Low early complication rates after arthroscopic meniscus repair and meniscectomy.

PURPOSE: To evaluate the 30-day complication rates after arthroscopic meniscus repair and meniscectomy using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, with subgroup analysis of patients aged > 40 years. METHODS: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing arthroscopic meniscus repair (CPT 29882, 29883) and meniscectomy (29880, 29881). The following 30-day complications were assessed: pulmonary embolism (PE), venous thromboembolism (VTE), surgical site infection (SSI), reoperation, and readmission. Complications rates between treatment groups were compared using multivariate logistic regression analyses adjusted for sex, age, steroid use, and smoking/dyspnoea/COPD. A subgroup analysis was performed for patients aged > 40 years. RESULTS: A total 6354 meniscus repairs and 99,372 meniscectomies were identified. Complication rates were < 1% for both meniscus repair and meniscectomy. Meniscus repair was associated with significantly higher rates of PE, VTE, and readmission compared to meniscectomy: PE (0.2% vs 0.1%, p < 0.001), VTE (0.8% vs 0.4%, p < 0.001), superficial SSI (0.1% vs 0.2%, n.s), deep SSI (0.07% vs 0.1%, n.s), reoperation (0.5% vs 0.4%, n.s), and readmission (0.9% vs 0.8%, p = 0.003). Among patients aged > 40 years, complication rates were < 1.3% for both meniscus repair and meniscectomy. Similar trends and rates were found in patients aged > 40 years undergoing meniscus repair versus meniscectomy: PE (0.38% vs 0.12%, p < 0.001), VTE (1.07% vs 0.46%, p < 0.001), superficial SSI (0.03% vs 0.19%, n.s), deep SSI (0.1% vs 0.06%, n.s), reoperation (0.48% vs 0.43%, n.s), and readmission (1.2% vs 0.85%, p = 0.01). CONCLUSION: Arthroscopic meniscus repair and meniscectomy are both low-risk procedures with 30-day complication rates < 1% overall and < 1.3% among patients aged > 40 years. These findings support meniscus repair whenever feasible in the setting of preserved articular cartilage. Understanding of the short-term complication rates after arthroscopic meniscus repair and meniscectomy can aid surgeons in providing comprehensive preoperative counselling to patients considering such treatments, specifically when discussing the risks and benefits of meniscus repair. LEVEL OF EVIDENCE: III.

Hand Replantation With Dorsal Spanning Plate Following a Self-Inflicted Radiocarpal Amputation.

Upper extremity amputations represent a prime opportunity to restore function through replantation. There are a variety of options that treating surgeons use to protect neurovascular repairs and restore function including Kirschner wire fixation, external fixation, wrist arthrodesis, and proximal row carpectomy. Additionally, the dorsal spanning plate may be a valuable tool for protecting neurovascular repairs. Compared to temporary immobilization with Kirschner wire fixation, which has previously been described in conjunction with upper extremity replantation, dorsal spanning plates can be left in place for longer durations with a lower risk of loosening and loss of fixation and for preventing postoperative sabotage or repeat amputation of the replant by the patient. In this article, we describe a unique case of a patient with acute psychiatric illness that presented with a self-inflicted amputation through the radiocarpal joint and was initially treated with emergent replantation and application of a dorsal spanning plate to protect the neurovascular repair from patient sabotage and allow for early rehabilitation. We found the dorsal spanning plate to be an effective option in this complex clinical scenario. This case illustrates the utility of the dorsal spanning plate in protecting complex neurovascular repairs in the setting of severe skeletal and psychiatric instability.

The Statistical Fragility of Operative vs Nonoperative Management for Achilles Tendon Rupture: A Systematic Review of Comparative Studies.

