In vivo effects of cell seeding technique in an ex vivo regional gene therapy model for bone regeneration.

When delivering cells on a scaffold to treat a bone defect, the cell seeding technique determines the number and distribution of cells within a scaffold, however the optimal technique has not been established. This study investigated if human adipose-derived stem cells (ASCs) transduced with a lentiviral vector to overexpress bone morphogenetic protein 2 (BMP-2) and loaded on a scaffold using dynamic orbital shaker could reduce the total cell dose required to heal a critical sized bone defect when compared with static seeding. Human ASCs were loaded onto a collagen/biphasic ceramic scaffold using static loading and dynamic orbital shaker techniques, compared with our labs standard loading technique, and implanted into femoral defects of nude rats. Both a low dose and standard dose of transduced cells were evaluated. Outcomes investigated included BMP-2 production, radiographic healing, micro-computerized tomography, histologic assessment, and biomechanical torsional testing. BMP-2 production was higher in the orbital shaker cohort compared with the static seeding cohort. No statistically significant differences were noted in radiographic, histomorphometric, and biomechanical outcomes between the low-dose static and dynamic seeding groups, however the standard-dose static seeding cohort had superior biomechanical properties. The standard-dose 5 million cell dose standard loading cohort had superior maximum torque and torsional stiffness on biomechanical testing. The use of orbital shaker technique was labor intensive and did not provide equivalent biomechanical results with the use of fewer cells.

Perioperative Intravenous Dexamethasone Use Is Not Associated with Periprosthetic Joint Infection or Wound Healing Complications Following Shoulder Arthroplasty.

BACKGROUND: Perioperative intravenous (IV) dexamethasone is commonly used in lower extremity total joint arthroplasty to manage postoperative pain and nausea/vomiting, and recent studies have demonstrated that its use may lower rates of acute postoperative medical complications. However, there is limited information regarding the safety and efficacy of IV dexamethasone in patients undergoing total shoulder arthroplasty (TSA). Additionally, there is concern surrounding corticosteroid use prior to surgery as preoperative corticosteroid injections have been associated with adverse outcomes after TSA, including periprosthetic joint infection (PJI) and revision surgery. Thus, the purpose of this study was to evaluate the effect of perioperative IV dexamethasone on 90-day rates of PJI, wound complications, and medical complications after TSA. METHODS: The Premiere national hospital database was used to identify adult patients undergoing elective TSA between 2016 and 2020; patients were excluded if they were under 18 years old, were undergoing revision TSA, or had a prior proximal humerus open reduction internal fixation (ORIF) procedure. Patients who did and did not receive perioperative IV dexamethasone were then compared in both univariate and multivariate analyses. A Bonferroni correction was utilized to adjust for multiple comparisons. The primary endpoint was risk of acute infectious complications within 90 days of surgery, including PJI and wound infection/dehiscence. Secondary endpoints included acute pulmonary, renal, and thromboembolic complications. RESULTS: A total of 135,333 patients underwent TSA during the study period; 61.2% underwent reverse total shoulder arthroplasty (RTSA), 33.8% underwent anatomic total shoulder arthroplasty (ATSA), and 5.0% underwent hemiarthroplasty (HA). From 2016 to 2020, perioperative IV dexamethasone use increased by 135%. Multivariate analysis revealed that patients who received perioperative IV dexamethasone did not have increased odds of PJI, superficial wound infection, or wound dehiscence (p = 0.15 - 0.47) but did have decreased odds of sepsis (OR 0.67, 95% CI 0.55-0.81) and other medical complications such as urinary tract infection (UTI) and acute kidney injury (AKI). Additionally, there was a trend towards decreased 90-day hospital readmission (OR 0.88, 95% CI 0.81-0.96, p=0.003). CONCLUSIONS: Perioperative IV dexamethasone was not associated with increased risk of acute infectious and wound healing complications. Moreover, patients who received perioperative IV dexamethasone had decreased odds of medical complications and trended towards lower rates of 90-day hospital readmission. The results of this study support the safety of perioperative IV dexamethasone use in patients undergoing elective TSA.

Evidence Guiding Commercial Payer Coverage Criteria for Total Ankle Arthroplasty.

