Inpatient Arthroscopic Rotator Cuff Repair Is Associated With Higher Postoperative Complications Compared With Same-Day Discharge: A Matched Cohort Analysis.

PURPOSE: To compare 90-day postoperative complications between patients undergoing outpatient versus inpatient arthroscopic rotator cuff repairs (RCR) and identify risk factors associated with postoperative complications. METHODS: An administrative claims database was used to identify patients undergoing arthroscopic RCR from 2007 to 2015. Patients were categorized based on length of hospital stay (LOS) with inpatient RCR defined as patients with ≥1 day LOS, and outpatient RCR as patients discharged day of surgery (LOS = 0). Inpatient and outpatient RCR groups were matched based on age, sex, Charlson comorbidity index (CCI), and various medical comorbidities using 1:1 propensity score analysis. Patient factors, concomitant procedures, total adverse events (TAEs), medical adverse events (MAEs), and surgical adverse events (SAEs) were compared between the matched groups. Multiple logistic regression analysis was performed to identify risk factors associated with increased complications. RESULTS: After matching, there were 2812 patients (50% outpatient) included in the study. Within 90 days following arthroscopic RCR, the incidence of TAEs (8.9% vs 3.6%, P < .0001), SAEs (2.7% vs 0.9%, P = .0002), and MAEs (6.4% vs 3.0%, P < .0001) were significantly greater for the inpatient RCR group. The multivariate model identified inpatient RCR (LOS ≥1 day), greater CCI, and anxiety or depression as independent predictors for TAEs after arthroscopic RCR. Open biceps tenodesis and inpatient RCR were independent predictors of SAEs, whereas greater CCI, anxiety or depression, and inpatient RCR were independent predictors for MAEs within 90 days after arthroscopic RCR. CONCLUSIONS: Inpatient arthroscopic RCR is associated with increased risk of 90-day postoperative complications compared with outpatient. However, there is no difference for all-cause or pain-related emergency department visits within 90 days after surgery. In addition, the multivariate model identified inpatient RCR, greater CCI, and diagnosis of anxiety or depression as independent risk factors for 90-day TAEs after arthroscopic RCR. LEVEL OF EVIDENCE: 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.

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.

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 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.

Opioid Use After Total Knee Arthroplasty: Does Tramadol Have Lower Risk Than Traditional Opioids?

BACKGROUND: Preoperative opioid use has been shown to increase postoperative opioid use following total knee arthroplasty (TKA). Tramadol is recommended for symptomatic treatment of osteoarthritis; however, it acts on opioid receptors and may confer similar adverse effects. The purpose of this study is to assess postoperative opioid use with preoperative opioid and tramadol use. METHODS: Patients undergoing primary TKA were identified in the Humana administrative claims database. Patients were stratified by whether they filled a prescription for an opioid, tramadol, either, or neither within 3 months of TKA. Prescription claims were tracked for 12 months postoperatively and relative risk for each group was calculated. RESULTS: In total, 107,973 patients undergoing TKA were identified. Preoperatively, 29,890 (27.7%) patients filled a prescription for opioids, 8049 (7.5%) for tramadol, 44,403 (41.1%) for tramadol or opioids, and 63,570 (58.9%) did not fill a prescription for either. At 12 months postoperatively, an opioid prescription was filled by 6.0% of preoperative narcotic-free patients, 35.2% opioid users (relative risk [RR] 5.83 [5.63-6.03]), 9.2% tramadol users (RR 1.52 [1.40-1.63]), and 29.5% opioid or tramadol users (RR 4.88 [4.72-5.05]). Opioid or tramadol prescriptions were filled by 7.7% of preoperative narcotic-free patients, 37.3% opioid users (RR 4.84 [4.70-4.99]), 26.2% tramadol users (RR 3.40 [3.26-3.57]), and 35.7% opioid or tramadol users (RR 4.64 [4.50-4.78]) at 12 months. CONCLUSION: Patients taking tramadol preoperatively were found to be at lower risk for prolonged postoperative opioid use following TKA. Patients taking either narcotics preoperatively continued use of these medications at a higher rate than those who were not.

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.

Ruptured Appendicitis and Retrocecal Abscess Masquerading as Knee Pain in a Pediatric Patient: A Case Report.

