Corticosteroid injection of the knee within one month prior to meniscus repair increases the risk of repair failure requiring meniscectomy.

OBJECTIVE: Meniscal tears are common knee injuries with limited endogenous healing capacity. This study aimed to investigate the association between the timing and administration of preoperative intra-articular corticosteroid injections (CSIs) and the risk of subsequent meniscectomy following meniscus repair. METHODS: Using a national insurance claims database, patients aged 18-40 years undergoing meniscus repair within six months of tear diagnosis were studied. Patients were categorized based on whether they received preoperative CSIs within three intervals prior to repair. Multivariable logistic regression was used to analyze the risk of follow-up meniscectomy while controlling for various patient-related variables. RESULTS: Among 5,390 patients meeting inclusion criteria, 201 received preoperative CSIs. The CSI group was older and had higher rates of diabetes, obesity, and knee osteoarthritis. The overall rate of follow-up meniscectomy did not differ between groups. However, CSIs performed within one month prior to repair were associated with significantly higher odds of subsequent meniscectomy compared to CSIs performed between three and six months prior. Obesity, tobacco use, and knee osteoarthritis were also independently associated with higher risk, while increasing age was associated with lower risk. CONCLUSION: The study highlights an increased risk of repair failure requiring follow-up meniscectomy for patients receiving intra-articular CSIs within one month prior to meniscus repair. These findings suggest caution when considering CSIs as a treatment option for patients scheduled for meniscus repair. Further research is needed to establish optimal timing guidelines for CSIs in relation to meniscus repair and to understand the underlying mechanisms.

Lower Extremity Stress Fractures in the National Basketball Association, 2013-2014 Through 2018-2019.

Background: Players in the National Basketball Association (NBA) are at risk for lower extremity stress fractures, partly because of the sport's high-intensity demand on the lower body. Purpose: To provide insight on the identification and management of potential risk factors associated with lower extremity stress fractures in NBA athletes. Study Design: Case series; Level of evidence, 4. Methods: A retrospective study was conducted using the NBA electronic medical record database for all players who were on an NBA roster for ≥1 game from the 2013-2014 through 2018-2019 seasons. Player characteristics, games missed, and treatment methodology were independently analyzed. Results were presented as incidence per 1000 player-games. Results: There were 22 stress fractures identified in 20 NBA players over the course of 6 years, with an average of 3.67 stress fractures per year and an incidence of 0.12 stress fractures per 1000 player-games. Most stress fractures occurred in the foot (17/22), and 45% (10/22) of stress fractures were treated surgically, with the most common site of operation being the navicular. On average, approximately 37 games and 243 days were missed per stress fracture injury. There was no significant difference in time to return to play between high-risk stress fractures treated operatively versus nonoperatively (269.2 vs 243.8 days; P = .82). Conclusion: The overall incidence of stress fractures in NBA players was 0.12 per 1000 player-games, and a high percentage of players returned to NBA activity after the injury. There was a relatively even distribution between high-risk stress fractures treated operatively and nonoperatively. When comparing high-risk stress fractures treated operatively to ones treated nonoperatively, no significant difference in average time to return to play in the NBA was found.

Concussions Increase the Odds of Lower-Extremity Injuries in National Football League Players: Four-Year Review of Publicly Available Data.

Objective: To investigate the effect of multiple concussions on the risk of lower-extremity injuries in National Football League (NFL) players. Methods: All active NFL players from September 2016 to January 2017 through September 2019 to January 2020 regular seasons were eligible for inclusion. All players who sustained multiple concussions during the study period were identified using publicly available data and included in the multiple concussion (MC) cohort. Players who sustained a single concussion (SC) as well as controls were age and position matched to the MC cohort using MEDCALC case-control. Lower-extremity injuries were then documented for the players included in all 3 cohorts. Results: The odds of sustaining a lower-extremity injury were significantly greater in the MC as well as the SC cohort when compared with the no concussion (NC)-matched cohort (odds ratio 2.92, standard deviation [SD] 1.7-4.9) and 2.28 (SD 1.5-3.6), respectively. However, we found no significant difference in the odds of sustaining a lower-extremity injury when comparing the SC with the MC cohort (odds ratio 1.00, SD 0.7-1.3). The time to lower-extremity injury after return to play from a concussion was significantly shorter in the SC group when compared with the MC group, within 1 year following a concussion injury (P = .01). Conclusions: There was a significant increase in the odds of suffering a lower-extremity injury after return to play in NFL players exposed to SC or MC when compared with age- and position-matched controls who did not sustain a concussion within the study period. There was no significant difference in the odds of suffering a lower-extremity injury after return to play for NFL players exposed to MC when compared with players exposed to a SC during our study period. Our findings suggest a potential need for injury-prevention protocols following concussion injuries. Level of Evidence: Level III, retrospective comparative prognostic trial.

