Editorial Commentary: Biologic Stimulation Using Marrow Venting for Meniscus Repair is Cost Effective and Recommended.

Current literature offers little guidance on the most cost-effective approach to intraoperative biologic stimulation in the setting of arthroscopic meniscus repair. Combining data from robust systematic reviews into a Markov Decision Making Model reveal the ideal strategy: Strong consideration should be given to biologic stimulation for all meniscal repairs, and the most cost effective technique is marrow stimulation.

Harvest of All-Soft Tissue Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction With or Without Closure of Resulting Defect Has No Effect on Patellar Height.

Purpose: To evaluate the radiographic effect of quadriceps tendon harvest on patellar height and to determine whether closure of a quadriceps graft harvest defect resulted in a significant change in patellar height compared to nonclosure. Methods: We conducted a retrospective review of prospectively enrolled patients. The institutional database was queried and all patients who underwent quadriceps autograft anterior cruciate ligament reconstruction between 2015 and March 2020 were included. Graft harvest length in millimeters and final graft diameter after preparation for implantation were obtained from the operative record and demographic data were obtained from the medical record. Radiographic analysis was performed of eligible patients using standard ratios of patellar height: Insall-Salvati (IS), Blackburn-Peele (BP), and Caton-Deschamps (CD). Measurements were performed using digital calipers on a digital imaging system by 2 postgraduate fellow surgeons. Preoperative and postoperative radiographs were performed at 0° according to a standard protocol. Postoperative radiographs were performed 6 weeks postoperatively in all cases. Preoperative patellar height ratios were compared with postoperative patellar height ratios for all patients using t-tests. Subanalysis was then performed to compare the effect of closure of with nonclosure on patellar height ratios using repeated-measures analysis of variance. Interrater reliability between the 2 reviewers was assessed using an intraclass correlation coefficient calculation. Results: In total, 70 patients met final inclusion criteria. There were no statistically significant changes from pre- to postoperative values for either reviewer for IS (reviewer 1, P = .47; reviewer 2, P = .353), BP (reviewer 1, P = .98; reviewer 2, P = .907), or CD (reviewer 1, P = .107; reviewer, 2 P = .188). The closure and nonclosure groups were adequately powered and no statistically significant demographic differences between the closure and nonclosure groups was identified for sex (P = .066), age (P = .343), weight (P = .881), height (P = .42), laterality (P = 1), meniscal repair (P = .332), graft diameter (P = .068), or graft length (P = .183). According to the repeated measures analysis of variance, closure of the quadriceps defect had no significant impact on any of the knee ratios. However, reviewer identity had a significant influence on the CD ratio. Intraclass correlation coefficient analysis revealed excellent agreement between reviewers for the IS (0.982) and BP (0.954) ratios, but only moderate-to-good agreement for the CD (0.751) ratio. Conclusions: Harvest of quadriceps tendon graft does not result in radiographic changes in patellar height. Furthermore, closure of the quadriceps defect does not appear to result in radiographic changes in patellar height. Level of Evidence: III, retrospective comparative trial.

Editorial Commentary: First They Came for My Examination Skills: Diagnostic Injections of the Biceps Sheath Are No Substitute for a Careful Collaboration of History, Examination, and Clinical Acumen.

Diagnostic injections have been used in the workup of many musculoskeletal complaints, especially when a good history and physical examination don't point to a concrete diagnosis. However, the accuracy of blind injections, especially in locations like the biceps sheath, has been called into question. This has led to the use of image guidance to improve injection accuracy, usually with great success. However, even with great accuracy, the diagnostic utility of an injection may still be quite limited because of fluid extravasation.

Editorial Commentary: To Boldy Go to the Back of the Glenoid: Bone is the Key to Success.

Risk factors of failure after arthroscopic posterior shoulder stabilization are not well understood. Careful attention to anatomy may be the key to helping patients understand their risk of failure after surgery. Posterior stabilization may be even more sensitive to small amounts of bone loss than is anterior stabilization.

Editorial Commentary: Morton Forks a Knee: Magnetic Resonance Imaging Versus Needles Arthroscopy for Knee Meniscus Tears.

Recent literature tells us that knee arthroscopy in the setting of osteoarthritis is no better than placebo, but arthroscopy for isolated, nondegenerative meniscus tears is both helpful to patients and cost-effective. Since most patients with osteoarthritis have meniscus pathology, we need an accurate way to rule out degenerative disease in patients who are otherwise good candidates for arthroscopic partial meniscectomy. Magnetic resonance imaging can be misleading. Needle arthroscopy is a new tool that can potentially help dig us out of this diagnostic dilemma.

