Social Determinants of Health in Maryland Hip Arthroscopy Patients.

Background Prior studies have demonstrated racial and socioeconomic disparities in patient-reported outcome measure (PROM) completion rates, and improvement exists across multiple orthopedic conditions. The purpose of this study was to assess whether these disparities are present in patients undergoing hip arthroscopy (HA) procedures. Methods A retrospective study of 306 patients undergoing HA from 2021 to 2023 was performed. Social determinants of health (SDOH) were compared between HA patients and the general Maryland population. Patients were then classified by whether they completed baseline and six-month PROMs (Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) instrument). Patients who completed PROMIS-PF were classified by whether or not they achieved minimal clinically important difference (MCID) at six months. Demographics and SDOH were compared using univariate analyses between patients who did and did not complete PROMs and between those who did and did not achieve MCID. SDOH were evaluated at the zip-code level using regional health information exchange measures. Results Compared to the Maryland population, HA patients resided in areas of lower social vulnerability. Preoperative and six-month PROMs were completed by 102 (33%) patients. No significant differences in demographics or any SDOH were found between patients who did and did not complete PROMs. Six-month MCID was achieved in 75 of 102 (74%) patients with complete PROMs; no significant differences in demographics or SDOH were observed between patients who did and did not achieve MCID. Conclusions For patients undergoing HA, disparities in patient-reported outcome completion rates and postoperative functional improvement do not appear to be present across demographics and SDOH, indicating equitable care is being delivered.

Injections prior to hip arthroscopy are associated with increased risk of repeat hip arthroscopy at 1 and 5 years.

INTRODUCTION: Previous studies have shown that intra-articular hip injections prior to hip arthroscopy (HA) can be a helpful diagnostic tool. However, local anesthetic and corticosteroid injections can be chondrotoxic and corticosteroid injections have been shown to increase the risk of infection during subsequent surgical intervention. The purpose of this study was to evaluate whether preoperative injections adversely affect outcomes of HA using a national database. MATERIALS AND METHODS: The TriNetX database was retrospectively queried. Patients undergoing HA for femoroacetabular impingement with at least 1 year of claims runout were included in the analysis. Patients were grouped by whether they had a hip injection within 1 year prior to HA. The rates of repeat HA, total hip arthroplasty (THA), infection, osteonecrosis, and new onset hip OA at 1- and 5-years postoperatively were compared between groups. Statistical significance was assessed at α = 0.05. RESULTS: 6511 HA patients with previous injection and 1178 HA patients without previous injection were included. Patients with a previous injection were overall younger (32.3 vs. 34.7 years, p < 0.001), more likely to be female (69 vs. 48%, p < 0.001) and had a higher BMI (26.3 vs. 25.7 kg/m2, p = 0.043). At 1 and 5-years postoperatively, patients with any injection were 1.43 (p < 0.001) and 1.89 (p < 0.001) times more likely to undergo repeat HA, respectively. At 1 and 5-years postoperatively, patients who underwent a corticosteroid injection were 2.29 (p < 0.001) and 1.89 (p < 0.001) times more likely to undergo repeat HA than patients with local anesthetic injection only and 1.56 (p < 0.001) and 2.08 (p < 0.001) times more likely to undergo repeat HA than patients with no injection. CONCLUSIONS: Intraarticular hip injections prior to hip arthroscopy, particularly corticosteroid injections, are associated with increased risk of repeat hip arthroscopy at 1 and 5 years. Additional studies are needed to elucidate this risk.

What is the Optimal Construct to Reduce Failure in Arthroscopic Four Anchor Rotator Cuff Repair?