The Relationship Between Preoperative Opioid Use and Adverse Events Following Total Knee Arthroplasty.

This study aims to compare perioperative events following total knee arthroplasty (TKA) amongst various degrees of preoperative opioid use. In total, 84,569 patients undergoing TKA were identified from a Humana Claims Dataset, and stratified by their preoperative opioid use based on number of prescriptions filled within 6 months of surgery (naïve 0 [50,561]; sporadic 1 [12,411]; chronic 2 or greater [21,687]). Outcomes of interest included Center for Medicare and Medicaid Services (CMS)-reportable complications, need for postoperative supplemental oxygen, 90-day readmission, and hospital length of stay. Complication rates (9.8% vs 8.9% vs 12.6%; p < 0.01), need for supplemental oxygen (3.0% vs 3.1% vs 5.3%; p = 0.03), mean length of stay (2.1 vs 2.8 vs 3.5; p < 0.01), and 90-day readmission (9.7% vs 10.8% vs 16.4%; p < 0.01) significantly differed amongst groups. On logistic regression, only the chronic opioid use group was associated with significantly increased likelihood of complications, need for supplemental oxygen, and readmission. (Journal of Surgical Orthopaedic Advances 31(2):100-103, 2022).

Temporal Relationship of Corticosteroid Injection and Open Release for Trigger Finger and Correlation With Postoperative Deep Infections.

PURPOSE: Previous single-institution studies have shown a relationship between corticosteroid injection and infection after surgery if open trigger release occurs within 90 days. We queried an insurance claims database to evaluate the temporal relationship between a corticosteroid injection and the development of a surgical site infection requiring secondary surgery in patients undergoing trigger release. METHODS: The PearlDiver database was queried for adults who underwent unilateral trigger finger release surgery from 2012 to 2018. The total number of injections, time from last injection to surgery, and preoperative antibiotic use were determined, in addition to the rates of postoperative administration of antibiotics and deep infection requiring surgery at 30, 60, and 90 days after surgery. Logistic regression analysis was used to evaluate the odds of deep infection at 30, 60, and 90 days. RESULTS: A total of 14,686 patients were included; at least 1 corticosteroid injection was administered to 5,173 patients prior to surgery. When grouped based on whether a corticosteroid injection was administered prior to surgery, the postoperative infection rates between the groups were similar at 30, 60, and 90 days. When surgery was performed within 1 month of injection, increased odds of deep infection requiring irrigation and debridement were seen at 60 (odds ratio 2.92 [1.01-7.52]) and 90 days (odds ratio 3.01 [1.13-7.25]). Postoperative antibiotic use in the groups with and without a preoperative injection was similar at all queried time points, but patients who underwent open trigger finger release within 1 month of a prior injection had significantly increased odds (odds ratio 5.77 [1.41-22.06]) of using antibiotics after surgery. Male sex, a higher Elixhauser comorbidity index, and rheumatoid arthritis were additional independent risk factors for a deep infection. CONCLUSIONS: Patients who undergo open trigger release within 1 month of a corticosteroid injection are at increased odds of developing a postoperative infection requiring surgical debridement. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The targeting rule does not increase the rate of lower extremity injuries in NFL players over two seasons.