Background: Total ankle arthroplasty (TAA), first developed as an alternative to ankle arthrodesis, has become an increasingly popular management option for end-stage ankle arthritis. Prior studies have shown commercial insurance payers base their coverage criteria on limited and low level of evidence research. This study aims to quantify and describe the evidence insurance companies use to support TAA coverage policies. Methods: The top 11 national commercial health insurance payers for TAA were identified. A google search was performed to identify payer coverage policies. Policy documents were examined and cited references were classified by type of reference as well as reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted. Criteria were compared to assess for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria. Results: Six of the 11 payers had accessible coverage policies. The majority of cited references were primary journal articles (145, 60.9%) and the majority of references cited (179, 75.2%) were level III or level IV evidence. We found significant homogeneity in coverage criteria among payers. In addition, cited sources inconsistently mentioned specific payer coverage criteria. Conclusion: This study demonstrates that commercial insurance payers rely on the relatively low level of currently available scientific evidence when formulating coverage policies for TAA use and adopt criteria that have not been thoroughly analyzed in the literature. More high level of evidence research is needed to help clinicians and insurance companies further refine indications for TAA so that patients who might benefit from the procedure are adequately covered. Level of Evidence: Level IV, review.

Subjective Causes for Failure to Return to Sport After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

CONTEXT: While current literature has explored the outcomes of athletes who return to sport (RTS) after anterior cruciate ligament (ACL) injuries, less is known about the outcomes of those who are unsuccessful in returning to sport. OBJECTIVE: To determine the rate of athletes who did not RTS after primary ACL reconstruction (ACLR) and to identify the specific subjective reasons for failure to RTS. DATA SOURCES: A comprehensive search of the PubMed/MEDLINE, Scopus, and Web of Science databases was conducted through April 2021. STUDY SELECTION: Eligible studies included those explicitly reporting the rate of failure for RTS after ACLR as well as providing details on reasons for athletes' inability to return; 31 studies met the inclusion criteria. STUDY DESIGN: Systematic review and meta-analysis. LEVEL OF EVIDENCE: Level 2 to 4. DATA EXTRACTION: The reasons for failure to RTS referred to in our study are derived from those established previously in the studies included. Data were collected on the number of athletes, mean age, mean follow-up time, type of sport played, failure to RTS rate, and specific reasons for failure to return. RESULTS: The weighted rate of failure to RTS after ACLR was 25.5% (95% CI, 19.88-31.66). The estimated proportion of psychosocial-related reasons cited for failure to RTS was significantly greater than knee-related reasons for failure RTS (55.4% vs 44.6%, P < 0.01). The most cited reason for failure to RTS was fear of reinjury (33.0%). CONCLUSION: This study estimates the rate of failure to RTS after ACLR to be 25.5%, with the majority of athletes citing fear of reinjury as the major deterrent for returning to sports. We highlight how factors independent of surgical outcomes may impact an athlete's ability to return to play given that the predominant reason for no RTS after ACLR was unrelated to the knee.

An Updated Estimate of Total Hip and Total Knee Arthroplasty Inpatient Case Volume During the 2020 COVID-19 Pandemic in the United States.

Background: Inpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) practices were dramatically affected in the United States in 2020 as elective surgeries were paused in response to the COVID-19 pandemic. This study sought to provide an updated estimate of inpatient total joint arthroplasty (TJA) case volumes in the United States in 2020. Methods: A retrospective cohort study was performed by identifying all adult patients who underwent primary, elective TJA from January 1st, 2017 to December 31st, 2020, using the National Inpatient Sample. Monthly and annual case volumes were reported with descriptive statistics. Baseline case volumes were established by taking the average number of monthly cases performed in 2017, 2018, and 2019. These monthly averages were compared to 2020 values. Results: From 2017 to 2019, the average case volume was 1,056,669 cases per year (41.0% THA, 59.0% TKA) and 88,055 cases per month. In 2020, 535,441 cases were identified (45.4% THA, 54.6% TKA), corresponding to a 49.3% reduction from the 2017-2019 annual average. Monthly cases decreased to 4515 in April during the "first wave" of COVID-19, corresponding to a 94.8% decrease from prior years. In June, cases rebounded to 55,520 before decreasing again in July to 50,100 during the "second wave" of COVID-19. During the "third wave," COVID-19 cases decreased month-over-month from October through December (56.5% decrease). Conclusions: This updated estimate identified a 49.3% decrease in inpatient TJA cases in 2020 compared to prior years. This is similar to the 46.5-47.7% decrease in case volume previously reported.

Reporting Bias is Highly Prevalent in Systematic Reviews and Meta-Analyses of Platelet Rich Plasma Injections for Hip Osteoarthritis.

