Editorial Commentary: Complications After Meniscal Surgery Are Rare and Generally Associated With Medical Comorbidity.

Meniscal tears are prevalent and frequently require surgical intervention. This injury affects younger, active patients after acute trauma. Meniscal repair is often indicated. Degenerative tears are more common in elderly patients and are generally treated with partial meniscectomy. Other factors such as chronicity, stability, tear type, and associated injuries may also play a role in the treatment algorithm. In terms of complications, both procedures are generally safe, with a complication rate approximating 1%, but adverse effects such as deep venous thrombosis, pulmonary embolism, surgical-site infection, readmission, and reoperation can occur. Complications are more common in elderly patients. Moreover, recent research shows that complications are associated with medical comorbidities, with smoking, and with longer operating times.

Single-Dose Intravenous Tranexamic Acid Does Not Increase Venous Thromboembolic Rate or Complication Rate During Hip Arthroscopy.

PURPOSE: To determine whether tranexamic acid (TXA) is safe to administer preoperatively in patients undergoing hip arthroscopy by comparing the venous thromboembolic rate and complication rate between patients who did and did not receive TXA preoperatively. METHODS: This was a multicenter consecutive-cohort series of patients who underwent arthroscopic hip surgery between 2014 and 2021. The 2 cohorts comprised patients who did and did not receive TXA preoperatively (single dose of 1-2 g), after a practice change. Data were collected via chart review. Surgical outcomes included days until follow-up, visual analog scale pain score at first follow-up, total operating room (OR) time, number of arthroscopic fluid bags (3 L/bag), and complications and revision operations up to 1 year after surgery. The Mann-Whitney U test was performed for continuous variables, and the χ2 test, for categorical variables. RESULTS: A total of 862 patients were identified: 449 (52%) received TXA and 413 (48%) did not. Patient demographic characteristics including age, sex, height, weight, body mass index, smoking status, and procedures performed, as well as number of anchors used (3.5 anchors for no TXA vs 3.7 anchors for TXA) and traction time (38 minutes for no TXA vs 40 minutes for TXA), did not significantly differ between groups. Significantly more patients underwent prior hip arthroscopy in the TXA group (n = 45; primary, n = 404) than in the group that did not receive TXA (n = 25; primary, n = 388) (P = .03). Visual analog scale pain scores at the first follow-up visit (2.61 for no TXA vs 2.62 for TXA, P = .62) and the need for subsequent revision surgery (24 patients with no TXA vs 18 patients with TXA, P = .68) were not significantly different. TXA use was associated with less arthroscopic fluid utilization (5.9 bags of 3 L of fluid for no TXA vs 5.3 bags of 3 L of fluid for TXA, P < .01) and less total OR time (99.5 minutes for no TXA vs 90.0 minutes for TXA, P < .01). There was a higher overall complication rate in the group that did not receive TXA (n = 27) than in the group that did (n = 10) (P = .01). However, if lateral femoral cutaneous nerve neurapraxia was excluded, then no difference in complication rate was observed (P = .24). CONCLUSIONS: There was no difference in the incidence of venous thromboembolic complications between patients who did and did not receive TXA preoperatively. We observed a lower overall complication rate in patients who received TXA preoperatively; however, this normalized between the 2 groups when lateral femoral cutaneous nerve neuritis was excluded. No difference in early pain control or revision surgery rate was observed between groups. Although there was statistically less arthroscopic fluid utilization and less total OR time in the group that received TXA, further studies are needed to clarify whether this is clinically meaningful. Preoperatively administered TXA is a safe adjunct medication in patients undergoing arthroscopic hip surgery. LEVEL OF EVIDENCE: Level III, retrospective multicenter consecutive series.

Evaluation and Management of the Athlete's Hip.

Hip and groin pain is common in athletes, and there are many possible underlying pathologies. It is important to describe athletic hip pathology in the context of sport-specific physiologic loads and biomechanical demands. Three distinct types of athletes with this pathology are collision athletes, hypermobility athletes, and endurance athletes. Although there is considerable overlap between sports, athletes with hip pain should always be evaluated in the context of their sport. Understanding the effect of sport-specific biomechanical demands may help with both diagnosis and treatment of athletic hip pathology; however, each athlete's injury should be analyzed on an individual basis.

Intra-labral pigmented villonodular synovitis: a rare case in two adult patients.