OBJECTIVES: In 2018 the NFL instituted playing rule article 8, which aimed to help decrease sport related concussion (SRC) by broadening the helmet-hit rule, making it a foul when a player lowers his head to make contact with his helmet against an opponent. Previous studies have demonstrated that the rate of lower extremity injuries increased following the institution of the targeting rule in NCAA football. The objective of this study was to determine if playing rule article 8 unintentionally led to a significant increase in the rate of lower extremity injuries sustained by NFL players during regular season games. METHODS: This study was a retrospective review of all NFL players who were placed on the publically available injury reports for a lower extremity injury from the 2016-2017 through 2019-2020 regular seasons. With article 8 taking effect starting with the 2018-2019 season, players were assigned to a pre- or post-rule cohort based on date of injury for purposes of injury rate comparison. Injury rates were calculated per 1000 athletic exposures (AE). Incidence rate ratio (RR) with 95% confidence intervals (CI) compared injury rates between the two cohorts. RESULTS: There was a 3% decrease in the lower extremity injury rate in 2018-2019 to 2019-2020 compared with 2016-2017 to 2017-2018, however this was not statistically significant (33.6 versus 34.3/1000 AEs, respectively; RR, 0.97; 95% CI 0.92-1.04). There was a 40% decrease in the SRC rate when comparing the post- to the pre-article-8 cohort (3.3 vs. 5.5/1000 AEs, respectively; RR 0.60; 95% CI 0.50-0.73). CONCLUSIONS: The rate of lower extremity injuries and players placed on the injury reserve over the past two NFL seasons following the enactment of playing rule article 8 has not significantly increased. However, the average games missed due to lower extremity injuries significantly increased under playing rule article 8, which suggests that the severity of lower extremity injuries possibly increased. LEVEL OF EVIDENCE: IV Diagnostic.

Unicompartmental Knee Arthroplasty Is Associated With a Lower Rate of Periprosthetic Joint Infection Compared to Total Knee Arthroplasty.

BACKGROUND: Several studies have reported lower perioperative complications with unicompartmental knee arthroplasty (UKA) than with total knee arthroplasty (TKA). However, there is a paucity of data analyzing the incidence of periprosthetic joint infection (PJI) in similar patients undergoing UKA and TKA. As such, we sought to analyze the incidence of UKA and TKA PJI in a large matched population. MATERIAL AND METHODS: The Mariner data set of the PearlDiver database was queried for all patients undergoing UKA or TKA during 2010-2017. Included patients were required to have at least 2 years of database inclusion after surgery. Patients were then matched at a 1:3 ratio (UKA:TKA) on age, gender, Elixhauser Comorbidity Index, tobacco use, and obesity. Rates of PJI requiring operative intervention within 90 days and 1 year were calculated. RESULTS: In total, 5636 patients having undergone UKA were matched to 16,890 patients having undergone TKA. Fifteen (0.27%) after UKA and 79 (0.47%) after TKA had a PJI surgically managed within 90 days (risk ratio = 0.57, 95% confidence interval = 0.33-0.99, P = .04). Thirty (0.53%) after UKA and 136 (0.81%) after TKA had a PJI surgically managed within 1 year (risk ratio = 0.66, 95% confidence interval = 0.45-0.98, P = .04). CONCLUSIONS: In a large group of rigorously matched patients, UKA was associated with a significantly lower rate of surgically managed PJI than TKA at 90 days and 1 year; however, the rate of PJI in both groups remained low at <1% at 90 days and 1 year.

Self-Tensioning Feature of Knotless Suture Anchor Provides Reproducible Knotless Fixation Independent of Initial Tension.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction with suture tape reinforcement has been shown to biomechanically reduce elongation and increase ultimate strength. However, the amount and consistency of the achieved tension after primary fixation using knotless suture anchors remains unclear. PURPOSE: To determine whether initial tensioning of suture tape before fixation with a knotless suture anchor significantly affects final tension of the suture tape. STUDY DESIGN: Controlled laboratory study. METHODS: We secured 15 pairs of Sawbones blocks with predrilled tunnels to a tensile testing machine. Suture tape was inserted through a suspensory fixation button on the representative femoral block and threaded top-down through the base of the tibial block over an attachable button system. The suture tape was attached with a knotless suture anchor in a predrilled and tapped hole on the tibial block under the following pretensioning conditions: (1) slight tension of 5 N, (2) no tension, and (3) initial slack. The suture anchor was inserted as the load-time data were recorded. After initial block testing, a porcine model of 24 tibias was used to test the same pretensioning conditions. The initial loads during anchor insertion and screw-in were measured, as well as final tension. RESULTS: During block testing, no difference in final tensioning was found when comparing the slight-tension, no-tension, and slack groups (42.3 ± 5.3, 37.7 ± 6.4, and 40.2 ± 7.0 N, respectively; P = .528). Similar to block testing, no difference in final tensioning was found when comparing the slight-tension, no-tension, and slack groups using the porcine model (43.64 ± 6.69, 48.09 ± 13.93, and 44.52 ± 6.84 N, respectively; P = .633). CONCLUSION: The final tension of the suture tape construct appears to be reproducible and consistent, independent of the initial tension introduced with suture anchor placement within the tested parameters. CLINICAL RELEVANCE: The results of the current study can help optimize the placement technique of independent suture tape reinforcement for ACL reconstruction, which is a promising strategy to help prevent ACL rerupture, particularly in the early phases of postoperative rehabilitation.

