Risk Factors Associated With Poor Outcomes After Quadriceps Tendon Repair.

Background: Ruptures of the quadriceps tendon present most frequently in older adults and individuals with underlying medical conditions. Purpose: To examine the relationship between patient-specific factors and tear characteristics with outcomes after quadriceps tendon repair. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review was conducted on all patients who underwent quadriceps tendon repair between January 1, 2016, and January 1, 2021, at a single institution. Patients <18 years and those with chronic quadriceps tendon tears (>6 weeks to surgery) were excluded. Information was collected regarding patient characteristics, presenting symptoms, tear characteristics, physical examination findings, and postoperative outcomes. Poor outcome was defined as a need for revision surgery, complications, postoperative range of motion of (ROM) <110° of knee flexion, and extensor lag of >5°. Results: A total of 191 patients met the inclusion criteria. Patients were aged 58.5 ± 13.2 years at the time of surgery, were predominantly men (90.6%), and had a mean body mass index (BMI) of 32.2 ± 6.3 kg/m2. Patients underwent repair with either suture anchors (15.2%) or transosseous tunnels (84.8%). Postoperatively, 18.5% of patients experienced knee flexion ROM of <110°, 11.3% experienced extensor lag of >5°, 8.5% had complications, and 3.2% underwent revision. Increasing age (odds ratio [OR], 1.03 [95% CI, 1.004-1.07]) and female sex (OR, 3.82 [95% CI, 1.25-11.28]) were significantly associated with postoperative knee flexion of <110°, and increasing age (OR, 1.08 [95% CI, 1.04-1.14]) and greater BMI (OR, 1.14 [95% CI, 1.05-1.23]) were significantly associated with postoperative extensor lag of >5°. Current smoking status (OR, 15.44 [95% CI, 3.97-65.90]) and concomitant retinacular tears (OR, 9.62 (95% CI, 1.67-184.14]) were associated with postoperative complications, and increasing age (OR, 1.05 [95% CI, 1.02-1.08]) and greater BMI (OR, 1.08 [95% CI, 1.02-1.14]) were associated with risk of acquiring any poor outcome criteria. Conclusion: Patient-specific characteristics-such as increasing age, greater BMI, female sex, retinacular involvement, and current smoking status-were found to be risk factors for poor outcomes after quadriceps tendon repair. Further studies are needed to identify potentially modifiable risk factors that can be used to set patient expectations and improve outcomes.

How Patients Dispose of Unused Prescription Opioids: A Survey of over 300 Postoperative Patients.

Introduction Diversion of unused prescription opioids is a common source of opioid sensitization in the community. Educating patients about safe opioid use has been shown to be effective in decreasing opioid use. However, decreasing diversion will also require educating patients on proper opioid disposal. A survey was administered to better understand patients' habits with opioid disposal for opioids prescribed after orthopedic surgery. Methods A cross-sectional survey study of 469 patients who had undergone orthopedic surgery was conducted to learn their preferences and habits regarding the disposal of unused prescription opioids received after orthopedic surgery. Results The survey respondents consisted of 48.8% female and 51.2% male patients. Ninety-four point two percent (94.2%) of those receiving opioid prescriptions reported having leftover unused opioids. In terms of voluntary disposal, 68.8% claimed to dispose of their prescription opioids while 31.2% did not. Gender, but not age, had a significant effect on plans for opioid disposal and how seriously respondents viewed issues of opioid misuse. When asked their preferred location for prescription opioid disposal, the most common preference was a local pharmacy. Discussion This survey identified that most patients do not store their prescription opioids in a locked location, claim to dispose of their unused prescription opioids, and would prefer to dispose of them at a pharmacy if possible. This information points to the need for close prescriber-to-pharmacy collaboration to promote the safe disposal of prescription opioids and mitigate drug diversion.

In-Hospital Complications following Arthrotomy versus Arthroscopy for Septic Knee Arthritis: A Cohort-Matched Comparison.