Background: Re-tear following rotator cuff repair (RCR) is a concerning complication that can lead to poor patient outcomes and necessitate the need for revision surgery. The purpose of our study was to look at the combined construct of knotted vs. knotless medial row and suture vs. suture tape, focusing primarily on re-tear rates following surgery. Methods: A retrospective observational study of 343 consecutive patients undergoing arthroscopic double row, 4-anchor rotator cuff repair from February 2014 to March 2020 was conducted. Univariate and multivariate statistics were used to assess differences in demographics, comorbidities and tear characteristics between patients who experienced a symptomatic re-tear and those who did not. Results: The overall symptomatic re-tear rate was 7.6%. Patients who had a knotted medial row repair had a significantly lower rate of re-tear (4.7 vs. 11.3%, p = 0.022). Patients that had a knotted medial row and suture tape repair were significantly less likely to experience a re-tear (OR: 0.180, p = 0.001). Discussion: The use of suture tape and a knotted medial row repair decreases the incidence of symptomatic re-tear following rotator cuff repair. The combined construct of suture tape and a knotted medial row in rotator cuff repair decreases the risk for symptomatic re-tear following surgery.

Elimination of a Postoperative Brace Does Not Increase Complications Following Hip Arthroscopy.

Background The practice of routine postoperative bracing to limit abduction and internal rotation, along with weight-bearing restrictions after hip arthroscopy (HA), varies significantly among surgeons. It is unclear whether the use of a postoperative brace improves short-term outcomes in patients undergoing HA. The purpose of this study was to determine the differences in patient outcomes before and after eliminating routine usage of a postoperative brace. Methods A retrospective review was conducted of 176 adult patients undergoing HA by a single, high-volume surgeon. The no-brace protocol was implemented in October 2020. The patients were divided into two groups: pre-implementation (January-October 2020) and post-implementation (October 2020-April 2021). Twenty-three patients that used a brace during the post-implementation period were excluded. All patients had weight-bearing restrictions with crutches for three weeks postoperatively. The primary endpoint was any complication in the first six weeks postoperatively. Results There were no significant differences in demographics between groups, although the body mass index in the brace group was higher (28.1 vs. 26.4 kg/m2, p = 0.066) and the rate of additional procedures performed was higher in the brace group (55.2% vs. 40.1%, p = 0.056). There was no significant difference in postoperative outcomes between groups when looking at 90-day emergency department visits (1.7% vs. 0%, p = 0.548), complications at two (1.7% vs. 1.7%, p = 1.000) and six weeks (0% vs. 1.7%, p = 0.341) postoperatively, all complications in the first six weeks (1.7% vs. 1.7%, p = 1.000), and continued pain at six weeks (10.3% vs. 16.7%, p = 0.238). Conclusion The brace and no-brace groups were similar demographically. Patients undergoing HA with no brace and crutches experienced no significant differences in pain or complications in comparison to those receiving a traditional bracing protocol. Routine use of a postoperative brace may not be necessary in this population.

Clinical Results of Knot-tying Versus Knotless Suture Anchors in Arthroscopic Anteroinferior Labral Repair.

Background Arthroscopic repair of glenohumeral instability is becoming an increasingly common procedure. These repairs can be undertaken using knot-tying and knotless suture anchors; there is currently no clear consensus in the literature about what type of repair is most cost-effective and provides superior outcomes. The purpose of this study is to examine postoperative outcomes of patients undergoing arthroscopic anteroinferior labral repair (AALR) with either knot-tying or knotless anchors. Methods A single institution retrospective observational cohort study of 122 patients undergoing AALR from January 2014 to June 2021 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes between repair types; multivariate analysis was used to evaluate risk factors for recurrent instability and reoperation. Results Patients undergoing AALR with knotless anchors had a shorter case duration than those with knot-tying anchors (112.64 vs. 89.86 minutes, p<0.001). There were no significant differences between groups in the size of labral tear, presence of a glenoid bone defect, or Hill-Sachs lesion. After controlling for age, BMI, sex, glenoid bone defect, number of preoperative dislocations, and fixation type, only age (OR=0.896, p=0.010) and female sex (OR=5.341, p=0.008) were independent risk factors for recurrent instability and no factors were independent predictors of reoperation. Conclusion Patients undergoing AALR experienced similar rates of reoperation and recurrent instability regardless of whether a knot-tying or knotless repair was performed. The use of knotless suture anchors may improve cost-effectiveness due to decreased surgical time without diminishing postoperative outcomes.

