Buffering Mitigates Chondrocyte Oxidative Stress, Metabolic Dysfunction, and Death Induced by Normal Saline: Formulation of a Novel Arthroscopic Irrigant.

For decades, surgeons have utilized 0.9% normal saline (NS) for joint irrigation to improve visualization during arthroscopic procedures. This continues despite mounting evidence that NS exposure impairs chondrocyte metabolism and compromises articular cartilage function. We hypothesized that chondrocyte oxidative stress induced by low pH is the dominant factor driving NS toxicity, and that buffering NS to increase its pH would mitigate these effects. Effects on chondrocyte viability, reactive oxygen species (ROS) production, and overall metabolic function were assessed. Even brief exposure to NS caused cell death, ROS overproduction, and disruption of glycolysis, pentose phosphate, and tricarboxylic acid (TCA) cycle pathways. NS also stimulated ROS overproduction in synovial cells that could adversely alter the synovial function and subsequently the entire joint health. Buffering NS with 25 mM 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (HEPES) significantly increased chondrocyte viability, reduced ROS production, and returned metabolite levels to near control levels while also reducing ROS production in synovial cells. These results confirm that chondrocytes and synoviocytes are vulnerable to insult from the acidic pH of NS and demonstrate that adding a buffering agent to NS averts many of its most harmful effects.

Editorial Commentary: The Medial Patellofemoral Ligament Is Not Isometric and Anatomic Reconstruction Is Important, But Just a Small Piece of the Patellar Instability Puzzle.

Medial patellofemoral ligament (MPFL) reconstruction has proven to be a reliable procedure to reduce patellar instability events in patients with recurrent patellar instability. As our reconstruction techniques have evolved to address pathology in a diverse patient population, there continues to be an obsessive focus on the precise anatomy of the MPFL origin on the medial knee, due in large part to concerns that improper femoral tunnel position may result in excessive graft anisometry and failure. However, recurrent patellar instability involves many complexities and should not be simply reduced to a single point on the medial knee.

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.

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.

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.

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.

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 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.

Total Ankle Arthroplasty and Ankle Arthrodesis Use: An American Board of Orthopaedic Surgery Part II Database Study.

Total ankle arthroplasty (TAA) use has increased during the past 20 years, whereas ankle arthrodesis (AAD) use has remained constant. The purpose of this study was to examine trends in TAA and AAD use in American Board of Orthopedic Surgery Part II candidates while considering the influence of fellowship training status on treatment of end-stage ankle arthritis. The American Board of Orthopedic Surgery Part II database was queried to identify all candidates who performed ≥1 TAA or AAD from examination years 2009 through 2018. Candidates were categorized by examination year and by self-reported fellowship training status. Descriptive statistical methods were used to report procedure volumes. Trends in use of TAA and AAD were examined by using log-modified regression analyses. From 2009through 2018, there was no significant change in TAA or AAD use among all candidates (p = .92, p = .20). Candidates reporting a foot and ankle fellowship trended toward increased use of TAA relative to AAD compared with non-foot and ankle fellowship candidates, but this failed to reach statistical significance (p = .06). The use of arthroscopic AAD increased over time (p < .01) among all candidates. TAA and AAD use did not change over the study period. Volume of TAA and AAD performed by early-career surgeons remains low. The findings in this study should serve as an important reference for orthopedic trainees, early-career surgeons, and orthopedic educators interested in optimizing training curriculum for surgical management of end-stage ankle arthritis.

Graft use in the treatment of large and massive rotator cuff tears: an overview of techniques and modes of failure with MRI correlation.

Despite technical advances, repair of large or massive rotator cuff tears continues to demonstrate a relatively high rate of failure. Rotator cuff repair or superior capsular reconstruction (SCR) using a variety of commercially available grafts provides a promising option in patients with tears that may be at high risk for failure or otherwise considered irreparable. There are three major graft constructs that exist when utilizing graft in rotator cuff repair or reconstruction: augmentation at the rotator cuff footprint, bridging, and SCR. Each construct has a unique appearance when evaluated using postoperative magnetic resonance imaging (MRI), and each construct has unique sites that are predisposed to failure. Understanding the basic principles of these constructs can help the radiologist better evaluate the postoperative MRI appearance of these increasingly utilized procedures.

Editorial Commentary: Trends in Cartilage Surgery-Who Is Steering the Ship?

