Perioperative non-opioid analgesia strategies after high tibial osteotomy: a systematic review of prospective studies.

PURPOSE: Little is known about the optimal analgesia regimen after HTO. Thus, this study systematically reviewed the literature on clinical and patient-reported outcomes of pain management strategies for patients after HTO. METHODS: A comprehensive search of the PubMed, Cochrane CENTRAL, and CINAHL databases was conducted from inception through September 2023. Studies were included if they evaluated pain reduction with analgesia strategies after HTO and were excluded if they did not report pain control outcomes. RESULTS: Five studies with 217 patients were included. Patients with a multimodal intraoperative injection cocktail to the knee, femoral nerve block (FNB), or adductor canal block (ACB) for HTO had significant improvement in visual analog scale (VAS) and numerical rating scale (NRS) scores in the first 12 h postoperatively compared to controls. Patients on duloxetine had significantly lower NRS scores at 1, 7, and 14 days postoperatively and significantly lower nonsteroidal anti-inflammatory drug (NSAID) usage throughout the two-week postoperative period than the control group. Patients receiving an ACB had significantly lower opioid consumption than controls at 12 h postoperative. In patients with an FNB or ACB, no significant difference in quadriceps strength or time to straight leg raise postoperatively was observed compared to controls. CONCLUSION: A multimodal periarticular injection cocktail, FNB, or an ACB effectively reduces pain on the first day after HTO, with an ACB able to reduce opioid consumption on the first postoperative day. Duloxetine combined with an ACB effectively decreases pain for two weeks postoperatively while reducing NSAID consumption in patients after HTO. LEVEL OF EVIDENCE: IV.

The Effect of Lower Limb Alignment on Tibiofemoral Joint Contact Biomechanics after Medial Meniscus Posterior Root Repair: A Finite-Element Analysis.

INTRODUCTION: The purpose of this study was to determine how variations in lower limb alignment affect tibiofemoral joint contact biomechanics in the setting of medial meniscus posterior root tear (MMPRT) and associated root repair. METHODS: A finite-element model of an intact knee joint was developed. Limb alignments ranging from 4° valgus to 8° varus were simulated under a 1,000 N compression load applied to the femoral head. For the intact, MMPRT, and root repair conditions, the peak contact pressure (PCP), total contact area, mean and maximum local contact pressure (LCP) elevation, and total area of LCP elevation of the medial tibiofemoral compartment were quantified. RESULTS: The PCP and total contact area of the medial compartment in the intact knee increased from 2.43 MPa and 361 mm 2 at 4° valgus to 9.09 MPa and 508 mm 2 at 8° of varus. Compared with the intact state, in the MMPRT condition, medial compartment PCP was greater and the total contact area smaller for all alignment conditions. Root repair roughly restored PCPs in the medial compartment; however, this ability was compromised in knees with increasing varus alignment. Specifically, elevations in PCP relative to the intact state increased with increasing varus, as did the total contact area with LCP elevation. After root repair, medial compartment PCP remained elevated above the intact state at all degrees tested, ranging from 0.05 MPa at 4° valgus to 0.27 MPa at 8° of varus, with overall PCP values increasing from 2.48 to 9.09 MPa. For varus alignment greater than 4°, root repair failed to reduce the total contact area with LCP elevation relative to the MMPRT state. DISCUSSION: Greater PCPs and areas of LCP elevation in varus knees may reduce the clinical effectiveness of root repair in delaying or preventing the development of tibiofemoral osteoarthritis.

Patients With Posterior Cruciate Ligament Injuries Obtain Information Regarding Diagnosis, Management, and Recovery from Low-Quality Online Resources.

OBJECTIVES: This study investigates the most common online patient questions pertaining to posterior cruciate ligament (PCL) injuries and the quality of the websites providing information. METHODS: Four PCL search queries were entered into the Google Web Search. Questions under the 'People also ask' tab were expanded in order and 100 results for each query were included (400 total). Questions were categorized based on Rothwell's Classification of Questions (Fact, Policy, Value). Websites were categorized by source (Academic, Commercial, Government, Medical Practice, Single Surgeon Personal, Social Media). Website quality was evaluated based on the Journal of the American Medical Association (JAMA) Benchmark Criteria. Pearson's chi-squared was used to assess categorical data. Cohen's kappa was used to assess inter-rater reliability. RESULTS: Most questions fell into the Rothwell Fact category (54.3%). The most common question topics were Diagnosis/Evaluation (18.0%), Indications/Management (15.5%), and Timeline of Recovery (15.3%). The least common question topics were Technical Details of Procedure (1.5%), Cost (0.5%), and Longevity (0.5%). The most common websites were Medical Practice (31.8%) and Commercial (24.3%), while the least common were Government (8.5%) and Social Media (1.5%). The average JAMA score for websites was 1.49 ± 1.36. Government websites had the highest JAMA score (3.00 ± 1.26) and constituted 42.5% of all websites with a score of 4/4. Comparatively, Single Surgeon Personal websites had the lowest JAMA score (0.76 ± 0.87, range [0-2]). PubMed articles constituted 70.6% (24/34) of Government websites, 70.8% (17/24) had a JAMA score of 4 and 20.8% (5/24) had a score of 3. CONCLUSION: Patients search the internet for information regarding diagnosis, treatment, and recovery of PCL injuries and are less interested in the details of the procedure, cost, and longevity of treatment. The low JAMA score reflects the heterogenous quality and transparency of online information. Physicians can use this information to help guide patient expectations pre- and post-operatively.