Change in Postoperative Weightbearing Protocol Does Not Increase Postoperative Complications Following Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

Background Postoperative rehabilitation protocols, including weightbearing restrictions following hip arthroscopy (HA) for femoracetabular impingement syndrome (FAIS), vary widely among surgeons, from complete non-weightbearing to immediate weightbearing as tolerated; it is unclear if weightbearing restrictions affect short-term outcomes in patients undergoing HA. The purpose of this study is to evaluate patients undergoing hip arthroscopy for FAIS before and after a change in weightbearing protocol, from partial weightbearing with crutches for three weeks to weightbearing and weaning from crutches as tolerated, by examining postoperative outcomes. We hypothesize that the change in weightbearing protocol will have no significant effect on patient outcomes. Methods A retrospective review was conducted of 211 patients undergoing hip arthroscopy by a single high-volume surgeon. The change in weightbearing was implemented in February 2022; previously, all patients were toe-touch weightbearing with crutches for the first three weeks postoperatively. Following this change, patients were allowed to weightbear as tolerated with crutches immediately and wean from crutches as tolerated. The patients were divided into two groups: 119 patients pre-implementation (January 2021 to January 2022) and 92 patients post-implementation (February 2022 to December 2022). The primary endpoint was any complication in the first six weeks postoperatively, divided into complications at two and six weeks, emergency department returns in the first 90 days, reoperations in the first 30 days, and pain at six weeks. We also compared patient-reported outcomes at six weeks. Results There were no significant differences in demographics between groups. There were no significant differences in postoperative outcomes between patients that had weightbearing restrictions and those that did not when looking at 30 day return to operating room (0 vs 0%, p=1.000), 90-day return to emergency department (8.4 vs. 13.0%, p=0.386), two-week complications (2.5 vs. 6.5%, p=0.279), six-week complications (1.7 vs. 1.1%, p=1.000), pain score at six weeks postoperatively (0.34 vs. 0.33, p=0.971), any pain at six weeks postoperatively 37.8 vs. 32.6%, p=0.523), and six-week Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) score (36.0 vs. 34.5, p=0.330). Conclusion Patients undergoing HA after the discontinuation of a mandatory period of protected weightbearing did not experience any significant increase in complications or continued pain, and patient-reported outcomes were similar. Routine postoperative weightbearing restrictions may not be necessary for patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. Further study is required to validate these findings and determine the optimal postoperative protocol for this patient population.

Risk of Lower Extremity Ligamentous Injury Following Concussion Diagnosis: A TriNetX Database Study.

Background Concussion is one of the most frequently reported sports-related injuries in the United States; there is evidence that residual deficits in neurocognition may increase the risk of lower extremity musculoskeletal injury after concussion in high school, college, and professional athletes. The purpose of this study is to identify whether similar trends are identified in community-based populations.  Methods The TriNetX Research Network database was queried for patients 10-60 years old who experienced an ambulatory or emergency visit from 2018-2020. Cohorts were defined by patients seen for concussion and patients seen for other reasons. These cohorts were then propensity score matched based on significant differences in demographics; after matching, each cohort included 97,708 patients. The propensity score-matched cohorts were then evaluated to identify patients who experienced subsequent lower extremity ligamentous injury within 12 months. Results Patients with a history of concussion were more likely to experience posterior cruciate ligament (PCL) sprain (0.04% vs. 0.02%, risk ratio (RR)=1.79, p=.039), medial collateral ligament (MCL) sprain (0.18% vs. 0.08%, RR=2.355, p<.001), lateral collateral ligament (LCL) sprain (0.05% vs. 0.02%, RR=2.202, p=.003) and ankle sprain (1.05% vs. 0.47%, RR=2.265, p<.001). Conclusion Patients diagnosed with concussion were more likely to experience a lower extremity ligamentous injury when compared with patients who did not have concussion. Patients should be counseled regarding this increased risk and additional neuromuscular evaluation and injury prevention education may be indicated following concussion diagnosis.

Rates of medial and lateral row failure and risk factors for Re-tear in arthroscopic double row rotator cuff repair.