There is a paucity of literature comparing the relative merits of open arthrotomy versus arthroscopy for the surgical treatment of septic knee arthritis. The primary goal of this study is to compare the risk of perioperative complications between these two surgical techniques. To this end, 560 patients treated for septic arthritis of the native knee with arthroscopy were statistically matched 1:1 with 560 patients treated with open arthrotomy. The outcome measures included major complications, minor complications, mortality, inpatient hospital charges, and length of stay (LOS). Major complications were defined as myocardial infarction, cardiac arrest, stroke, deep vein thrombosis, pulmonary embolism, pneumonia, postoperative shock, unplanned ventilation, deep surgical site infection, wound dehiscence, infected postoperative seroma, hospital acquired urinary tract infection, and retained surgical item. Minor complications included phlebitis and thrombophlebitis, postprocedural emphysema, minor surgical site infection, peripheral nerve complication, and intraoperative hemorrhage. Mortality data were extracted from the database using the Uniform Bill patient disposition. Complications were analyzed using univariate and multivariate logistic regression models, whereas mean costs and LOS were compared using the Kruskal-Wallis H-test. Major complications occurred in 3.8% of the patients in the arthroscopy cohort and 5.4% of the patients in the arthrotomy cohort (p = 0.20). Too few patients in our sample died to report based on National (Nationwide) Impatient Sample (NIS) minimum reporting standards. Rates of minor complications were similar for the arthroscopy and arthrotomy cohorts (12.5 vs. 13.9%; p = 0.48). Multivariate analysis did not reveal any greater risk of minor or major complication between the two procedures. Inpatient hospital cost was similar for arthroscopy ( = $15,917; standard deviation [SD] = 14,424) and arthrotomy ( = $16,020; SD = 18,665; p = 0.42). LOS was also similar for both arthrotomy (6.78 days, SD = 6.75) and arthroscopy (6.24 days, SD = 5.95; p = 0.23). Patients undergoing arthroscopic treatment of septic arthritis of the knee showed no difference in relative risk of perioperative complications, LOS, or hospital cost compared with patients who underwent open arthrotomy.

Knee Arthroplasty with Prior Ligamentous Knee Surgery: A Matched Case-Control Study.

We aimed to evaluate the timing, operative details, and outcomes of total knee arthroplasty (TKA) in patients with prior ligamentous knee surgery (LKS). All consecutive patients undergoing TKA with prior LKS at a single institution were identified from a large prospectively collected database. Patients were matched on a 2:1 basis according to age, sex, and body mass index to a group of patients without previous LKS undergoing primary TKA. A total of 39 patients with prior LKS and a mean age of 55.6 years (range: 42.8-76.4) were identified and matched with 78 patients without LKS with a mean age of 57.6 years (range: 44.0-79.4) undergoing primary TKA (p = 0.24). Significantly more posterior stabilized implants were used in patients with LKS compared with control patients (29 [74.3%] vs. 27 [34.6%], p < 0.001). In the LKS group, 15 patients (38.4%) required hardware removal. Postoperative complications and rate of further surgery were greater in the LCS group, but the difference was not significant (10.6 vs. 6.4%, p = 0.25). Mean difference in pre- to postoperative knee flexion and clinical outcome scores (12-item Short Form Survey, International Knee Documentation Committee, and Oxford Knee Score) were similar between the two groups, with no cases of loosening or osteolysis. TKA with prior LKS often warranted hardware removal and generally more constrained implants. Those patients with prior LKS undergoing subsequent TKA have higher complication rates and an increased rate of subsequent surgery related to post-TKA stiffness.

Socioeconomic Status Is Associated with Risk of Above-knee Amputation After Periprosthetic Joint Infection of the Knee.

