Clinical and Radiographic Healing of Nonoperative and Operative Treatment of Jones Fractures.

BACKGROUND: Significant heterogeneity in the classification and treatment of zone 3 proximal fifth metatarsal base fractures ("true Jones fractures") exists. This study compared time to clinical and radiographic healing between patients treated operatively and nonoperatively. We hypothesized that patients treated nonoperatively may demonstrate a greater time to clinical healing. METHODS: This was a retrospective cohort study of patients presenting to a large, urban, academic medical center with "Jones" fractures between December 2012 and April 2022. Jones fractures were defined as fifth metatarsal base fractures occurring in the proximal metadiaphyseal region, distal to the articulation of the fourth and fifth metatarsals on the oblique radiographic view. Clinical healing was the time point at which the patient had returned to their baseline ambulatory status with no tenderness to palpation. Radiographic healing was the presence of bridging callus across at least 3 cortices. RESULTS: A total of 2450 patients presented with fifth metatarsal fractures, and 166 fractures (6.8%) were true Jones fractures. Among patients with Jones fractures, 120 patients with 121 Jones fractures followed up at our institution and were included in the analysis (mean age 46.5 ± 18.5 years). Ninety-nine fractures (81.8%) were treated nonoperatively and 22 fractures (18.2%) operatively. There were no differences between nonoperative and operative groups in time to clinical healing (12.7 ± 7.1 vs 12.8 ± 4.8 weeks, P = .931) or radiographic healing (13.2 ± 8.1 vs 11.7 ± 5.9 weeks, P = .331). Overall healing rate was 96% for the nonoperative group compared with 96.2% for the operative group. CONCLUSION: In this study, nonoperative and operative treatment of true Jones fractures were associated with equivalent clinical and radiographic healing. The rate of delayed union in true Jones fractures was lower than previously described, and there was no difference in delayed union rate between nonoperative and operative management. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Hip Arthroscopy Improves Sexual Function in Receptive Partners with Femoroacetabular Impingement Syndrome.

BACKGROUND: Hip pain due to femoroacetabular impingement (FAI) is thought to adversely impact sexual satisfaction because of exacerbation of symptoms with hip ROM. However, the effect of FAI on sexual satisfaction and improvement after surgery to treat FAI is largely absent from published studies, despite patients' apparent interest in it as registered by the frequent appearance of these topics on online anonymous discussion platforms. In addition, details regarding its impact on the decision to pursue surgery and the success of hip arthroscopy in alleviating FAI-related sexual dysfunction based on the specific role assumed during intercourse (penetrative versus receptive) remains unknown. QUESTIONS/PURPOSES: Given that sexual intercourse involves different amounts of hip ROM depending on whether patients assume the penetrative or receptive role, this study evaluated the effect of FAI and hip arthroscopy on sexual activity based on role. Compared with patients who participate in the penetrative role during sexual intercourse, do patients who participate in the receptive role (1) experience greater difficulty with sexual function because of FAI symptoms, (2) take longer to return to sexual intercourse after hip arthroscopy, and (3) experience greater improvements in reported sexual function after hip arthroscopy for FAI? METHODS: This was a retrospective cohort study of patients undergoing hip arthroscopy for FAI. Between January 2017 and December 2021, 293 patients were treated with hip arthroscopy for FAI and enrolled in our longitudinally maintained database. Among all patients treated surgically, 184 patients were determined to be potentially eligible for study inclusion based on a minimum follow-up of 6 months postoperatively. The 6-month timepoint was chosen based on published data suggesting that at this timepoint, nearly 100% of patients resumed sexual intercourse with minimal pain after hip arthroscopy. Of the potentially eligible patients, 33% (61 patients) could not be contacted by telephone to obtain verbal consent for participation and 9% (17 patients) declined participation, leaving 106 eligible patients. Electronic questionnaires were sent to all eligible patients and were returned by 58% (61 patients). Forty-two percent of eligible patients (45) did not respond to the questionnaire and were therefore excluded from the analysis. Two percent (2) completed most survey questions but did not specify their role during intercourse and were therefore excluded. The mean age of included patients was 34 ± 9 years, and 56% were women The mean follow-up time was 2 ± 1 years. In total, 63% of included patients reported participating in the receptive role during sexual intercourse (49% receptive only and 14% both receptive and penetrative). Hip symptoms during sexual intercourse preoperatively and postoperatively were evaluated using a questionnaire created by our team to answer our study questions, drawing from one of the only published studies on the matter and combining the questionnaire with sexual position-specific questions garnered from arthroplasty research. Patients who reported participating in the receptive role during intercourse (either exclusively or in addition to the penetrative role) were compared with those who participated exclusively in the penetrative role. There were no specific postoperative recommendations in terms of the timing of return to sexual intercourse, other than to resume when comfortable. RESULTS: Overall, 61% of patients (36 of 59) reported that hip pain somewhat or greatly interfered with sexual intercourse preoperatively. Patients who participated in receptive intercourse were more likely to experience preoperative hip pain that interfered with intercourse than patients who participated exclusively in penetrative intercourse (odds ratio 5 [95% confidence interval 2 to 15]; p = <0.001). Postoperatively, there was no difference in time until return to sexual activity between those in the penetrative group (median 6 weeks [range 2 to 14 weeks]) and those in the receptive group (median 6 weeks [range 4 to 14 weeks]; p = 0.28). Postoperatively, a greater number of patients participating in the penetrative role reported no or very little pain, compared with patients participating in the receptive role (67% [14 of 21] versus 49% [17 of 35]). However, with regard to preoperative to postoperative improvement, patients who participated in the receptive role had greater pain with positions involving more hip flexion and abduction and experienced a greater improvement than their penetrative counterparts in these positions postoperatively. Despite this improvement, however, 33% of patients (7 of 21) participating in the penetrative role and 51% of patients (18 of 35) participating in the receptive role continued to report either some or a great amount of pain at final follow-up. CONCLUSION: Hip pain secondary to FAI interferes with sexual relations, particularly for partners who participate in the receptive role. Postoperatively, both patients participating in receptive and penetrative intercourse resumed sexual intercourse at a median of 6 weeks. After hip arthroscopy, the greatest improvement in pain was seen in receptive partners during sexual positions that involved more hip flexion and abduction. Despite this improvement, most patients, regardless of sexual role assumed, reported some degree of residual pain. Patients planning to undergo arthroscopic surgery for FAI, particularly those who participate in receptive intercourse, should be appropriately counseled about reasonable postoperative expectations based on our findings. LEVEL OF EVIDENCE: Level III, therapeutic study.

