Is anterior knee pain following anterior cruciate ligament reconstruction a consideration for graft choice, and the influence of COVID: a qualitative analysis in recreational athletes.

BACKGROUND: We set out to investigate whether anterior knee pain following anterior cruciate ligament reconstruction has a significant effect on patients, and whether it should influence graft choice. METHODS: This was a qualitative analysis of a set of recreational athletes treated at a university hospital at about 1 year following anterior cruciate ligament reconstruction surgery. Participants were interviewed by an orthopaedic fellow and resident using structured, open-ended questions. Inductive theme analysis was used to code the data. RESULTS: There were 4 major themes: (1) Our hypothesis was that patients would be given adequate information to make an appropriate graft choice. This hypothesis was rejected. Discussion took place, but with little details or rationale for the graft choice. The predominant theme was that the surgeon made the decision, and there was a lack of reliable information for the patient to make a choice. (2) The overall theme was that most patients had no anterior knee pain, and it did not interfere with activities of daily living. (3) One theme was that patients were able to resume all sports without restriction, but in some, the anterior knee pain interfered with the more demanding activities such as impact, cutting, and pivoting. A separate theme was that fear was a major impediment to return to sports and was not related to the anterior knee pain. (4) The overriding theme was that the generalized closures associated with the COVID-19 pandemic slowed the rehabilitation process. Although virtual care was available in general, it was not particularly satisfactory. Patients indicated that they had not been able to return to the gym or to their sporting activities as a result. CONCLUSIONS: Amongst non-competitive athletes, anterior knee pain post-anterior cruciate ligament reconstruction surgery does not significantly affect activities of daily living. Although there is a minor effect on sporting activities, the inability to return to sports is related to factors such as the COVID-19 pandemic, fear, or insufficient rehabilitation, rather than anterior knee pain. Overall, anterior knee pain is not a significant factor that plays a role in determining graft choice.

Limiting the Risk of Osteoarthritis After Anterior Cruciate Ligament Injury: Are Health Care Providers Missing the Opportunity to Intervene?

OBJECTIVE: To understand what sports orthopedic surgeons (OS), primary care physicians (PCPs) with sports medicine training, and physical therapists (PTs) managing nonelite athletes with anterior cruciate ligament (ACL) injury tell their patients about their osteoarthritis (OA) risk. METHODS: An electronic survey was distributed by the Canadian Academy of Sport and Exercise Medicine (PCPs, OS), the Sports and Orthopedic Divisions of the Canadian Physiotherapy Association (PTs), and to OS identified through the Royal College of Physicians and Surgeons and the Canadian Orthopaedic Association. The survey included 4 sections: demographics, factors discussed, timing of discussions, and discussion of risk factors and their management. Proportions or means with 95% confidence intervals were calculated. RESULTS: A total of 501 health care professionals (HCPs) responded (98 PCPs, 263 PTs, and 140 OS). Of those responding, 70-77% of physicians reported always discussing OA risk, but only 35% of PTs did. All HCPs reported that patient activities perceived as detrimental to knee health, ACL reinjury, and simultaneous injury to other structures in the knee were most often the reason for discussing OA risk. OA risk was discussed at initial management post-injury (65-94%), with few discussing risk subsequently. Eighty percent of physicians and 99% of PTs indicated that PTs were suited to provide OA risk and management information. CONCLUSION: HCPs routinely managing people with ACL injury do not consistently discuss OA risk post-injury with them. Educational strategies for HCPs are urgently needed to develop care pathways inclusive of support for OA risk management following ACL injury.

Conventional Follow-up Versus Mobile Application Home Monitoring for Postoperative Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial.

PURPOSE: To determine whether a mobile app can reduce the need for in-person visits and examine the resulting societal cost differences between mobile and conventional follow-up for postoperative anterior cruciate ligament (ACL) reconstruction patients. METHODS: Study design was a single-center, 2-arm parallel group randomized controlled trial. All patients undergoing ACL reconstruction aged 16 to 70 years were screened for inclusion in the study. Competent use of a mobile device and ability to communicate in English was required. Patients were randomly assigned to receive follow-up via a mobile app or conventional appointments. Analysis was intention-to-treat. The primary outcome was the number of in-person visits to any health care professional during the first 6 postoperative weeks. Secondary outcomes included analysis of costs incurred by the health care system and personal patient costs related to both methods of follow-up. Patient-reported satisfaction and convenience scores, rates of complications, and clinical outcomes were also analyzed. RESULTS: Sixty patients were analyzed. Participants in the app group attended a mean of 0.36 in-person visits versus 2.44 in-person visits in the conventional group (95% confidence interval 0.08-0.28; P < .0001). On average, patients in the app group spent $211 (Canadian dollars) less than the conventional group over 6 weeks (P < .0001) on personal costs related to follow-up. Health care system costs were also significantly less in the app group ($157.5 vs CAD $202.2; P < .0001). There was no difference between groups in patient satisfaction, convenience, complication rates, or clinical outcome measures. CONCLUSIONS: Mobile follow-up can eliminate a significant number of in-person visits during the first 6 postoperative weeks in patients undergoing ACL reconstruction with cost savings to both the patient and health care system. This method should be considered for dissemination among similar orthopaedic procedures during early postoperative care. LEVEL OF EVIDENCE: I: Prospective randomized controlled trial.