This article discusses two rare cases of intra-labral pigmented villonodular synovitis (PVNS) of the hip. The hip joint represents the second most common location of pigmented villonodular synovitis, second to the knee [1]. The majority of hip PVNS cases either diffusely involve the synovium or are focal lesions within the joint. The lesions and synovium show foci of low signal intensity related to hemosiderin deposition, a finding that differentiates PVNS from other causes of synovial proliferation. Our case report presents two rare manifestations of PVNS lesions localized within the hip labrum. This presentation could easily be mistaken for a cyst by imaging modality. Despite the rarity of this condition, we highlight the importance of questioning the possibility of intra-labral PVNS, when patients have persistent hip pain not responding to therapy and atypical imaging findings. Highlighting this rare presentation is crucial for establishing the correct diagnosis, guiding treatment, and obtaining the best clinical outcome.

Automated Text-Messaging After Hip Arthroscopy: A Randomized-Controlled Trial of "Post-Op Buddy".

PURPOSE: To assess an automated text-messaging system for patients after hip arthroscopy and its impact at 90 days on the Hip Disability Osteoarthritis Outcome Score Physical Function Short form (HOOS-PS, HOOS-Pain), compliance with rehabilitation guidelines, and patient satisfaction. METHODS: One hundred twenty-one participants (average age 29 ± 8.7 years, 52% female) undergoing hip arthroscopy at 2 academic institutions were prospectively enrolled and randomized to receive (1) standard perioperative communication or (2) additional automated mobile phone text messages. Inclusion criteria included ability to communicate in written English and access to a mobile phone with text-messaging capability. Patients undergoing revision surgery or simultaneous femoral or acetabular osteotomy were excluded. HOOS-PS and HOOS-Pain were collected preoperatively, and after surgery an automated mobile phone robot sent participants in the therapeutic arm intermittent text messages for 90 days. At 90 days all participants again completed HOOS-PS, HOOS-Pain, and additional survey questions on satisfaction with their experience (10-point scale), communication from the surgical team (10-point scale) and adherence to physical therapy exercises, weight-bearing guidelines, and brace use, The primary outcome assessed was a statistically significant change in HOOS-PS and HOOS-Pain; secondary outcomes included change in satisfaction, communication, and adherence to physical therapy exercises, weightbearing guidelines, or brace use. Wilcoxon rank sum was used to compare HOOS-PS and HOOS-Pain scores at 0 and 90 days. Demographic characteristics and survey variables were compared using Students t test for continuous variables and χ2 or Fisher exact test for categorical variables as appropriate. RESULTS: There were statistically significant and clinically relevant improvements in HOOS-PS and HOOS-Pain in both groups (P < .05). Subjective feedback was strongly positive, with 96% of text message participants reporting they would choose automated messages if it was offered to them again in the future. CONCLUSIONS: Ninety days of automated text messaging after hip arthroscopy failed to show a significant difference in HOOS-PS (P = .09), HOOS-Pain (P = .13), patient-reported compliance with postoperative guidelines, or satisfaction with support and communication from the surgical team. LEVEL OF EVIDENCE: I, randomized control trial (RCT).

Periarticular Local Infiltrative Anesthesia and Regional Adductor Canal Block Provide Equivalent Pain Relief After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare postoperative pain and recovery after anterior cruciate ligament reconstruction (ACLR) in patients who received an adductor canal block (ACB) or periarticular local infiltrative anesthesia (LIA). METHODS: A retrospective review of a prospectively collected ACL registry was performed. Patients underwent ACLR at a single institution between January 2015 and September 2020 and received long-acting local anesthesia with a preoperative ultrasound-guided ACB or periarticular LIA after surgery. Visual analog scale (VAS) pain scores, milligram morphine equivalents (MME) consumed in the post-anesthesia care unit (PACU), and total hospital recovery time were compared. Univariate analysis was used to compare VAS pain and MME totals between overall groups and groups propensity score matched for age, sex, body mass index, graft type, and meniscal treatment. Results are presented as mean (95%CI) unless otherwise indicated. RESULTS: There were 265 knees (253 patients) included (LIA, 157 knees; ACB, 108 knees). Overall, VAS pain scores before hospital discharge (LIA: 2.6 [2.4-2.8] vs ACB: 2.4 [2.1-2.7]; P = .334) and total MMEs were similar (LIA: 17.6 [16.4-18.8] vs ACB: 18.5 [17.2-19.8] (MME); P =.134). Median time to discharge also did not significantly differ (LIA: 137.5 [IQR: 116-178] vs. ACB: 147 [IQR: 123-183] (min); P = .118). Matched subanalysis (LIA and ACB; n = 94) did not reveal significant differences in VAS pain before discharge (LIA: 2.4 [2.1-2.7] vs ACB: 2.7 [2.4-3.0]; P = .134) or total MMEs (LIA: 18.6 (17.2-20.0) vs ACB: 17.9 (16.4-19.4); P = .520). CONCLUSION: The use of ACB or LIA resulted in similar early pain levels, opioid consumption, and hospital recovery times after ACLR surgery. LEVEL OF EVIDENCE: III, retrospective comparison study.