Playing Rule Article Eight Decreases the Rate of Sport Related Concussion in NFL Players Over Two Seasons.

OBJECTIVES: The objectives of this study were to determine if rule article 8 significantly reduced (1) the rate of concussions sustained by NFL players during regular season games, (2) the average games missed secondary to concussion injury, and (3) the number of players placed on the injury reserve for sport-related concussions (SRC). METHODS: This study was a retrospective review of all NFL players who were placed on the publically available injury reports for a concussion from the 2016-2017 to 2019-2020 regular seasons. Player's date of injury was cross-referenced with an absence of statistics from the respective games for which they were ruled out to ensure accuracy. With article 8 taking effect starting with the 2018-2019 season, players were assigned to a pre- or postrule cohort based on date of injury for purposes of injury rate comparison. Injury rates were calculated per 1000 athletic exposures (AE). Relative risk (RR) with 95% confidence intervals (CI) compared injury rates between the two cohorts. Average number of games missed and number of players placed on injury reserve (IR) per year were also calculated. Continuous variables were statistically compared using two-tailed t-test, while categorical variables were compared using Chi-squared test. Statistical significance was set at P ≤ 0.05. RESULTS: There was a 40% decrease in the SRC rate when comparing the post- to the pre-article-8 cohort (3.3 vs 5.5/1000 AEs, respectively; RR 0.60; 95% CI 0.50-0.73). There was no significant difference in average games missed per concussion or percentage of players placed on the IR due to SRC between the two cohorts. CONCLUSIONS: The rate of SRC over the past two NFL seasons following the enactment of playing rule article 8 has significantly decreased when compared with the two seasons prior. The average games missed per concussion and the number of players placed on the IR due to SRC has not significantly changed under playing rule article 8.

Trends of Ulnar Collateral Ligament Reconstruction in the United States from 2003 to 2014: Analysis of 3,133 Patients.

PURPOSE: The purpose of this study is to investigate the trends concerning ulnar collateral ligament (UCL) reconstruction (UCLR) for athletic injuries within the United States over the years 2003 to 2014. METHODS: A retrospective review of the Truven Health Marketscan® Commercial Database was conducted for patients undergoing UCLR. Data was reviewed for patients treated between 2003 and 2014, and the cohort of patients undergoing UCLR was queried using Common Procedural Terminology code 24346. Patients ages 11 to 40 years were included and divided into 6 different age groups, with the rate of UCLR calculated for each group. RESULTS: The overall rate of UCLR increased from 4.4 per million in 2003 to 11.9 per million in 2014 (p < .01). Throughout the same time period, the rate per million increased from 3.3 to 22.1 in 11- to 15-year-olds (p < .01), from 105.4 to 293.2 in 16- to 20-year-olds (p < .01), from 23.1 to 67.0 in 21- to 25-year-olds (p < .01), and from 2.1 to 5.7 in 31- to 35-year-olds (p < .01). There was no significant increase in the rate of UCLR in the age groups of 26 to 30 and 36 to 40 years. CONCLUSION: UCLR was mostly performed in patients aged 11 to 25 years (96.6%), and specifically most common in those patients aged 16 to 20 years (67.4%). The rate of UCLR procedures increased over time for younger age groups significantly more than for their older counterparts. CLINICAL RELEVANCE: UCLR rates are increasing in young patients despite efforts addressing injury risk reduction strategies and education for coaches, players, and parents regarding risk factors for UCL injury.