BACKGROUND: Knee pain has a variety of etiologies in the pediatric population, including septic arthritis, osteomyelitis, fracture, ligamentous injury, and neoplasms. Extrinsic sources of knee pain may also be intra-abdominal, although abdominal pathology is much more likely to manifest as hip or proximal thigh musculature pain. CASE REPORT: A 5-year-old healthy male presented with atraumatic right knee pain, discomfort with weightbearing, fever, and elevated inflammatory laboratory markers. Physical examination and magnetic resonance imaging findings of the knee were benign, leading to low clinical suspicion for knee septic arthritis. Blood cultures were positive for a gastrointestinal organism, Granulicatella adiacens, suggesting abdominal pathology leading to referred pain. Ultrasound evaluation and computed tomography (CT) of the abdomen revealed a large abscess secondary to perforated appendicitis, which was treated with CT-guided drainage and i.v. antibiotics. The patient's musculoskeletal pain subsided with treatment of the appendicitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute appendicitis may present as knee pain, with other signs and symptoms mimicking septic arthritis, such as fever, inability to bear weight, and elevated inflammatory markers. Considering an array of differential diagnoses in pediatric patients with apparent knee septic arthritis is crucial to prevent delay in diagnosis of alternative infectious sources.

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.

Carpal Tunnel Surgery: Can Patients Read, Understand, and Act on Online Educational Resources?

Background: Patients often access online resources to educate themselves prior to undergoing elective surgery such as carpal tunnel release (CTR). The purpose of this study was to evaluate available online resources regarding CTR on objective measures of readability (syntax reading grade-level), understandability (ability to convey key messages in a comprehensible manner), and actionability (providing actions the reader may take). Methods: The study conducted two independent Google searches for "Carpal Tunnel Surgery" and among the top 50 results, analyzed articles aimed at educating patients about CTR. Readability was assessed using six different indices: Flesch-Kincaid Grade Level Index, Flesch Reading Ease, Gunning Fog Index, Simple Measure of Gobbledygook (SMOG) Index, Coleman Liau Index, Automated Readability Index. The Patient Education Materials Assessment Tool evaluated understandability and actionability on a 0-100% scale. Spearman's correlation assessed relationships between these metrics and Google search ranks, with p<0.05 indicating statistical significance. Results: Of the 39 websites meeting the inclusion criteria, the mean readability grade level exceeded 9, with the lowest being 9.4 ± 1.5 (SMOG index). Readability did not correlate with Google search ranking (lowest p=0.25). Mean understandability and actionability were 59% ± 15 and 26% ± 24, respectively. Only 28% of the articles used visual aids, and few provided concise summaries or clear, actionable steps. Notably, lower grade reading levels were linked to higher actionability scores (p ≤ 0.02 in several indices), but no readability metrics significantly correlated with understandability. Google search rankings showed no significant association with either understandability or actionability scores. Conclusion: Online educational materials for CTR score poorly in readability, understandability, and actionability. Quality metrics do not appear to affect Google search rankings. The poor quality metric scores found in our study highlight a need for hand specialists to improve online patient resources, especially in an era emphasizing shared decision-making in healthcare. Level of Evidence: IV.

Health Literacy in Shoulder Arthroscopy: A Quantitative Assessment of the Understandability and Readability of Online Patient Education Material.

Background: The National Institutes of Health (NIH) and American Medical Association (AMA) recommend that online health information be written at a maximum 6th grade reading level. The aim was to evaluate online resources regarding shoulder arthroscopy utilizing measures of readability, understandability, and actionability, using syntax reading grade level and the Patient Education Materials Assessment Tool (PEMAT-P). Methods: An online Google™ search utilizing "shoulder arthroscopy" was performed. From the top 50 results, websites directed at educating patients were included. News and scientific articles, audiovisual materials, industry websites, and unrelated materials were excluded. Readability was calculated using objective algorithms: Flesch-Kincaid Grade-Level (FKGL), Simple Measure of Gobbledygook (SMOG) grade, Coleman-Liau Index (CLI), and Gunning-Fog Index (GFI). The PEMAT-P was used to assess understandability and actionability, with a 70% score threshold. Scores were compared across academic institutions, private practices, and commercial health publishers. The correlation between search rank and readability, understandability, and actionability was calculated. Results: Two independent searches yielded 53 websites, with 44 (83.02%) meeting inclusion criteria. No mean readability score performed below a 10th grade reading level. Only one website scored at or below 6th grade reading level. Mean understandability and actionability scores were 63.02%±12.09 and 29.77%±20.63, neither of which met the PEMAT threshold. Twelve (27.27%) websites met the understandability threshold, while none met the actionability threshold. Institution categories scored similarly in understandability (61.71%, 62.68%, 63.67%) among academic, private practice, and commercial health publishers respectively (p=0.9536). No readability or PEMAT score correlated with search rank. Conclusion: Online shoulder arthroscopy patient education materials score poorly in readability, understandability, and actionability. One website scored at the NIH and AMA recommended reading level, and 27.27% of websites scored above the 70% PEMAT score for understandability. None met the actionability threshold. Future efforts should improve online resources to optimize patient education and facilitate informed decision-making. Level of Evidence: IV.