Cam Morphology Is Associated With Increased Femoral Version: Findings From a Collection of 1,321 Cadaveric Femurs.

BACKGROUND: To evaluate the relationship between femoral version (FV) and α angle (AA) in a large osteological collection of human femurs. METHODS: The University of Iowa-Stanford osteological collection was used to evaluate the research aims. To measure FV and AA, axial photographs of the proximal femurs were taken, referenced from the posterior condylar axis. FV and AA measurements were obtained using ImageJ software, and the relationship between FV and AA was assessed with repeated-measures analysis of variance and generalized linear models. A P value of <.05 was considered statistically significant. RESULTS: A total of 1321 cadaveric femurs (666 left and 655 right) in 721 cadavers were examined. The average AA for all femurs was 47.8° ± 10.9°, and the average FV for all femurs was 8.53° ± 8.09°. Overall, 191 femurs (14.5%) exhibited cam morphology (AA ≥ 60°). Of the 721 cadavers, 600 had both femurs available for side-to-side comparison. The average FV of femurs with cam morphology was significantly higher than that of femurs without cam morphology (11.70° ± 8.82° vs. 7.99° ± 8.82°, P < .001). Linear regression analysis demonstrated that increased AA was significantly correlated with increased FV (ß ± standard error of the mean = 0.21 ± 0.02, P < .0001). CONCLUSION: In a large osteological collection of human femurs, a significant positive relationship between AA and increasing FV was identified. CLINICAL RELEVANCE: FAI and hip impingement morphology are more complex than cam or pincer morphology. Cam morphology with high femoral anteversion may allow for normal or near-normal hip mechanics without impingement, and this may partially explain the high rates of asymptomatic cam-type femoroacetabular impingement (FAI) morphology in active and general populations. Given the multiple morphological factors implicated in the development of FAI syndrome, these findings warrant further investigation.

Editorial Commentary: With Properly Indicated and Performed Surgery, We Can (Hopefully) Prevent Osteoarthritis in Patients With Hip Femoroacetabular Impingement.

Surgical treatment of femoroacetabular impingement (FAI) syndrome has been proven to be tremendously successful, outperforming the best conservative care and physical therapy in several prospective multicenter randomized controlled trials. The durability of this operation over time is less commonly reported on. We do know that FAI is associated with the development of hip osteoarthritis, and this is well established. We also know that surgical FAI treatment results in good short-term return to function/sport and improvements in patient-reported outcomes. We do not yet know if we are able to alter the natural history of FAI and prevent or delay conversion to total hip arthroplasty in this population.

Magnetic Resonance Imaging Predictors of Chondral Lesions in Patients With Femoroacetabular Impingement: An Analysis of 545 Cases.

PURPOSE: A large prospective cohort was used (1) to evaluate the overall ability of magnetic resonance imaging (MRI) to detect Outerbridge grade III and IV cartilage defects found during surgery and (2) to identify the specific MRI findings most associated with these cartilage defects so that the practicing hip arthroscopist can better predict cartilage injury before surgery. METHODS: All patients undergoing hip arthroscopy between February 2015 and May 2017 at 1 institution were enrolled in a prospective cohort. Intra-articular findings were documented at the time of surgery. MRI reports were retrospectively reviewed for radiologist-reported articular cartilage, osseous, or synovial abnormalities. Sensitivity and specificity of MRI findings were calculated; multivariate logistic regression analysis determined which findings were associated with high-grade chondral damage at the time of arthroscopy and used to create an online risk calculator, https://orthop.washington.edu/hiprisk/. RESULTS: Of 598 patients who underwent hip arthroscopy, 550 had MRI reports available for review (92%). Grade III and IV cartilage injuries were reported on arthroscopy in 70 patients (13%) of average age 33 ± 13 years. On univariate analyses, individual MRI findings were not sensitive in detection of articular cartilage injury (mean 22%; range, 1.4%-46%), but positive findings were highly specific (mean 90%,; range, 76%-99%). Multivariate analysis revealed that older age (odds ratio [OR] 1.09 [1.06-1.11], P < .001) and osseous findings such as subchondral cyst or edema (OR 4.77 [2.51-9.05], P < .001) were most predictive of grade III and IV defects (P < .001). CONCLUSION: MRI was a specific but not sensitive tool in diagnosing articular cartilage injury. Surgeons should be aware that osseous findings such as cysts or edema are highly predictive of full-thickness cartilage loss in FAI. LEVEL OF EVIDENCE: Level III, development of diagnostic criteria (consecutive patients with consistently applied reference standard, no blinding).