Anatomic total shoulder arthroplasty with inlay glenoid component: A systematic review.

Background: A total shoulder arthroplasty (TSA) system utilizing an inlay glenoid component has been proposed as a means of reducing glenoid component loosening while still providing patients with desirable functional and clinical outcomes. The purpose of this study was to systematically review current outcomes literature on TSA using an inlay glenoid component. Methods: A literature search was conducted using PubMed/MEDLINE, Cochrane Database of Systematic Reviews, and Web of Science databases. Studies comparing pre- and postoperative functional and clinical outcomes were included. Results: Five studies with 148 shoulders (133 patients) were included. Patient-reported outcomes improved, including the American Shoulder and Elbow Surgeons score (mean change 34.1 to 80.6), Penn Shoulder Score (mean change 43.3 to 85.5), Single Assessment Numeric Evaluation score (mean change 34.1 to 80.6), and visual analog scale-pain (mean change 6.9 to 1.6). Range of motion improved for forward elevation (mean change 109.6 to 156.2) and external rotation (mean change 21.5 to 50.8). Glenoid component loosening occurred in one shoulder (0.68%). Two revision surgeries (1.35%) were performed. Discussion: The use of an inlay glenoid component is associated with improvements in postoperative pain, function, and satisfaction while minimizing rates of glenoid component loosening and the need for revision surgery over short-term follow-up. Level of evidence: systematic review, level IV.

Lower Extremity Surfing Injuries Seen at United States Emergency Departments From 2002 to 2022.

Background: Surfing is an increasingly popular sport with a high propensity for both traumatic and atraumatic injuries. Purpose: To analyze the trends, etiologies, and diagnoses of lower extremity orthopaedic-related surfing injuries presenting to United States (US) emergency departments (EDs) within a 21-year study period. Study Design: Descriptive epidemiology study. Methods: The National Electronic Injury Surveillance System database was queried for data on lower extremity surfing injuries presenting to US EDs from January 1 to December 31, 2022. Data collected included year, injury mechanism, injury location, diagnosis, and disposition. The raw data were used to calculate national estimates (NEs) based on each hospital's assigned statistical sample weight. Linear regressions were performed to analyze annual trends. Results: A total of 776 lower extremity surfing injuries were included (NE = 49,218 injuries). The mean age of the patients was 29.4 ± 13.6 years. The most common injured areas were the foot (NE = 17,411; 35.4%), lower leg (NE = 8673, 17.6%), and knee (NE = 8139; 16.5%). The most common mechanism of injury was impact with board (NE = 17,144; 34.8%), and the most common fracture locations were the lower leg (NE = 1195; 29.5%), ankle (NE = 1594; 24.5%), and foot (NE = 1495; 23.0%). There were statistically significant decreases in weighted estimates for lower extremity surfing injuries by 108 per year (P < .001), for lacerations by 76 per year (P < .001), and for sprains by 18 per year (P = .01). Impact-with-board injuries decreased by 59 injuries per year (P < .001) and constituted 63.5% of lacerations and 12.1% of fractures. Only 3.9% of patients were admitted for hospitalization. Conclusion: There was a decreasing trend in lower extremity surfing injuries presenting to US EDs during the 21-year study period.

Impacts of the Early COVID-19 Pandemic on Depressive Symptoms and Mental Health Among Student-Athletes.