A common postoperative complication after rotator cuff repair is re-tear requiring a secondary procedure. Double row and trans-osseous equivalent repair techniques have become increasingly popular in recent years, however repair failure remains a relatively common complication after primary rotator cuff repair. A retrospective observational study of 389 consecutive patients undergoing arthroscopic double-row rotator cuff repair from February 1, 2014 to March 31, 2020 was conducted. Univariate and multivariate statistics were used to assess differences in demographics, comorbidities, and tear characteristics between patients who experienced re-tear and those who did not. Repair failures were confirmed by plain MRI or intraoperatively during repeat surgical treatment. A subgroup analysis of patients who experienced re-tear due to medial row failure was conducted. The overall re-tear rate was 8.2% (32 patients). Six patients (1.5%) experienced medial row failure, while 26 patients (6.7%) experienced lateral row failure. The average time to re-tear was 279.3 ± 291.2 days. On multivariate analysis, patients with Goutallier Classification ≥3 (OR: 4.274, p = 0.046) and 3 anchor repair (OR: 5.387, p = 0.027) were at significantly increased risk for any re-tear after controlling for other tear characteristics. No statistically significant independent risk factors for medial row failure were identified after controlling for confounding variables. Goutallier classification greater than 3 and a primary repair with 3 anchors are significant risk factors for re-tear after double row rotator cuff repair, however they are not associated with increased occurrence of medial row failure. Further evaluation of risk factors for medial row failure is required to avoid this rare but serious re-tear pattern.

Postoperative Outcomes in Patients Undergoing Orthopaedic Surgery Within 90 Days of Coronavirus Disease 2019.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic with several hundred million infections worldwide. COVID-19 causes systemic complications that last beyond the initial infection. It is not known whether patients who undergo elective orthopaedic surgeries after COVID-19 are at increased risk of complications. The purpose of this study was to evaluate whether patients who undergo orthopaedic procedures after recent COVID-19 diagnosis are at increased risk of complications compared with those who have not had a recent COVID-19 diagnosis. METHODS: The TriNetX Research Network database was queried for patients undergoing elective orthopaedic surgeries from April 2020 to January 2022 in the following subspecialties: arthroscopic surgery, total joint arthroplasty, lumbar fusion, upper extremity surgery, foot and ankle (FA) surgery. Cohorts were defined by patients undergoing surgery with a diagnosis of COVID-19 from 7 to 90 days before surgery and those with no COVID-19 diagnosis 0 to 90 days before surgery. These cohorts were propensity-score matched based on differences in demographics and comorbidities. The matched cohorts were evaluated using measures of association analysis for complications, emergency department (ER) visits, and readmissions occurring 90 days postoperatively. RESULTS: Patients undergoing arthroscopic surgery were more likely to experience venous thromboembolism (VTE) ( P = 0.006), myocardial infarction ( P = 0.001), and ER visits ( P = 0.001). Patients undergoing total joint arthroplasty were more likely to experience VTE ( P < 0.001), myocardial infarction ( P < 0.001), pneumonia ( P < 0.001), and ER visits ( P = 0.037). Patients undergoing lumbar fusion were more likely to experience VTE ( P = 0.016), infection ( P < 0.001), pneumonia ( P < 0.001), and readmission ( P = 0.006). Patients undergoing upper extremity surgery were more likely to experience VTE ( P = 0.001) and pneumonia ( P = 0.015). Patients undergoing foot and ankle surgery were more likely to experience VTE ( P < 0.001) and pneumonia ( P < 0.001). CONCLUSION: There is an increased risk of complications in patients undergoing orthopaedic surgery after COVID-19 infection; all cohorts were at increased risk of VTE and most at increased risk of pneumonia. Additional investigation is needed to stratify the risk for individual patients.

Total Intravenous Anesthesia Compared to Inhalational Anesthesia in Patients Undergoing Arthroscopic Rotator Cuff Repair.

