preoperatively and at 2 years after ACLR. Additionally, patients completed a CB anchor question at 2 years after ACLR. Thresholds for 2-year and change in PRO scores associated with achieving a CB status were identified with 90% specificity. RESULTS: Overall, 95 of the 136 patients (69.9%) considered their condition to be CB at 2 years after surgery. The 2-year and change in PROMIS PF, PROMIS PI, and IKDC scores were significantly better in the CB group than in the non-CB group. Thresholds associated with a CB status for 2-year PROMIS PF, PROMIS PI, and IKDC scores were more reliable than those for changes in scores and were ≥63, ≤44, and ≥80, respectively. Thresholds for the change in PROMIS PF, PROMIS PI, and IKDC scores were ≥19, ≤-16, and ≥44, respectively. CONCLUSION: The majority of patients reported that they were CB at 2 years after ACLR. This study may serve as a reference for orthopaedic surgeons and researchers when considering outcomes after ACLR.

Correlation of Press Ganey Scores With Early Patient Satisfaction After Anterior Cruciate Ligament Reconstruction.

Background: Patient satisfaction metrics are commonly used to assess the quality of health care and affect reimbursement. The Press Ganey Ambulatory Surgery (PGAS) is a satisfaction survey that has emerged as a prominent quality assessment tool; however, no data exist on whether PGAS scores correlate with early postsurgical satisfaction during the PGAS survey administration period in patients who underwent anterior cruciate ligament reconstruction (ACLR). Purpose: To determine if PGAS scores correlate with measures of satisfaction and patient-reported outcomes (PROs) at 2 weeks postoperatively in ACLR patients. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A retrospective review of patients who underwent ACLR at a single institution was performed. Patients who completed the PGAS survey and PROs at 2 weeks postoperatively were included in the study. Surgical satisfaction was measured with the Surgical Satisfaction Questionnaire (SSQ-8), and PROs included 6 Patient-Reported Outcomes Measurement Information System domains. Bivariate analysis between PGAS and PRO scores was conducted using the Spearman rank correlation coefficient (r S). Results: Of the 716 patients who received the PGAS survey after ACLR, 81 patients completed the survey, and 39 patients also completed PROs and were included in the study. Total converted (mean scaled score) and "top box" (percentages of questions with highest rating selected) PGAS scores showed no significant correlations with the SSQ-8 (r S =-0.24; P = .14). There were no significant correlations between SSQ-8 and PGAS domain scores except for a negative correlation with Facility domain top box scores (r S =-0.33; P = .04), meaning that patients with higher surgical satisfaction had lower PGAS Facility scores. Total PGAS (converted and top box scores) and PGAS domain scores showed no significant correlation with any of the other PROs. Conclusion: PGAS scores showed no significant positive correlation with surgical satisfaction, function, pain, mental health, activity, or expectations of surgery in patients 2 weeks after ACLR. This suggests little to no relationship between PGAS score and surgical satisfaction in the early recovery period after ACLR.

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

The objectives of this study are to assess perioperative opioid use in patients undergoing knee surgery and to examine the relationship between preoperative opioid use and 2-year postoperative patient-reported outcomes (PROs). We hypothesized that preoperative opioid use and, more specifically, higher quantities of preoperative opioid use would be associated with worse PROs in knee surgery patients. We studied 192 patients undergoing knee surgery at a single urban institution. Patients completed multiple PRO measures preoperatively and 2-year postoperatively, including six patient-reported outcomes measurement information system (PROMIS) domains; the International Knee Documentation Committee (IKDC) questionnaire, numeric pain scale (NPS) scores for the operative knee and the rest of the body, Marx's knee activity rating scale, Tegner's activity scale, International Physical Activity Questionnaire, as well as measures of met expectations, overall improvement, and overall satisfaction. Total morphine equivalents (TMEs) were calculated from a regional prescription monitoring program. Eighty patients (41.7%) filled an opioid prescription preoperatively, and refill TMEs were significantly higher in this subpopulation. Opioid use was associated with unemployment, government insurance, smoking, depression, history of prior surgery, higher body mass index, greater comorbidities, and lower treatment expectations. Preoperative opioid use was associated with significantly worse 2-year scores on most PROs, including PROMIS physical function, pain interference, fatigue, social satisfaction, IKDC, NPS for the knee and rest of the body, and Marx's and Tegner's scales. There was a significant dose-dependent association between greater preoperative TMEs and worse scores for PROMIS physical function, pain interference, fatigue, social satisfaction, NPS body, and Marx's and Tegner's scales. Multivariable analysis confirmed that any preoperative opioid use, but not quantity of TMEs, was an independent predictor of worse 2-year scores for function, activity, and knee pain. Preoperative opioid use and TMEs were neither independent predictors of met expectations, satisfaction, patient-perceived improvement, nor improvement on any PROs. Our findings demonstrate that preoperative opioid use is associated with clinically relevant worse patient-reported knee function and pain after knee surgery.

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.