Unplanned reoperation is common following intramedullary nailing of open femoral shaft fractures: A retrospective review.

Background: The objective of this study is to investigate the incidence of unplanned reoperation, nonunion and infection following open femoral shaft fractures treated with an intramedullary nail and correlate these occurrences with patient variables and injury characteristics. Methods: A retrospective review of open femur fractures from a level 1 trauma center between 2012 and 2020 was performed. Ninety-five patients who sustained an open femur fracture, were treated definitively with an intramedullary nail, and had at least 3 months of follow-up were included in the analysis for surgical site infection. Seventy-three of these patients had at least one year of follow-up. After excluding planned bone grafting for segmental defects, 67 patients were included in the analysis of unplanned reoperation. Results: The rate of unplanned reoperation was 31.3 %, with 57 % of these operations occurring to address nonunion. The overall nonunion rate was 18 %. In patients who did not require reoperation to obtain union, the median time to union for the cohort was 6 months, with an interquartile range of 3-7.5 months. Post-operative surgical site infection occurred in 11.6 % of patients. Conclusions: In conclusion, unplanned reoperation following intramedullary nailing of open femur fractures occurs in nearly 1/3rd of patients and the rates of nonunion and surgical site infection may be higher than previously reported in the literature. Reoperation most closely correlates with the OTA Open Fracture Classification System. Patients with open femur fractures should be counseled that reoperation is often required to obtain fracture union, with soft tissue and fracture injury severity predicting complications.

Efficacy of Hematoma Block After Intramedullary Rod Fixation of Femoral Shaft Fractures: A Prospective, Double-Blinded, Randomized Controlled Trial.

OBJECTIVES: To evaluate the efficacy of an intraoperative, postfixation fracture hematoma block on postoperative pain control and opioid consumption in patients with acute femoral shaft fractures. DESIGN: Prospective, double-blinded, randomized controlled trial. SETTING: Academic Level I Trauma Center. PATIENTS/PARTICIPANTS: Eighty-two consecutive patients with isolated femoral shaft fractures (OTA/AO 32) underwent intramedullary rod fixation. INTERVENTION: Patients were randomized to receive an intraoperative, postfixation fracture hematoma injection containing 20 mL of normal saline or 0.5% ropivacaine in addition to a standardized multimodal pain regimen that included opioids. MAIN OUTCOME MEASUREMENTS: Visual analog scale (VAS) pain scores and opioid consumption. RESULTS: The treatment group demonstrated significantly lower VAS pain scores than the control group in the first 24-hour postoperative period (5.0 vs. 6.7, P = 0.004), 0-8 hours (5.4 vs. 7.0, P = 0.013), 8-16 hours (4.9 vs. 6.6, P = 0.018), and 16-24 hours (4.7 vs. 6.6, P = 0.010), postoperatively. In addition, the opioid consumption (morphine milligram equivalents) was significantly lower in the treatment group compared with the control group over the first 24-hour postoperative period (43.6 vs. 65.9, P = 0.008). No adverse effects were observed secondary to the saline or ropivacaine infiltration. CONCLUSIONS: Infiltrating the fracture hematoma with ropivacaine in adult femoral shaft fractures reduced postoperative pain and opioid consumption compared with saline control. This intervention presents a useful adjunct to multimodal analgesia to improve postoperative care in orthopaedic trauma patients. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors and Characteristics of Recalcitrant Osteomyelitis After Initial Surgical and Antibiotic Treatment.