Unicompartmental Knee Arthroplasty Utilization among Early Career Surgeons: An Evaluation of the American Board of Orthopaedic Surgery Part-II Database.

An updated understanding of unicompartmental knee arthroplasty (UKA) utilization is needed. The purpose of this study was to evaluate temporal trends in volume and utilization of UKA among early-career surgeons and to examine the influence of fellowship training status on utilization of UKA. The American Board of Orthopaedic Surgery (ABOS) Part-II database was queried from 2010 to 2019 to identify candidates who reported ≥1 total knee arthroplasty (TKA) or UKA. Self-reported history of fellowship training experiences was recorded. "High-volume" surgeons were defined as performing ≥7 UKA over the ABOS Part-II collection period. Trends were evaluated with the Cochrane-Armitage test and generalized linear models. From 2010 to 2019, a total of 2,045 candidates (28.1%) reported ≥1 TKA, while 585 candidates (8.0%) reported ≥1 UKA. The number of candidates reporting ≥1 UKA significantly increased (p = 0.001). An increase in UKA volume was observed over the study period (p < 0.001). Rates of utilization of UKA relative to TKA did not change significantly over the study period (p = 0.11). Sixty-three (2.4%) candidates met the study definition for high-volume UKA utilization. UKA procedure volume increased among ABOS Part-II candidates over the study period; however, rates of UKA utilization relative to TKA volume remained unchanged. Increasing volume of UKA performed by early-career surgeons is likely secondary to an increased number of surgeons trained in adult reconstruction. Only 2.4% of candidates who reported performing at least one knee arthroplasty procedure met the threshold for a high-volume UKA practice. Early-career surgeons should remain conscientious of UKA volume in their practice.

Cartilage and Meniscus Injuries Are More Common in Patients Undergoing Delayed Multiligament Reconstruction.

The purpose of this study was to describe the pattern of meniscus and cartilage pathology in multiligament knee injuries (MLKIs) and determine the relationship between surgical timing and injury mechanism with degree of intra-articular injury. Patients with surgically treated MLKIs over a 15-year period were retrospectively reviewed and grouped based on surgical intervention, time to intervention, and injury mechanism. The presence or absence of meniscus and chondral injury were recorded at the time of surgery. Surgical intervention within 6 weeks of injury was deemed acute, while surgery occurring more than 6 weeks from injury was classified as delayed. Over the 15-year study period, 207 patients with MLKIs were identified. Compared with acutely managed patients, the delayed intervention group had significantly more meniscus (p = 0.03) and cartilage (p < 0.01) pathology. Meniscus injury rates in MLKIs sustained during sporting activity did not differ from nonsporting injuries (p = 0.63). However, the nonsporting group had significantly more chondral injuries (p < 0.01). High-energy injury mechanism was associated with increased cartilage (p = 0.02), but not meniscus (p = 0.61) injury rates. In conclusion, surgical reconstruction of MLKIs delayed for more than 6 weeks was associated with increased meniscus and cartilage pathology.

Utilization of Arthroscopy During Ankle Fracture Fixation Among Early Career Surgeons: An Evaluation of the American Board of Orthopaedic Surgery Part II Oral Examination Database.