Suture Tape-Reinforced Human Dermal Allograft Used for Superior Capsule Reconstruction Demonstrates Improved Ability to Withstand Elongation.

PURPOSE: To investigate the potential for a suture tape-reinforcement technique to prevent elongation with repetitive use of a human dermal (HD) allograft traditionally used for superior capsule reconstruction in a biomechanical model. METHODS: Using 8 scapulae and humeri Sawbones models, the standard superior capsule reconstruction was performed using 8 HD allografts. Four grafts were tested in the native state, whereas 4 were tested using reinforcement. Allografts were reinforced using suture tape in a running 360° fashion around the allograft borders, maintaining 5 mm of space from the edges. Allografts were measured pre- and postdynamic testing for length, width, and thickness. All specimens were affixed to a materials testing machine that allowed for allograft orientation in a longitudinal plane throughout testing. Specimens were preloaded to 10 N and then cyclically loaded to 100 N at a rate of 15 mm/s for 30 cycles. RESULTS: After dynamic, cyclic loading, suture tape-reinforced allografts experienced a significantly smaller percent change in anterior length (6.36% vs 14.50%, P = .013), posterior length (6.00% vs 13.68%, P = .002), medial width (5.80% vs 21.05%, P = .001), lateral width (5.45% vs 19.29%, P < .001), medial thickness (4.38% vs 17.93%, P = .005), central thickness (7.03% vs 16.11%, P = .026), and lateral thickness (4.55% vs 20.80%, P < .001). Linear stiffness values obtained for suture tape -reinforced allografts were significantly greater than those for native allografts when measured at cycles 1 (21.18 ± 1.03 N/mm vs 17.69 ± 1.91 N/mm, P = .02), 15 (29.90 ± 1.45 vs 24.93 ± 2.79, P = .03), and 30 (32.13 ± 1.98 N/mm vs 25.72 ± 3.01 N/mm, P = .01) of dynamic testing. CONCLUSIONS: The suture tape-reinforcement technique described decreased HD allograft elongation, maintained graft thickness, and improved linear stiffness values following uniplanar cyclic loading in a biomechanical Sawbones model. CLINICAL RELEVANCE: Suture tape reinforcement of the HD allograft could serve as one strategy to overcome the issue of allograft elongation with time following superior capsule reconstruction.

Wikipedia: A Medical Student Educational Project to Edit Wikipedia in Preparation for Practicing Evidence-Based Pain Medicine.

OBJECTIVE: Wikipedia is commonly used to acquire information about various medical conditions such as chronic pain. Ideally, better online pain management content could reduce the burden of opioid use disorders. Our goal was to improve the quality of the content available on Wikipedia to make it more accurate and applicable to medical students and the general public while training medical students to practice evidence-based medicine and critically assess their sources of information. METHODS: An elective class in Neuroscience, Pain, and Opioids composed of 10 medical students met biweekly to discuss landmark and practice-changing research articles in the fields of acute pain, chronic pain, and opioid management. The professor chose Wikipedia articles relevant to this course. Three independent viewers analyzed the quality of citations, anecdotal medical content, and content value for both patients and medical professionals. As part of their coursework, students then edited the Wikipedia articles. RESULTS: Although some of the Wikipedia pain topic content (6.7% ± 2.0) was anecdotal, financially biased, or inconsistent with Western Medical Practice content, overall articles included primarily high-quality citations (85.6% ± 3.1). On a 0-5 Likert scale, students felt content would be moderately helpful for both medical students/professionals (3.4 ± 0.2) and laypersons (3.5 ± 0.2). Editing and adding citations was feasible, but novel material was often reverted. CONCLUSION: A significant amount of pain medicine content was relevant and amenable to student editing. Therefore, future use of this tactic could provide a unique opportunity to integrate evidence-based medicine into the medical curriculum and have a direct impact on the widely available medical information. Future refinement in the editorial process may also further improve online information.

Periprosthetic Hip Fractures Outside the Initial Postoperative Period: Does Time from Diagnosis to Surgery Matter?