Objective: Social distancing protocols due to the COVID-19 pandemic resulted in premature ending of athletic seasons and cancellation of upcoming seasons, placing significant stress on young athletes. Inability to play or forced early retirement has significant consequences on athlete's mental health, as demonstrated by an extensive body of injury literature. We hypothesize that premature suspension and cancellation of athletic events due to the COVID-19 pandemic leads to higher incidence of depressive symptoms among high-school and collegiate athletes. Further, athletes who strongly derive their sense of self-worth centered around athletics would have higher rates of depressive symptoms. Methods: High school and collegiate athletes were evaluated for depressive symptoms, emotional health and athletic identity measures through validated assessment instruments from May 2020 through July 2020. The Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test (PROMIS-10 Depression CAT), Veterans RAND-12 (VR-12), which comprises both a physical and mental health component, and Athletic Identity Measurement Scale (AIMS) were utilized. Results: Mental health assessments were completed by 515 athletes (52.4% male, 47.6% female; .84.5% collegiate, 15.5% high school). Female athletes scored significantly worse than males on VR-12 mental health assessments, as well as PROMIS-10 Depression scores; however, males scored significantly lower than females on VR-12 physical health assessments, irrespective of education level. Athletes who had strong associations with athletics as central to their personal identity exhibited worse psychologic impact on VR-12 mental health and PROMIS-10 Depression measures and female athletes in this cohort reported greater depressive symptoms than males. Conclusion: Social distancing protocols due to the COVID-19 pandemic have limited athlete's ability to participate in sports at the training and competition level. Higher rates of depressive symptoms in high school and college athletes have resulted among female athletes and those who identify strongly as an athlete.

Outcomes of the Latarjet procedure in female patients: A case series and matched-pair analysis.

Background: The objective of this study was to retrospectively report on the outcomes of female patients undergoing the Latarjet procedure. Methods: Female patients undergoing the Latarjet procedure with minimum 1 year follow-up were identified and contacted to obtain Numeric Pain Rating Scale (NPRS), Subjective Shoulder Value (SSV), and return to sport (RTS) data. Eligible females were then matched 1:1 with a male counterpart based on laterality and age (± 3 years), and outcomes compared. Results: A total of 20 female patients with a mean follow-up of 73.8 months reported postoperative NPRS and SSV scores of 2.2 ± 2.3 and 69.3 ± 22.0, respectively. Of the nine athletes, 3 (33%) reported a successful RTS at a mean of 9 months. Four patients (20.0%) required reoperation at a mean of 27.1 months. The matched analysis demonstrated similar NPRS scores between male and female patients and a trend towards lower SSV scores and rates of RTS. Conclusion: At mid-term follow-up female patients reported pain levels similar to female-specific literature reports, but overall low subjective shoulder function and RTS. Compared to propensity-matched males, females reported similar levels of pain, lower shoulder function, and lower rates of RTS, however, differences did not reach statistical significance. Level of Evidence: IV, retrospective case series.

Particulated Juvenile Articular Cartilage Allograft Transplantation for Patellofemoral Defects Shows Favorable Return-to-Sport Rates and Patient-Reported Outcomes.

PURPOSE: To report return-to-sport rates, postoperative patient-reported outcomes (PROs), complication rates, and reoperation rates of a cohort of patients undergoing particulated juvenile articular cartilage (PJAC) allograft transplantation for patellofemoral articular cartilage defects. METHODS: We performed a single-institution retrospective review of all patients with patellofemoral articular cartilage defects who received PJAC allograft transplantation from 2014 to 2022. Baseline demographic characteristics and surgical data, including concomitant surgical procedures, were collected. Clinical outcomes recorded included return-to-sport rates, complications, reoperations, and the following PRO scores: Kujala knee score, Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference score, and PROMIS Physical Function score. RESULTS: Forty-one knees with a mean age of 23.4 ± 9.7 years and mean follow-up period of 30.3 months (range, 12-107 months) were included. The mean postoperative PROMIS Pain Interference, PROMIS Physical Function, and Kujala knee scores were 47.4 ± 7.7, 52.2 ± 10.8, and 81.7 ± 16.1, respectively, reflecting low residual anterior knee pain and a return to normal function. For patients playing organized sports at the high school and collegiate levels, the overall return-to-sport rate was 100% (17 of 17). During follow-up, complications developed in 12 knees (29.3%), the most common of which was anterior-based knee pain, and 6 knees (14.6%) required a total of 8 reoperations, which occurred from 6 to 32 months postoperatively. CONCLUSIONS: The 100% return-to-sport rate and satisfactory PRO scores in our study suggest that PJAC allograft transplantation can effectively address patellofemoral cartilage defects in many patients. The complication and reoperation rates of 29.3% and 14.6%, respectively, are consistent with the challenging and heterogeneous etiology and treatment of patellofemoral articular defects. LEVEL OF EVIDENCE: Level IV, case series.

Clinical and radiographic outcomes of the modified McLaughlin procedure for locked posterior dislocation of the shoulder: a systematic review.