Background: Rotational ankle fractures are common injuries associated with high rates of intra-articular injury. Traditional ankle fracture open reduction and internal fixation (ORIF) techniques provide limited capacity for evaluation of intra-articular pathology. Ankle arthroscopy represents a minimally invasive technique to directly visualize the articular cartilage and syndesmosis while aiding with reduction and allowing joint debridement, loose body removal, and treatment of chondral injuries. The purpose of this study was to evaluate temporal trends in concomitant ankle arthroscopy during ankle fracture ORIF surgery amongst early-career orthopaedic surgeons while examining the influence of subspecialty fellowship training on utilization. Methods: The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination database was queried to identify all candidates performing at least one ankle fracture ORIF from examination years 2010 to 2019. All ORIF cases were examined to identify those that carried a concomitant CPT code for ankle arthroscopy. Concomitant ankle arthroscopy cases were categorized by candidates self-reported fellowship training status and examination year. Descriptive statistics were performed to report relevant data and linear regression analyses were utilized to assess temporal trends in concomitant ankle arthroscopy with ORIF for ankle fractures. Statistical significance was defined as p<0.05. Results: During the study period, there were 36,113 cases of ankle fracture ORIF performed of which 388 cases (1.1%) were performed with concomitant ankle arthroscopy. Ankle fracture ORIF was most frequently performed by trauma fellowship trained ABOS Part II candidates (n=8,888; 24.6%), followed by sports medicine (n=7,493; 20.8%) and foot and ankle (n=6,563; 18.2%). Arthroscopy was most frequently utilized by foot and ankle fellowship trained surgeons (293/6,270 cases; 4.5%) followed by sports medicine (29/7,464 cases; 0.4%) and trauma (4/8,884 cases; 0.1%). With respect to arthroscopic cases, 293 cases (75.5%) were performed by foot and ankle fellowship trained surgeons, 29 (7.5%) sports medicine, and 4 (1.0%) trauma. Ankle arthroscopy utilization significantly increased from 3.65 cases per 1,000 ankle fractures in 2010 to 13.91 cases per 1,000 ankle fractures in 2019 (p=0.010). Specifically, foot and ankle fellowship trained surgeons demonstrated a significant increase in arthroscopy utilization during ankle fracture ORIF over time (p<0.001; OR: 1.101; CI: 1.054-1.151). Conclusion: Ankle arthroscopy utilization during ankle fracture ORIF has increased over the past decade. Foot and ankle fellowship trained surgeons contribute most significantly to this trend. Level of Evidence: IV.

Physician-Patient Communication in the Orthopedic Clinic: Surgeon-Identified Challenges.

Background: Effective communication between the physician and the patient is crucial to quality healthcare. The orthopedic surgery clinic setting provides an environment for cultivating the physician-patient relationship, eliciting diagnostic data, and developing treatment strategies. However, little is known about the orthopedic surgeon perspective on communicating with patients. The purpose of the study was to identify patient communication and care issues faced in the orthopedic surgery clinic setting that physicians categorize as challenging. Methods: All surgeons in the department of orthopedics in a large tertiary care center were invited to respond to an online survey on common communication challenges. Physicians were asked to rate 13 challenges identified by the literature and opinion leaders using a four-point Likert scale ranging from "Not at all challenging" to "Extremely challenging". In addition, the survey included open ended questions regarding common challenges in communicating with patients and types of encounters, and thematic analysis was applied. Mean scores were calculated. Results: Nineteen orthopedic surgeons completed the survey and were included in the analysis. Orthopedic surgeons identified misaligned expectations for surgical intervention for a nonsurgical diagnosis as the most challenging encounter in the clinic (16/19). Managing postoperative patient expectations (14/19) and communicating with patients who were dissatisfied with their surgical outcome (13/19) were also commonly rated as particularly challenging. Open ended responses echoed these ratings and additional difficulty facilitating patient understanding of complex information as common communication challenges. Conclusion: Common challenges in the orthopedic clinic often surround managing patient expectations and providing effective explanations, particularly where physicians perceive a surgical intervention as inappropriate for addressing the patient complaint. Identifying these issues can guide training efforts to help orthopedic physicians in managing these and improving communication. These findings can also provide basis for collecting information about communication challenges from orthopedic surgeons across institutions. Level of Evidence: IV.

Total Knee Arthroplasty: A Quantitative Assessment of Online Patient Education Resources.