Hip Arthroscopy With and Without A Perineal Post: A Comparison of Early Postoperative Pain.

PURPOSE: To compare postoperative pain and early recovery after hip arthroscopy with and without a perineal post for joint distraction. METHODS: We retrospectively reviewed a consecutive series of patients who underwent hip arthroscopy before and after the adoption of a postless technique. Patients who underwent concurrent periacetabular or femoral osteotomy were excluded. Demographic information, procedure variables, and visual analog scale (VAS) pain scores were recorded. Analgesic medications given were converted to morphine milligram equivalents (MME) for comparison. Uni- and multivariate analyses were conducted to compare total MME, postoperative pain, and time to discharge between groups. RESULTS: One hundred patients were in each group. The overall age (mean ± standard deviation) was 26.5 ± 9.9 years (Post [P]: 57 females; No Post [NP]: 68 females). Total operative time (P 100.4 ± 17.9 minutes vs NP 89.1 ± 25.5 minutes, P = .0004), traction time (P 45.8 ± 10.3 minutes vs NP 40.9 ± 11.1 minutes, P = .0017), and operating room time (P 148.8 ± 19.3 minutes vs NP 137.3 ± 25.8 minutes, P = .0005) were found to be shorter in the NP group. Total MME, and final VAS pain scores in the PACU were similar between both groups (MME, P = .1620; VAS, P = .2139). Time to discharge was significantly shorter in the NP group (P 207.2 ± 58.8 vs NP 167.5 ± 47.9, P < .0001). Patient age (≥25 years) (65.2 ± 18.1 vs 59.8 ± 15.7 [MME], P = .0269) and elevated body mass index (≥25) (65.1 ± 17.1 vs 59.3 ± 16.4 [MME], P = .0164) were factors associated with greater total MME consumption. Female sex was associated with higher postoperative VAS pain scores (FM 4.1 ± 1.6 vs M 3.4 ± 1.8 P = .0027). CONCLUSIONS: Adoption of the postless technique did not result in prolonged operating room or operative time. Overall, both groups had similar postoperative pain, however, the time from surgery to hospital discharge was shorter in the postless group. LEVEL OF EVIDENCE: III, retrospective comparison study.

Increased Prevalence and Associated Costs of Psychiatric Comorbidities in Patients Undergoing Sports Medicine Operative Procedures.

PURPOSE: To evaluate the prevalence of preoperatively diagnosed psychiatric comorbidities and the impact of these comorbidities on the healthcare costs of ten common orthopaedic sports medicine procedures. METHODS: Patients undergoing 10 common sports medicine procedures from 2007 to 2017q1 were identified using the Humana claims database. These procedures included anterior cruciate ligament reconstruction; posterior cruciate ligament reconstruction; medial collateral ligament repair/reconstruction; Achilles repair/reconstruction; Rotator cuff repair; meniscectomy/meniscus repair; hip arthroscopy; arthroscopic shoulder labral repair; patellofemoral instability procedures; and shoulder instability repair. Patients were stratified by preoperative diagnoses of depression, anxiety, bipolar disorder, or schizophrenia. Cohorts included patients with ≥1 psychiatric comorbidity (psychiatric) versus those without psychiatric comorbidities (no psychiatric). Differences in costs across groups were compared using Mann-Whitney U tests, with significance defined as P < .05. Linear regression analysis was used to assess rates of procedures per year from 2006 to 2016. RESULTS: In total, 226,402 patients (57.7% male) from 2007 to 2017q1 were assessed. The prevalence of ≥1 psychiatric comorbidity within the entire database was 10.31% (reference) versus 21.21% in those patients undergoing the 10 investigated procedures. Patients with psychiatric comorbidity most frequently underwent rotator cuff repair (28%), hip labral repair (26.3%) and meniscectomy/meniscus repair (25.0%%) had ≥1 psychiatric comorbidity. Compared with the no psychiatric cohort, diagnosis of ≥1 psychiatric comorbidity was associated with increased health care costs for all 10 sports medicine procedures ($9678.81 vs $6436.20, P < .0001). CONCLUSIONS: The prevalence of preoperatively diagnosed psychiatric comorbidities among patients undergoing orthopaedic sports medicine procedures is high. The presence of psychiatric comorbidities preoperatively was associated with increased postoperative costs following all investigated orthopaedic sports medicine procedures. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Editorial Commentary: How to Reduce Postoperative Shoulder Pain in Your Practice-Stick to Instability and Opioid-Naive Patients.