Top 50 most impactful publications on massive rotator cuff tears.

Background: Bibliometric analysis is a useful tool for measuring the scholarly impact of a topic and its more and less heavily studied aspects. The purpose of this study is to use bibliometric analysis to comprehensively analyze the 50 articles with the highest citation indices in studies evaluating the treatment and outcomes of massive rotator cuff tears (mRCTs). Methods: This cross-sectional study identified articles within the Scopus database published through December 2022. Keywords used were "massive rotator cuff tear." Articles were sorted in chronological order. The year published and number of citations were recorded. A citation index (CI) was calculated for each article by dividing the number of citations by number of years published [1 citation/1 year published (2021) = CI of 1]. Of these, the 50 articles with the highest CIs were carried forward for evaluation. Frequencies and distributions were assessed for data of each variable collected. Results: These search methods produced 625 articles regarding mRCT research (ranging from January 1986 to December 2022). Four of the top 10 most impactful articles were published in the 2010s. The level of evidence (LOE) published with the greatest frequency was level of evidence 4 (41%). The journal Arthroscopy published the highest number within the top 50 (26%) followed by the Journal of Bone and Joint Surgery and the American Journal of Sports Medicine (20% each). Clinical studies composed 88% of the top 50. Case series (38%) predominated, while systematic reviews (20%) and randomized control trials (8%) were less prevalent. The majority of studies concentrated on the clinical outcomes of certain interventions (62%), mainly comparing multiple interventions. Conclusion: Despite the relatively high prevalence of mRCTs (40% of all tears), this topic comprises only a small proportion of all rotator cuff research. This analysis has identified gaps within and limitations of the findings concerning mRCTs for researchers to propose research questions targeting understudied topics and influence the future treatment and outcomes of this clinically difficult diagnosis.

Zone 2 Fifth Metatarsal Fractures Treated Nonoperatively Have Similar Time to Healing to Those Treated Operatively.

OBJECTIVES: To quantify the rate of union and time to clinical and radiographic healing in Zone 2 proximal fifth metatarsal (MT) fractures and compare these outcomes between Zone 2 fractures treated operatively and nonoperatively. DESIGN: Retrospective cohort study. SETTING: Academic Level I Trauma Center. PATIENT SELECTION CRITERIA: Patients with fifth MT fractures who presented between December 2012 and April 2022 and confirmed to have Zone 2 fractures (defined as fractures entering the proximal 4-5 MT articulation on the oblique radiographic view) were included in the study analysis in either the operative or nonoperative cohort. OUTCOME MEASURES AND COMPARISONS: Nonunion, time to clinical healing by, and time to radiographic healing between operative and nonoperative treatment. RESULTS: Among the 499 included patients, 475 patients (95.2%) were initially treated nonoperatively and 24 patients (4.8%) were treated operatively. Both groups were similar in demographics. There was no difference in the proportion of patients with nonunions between groups (6.1% in the nonoperative group vs. 3.8% in the operative group, P = 1.000). In addition, there was no statistically significant difference between groups with respect to the time to clinical healing (9.9 ± 8.3 weeks for the nonoperative group vs. 15.4 ± 15.0 weeks for the operative group, P = 0.117) or the time to radiographic healing (18.7 ± 12 weeks for the nonoperative group vs. 18.5 ± 16.6 weeks for the operative group, P = 0.970). CONCLUSIONS: Zone 2 fifth MT base fractures were successfully treated with nonoperative management. There was no evidence in this study that operative treatment leads to significantly faster clinical or radiographic healing. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intermediate-Term Outcomes of Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Patients With Global Versus Isolated Lateral Acetabular Overcoverage.