BACKGROUND: The statistical significance of randomized controlled trials (RCTs) and comparative studies is often conveyed utilizing the P value. However, P values are an imperfect measure and may be vulnerable to a small number of outcome reversals to alter statistical significance. The interpretation of the statistical strength of these studies may be aided by the inclusion of a Fragility Index (FI) and Fragility Quotient (FQ). This study examines the statistical stability of studies comparing operative vs nonoperative management for Achilles tendon rupture. METHODS: A systematic search was performed of 10 orthopaedic journals between 2000 and 2021 for comparative studies focusing on management of Achilles tendon rupture reporting dichotomous outcome measures. FI for each outcome was determined by the number of event reversals necessary to alter significance (P < .05). FQ was calculated by dividing the FI by the respective sample size. Additional subgroup analyses were performed. RESULTS: Of 8020 studies screened, 1062 met initial search criteria with 17 comparative studies ultimately included for analysis, 10 of which were RCTs. A total of 40 outcomes were examined. Overall, the median FI was 2.5 (interquartile range [IQR] 2-4), the mean FI was 2.90 (±1.58), the median FQ was 0.032 (IQR 0.012-0.069), and the mean FQ was 0.049 (±0.062). The FI was less than the number of patients lost to follow-up for 78% of outcomes. CONCLUSION: Studies examining the efficacy of operative vs nonoperative management of Achilles tendon rupture may not be as statistically stable as previously thought. The average number of outcome reversals needed to alter the significance of a given study was 2.90. Future analyses may benefit from the inclusion of a fragility index and a fragility quotient in their statistical analyses.

Osteochondral Allografts in Knee Surgery: Narrative Review of Evidence to Date.

Knee articular cartilage defects can result in significant pain and loss of function in active patients. Osteochondral allograft (OCA) transplantation offers a single-stage solution to address large chondral and osteochondral defects by resurfacing focal cartilage defects with mature hyaline cartilage. To date, OCA transplantation of the knee has demonstrated excellent clinical outcomes and long-term survivorship. However, significant variability still exists among clinicians with regard to parameters for graft acceptance, surgical technique, and rehabilitation. Technologies to optimize graft viability during storage, improve osseous integration of the allograft, and shorten recovery timelines after surgery continue to evolve. The purpose of this review is to examine the latest evidence on treatment indications, graft storage and surgical technique, patient outcomes and survivorship, and rehabilitation after surgery.

Low-Intensity Pulsed Ultrasound Augments Tendon, Ligament, and Bone-Soft Tissue Healing in Preclinical Animal Models: A Systematic Review.

PURPOSE: To appraise the available animal and human studies investigating low-intensity pulsed ultrasound stimulation (LIPUS) on tendon, ligament, and bone-soft tissue (B-ST) junction healing. METHODS: A systematic review of PUBMED, EMBASE, and the Cochrane Library was performed for animal and human studies investigating the effects of LIPUS on tendon, ligament, and B-ST junction healing. The systematic search was performed using the key term "low intensity pulsed ultrasound" and any of the following: "tendon," "ligament," "tendon-bone," and "bone-tendon." Inclusion criteria consisted of (1) randomized controlled trials assessing the effect of LIPUS on bone, tendon, and soft tissue in animals or humans and (2) English-language articles. RESULTS: A total of 28 animal and 2 human studies met inclusion criteria. Animal studies utilized various models, including Achilles and patellar tendon transections, medial collateral ligament transections, and surgical repair of patellar tendon, rotator cuff tendon, and anterior cruciate ligament, to evaluate the effects of LIPUS. Animal studies demonstrated significantly improved collagen content and organization, bone formation, fibrocartilage remodeling, and mechanical strength with LIPUS treatment compared with controls. In human trials, LIPUS treatment of chronic tendinopathies did not improve clinical outcomes. CONCLUSIONS: In acute injury animal models, LIPUS augmented healing of acute tendon, ligament, and B-ST junction injuries through increased collagen content and organization; increased anti-inflammatory cellular signaling; and increased angiogenesis. However, in 2 human studies investigating chronic tendinopathy, LIPUS did not lead to superior outcomes compared with controls. CLINICAL RELEVANCE: Animal models suggest that LIPUS may be a promising noninvasive treatment modality for accelerating patient recovery after acute tendon and ligament injuries, as well as after surgical repair of B-ST junction injuries, but this has not been demonstrated in human studies. Randomized clinical trials evaluating LIPUS for acute tendon and ligament injuries are warranted.

Blood transfusion rates and predictors following geriatric hip fracture surgery.