OBJECTIVES: To evaluate the injury, patient, and microbiological characteristics that place patients at risk for recalcitrant fracture-related infection and osteomyelitis despite appropriate initial treatment. DESIGN: Retrospective chart review. SETTING: Three level I trauma centers. PATIENTS AND PARTICIPANTS: Two hundred and fifty-seven patients undergoing surgical debridement and antibiotic therapy for osteomyelitis from 2003 to 2019. MAIN OUTCOME MEASUREMENTS: Patients were categorized as having undergone serial bone debridement if they had 2 separate procedures a minimum of 6 weeks apart with a full course of appropriate antibiotics in between. Patient records were reviewed for age, injury location, body mass index, smoking status, comorbidities, and culture results including the presence of multidrug-resistant organisms and culture-negative osteomyelitis. RESULTS: A total of 257 patients were identified; 49% (n = 125) had a successful single course of treatment, and 51% (n = 132) required repeat debridement for recalcitrant osteomyelitis. At the index treatment for osteomyelitis, the most common organisms in both groups were methicillin-resistant (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA). There was no significant difference in incidence of polymicrobial infection between the 2 groups (25% vs. 20%, P = 0.49). The most common organisms cultured at the time of repeat saucerization remained MRSA and MSSA; however, the same organism was cultured from both the index and repeat procedures in only 28% (n = 37) of cases. Diabetic patients, intravenous drug use status, delay to diagnosis, and open fractures of the lower leg are independent risk factors for failure of initial treatment of posttraumatic osteomyelitis. CONCLUSIONS: Successful eradication of fracture-related infection and posttraumatic osteomyelitis is difficult and fails 51% of the time despite standard surgical and antimicrobial therapy. Although MRSA and MSSA remain the most common organisms cultured, patients who fail initial treatment for osteomyelitis often do not culture the same organisms as those obtained at the index procedure. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Diagnosis of Occult Infection Using Fracture-Related Infection Criteria at the Time of Nonunion Repair.

OBJECTIVES: To apply the recently developed fracture-related infection criteria to patients presenting for repair of fracture nonunion and determine the incidence and associated organisms of occult infection in these patients. DESIGN: Retrospective study. SETTING: Tertiary referral trauma center. PATIENTS AND PARTICIPANTS: Patients presenting with fracture nonunion after operative intervention. MAIN OUTCOME MEASUREMENTS: Demographic variables, injury characteristics, culture results, and physical examination and laboratory values at the time of presentation. RESULTS: A total of 270 nonunion patients were identified. Sixty-eight percent (n = 184) had no clinical or laboratory signs of infection at presentation before nonunion repair. After operative intervention, 7% of these clinically negative patients (n = 12/184) had positive intraoperative cultures indicating occult infection. The most common organisms causing occult infection were low-virulence coagulase-negative Staphylococcu s (83%) and Cutibacterium acnes (17%). Thirty-two percent of patients (n = 86/270) presented with clinical and/or laboratory signs of infection at presentation before nonunion repair, with 19% of these patients (n = 16/86) having negative cultures. The most common organisms in this group of patients with positive clinical signs and intraoperative cultures were methicillin-resistant Staphylococcus Aureus (21%) and gram-negative rods (29%). Patients with nonunion of the tibia were significantly more likely to have high-virulence organism culture results ( P < 0.001). CONCLUSIONS: Based on this analysis, occult infection occurs in 7% of patients presenting with nonunion and no clinical or laboratory signs of infection. We recommend that all patients should be carefully evaluated for infection with intraoperative cultures regardless of presentation. Organisms associated with occult infection at the time of nonunion repair were almost exclusively of low virulence ( CoNS and C. Acnes ) and were more likely to present in the upper extremity. Patients with nonunion of the tibia were more likely to have infection secondary to high-virulence organisms and demonstrate clinical or laboratory signs of infection at the time of presentation. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hybrid 2-Point Suture Anchor Technique for Patellar Fixation in Medial Patellofemoral Ligament Reconstruction.

Several techniques for patellar fixation for reconstruction of the medial patellofemoral ligament (MPFL) have been described in the literature. Despite the success of MPFL reconstruction reported in the literature, there is insufficient evidence to recommend a standard method of patellar fixation. A hybrid 2-point fixation technique allows for increased contact area and contact pressure between the insertion of the graft and the patella and offers a broad insertion of the graft onto the width of the patella, thus allowing for a more native attachment site to be re-created. The technique involves 2 suture anchors to increase graft compression onto the patella. This construct increases the primary load to failure of the repair, increases the surface contact area, and increases the stability of the MPFL reconstruction. These mechanical advantages decrease the chance of recurrent patellar instability and the chance of patellar fracture by avoiding transpatellar fixation.