Background: Patients often turn to the online resources to learn about orthopedic procedures. As the rate of joint arthroplasty is projected to increase, the corresponding interest in relevant online education material will increase as well. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that publicly available online health information be written at the 6th grade or lower reading level to be fully understood by the average adult in the United States. Additionally, educational resources should be written such that readers can process key information (understandability) or identify available actions to take (actionability). The purpose of this study was to quantify the readability, understandability, and actionability of online patient educational materials regarding total knee arthroplasty (TKA). Methods: The most common Google™ search term utilized by the American public was determined to be "knee replacement". Subsequently two independent online searches (Google.com) were performed. From the top 50 search results, websites were included if directed at educating patients regarding TKA. Non-text websites (audiovisual), articles (news/research/industry), and unrelated resources were excluded. Readability was quantified using the following valid objective algorithms: Flesch-Kincaid Grade-Level (FKGL), Simple Measure of Gobbledygook (SMOG) grade, Coleman-Liau Index (CLI), and Gunning-Fog Index (GFI). PEMAT was utilized to assess understandability and actionability (0-100%; score ≥70% indicates acceptable scoring). The relationship between search rank with FKGL and PEMAT scores was quantified. Results: A total of 34 (68%) unique websites met inclusion criteria. The mean FKGL, SMOG, CLI, and GFI was 11.8±1.6, 11.1±1.2, 11.9±1.4, and 14.7±1.6, respectively. None of the websites scored within the acceptable NIH/AMA recommended reading levels. Mean understandability and actionability scores were 54.9±12.1 and 30.3±22.0. Only 5.9% (n=2) and 9.2% (n=1) of websites met the ≥70% threshold for understandability and actionability. Only 29.4% (n=10) sources used common language and only 26.9% (n=9) properly defined complicated medical terms. Based on website type, the mean understandability scores for academic institution, private practice, and health information publisher websites were 57.2±8.8%, 52.6±11.1%, and 54.3±15.3% (p=0.67). Readability (rho: -0.07; p=0.69), understandability (rho: -0.02; p=0.93), and actionability (rho: -0.22; p=0.23) scores were not associated with Google™ search rank. Conclusion: TKA materials scored poorly with respect to readability, understandability, and actionability. None of the resources scored within the recommended AMA/NIH reading levels. Only 5.9% scored adequately on understandability measures. Substantial efforts are needed to improve online resources to optimize patient comprehension and facilitate informed decision-making. Level of Evidence: III.

Resident Participation During Revision Total Knee Arthroplasty Is Not Associated With Increased Risk of 30-Day Postoperative Complication.

Background: Academic teaching institutions perform approximately one third of all orthopedic procedures in the United States. Revision total knee arthroplasty (rTKA) is a complex and challenging procedure that requires expertise and extensive planning, however the impact of resident involvement on outcomes is poorly understood. The aim of the study was to investigate whether resident involvement in rTKA impacts postoperative complication rates, operative time, and length of hospital stay (LOS). Methods: The American College of Surgeons National Surgical Quality Improvement Program registry was queried to identify patients who underwent rTKA procedures from 2006-2012 using CPT codes 27486 and 27487. Cases were classified as resident involved or attending only. Demographics, comorbidities, and 30-day postoperative complications were analyzed. Multiple logistic regression analysis was performed to identify independent risk factors for increased 30-day postoperative complications. Wilcoxon rank sum tests were performed to determine the impact of resident involvement on operative time and LOS with significance defined as p<0.05. Results: In total, 2,396 cases of rTKA were identified, of which 972 (40.6%) involved residents. The two study groups were similar, however the resident involved cohort had more patients with hypertension and ASA class 3 (p=0.02, p=0.04). There was no difference in complications between the cohorts (No Resident vs Resident-involved: 7.0% vs 6.7%, p=0.80). Multivariate analysis identified obesity (OR: 1.81, 95% CI: 1.18-2.79, p=0.01), morbid obesity (OR: 1.66, 95% CI: 1.09-2.57, p=0.02), congestive heart failure (OR: 5.97, 95% CI: 1.19-24.7, p=0.02), and chronic prosthetic joint infection (OR: 3.16, 95% CI: 2.184.56, p<0.01), as independent risk factors for 30-day complications after rTKA. However, resident involvement was not associated with complications within 30-days following rTKA (OR: 0.91, 95% CI: 0.65-1.26, p=0.57). Resident involvement was associated with increased operative time (p<0.001) and LOS (P<0.001). Conclusion: Resident involvement in rTKA cases is not associated with an increased risk of 30-day postoperative complications. However, resident operative involvement was associated with longer operative time and length of hospital stay. Level of Evidence: III.