Background: Multiple treatment options for locked posterior dislocation of the shoulder (LPDS) have been described, including the modified McLaughlin procedure. The purpose of this review, therefore, was to perform a systematic review of the literature to synthesize the available data reporting on the clinical and radiographic outcomes of patients undergoing the modified McLaughlin procedure for the treatment of LPDS. Methods: A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library databases from inception through January 2023 was performed. Outcomes studies reporting on clinical and radiographic outcomes in patients undergoing the modified McLaughlin procedure for LPDS were included. Postoperative complications and episodes of recurrent instability were noted. Results: A total of 1322 studies were initially identified, of which 9 were deemed eligible for inclusion in our review. Among included studies, a total of 97 shoulders (96 patients) with a mean age of 37.7 years (range, 26-51) were identified. The most common mechanisms of injury included trauma, seizure, and electrocution. Reverse Hill-Sachs lesions ranged in size from 20% to 50% of the humeral head articular surface. At final follow-up, the weighted mean University of California at Los Angeles shoulder score, Constant-Murley Score, American Shoulder and Elbow Surgeons shoulder score, and visual analog scale for pain score were 29 (range, 27-31), 75 (range, 65-92), 92 (range, 83-98), and 1.9 (range, 1-2.4), respectively. Postoperative Constant-Murley Score and University of California at Los Angeles scores were highest in the one study reporting exclusively on treatment during the acute period. Weighted mean postoperative forward flexion, abduction, external rotation, and internal rotation were 154° (range, 102-176), 144° (range, 118-171), 64° (range, 44-84), and 47° (range, 42-56), respectively. Osteointegration of the lesser tuberosity was noted in all patients at the final follow-up. Postoperative complications occurred in one patient (1.0% of cohort); a screw migration successfully treated with operative removal. Recurrent instability was noted in two epileptic patients (2.1% of cohort). Conclusion: The literature surrounding the use of the modified McLaughlin procedure for LPDS remains sparse. This review demonstrates that this procedure is associated with favorable clinical and radiographic outcomes with overall low rates of complication and recurrent instability, especially when the time from injury to surgery is minimized. These findings illustrate that in patients presenting with LPDS and a reverse Hill-Sachs lesion between 20% and 50% of the humeral head articular surface, the modified McLaughlin procedure is a safe and effective treatment option.

The Finger, Wrist, and Shoulder are the Most Commonly Injured Areas in Youth Volleyball Players but the Incidence of Injuries Decreased Overall Between 2012 and 2022.

Purpose: To analyze epidemiology, mechanisms, and diagnoses of upper extremity volleyball injuries in youth who present to United States emergency departments. Methods: Data from the National Electronic Injury Surveillance System were analyzed for upper extremity volleyball injuries in patients ≤18 years old from January 1, 2012, to December 31, 2022. Data were collected for body part, diagnosis, mechanism of injury, and disposition. Weighted national estimates were calculated using the hospitals' corresponding statistical sample weights. Linear regressions were used to analyze annual trends. χ2 tests were used to analyze categorical variables. Results: A weighted national estimate of 131,624 upper extremity volleyball-related injuries occurred in the study period. Average age was 13.9 ± 2.3 years. Female patients constituted 77.6% of patients; 99.3% of patients did not require admission. The most common body parts injured were fingers (43.0%), wrists (22.8%), and shoulders (12.2%). The most common identifiable mechanisms of injury were impacts with the floor (19.4%), impacts with the ball (14.7%), and spikes/serves (5.7%). Most common diagnoses were strains/sprains (42.6%) and fractures (19.5%). Most common locations of fracture were fingers (57.4% of all fractures), wrists (16.6%), and lower arms (12.4%). There was a decrease of 544 overall injuries per year (P = .03, 95% confidence interval [CI] -1031 to -58). Female players experienced more contusions/abrasions (16.0% vs 9.9%, P < .001) and strains/sprains (46.1% vs 30.4%, P < .001) compared with male players. Female patients had decreases of 513 overall injuries (P = .01, 95% CI -881 to -144), 349 strains/sprains (P = .002, 95% CI -530 to -168), 102 contusions/abrasions (P = .008, 95% CI 170 to -34), and 92 fractures per year (P = .03, 95% CI -175 to -10). Conclusions: Youth volleyball players are at risk of upper extremity injury, particularly involving the fingers, wrist, and shoulder. Despite increasing national participation in youth volleyball, there is a decreasing incidence of upper extremity injuries. Level of Evidence: Level IV, prognostic case series.

Epidemiology and Sex-Specific Analysis of Basketball-Related Lower Extremity Fractures: A 10-Year Analysis of National Injury Data.