Background Inhalation anesthesia (IA) and total intravenous anesthesia (TIVA) are common general anesthesia techniques. During rotator cuff repair (RCR), an interscalene block is beneficial for intraoperative and early postoperative pain control. This study aimed to evaluate postoperative outcomes and opioid usage in patients undergoing arthroscopic RCR with an interscalene block and either IA or TIVA. Methodology A retrospective observational study was performed of 478 patients undergoing RCR at a single institution. Demographics, surgical details, intra and postoperative medications, and 90-day outcomes were collected. Univariate and multivariate analyses were performed to evaluate differences between groups. Results In total, 309 (64.6%) patients received IA and 169 (35.3%) received TIVA. Patients receiving IA were more likely to have comorbidities, such as diabetes (p = 0.002), sleep apnea (p = 0.006), gastroesophageal reflux disease (p < 0.001), and hypertension (p < 0.001). After adjusting for differences between groups in the multivariate analysis, patients who received TIVA had significantly shorter surgical time (ß = -14.85, p < 0.001) and perioperative time (ß = -21.01, p < 0.001) and significantly lower first post-anesthesia care unit Pasero opioid-induced sedation scores (ß = -0.022, p = 0.040). Patients who received TIVA were less likely to receive intraoperative narcotics (odds ratio = 0.38; p = 0.031). Conclusions TIVA appears to be a safe and effective anesthetic for patients undergoing arthroscopic RCR. TIVA is a potentially beneficial alternative to IA for this patient population.

Effects of preexisting depression and anxiety on postoperative outcomes following arthroscopic rotator cuff repair.

Background: Rotator cuff repairs (RCRs) are one of the most commonly performed shoulder surgeries in the United States. Psychological health has been shown to influence postoperative outcomes in orthopedic procedures. The purpose of this study is to evaluate the relationship between depression and anxiety (DA) and psychotropic medication and postoperative outcomes following RCR. Methods: A single institution retrospective observational cohort study of 816 patients undergoing arthroscopic RCR from January 2014 to October 2020 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes; multivariate analysis was used to evaluate risk factors for postoperative complications. Results: Patients with DA were more likely to have a higher first (3.60 vs. 3.00, P = .004) and last (1.23 vs. 0.96, P = .042) postoperative pain scores, lower first (18.67 vs. 21.85, P = .008) and last (61.87 vs. 64.71, P = .014) Upper Extremity Functional Score (UEFS), more likely to experience an emergency department visit postoperatively (9.1 vs. 5.0%, P = .028), have a symptomatic recurrent tear (8.2 vs. 3.3%, P = .003), and persistent pain (4.3 vs. 1.2%, P = .011). After controlling for age, sex, body mass index, American Society of Anesthesiologists score, diabetes, smoking, coronary artery disease, asthma, hypertension, psychotropic medication and DA, having DA at the time of surgery was independently predictive of any complication (odds ratio, 2.033; P = .028) and persistent pain (odds ratio, 8.232; P ≤ .001). Patients with and without DA showed significant improvement in postoperative pain and UEFS from the first to the last measurement (P < .001). Conclusion: DA is not a deterrent for RCR but targeted interventions may be needed to decrease the occurrence of complications.

Racial disparities in outcomes of arthroscopic rotator cuff repair: A propensity score matched analysis using multiple national data sets.

BACKGROUND: Disparities in access, utilization and outcomes exist throughout the healthcare system for minority groups, including racial and ethnic minorities; these disparities have wide-reaching implications for individuals as well as the healthcare system as a whole. This study will examine the impact of race on short and medium term outcomes for patients undergoing rotator cuff repair (RCR) using matched cohorts. METHODS: Patients undergoing arthroscopic rotator cuff repair from 2016 to 2018 were extracted from two national databases: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and TriNetX Research Network. Using the ACS-NSQIP database, univariate analysis was performed to identify differences in comorbidities between white and minority patients. Patients were propensity score matched based on significant differences between groups and 30-day postoperative outcomes were assessed. These comorbidities were then used to propensity score match white and minority patients in the TriNetX database and two-year postoperative outcomes were evaluated. RESULTS: Following propensity score matching, 3716 patients remained in each group from the ACS-NSQIP database and 4185 patients remained in each group from the TriNetX database. The OR time for minority patients was longer than white patient in the ACS-NSQIP database (92.2 vs. 87.6 min, p < .001). There was no difference in medium-term outcomes for repeat RCR, infection or frozen shoulder between white and minority patients in the TriNetX database. CONCLUSION: After propensity score matching the only significant short-term outcome between white and minority patients undergoing RCR was a difference in OR time; there were no differences in medium-term outcomes. This may indicate that the source of racial disparities is one of access to healthcare rather than an innate difference in the patients' outcomes. Further study is needed to elucidate this issue.