Preoperative opioid use independently predicts persistent postoperative use after most surgical procedures, and surgery on the shoulder (and labrum specifically) is no exception. Thoughtful preoperative counseling of patients regarding the risks of continued postoperative opioid use, dangers of long-term narcotic use, expectations for postoperative pain control, and potential negative effect on postoperative outcomes is time-consuming and not easy. It is important to note that we have yet to determine whether preoperative opioid users can be restored to an opioid-naive state regarding the associated superior patient-reported outcomes observed postoperatively. Indications for surgery are important predictors of outcomes as well-athletes we treat for shoulder instability do not often present with pain unless associated with an acute instability event. Therefore, postoperative pain and opioid use are not commonly concerns if the indication for surgery is not pain related. The same cannot be said for SLAP tears.

Iatrogenic Articular Cartilage Injury in Arthroscopic Hip and Knee Videos and the Potential for Cartilage Cell Death When Simulated in a Bovine Model.

PURPOSE: To determine the incidence and characterize the severity of iatrogenic cartilage injuries. METHODS: Technique videos of arthroscopic femoral acetabular impingement procedures and meniscus repairs on VuMedi (n = 85) and Arthroscopy Techniques (n = 45) were reviewed and iatrogenic cartilage injuries were identified and graded (minor, intermediate, and major injury) by 2 independent reviewers. To demonstrate that even minor injuries on a cellular scale result in damage, a bovine osteochondral explant was used to create comparable minor iatrogenic injuries at varied forces that do not disrupt the articular surface (1.5 N, 2.5 N, and 9.8 N). Dead chondrocytes at the site of injury were stained with ethidium homodimer-2 and imaged with an Olympus FV1000 confocal microscope. χ2 tests were used for analysis; all results with P < .05 were considered significant. RESULTS: In total, 130 videos of arthroscopic meniscus and femoral acetabular impingement procedures were analyzed and the incidence of iatrogenic cartilage injury was 73.8%. There were 110 (70.0%) minor, 35 (22.3%) intermediate, and 11 (7.0%) major iatrogenic injuries. All forces tested in the minor injury bovine model resulted in chondrocyte death at the site of contact. CONCLUSIONS: Iatrogenic articular cartilage injuries are common in arthroscopy, occurring in more than 70% of the surgeon-published instructional videos analyzed. At least some chondrocyte death occurs with minor simulated iatrogenic injuries (1.5 N). CLINICAL RELEVANCE: The high rate of cartilage damage during arthroscopic technique videos likely under-represents the true incidence in clinical practice. Cell death occurs in the bovine minor injury model with minimal contact forces. This suggests iatrogenic cartilage damage during arthroscopy could contribute to clinical outcomes.

Arthroscopy Versus Open Arthrotomy for Treatment of Native Hip Septic Arthritis: An Analysis of 30-Day Complications.

PURPOSE: To evaluate differences in short-term complications in patients treated with open arthrotomy or arthroscopy for septic arthritis (SA) of the native hip and identify risk factors associated with return to the operating room (ROR). METHODS: Patients who underwent hip arthrotomy or arthroscopy for native hip SA between 2007 and 2017 were queried in the Humana database via the PearlDiver research tool. Patients with a previous history of total hip arthroplasty were excluded from this study. Basic demographics and various 30-day perioperative complications, including ROR, were compared between the 2 cohorts. Multivariate analysis was performed for ROR within 30 days following arthroscopy and arthrotomy. RESULTS: We identified 421 patients with SA of the native hip, of whom 387 (91.9%) and 34 (8.1%) were treated with open arthrotomy and arthroscopy, respectively. There were no significant differences in demographic variables between groups. On univariate analysis, the incidence of total adverse events (arthrotomy: 75.7% vs arthroscopy: 52.9%, P = .0038) was significantly greater in the open arthrotomy cohort. However, there was little difference in ROR between both cohorts (arthrotomy: 45.9% vs arthroscopy: 38.2%, P = .3836). Multivariate analysis identified preoperative septicemia or septic shock (odds ratio [OR] 1.90; 95% confidence interval [CI] 1.25-2.89, P = .0026) as a significant risk factor for ROR within 30 days after surgery. Neither arthrotomy (OR 4.93, 95% CI 0.42-115.2, P = .2174) nor arthroscopy (OR 3.55, 95% CI 0.33-78.01, P = .3077) were significant risk factors to ROR. CONCLUSIONS: Patients with SA of the hip had similar short-term complication rates and ROR regardless of open arthrotomy or arthroscopic management. This suggests that arthroscopic management may be a safe option for the treatment of SA of the hip with potentially limited morbidity. LEVEL OF EVIDENCE: Level IV (treatment harms investigation).

