Return to Sport After Primary Anterior Cruciate Ligament (ACL) Reconstruction: A Survey of The American Orthopaedic Society for Sports Medicine.

Introduction: Anterior cruciate ligament (ACL) tears are a common sports injury, and typically require a prolonged post-operative rehabilitation. The purpose of this study was to survey members of the American Orthopaedic Society for Sports Medicine (AOSSM) to determine their return to sport (RTS) criteria after primary ACL reconstruction (ACLR). Methods: A 23-question, anonymous survey hosted through Google® Docs was distributed electronically to AOSSM members. This survey included questions regarding the timing, as well as any functional tests or other metrics used to determine when an athlete is ready to RTS. Results: A total of 863 surgeons responded over four months. The most popular graft choice was bone patellar tendon bone autograft (63%). For non-pivoting sports, 43% of respondents allowed RTS at five to six months, while 31% allowed RTS at seven to eight months. For pivoting sports, 34% of respondents allowed RTS at seven to eight months, while 36% allowed RTS at nine to ten months. The most common criteria for return to non-pivoting sports include full knee motion (89%) and time after ACLR (76%). The most common criteria for return to pivoting sports include full knee motion (87%) and passing a hop test (80%). Only 21% of respondents assessed for psychological readiness to RTS. Conclusions: RTS occurred sooner in non-pivoting than pivoting sports, with similar RTS criteria in both groups. Most respondents did not assess for psychological readiness to RTS.

Arthroscopic Identification and Management of Hourglass Biceps.

The hourglass biceps is a condition in which the intra-articular portion of the biceps tendon becomes inflamed and hypertrophies relative to the remaining tendon. This condition can be seen in association with rotator cuff and labral pathology and may lead to anterior shoulder pain. Diagnosis requires careful visualization and inspection of the biceps tendon during shoulder arthroscopy, as the presentation may be subtle. Surgical treatment includes tenotomy or tenodesis, depending on patient factors and surgeon preference.

Males and Females Exhibit Comparable Outcomes Following Treatment of Osteochondritis Dissecans Lesions of the Knee: A Systematic Review.

PURPOSE: The purpose of this study was to evaluate the impact of patient sex on outcomes after treatment of osteochondritis dissecans (OCD) lesions of the knee through a systematic review of current evidence. METHODS: This review was conducted according to the PRISMA guidelines using the PubMed, PubMed Central, Embase, Ovid Medline, Cochrane Libraries, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Relevant outcomes included functional (e.g., International Knee Documentation Committee and Subjective Knee Evaluation, Lysholm Knee Score) and clinical outcomes (e.g., symptom/pain resolution, reoperation rates) for males and females after operative or nonoperative treatment of knee OCD lesions. RESULTS: Ten articles with a total of 691 (73%) males and 260 (27%) females were included. Mean age ranged from 11.3 ± 2.1 years to 34.5 ± 10.3 years, and follow-up ranged from 6 months to 16.3 years. In four studies reporting functional outcomes, no significant differences were found between males and females in any metric assessed (all P > .05). Seven studies reported clinical outcomes after treatment of knee OCD lesions. One study determined males were more likely to have a successful nonoperative outcome than females (OR: 1.85, 95% CI: 1.00-3.40). Another study found males had a lower risk of developing symptomatic knee pain following operative or nonoperative treatment at a mean 14-year follow-up (HR: 0.24; 95% CI: 0.07-0.81). The remaining 5 studies reported statistically comparable clinical outcomes between males and females (all P > .05). CONCLUSION: The present systematic review found mostly comparable clinical and functional outcomes between males and females following treatment of knee OCD lesions. Despite sex-related differences in the prevalence of these lesions and limited evidence of differences in clinical outcomes, these data suggest that sex does not independently predict outcomes after treatment. LEVEL OF EVIDENCE: III, systematic review of Level II and III studies.

CD5 on dendritic cells regulates CD4+ and CD8+ T cell activation and induction of immune responses.

The role of CD5 as a regulator of T cell signaling and tolerance is well recognized. Recent data show expression of CD5 on different subtypes of human dendritic cells, however its functional relevance in modulating DC mediated responses remains poorly understood. In this study, we show CD5 is expressed on CD11c+ DC from murine thymus, lymph node, spleen, skin and lung. Although the development of DC subpopulations in CD5-/- mice was normal, CD5-deficient DC produced significantly higher levels of IL-12 than wild type DC in response to LPS. CD5-/- DC, in comparison to CD5+/+ DC, enhanced the activation of CD4+ and CD8+ T cells in vitro and in vivo and induced significantly higher production of IL-2 and IFN-gamma by T cells. Consequently, CD5-/- DC were significantly more potent than wild type DC in the induction of anti-tumor immunity and contact hypersensitivity responses in mice. Restoration of CD5 expression in CD5-/- DC reduced IL-12 production and inhibited their capacity to stimulate T cells. Collectively, these data demonstrate that the specific expression of CD5 on DC inhibits the production of inflammatory cytokines and has a regulatory effect on their activity to stimulate T cells and induce immune responses. This study reveals a previously unrecognized regulatory role for CD5 on DC and provides novel insights into mechanisms for DC biology in immune responses.