Editorial Commentary: The Ever-changing Landscape of Health Care Economics-"The Future Ain't What It Used to Be".

Payment models for orthopaedic services are constantly changing. Rather than have changes dictated to us, it is our responsibility as experts in arthroscopic surgery to advocate for patients and offer our unique insight to governmental agencies and payers. Before we can begin to understand this complex landscape, we need to start at the beginning and master the fundamentals of health care economics: cost-effectiveness analysis, cost minimization, cost benefit, and the like. Failure to do so will mean being left out of a conversation that will ultimately affect our ability to care for patients.

Knotless Arthroscopic Repair of Subscapularis Tendon Tears Using Looped Suture.

Subscapularis tendon tears present a technical challenge because both diagnosis and arthroscopic treatment can be difficult. One difficulty is the limited visualization and working space of the anterior shoulder. Although most tears of the subscapularis are partial- or full-thickness tears of the upper third of the tendon, occasionally, larger or more retracted tears are encountered. Various techniques have been developed to treat a wide variety of tear patterns. We present a simple technique using a looped suture that remains easy to use in the limited working space of the anterior shoulder; can be easily modified to accommodate a broad spectrum of subscapularis pathology, from partial to full and retracted tears; and uses familiar viewing and working portals. This technique creates a single-row, knotless repair. Traction on the superior suture improves visualization and ease of passing more inferior sutures. Risks include unintentional over-tensioning of the repair and medialization of the femoral footprint, which can be avoided with appropriate exposure and arm positioning during repair. Postoperative care includes restriction of external rotation for 3 to 6 weeks and strengthening at 3 months.

Anatomic All-Inside Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autograft.

All-inside anterior cruciate ligament reconstruction has recently gained popularity, in part because of its bone-sparing socket preparation and reported lower pain levels after surgery. However, because this technique uses suture loops and cortical suspension buttons for graft fixation, it has mostly been limited to looped graft constructs (e.g., hamstring autograft, peroneus longus allograft). Quadriceps tendon autograft offers several advantages in anterior cruciate ligament reconstruction but, until recently, has not been compatible with suture-loop and cortical suspensory fixation. We describe a technique that allows a relatively short (<75 mm) quadriceps tendon autograft (without bone block) to be used with established all-inside anatomic techniques.

Cost-effectiveness analysis of primary arthroscopic stabilization versus nonoperative treatment for first-time anterior glenohumeral dislocations.

PURPOSE: The purpose of this study was to compare the cost-effectiveness of initial observation versus surgery for first-time anterior shoulder dislocation. METHODS: The clinical scenario of first-time anterior glenohumeral dislocation was simulated using a Markov model (where variables change over time depending on previous states). Nonoperative outcomes include success (no recurrence) and recurrence; surgical outcomes include success, recurrence, and complications of infection or stiffness. Probabilities for outcomes were determined from published literature. Costs were tabulated from Medicare Current Procedural Terminology data, as well as hospital and office billing records. We performed microsimulation and probabilistic sensitivity analysis running 6 models for 1,000 patients over a period of 15 years. The 6 models tested were male versus female patients aged 15 years versus 25 years versus 35 years. RESULTS: Primary surgery was less costly and more effective for 15-year-old boys, 15-year-old girls, and 25-year-old men. For the remaining scenarios (25-year-old women and 35-year-old men and women), primary surgery was also more effective but was more costly. However, for these scenarios, primary surgery was still very cost-effective (cost per quality-adjusted life-year, <$25,000). After 1 recurrence, surgery was less costly and more effective for all scenarios. CONCLUSIONS: Primary arthroscopic stabilization is a clinically effective and cost-effective treatment for first-time anterior shoulder dislocations in the cohorts studied. By use of a willingness-to-pay threshold of $25,000 per quality-adjusted life-year, surgery was more cost-effective than nonoperative treatment for the majority of patients studied in the model. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis.