With myriad cartilage surgery techniques available, including marrow stimulation, autologous osteochondral transfer, osteochondral allograft transplantation, and autologous chondrocyte implantation, treatment of knee articular cartilage injuries has become increasingly complex. Recent evidence suggests that advanced cartilage restoration procedures may provide improved outcomes and durability when compared with marrow stimulation techniques. When investigating orthopaedic surgeons early in practice, it appears that utilization of marrow stimulation techniques has decreased, an encouraging trend that is in line with recent evidence. However, it is important to consider how other factors not investigated, including insurance approval and payor reimbursement, may influence these trends moving forward.

Incidence and Risk Factors for Venous Thromboembolism Following Hip Arthroscopy: A Population-Based Study.

PURPOSE: To determine the incidence of symptomatic venous thromboembolism (VTE) after hip arthroscopy (HA) using a large national database while considering several patient demographic factors. METHODS: Patients ≥20 years old who underwent HA between 2007 and 2017 were identified within the Humana administrative claims database using relevant Current Procedural Terminology and International Classification of Diseases Ninth and Tenth Revision codes. Basic demographics, including age, gender, obesity (body mass index ≥ 30 kg/m2), oral contraceptive use, smoking history, diabetes, and chronic obstructive pulmonary disease (CLD) were recorded. Postoperative incidence of deep vein thrombosis, pulmonary embolism, and VTE was identified at 30 and 90 days postoperatively. Multivariate logistic regression analysis was performed to identify independent risk factors for VTE after HA, with statistical significance set at P < .05. RESULTS: Overall, 9,477 patients underwent HA procedures over the study period, of whom 5,085 (53.7%) were female. The overall incidence of VTE in all patients was 0.77% (n = 73) and 1.14% (n = 108) at 30 and 90 days, respectively. Multivariate analysis identified age ≥ 45 (odds ratio [OR] = 1.82; 95% confidence interval [CI], 1.36-2.49; P = .0001), obesity (OR = 1.54; 95% CI, 1.27-1.86; P < .0001), smoking (OR = 1.26; 95% CI, 1.04-1.53; P = .0177), diabetes (OR = 1.59; 95% CI, 1.32-1.92; P < .0001), and CLD (OR = 2.10; 95% CI, 1.63-2.68; P < .0001) as independent risk factors for higher incidence of VTE after HA. However, neither gender nor oral contraceptive use were risk factors for VTE after HA. CONCLUSIONS: For patients undergoing HA, the incidence of symptomatic postoperative VTE is low. This study identified age ≥45, obesity, tobacco use, diabetes, and CLD as independent risk factors for VTE after HA. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Arthroscopic Remplissage for Anterior Shoulder Instability: A Systematic Review of Clinical and Biomechanical Studies.

PURPOSE: To examine the clinical outcomes and biomechanical data supporting the use of the remplissage procedure. METHODS: A query of the Embase, PubMed, Scopus, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from 2000 to 2017. Data were extracted from included studies for a qualitative review of both clinical and biomechanical outcomes. RESULTS: After review, 18 clinical and 10 biomechanical studies were available for analysis; 10 of 18 clinical studies (55.6%) were Level IV evidence. Within the clinical studies, there were 567 patients (570 shoulders) evaluated with follow-up ranging from 6 to 180 months. Overall, 5.8% of shoulders (33 of 570) displayed recurrent instability after arthroscopic remplissage. Of the shoulders with recurrent instability, 42.4% of shoulders (14 of 33) underwent further surgical management. In all studies evaluating pre- and postoperative patient-reported outcomes, the arthroscopic remplissage procedure improved patient-reported outcomes a statistically significant amount postoperatively. Within individual clinical studies, external rotation with the arm in neutral was the most consistently limited range of motion (ROM) parameter, with deficits compared with the contralateral shoulder ranging from 9° to 14°. Biomechanical analysis appeared to corroborate the clinical results, although significant conclusions were limited by heterogeneity of reporting. CONCLUSIONS: Arthroscopic remplissage performed in conjunction with arthroscopic Bankart repair is a safe and effective procedure for patients with engaging Hill-Sachs lesions and subcritical glenoid bone loss. Although both the included clinical and biomechanical studies would suggest minimal changes in glenohumeral ROM following the remplissage procedure, strong conclusions are limited by the heterogeneity in reporting ROM data and lack of comparative studies. LEVEL OF EVIDENCE: IV, systematic review.

Trends in Hip Arthroscopic Labral Repair: An American Board of Orthopaedic Surgery Database Study.