An MRI-based Study to Investigate If the Patella is Truly Centred between the Femoral Condyles in the Coronal Plane.

Background: An AP knee radiograph is considered adequate if the patella is centred between the femoral condyles. Our previous studies demonstrated a tendency for lateral patellar deviation on an AP view orthogonal to the posterior femoral condyles. However, findings were based on cadaveric samples limited by the lack of soft tissue effects on patellar positioning. Materials and methods: After excluding those with deformity or damage to osseous or ligamentous structures, 106 knee MRI scans were randomly selected. Patellar centring was calculated as a percentage of total distal femoral intercondylar width and represented how lateral the centre of the patella is located with respect to the midpoint of the femoral condyles. Multiple regression analysis was performed to determine the relationship between patellar centring and age, gender, anatomic lateral distal femoral angle (aLDFA), medial proximal tibial angle (MPTA) and tibial tuberosity to trochlear groove (TT-TG) distance. Results: There were 35 males and 71 females included in the study with a mean age of 29 ± 14 years. Mean patellar centring was 8 ± 4%. There was a statistically significant correlation between TT-TG distance and positive (lateral) patellar centring (standardised ß = 0.36, p <0.01). There were no associations between aLDFA and MPTA with patellar centring. Conclusion: This study demonstrates that the patella is rarely perfectly centred and is usually positioned slightly laterally within the femoral condyles in an AP view orthogonal to the posterior aspect of the femoral condyles. The use of supine MRI scans makes this data relevant to a patient on the operating room table. How to cite this article: Shah NS, Kyriakedes JC, Liu RW. An MRI-based Study to Investigate If the Patella is Truly Centred between the Femoral Condyles in the Coronal Plane. Strategies Trauma Limb Reconstr 2022;17(2):63-67.

Anterior Pelvic Ring Fracture Pattern Predicts Subsequent Displacement in Lateral Compression Sacral Fractures.

OBJECTIVE: To determine if anterior pelvic fracture pattern in lateral compression (LC) sacral fractures correlates with subsequent displacement on examination under anesthesia (EUA) or follow-up in both nonoperative and operative cases. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS: Two hundred twenty-seven skeletally mature patients with traumatic LC (OTA/AO 61B1.1, 61B2.1-2, and 61B3.1-2) pelvic ring injuries treated nonoperatively, with EUA, or with pelvic fixation were included. INTERVENTION: The study intervention included retrospective review of patients' charts and radiographs. MAIN OUTCOME MEASUREMENT: Displacement on EUA or follow-up radiographs (both operative and nonoperative) correlated with anterior pelvic ring fracture pattern. RESULTS: Independent of sacral fracture pattern (complete or incomplete), risk of subsequent displacement on EUA or at follow-up after both nonoperative and operative treatments correlated strongly with ipsilateral superior and inferior pubic rami fractures that were either comminuted (95.6%, P < 0.001) or oblique (100%, P < 0.001). Patients with transverse or lack of inferior pubic ramus fracture did not displace (0%, P < 0.001). Out of 21 LC injuries treated with posterior-only fixation, displacement at follow-up occurred in all 11 patients (100%) with comminuted and/or oblique superior and inferior pubic rami fractures. Nakatani zone I and II rami fractures correlated most with risk of subsequent displacement. CONCLUSIONS: Unstable anterior fracture patterns are characterized as comminuted and/or oblique fractures of ipsilateral superior and inferior pubic rami. EUA should be strongly considered in these patients to disclose occult instability, for both complete and incomplete sacral fracture patterns. Additionally, these unstable anterior fracture patterns are poor candidates for posterior-only fixation and supplemental anterior fixation should be considered. Irrespective of sacral fracture pattern (complete or incomplete), nonoperative management is successful in patients with transverse or lack of inferior pubic ramus fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Low interobserver and intraobserver reliability using the Matta radiographic system for intraoperative assessment of reduction following acetabular ORIF.