BACKGROUND: Basketball-related fractures involving the lower extremities frequently present to emergency departments (ED) in the United States (US). This study aimed to identify the primary mechanisms, distribution, and trends of these injuries. HYPOTHESIS: We hypothesize that (1) lower extremity fracture frequency will decrease from 2013 to 2022, (2) the ankle will be the most common fracture site, and (3) noncontact twisting will be the most common injury mechanism. STUDY DESIGN: Descriptive epidemiological. LEVEL OF EVIDENCE: Level 3. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried for lower extremity fractures from basketball presenting to US EDs from January 1, 2013 to December 31, 2022. Patient demographics, injury location, and disposition were recorded. The injury mechanism was characterized using the provided narrative. National estimates (NEs) were calculated using the NEISS statistical sample weight. Injury trends were evaluated by linear regression. RESULTS: There were 6259 cases (NE: 185,836) of basketball-related lower extremity fractures. Linear regression analysis of annual trends demonstrated a significant decrease in lower extremity fractures over the study period (2013-2022: P = 0.01; R2 = 0.64). The most common injury mechanism was a noncontact twisting motion (NE: 49,897, 26.9%) followed by jumping (NE: 39,613, 21.3%). The ankle was the most common fracture site (NE: 69,936, 37.6%) followed by the foot (NE: 49,229, 26.49%). While ankle and foot fractures decreased significantly (P < 0.05), fractures of the lower leg, knee, toe, and upper leg showed no significant trends (P = 0.09, 0.75, 0.07, and 0.85, respectively). CONCLUSION: Basketball-related lower extremity fractures decreased from 2013 to 2022, with the ankle being the most common fracture site and most fractures arising from a noncontact twist. Increasing utilization of outpatient clinics may have contributed to the decline, particularly for ankle and foot fractures. The prevalence of ankle fractures and twisting-related injuries reinforces the importance of protective footwear and targeted strengthening protocols.

Patient-reported outcomes measurement information system instruments in knee arthroplasty patients: a systematic review of the literature.

BACKGROUND: The purpose of this study is to provide a systematic review of the literature pertaining to Patient-Reported Outcome Measurement Information System (PROMIS) validation and utilization as an outcomes metric in total knee arthroplasty (TKA) patients. This is the first systematic review on PROMIS use in total knee arthroplasty patients. METHODS: A systematic search of the Pubmed/MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study characteristics, patient demographics, psychometric properties (Pearson and Spearman correlation) with legacy patient-reported outcome measurement (PROM) instruments, floor and ceiling effects, responsiveness, and minimum clinically important difference (MCID) and PROMIS outcomes were recorded and analyzed. RESULTS: Fifteen studies investigating PROMIS in 11,140 patients were included. The weighted-average Pearson correlation coefficient comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.62 [standard error (SE) = 0.06] and the weighted-average Spearman correlation comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.59 (SE = 0.06), demonstrating moderate-to-strong correlation and validity. There were no differences in weighted average floor [0.03% (SE = 3.1) versus 0% (SE = 0.1) versus 0.01% (SE = 1.1); p = 0.25] or ceiling effects [0.01% (SE = 0.7) versus 0.02% (SE = 1.4) versus 0.04% (SE = 3.5); p = 0.36] between PROMIS and legacy instruments. The weighted average for percentage of patients achieving MCID was 59.1% for global physical health (GPH), 26.0% for global mental health (GMH), 52.7% for physical function (PF), 67.2% for pain interference (PI), and 37.2% for depression. CONCLUSION: Notably, PROMIS global physical health, physical function, and pain interference were found to be significantly responsive, with PROMIS pain interference most effectively capturing clinical improvement as evidenced by the achievement of MCID.

The Quality of YouTube Content on Ulnar Collateral Ligament Injuries Is Low: A Systematic Review of Video Content.

Purpose: To provide an evaluation of the quality of diagnostic and treatment information regarding ulnar collateral ligament injuries on YouTube. Methods: YouTube was searched using the terms "ulnar collateral ligament," "Tommy John surgery," and "UCL surgery." The first 100 results for each 3 terms were screened for inclusion. Each included video was graded based on its diagnostic and treatment content and assigned a quality assessment rating. Video characteristics such as duration, views, and "likes" were recorded and compared between video sources and quality assessment ratings. Results: A total of 120 videos were included in the final analysis. Only 17.5% provided very useful to excellent quality content. Only 3 videos (2.5%) provided excellent quality content; these were all physician-sponsored videos. These 3 videos only achieved an excellent score for diagnostic content; no video achieved an excellent score for treatment content. Most videos were scored as somewhat useful for both diagnostic (40%) and treatment (56.7%) content. Videos classified as somewhat useful had the highest number of average views (27,197), with a mean duration of 7 minutes 40 seconds. The most common video source was physician sponsored (32%), followed by educational (26%). Physician videos had the lowest number of views (5,842 views). Conclusions: The quality of ulnar collateral ligament-related information on YouTube is low. Differential diagnoses for related symptoms, accurate surgical indications, and thorough discussions of adverse outcomes were the most lacking information. Physician-sponsored and educational videos provided the highest-quality information but had the lowest number of average views. Clinical Relevance: Because most Internet users in the United States search for information regarding their medical issues online, it is important to understand the quality of available online medical information. Knowing this can help inform the necessary next steps to improve the quality and comprehensibility of online medical information.