The impact of fascia iliaca nerve blockade on early postoperative pain and recovery after hip arthroscopy for femoroacetabular impingement syndrome.

Fascia iliaca nerve blockade (FIB) has been previously described as an effective technique for reducing postoperative pain and opioid consumption after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). We hypothesize that an FIB will significantly reduce opioid consumption, pain scores and recovery time in our population. A retrospective observational study of 326 consecutive patients undergoing hip arthroscopy for FAIS at a single institution was performed. Patients were classified based on whether or not they received an FIB. Patient demographics, surgical details, medication details and 6-month postoperative outcomes were collected. The primary endpoint was the amount of narcotics required intraoperatively and in the postanesthesia care unit (PACU). Of the 326 patients included in the study, 37 received an FIB. No differences in sex, age or other surgical details were observed between groups. Patients receiving an FIB were more likely to receive celecoxib (P < 0.001), pregabalin (P = 0.001) and methocarbamol (P = 0.002). The FIB group received lower doses of narcotics intraoperatively (P = 0.001), postoperatively (P < 0.001) and in total (P < 0.001). The FIB group also self-reported lower first pain scores upon arrival to PACU (P = 0.001) and experienced shorter PACU recovery times (P < 0.001). After controlling for differences between groups, patients who received an FIB required significantly lower amounts of narcotics, had shorter PACU times and lower first PACU pain score than those who did not (P < 0.001). No differences in complication rates were noted between groups. The use of FIB resulted in lower pain scores, reduced recovery time and decreased early postoperative narcotic requirements for patients undergoing hip arthroscopy for femoroacetabular impingement. Further study is required to validate these findings and determine the optimal approach to regional analgesia in this patient population.

Risk factors for all-inside meniscal repair failure in isolation and in conjunction with anterior cruciate ligament reconstruction.

BACKGROUND: This study examines the relationship between meniscus tear presentations and failure rates following all-inside repair in isolation and in conjunction with an anterior cruciate ligament (ACL) reconstruction. METHODS: Eighty seven consecutive patients undergoing all-inside meniscal repair at a single institution from July 2016 to June 2018 were retrospectively reviewed. Details of patient presentation, tear type and location, the presence or absence of simultaneous ACL reconstruction, and surgical repair details were recorded to evaluate the relationship between patient characteristics and the primary endpoint of repair failure. RESULTS: Patients were followed for an average of 2.7 ± 0.8 years. Three patients (3.4%) experienced 30-day complications including 1 deep vein thrombosis and 2 joint aspirations. Within the study time frame, 15 repairs (17.2%) failed, with 10 (11.5%) failing within one year of the initial procedure; the average time to failure was 12.3 ± 9.0 months. Patients undergoing concurrent ACL reconstruction were less likely to experience repair failure (9.7% vs. 36.0%, p = .009), while bucket-handle repairs were more likely to fail during the study period (45.0% vs. 9.0%, p = .001). These trends remained after controlling for tear location, body mass index, and number of sutures (ACL reconstruction Odds Ratio [OR]: 0.229, p = .029; Bucket-handle OR: 9.400, p = .003). CONCLUSION: Our findings suggest concurrent ACL reconstruction at the time of meniscal repair is associated with increased repair survival. The all-inside technique may be successfully used across a variety of tear types and locations, although further study of its efficacy in repairing bucket-handle tears is warranted.

Maintaining Access to Orthopaedic Surgery During Periods of Operating Room Resource Constraint: Expanded Use of Wide-Awake Surgery During the COVID-19 Pandemic.