BACKGROUND: Postoperative blood product transfusions in elderly hip fracture patients cause concern for morbidity and mortality. The purpose of this study was to identify predictors and short-term sequelae of postoperative transfusion following geriatric hip fracture surgery. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify geriatric (⩾65 years) patients who sustained operative femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to determine risk-adjusted odds ratios (OR) of associated perioperative risk factors and sequelae of postoperative transfusion. RESULTS: In total, 8416 geriatric hip fracture patients were identified of whom 28.3% had documented postoperative transfusion. In multivariate analysis, age (OR 1.03 [1.02-1.04], p < 0.001), preoperative anaemia (OR 4.69 [3.99-5.52], p = 0.001), female sex (OR 1.61 [1.39-1.87], p < 0.001), lower BMI (OR 0.97 [0.96-0.98], p < 0.001), American Society of Anesthesiologists (ASA) classification (OR 1.14 [1.01-1.27], p = 0.031), COPD (OR 1.30 [1.06-1.59], p = 0.011), hypertension (OR 1.17 [1.01-1.35], p = 0.038), increased OR time (OR 1.02 [1.01-1.03], p < 0.001), and intertrochanteric (OR 2.99 [2.57-3.49], p < 0.001) and subtrochanteric femur fractures (OR 5.07 [3.84-6.69], p < 0.001) were independent risk factors for receiving postoperative blood transfusion. Patients with postoperative transfusion had a significantly higher risk-adjusted 30-day mortality (8.4% vs. 6.4%, OR 1.29 [1.02-1.64], p = 0.035), hospital readmission rate (9.4% vs. 7.7%, OR 1.27 [1.04-1.55], p = 0.018), and total hospital LOS (7.3 vs. 6.3 days, p < 0.001). CONCLUSIONS: Postoperative transfusion is a common occurrence in geriatric fragility hip fractures with multiple risk factors. Careful preoperative planning and multidisciplinary management efforts are warranted to reduce use of postoperative transfusions.

Postacute Care Utilization in Postsurgical Orthogeriatric Hip Fracture Care.

INTRODUCTION: Among surgical patients, utilization of institutional-based postacute care (PAC) presents a notable financial burden and is associated with increased risk of complications and mortality rates when compared with discharge home. The purpose of this study was to identify predictors of postdischarge disposition to PAC in geriatric patients after surgical fixation of native hip fractures. METHODS: We have done a query of the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained surgical femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to compute risk factors for discharge to and prolonged stay (>30 days) in PAC. RESULTS: Eight thousand one hundred thirty-three geriatric hip fracture patients with sufficient follow-up data were identified. Of these, 6,670 patients (82.0%) were initially discharged to PAC after their hip fracture episode of care, and 2,986 patients (36.7%) remained in PAC for >30 days. Age (odds ratio [OR] 1.06 [1.05 to 1.08], P < 0.001), partial (OR 2.41 [1.57 to 3.71], P < 0.001) or total dependence (OR 3.03 [1.92 to 4.46], P < 0.001) for activities of daily living, dementia (OR 1.62 [1.33 to 1.96], P < 0.001), diabetes (OR 1.46 [1.14 to 1.85], P = 0.002), hypertension (OR 1.32 [1.10 to 1.58], P = 0.002), and total hospital length of stay (OR 1.04 [1.01 to 1.08], P = 0.006) were independent risk factors for discharge to PAC. Age (OR 1.05 [1.04 to 1.06], P < 0.001), partial (OR 2.86 [1.93 to 3.79], P < 0.001) or total dependence (OR 3.12 [1.45 to 4.79], P < 0.001) for activities of daily living, American Society of Anesthesiologist's classification (OR 1.27 [1.13 to 1.43], P < 0.001), dementia (OR 1.49 [1.28 to 1.74], P < 0.001), and total hospital length of stay (OR 1.10 [1.08 to 1.13], P < 0.001) were independent risk factors for prolonged PAC stay >30 days. DISCUSSION: Discharge to PAC is the norm among patients undergoing hip fracture surgery. Provider foreknowledge of risk factors may help improve hip fracture outcomes and decrease healthcare costs.

Incidence and predictors of early complications following primary and revision total ankle arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) offers an effective option for end-stage osteoarthritis. The incidence and preoperative risk factors for early adverse events (AEs) following primary and revision TAA may be useful information for providers. METHODS: A large database was queried from 2010 to 2016 to identify 905 patients of whom 818 underwent primary TAA (90.4%) and 87 underwent revision TAA (9.6%). Data on patient demographics, comorbidities, and hospital length of stay were analyzed as risk factors for reported 30-day AEs. RESULTS: The overall AE rate was 5.5% (50/905) for the entire cohort. AEs occurred more frequently for revision TAA (9/87) than primary TAA (41/818) cases (OR 2.43, p=0.022). Age (OR 1.03, p=0.045), BMI (OR 1.04, p=0.046), and revision TAA (OR 2.56, p=0.002) were independent risk factors for 30-day AEs in multivariate analysis. CONCLUSIONS: Older age, higher BMI, and revision cases are associated with a higher risk of AEs.