INTRODUCTION: The system described by Matta for rating acetabular fracture quality of reduction following ORIF has been used extensively throughout the literature. However, the reliability of this system remains to be validated. We sought to determine the interobserver and intraobserver reliability of this system when used by fellowship-trained pelvic and acetabular surgeons to evaluate intraoperative fluoroscopy. METHODS: This is a retrospective evaluation of a prospectively collected acetabular fracture database at an academic level I trauma center. The quality of reduction of all acetabular fractures treated with open reduction internal fixation (ORIF) between May 2013 and December 2015 was assessed using three standard intraoperative fluoroscopic views (anteroposterior and two 45˚ oblique Judets). Displacement of ≤1 mm was considered to be an anatomic reduction, 2-3 mm imperfect, and >3 mm poor according to the system described by Matta. A total of 107 acetabular fractures treated with ORIF with complete intraoperative fluoroscopic images during that time period were available for review. Acetabular fracture reductions were reviewed by the operative surgeon at the time of surgery and subsequently reviewed by two fellowship-trained pelvic and acetabular surgeons. All reduction assessments were performed in a blinded fashion. The primary outcome measure was interobserver reliability for assessing reduction quality. This was evaluated using a weighted kappa (κw) statistic between each evaluator and the operative surgeon and a generalized kappa (κg) for all 3 surgeons. After a 6-week "washout interval," the surgeons reviewed the images again and intraobserver agreement was calculated using a weighted kappa statistic. RESULTS: Interobserver reliability based on the initial assessment was low (κg = 0.09); however, did slightly improve with the second assessment to fair (κg = 0.24). Intraobserver reliability ranged from slight (κw = 0.20) to moderate (κw = 0.53) among the surgeons. DISCUSSION: Low interobserver and intraobserver reliability was found when quality of reduction was assessed with intraoperative fluoroscopic images by the operative and two other pelvic and acetabular surgeons using the Matta system. Given the importance of an anatomic reduction on functional and radiographic outcomes, an accurate and reliable system for assessing intraoperative quality of reduction is essential.

Rotator cuff tear with scapular dyskinesis treated with a pectoralis major transfer and rotator cuff repair: a case report.

We report a 45-year-old man who presented with a rotator cuff tear and scapular dyskinesis of his left shoulder and underwent a pectoralis major split transfer with an allograft to the inferior border of his scapula. The patient reported significant improvement in shoulder function and decreased severity of his scapular dyskinesis. Combined arthroscopic rotator cuff repair and allograft scapula stabilization is a novel technique for the unusual clinical presentation reported in this case report. To the best of our knowledge, this is the first reported surgical management of a patient with rotator cuff repair and non-palsy-related scapular dyskinesis.

Recall Bias in Retrospective Assessment of Preoperative American Shoulder and Elbow Surgeons Scores After Reverse Total Shoulder Arthroplasty.

INTRODUCTION: Although reverse total shoulder arthroplasty (RTSA) has been shown to be effective for the treatment of cuff tear arthropathy (CTA), the patient's inability to accurately recall their preoperative shoulder condition could skew their perception of the effectiveness of the procedure. Identifying patients who are susceptible to notable recall bias before surgery can help surgeons counsel patients regarding expectations after surgery. The purpose of this study was to evaluate whether patients who undergo RTSA are susceptible to recall bias and, if so, which factors are associated with poor recollection. METHODS: Patients who underwent RTSA for CTA by the senior author between September 2016 and September 2018 were identified. All patients completed the American Shoulder and Elbow Surgeons (ASES scores) Standardized Assessment Form at the time of preoperative assessment. Patients were contacted at a minimum of 24 months after surgery to retrospectively assess their preoperative condition. RESULTS: A total of 72 patients with a mean age of 72.2 ± 7.65 years completed a retrospective shoulder assessment at 28.3 ± 7.3 months postoperatively. Patient assessment of shoulder condition showed poor reliability (intraclass correlation coefficient = 0.453, confidence interval, 0.237-0.623). Greater preoperative shoulder ASES scores were associated with a greater difference between preoperative ASES scores and recall ASES scores (ß = 0.275, P < 0.001). CONCLUSION: Patients who undergo RTSA for CTA are susceptible to clinically significant recall bias. Patients with better preoperative condition recall worse preoperative shoulder conditions compared with patients with worse preoperative conditions and are susceptible to a higher degree of recall bias. This patient population should be identified preoperatively and have notable counseling before and after surgery to help them better understand their disease burden and what to expect after surgical intervention. LEVEL OF EVIDENCE: III, diagnostic cohort study.