BACKGROUND: Above-knee amputation (AKA) is a severe but rare complication of TKA. Recent evidence suggests there are sex and racial disparities with regard to AKA after TKA. However, whether lower socioeconomic status is associated with an increased risk of AKA after TKA has not been conclusively established. QUESTIONS/PURPOSES: (1) Is low socioeconomic status or use of public health insurance plans associated with an increased risk of AKA after periprosthetic joint infection (PJI) of the knee? (2) Is race or sex associated with an increased risk of AKA after PJI of the knee? METHODS: This cross-sectional study screened the National Inpatient Sample (NIS) between 2010 and 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure and diagnosis codes to identify 912 AKAs (ICD 84.17) among 32,907 PJIs of the knee. The NIS is a large national database of inpatient hospitalizations frequently used by researchers to study outcomes and trends in orthopaedic procedures. The NIS was selected over other databases with more complete followup data such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) due to its unique ability to examine income levels and insurance type. Cases were identified by taking all patients with an ICD diagnosis code related to PJI of the knee and limiting that cohort to patients with an ICD procedure code specific to TKA. A total of 912 AKAs after PJI were identified (912 of 32,907, [3%] of all PJIs of the knee) with males comprising 52% of the AKA sample (p = 0.196). Multivariate logistic regression was used to compare risk of AKA after PJI of the knee after controlling for patient demographics, hospital characteristics, and comorbidities. RESULTS: Compared with the wealthiest income quartile by ZIP code, patients in the lowest income quartile by ZIP code were more likely to sustain an AKA (OR = 1.58; 95% confidence interval [CI] 1.25-1.98; p < 0.001). Compared with patients with private insurance, patients with Medicare (OR = 1.94; 95% CI, 1.55-2.43; p < 0.001) and Medicaid (OR = 1.86; 95% CI, 1.37-2.53; p < 0.001) were at higher risk of AKA. There were no differences with regard to risk of AKA for white patients (670 of 24,004 [3%]; OR = 0.99; 95% CI, 0.77-1.26; p = 0.936) and black patients (95 of 3178 [3%], OR = 0.95; 95% CI, 0.69-1.30; p = 0.751) when compared with others (reference, 83 of 3159 [3%]). When compared with female patients, male patients did not have a greater risk of undergoing AKA (OR = 1.02; 95% CI, 0.88-1.29; p = 0.818). CONCLUSIONS: This study did not observe any racial or sex disparities with regard to risk of AKA after PJI. However, there was a greater risk of AKA after PJI for poorer patients and patients participating in Medicare or Medicaid insurance plans. Surgeons should be cognizant when treating PJI in patients from lower income backgrounds as these patients may be at greater risk for AKA. Future research should explore the role of physician attitudes or preconceptions about predicted patient followup in treating PJI, as well as the effect of concurrent peripheral vascular disease on the risk of AKA after PJI. LEVEL OF EVIDENCE: Level III, therapeutic study.

The subscapularis footprint: an anatomic study of the subscapularis tendon insertion.

PURPOSE: Arthroscopic repair of the subscapularis tendon has become more prevalent in recent years. Tears of the subscapularis insertion can be measured arthroscopically when the size of the average subscapularis tendon insertion is known. This anatomic study was performed to measure the dimensions and describe the anatomy of the subscapularis footprint. METHODS: A total of 6 male and 6 female shoulders were dissected down to the insertion of the subscapularis tendon. The insertion was demarcated, the tendon was detached, and the dimensions of the insertion site were measured. RESULTS: The footprint is the insertion of the subscapularis tendon onto the lesser tubercle. The shape of the footprint was characterized as resembling a human ear. The insertion is broad proximally and tapered distally and has a straight medial border that is almost parallel to the longitudinal axis of the humerus. The total average cephalocaudal height of the footprint was 25.8 mm (+/-3.2 mm). The total average width was 18.1 mm (+/-1.6 mm). Average male cephalocaudal height was 26.7 mm (range, 22 to 32 mm), and width was 18.3 mm (range, 16 to 21 mm). Average female cephalocaudal height was 24.8 mm (range, 22 to 29 mm), and width was 17.8 mm (range, 15 to 19 mm). Although the male footprint was slightly larger than the female footprint, differences were not statistically significant (P = .18 and .31 for height and width, respectively). CONCLUSIONS: An anatomic study was performed to determine the size of the footprint of the subscapularis tendon. We found that the average cephalocaudal height of the footprint was 25.8 mm, and the average width was 18.1 mm. CLINICAL RELEVANCE: Subscapularis tears are now more frequently addressed arthroscopically. This anatomic study was performed to characterize the anatomy of the subscapularis footprint so that the surgeon can achieve a more anatomic repair.