Chronic lateral epicondylitis: challenges and solutions.

Lateral epicondylitis (LE) is a significant source of pain and dysfunction resulting from repetitive gripping or wrist extension, radial deviation, and/or forearm supination. Although most cases are self-limiting over several years, controversy exists regarding the best treatment strategy for chronic LE. Nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), shockwave therapy, and injections with corticosteroids or biologics are all conservative treatment options for LE. For refractory cases, surgical options include open, arthroscopic, and percutaneous techniques. In this review, the current evidence behind these treatment strategies is presented. The data demonstrate that NSAIDs, PT, bracing, and shockwave therapy provide limited benefit for treating LE. Biologics such as platelet-rich plasma and autologous whole-blood injections may be superior to steroid injections in the long-term management of LE. Although the initial results are promising, larger comparative studies on stem cell injections are needed. For refractory LE, open, arthroscopic, and percutaneous techniques are all highly effective, with no method seemingly superior over another. Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work.

Efficacy of intraarticular corticosteroid hip injections for osteoarthritis and subsequent surgery.

OBJECTIVE: Our study aimed to determine the duration of pain relief from intraarticular hip corticosteroid injections and identify patient predictive factors on injection response. We also sought to determine the subsequent rate of hip surgery and whether severity of hip osteoarthritis or injection response correlated with the decision to undergo surgery. MATERIALS AND METHODS: All intraarticular hip steroid injections performed for osteoarthritis under fluoroscopic guidance at a single institution between January 2010 to December 2012 were retrospectively reviewed. Response was divided into three groups: no relief, immediate (≤ 2 weeks of pain relief), and continued (> 2 weeks of pain relief). Presence of hip surgery for osteoarthritis performed within 2 years following injection was obtained. Correlation between patient characteristics with injection outcome and hip surgery was analyzed. RESULTS: Of 78 patients, a total of 82 injections were analyzed. For injections, 19.5% (16/82) showed no response, 47.6% (39/82) showed immediate response, and 32.9% (27/82) showed continued response. There was no significant correlation between injection outcome with age, Tönnis grade, BMI, or duration of symptoms. In total, 48.7% had hip surgery within 2 years after initial injection. There was a significant association between Tönnis grade and surgery, with higher Tönnis grades correlating with decision to undergo surgery (p = 0.002). CONCLUSIONS: Gender, age, BMI, duration of symptoms, and radiographic severity of disease do not predict injection response. Due to high surgical rates and poor response, intraarticular hip steroid injections may be less effective in the long term, and surgical management may be considered earlier.

Predictors and Sequelae of Postoperative Delirium in Geriatric Hip Fracture Patients.

INTRODUCTION: Perioperative delirium in elderly hip fracture patients has been correlated with significant morbidity. The purpose of this study was to determine the preoperative risk factors for and short-term sequelae of postoperative delirium in geriatric hip fracture patients. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained operative hip fractures in 2016. Cohorts of patients with and without documented postoperative delirium were identified. Primary data on patient demographics and comorbidities were collected and correlated with postoperative complications and hip fracture outcome measures. Multivariate regression was used to compute risk-adjusted odds ratios (OR) of risk factors and sequelae of delirium. RESULTS: In total, 8,439 geriatric hip fracture patients were identified of whom 2,569 patients (30.4%) had postoperative delirium. Age (OR 1.03 [1.02-1.04, p < 0.001), white race (OR 1.54 [1.19-2.00], p = 0.001), American Society of Anesthesiologists classification (OR 1.20 [1.07-1.36], p = 0.003), baseline dementia (OR 2.46 [2.11-2.86], p < 0.001), and preoperative delirium (OR 10.06 [8.12-12.45], p < 0.001) were independent risk factors for postoperative delirium in multivariate analysis. Patients with postoperative delirium had a significantly higher risk-adjusted 30-day mortality (12.0% vs. 4.8%, OR 2.22 [1.74-2.84], p < 0.001) and morbidity profile. Postoperative delirium was also independently associated with higher rates of discharge to (OR 1.65 [1.32-2.06], p < 0.001) and prolonged stay in (OR 1.79 [1.53-2.09], p < 0.001) an inpatient facility, hospital readmission (OR 1.94 [1.58-2.38], p < 0.001) and hospital length of stay (7.6 ± 5.0 vs. 6.1 ± 4.1 days, p < 0.001), as well as lower rates of immediate postoperative weight bearing (OR 0.73 [0.63-0.86], p < 0.001). DISCUSSION: Postoperative delirium is a common occurrence in geriatric hip fractures with multiple risk factors. Delirium portends higher mortality and worse perioperative hospital-based outcomes. CONCLUSIONS: Multidisciplinary foreknowledge and management efforts are warranted to mitigate the risk of developing delirium, which strongly predicts perioperative morbidity, mortality, and hip fracture outcomes.