BACKGROUND: The optimal management strategy for primary traumatic anterior glenohumeral dislocation remains controversial. Patients have traditionally been managed nonoperatively, but high recurrence rates in certain populations have led to increased interest in early operative stabilization. The purpose of this study was to use expected-value decision analysis to determine the optimal management strategy--nonoperative treatment or arthroscopic stabilization--for a first-time traumatic anterior shoulder dislocation. MATERIALS AND METHODS: Probabilities for the occurrences of the potential outcomes after nonoperative and arthroscopic treatment of a first-time traumatic anterior glenohumeral dislocation were determined from a systematic review of the literature. Utilities for these outcomes were obtained from a questionnaire on patient preferences completed by 42 subjects without a history of shoulder injury. A decision tree was constructed, fold-back analysis was performed to determine optimal management, and sensitivity analyses were used to determine the effect on decision making of varying outcome probabilities and utilities. RESULTS: Nonoperative treatment was associated with a utility value of 5.9 and early arthroscopic surgery with a value of 7.6. On sensitivity analysis, it was found that when the rate of recurrence after nonoperative treatment falls below 32% or when the utility value for successful arthroscopic stabilization falls below 6.6, nonoperative treatment is the preferred management strategy. CONCLUSIONS: Arthroscopic stabilization was the preferred strategy after a primary anterior glenohumeral dislocation. In clinical settings where the likelihood of recurrent instability is low after nonoperative care or when an informed patient has an aversion to surgery, nonoperative treatment may be the preferred treatment strategy.

The diagnostic effect of various needle tip positions in selective lumbar nerve blocks: an analysis of 1202 injections.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To determine the effect of various needle tip positions on immediate postinjection pain in selective lumbar nerve blocks. SUMMARY OF BACKGROUND DATA: To our knowledge, no large study has examined the effect of various needle tip positions within or adjacent to the intervertebral foramen on immediate pain outcome. METHODS: A total of 1774 cases of intervertebral lumbar nerve blocks performed by our radiology staff between April 7, 1997 and May 31, 2002, were reviewed. Of the 1774 cases, 1202 met the study criteria (i.e., a single-level injection in an adult). The position of the needle tip and degree of immediate postinjection pain relief were examined. RESULTS: The blocks resulted in an average pain reduction of 4.14 U, as graded on a 0-10 ordinate scale (95% confidence interval 3.98-4.30). The degree of pain reduction was not associated with the needle tip position. CONCLUSIONS: Our results suggest that precise needle tip position within or adjacent to the intervertebral foramen made no difference on immediate pain reduction. These findings allow the practitioner more freedom in performing an injection. This study does not evaluate the long-term effects of various needle tip positions in selective lumbar nerve blocks.

Influence of needle-tip position on the incidence of immediate complications in 2,217 selective lumbar nerve root blocks.

BACKGROUND CONTEXT: Selective lumbar nerve blocks (SLNBs) are a popular, minimally invasive treatment and diagnostic tool for lumbar radiculopathy. It is therefore relevant to determine the complication rate for SLNBs, as well as examine the association between needle-tip position and complication rates in order to improve safety. PURPOSE: The purposes of the present study are to determine the overall rate of immediate, postprocedural complications in a large cohort of patients who received SLNBs and determine if certain needle-tip positions are less likely to cause complications. To our knowledge, this is the first paper to examine the relationship between needle-tip position and complications. STUDY DESIGN: A large retrospective cohort was assembled from patients who had undergone a SLNB. We determined the overall immediate complication rate for all injections. In addition, all patients who received only a single injection were compiled into another cohort, and needle-tip position was determined. The complication rate was determined for each needle-tip position. PATIENT SAMPLE: All adult patients who underwent a SLNB in a single radiology department from April 1, 1997 to May 31, 2002. OUTCOME MEASURES: Patients were observed for 15-30 minutes after their procedure, then interviewed about any self-reported weakness, light-headedness, increase in pain from the preprocedural levels, or development of new pain. Their postprocedural pain was then rated on the Visual Analogue Scale. The radiologic notes from each examination were reviewed for incidence of these, or any other, complications. METHODS: SLNBs were performed as they would be in the normal course of care, using fluoroscopic guidance and methodology established by a single radiologist overseeing the procedures. The radiologist's record of each visit was examined for note of immediate, postprocedural complications. The radiographs from the patients who received a single injection during their visit were examined to determine the position of the needle tip during the procedure. The needle-tip positions from the "Complications" and "No Complications" single injection cohorts were compared to determine if certain needle-tip positions cause less complications than others. RESULTS: Minor complications were encountered in 98 of the 1,777 total patient visits, for an overall complication rate of 5.5%. All complications were transient, and no patient suffered lasting harm. There were 1,232 procedures in which the patient received a single injection, and a minor complication was encountered in 62 of these visits. The complication rate approached 5% for all needle-tip positions, which is not statistically different from the overall complication rate. However, there was an increased likelihood of complications in patients undergoing a multiple injection procedure vs. those who had only one injection. CONCLUSIONS: Our results suggest that SLNBs performed with fluoroscopic guidance have a low incidence of complications. All of our complications were minor. The specific needle-tip position within or adjacent to the lumbar neural foramen does not appear to be associated with the incidence of complications.