BACKGROUND: Despite an increasing incidence and associated morbidity, the optimal timing for the surgical management of periprosthetic hip fractures remains unknown. This study sought to explore whether time to surgery was associated with medical or surgical complications. METHODS: A retrospective review of Medicare data from 2010 to 2014 was performed using PearlDiver. All patients with a periprosthetic hip fracture greater than 90 days from surgery and undergoing open reduction internal fixation (ORIF) or revision total hip arthroplasty (RTHA) were included. Time to surgery was measured from diagnosis and dichotomized at 48 hours. RESULTS: Of 342 patients undergoing ORIF, 269 (79%) had surgery within 48 hours. Of 255 patients undergoing RTHA, 142 (56%) had surgery within 48 hours. For ORIF, surgery more than 48 hours after diagnosis was associated with an increased rate of 30-day deep vein thrombosis or pulmonary embolism (15% vs 7%, P = .03), which remained after adjustment (odds ratio [OR]: 2.71, 95% confidence interval [CI]: 1.11-6.45). A similar association was seen for RTHA (12% vs 6%, P = .09 and OR: 2.61, 95% CI 1.01-7.24). For RTHA, surgery more than 48 hours after diagnosis was associated with an increased rate of 90-day periprosthetic joint infection (12% vs 4%, P = .007), which remained after adjustment (OR: 3.86, 95% CI: 1.36-12.72). A similar but not significant association was seen for ORIF (7% vs 3%, P = .18 and OR: 2.65, 95% CI: 0.73-8.91). CONCLUSIONS: Among Medicare patients with a periprosthetic hip fracture, time to surgery greater than 48 hours was associated with increased medical and surgical complications.

Effect of Global Fracture Care Billing on Distal Radius Fractures.

Nonoperative distal radius fracture treatment without manipulation can be coded and billed in a global fee or itemized structure. Little is known regarding the association between these coding/billing structures and subsequent clinical care. The MarketScan Research Database (IBM, Armonk, New York) was retrospectively queried for patients with a distal radius fracture diagnosis code from 2003 to 2014. Patients with a Current Procedural Terminology code for surgical treatment or closed treatment with manipulation were excluded. The remaining nonoperatively treated patients were separated based on billing structure. Results were analyzed for provider initiating global fracture care, as well as the likelihood and frequency of follow-up visits related to the injury for each group. A total of 381,561 patients were identified based on inclusion criteria. Global fracture care billing was initiated for 177,153 (46%) patients, whereas itemized billing was performed for 204,408 (54%) patients. Orthopedic surgeons were the most likely provider (69%) to initiate global fracture care after diagnosis of distal radius fracture. Emergency physicians were the second most common specialty (6%). Patients for whom global fracture care was initiated were more likely to not receive any follow-up office visits compared with patients for whom itemized billing was performed (39.2% vs 25.4%). Additionally, patients with global billing had significantly fewer office visits during the 90-day global period (1.3 vs 2.3). This study demonstrates that patients billed via global fracture care have less frequent follow-up and fewer office visits during the 90-day global period than patients billed in itemized fashion. [Orthopedics. 2020;43(5);e471-e475.].

Rates of Subsequent Shoulder Surgery Within Three Years for Patients Undergoing SLAP Repair Versus Biceps Tenodesis.

PURPOSE: To investigate the demographics of patients for whom SLAP repair or biceps tenodesis was performed, as well as to compare rates of additional shoulder surgery for these 2 procedures within 3 years postoperatively. METHODS: Using the MarketScan Commercial Database, we examined all patients with SLAP tear who underwent arthroscopic SLAP repair or open or arthroscopic biceps tenodesis within the encompassed time period (2003-2014). Rates of repeat shoulder surgery within 3 years were evaluated, as were comparative demographics. RESULTS: In total, 25,142 patients initially underwent SLAP repair, of whom 11.5% had subsequent shoulder surgery within 3 years. A total of 840 patients initially underwent biceps tenodesis as treatment for a SLAP tear, of whom 13.0% underwent additional shoulder surgery within 3 years. Rates of subsequent shoulder surgery between the 2 procedural groups did not statistically differ (P = .19). Patients who underwent SLAP repair were younger than those who underwent tenodesis (mean age 38.3 vs 49.3 years, P < .01). For patients requiring additional surgery, the SLAP repair group had a greater representation of those ≥35 years old, whereas the tenodesis group had a greater representation of those <35 years old (P < .01). Male patients experienced an increase in rate of subsequent shoulder surgery when initially undergoing tenodesis versus SLAP repair (13.3% vs 11.1%, P < .01). CONCLUSIONS: The rates of additional shoulder surgery for patients undergoing SLAP repair and biceps tenodesis were similar within 3 years of the index procedure. Patients who underwent SLAP repair were younger than those who underwent tenodesis. Of those requiring additional surgery, patients initially treated with SLAP repair were older (≥35 years) and those treated with tenodesis were younger (<35 years). Male patients experienced an increase in rate of subsequent shoulder surgery when initially treated with tenodesis versus SLAP repair. LEVEL OF EVIDENCE: III, retrospective comparative study.