Lower Quarter Y-Balance Test Scores and Lower Extremity Injury in NCAA Division I Athletes.

BACKGROUND: Functional movement tests that are predictive of injury risk in National Collegiate Athletic Association (NCAA) athletes are useful tools for sports medicine professionals. The Lower Quarter Y-Balance Test (YBT-LQ) measures single-leg balance and reach distances in 3 directions. PURPOSE: To assess whether the YBT-LQ predicts the laterality and risk of sports-related lower extremity (LE) injury in NCAA athletes. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The YBT-LQ was administered to 294 NCAA Division I athletes from 21 sports during preparticipation physical examinations at a single institution. Athletes were followed prospectively over the course of the corresponding season. Correlation analysis was performed between the laterality of reach asymmetry and composite scores (CS) versus the laterality of injury. Receiver operating characteristic (ROC) analysis was used to determine the optimal asymmetry cutoff score for YBT-LQ. A multivariate regression analysis adjusting for sex, sport type, body mass index, and history of prior LE surgery was performed to assess predictors of earlier and higher rates of injury. RESULTS: Neither the laterality of reach asymmetry nor the CS correlated with the laterality of injury. ROC analysis found optimal cutoff scores of 2, 9, and 3 cm for anterior, posteromedial, and posterolateral reach, respectively. All of these potential cutoff scores, along with a cutoff score of 4 cm used in the majority of prior studies, were associated with poor sensitivity and specificity. Furthermore, none of the asymmetric cutoff scores were associated with earlier or increased rate of injury in the multivariate analyses. CONCLUSION: YBT-LQ scores alone do not predict LE injury in this collegiate athlete population. Sports medicine professionals should be cautioned against using the YBT-LQ alone to screen for injury risk in collegiate athletes.

Precollegiate Knee Surgery Predicts Subsequent Injury Requiring Surgery in NCAA Athletes.

BACKGROUND: The effect of precollegiate orthopaedic surgery on injury risk in the elite collegiate athlete is unknown. PURPOSE: To (1) assess the relationship between precollegiate surgery and subsequent injury requiring surgery in National Collegiate Athletic Association (NCAA) Division I athletes at a single institution and (2) compare the risk of subsequent surgery in the ipsilateral versus contralateral extremity in those with a history of precollegiate surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective chart review was performed of all athletes who began participation from 2003 to 2009 until completion of eligibility. Athletes who received orthopaedic surgery in college were identified through the Sports Injury Monitoring System and were cross-referenced with medical records. The risk of orthopaedic surgery was evaluated using multivariate Cox and Poisson regression models, with sex and sport as additional covariates. Risk of subsequent surgery in the ipsilateral versus contralateral extremity was compared using Kaplan-Meier survival estimates and Cox proportional hazards regression. Hazard ratios (HRs) and rate ratios (RRs) with corresponding 95% confidence intervals were used to compare groups. RESULTS: In total, 1141 athletes were identified for analysis. Of these, 186 athletes (16.3%) had a history of precollegiate orthopaedic surgery. There were 261 documented intracollegiate orthopaedic surgeries in 181 athletes (15.9%). Precollegiate knee surgery was an independent predictor of orthopaedic surgery (HR, 1.85; 95% CI, 1.16-2.83) in college. When examining only surgeries resulting from acute or primary injuries, precollegiate knee surgery was an independent predictor of primary knee injury requiring surgery in college (HR, 4.45; 95% CI, 2.51-7.59). Athletes with a history of precollegiate surgery were more susceptible to subsequent surgery in their ipsilateral extremity compared with their other extremities (HR, 1.89; 95% CI, 1.03-3.53). In contrast, there was no additional risk of receiving subsequent surgery in the contralateral extremity (P = .54). CONCLUSION: Precollegiate knee surgery in the Division I athlete is associated with subsequent injury requiring surgery in college. Athletes with a history of precollegiate surgery are at higher risk of subsequent surgery in their ipsilateral extremity compared with other extremities.