BACKGROUND: Previous studies evaluating the outcomes of hip arthroscopy for patients with global acetabular overcoverage and focal superolateral acetabular overcoverage suffer from short-term follow-up and inconsistent radiographic criteria when defining these subpopulations of patients with femoroacetabular impingement syndrome (FAIS). PURPOSE: To evaluate the intermediate-term postoperative outcomes for patients with FAIS in the setting of global acetabular overcoverage, lateral acetabular overcoverage, and normal acetabular coverage. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing hip arthroscopy for FAIS were enrolled in a prospective cohort study, and those with a minimum follow-up of 5 years were included in this analysis. Patients were grouped based on type of acetabular coverage: global overcoverage (lateral center-edge angle [LCEA] ≥40°, with coxa profunda), lateral overcoverage (LCEA ≥40°, without coxa profunda), and no overcoverage (LCEA <40°). Functional outcomes (modified Harris Hip Score and Nonarthritic Hip Score) and failure of primary hip arthroscopy were compared between groups. RESULTS: In total, 94 patients (mean age, 41.9 ± 14.2 years) were included with a mean follow-up duration of 6.1 ± 0.9 years. Of these patients, 40.4% had no acetabular overcoverage, 36.2% had lateral overcoverage, and 23.4% had global overcoverage. There was no difference between groups with respect to percentage of patients who underwent reoperation for either revision arthroscopy or conversion to total hip arthroplasty (28.9% for the normal acetabular coverage group, 29.4% for the lateral overcoverage group, and 31.8% for the global overcoverage group; P = .971). Among patients for whom primary hip arthroscopy did not fail, there was no difference in 5-year functional outcomes between groups. Postoperative LCEA >40° (ß = -13.3; 95% CI, -24.1 to -2.6; P = .016), female sex (ß = -14.5; 95% CI, -22.7 to -6.2; P = .001), and higher body mass index (ß = -1.9; 95% CI, -2.8 to -1.0; P < .001) were associated with worse intermediate-term hip function in terms of modified Harris Hip Score. CONCLUSION: There was no difference in functional outcomes or rate of reoperation at a minimum of 5 years postoperatively between those with global acetabular overcoverage, those with regional lateral overcoverage, and those with normal acetabular coverage. Provided that an appropriate acetabuloplasty is performed, there is no evidence to suggest that global acetabular overcoverage portends a worse prognosis than other FAIS subtypes.

Fracture related infection (FRI) of the upper extremity correlates with poor bone and soft tissue healing.

PURPOSE: The purpose of this study was to evaluate the specific course and complication profile following the development of FRI in the upper extremity. METHODS: An IRB-approved retrospective review was conducted on a consecutive series of operatively managed patients within an academic medical center between 1/2010 and 6/2022. Included patients met the following criteria: (1) upper extremity fracture definitively treated with internal fixation (2) development of criteria for suggestive or confirmatory FRI (as per the FRI Consensus Group) and (3) age ≥ 18 years. Baseline demographics, medical history, injury information, infection characteristics, hospital quality measures, and outcomes were recorded. A 3:1 propensity-matched control cohort of patients without FRI was obtained using the same dataset. Univariable analysis was performed to compare the outcomes (rate of nonunion, time to bone healing, need for soft tissue coverage, patient reported joint stiffness at final follow-up) of the FRI vs Non-FRI cohorts. RESULTS: Of 2827 patients treated operatively for an upper extremity fracture, 43 (1.53%) met criteria for suggestive of confirmatory FRI. The successful propensity match (43 FRI, 129 Non-FRI) revealed no differences in demographics, baseline health status, or fracture location. FRI patients underwent more reoperations (p < 0.001), experienced an increased rate of removal of hardware (p < 0.001), and were admitted more frequently following index operation (p < 0.001). The FRI cohort had higher rates of fracture nonunion (p = 0.003), and a prolonged mean time to bone healing in months (8.37 ± 7.29 FRI vs. 4.14 ± 5.75 Non-FRI, p < 0.001). Additionally, the FRI cohort had a greater need for soft tissue coverage throughout their post-operative fracture treatment (p = 0.014). While there was no difference in eventual bone healing (p = 0.250), FRI patients experienced a higher incidence of affected joint stiffness at final follow-up (p < 0.001). CONCLUSION: Patients who develop an FRI of the upper extremity undergo more procedures and experience increased complications throughout their treatment, specifically increased joint stiffness. Despite this, ultimate outcome profiles are similar between patients who experience FRI and those who do not following operative repair of an upper extremity fracture. LEVEL OF EVIDENCE: III.