Analysis of the referral pattern and wait time for hip arthroscopy in a single payer publicly funded health care system.

RATIONALE AND OBJECTIVES: To analyse the referral pattern for hip pain and to investigate the wait time for an orthopaedic assessment by a hip arthroscopy surgeon in a single payer health care system. We hypothesized that a significant delay from time of onset of symptoms to time of assessment by a hip arthroscopy surgeon exists. METHOD: Retrospective review of prospectively collected data in an academic hospital in a single payer health care system. An electronic database analysis was conducted searching for all referrals for hip pain between February 2017 and June 2017. Data were then analysed with the aim to identify the most common reason for hip referral, calculate the duration of symptoms between onset and orthopaedic assessment, and categorize previous investigations and treatments. RESULTS: A total of 96 patients were included (47 male and 49 female). Main source of referrals was Family Medicine Physicians in 37% of cases and Primary Care Sports Medicine Physicians in 35%. The most common reason for referral was labral tear in 44.7% of cases followed by combined femoroacetabular impingement and labral tear in 21.8%. The duration of symptoms was longer than 2 years in 42% of cases and between 1 and 2 years in 40% of cases. Twenty percent of patients had previous intra-articular injection while 53% of patients had physiotherapy treatment (64% of patient underwent physiotherapy for longer than 6 months). CONCLUSION: In the Canadian single payer health care system, a significant delay from the time of onset of symptoms to the time of assessment by a hip arthroscopy surgeon exists with the vast majority of patients in our cohort waiting more than 1 year. It is unknown if this delay affects the patient outcomes. This will require further investigation. Certainly, based on our findings, we should advocate for a better screening process, centralized referrals to hip arthroscopy specialists, and appropriate patient work-up.

Diabetes and Healing Outcomes in Lower Extremity Fractures: A Systematic Review.

OBJECTIVE: The purpose of this study was to review the rates of adverse healing outcomes following surgical fixation of lower extremity fractures in diabetic patients and matched controls. MATERIALS AND METHODS: Searches of PubMed, MEDLINE, CINAHL and Embase were performed for studies published between the date of database inception and July 6, 2015. Patient characteristics and the incidence of adverse healing outcomes (nonunion, malunion, delayed union, infection and reoperation) were extracted from each study. The occurrence of each fracture healing complication was pooled and analyzed for comparisons between diabetic and non-diabetic patients. An odds ratio with a 95% confidence interval for each healing outcome was calculated between the diabetic and non-diabetic groups. RESULTS: Diabetes was found to significantly increase rates of malunion, infection and reoperation in patients with surgically treated lower extremity fractures. In addition, when only peripheral lower extremity fractures (i.e. below the knee) were examined, diabetes significantly increased the rates of nonunion. CONCLUSION: Diabetes substantially alters bone metabolism and soft tissue healing, posing a risk of adverse fracture healing and other complications. This systematic review provides evidence that the presence of diabetes significantly increases the risks of infection, malunion, nonunion and re-operation across a wide variety of surgically treated lower extremity fractures. This study provides prognostic information for clinicians and may aid in guiding treatment for this population.

Validation of a Dry Model for Assessing the Performance of Arthroscopic Hip Labral Repair.

