Effects of Opioid-Limiting Legislation in the State of Ohio on Opioid Prescriptions After Shoulder Arthroscopy.

Background: Recent studies have shown that legislation regulating opioid prescriptions in the United States has been successful in reducing the morphine milligram equivalent (MME) prescribed after certain orthopaedic procedures. Purpose: To (1) determine the effect of Ohio's legislation limiting opioid prescriptions after shoulder arthroscopy and (2) identify risk factors associated with prolonged opioid use and increased postoperative opioid dosing. Study Design: Cohort study; Level of evidence, 3. Methods: We reviewed the data of patients who underwent shoulder arthroscopy between January 1, 2016, and March 31, 2020. Patients were classified according to the date of legislation passage (August 31, 2017) as before legislation (PRE) or on/after legislation (POST). Patients were also classified based on the number of opioid prescriptions filled within 30 days of surgery as opioid-tolerant (at least 1 prescription) or opioid-naïve (zero prescriptions). We recorded patient characteristics, medical comorbidities, and surgical details, as well as the number of opioid prescriptions, MME per prescription from 30 days preoperatively to 90 days postoperatively, and the number of gamma-aminobutyric acid (GABA) analogues and benzodiazepine prescriptions from 30 days preoperatively to the date of surgery. Differences between cohorts were compared with the Fisher exact test and Wilcoxon test. A covariate-adjusted regression analysis was used to evaluate risk factors associated with increased postoperative opioid dosing. Results: Overall, 279 patients (n = 97 PRE; n = 182 POST; n = 42 opioid-tolerant; n = 237 opioid-naïve) were included in the final analysis. There was a significant reduction in the cumulative MME prescribed in the immediate (0-7 days) postoperative period (PRE, 450 MME vs POST, 315 MME), the first 30 postoperative days (PRE, 590 MME vs POST, 375 MME), and the first 90 postoperative days (PRE, 600 MME vs POST, 420 MME) (P < .001 for all). The opioid-tolerant cohort had higher MME at every time point in the postoperative period (P < .001). Consumption of preoperative opioid (ß = 1682.5; P < .001), benzodiazepine (ß = 468.09; P < .001), and GABA analogue (ß = 251.37; P = .04) was associated with an increase in the cumulative MME prescribed. Conclusion: Opioid prescription-limiting legislation in Ohio significantly reduced the cumulative MME prescribed in the first 30 days postoperatively for both opioid-naïve and opioid-tolerant patients after shoulder arthroscopy. Consumption of opioids, benzodiazepines, and GABA analogues preoperatively was associated with increased postoperative opioid dosage.

Management of Bone Loss and Tunnel Widening in Revision ACL Reconstruction.

➤ Both mechanical and biological factors can contribute to bone loss and tunnel widening following primary anterior cruciate ligament (ACL) reconstruction.➤ Revision ACL surgery success is dependent on graft position, fixation, and biological incorporation.➤ Both 1-stage and 2-stage revision ACL reconstructions can be successful in correctly indicated patients.➤ Potential future solutions may involve the incorporation of biological agents to enhance revision ACL surgery, including the use of bone marrow aspirate concentrate, platelet-rich plasma, and bone morphogenetic protein-2.

Biologics, Stem Cells, Growth Factors, Platelet-Rich Plasma, Hemarthrosis, and Scaffolds May Enhance Anterior Cruciate Ligament Surgical Treatment.

Biologics including mesenchymal stem cells (MSCs), growth factors, and platelet-rich plasma may enhance anterior cruciate ligament (ACL) reconstruction and even ACL primary repair. In addition, hemarthrosis after acute ACL injury represents a source of biologic factors. MSCs can differentiate into both fibroblasts and osteoblasts, potentially providing a transition between the ligament or graft and bone. MSCs also produce cytokines and growth factors necessary for cartilage, bone, ligament, and tendon regeneration. MSC sources including bone marrow, synovium, adipose tissue, ACL-remnant, patellar tendon, and umbilical cord. Also, scaffolds may represent a tool for ACL tissue engineering. A scaffold should be porous, which allows cell growth and flow of nutrients and waste, should be biocompatible, and might have mechanical properties that match the native ACL. Scaffolds have the potential to deliver bioactive molecules or stem cells. Synthetic and biologically derived scaffolds are widely available. ACL reconstruction with improved outcome, ACL repair, and ACL tissue engineering are promising goals. LEVEL OF EVIDENCE: Level V, expert opinion.