Purpose: To describe the incidence and types of spin in systematic reviews of platelet-rich plasma (PRP) injections for hip osteoarthritis (OA) and to determine whether patterns in study characteristics could be identified among studies with identifiable spin. Methods: The PubMed, Scopus, and SPORTDiscus databases were queried. Inclusion criteria were systematic reviews or meta-analyses that included an assessment of intra-articular PRP injections as a stand-alone treatment for hip OA. Two authors independently assessed the presence of spin in the included studies and recorded general study characteristics. The prevalence of the 15 different categories of spin was quantified using descriptive statistics. Results: Fifteen studies met inclusion criteria for this study. All studies contained at least two types of spin (range 2-9), with a median of 2. The most common type of spin was type 14 ("Failure to report a wide confidence interval of estimates"), which was observed in 10 studies. The second most common type of spin was type 13 ("Failure to specify the direction of the effect when it favors the control intervention"), found in 6 studies. Conclusions: Spin is highly prevalent in abstracts of systematic reviews of PRP in the treatment of hip OA. Several associations were found between spin types and the study characteristics of AMSTAR 2 rating, Scopus CiteScore, journal impact factor, and PROSPERO preregistration. When present, spin in the abstracts of reviewed studies tended to favor the use of PRP in hip osteoarthritis. Clinical Relevance: It is important to understand the prevalence of spin in published abstracts, especially in areas of great impact or interest, so authors and readers can have a greater awareness of this potential form of bias.

Randomized Controlled Trials in the Shoulder Arthroplasty Literature Rarely Include Key Demographic and Socioeconomic Patient Data.

BACKGROUND: It is well known that socioeconomic and demographic variables can greatly affect health outcomes. Previous studies across medical and surgical subspecialties have demonstrated that these variables are frequently under-reported in randomized controlled trials (RCTs). No such study currently exists that examines rates of reporting sociodemographic variables in shoulder arthroplasty RCTs. This study aims to present these rates and explore the impacting of failing to report socioeconomic variables in shoulder arthroplasty RCTs. METHODS: The PubMed database was queried for the term "shoulder arthroplasty." 65 RCTs from the last ten years were identified for inclusion from five high-impact orthopedic surgery journals. Each RCT was analyzed for patient age and sex or gender as well as the following sociodemographic variables: race, ethnicity, insurance status, income, work status, and education. It was also noted whether each above variable was mentioned in the results section of the paper. Data was presented in a descriptive fashion as well as analyzed using Chi-squared and Fisher's exact test where appropriate. RESULTS: From 2014-2023, 65 shoulder arthroplasty RCTs published reported age in 40/65 (61.5%) of results sections and 61/65 (93.8%) of any section. Sex or gender were reported in 27/65 (41.5%) of results sections and 61/65 (93.8%) of any section. No manuscripts included any sociodemographic variables in the results section. Reporting rates for sociodemographic variables in any section were: race 6/65 (9.2%), ethnicity 5/65 (7.7%), work status 4/65 (6.2%), and insurance status 1/65 (1.5%). No studies included income or education of the enrolled patients. There was no difference in reporting sociodemographic variables by journal (p = 0.45) or by year of publication (p = 0.57). However, no study prior to 2020 included any sociodemographic variable (0/27, 0%) whereas from 2020 onward six studies included at least one (6/38, 15.8%). Sociodemographic variables were reported significantly less frequently than age and sex or gender (p = 0.001). DISCUSSION: Our study found sociodemographic variables are rarely reported in shoulder arthroplasty RCTs, whereas age and sex or gender are reported with great frequency. In order to understand the results of shoulder arthroplasty RCTs, apply their findings to the care of our patients and address health disparities we must ensure these studies include patient sociodemographic data.

Demographic and Socioeconomic Patient Data Are Rarely Included in Randomized Controlled Trials for Femoral Acetabular Impingement and Hip Arthroscopy: A Systematic Review.

Purpose: To determine the rate of reporting for sociodemographic variables in randomized controlled trials (RCTs) investigating femoral acetabular impingement (FAI) and hip arthroscopy. Methods: PubMed, Scopus, and Web of Science were queried for articles relating to FAI and hip arthroscopy. Articles included in final analysis were RCTs investigating operative management of FAI. Included RCTs were analyzed for reporting of age and sex or gender as well as the following sociodemographic variables: race, ethnicity, insurance status, income, housing status, work status, and education level in the results section or any section of the paper. Data was analyzed using χ2 and Fisher exact tests with significance defined as P < .05. Results: Forty-eight RCTs were identified from 2011 to 2023. Age was reported in 48 of 48 (100%) of included papers; sex or gender was reported in 47 of 48 (97.9%). Reporting of sociodemographic variables in any section respectively was: race (7/48, 14.6%), ethnicity (4/48, 8.33%), insurance status (0/48, 0%), income (1/48, 2.08%), housing status (0/48, 0%), work status (3/48, 6.25%), and education (2/48, 4.17%). There was no significant difference for reporting demographic variables with respect to journal or year of publication (P = .666 and P = .761, respectively). Sociodemographic variables (9/48) were reported significantly less frequently than age and sex or gender (48/48) (P < .001). Conclusions: This study found that sociodemographic variables in FAI and hip arthroscopy RCTs are reported with much lower frequency than age and sex or gender. These findings may demonstrate the need to include patient sociodemographic data in RCTs so that their results can be better generalized and applied to the appropriate patient population. Level of Evidence: Level II, systematic review of level I and II evidence.