BACKGROUND: Arthroscopic hip labral repair is a technically challenging and demanding surgical technique with a steep learning curve. Arthroscopic simulation allows trainees to develop these skills in a safe environment. PURPOSE: The purpose of this study was to evaluate the use of a combination of assessment ratings for the performance of arthroscopic hip labral repair on a dry model. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 47 participants including orthopaedic surgery residents (n = 37), sports medicine fellows (n = 5), and staff surgeons (n = 5) performed arthroscopic hip labral repair on a dry model. Prior arthroscopic experience was noted. Participants were evaluated by 2 orthopaedic surgeons using a task-specific checklist, the Arthroscopic Surgical Skill Evaluation Tool (ASSET), task completion time, and a final global rating scale. All procedures were video-recorded and scored by an orthopaedic fellow blinded to the level of training of each participant. RESULTS: The internal consistency/reliability (Cronbach alpha) using the total ASSET score for the procedure was high (intraclass correlation coefficient > 0.9). One-way analysis of variance for the total ASSET score demonstrated a difference between participants based on the level of training ( F3,43 = 27.8, P < .001). A good correlation was seen between the ASSET score and previous exposure to arthroscopic procedures ( r = 0.52-0.73, P < .001). The interrater reliability for the ASSET score was excellent (>0.9). CONCLUSION: The results of this study demonstrate that the use of dry models to assess the performance of arthroscopic hip labral repair by trainees is both valid and reliable. Further research will be required to demonstrate a correlation with performance on cadaveric specimens or in the operating room.

Treatment of Osteoarthritis of the Knee with Bracing: A Scoping Review.

Knee osteoarthritis is a leading cause of disability around the world. Knee bracing provides a conservative management option for symptom relief. A variety of different bracing types, manufacturers and products are currently available on the market. The goal of this study is to examine the current state of the literature regarding the treatment of knee osteoarthritis with unloader bracing, specifically examining the representation of specific brace types, manufacturers and models within the literature. A scoping review technique was used because of its ability to evaluate research activity within an area of study and identify gaps within the literature. A thorough search of the MEDLINE database was conducted for articles where a knee brace model was identified, and we identified characteristics of the studies to evaluate important information about the body of literature related to knee bracing for the treatment of osteoarthritis. Fifty eligible studies were identified. The majority of studies have been published in the United States, and a large increase in the number of publications in this field was seen between 2010-2014. The most prominent study type was prospective comparative studies (44%), however there is a lack of randomized controlled trials (6%) within the literature. The most prominent hinge type within the literature is the dual hinge push brace, followed by the single hinge pull. While a large increase in the number of studies evaluating the treatment of knee osteoarthritis with bracing has occurred in the past 5 years, there is a lack of high quality studies evaluating the efficacy of the technique, as well as a lack of studies comparing bracing types and models.

Risk factors for the development of heterotopic ossification after knee dislocation.

BACKGROUND: Results of treatment for acute knee dislocations and multiligament knee injuries may be influenced by a multitude of patient- and injury-related factors, including neurologic function, vascular status, ipsilateral fractures, and joint stability. The development of heterotopic ossification (HO) may nullify any benefits of reconstruction, because it can cause stiffness and discomfort. Identifying factors associated with HO after knee dislocation may help identify patients who might benefit from prophylaxis. QUESTIONS/PURPOSES: The purposes of this study were (1) to identify specific risk factors for the development of HO in patients with knee dislocation; and (2) to elucidate the relationship between the presence of absence of HO and postoperative range of motion. METHODS: Between 2005 and 2010, we performed 101 multiligament reconstructions for patients with knee dislocations, of which 91 (90%) in 91 patients were available for followup at a minimum of 6 months (mean, 18 months; range, 6-44 months), and were reviewed here. AP and lateral radiographs were reviewed for all patients and HO was classified according to the Mills and Tejwani classification system. This knee dislocation cohort was separated into two groups based on the presence or absence of HO for comparison. Using a significance level of p < 0.05 for factors in the univariate analyses, we identified potential variables for a multivariate logistic regression model to identify risk factors predicting development of HO in patients with multiligament knee injuries; multivariate analysis then was performed to mitigate the influence of potentially confounding variables. Thirty patients (34%) developed HO after multiligament knee injury in our series. RESULTS: Posterior cruciate ligament reconstruction was the only independent predictor of HO that we identified (odds ratio, 6.3; 95% confidence interval, 1.2-34.6). Patients who developed HO were more likely to develop stiff knees and undergo surgery (50%; 15 of 30 patients) versus those without HO (12%; seven of 58 patients) to attempt to restore functional range of motion (p < 0.001). CONCLUSIONS: HO is a common complication after knee dislocation and can diminish range of motion and cause patients to undergo further surgery. Posterior cruciate ligament reconstruction is an independent risk factor for the development of HO. Strategies to identify risk factors for, and safe prevention of, HO after multiple ligament injury and surgery should be investigated going forward. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A systematic review and meta-analysis comparing complications following total joint arthroplasty for rheumatoid arthritis versus for osteoarthritis.