Anterior and superior plate positions in diaphyseal clavicle fractures produce similar patient outcomes.

PURPOSE: While diaphyseal clavicle fractures can be treated with plate fixation on either the superior or anteroinferior aspect of the clavicle, the optimal plate position remains controversial. The purpose of this study was to determine if anteroinferior vs. superior plating for clavicle fracture fixation leads to better patient outcomes. METHODS: A retrospective review of patients who sustained clavicle fractures (OTA/AO 15.2) treated with superior or anteroinferior plating at a tertiary Level I trauma center from 2015 to 2021 was performed. The clinical outcomes of clavicle fractures were compared between groups treated with an anterior versus a superior approach via Mann-Whitney U and Chi-squared tests as appropriate to evaluate for differences in outcomes between the two plate positions. RESULTS: A total of 315 diaphyseal clavicle fractures were identified. One hundred and forty patients were excluded due to inadequate follow-up. Of the remaining 175 patients, 25 were treated with an anteroinferior approach (14%) and 150 were treated with a superior approach (86%). There were no differences in age, BMI, tobacco use, or substance use between the two groups (p > 0.05 for all). On univariate analysis, there was no difference in rate of union (p = 0.60), nerve injury (p = 0.60), infection (p = 1.0), implant-related irritation (p = 0.42), implant removal (p = 0.26), or revision (p = 1.0) based on approach. Contoured plates had an association with risk of nerve injury (p = 0.04). CONCLUSION: There are no differences in union, nerve injury, infection, symptomatic implant, or revision rate between anteroinferior and superior clavicle approaches. Plate positioning during diaphyseal clavicle fracture fixation can reasonably be dictated based on surgeon preference and ideal reduction quality.

Wearable Sensor Technology to Predict Core Body Temperature: A Systematic Review.

Heat-related illnesses, which range from heat exhaustion to heatstroke, affect thousands of individuals worldwide every year and are characterized by extreme hyperthermia with the core body temperature (CBT) usually > 40 °C, decline in physical and athletic performance, CNS dysfunction, and, eventually, multiorgan failure. The measurement of CBT has been shown to predict heat-related illness and its severity, but the current measurement methods are not practical for use in high acuity and high motion settings due to their invasive and obstructive nature or excessive costs. Noninvasive predictions of CBT using wearable technology and predictive algorithms offer the potential for continuous CBT monitoring and early intervention to prevent HRI in athletic, military, and intense work environments. Thus far, there has been a lack of peer-reviewed literature assessing the efficacy of wearable devices and predictive analytics to predict CBT to mitigate heat-related illness. This systematic review identified 20 studies representing a total of 25 distinct algorithms to predict the core body temperature using wearable technology. While a high accuracy in prediction was noted, with 17 out of 18 algorithms meeting the clinical validity standards. few algorithms incorporated individual and environmental data into their core body temperature prediction algorithms, despite the known impact of individual health and situational and environmental factors on CBT. Robust machine learning methods offer the ability to develop more accurate, reliable, and personalized CBT prediction algorithms using wearable devices by including additional data on user characteristics, workout intensity, and the surrounding environment. The integration and interoperability of CBT prediction algorithms with existing heat-related illness prevention and treatment tools, including heat indices such as the WBGT, athlete management systems, and electronic medical records, will further prevent HRI and increase the availability and speed of data access during critical heat events, improving the clinical decision-making process for athletic trainers and physicians, sports scientists, employers, and military officers.