Five-Year Risk of Conversion to Total Knee Arthroplasty After Operatively Treated Periarticular Knee Fractures in Patients Over 40 Years of Age.

BACKGROUND: Periarticular knee fractures present a significant challenge to minimize post-traumatic osteoarthritis. The purpose of this study is to compare the rates of conversion to total knee arthroplasty (TKA) for different periarticular knee fractures, investigate the rate of knee injections as a more rapid assessment of knee symptoms, and identify risk factors that lead to conversion to TKA following periarticular fractures. METHODS: A comprehensive retrospective review of the Humana administrative claims database was performed. A total of 2813 patients greater than 40 years of age with diagnosis code for tibial plateau fracture or distal femur fracture linked to a Current Procedural Terminology code of open reduction internal fixation between 2007 and 2011 were evaluated. The rates of TKA and knee injections within 5 years were compared. Cox proportional hazards model was used to evaluate risk factors for conversion. RESULTS: Of 2813 periarticular fractures, the 5-year rate of conversion to TKA was 3.3%. The rate of conversion for tibial plateau fractures was significantly higher at 4.5% compared to 2.3% for distal femur fractures (P = .001). Tibial plateau fracture, obesity, and female gender were risk factors found to portend an increased risk of conversion to TKA with hazard ratios of 1.77, 1.69, and 1.88, respectively. The overall rate of knee injections was 12.8% with an average time to injection of 18.2 months after open reduction internal fixation. CONCLUSION: The rate of conversion to TKA for periarticular knee fractures overall was 3.3%, while the rate of knee injections within 5 years of surgery was 12.8%, suggesting a not insignificant minority of patients require treatment for symptomatic knee pain. LEVEL OF EVIDENCE: Therapeutic Level III.

Rare Epstein-Barr Virus-Associated Smooth Muscle Tumor in a Patient with AIDS: A Case Report.

CASE: A 34-year-old man with poorly controlled acquired immune deficiency syndrome underwent excision of a left arm mass. The histopathologic workup identified the features of an Epstein-Barr virus-associated smooth muscle tumor (EBV-SMT). The patient was readmitted 5 months later for vomiting and found to have liver metastases that were confirmed to be EBV-SMT. Six months after discharge, there was no recurrence of the arm mass or increase in the size of the liver metastases. CONCLUSION: Most commonly found in immunocompromised patients, EBV-SMTs are rare tumors that can be mistaken for a leiomyosarcoma.

Nonoperative Management of Hip Labral Tears Yields Similar Total Hip Arthroplasty Conversion Rate to Arthroscopic Treatment.

BACKGROUND: Arthroscopic treatment of hip labral tears has increased significantly in recent years. There is limited evidence comparing nonoperative management to arthroscopic treatment. The purpose of this study is to evaluate the progression to total hip arthroplasty (THA), as well as the cost associated with arthroscopic management of labral tears compared to nonoperative treatment. METHODS: The Humana claims database was queried from 2007 through 2016. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients with hip labral tears and hip arthroscopy and THA procedures. Two cohorts were created: a nonoperative group and an operative group. Following propensity score matching, the rate of conversion and time to THA conversion were calculated. Cost was calculated using the total cost reimbursed for encounters within 6 months. Continuous variables were analyzed using Student t-test and Mann-Whitney test, and categorical variables were analyzed using chi-square test. RESULTS: After propensity matching, 864 patients were included in the analysis. The conversion rate to THA in the operative group (6.7%) and the nonoperative group (5.3%) was not statistically different (P = .391). The operative group had a longer time to THA (21.5 ± 16.8 months) than the nonoperative group (15.9 ± 19.5 months; P = .044). The cost for the operative group was significantly higher ($14,266.55 ± $7187.96) compared to the nonoperative group ($2941.96 ± $2664.00; P < .001). CONCLUSION: This study did not find a difference in the rate of conversion to THA for operative vs nonoperative groups. Time to THA in the operative group was longer, however, at the expense of higher costs.