OBJECTIVE: Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is based on studies of patients with osteoarthritis (OA), with little being known about outcomes in patients with rheumatoid arthritis (RA). The objective of the present study was to review the current evidence regarding rates of THA/TKA complications in RA versus OA. METHODS: Data sources used were Medline, EMBase, Cinahl, Web of Science, and reference lists of articles. We included reports published between 1990 and 2011 that described studies of primary total joint arthroplasty of the hip or knee and contained information on outcomes in ≥200 RA and OA joints. Outcomes of interest included revision, hip dislocation, infection, 90-day mortality, and venous thromboembolic events. Two reviewers independently assessed each study for quality and extracted data. Where appropriate, meta-analysis was performed; if this was not possible, the level of evidence was assessed qualitatively. RESULTS: Forty studies were included in this review. The results indicated that patients with RA are at increased risk of dislocation following THA (adjusted odds ratio 2.16 [95% confidence interval 1.52-3.07]). There was fair evidence to support the notion that risk of infection and risk of early revision following TKA are increased in RA versus OA. There was no evidence of any differences in rates of revision at later time points, 90-day mortality, or rates of venous thromboembolic events following THA or TKA in patients with RA versus OA. RA was explicitly defined in only 3 studies (7.5%), and only 11 studies (27.5%) included adjustment for covariates (e.g., age, sex, and comorbidity). CONCLUSION: The findings of this literature review and meta-analysis indicate that, compared to patients with OA, patients with RA are at higher risk of dislocation following THA and higher risk of infection following TKA.

Risk factors for peroneal nerve injury and recovery in knee dislocation.

BACKGROUND: Acute knee dislocation is rare but has a high rate of associated neurovascular injuries and potentially limb-threatening complications. These include the substantial morbidity associated with peroneal nerve injury: neuropathic pain, decreased mobility, and considerably reduced function, which not only impairs patient function but complicates treatment. QUESTIONS/PURPOSES: We therefore identified and quantified the risks associated with specific factors for peroneal nerve injury and recovery in patients with knee dislocations. PATIENTS AND METHODS: We retrospectively reviewed the charts of 26 patients, from among a cohort of all 91 knee dislocations, with a peroneal nerve palsy over a 5-year period. We then used univariable and multivariable statistics to identify risk factors predicting peroneal nerve injury and recovery. RESULTS: Gender (odds ratio, 5.47), body mass index (odds ratio, 1.14), and fibular head fracture (odds ratio, 4.77) were associated with peroneal nerve injury. Only younger age was associated with peroneal nerve recovery. CONCLUSIONS: Knowledge of the risk factors for peroneal nerve injury and the predictors of recovery in knee dislocation allows the treating surgeon to have a better understanding of the nature of the neurologic injury and modify management based on the anticipated return of nerve function. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Diagnostic and treatment differences among experienced shoulder surgeons for instability conditions of the shoulder.

OBJECTIVE: To quantify interobserver agreement in the diagnosis and treatment of shoulder instabilities among expert North American shoulder surgeons. We hypothesized that interobserver consistency among this group will be significantly low in both diagnosis and treatment. DESIGN: Survey/Descriptive Epidemiology Study. SETTING: Self-administered survey via e-mail. PARTICIPANTS: Active members of American Shoulder and Elbow Surgeons (ASES) and JOINTS Canada (Joined Orthopaedic Initiatives for National Trials of the Shoulder), whose practices consisted primarily of shoulder surgery. INTERVENTIONS: Participants were sent a self-administered survey via e-mail and polled as to their choice of diagnosis and treatment in 5 different shoulder conditions. MAIN OUTCOME MEASUREMENTS: A Kappa coefficient of agreement, Ksc, was used to measure relative interobserver reliability. RESULTS: Overall response rate was 62.7% (42/67 surveys). The level of interobserver reliability was fair (Ksc 0.38, P < 0.0001) to almost perfect (Ksc 0.97, P < 0.0001) in diagnosing shoulder instability and slight (Ksc 0.23, P < 0.0001) to substantial (Ksc 0.69, P < 0.0001) for therapeutic approach. The greatest diagnostic differences were noted for a painful shoulder in a throwing athlete with subtle anterior instability (Ksc 0.43, P < 0.0001) and for a patient with voluntary posterior instability with an asymptomatic sulcus sign (Ksc 0.38, P < 0.0001). The greatest differences in treatment choice were for the throwing athlete with subtle anterior instability (Ksc 0.38, P < 0.0001), a patient with voluntary posterior instability (Ksc 0.34, P < 0.0001), and a patient with bidirectional instability (Ksc 0.23, P < 0.0001). CONCLUSIONS: These inconsistencies highlight the need for greater awareness and standardization of diagnostic criteria. This work may serve as the foundation for more universal treatment plans and subsequently more meaningful clinical outcomes.