Interprosthetic Femur Fractures: A Review Article.

➢: The prevalence of interprosthetic femur fractures (IFFs) is rising with the aging population and increased prevalence of total joint arthroplasty. ➢: IFFs have high rates of complications and high associated morbidity and mortality. ➢: The main treatment methods available for IFFs include plate fixation, intramedullary nailing, combined plate fixation and intramedullary nailing, and revision arthroplasty including partial and total femur replacement. ➢: There have been several proposed classification systems and at least 1 proposed treatment algorithm for IFFs; however, there is no consensus. ➢: Whichever treatment option is chosen, goals of surgery should include preservation of blood supply, restoration of length, alignment, rotation, and sufficient stabilization to allow for early mobilization.

Complete Isolated Ruptures of the Distal Biceps Brachii During Athletic Activity: A Systematic Review.

Complete, isolated ruptures of the distal biceps brachii sustained during athletic activities are uncommon. A systematic review of the literature was performed to identify complete distal biceps brachii tears experienced during athletic activities to determine injury prevalence, athletic activities/mechanisms responsible for injury and return to activity timing following operative management. A total of 10 studies, comprising 16 athletes undergoing surgery for 18 cases, were identified. Injuries were predominately associated with weightlifting. Injuries were treated utilizing a single incision in 56% of cases and primary repair performed in 89% of cases. Mean time to return to activity was 4.86 ± 1.14months. Athletes undergoing surgery ≤ 10 days following injury and those undergoing primary repair returned to activity significantly quicker. Isolated tears of the distal biceps remain uncommon during athletic activities, occurring primarily during weightlifting. Return to activity timing was not significantly delayed based on surgical approach, steroid use, or athlete age.

Restoration of the native humeral anatomy during stemless anatomic total shoulder arthroplasty: a radiographic comparison of intramedullary versus freehand resection.

BACKGROUND: During anatomic total shoulder arthroplasty (aTSA), the humeral head can be resected with or without the use of an intramedullary cutting guide, the former referred to as intramedullary (IM) resection and the latter referred to as freehand (FH) resection. Outcomes following aTSA are predicated upon the restoration of the native humeral anatomy, which can be more challenging with stemless implants. To date, no studies have determined which method of humeral head resection is superior in restoring native anatomy. Our purpose was to determine whether FH or IM resection was superior in restoring native anatomy during aTSA with stemless implants. METHODS: A review of all patients who underwent aTSA using the stemless Tornier Simpliciti Shoulder System at two academic institutions by two separate surgeons between January 2017 and June 2020 was performed. One surgeon at one institution performed stemless aTSA using the IM resection technique, while the second surgeon utilized the FH resection technique. Patients were excluded if they underwent surgery for an indication other than glenohumeral osteoarthritis, if they received a short-stem or standard-stem implant, or if they lacked adequate preoperative and postoperative Grashey radiographs. One hundred eleven patients across both institutions (51 IM, 60 FH) were included for the final radiographic assessment. The humeral head height (HH) and neck-shaft angle (NSA) were measured on preoperative and postoperative Grashey radiographs. The centers of rotation (CORs) were measured on postoperative Grashey radiographs. Patients were classified as having acceptable restoration of their native anatomy if the change (Δ) in COR or HH was ≤3 mm and ≤ 5 mm, respectively, or if the postoperative NSA was ≥130°. RESULTS: IM resection had the greatest acceptable restoration of COR (90.2% IM versus 70% FH, P = .009), HH (96.1% IM vs. 63.3% FH, P < .001), and NSA (96.1% IM vs. 78.3% FH, P = .006) relative to FH resection. The mean postoperative NSAs for the IM and FH cohorts were 134.4° (±2.1°) and 133.8° (±5.4°), respectively (P = .208). The mean ΔCORs for the IM and FH groups were 1.2 (±1.5) and 2.3 (±1.2) mm, respectively (P < .001). Finally, the mean ΔHHs for the IM and FH cohorts were 1.7 (±1.4) and 4.4 (±2.9) mm, respectively (P < .001). CONCLUSIONS: Restoration of the native humeral anatomy following stemless aTSA occurred at a significantly higher rate when using IM vs. FH resection.