Cartilaginous defect of the lateral trochlea following suprapatellar nailing of an open tibial shaft fracture: a case report.

A 34-year-old female sustained a 1.8 cm full-thickness chondral defect of the right lateral trochlear surface as the result of intramedullary tibial nailing via a suprapatellar portal to treat a displaced right sided open comminuted spiral fracture of the distal tibial shaft. An osteochondral allograft was used to treat the chondral defect. Iatrogenic injury to intraarticular structures is a potential complication when inserting a tibial nail via a suprapatellar portal. Using proper technique with cannula systems and guide pins is essential to lowering the risk of damage to intraarticular structures.

Effect of the COVID-19 Pandemic on Sports-Related Injuries Evaluated in US Emergency Departments.

BACKGROUND: Organized athletics are undergoing a gradual resumption after a prolonged hiatus in 2020 because of the coronavirus disease 2019 (COVID-19) pandemic. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the effect of the 2020 COVID-19 period on emergency department (ED) visits for sports-related injuries in the United States. It was hypothesized that such visits decreased in response to the pandemic conditions. STUDY DESIGN: Descriptive epidemiology study. METHODS: A selection of sports (baseball, basketball, softball, soccer, American football, weightlifting, track and field, martial arts, boxing, golf, personal fitness, cycling, tennis, and ice hockey) were classified as being an organized team, organized individual, or nonorganized sport. The National Electronic Injury Surveillance System database was then queried for ED visits for sports-related injuries between January 1, 2018, and December 31, 2020, and we compared weighted national injury estimates and injury characteristics from athletes presenting to EDs in 2018 and 2019 versus those from the 2020 COVID-19 pandemic period and between March 1 and May 31, 2020 (government-imposed lockdown period). Bivariate comparisons between variables were conducted using chi-square analysis, with strength of association assessed using odds ratios. RESULTS: The 164,151 unweighted cases obtained from the query resulted in a weighted national estimate of 5,664,795 sports-related injuries during the study period. Overall, there was a 34.6% decrease in sports-related ED visits in 2020 compared with the yearly average between 2018 and 2019 (baseline). The number of ED visits in 2020 decreased by 53.9% versus baseline for injuries incurred by participation in an organized team sport and by 34.9% for injuries incurred by participation in an organized individual sport. The number of ED visits during the 2020 lockdown period decreased by 76.9% versus baseline for injuries incurred by participation in an organized team sport and by 65.8% for injuries incurred by participation in an organized individual sport. Injuries sustained while participating in a nonorganized sport remained relatively unaffected and decreased by only 8.1% in 2020. CONCLUSION: ED visits in the United States for injuries sustained while participating in an organized team or individual sport underwent a decrease after the beginning of the COVID-19 pandemic in 2020, especially during the lockdown period.

Long-Term Outcomes of Massive Rotator Cuff Tear Repair: A Systematic Review.

BACKGROUND: With an increase in the treatment options available for massive rotator cuff tears, understanding the long-term outcomes of the chosen modality is important. QUESTIONS/PURPOSE: The purpose of this study was to systematically review the available literature on repair of massive rotator cuff repairs and learn the longevity of outcomes, the failure rate, outcomes after failure, and any contributing factors to poor outcomes or failure. METHODS: We conducted a systematic review of the MEDLINE, Cochrane, and Embase databases to find studies that investigated the long-term results of repair of massive rotator cuff repairs. Studies were excluded if they did not stratify results of massive tears, provide a definition for a massive rotator cuff tear, or report isolate patients with long-term follow-up. RESULTS: Six studies met the inclusion criteria, for a total of 472 shoulders; average patient age was 57.6 years. Follow-up ranged from 119 to 240 months. Outcome scores improved significantly following repair and were maintained throughout follow-up. The repair failure rate across studies was 39.2%. Patients who suffered retear had significantly worse outcome scores than patients with intact tendons at long-term follow-up. CONCLUSIONS: The existing literature on long-term follow-up after massive rotator cuff repair is scarce and not of high level of evidence. This review found repair of massive rotator cuff tears leads to long-term maintained improvements in outcome measures. Failure of repair is quite common, but results following failure are superior to preoperative outcomes.