Trends in the treatment of proximal humerus fractures from 2010 to 2020.

BACKGROUND: The incidence of proximal humerus fractures (PHF) is continuing to rise due to shifts towards a more aged population as well as advancements in surgical treatment options. The purpose of this study is to examine and compare trends in the treatment of PHFs (nonoperative vs. operative; different surgical treatments) across different age groups over the last decade (2010-2020). METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried using International Classification of Diseases and Current Procedural Terminology codes to identify all patients presenting with or undergoing surgery for PHF between 2010 and 2020. Treatment trends, demographics, and insurance information were analyzed during the study period. Comparisons were made between operative and nonoperative trends with respect to the number and type of surgeries performed among 3 age groups: ≤49 years, 50-64 years, and ≥65 years. The rate of postoperative complications and reoperations was evaluated and compared among different surgical treatments for patients with a minimum 1-year postoperative follow-up. RESULTS: A total of 92,308 patients with a mean age of 67.8 ± 16.8 years were included. Over the last decade, there was no significant increase in the percentage of PHFs treated with surgery. A total of 15,523 PHFs (16.82%) were treated operatively, and these patients, compared with the nonoperative cohort, were younger (64.9 years vs. 68.4 years, P < .001), more likely to be White (80.2% vs. 74.7%, P < .001), and more likely to have private insurance (41.4% vs. 32.0%, P < .001). For patients ≤49 years old, trends in operative treatment have remained stable with internal fixation (IF) as the most used surgical modality. For patients 50-64 years old, we observed a gradual decline in the use of hemiarthroplasty (HA), with a corresponding increase in the use of reverse total shoulder arthroplasty (rTSA), but IF continued to be the most used operative modality. In patients over 65 years, a steep decline in the use of IF and HA was noted during the first half of the decade along with a significant exponential increase in the use of rTSA, which surpassed the use of IF in 2019. Despite the increase in the use of rTSA, no differences in rate of surgical complications were noted between rTSA and IF (χ2 = 0.245, P = .621) or reoperations (χ2 = 0.112, P = .730). CONCLUSION: Nonsurgical treatment remains the mainstay treatment of PHFs. Although there is no increase in the prevalence of operative treatment in patients ≥50 years in the last decade, there is an exponential increase in the use of rTSA with a corresponding decrease in HA and IF, a trend more substantial in patients ≥65 years compared with patients between 50 and 64 years.

Cartilage Biopsy for Autologous Cell-Based Repair of the Knee in the Wide-Awake Setting Using Needle Arthroscopy.

Chondral and osteochondral lesions of the knee are a commonly occurring pathology that can pose challenges to the treating surgeon. For the appropriate cartilage injury, autologous cell-based articular cartilage repair techniques have shown promising results. However, these treatments traditionally require 2 separate surgical procedures. Recent advances in needle arthroscopy technology have made it possible to conduct the first stage of autologous chondrocyte implantation surgery in the wide-awake office setting, mitigating cost and resource utilization. The purpose of this technical note is to serve as a proof of concept and describe the process of obtaining a cartilage sample in the wide-awake patient using a needle arthroscope.

Treatment of Glenoid Wear with the Use of Augmented Glenoid Components in Total Shoulder Arthroplasty: A Scoping Review.

¼ Treatment of glenoid bone loss continues to be a challenge in total shoulder arthroplasty (TSA). Although correcting glenoid wear to patient's native anatomy is desirable in TSA, there is lack of consensus regarding how much glenoid wear correction is acceptable and necessary in both anatomic and reverse TSA.¼ Use of augmented glenoid components is a relatively new treatment strategy for addressing moderate-to-severe glenoid wear in TSA. Augmented glenoid components allow for predictable and easy correction of glenoid wear in the coronal and/or axial planes while at the same time maximizing implant seating, improving rotator cuff biomechanics, and preserving glenoid bone stock because of off-axis glenoid reaming.¼ Augmented glenoid components have distinct advantages over glenoid bone grafting. Glenoid bone grafting is technically demanding, adds to the surgical time, and carries a risk of nonunion and graft resorption with subsequent failure of the glenoid component.¼ The use of augmented glenoid components in TSA is steadily increasing with easy availability of computed tomography-based preoperative planning software and guidance technology (patient-specific instrumentation and computer navigation).¼ Although different augment designs (full wedge, half wedge, and step cut) are available and a particular design may provide advantages in specific glenoid wear patterns to minimize bone removal (i.e. a half wedge in B2 glenoids), there is no evidence to demonstrate the superiority of 1 design over others.

No difference in complications between two-week vs. six-week duration of sling immobilization after reverse total shoulder arthroplasty.