Gout Presenting as Acute Hip Pain in a Young Woman: A Case Report.

CASE: A 28-year-old previously healthy woman developed worsening right hip pain without any preceding trauma or injury. Because of concern for septic arthritis, she underwent arthroscopic irrigation and debridement. The culture specimens were negative; crystal analysis showed monosodium urate crystals, which are consistent with an acute gout flare. The patient was started on naproxen and prednisone therapy and had substantial improvement in hip pain. CONCLUSION: Gout is a common cause of joint pain in older individuals. While rare in younger patients, our case report shows that gout should be included in the differential diagnosis when a patient presents with acute monoarthritis, regardless of age.

Trends and Risk Factors in Orthopedic Lawsuits: Analysis of a National Legal Database.

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms "orthopaedic or orthopedic" and "malpractice." Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260-e267.].

Risk factors for same-admission mortality after pathologic fracture secondary to metastatic cancer.

PURPOSE: The skeleton is the third most common site of cancer metastases. Approximately 10 % of patients with bone metastases will develop a pathologic fracture, with significant associated morbidity and mortality. The purpose of this study was to identify risk factors for same-admission mortality after pathologic fractures secondary to metastatic cancer. METHODS: The Nationwide Inpatient Sample database was queried from 2002 to 2013 for hospitalized patients with diagnoses of pathologic fracture and a primary cancer at high risk for skeletal metastasis. Univariate and multivariate analyses were performed to determine risk factors associated with same-admission mortality after fracture. RESULTS: A total of 371,163 patients were identified. The spine was the most common site of pathologic fracture (68.0 %) followed by lower extremity (25.0 %) and upper extremity (8.7 %). The following factors were independently associated with increased mortality (p < 0.001): cancer of lung or unspecified location; fracture of upper or lower extremity; male gender; age ≥65; non-Medicare insurance; coexisting congestive heart failure, chronic pulmonary disease, renal failure, or liver disease; and postoperative surgical site infection, acute myocardial infarction, pulmonary embolism, or pneumonia. Closed reductions were associated (p < 0.001) with increased mortality while open or percutaneous surgical treatments were protective (p < 0.001) against mortality. CONCLUSIONS: Pathologic fractures are a devastating consequence of metastatic bone disease, contributing significantly to morbidity and mortality. Numerous demographic and medical factors are associated with increased same-admission mortality. This data is useful for counseling patients with skeletal metastatic disease and should be taken into consideration when conducting routine skeletal surveillance in patients with metastatic cancer.

The Burden of the Fellowship Interview Process on General Surgery Residents and Programs.

OBJECTIVES: This study evaluated the effect of the fellowship interview process in a cohort of general surgery residents. We hypothesized that the interview process would be associated with significant clinical time lost, monetary expenses, and increased need for shift coverage. DESIGN: An online anonymous survey link was sent via e-mail to general surgery program directors in June 2014. Program directors distributed an additional survey link to current residents in their program who had completed the fellowship interview process. SETTING: United States allopathic general surgery programs. PARTICIPANTS: Overall, 50 general surgery program directors; 72 general surgery residents. RESULTS: Program directors reported a fellowship application rate of 74.4%. Residents most frequently attended 8 to 12 interviews (35.2%). Most (57.7%) of residents reported missing 7 or more days of clinical training to attend interviews; these shifts were largely covered by other residents. Most residents (62.3%) spent over $4000 on the interview process. Program directors rated fellowship burden as an average of 6.7 on a 1 to 10 scale of disruption, with 10 being a significant disruption. Most of the residents (57.3%) were in favor of change in the interview process. We identified potential areas for improvement including options for coordinated interviews and improved content on program websites. CONCLUSIONS: The surgical fellowship match is relatively burdensome to residents and programs alike, and merits critical assessment for potential improvement.

Risk Factors for Early Readmission After Anatomical or Reverse Total Shoulder Arthroplasty.

Hospital readmissions are costly for patients and institutions. We conducted a study to evaluate rates of readmission within 30 days after anatomical total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) and to determine independent risk factors for readmission. We queried the National Surgical Quality Improvement Program database for ATSAs and RTSAs performed between 2011 and 2013 and found a combined total of 3501 cases and an overall readmission rate of 2.7%. Of the readmissions, 67% were for medical complications, and 33% were for surgical complications. Of the medical complications, pneumonia was the most common (11.8%), followed by urinary tract infection (7.8%). Regarding surgical complications, surgical-site infection was the most common (13.7%), followed by prosthetic joint dislocation (9.8%). Hospital-acquired conditions, including surgical-site infection, urinary tract infection, deep vein thrombosis, and pulmonary embolism, accounted for 33% of all 30-day readmissions. Three independent risk factors for readmission were identified: revision surgery (odds ratio, 2.59), 3 or more comorbidities (odds ratio, 2.02), and extended length of stay (>4.3 days) during the index admission (odds ratio, 2.48). Other factors significantly (P < .05) associated with readmission were age over 75 years, dependent functional status, American Society of Anesthesiologists score of 4 or higher, cardiac comorbidity, 2 or more comorbidities, and urinary tract infection before discharge.