PURPOSE: The purpose of this study is to evaluate the trends in labral repair in American Board of Orthopaedic Surgery Part II candidates performing hip arthroscopy. METHODS: Candidates who performed arthroscopic hip surgery between 2011 and 2015 during their American Board of Orthopaedic Surgery Part II board collection period were identified using Current Procedural Terminology codes (29860, 29861, 29862, 29863, 29914, 29915, 29916). The proportion of hip arthroscopy cases including labral repair (Current Procedural Terminology code 29916) were calculated for each year and analyzed by fellowship training experience. Trends in labral repair utilization were calculated using univariate and regression analyses, with significance set at P < .05. RESULTS: During the study period, 1,606 hip labral repair cases were performed, with a 35% increase in utilization between 2011 and 2015. Overall, labral repair was performed in 64.8% (1,606/2,480) of hip arthroscopy cases, with a significant increase between 2011 and 2015 (47.4% vs 79.2%; P < .001). Of the hip arthroscopy cases including labral repair, 80.4% (1,291/1,606) were performed by candidates with sports medicine fellowship training. The proportion of hip arthroscopy cases including labral repair was highest for surgeons with sports medicine fellowship training compared with those without sports medicine fellowship training (66.1% vs 59.8%; P = .007). Candidates with sports medicine training performing at least 1 labral repair each year increased from 68% to 89% over the study period (P = .0007). The average number of labral repairs per candidate increased significantly over the duration of the study period (P = .0072). CONCLUSIONS: Labral repair utilization during hip arthroscopy procedures nearly doubled from 2011 to 2015 for American Board of Orthopaedic Surgery Part II candidates, reflecting a significant change in practice. Current data suggest that nearly 80% of hip arthroscopy procedures include labral repair. These trends may reflect the current practice patterns at academic institutions with sports medicine fellowships.

Prescription Opioid Use Before and After Hip Arthroscopy: A Caution to Prescribers.

PURPOSE: To determine pre- and postoperative opioid utilization while identifying risk factors for prolonged postoperative opioid use following hip arthroscopy. METHODS: All patients undergoing hip arthroscopy between 2007 and the second quarter of 2016 were identified within the Humana Inc. administrative claims database. Chronic preoperative opioid utilization was defined as filling of any opioid prescription 1 to 3 months before surgery, whereas acute preoperative opioid utilization was defined as filling any opioid prescription within 1 month of surgery. Rates of pre- and postoperative opioid utilization were calculated, and patient demographic characteristics and medical conditions associated with pre- and postoperative opioid utilization were identified. RESULTS: Of the 1,208 patients undergoing hip arthroscopy, chronic and acute preoperative opioid utilization was observed in 24.9% and 17.3% of patients, respectively. Chronic preoperative opioid utilization was more frequently observed in obese (P < .001) patients, those ≥50 years of age (P = .002), and those with preexisting anxiety and/or depression (P < .001). In multivariate analysis, chronic preoperative opioid utilization was the strongest predictor of opioid prescription filling at 3, 6, 9, and 12 months postoperatively (odds ratio at 3 months, 18.60, 95% confidence interval, 12.41 to 28.55), whereas preexisting anxiety and/or depression and obesity were additionally identified as predictors of prolonged postoperative opioid utilization. CONCLUSIONS: Chronic preoperative opioid utilization before hip arthroscopy is common at 24.9%. The high rate of chronic preoperative opioid utilization is particularly important considering that chronic preoperative opioid utilization is the strongest predictor of continued postoperative opioid prescription filling out to 12 months postoperatively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Opioid use following shoulder stabilization surgery: risk factors for prolonged use.

HYPOTHESIS: The purpose of this study was to determine the rate of opioid use before and after shoulder stabilization surgery for instability due to recurrent dislocation and assess patient factors associated with prolonged opioid use postoperatively. METHODS: Patients undergoing primary shoulder stabilization procedures for shoulder instability due to recurrent dislocation were accessed from the Humana administrative claims database. Patients were categorized as those who filled 1 or more opioid prescriptions within 1 month, those who filled opioid prescriptions between 1 and 3 months, and those who never filled opioid prescriptions before surgery. Rates of opioid use were evaluated preoperatively and longitudinally tracked for each group. Multiple binomial logistic regression analysis was used to identify factors associated with opioid use at 3 months and 1 year after surgery. RESULTS: Overall, 4802 patients (45.9% opioid naive) underwent shoulder stabilization surgery for shoulder instability during the study period. Rates of opioid use significantly declined after the first postoperative month; however, at 1 year, the rate of opioid use was significantly greater in patients who filled opioid prescriptions preoperatively (13.4% vs. 1.9%, P < .0001). Filling opioid prescriptions 1 to 3 months prior to surgery was the strongest risk factor for opioid use at 1 year after surgery. CONCLUSIONS: Patients who were prescribed opioids 1 to 3 months before surgery had the highest risk of prolonged opioid use following surgery. Obesity, tobacco use, and a preoperative diagnosis of fibromyalgia were independently associated with prolonged opioid use following surgery.