Background: The purpose of our study was to compare the outcomes and complications after a two- vs. six-week duration of sling immobilization following reverse total shoulder arthroplasty (rTSA). Methods: We conducted a retrospective review from our institutional database on 960 patients treated by primary rTSA between 2011 and 2021. Patients were separated into two cohorts of postoperative sling immobilization (a two-week and six-week group). Multivariate analysis was conducted to evaluate what factors were associated with patients experiencing either a postoperative complication or requiring reoperation. Results: A total of 276 patients were instructed to keep their operative arm in a sling for six weeks postoperatively, and 684 patients discontinued use at two weeks. There was no difference in postoperative complication rate (15.0% vs. 12.0%, P = .21), dislocation rate (P = .79), acromion stress fractures (P = .06), implant loosening (P = .15), and periprosthetic joint infections (P = .48) between the six- and two-week sling cohorts. In the immediate 90-day postoperative time period, no difference was seen in the reoperation rates (P = .73). Discussion: Shorter duration of sling immobilization (two weeks) does not incur additional risk of complications compared to standard duration (six weeks) of sling immobilization following rTSA.

Long-Term Outcomes of Primary Anterior Cruciate Ligament Reconstruction Using Achilles Tendon Allograft.

PURPOSE: This study sought to assess the long-term structural integrity of primary anterior cruciate ligament (ACL) reconstructions using Achilles tendon allografts by measuring the side-to-side difference in anterior-posterior tibial translation between the operative knee and the contralateral, asymptomatic knee. METHODS: This study was a retrospective case series consisting of patients who underwent primary ACL reconstruction with Achilles tendon allograft. Allografts were chemically processed using the AlloWash or AlloTrue methods and then received either gamma radiation or electron beam radiation (range: 0.95 to 1.4 Mrad dose). At the time of follow-up, anterior-posterior tibial translation of both the operative and contralateral knees was measured using the Lachmeter® device. Functional outcomes were assessed using the International Knee Documentation Committee (IKDC) questionnaire and the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. RESULTS: The analysis included 20 patients (mean age: 41.38 ± 14.27 years) with a mean follow-up time of 7.01 ± 5.24 years. There were no graft failures requiring revision during the study period. The mean side-to-side difference in laxity between operative and contralateral knees was 1.10 ± 2.02 mm. Two patients (10%) met the criteria for complete ACL injury at the time of follow-up, while the remaining 18 patients (90%) met the criteria for no ACL injury. The mean IKDC score was 83.5 ± 13.8, and mean KOOS score was 88.4 ± 10.7. CONCLUSIONS: Primary ACL reconstruction using an Achilles tendon allograft in skeletally mature patients resulted in maintained knee stability and good functional outcomes over the long-term postoperative period.

Return to Play After Knee Articular Cartilage Restoration: Surgical Options, Rehabilitation Protocols, and Performance Outcomes.

PURPOSE OF REVIEW: Numerous cartilage restoration techniques have proven to be effective in the treatment of articular cartilage defects. The ultimate goal of these procedures is to improve pain and function, thereby increasing the likelihood of a patient's return to physical activity. Postoperative rehabilitation is a key component for a successful and expedient return to activities. The purpose of this article is to review the current literature regarding common surgical options, rehabilitation protocols, and performance outcomes after operative treatment of articular cartilage defects. RECENT FINDINGS: Studies have demonstrated improved short- to long-term outcomes in a majority of techniques. However, the clinical benefits of microfracture are short-lived, which has led to the use of alternative procedures. Rehabilitation protocols are not standardized, but emphasis has been placed on bracing, weightbearing, early continuous passive range of motion, and strengthening to improve function. There is growing evidence to suggest that accelerated rehabilitation after matrix-induced autologous chondrocyte implantation may result in superior outcomes compared to delayed rehabilitation. Overall, most techniques result in satisfactory rates of return to play, though existing comparative studies typically include patients with heterogeneous pathology, complicating effective synthesis of outcomes data. In appropriately selected patients, cartilage restoration procedures after articular cartilage injury result in favorable patient-reported clinical outcomes and high rates of return to play. While studies emphasize the critical role that rehabilitation plays with respect to outcomes after surgery, there are substantial inconsistencies in protocols across techniques.

After Anterior Cruciate Ligament Injury, Patients With Medicaid Insurance Experience Delayed Care and Worse Clinical Outcomes Than Patients With Non-Medicaid Insurance.