Modified Grammont Soft-Tissue Distal Patellar Realignment and Medial Patellofemoral Ligament Reconstruction for Patellofemoral Instability in Pediatric Patients.

Patellar dislocation is a relatively common pediatric injury, which often results in recurrent patellofemoral instability. An increased tibial tubercle-trochlear groove distance predisposes to patellofemoral instability and can be corrected with a distal realignment procedure. Soft-tissue distal realignment procedures must be used in the pediatric population to avoid the risks of premature physeal closure associated with tibial tubercle osteotomies. Several soft-tissue distal realignment procedures have been described, with no consensus as to the optimal technique. When combined with medial patellofemoral ligament reconstruction, distal realignment procedures can restore patellofemoral stability through the entire flexion arc. This article describes a modification of the Grammont distal patellar realignment procedure in conjunction with medial patellofemoral ligament reconstruction for the management of pediatric patellofemoral instability.

Immunologic Contributions Following Rotator Cuff Injury and Development of Cuff Tear Arthropathy.

¼: Rotator cuff tear arthropathy (RCTA) describes a pattern of glenohumeral degenerative changes following chronic rotator cuff tears that is characterized by superior humeral head migration, erosion of the greater tuberosity of the humeral head, contouring of the coracoacromial arch to create a socket for the humeral head, and eventual glenohumeral arthritis. ¼: Acute and chronic inflammatory changes following rotator cuff tears are thought to contribute to cartilage damage, muscle fibrosis, and fatty infiltration in the glenohumeral joint. ¼: In vitro animal studies targeting various inflammatory modulators, including macrophages, insulin-like growth factor-I, and transforming growth factor-beta pathways, provide promising therapeutic targets to improve healing after rotator cuff tears. ¼: The role of platelet-rich plasma in the treatment and prevention of RCTA has been investigated, with conflicting results.

Acute Fixation of Displaced Intra-articular Calcaneus Fractures Is Safe Using the Sinus Tarsi Approach.

OBJECTIVE: To analyze the correlation between surgical timing and outcomes for calcaneus fractures treated using a sinus tarsi approach (STA). SETTING: Single Level-1 trauma center. DESIGN: Retrospective. PATIENTS/PARTICIPANTS: Seventy consecutive intra-articular calcaneus fractures (OTA/AO 82C; Sanders II-IV) treated operatively using STA with a minimum of 1-year follow-up. INTERVENTION: Open management using STA. MAIN OUTCOME MEASUREMENT: Surgery timing, wound complications, American Orthopaedic Foot and Ankle Society ankle and hindfoot and Patient-reported Outcomes Measurement System scores. RESULTS: Patients were primarily men (68.6%) averaging 46 years (range, 18-77 years). Nineteen (27%) were obese, 27 (38.6%) were smokers, and 3 (4.3%) were diabetic, and 10 (14.3%) had open fractures. Sanders III fracture patterns were most common (45.7%). Mean time to surgery was 4.9 days (range, 0-23 days). Three patients (4.2%) developed postoperative infections requiring surgical debridement and antibiotics. Forty patients (57%) underwent operative repair within 72 hours of injury, 9 (22.5%) of which had open fractures. Of this group, only one patient developed wound necrosis. Restoration of Bohler angle and angle of Gissane and reductions in calcaneal varus angle and heel width were achieved (all P < 0.001). No differences in Ankle Society ankle and hindfoot or Patient-reported Outcomes Measurement System scores were noted between patients treated within or beyond 72 hours from injury. CONCLUSION: Intra-articular calcaneus fractures can be treated acutely within 72 hours of injury using STA with minimal wound complications and without compromising short-term functional outcome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of time to healing and major complications after surgical fixation of nondisplaced femoral neck stress fractures: A systematic review.