Early Postoperative Complications and Associated Variables After Tibial Tubercle Osteotomy: A 15-Year Experience From a Single Academic Institution.

Background: Tibial tubercle osteotomy (TTO) is a well-established surgical treatment option for patients with patellofemoral disorders. Purpose: To determine the rate of early (≤90 day) postoperative complications after TTO and variables related to postoperative complications. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent TTO at a single academic institution within a 15-year period (2008-2022) were identified. All patients with a minimum 90-day follow-up were considered for study inclusion. Exclusion criteria were age younger than 14 years and revision surgery. Patient characteristics, surgical history, and concomitant procedures were identified, and risk factor analysis was performed to identify variables associated with early postoperative complications. Results: A total of 344 knees in 313 patients met eligibility criteria and were included in the final analysis. One intraoperative complication (0.3%), a premature closure of the incision before repair of the vastus medialis, was identified. There were 141 postoperative complications (138 surgical, 3 medical) in 118 patients for a complication rate of 34.3%. The most common complications were stiffness requiring a nonstandard-of-care intervention (16.3%), superficial wound infection/wound dehiscence (8.1%), and hemarthrosis/effusion requiring aspiration (5.8%). Patients experiencing postoperative complications were older (mean difference, 3.49 years; 95% CI, 1.26-5.73 years; P = .002), had a higher mean Charlson Comorbidity Index (mean difference, 0.26; 95% CI, 0.08-0.45; P = .006), and were more likely to be current smokers (P = .015) compared with patients with no complications. Inpatient surgery (defined as surgery in a hospital setting with at least 1 overnight stay) was associated with postoperative complications (odds ratio [OR], 2.29; 95% CI, 1.39-3.77; P = .001); this association remained significant generation of a multivariate model (OR, 2.07; 95% CI, 1.19-3.58; P = .010). Previous surgery on the ipsilateral knee (P < .001) and concomitant autologous chondrocyte implantation (P = .046) were also associated with postoperative complications. Conclusion: The study findings indicated a low intraoperative complication rate (0.3%) and a relatively high early postoperative (≤90 day) complication rate (34.3%) after TTO. Variables associated with postoperative complications included greater age, higher Charlson Comorbidity Index, surgery in an inpatient setting, previous surgery on the ipsilateral knee, and concomitant autologous chondrocyte implantation.

Decreasing Trend in Upper Extremity Surfing Injuries Presenting to United States Emergency Departments - A 20-Year Analysis.

Surfing is a globally popular recreational sport with limited epidemiologic data. Currently, there is a paucity of literature regarding injury profiles and mechanisms of orthopaedic-related injuries. This study analyzed trends, etiologies, and diagnoses of upper extremity orthopaedic-related surfing injuries presenting to United States (US) emergency departments. The National Electronic Injury Surveillance System database was accessed to query upper extremity surfing-related injuries presenting to US emergency departments from January 1, 2002 to December 31, 2021. Data were analyzed for year, body part, mechanism of injury, diagnosis, and disposition. National estimates were calculated based on the assigned statistical sample weight of each hospital. A total of 33 323 surfing-related injuries were included. The most common upper extremity body parts involved 15 169 shoulders (45.5%), 4220 fingers (12.7%), and 3753 hands (11.3%). The most common identifiable mechanisms of injuries were 7474 board-to-body (22.4%), 4188 impact with sand (12.6%), and 2639 impact with water (7.9%). Overuse constituted 7.2% of overall upper extremity injuries but 40% of strains. Only 2.2% of injuries required hospital admission. Between 2002 and 2021, there was a decreasing annual trend in upper extremity surfing-related injuries (P=.01). The decreasing trend in emergency department visits may be due to urgent care utilization and training for surfers and lifeguards to manage these injuries on-site, as the majority were minor given the small proportion requiring hospital admission. Chronic stress on rotator cuff and peri-scapular musculature while paddling in the prone position likely contributed to the large proportion of overuse injury.

Statistical Fragility of Randomized Controlled Trials Evaluating Platelet-Rich Plasma Use for Knee Osteoarthritis: A Systematic Review.