Purpose: To evaluate the effects of socioeconomic factors on the operative treatment of anterior cruciate ligament injuries and outcomes following surgical reconstruction. Methods: A retrospective cohort study of primary anterior cruciate ligament reconstruction surgeries at a single institution performed from 2011 to 2015 with minimum 2-year follow-up was conducted. Patient demographics, insurance type, workers' compensation status, surgical variables, International Knee Documentation Committee score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups. Results: In total, 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group, overall mean follow-up of 3.1 ± 0.8 years). The Medicaid group demonstrated lower annual income (P < .001) and a lower level of completed education compared with the non-Medicaid group (P < .001). Patients who received Medicaid had a greater duration between time of initial knee injury and surgery compared with the those in non-Medicaid group (11.8 ± 16.3 months vs 6.1 ± 16.5 months, P < .001). At the time of follow-up, patients in the non-Medicaid group had a significantly greater International Knee Documentation Committee score compared with patients who received Medicaid (82.5 ± 13.8 vs 75.3 ± 20.8, P = .036). Conclusions: Patients with Medicaid insurance were seen in the clinic significantly later after initial injury and had worse outcomes compared with patients with other insurance types. Also, patients in higher annual income brackets had significantly better clinical outcomes scores at a minimum of 2 years postoperatively. Level of Evidence: Level III, retrospective cohort study.

The Effect of Surgical Timing on Upper Extremity Nerve Repair.

BACKGROUND: The purpose of this study was to evaluate the association between timing of nerve repair and the ability to perform a primary nerve repair versus a bridge repair requiring the use of allograft, autograft, or a conduit in lacerated upper extremity peripheral nerve injuries. METHODS: This is a retrospective case-control study of patients who underwent upper extremity nerve repair for lacerated peripheral nerves identified by Current Procedural Terminology codes. Timing of injury and surgery, as well as other information such as demographic information, mechanism of injury, site of injury, and type of nerve repair, was recorded. The odds of a patient requiring bridge repair based on the duration of time between injury and surgery was evaluated using logistic regression. RESULTS: A total of 403 nerves in 335 patients (mean age 35.87 ± 15.33 years) were included. In all, 241 nerves were primarily repaired and 162 required bridge repair. Patients requiring bridge repair had a greater duration between injury and surgery compared with patients who underwent primary repair. Furthermore, the nerves requiring bridge repair were associated with a greater gap compared with the nerves repaired primarily. Based on logistic regression, each 1-day increase in duration between injury and surgery was associated with a 3% increase in the odds of requiring bridge repair. CONCLUSIONS: There is no defined critical window to achieve a primary nerve repair following injury. This study demonstrated that nerve injuries requiring bridge repair were associated with a significantly greater delay to surgery.

Inpatient charges, complication, and revision rates for shoulder arthroplasty in Parkinson disease: a regional database study.

BACKGROUND: Parkinson disease (PD) is an established risk factor for higher rates of complications and revision surgery following shoulder arthroplasty, yet the economic burden of PD remains to be elucidated. The purpose of this study is to compare rates of complication and revisions as well as inpatient charges for shoulder arthroplasty procedures between PD and non-PD patients using an all-payer statewide database. METHODS: Patients undergoing primary shoulder arthroplasty from 2010 to 2020 were identified from the New York (NY) Statewide Planning and Research Cooperative System (SPARCS) database. Study groups were assigned based on concomitant diagnosis of PD at the time of index procedure. Baseline demographics, inpatient data, and medical comorbidities were collected. Primary outcomes measured were accommodation, ancillary, and total inpatient charges. Secondary outcomes included postoperative complication and reoperation rates. Logistic regression was performed to evaluate effect of PD on shoulder arthroplasty revision and complication rates. All statistical analysis was performed using R. RESULTS: A total of 39,011 patients (429 PD vs. 38,582 non-PD) underwent 43,432 primary shoulder arthroplasties (477 PD vs. 42,955 non-PD) with mean follow-up duration of 2.9 ± 2.8 years. The PD cohort was older (72.3 ± 8.0 vs. 68.6 ± 10.4 years, P < .001), with greater male composition (50.8% vs. 43.0%, P = .001), and higher mean Elixhauser scores (1.0 ± 4.6 vs. 7.2 ± 4.3, P < .001). The PD cohort had significantly greater accommodation charges ($10,967 vs. $7,661, P < .001) and total inpatient charges ($62,000 vs. $56,000, P < .001). PD patients had significantly higher rates of revision surgery (7.7% vs. 4.2%, P = .002) and complications (14.1% vs. 10.5%, P = .040), as well as significantly higher incidences of readmission at 3 and 12 months postoperatively. After controlling for age and baseline comorbidities, PD patients had 1.64 times greater odds of reoperation compared to non-PD patients (95% CI 1.10, 2.37; P = .012) and a hazard ratio of 1.54 for reoperation when evaluating revision-free survival following primary shoulder arthroplasty (95% CI 1.07, 2.20; P = .019). CONCLUSIONS: PD confers a longer length of stay, higher rates of postoperative complications and revisions, and greater inpatient charges in patients undergoing TSA. Knowledge of the associated risks and resource requirements of this population will aid surgeons in their decision making as they continue to provide care to a growing number of patients affected by PD.