Editorial Commentary: When Is Too Small, Too Small? Allograft Augmentation of Autologous Hamstring Grafts During Anterior Cruciate Ligament Reconstruction.

Soft tissue allograft augmentation of small hamstring autografts, so-called hybrid grafts, has been proposed as an option during anterior cruciate ligament reconstruction (ACL-R). However, notable concerns exist with both small autograft use and allograft use during ACL-R, particularly in young, active patients. We currently choose to augment hamstring autografts with diameters <8.0 mm, adding only enough allograft to create a hybrid graft with an overall diameter no larger than 8.5 mm. Based on the available evidence, surgeons continue to seek the tipping point where the benefit of additional allograft tissue exceeds the consequence of its use.

Short-term Morbidity and Readmissions Increase With Skilled Nursing Facility Discharge After Total Joint Arthroplasty in a Medicare-Eligible and Skilled Nursing Facility-Eligible Patient Cohort.

BACKGROUND: The benefits of discharge to a skilled nursing facility (SNF) in Medicare-eligible patients after total joint arthroplasty (TJA) have recently been scrutinized. The purpose of this study was to determine short-term complication and readmission rates for SNF versus home discharge in patients eligible for Medicare and SNF discharge. METHODS: Patients who underwent TJA between 2012 and 2013 were identified in the National Surgical Quality Improvement Project database. Patients over 65 years and who discharged at or after postoperative day 3, and thus SNF eligible by Medicare rule, were included. Patient demographics and comorbidities were compared in the 2 cohorts (home versus SNF), and subsequent univariate and multivariate analyses were used to determine risk factors for short-term complications. RESULTS: We identified 34,610 Medicare- and SNF-eligible TJA patients; 54.8% discharged home. Patients with SNF discharge were older, had higher rates of comorbidities, and were more frequently American Society of Anesthesiologists class 3 or 4 (P < .001). Univariate analysis revealed that patients with SNF discharge had higher rates of any complication (7.9% vs. 4.7%, P < .001) and readmission (5.3% vs. 3.3%, P < .001). Multivariate regression analysis identified SNF discharge (adjusted odds ratio 1.9, 95% confidence interval 1.7-2.0) as an independent risk factor for a 30-day complication and readmission. CONCLUSIONS: In a cohort of Medicare- and SNF-eligible patients, SNF discharge was the strongest predictor of 30-day complication after TJA. SNF discharge was also an independent predictor of readmission after TJA.

What is the Impact of Smoking on Revision Total Hip Arthroplasty?

BACKGROUND: There is a paucity of literature evaluating the impact of smoking on revision total hip arthroplasty (THA) outcomes. The purpose of this study was to identify the effect of smoking on complications after revision THA. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent revision THA between 2006 and 2014. Patients were divided into current smokers and nonsmokers. Each cohort was compared in terms of demographics, preoperative comorbidities, and operative time. Multivariate logistic regression analysis was utilized. Adjusted odds ratios (OR) for the outcomes of any wound complication, deep infection, and reoperation within 30 days of revision THA were calculated. RESULTS: In total, 8237 patients had undergone a revision THA. Of these patients, 14.7% were current smokers and 85.3% were nonsmokers. Univariate analyses demonstrated that smokers had a higher rate of any wound complication (4.1% vs 3.0%, P = .04), deep infection (3.2% vs 1.9%, P = .003), and reoperation (6.8% vs 4.8%, P = .003). Multivariate analysis controlling for confounding demographic, comorbidity, and operative variables identified current smokers as having a significantly increased risk of deep infection (OR, 1.58; 95% CI, 1.04-2.38) and reoperation (OR, 1.37; 95% CI, 1.03-1.85). CONCLUSION: Smoking significantly increases the risk of infection and reoperation after revision THA. The results are even more magnified for revision procedures compared to published effects of smoking on primary THA complications. Further research is needed regarding the impact of smoking cessation on mitigation of these observed risks.