Preoperative Opioid Usage, Male Sex, and Preexisting Knee Osteoarthritis Impacts Opioid Refills After Isolated Arthroscopic Meniscectomy: A Population-Based Study.

PURPOSE: To identify risk factors for opioid consumption after arthroscopic meniscectomy using a large national database. METHODS: Patients undergoing primary arthroscopic meniscectomy from 2007 to 2016 were retrospectively accessed from the Humana database. Patients were categorized as those who filled opioid prescriptions within 3 months (OU), within 1 month (A-OU), between 1 and 3 months (C-OU), and never filled opioid prescriptions (N-OU) before surgery. Rates of opioid use were evaluated preoperatively and longitudinally tracked for each cohort. Prolonged opioid use was defined as continued opioid prescription filling at ≥3 months after surgery. Multiple logistic regression analysis was used to identify factors associated with opioid refills at 12 months after surgery. RESULTS: There were 88,120 patients (53.7% female) who underwent arthroscopic meniscectomy, of whom 46.1% (n = 39,078) were N-OU. About a quarter (25.3%) of patients continued filling opioid prescriptions at 1 year postoperatively. In addition, opioid fill rate at 1 year was significantly greater in the OU group compared with the N-OU group with a relative risk of 2.89 (40.7% vs 14.1%; 95% confidence interval 2.81-2.98; P < .0001). Multiple logistic regression model identified C-OU (odds ratio 3.67; 95% confidence interval 3.53-3.82; P < .0001) as the strongest predictor of opioid use at 12 months postoperatively. Furthermore, male sex, A-OU, knee osteoarthritis, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, fibromyalgia, anxiety or depression, alcohol use disorder, and tobacco use (P < .02 for all) had significantly increased odds of opioid use at 12 months postoperatively. However, patients <40 years (P < .0001) had significantly decreased odds of opioid use 12 months postoperatively. CONCLUSIONS: Preoperative opioid filling is a significant risk factor for opioid use at 12 months postoperatively. Male sex, preexisting knee osteoarthritis, and diagnosis of anxiety or depression were independent risk factors for opioid use 12 months following arthroscopic meniscectomy. LEVEL OF EVIDENCE: Level-III, Retrospective Cohort Study.

Preoperative Validation of the Patient-Reported Outcomes Measurement Information System in Patients With Articular Cartilage Defects of the Knee.