Background: Numerous studies have been published on the use of platelet-rich plasma (PRP) for knee osteoarthritis (OA), with conflicting results. Purpose: To determine the fragility index (FI) and fragility quotient (FQ) of randomized controlled trials (RCTs) that evaluated the use of PRP to treat knee OA. Study Design: Systematic review. Methods: RCTs evaluating the efficacy of PRP injections for knee OA from 2000 to 2020 were included for analysis according to PRISMA guidelines. The FI was determined by calculating the number of outcome event reversals required to change the statistical significance. The associated FQ was determined by dividing the FI by the sample size. Results: Our initial search resulted in 41,149 studies, of which 8 RCTs (678 patients, 72 outcome events) were included in the analysis. One study failed to report PRP formulation details, whereas 87.5% of studies reported using either leukocyte-rich or leukocyte-poor PRP. The platelet concentration was reported in 25% of the included trials. The overall FI of the 72 outcome events was 8.5. Accounting for sample size, the associated FQ was determined to be 0.14, suggesting that the reversal of 14% of outcome events was required to change outcome significance. There were 51 statistically significant outcomes, of which the FI and FQ were 12 and 0.164, respectively. Conclusion: Comprehensive fragility analysis suggested that the published literature evaluating the efficacy of PRP use for knee OA may lack statistical stability. We recommend the reporting of both an FI and FQ in addition to P value analysis to provide a clear and thorough understanding of the statistical integrity of studies reporting on PRP use for knee OA.

Republication of "Evidence Versus Practice: Operative Treatment Preferences in Hallux Valgus".

Background: There is substantial variability in the operative treatment of hallux valgus despite the existence of high quality evidence to guide treatment decisions. The purpose of this study was to determine the current trends in the treatment of mild, moderate, and severe hallux valgus and if greater degrees of consensus correlate with the presence of higher-level evidence. Methods: Members of the American Orthopaedic Foot & Ankle Society completed a 14-item survey. A total of 131 (14%) of 922 members completed the survey. Three cases representing 3 stages of HV were presented, and respondents selected their preferred treatment. Preferred forms of proximal and distal metatarsal osteotomies, as well as mode of fixation for each, were inquired. Results: In the treatment of mild hallux valgus without second metatarsalgia, 80% of those surveyed chose a distal metatarsal osteotomy, while, if second metatarsalgia was present, 56% chose a distal metatarsal osteotomy with a second metatarsal-shortening osteotomy. In the treatment of moderate hallux valgus, there was generally less consensus, while, in the treatment of severe hallux valgus, a majority of those surveyed chose a Lapidus procedure, with the addition of a second metatarsal-shortening osteotomy in the presence of second metatarsalgia. The most popular distal and proximal metatarsal osteotomies, respectively, were chevron osteotomy (80%) and opening wedge osteotomy (33%). The presence of Level I evidence did not significantly correlate with higher degrees of consensus. Conclusion: Despite the existence of high-quality evidence supporting the use of certain procedures in the treatment of HV, there exists an apparent lack of consensus among surgeons about the choice of surgical procedures. Moreover, higher-level evidence was not correlated with greater consensus in hallux valgus. Level of Evidence: Level II.

Early Postoperative Complications and Associated Variables After High Tibial Osteotomy and Distal Femoral Osteotomy: A 15-Year Experience From a Single Academic Institution.

BACKGROUND: High tibial osteotomy (HTO) and distal femoral osteotomy (DFO) are well-recognized treatments to address varus and valgus malalignment, respectively, in the setting of symptomatic unicompartmental arthritis of the tibiofemoral joint. The existing literature is limited in its ability to characterize complications after HTO or DFO procedures. PURPOSE: The objective of this study was to determine the rate of early (≤90 days) postoperative complications and associated variables from the 15-year experience of a single academic institution. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients treated at a single academic institution between 2008 and 2022 who underwent HTO or DFO procedures were identified. All patients with minimum 90-day follow-up were considered for inclusion in the study. Exclusion criteria were inadequate follow-up, unavailable medical records, age <14 years, and revision osteotomy. Patient demographic characteristics, surgical history, and concomitant procedures were identified, and risk factor analysis was performed to identify variables associated with early postoperative complications. All intraoperative complications were recorded. RESULTS: A total of 243 knees in 232 patients met eligibility and were included in the final analysis. Three intraoperative complications (1.2%) involving fracture extension of the osteotomy occurred. There were 127 early postoperative complications (121 surgical, 6 medical) in 102 knees (68 with HTO and 34 with DFO). Medical complications included pulmonary embolus in 3 patients (1.2%), urinary tract infection in 2 patients (0.8%), and postoperative ileus requiring prolonged hospitalization in 1 patient (0.4%). The most common complications were stiffness requiring a non-standard of care intervention (17.7%), superficial wound infection or wound dehiscence (13.2%), and hemarthrosis or effusion requiring aspiration (6.6%). The rate of deep infection requiring irrigation and debridement was 4.1%. Variables associated with early postoperative complications included smoking (odds ratio [OR], 3.05; 95% CI, 1.34-6.94; P = .008), concomitant chondroplasty and/or loose body removal (OR, 2.55; 95% CI, 1.50-4.33; P = .001), and concomitant ligament reconstruction (OR, 3.97; 95% CI, 1.37-11.53; P = .011). CONCLUSION: These 15-year data revealed a low rate of intraoperative complications (1.2%) and a relatively high rate of early (≤90 days) postoperative complications (42.0%) after an HTO or DFO procedure. Surgeons should be aware of the increased postoperative complications associated with smoking, concomitant chondroplasty, and concomitant ligament reconstruction and should use this information to counsel patients regarding appropriate expectations in the postoperative period.