Patellar Morphology and Osteoarthritis: A Cadaveric Analysis.

Previous studies have attempted to characterize patellar morphology and its relation to patellofemoral osteoarthritis but have utilized relatively small samples. We designed a large-scale cadaveric analysis to elucidate any potential relationship. Patellar morphology in 1,032 patellae was characterized using patellar facet concavity patterns initially developed by Wiberg and using the ratio of the lateral and medial facet lengths. Patellofemoral arthritis grading for specimens was previously completed based primarily on osteophytic burden. The average age at time of death was 56 ± 10 years. Wiberg's grading returned kappa values of 0.43 for intrarelator reliability and 0.27 for interrelator reliability. Using multiple regression analysis, Wiberg's type II was found to be correlated with patellofemoral arthritis (p = 0.003). Lateral to medial facet ratio measurements returned intraclass coefficients of 0.91 for intrarelator reliability and 0.85 for interrelator reliability. There was no association between lateral to medial facet ratio and osteoarthritis. Regression analysis between Wiberg's typing and lateral-to-medial ratio (L:M) resulted in a coefficient of determination of 0.14. To our knowledge, this is the largest study evaluating the relationship between patellar morphology and arthritis. Although there was a relationship between Wiberg's type II and patellofemoral arthritis, the Wiberg systems was not easily reproducible in our study and returned a correlation with arthritis different then anatomically expected. A more reproducible system of lateral to medial facet ratio was investigated but did not find an association with arthritic changes. Given these findings, we did not find a patella morphology grading system which is both reliable and valid in regard to association with patellofemoral arthritis.

No difference between lag screw and helical blade for cephalomedullary nail cut-out a systematic review and meta-analysis.

INTRODUCTION: Cephalomedullary nail (CMN) cut-out is a severe complication of treatment of intertrochanteric femur fractures. This study aimed to identify modifiable risk factors predictive of implant cut-out including: CMN proximal fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, screw location, and surgeon fellowship training. METHODS: A systematic review of the published literature was conducted on Pubmed/MEDLINE and Cochrane Library databases for English language papers (January 1st, 1985-May 10th, 2020), with 21 studies meeting inclusion/exclusion criteria. Studies providing quantitative data comparing factors affecting CMN nail cut-out were included, including fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, and screw location. Twelve studies were included and graded by MINOR and Newcastle-Ottawa Scale to identify potential biases. Meta-analysis and pooled analysis were conducted when possible with forest plots to summarize odds ratios (OR) and associated 95% confidence interval (CI). RESULTS: There was no difference in implant cut-out rate between lag screws (n = 745) versus helical blade (n = 371) (OR: 1.03; 95% CI: 0.25-4.23). Pooled data analysis revealed TAD > 25 mm (n = 310) was associated with higher odds of increased cut-out rate relative to TAD < 25 mm (n = 730) (OR: 3.72; 95% CI: 2.06-6.72). CONCLUSION: Our review suggests that cephalomedullary implant type (lag screw vs. helical blade) is not a risk factor for implant cut-out. Consistent with the previous literature, increased tip-apex distance > 25 mm is a reliable predictor of implant cut-out risk. Suboptimal screw location and poor reduction quality are associated with increased risk of screw cut-out. LEVEL OF EVIDENCE: Level III.

Graft choice or drilling technique does not influence outcomes of ACL reconstruction in patients over forty-five.