INTRODUCTION: There is no recent literature review comparing outcomes of fixation methods for nondisplaced stress fractures of the femoral neck. METHODS: A systematic review of the literature on operative fixation of femoral neck stress fractures was performed. Inclusion criteria consisted of diagnosis of nondisplaced femoral neck stress fractures, implants used for fixation, articles in English language or available English translation, all ages, and Level 1-5 evidence, documented time to healing, and incidence of complications. Statistical analysis was performed to compare outcomes. RESULTS: Eight studies with 13 subjects and 15 fractures undergoing operative fixation were included. Six fracture were compression sided, five were tension sided, and four were complete. Radiographic healing occurred on average at 32.7 ± 36.3 weeks (range 8-121 weeks). Four subjects were noted to have a metabolic disturbance. Six subjects did not participate in vigorous exercise. There were no complications. There was no significant difference in radiographic healing time between: cannulated screws or SHS ± osteotomy (p = 0.21); compression sided, tension sided, or complete fractures (p = 0.41); ages (p = 0.09); sex (p = 0.09) or individuals with or without metabolic disturbances (p = 0.92). There was no difference between use of cannulated screw fixation, SHS + osteotomy, and SHS alone based on the subject's age (p = 0.27) or cannulated screw vs SHS ± osteotomy given subject's age (p = 0.19) or sex (p = 1.0). Time to full weight bearing (FWB) did not significantly differ between implants (p = 0.22). However, >8 weeks restricted weight bearing had increased healing times (p = 0.002). DISCUSSION: Time to healing was not dependent on subjects' sex or age, fracture location, implant choice, or presence of metabolic abnormality. No complications were reported. Time to full weight bearing was not dependent on implant choice. However, restricted weight bearing beyond 8 weeks can lead to prolonged healing times. Fixation should be safe, effective and promote early weight bearing and mobilization.

Suture-Only Repair Versus Suture Anchor-Augmented Repair for Achilles Tendon Ruptures With a Short Distal Stump: A Biomechanical Comparison.

BACKGROUND: Chronic noninsertional Achilles tendinosis can result in an acute Achilles tendon rupture with a short distal stump. In such tendon ruptures, there is a limited amount of adequate tissue that can hold suture, thus presenting a challenge for surgeons who elect to treat the rupture operatively. HYPOTHESIS: Adding suture anchors to the repair construct may result in biomechanically stronger repairs compared with a suture-only technique. STUDY DESIGN: Controlled laboratory study. METHODS: Nine paired Achilles-calcaneus complexes were harvested from cadavers. An artificial Achilles rupture was created 2 cm proximal to the insertion on the calcaneus. One specimen from each cadaver was assigned to a suture-only or a suture anchor-augmented repair. The contralateral specimen of the same cadaver received the opposing repair. Cyclic testing was then performed at 10 to 100 N for 2000 cycles, and load-to-failure testing was performed at 0.2 mm/s. This was followed by analysis of repair displacement, gapping at repair site, peak load to failure, and failure mode. RESULTS: The suture anchor-augmented repair exhibited a 116% lower displacement compared with the suture-only repair (mean ± SD, 1.54 ± 1.13 vs 3.33 ± 1.47 mm, respectively; P < .03). The suture anchor-augmented repair also exhibited a 45% greater load to failure compared with the suture-only repair (303.50 ± 102.81 vs 209.09 ± 48.12 N, respectively; P < .04). CONCLUSION: Suture anchor-augmented repairs performed on acute Achilles tendon ruptures with a short distal stump are biomechanically stronger than suture-only repairs. CLINICAL RELEVANCE: Our results support the use of suture anchor-augmented repairs for a biomechanically stronger construct in Achilles tendon ruptures with a short distal stump. Biomechanically stronger repairs may lead to less tendon repair gapping and failure, increasing the ability to start early active rehabilitation protocols and thus improving patient outcomes.