Trends in Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Background: Despite the prevalence of patient-reported outcomes (PROs) to evaluate results after anterior cruciate ligament (ACL) reconstruction, there exists little standardization in how these metrics are reported, which can make wider comparisons difficult. Purpose: To systematically review the literature on ACL reconstruction and report on the variability and temporal trends in PRO utilization. Study Design: Systematic review. Methods: We queried the PubMed Central and MEDLINE databases from inception through August 2022 to identify clinical studies reporting ≥1 PRO after ACL reconstruction. Only studies with ≥50 patients and a mean 24-month follow-up were considered for inclusion. Year of publication, study design, PROs, and reporting of return to sport (RTS) were documented. Results: Across 510 studies, 72 unique PROs were identified, the most common of which were the International Knee Documentation Committee score (63.3%), Tegner Activity Scale (52.4%), Lysholm score (51.0%), and Knee injury and Osteoarthritis Outcome Score (35.7%). Of the identified PROs, 89% were utilized in <10% of studies. The most common study designs were retrospective (40.6%), prospective cohort (27.1%), and prospective randomized controlled trials (19.4%). Some consistency in PROs was observed among randomized controlled trials, with the most common PROs being the International Knee Documentation Committee score (71/99, 71.7%), Tegner Activity Scale (60/99, 60.6%), and Lysholm score (54/99, 54.5%). The mean number of PROs reported per study across all years was 2.89 (range, 1-8), with an increase from 2.1 (range, 1-4) in studies published before 2000 to 3.1 (range, 1-8) in those published after 2020. Only 105 studies (20.6%) discretely reported RTS rates, with more studies utilizing this metric after 2020 (55.1%) than before 2000 (15.0%). Conclusion: There exists marked heterogeneity and inconsistency regarding which validated PROs are used in studies related to ACL reconstruction. Significant variability was observed, with 89% of measures being reported in <10% of studies. RTS was discretely reported in only 20.6% of studies. Greater standardization of outcomes reporting is required to better promote objective comparisons, understand technique-specific outcomes, and facilitate value determination.

Defining Operative Indications in Lisfranc Injuries: A Systematic Review.

OBJECTIVE: The aim of this review was to determine operative indications for Lisfranc injuries. METHODS: A systematic review using a MEDLINE literature search was performed using the index "Lisfranc Injury" from 1980 onward using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines where applicable. Inclusion criteria were all clinical studies reporting on the management of Lisfranc injuries obtained via the search index, including case reports, review articles, cohort studies, and randomized trials. Non-English-language articles, inaccessible articles, those not relevant to the management of Lisfranc injuries (biomechanical, cadaveric, and technique articles), and those that did not explicitly state operative indications (vague or absent indications) were excluded. RESULTS: After identifying 737 studies, the full text of 391 studies was reviewed, and 58 reports providing explicit operative indications were included in the final analysis. Fifty-one (81.1%) studies provided diastasis cutoffs varying ≥2 mm (35/58; 60.4%), ≥1 mm (13; 22.4%), and ≥3 mm (3; 5.2%); the diastasis location was most commonly unspecified (31/58; 53.5%) or varied between combinations of metatarsal, tarsal, cuboid, and cuneiform bones (20/58; 27.6%). Specific imaging criteria for surgery included an avulsion fracture or fleck sign (3/58; 5.2%), arch height loss (3/58; 5.2%), and a tear on magnetic resonance imaging (5; 8.6%). The 11 (19%) studies defining operative indications in terms of classification schemes used the Nunley and Vertullo (8/58; 13.8%), Myerson (2; 3.5%), and Buehren (1; 1.7%) systems. Twenty-one (36.2%) studies provided multiple operative indications. CONCLUSION: The most common Lisfranc operative indications among the limited reporting studies varied from a 1- to 3-mm diastasis across several locations. It is imperative for operative indications to be reported with an increased frequency and in a homogenous fashion to guide the clinical management of these subtle injuries. LEVELS OF EVIDENCE: Level IV; systematic Review.