Superior Capsule Reconstruction With Subacromial Allograft Spacer: Biomechanical Cadaveric Study of Subacromial Contact Pressure and Superior Humeral Head Translation.

PURPOSE: To investigate the biomechanical effects of superior capsule reconstruction with subacromial allograft spacer on superior humeral head translation and subacromial contact pressure. METHODS: Eight cadaveric shoulder specimens were tested in 4 conditions: (1) intact rotator cuff, (2) supraspinatus tear and superior capsule excision, (3) superior capsule reconstruction with human dermal allograft, and (4) superior capsule reconstruction with subacromial resurfacing using human dermal allograft. In each condition, specimens were tested at 0, 30, 60, and 90° of shoulder abduction in balanced and unbalanced loaded states for subacromial contact pressure and superior humeral head translation. Statistical comparisons were made using a repeated-measures analysis of variance test, followed by a Tukey post hoc test for pairwise comparisons. A P value <.05 was set as statistically significant. RESULTS: Superior humeral head translation and subacromial contact pressure were increased after irreparable rotator cuff tear (P = .001). There was no significant difference between superior capsule reconstruction and intact cuff in regard to superior humeral head translation and subacromial contact pressure at all abduction angles. Superior capsule reconstruction with subacromial resurfacing decreased superior humeral head translation relative to intact (0°, P = .004; 30°, P = .02; 60°, P = .08; 90°, P = .01), superior capsule reconstruction (0°, P = .001; 30°, P = .003; 60°, P = .019; 90°, P = .001), and cuff-deficient states (P = .001). Superior capsule reconstruction with subacromial resurfacing resulted in nonsignificant increases in subacromial contact pressure relative to intact cuff at 0 to 90° abduction angles. CONCLUSIONS: Superior capsule reconstruction with subacromial resurfacing using human dermal allograft results in decreased superior humeral head translation relative to superior capsule reconstruction with human dermal allograft only, while increasing subacromial contact pressure. CLINICAL RELEVANCE: Superior capsule reconstruction with subacromial resurfacing using human dermal allograft reduces superior humeral head translation while increasing subacromial contact pressure in a cadaveric model.

Financial Impact of Magnetic Resonance Imaging in the Surgical Treatment of Foot and Ankle Osteomyelitis.

Magnetic resonance imaging (MRI) is generally considered the most sensitive imaging for diagnosis of osteomyelitis; however, it is associated with significant cost and is at times ordered as initial screening imaging when a less resource-intensive test would suffice. The purpose of this retrospective cohort study was to examine the differences between patients with osteomyelitis of the foot and ankle, and their subsequent treatment course, who underwent MRI compared with those who did not. Financial impact of MRI as it relates to clinical decision-making was also calculated. Patients treated for a diagnosis of osteomyelitis of the foot and ankle from 2009 to 2015 were retrospectively identified. Demographics, imaging modalities, and operative procedures for each patient were collected. An "impact MRI" was defined as one that led to a subsequent operative procedure within the same admission. The impact cost of an MRI was estimated using the equation: (average MRI cost) × (total MRIs/impact MRIs). A total of 144 patients underwent 220 MRIs, and 399 patients did not have MRIs. The operative rate between the 2 groups was similar (70.8% versus 70.4%, p = .93). Multiple linear regression showed that MRI was not a significant predictor of operation (p = .50). However, we found a significant correlation between MRI use and operative intervention for patients with increased comorbidities. From 2011 to 2015, there was a significant increase in impact cost, while controlling for average MRI cost ($8172 to $15,292, p ≤ .05). Over the study period, the impact cost of an MRI significantly increased from 1.8 to 5.0 times the average cost.