Analysis of patient factors associated with selection of corticosteroid injection in the freezing phase of idiopathic adhesive capsulitis.

BACKGROUND: Primary idiopathic adhesive capsulitis (AC) is characterized by shoulder pain and global limitations in range of motion (ROM). The aim of this study was to determine (1) if a spectrum of symptom severity exists during the freezing phase of AC and (2) identify factors associated with patient selection of corticosteroid injection (CSI) for treatment. METHODS: Patients presenting within 6 months of symptom onset of AC (freezing phase) were enrolled in this single-site retrospective case control study. Visual analog pain scale (VAS) score, shoulder ROM, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, and Patient-Reported Outcomes Measurement Information System (PROMIS function and pain) scores were collected. Each patient was offered oral anti-inflammatory medication, physical therapy, and intra-articular CSI. Patients were divided into 2 cohorts: those electing vs. those deferring CSI. Multivariable logistic regression was performed to identify patient or symptom characteristics predictive of electing CSI. RESULTS: A total of 112 patients (mean age = 54.7 ± 8.8 years, female = 76 [67.9%], mean symptom duration = 13.2 ± 7.9 weeks, elected CSI = 74 [66.1%]) were included in our analysis. The overall study population demonstrated a wide spectrum of VAS pain scores (6.0 ± 2.8, range: 0-10) and ROM: forward elevation (99° ± 27°, range: 30°-150°), abduction (82° ± 24°, range: 30°-130°), external rotation (47° ± 13°, range: 0°-90°), internal rotation (38° ± 26°, range: 5°-90°). The CSI group had higher mean VAS pain score (6.6 ± 2.5 vs. 4.9 ± 3.0, P = .005) and greater limitations in ROM for forward elevation (92° ± 27° vs. 113° ± 25°, P = .001) and abduction (77° ± 24° vs. 90° ± 21°, P = .005) compared with the non-CSI cohort. The CSI group demonstrated significantly worse shoulder function based on Constant (P < .05), ASES (P = .001), P-UE (P = .016), P-Intensity (P = .002), and P-Interference (P = .004). Logistic regression demonstrated decreased total shoulder ROM in forward elevation and abduction plane (OR = 0.98, 95% CI = 0.97-0.99, P = .004). Hispanic ethnicity and increased VAS pain score (OR = 1.20, 95% CI = 1.01-1.43, P = .04) were associated with increased likelihood of electing CSI. CONCLUSION: A spectrum of symptom severity exists during the freezing phase of primary AC, despite similar etiology. AC patients with greater pain severity, and greater limitations in ROM at initial evaluation were associated with patient selection of CSI.

RANTES Concentration at the Time of Surgery Is Associated With Postoperative Stiffness in Patients Undergoing ACL Reconstruction.

BACKGROUND: Patients undergoing anterior cruciate ligament (ACL) reconstruction have been shown to be at risk for postoperative arthrofibrosis. Diagnostic biomarkers associated with the development of postoperative stiffness are unknown. HYPOTHESIS: Biomarkers found in the synovial fluid at the time of surgery are associated with the development of postoperative arthrofibrosis in a cohort of patients undergoing ACL reconstruction. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients undergoing ACL reconstruction were prospectively enrolled. Synovial fluid was collected before surgical incision. A cohort of patients with postoperative stiffness requiring manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) was retrospectively identified. Matching of cases to controls was performed using a 1:2 pair matching algorithm. Risk factor-adjusted single-biomarker and multivariable models were used to assess the association of synovial fluid biomarkers with postoperative stiffness requiring MUA/LOA. Stepwise logistic regression controlling for clinical risk factors was used to identify biomarkers that are possible predictors of postoperative stiffness. RESULTS: A total of 11 cases (3 male, 8 female) were identified and matched with 21 controls (6 male, 15 female) with no significant differences in age, sex, smoking history, or days from injury to surgery. Concentrations of the biomarker regulated upon activation, normal T-cell expressed and presumably secreted (RANTES) were significantly higher in patients requiring MUA/LOA versus controls (694.20 pg/mL [interquartile range, 214.75-3428.79] vs 113.04 pg/mL [interquartile range, 32.81-517.91], respectively; P = .034). On single-biomarker models, RANTES (odds ratio, 2.28; 95% CI, 1.29-5.37; P = .019) and basic fibroblast growth factor (bFGF) (odds ratio, 1.91; 95% CI, 1.07-3.99; P = .047) were associated with increased risk of postoperative stiffness requiring MUA/LOA after ACL reconstruction. Stepwise logistic regression identified 3 biomarkers that are possible predictors of postoperative stiffness, which were included in the final model: Interleukin 1 receptor antagonist (IL-1RA) (P = .198), bFGF (P = .157), and RANTES (P = .046). CONCLUSION: Higher concentrations of synovial fluid biomarkers bFGF and RANTES were associated with increased risk for stiffness requiring intervention after ACL reconstruction. Interleukin 6 (IL-6), vascular endothelial growth factor A (VEGF-A), tissue inhibitor of metalloproteinases 1 (TIMP-1), interleukin 1 receptor antagonist (IL-1RA), matrix metalloproteinase 3 (MMP-3), monocyte chemotactic protein 1 (MCP-1), and macrophage inflammatory protein 1B (MIP-1B) were not associated with the development of postoperative arthrofibrosis.