PURPOSE: To evaluate whether graft-type and tunnel location in ACL reconstruction impact patient-reported outcomes in individuals over the age of 45. METHODS: From 2015 to 2018, patients over 45 years old undergoing primary ACL reconstruction without multi-ligamentous injuries were enrolled in an institutional registry. Baseline International Knee Documentation Committee (IKDC) subjective scores, Knee Injury and Osteoarthritis Outcome Scores (KOOS), Marx Activity Scale, and patient characteristics were collected. Follow-up occurred at a minimum of two years to obtain patient-reported outcomes. RESULTS: Of the 51 patients who qualified for the study, 44 (86.3%) patients were available at a minimum of two years after surgery date (range 24-60 months). Average age at time of surgery of the available patients was 51.6 ± 4.87 (range 45-66). Between femoral tunnel drilling methods, there were no differences in the proportion of patients achieving clinically significant improvement or post-operative outcome scores. While patients who received patellar tendon autografts were more likely to achieve clinically significant improvement in the KOOS sports subscale, there were no other differences in outcomes measures between graft types. Two patients had a retear of their graft, and an additional five patients complained of subjective instability. CONCLUSIONS: In patients over the age of 45, neither the method used to create the femoral tunnel nor the graft type used in ACL reconstruction caused a significant difference in post-operative PROMs with a minimum of two years of follow-up. LEVEL OF EVIDENCE: Therapeutic IV, Case Series.

What are the risk factors associated with limited musculoskeletal health literacy in shoulder arthroplasty patients?

OBJECTIVES: Low health literacy is both pervasive in the United States and a substantial barrier to satisfactory patient care and the appropriate utilization of healthcare resources. This prospective study aims to evaluate the factors that contribute to limited musculoskeletal literacy in patients who undergo shoulder arthroplasty. METHODS: Ninety patients undergoing shoulder replacement surgery completed demographics and Literacy in Musculoskeletal Problems (LiMP) surveys. Scores of less than six were considered indicative of limited musculoskeletal literacy. RESULTS: The overall percentage of participants with limited musculoskeletal literacy was 38.8%. Multivariable logistic regression analysis with multiple imputation modeling demonstrated a significant positive relationship between patient income and adequate LiMP scores (p = 0.009) with an odds ratio of 1.15 (CI: 1.04; 1.28) while level of education (p = 0.173) and patient ethnicity (p = 0.830) among other patient characteristics did not have a significant relationship with LiMP scores. CONCLUSION: In patients undergoing shoulder replacement surgery, low income was the only variable found to be predictive of limited musculoskeletal health literacy scores. Therefore, when discussing the risks and benefits of shoulder arthroplasty, orthopaedic surgeons should be cognizant of the possibility that any given patient may not meet the threshold of adequate musculoskeletal literacy.

Does preoperative disease severity influence outcomes in reverse shoulder arthroplasty for cuff tear arthropathy?

BACKGROUND: The degree of symptomatic disease and functional burden has been demonstrated to influence patient results and satisfaction in total hip and knee arthroplasty. Although the relationship between preoperative diagnosis and patient outcomes has been an area of study for reverse total shoulder arthroplasty (RTSA), the influence of the progression of cuff tear arthropathy (CTA) has not yet been examined. The purpose of this study was to evaluate whether preoperative radiographic disease burden and scapular geometry impact patient outcomes and satisfaction in a cohort of patients with CTA treated with RTSA. METHODS: Eighty-six patients were treated for CTA with RTSA performed by the senior author (B.G.) between September 2016 and September 2018 and were enrolled in an institutional registry. At the time of initial evaluation, the baseline American Shoulder and Elbow Surgeons (ASES) score, patient demographic characteristics, history of shoulder surgery, and presence of pseudoparalysis were collected. Radiographs were obtained to evaluate the critical shoulder angle, acromial index, and progression of CTA as assessed by Hamada grading and the Seebauer classification. Patients were contacted to reassess the ASES score and their satisfaction with the improvement in their shoulder function. RESULTS: A total of 79 patients (91.6%) were available for evaluation at a minimum of 24 months of follow-up. Multivariate logistic regression modeling revealed that scapular geometry measurements (critical shoulder angle and acromial index) and the degree of CTA (Seebauer and Hamada classifications) were not associated with worse outcomes as assessed by the ASES score. However, degenerative changes as assessed by the Hamada grade (odds ratio, 0.13 [95% confidence interval, 0.02-0.86]; P = .03) and preoperative ASES score (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .008) were independently associated with higher satisfaction at 24 months of follow-up. CONCLUSION: The results indicate that patients with greater CTA disease progression did not show differing outcomes after RTSA compared with patients with milder disease. In contrast, both poorer preoperative function and degenerative changes as assessed by the Hamada classification were associated with greater satisfaction after RTSA for CTA. Given the broad spectrum of disease in CTA, there is likely a corresponding range in patient expectations that requires further study to maximize patient satisfaction.