INTRODUCTION: Wide-awake local anesthesia no tourniquet (WALANT) presents a nonstandard anesthetic approach initially described for use in hand surgery that has gained interest and utilization across a variety of orthopaedic procedures. In response to operating room resource constraints imposed by the COVID-19 pandemic, our orthopaedic service rapidly adopted and expanded its use of WALANT. METHODS: A retrospective review of 16 consecutive cases performed by 7 surgeons was conducted. Patient demographics, surgical details, and perioperative outcomes were assessed. The primary end point was WALANT failure, defined as intraoperative conversion to general anesthesia. RESULTS: No instances of WALANT failure requiring conversion to general anesthesia occurred. In recovery, one patient (6%) required narcotics for pain control, and the average postoperative pain numeric rating scale was 0.6. The maximum pain score experienced was 4 in the patient requiring postoperative narcotics. The average time in recovery was 42 minutes and ranged from 8 to 118 minutes. CONCLUSION: The WALANT technique was safely and effectively used in 16 cases across multiple orthopaedic subspecialties, including three procedures not previously described in the literature. WALANT techniques hold promise for use in future disaster scenarios and should be evaluated for potential incorporation into routine orthopaedic surgical care.

Early postoperative pain and opioid consumption after arthroscopic shoulder surgery with or without open subpectoral biceps tenodesis and interscalene block.

OBJECTIVE: The addition of open subpectoral biceps tenodesis to arthroscopic shoulder surgery with interscalene block has been anecdotally observed to result in increased postoperative pain. This study aims to evaluate the impact of tenodesis on early postoperative pain and recovery. METHODS: A retrospective review of patients undergoing arthroscopic shoulder surgery with general anesthesia and interscalene block was conducted. RESULTS: Patients undergoing tenodesis experienced longer OR time, pain numeric rating scale (NRS), and consumed more morphine milligram equivalents (MME) in PACU. After controlling for confounding factors, tenodesis was significantly associated with increased opioid MME consumption in the PACU (ß = 1.045, p = .028) and last PACU pain NRS (ß = 0.541, p = .009). CONCLUSION: Overall, pain scores and narcotic consumption were low after surgery, making these differences potentially clinically insignificant. Further study is required to evaluate whether these trends are consistent among this population.

Factors Affecting Perceptions of Open, Mini-Open, and Arthroscopic Rotator Cuff Repair Techniques Among Medical Professionals.

Although no long-term difference between arthroscopic and mini-open rotator cuff repairs has been documented, use of arthroscopic repair has exploded. We conducted a study to determine which repair technique medical professionals preferred for their own surgery and to analyze the perceptions shaping those opinions. A survey was emailed to selected professionals at our institution: attendings, residents, and allied health professionals; 84 (41, 20, and 23, respectively) responded. Irrespective of specialty or career length, almost half (39, 46%) preferred deferring the repair choice to their surgeon; the other 45 preferred arthroscopic (22, 26%), mini-open (19, 23%), open (2, 2%), or no (2, 2%) repair. Most agreed repairs were safe and fast but had no opinion about cost-effectiveness or which technique provided the best outcome. Significantly (P < .05) more respondents thought arthroscopic and mini-open repairs promoted quick healing, good cosmetic results, and patient satisfaction compared with open repair, but these repairs were also perceived as significantly (P < .05) harder to learn and more challenging than open repair. It is important for medical professionals to recognize these biases, especially given that many defer to the judgment of their medical peers.

T2 values of articular cartilage in clinically relevant subregions of the asymptomatic knee.

PURPOSE: In order for T2 mapping to become more clinically applicable, reproducible subregions and standardized T2 parameters must be defined. This study sought to: (1) define clinically relevant subregions of knee cartilage using bone landmarks identifiable on both MR images and during arthroscopy and (2) determine healthy T2 values and T2 texture parameters within these subregions. METHODS: Twenty-five asymptomatic volunteers (age 18-35) were evaluated with a sagittal T2 mapping sequence. Manual segmentation was performed by three raters, and cartilage was divided into twenty-one subregions modified from the International Cartilage Repair Society Articular Cartilage Mapping System. Mean T2 values and texture parameters (entropy, variance, contrast, homogeneity) were recorded for each subregion, and inter-rater and intra-rater reliability was assessed. RESULTS: The central regions of the condyles had significantly higher T2 values than the posterior regions (P < 0.05) and higher variance than the posterior region on the medial side (P < 0.001). The central trochlea had significantly greater T2 values than the anterior and posterior condyles. The central lateral plateau had lower T2 values, lower variance, higher homogeneity, and lower contrast than nearly all subregions in the tibia. The central patellar regions had higher entropy than the superior and inferior regions (each P ≤ 0.001). Repeatability was good to excellent for all subregions. CONCLUSION: Significant differences in mean T2 values and texture parameters were found between subregions in this carefully selected asymptomatic population, which suggest that there is normal variation of T2 values within the knee joint. The clinically relevant subregions were found to be robust as demonstrated by the overall high repeatability.