PURPOSE: To validate the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF CAT) with current patient-reported outcome (PRO) instruments in patients with cartilage injuries of the knee. METHODS: Patients scheduled for osteochondral autograft or allograft transplant, microfracture, autologous chondrocyte implantation, allograft cartilage resurfacing, and chondroplasty were prospectively enrolled in the study and completed PROMIS PF CAT, Knee Injury and Osteoarthritis Outcome Score (KOOS activities of daily living, pain, symptoms, sport, and quality of life), Short Form-36 Health Survey (SF-36 physical function [PF] and Physical Component Summary), and EuroQol-5 Dimension questionnaires. The Spearman correlation coefficient was used to compare instruments. Instrument correlations were defined as excellent (>0.7), excellent to good (0.61-0.69), good (0.4 to 0.6), and poor (<0.39), with significance defined as P < .05. RESULTS: A total of 293 knees in 275 patients (54.5% male) undergoing 319 cartilage procedures were analyzed. The most commonly performed cartilage procedure was chondroplasty (n = 118; 37.0%), followed by microfracture (n = 100; 31.3%). The mean age was 34.0 ± 14.7 and the mean body mass index was 30.0 ± 6.9. The PROMIS PF CAT had an excellent correlation with the SF-36 PF (r = 0.819; P < .001), SF-36 Physical Component Summary (r = 0.766; P < .001), KOOS activities of daily living (r = 0.733; P < .001), KOOS Sport (r = 0.709; P < .001), and EuroQol-5 Dimension (r = 0.752; P < .001) instruments; an excellent-good correlation with the KOOS pain (r = 0.662; P < .001), and KOOS quality of life (r = 0.640; P < .001) scores; and a good correlation with the KOOS symptoms (r = 0.519; P < .001) scale. The PROMIS PF CAT had no floor or ceiling effects and the smallest question burden (mean 4.17 ± 0.93 questions). Dimensionality analyses demonstrated that the smallest amount of unexplained variance was present in the PROMIS PF CAT (3.6%). CONCLUSION: The PROMIS PF CAT is an effective tool for preoperative outcome assessment in patients with cartilage defects of the knee. It correlates strongly with legacy PRO measures of physical function with no ceiling and floor effects and a minimal time burden for completion. Further study is warranted to determine postoperative performance and to evaluate the responsiveness of PROMIS to change within a patient. LEVEL OF EVIDENCE: III; Prognostic retrospective comparative study.

Resident Involvement Is Not Associated With Increased Risk of Postoperative Complications After Arthroscopic Knee Surgery: A Propensity-Matched Study.

PURPOSE: To investigate whether resident involvement in knee arthroscopy procedures affects postoperative complications or operative times. METHODS: The American College of Surgeons National Surgical Quality Improvement Program registry was queried to identify patients who underwent common knee arthroscopy procedures between 2006 through 2012. Patients with a history of knee arthroplasty, septic arthritis or osteomyelitis of the knee, concomitant open or mini-open procedures, or without information on resident involvement were excluded. A 1:1 propensity score match was performed based on age, sex, obesity, smoking history, and American Society of Anesthesiologist classification to match cases with resident involved to nonresident cases. Fisher exact tests, Pearson's χ2 tests, and Wilcoxon rank sum tests were used to compare patient demographics, comorbidities, and 30-day complications. Wilcoxon rank sum tests were used to compare operative time and length of hospital stay between the 2 groups, with statistical significance defined as P < .05. RESULTS: After matching, 2954 cases (50% resident involvement) were included in the study with no significant differences in demographics or comorbidities between the 2 cohorts. The overall rate of 30-day complications was 1.1% in the nonresident and resident involved group (P = 1.000). There was no significant difference in postoperative surgical (nonresident vs resident involved: 0.48% vs 0.83%, P = .2498) or medical (nonresident vs resident involved: 0.62% vs 0.83%, P = .5111) complications. However, knee arthroscopy cases that residents were involved with had significantly longer operative times (69.8 vs 66.8 minutes, P = .0002), and length of hospital stay (0.85 vs 0.21 days, P = .0332) when compared with cases performed without a resident. CONCLUSIONS: Resident involvement in knee arthroscopy procedures is not a significant risk for medical or surgical 30-day postoperative complications. Resident participation in knee arthroscopy was associated with statistically significant but likely clinically insignificant increased operative time as well as length of hospital stay. LEVEL OF EVIDENCE: Level III: Retrospective Cohort Study.

Preoperative Opioid Prescription Filling Is a Risk Factor for Prolonged Opioid Use After Elbow Arthroscopy.

