Recurrent cyclops lesion after primary anterior cruciate ligament reconstruction using bone tendon bone allograft: A case report.

BACKGROUND: Cyclops lesions are a known complication of anterior cruciate ligament (ACL) reconstruction, with symptomatic cyclops syndrome occurring in up to 11% of surgeries. Recurrent cyclops lesions have been rarely documented; this case study documents the successful treatment of a recurrent cyclops lesion. CASE SUMMARY: A 28-year-old female presented following a non-contact injury to the right knee. Workup and clinical exam revealed an ACL tear, and arthroscopic reconstruction was performed. Two years later a cyclops lesion was discovered and removed via arthroscopic synovectomy. Seven months postoperatively, the patient presented with pain, stiffness, and difficulty achieving terminal extension. A smaller recurrent cyclops lesion was diagnosed, and a repeat synovectomy was performed. The patient recovered fully. CONCLUSION: To the best of our knowledge, this is the first documented case of recurrent cyclops lesion after bone-patellar tendon-bone allograft ACL reconstruction presenting as cyclops syndrome.

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.

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.

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.

Tear of Quadriceps and Patellar Tendon with Superior Pole Avulsion of Patella: A Case Report.

CASE: A 58-year-old man presented with right knee pain and inability to extend the knee after falling. magnetic resonance imaging (MRI) demonstrated complete rupture of the quadriceps tendon, avulsion of the superior pole patella, and a high-grade partial tear of the proximal patellar tendon. Surgical dissection revealed that both tendon tears were full-thickness disruptions. Repair was performed without complications. The patient achieved independent ambulation and passive range of motion from 0° to 118° at 3.8 years postoperatively. CONCLUSIONS: We present a case of a simultaneous ipsilateral tear of the quadriceps and patellar tendons with superior pole patella avulsion that resulted in a clinically successful repair.

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.

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.

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.

Patellar instability.

Patellar instability is a generic term that is used to describe patellar dislocation, patellar subluxation, and general symptomatic instability. Patellofemoral instability is a relatively difficult condition to treat; accurate management of the condition should take into account the anatomy of the joint and its stabilizing structures. The goal of any treatment should be to restore the normal anatomy of the joint. It is important to understand the basic anatomy and biomechanics of this condition, the classification of different types of patellar instability, varying presentations, and diagnostic techniques and criteria, including the types of imaging studies that can be useful in determining the ultimate course of treatment.

Arthroscopic rotator cuff repair using the Opus knotless suture anchor fixation system.

BACKGROUND: The reported failure rate of arthroscopic rotator cuff repair varies widely. The influence of repair technique on failure rates and functional outcomes after arthroscopic cuff repair remains controversial. PURPOSE: To determine the functional outcome of arthroscopic knotless fixation using the Opus AutoCuff device for rotator cuff repair and to compare our results with those reported in the literature. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fifty-six consecutive patients underwent arthroscopic rotator cuff repair using an Opus AutoCuff device (Arthrocare, Sunnydale, California) with greater than 2 years' follow-up. Subjective and objective clinical examinations were performed to include the University of California at Los Angeles (UCLA) shoulder score, the American Shoulder and Elbow Surgeons (ASES) rating scale, the visual analog scale (VAS), and the Tegner Activity Level scale. RESULTS: Forty-eight patients were evaluated at a mean follow-up of 26 months (range, 24-35 months). The mean UCLA shoulder score was 33.1 of 35 (SD, 2.89) possible points, and the mean ASES rating scale was 94.2 of 100 (SD, 7.76) compared with a mean preoperative score of 65.7 (P < .001). Postoperative UCLA shoulder scores had 42 of 45 (93.3%) patients with good and excellent results. The mean preoperative ASES pain score was 1.3 (SD, 1.0), and the mean postoperative score was 4.4 (SD, 1.0) (P < .001). The Tegner Activity Level scores demonstrated restoration of function to preinjury status. There were 3 failures (6.3%), 2 by anchor failure (1 with specific trauma), and 1 by rotator cuff retear, all requiring revision surgery. CONCLUSION: Arthroscopic knotless suture fixation with the Opus AutoCuff device results in good to excellent results similar to those reported in the literature with conventional suture anchors.