Femoral cortical suspension devices for soft tissue anterior cruciate ligament reconstruction: a comparative biomechanical study.

BACKGROUND: Optimization of anterior cruciate ligament (ACL) fixation is desired to improve graft healing. New soft tissue cortical suspension devices for femoral tunnel fixation should be biomechanically evaluated. HYPOTHESIS: All femoral fixation devices would prevent a clinically significant amount of displacement and support loads significantly larger than in situ forces experienced by the ACL during early rehabilitation. STUDY DESIGN: Controlled laboratory study. METHODS: Four cortical soft tissue ACL graft suspension devices were tested under cyclic and pull-to-failure loading conditions in both an isolated device-only setup and as a complete bone-device-tendon construct in porcine femurs using a tensile testing machine. RESULTS: There were significant differences in the ultimate failure loads among the devices. The highest ultimate failure loads when tested as a construct were observed for the XO Button (1748 N), followed by the Endobutton CL (1456 N), ToggleLoc with ZipLoop (1334 N), and TightRope RT (859 N). Cyclic displacement after 1000 cycles during isolated device testing was less than 1 mm for all devices. Cyclic displacements after 1000 cycles in the porcine construct were 1.88 mm, 2.74 mm, 3.34 mm, and 1.82 mm for the Endobutton, TightRope, ToggleLoc, and XO Button, respectively; all were significantly different from each other except when the Endobutton was compared with the XO Button. The ToggleLoc exceeded the 3.0-mm displacement threshold defined as a clinical failure. The most displacement occurred during the first cycle, especially for the adjustable-length loop devices. Stiffness reapproximated the native ACL stiffness for all constructs. CONCLUSION: The Endobutton, TightRope, and XO Button have the necessary biomechanical properties with regard to ultimate failure strength, displacement, and stiffness for initial fixation of soft tissue grafts in the femoral tunnel for ACL reconstruction. The ToggleLoc had sufficient ultimate failure strength but crossed our 3.0-mm clinical failure threshold for cyclic displacement. Although this study was not designed to compare fixed and adjustable-length loop devices, it was noted that both fixed-loop devices allowed less cyclic displacement and initial displacement. CLINICAL RELEVANCE: Adjustable-length loop devices may need to be retensioned after cycling the knee and fixing the tibial side to account for the increased initial displacement seen with these devices.

Athletic cervical spine injury in the setting of fusion failure of the anterior and posterior atlas.

This article describes a rare congenital abnormality of anterior and posterior C1 fusion failure presenting after an acute athletic injury to the fibrous nonunion. C1 congenital malformations are rare, occurring in approximately 2% of patients; even rarer are combined anterior and posterior arch malformations in the same patient. Posterior ring abnormalities are more common than anterior ring injuries (4.5:1, respectively). To the authors' knowledge, combined anterior and posterior ring congenital malformations with subsequent injury have not been previously described. In the current patient, a congenital failure of fusion of the anterior and posterior arches of C1 was identified. The anterior fibrous nonunion was injured while the patient played football, leading to transient neurologic injury and dysphagia from soft tissue swelling. The patient was initially diagnosed with an acute fracture at another facility; however, given advanced imaging, flexion and extension views, and a normal neurologic examination, the authors diagnosed a traumatized congenital defect. The injury healed with a short period of cervical collar immobilization and supportive measures. Such malformations are usually found incidentally, but they can be symptomatic after trauma. Images to distinguish these deficits can be difficult because the differences between chronic nonunions and congenital malformations are subtle. Surgery is rarely indicated for congenital malformations because they are often stable even after injury; however, they may predispose patients to neurologic injury in the future with high-risk activities. Because the current patient had an increased chance of future injury secondary to the lack of bone formation in the C1 vertebrae, he was restricted from participating in contact sports.