Can Patients Read, Understand, and Act on Online Resources for Anterior Cruciate Ligament Surgery?

Background: Patients undergoing elective procedures often utilize online educational materials to familiarize themselves with the surgical procedure and expected postoperative recovery. While the Internet is easily accessible and ubiquitous today, the ability of patients to read, understand, and act on these materials is unknown. Purpose: To evaluate online resources about anterior cruciate ligament (ACL) surgery utilizing measures of readability, understandability, and actionability. Study Design: Cross-sectional study; Level of evidence, 4. Methods: Using the term "ACL surgery," 2 independent searches were performed utilizing a public search engine (Google.com). Patient education materials were identified from the top 50 results. Audiovisual materials, news articles, materials intended for advertising or medical professionals, and materials unrelated to ACL surgery were excluded. Readability was quantified using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, Coleman-Liau Index, Automated Readability Index, and Gunning Fog Index. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) was utilized to assess the actionability and understandability of materials. For each online source, the relationship between its Google search rank (from first to last) and its readability, understandability, and actionability was calculated utilizing the Spearman rank correlation coefficient (ρS). Results: Overall, we identified 68 unique websites, of which 39 met inclusion criteria. The mean Flesch-Kincaid Grade Level was 10.08 ± 2.34, with no website scoring at or below the 6th-grade level. Mean understandability and actionability scores were 59.18 ± 10.86 (range, 33.64-79.17) and 34.41 ± 22.31 (range, 0.00-81.67), respectively. Only 5 (12.82%) and 1 (2.56%) resource scored above the 70% adequate PEMAT-P threshold mark for understandability and actionability, respectively. Readability (lowest P value = .103), understandability (ρS = -0.13; P = .441), and actionability (ρS = 0.28; P = .096) scores were not associated with Google rank. Conclusion: Patient education materials on ACL surgery scored poorly with respect to readability, understandability, and actionability. No online resource scored at the recommended reading level of the American Medical Association or National Institutes of Health. Only 5 resources scored above the proven threshold for understandability, and only 1 resource scored above it for actionability.

Repair of gluteus medius tears with bioinductive collagen patch augmentation: initial evaluation of safety and imaging.

The purpose of this study was to perform an initial, prospective evaluation of imaging findings and outcomes after open surgical repair of gluteus medius tendon tears with bioinductive collagen patch augmentation. A prospective study was performed of patients with clinical and magnetic resonance imaging (MRI) evidence of symptomatic gluteus medius tears who underwent open, double-row suture anchor repair with bioinductive bovine collagen patch augmentation. Preoperative and 6-month postoperative MRIs were reviewed by a fellowship-trained musculoskeletal radiologist, and outcome scores were recorded preoperatively and 6 months postoperatively [Hip Outcome Score (HOS) Sport; HOS Activities of Daily Living (HOS ADL); Modified Harris Hip Score (mHHS) and International Hip Outcomes Tool (iHOT-33)]. Nine patients, four high-grade tears (≥50% tendon thickness) and five low-grade tears (<50% thickness) underwent surgical repair. At 6 months, 7/9 (77.8%) of tendons were qualitatively classified as completely healed on MRI, with no complications. Mean tendon thickness increased significantly: mediolateral dimension by 5.8 mm (P < 0.001), anteroposterior dimension by 4.1 mm (P = 0.02) and cross-sectional area (CSA) by 48.4 mm2 (P = 0.001). Gluteus medius and minimus CSA did not change significantly (P > 0.05). Patients demonstrated improvements in mean scores for HOS ADL, mHHS and iHOT that met defined minimum clinically important differences (P < 0.05). Open surgical repair of gluteus medius tendon tears with bioinductive collagen patch augmentation is safe and associated with increased tendon thickness on postoperative MRI. Early outcome scores are encouraging and should be evaluated after patients have completed postoperative rehabilitation to measure the whole effect of treatment.