Return to Work and Sport Following Tibial Tubercle Anteromedialization.

BACKGROUND: Tibial tubercle anteromedialization (AMZ) is a commonly performed procedure for patients with patellofemoral instability or patellofemoral osteochondral disease. While prior studies have demonstrated that this form of osteotomy produces generally good outcomes, the time needed for return to work and return to sport remains unclear. This study aimed to determine the mean length of time before return to work and the rate of return to sport following AMZ. PATIENTS AND METHODS: Patients who had undergone AMZ for either patellofemoral instability or isolated osteochon- dral defect with a minimum follow-up time of 1 year were identified. Patients less than 18 years of age were excluded. Patients were asked to complete a series of patient reported outcomes surveys including specific queries regarding their return to work and return to athletic activity. RESULTS: A total of 109 patients were included in this study. The majority were female (79 patients, 72.3%). The mean age was 30.74 ± 9.90 years at the time of surgery. The mean follow-up duration was 3.40 ± 1.97 years. Of the 109 patients, 104 (95.4%) had returned to work at the time of follow-up. Mean time to return to work was 2.96 ± 3.33 months (range: 0.25 to 24 months). Of the 90 patients who were involved in a sport or physical activity prior to injury, 64 patients (71.1%) had returned to sport at some level at the time of most recent follow-up. Of those who had returned to sport, mean time to return to sport was 9.21 ± 5.46 months (range: 1 to 24 months). CONCLUSIONS: At a minimum follow-up time of 1 year, patients who underwent AMZ were found to have a return to sport rate of 71% with a mean time of 9.21 months to return to athletic activity. Over 95% of AMZ patients had returned to work by 1 year after the procedure. Patients required an average of 3 months to return to work, although those with physically demanding jobs required slightly more time. Data from the current study is useful in setting expectations for patients undergoing tibial tubercle anteromedialization for patellofemoral instability or patellofemoral osteochondral disease.

Sex-Based Differences in Outcomes of Tibial Tubercle Anteromedialization.

Bulletin of the Hospital for Joint Diseases 2022;80(4):252-6252 Bloom DA, Gonzalez M, Hurley ET, Kingery MT, Carter CW, Jazrawi LM, Strauss EJ. Sex-based differences in outcomes of tibial tubercle anteromedi- alization. Bull Hosp Jt Dis. 2022;80(4):252-6. Abstract Background: Previous research has demonstrated sex- based differences in patient-reported outcomes of orthopedic surgical procedures. The hypothesis of the current study was that females would have inferior patient-reported outcomes to their male peers following a tibial tubercle anteromedial- ization (AMZ) procedure for both patellofemoral instability and cartilage defects. METHODS: Patients who had undergone AMZ for isolated osteochondral defect or patellofemoral instability with a minimum follow-up time of 1 year were identified. They were then asked to complete several patient-reported outcome questionnaires that were then statistically analyzed. RESULTS: Overall, 109 patients were included in this study. Seventy-nine patients (72.5%) were female with a mean follow-up duration of 3.4 ± 2.0 years. Forty-seven females had AMZ for patellar instability while 32 females had AMZ for osteochondral defects. There were no statistically signifi- cant differences between sexes with respect to concomitant procedures performed, visual analog scale (VAS) pain score, or patient reported outcome (PRO) scores at follow-up (p > 0.05). There was no statistically significant difference with respect to outcomes between the sexes for AMZ overall and when isolating the sexes based on indication. CONCLUSION: This study demonstrates that female patients undergoing AMZ have short-term clinical and functional outcomes that are not significantly different to those reported in males.

Operative Fixation of the Anteromedial Facet of the Coronoid Process.

SUMMARY: Anteromedial coronoid facet fractures typically occur with varus, pronation, and axial forces applied to the elbow. Due in part to the high rate of concomitant lateral collateral ligament (LCL) injuries, untreated anteromedial facet fractures can result in varus and posteromedial rotatory elbow instability. Although small fractures that are not amenable to open reduction and internal fixation can be treated with isolated LCL repair, larger fragments are treated with buttress plating on the anteromedial surface of the coronoid with or without LCL repair. The "over-the-top" approach via a split in the flexor pronator mass is the preferred method of accessing the anteromedial facet. Although data regarding the functional outcomes after operative fixation of the anteromedial facet are limited, observational studies have demonstrated good restoration of elbow stability and motion.