PURPOSE: To (1) report the frequency of postoperative opioid prescriptions after elbow arthroscopy, (2) evaluate whether filling opioid prescriptions preoperatively placed patients at increased risk of requiring more opioid prescriptions after surgery, and (3) determine patient factors associated with postoperative opioid prescription needs. METHODS: A national claims-based database was queried for patients undergoing primary elbow arthroscopy. Patients with prior total elbow arthroplasty or septic arthritis of the elbow were excluded. Patients who filled at least 1 opioid prescription between 1 and 4 months prior to surgery were defined as the preoperative opioid-use group. Monthly relative risk ratios for filling an opioid prescription were calculated for the first year after surgery. Multiple logistic regression analysis was performed to identify factors associated with opioid use at 3, 6, 9, and 12 months after elbow arthroscopy, with P < .05 defined as significant. RESULTS: We identified 1,138 patients who underwent primary elbow arthroscopy. The preoperative opioid-use group consisted of 245 patients (21.5%), 61 of whom (24.9%) were still filling opioid prescriptions 12 months after surgery. The multivariate analysis determined that the preoperative opioid-use group was at increased risk of postoperative opioid prescription filling at 3 months (odds ratio [OR], 9.02; 95% confidence interval [CI], 5.98-13.76), 6 months (OR, 8.74; 95% CI, 5.57-13.92), 9 months (OR, 7.17; 95% CI, 4.57-11.39), and 12 months (OR, 6.27; 95% CI, 3.94-10.07) after elbow arthroscopy. Patients younger than 40 years exhibited a decreased risk of postoperative opioid prescription filling at 3 months (OR, 0.49; 95% CI, 0.25-0.91), 6 months (OR, 0.19; 95% CI, 0.06-0.50), 9 months (OR, 0.48; 95% CI, 0.22-0.97), and 12 months (OR, 0.44; 95% CI, 0.19-0.94) after surgery. CONCLUSIONS: Preoperative opioid filling, fibromyalgia, and psychiatric illness are associated with an increased risk of prolonged postoperative opioid after elbow arthroscopy. Patient age younger than 40 years and chronic obstructive pulmonary disease are associated with a decreased risk of postoperative opioid prescription filling within the first postoperative year. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Preoperative opioid use is associated with inferior outcomes after patellofemoral stabilization surgery.

PURPOSE: The purpose of the study was to investigate the association between preoperative opioid use and persistent postoperative use, and determine the impact of preoperative opioid use on patient-reported outcomes (PROs) in patients undergoing patellofemoral stabilization surgery. METHODS: A retrospective analysis of 60 patients after patellofemoral stabilization surgery with a minimum of 2-year follow-up was performed using a prospectively collected patellar instability registry. Patients were categorized as opioid naïve (n = 48) or preoperative opioid users (n = 12). Postoperative opioid use was assessed for all patients at 2 and 6 weeks. Knee Injury and Osteoarthritis Outcome Score (KOOS) and Kujala questionnaires were administered at baseline, and 6 months and 2 years postoperatively. RESULTS: Preoperative opioid use was identified as an independent risk factor for postoperative opioid use at 2- and 6-weeks following surgery (p = 0.0023 and p < 0.0001, respectively). Preoperative opioid use was associated with significantly lower KOOS and Kujala scores at baseline, 6 months and 2 years postoperatively. Both groups significantly improved from baseline KOOS and Kujala scores at 6 months and 2 years postoperatively. Regardless of preoperative opioid use, opioid use at 6 weeks after surgery was associated with worse KOOS scores at 6 months and 2 years postoperatively. CONCLUSION: In patients undergoing patellofemoral stabilization surgery, preoperative opioid use was predictive of postoperative use. Additionally, preoperative opioid use was associated with worse PROs at 6 months and 2 years following surgery. LEVEL OF EVIDENCE: III.

Arthroscopic débridement has similar 30-day complications compared with open arthrotomy for the treatment of native shoulder septic arthritis: a population-based study.

HYPOTHESIS: This study aimed to determine whether there are significant differences in 30-day perioperative complications between arthroscopic and open débridement (irrigation and débridement [I&D]) for septic arthritis (SA) of the shoulder using the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: Patients undergoing arthroscopic or open I&D of the native shoulder from 2006-2016 were identified in the National Surgical Quality Improvement Program database. Those with a diagnosis of SA were included in the study. Patients with a concurrent diagnosis of osteomyelitis around shoulder (n = 25) or polyarthritis (n = 2) were excluded from the study. Patient demographics, comorbidities, and complications were compared between the groups. Poisson regression, which controlled for age and American Society of Anesthesiologists (ASA) score, was used to calculate the relative risks with 95% confidence intervals for minor adverse events, serious adverse events, total adverse events, and unplanned reoperations between the 2 treatment groups, with significance set at P < .0125 after Bonferroni correction. RESULTS: Overall, 147 and 57 patients underwent arthroscopic and open I&D, respectively, for SA of the shoulder. Patients in the open I&D group were more likely to be smokers (P = .0213), whereas patients in the arthroscopy group had higher ASA scores (P = .0008). After controlling for age and ASA score, we found no significant differences in the risk of minor adverse events (P = .0995), serious adverse events (P = .2241), total adverse events (P = .1871), or unplanned reoperations (P = .3855). CONCLUSION: Arthroscopic débridement appears to be a safe alternative to open débridement for SA of the native shoulder. The incidence and risk of 30-day perioperative complications are similar after arthroscopic and open I&D for SA of the shoulder.