Outcome Reporting in Total Ankle Arthroplasty: A Systematic Review.

Total ankle arthroplasty is an increasingly utilized treatment for ankle arthritis due to decreasing failure rates and improved outcomes. However, the literature on this procedure remains heterogeneous with large variability in outcome reporting methods. PRISMA guidelines were used to systematically review outcome reporting measures used in prospective studies and randomized control trials on total ankle arthroplasty published in 15 high-impact journals between Jan 1, 2009-May 1, 2020. A total of 43 studies were included and outcome measures were grouped into seven categories: pain, subjective function, patient satisfaction, complications, objective function, implant survivorship, and imaging. The most common topic of study was implant design followed by differences in outcomes when comparing total ankle arthroplasty and arthrodesis. The most commonly reported outcome measure was post-surgical complications. No study reported on all seven categories, while 22 (51.2%) studies reported on four or more. Subjective measures had significant variability with fifteen different Patient Reported Outcome Measures used across the studies. While the included studies were quite comprehensive, there was little consistency in reporting outcomes after total ankle arthroplasty. With improving outcomes and techniques in total ankle arthroplasty, and thus an expected increase in utilization and number of published studies, efforts should be made to use commonly employed outcome reporting methods to facilitate comparison of results across studies.

Differences in Access to Outpatient Care in the State of Ohio for an Orthopaedic Sports Medicine Patient.

PURPOSE: To evaluate the impact of either Medicaid or private insurance on securing an appointment in an outpatient orthopaedic clinic and to determine waiting periods until an appointment as well as the relationship between population metrics and access to care. METHODS: A total of 88 clinics were called. There were 2 fictitious patients, one with an anterior cruciate ligament (ACL) injury and the other with a medial meniscus injury, with each calling as having Medicaid or private insurance. Clinic responses were recorded for whether an appointment could be made, when it was scheduled, and with what provider. RESULTS: A total of 32 of 88 (36.4%) of the clinics scheduled an appointment for the Medicaid patient reporting an ACL injury versus 71 of 88 (80.6%) of the clinics that scheduled an appointment for the same patient with private insurance. A total of 34 of 88 (38.6%) of the clinics scheduled an appointment for the Medicaid patient reporting a medial meniscus injury versus 71 of 88 (80.6%) of the clinics that scheduled an appointment for the same patient with private insurance. Mean waiting period for ACL patients with Medicaid was 8.6 days and 4.5 days for patients with private insurance, whereas medial meniscus patients with Medicaid was 7.7 days and 5.4 days for patients with private insurance. In total, 60 of the 66 (90.9%) patients with Medicaid who received an appointment were scheduled to see the orthopaedic surgeon (30 in both ACL and medial meniscus groups). In total, 126 (71.6%) patients with Medicaid and 34 (19.3%) patients with private insurance of the 176 encounters faced barriers to scheduling an appointment. Rural communities were associated with appointment acceptance for patients with Medicaid (P < .05), and patients with private insurance had successful appointment scheduling in all community types (P < .05). CONCLUSIONS: This study suggests that patients with Medicaid are less likely to receive orthopaedic care for multiple sports medicine injuries, are more likely to encounter barriers, and endure longer waiting periods. There are different patterns of insurance acceptance according to population metrics. CLINICAL RELEVANCE: Serves as a baseline evaluation of the difference in access to health care that may be impacted by increases in Medicaid coverage and/or changes in government policies.