Patient Reported Clinical Outcomes Following PCL Suture Augmentation in Patients with Multiligamentous Knee Injury: A Retrospective Observational Study.

Purpose: To compare the patient-reported outcomes between patients with posterior cruciate ligament (PCL) reconstruction or repair alone versus PCL reconstruction or repair with internal bracing (IB) in the context of multi-ligament knee injuries (MLKI). Methods: All patients who underwent surgical management of MLKI at two institutions between 2006 and 2020 were retrospectively identified and offered participation in the study. Patient reported outcomes were measured via three instruments: Lysholm Knee score, Multiligament Quality of Life (ML-QOL), and the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT). The postoperative outcomes and reoperation rates were compared between the internal bracing and non-internal bracing groups. Results: Fifty-two patients were analyzed; 34 were included in the IB group (17.6% female; age 33.1 ±1.60 years), and 18 were included in the non-IB group (11.1% female; age 34.1 ±3.72 years). Mean follow-up time of the entire cohort was 1.44 ± 0.22 years (IB: 1.21 ± 0.18; non-IB: 2.1 ±0.65). There were no significant differences between PROMIS CAT [PROMIS Pain (54.4 ±1.78 vs 51.7 ±1.70, p=0.319), Physical Function (44.3 ±2.27 vs 47.9 ±1.52, p=0.294), Mobility (44.0 ±1.71 vs 46.1 ±2.10, p=0.463)], ML-QOL [ML-QOL Physical Impairment (40.7 ±4.21 vs 41.7±5.10, p=0.884), Emotional Impairment (49.2 ±4.88 vs 44.7±5.87, p=0.579), Activity Limitation (43.5 ±4.56 vs 31.5±3.62, p=0.087), Societal Involvement (44.9 ±4.96 vs 37.5 ±5.30, p=0.345)] and Lysholm knee score (61.8 ±4.55 vs 61.0 ±4.95, p=0.916) postoperatively compared to the non-IB group. Conclusion: In this group of patients, function and patient-reported outcomes between patients treated with PCL reconstruction and repair without internal brace versus those with additional internal brace augmentation were not significantly different. Further research encompassing a larger patient sample is necessary to investigate the efficacy of the internal brace for PCL injury in the context of MLKI injuries.

Total Hip and Total Knee Arthroplasty Outpatient Case Volume During the 2020 COVID-19 Pandemic in New York and California.

BACKGROUND: Inpatient total hip and total knee arthroplasty were substantially impacted by the SARS-CoV-2 (COVID-19) pandemic. We sought to characterize the transition of total joint arthroplasty (TJA) to the outpatient setting in 2 large state health systems during this pandemic. METHODS: Adult patients who underwent primary elective TJA between January 1, 2016 and December 31, 2020 were retrospectively reviewed using the New York Statewide Planning and Research Cooperative System and California Department of Health Care Access and Information datasets. Yearly inpatient and outpatient case volumes and patient demographics, including age, sex, race, and payer coverage, were recorded. Continuous and categorical variables were compared using descriptive statistics. Significance was set at P < .05. RESULTS: In New York during 2020, TJA volume decreased 16% because 22,742 fewer inpatient TJAs were performed. Much of this lost volume (46.6%) was offset by a 166% increase in outpatient TJA. In California during 2020, TJA volume decreased 20% because 34,114 fewer inpatient TJAs were performed. Much of this lost volume (37%) was offset by a 47% increase in outpatient TJA. CONCLUSIONS: This present study demonstrates a marked increase in the proportion of TJA being performed on an outpatient basis in both California and New York. In both states, despite a decrease in overall TJA volume in 2020, outpatient TJA volume increased markedly. LEVEL OF EVIDENCE: Therapeutic Level IV, Retrospective Cohort Study.

Reporting Bias in the Form of Positive Spin Is Highly Prevalent in Abstracts of Systematic Reviews on Primary Repair of the Anterior Cruciate Ligament.

PURPOSE: To analyze reporting bias in the form of spin present in systematic reviews and meta-analyses on the topic of primary anterior cruciate ligament (ACL) repair. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed throughout this study. Peer-reviewed systematic reviews were collected from 3 databases (PubMed, Scopus, and SPORTDiscus), and their abstracts were assessed for the 15 most common types of spin. Articles were excluded if they were not published in English, had no evidence, were retracted, were published without an abstract, did not have full text available, or included cadaveric or nonhuman subjects. Full text quality was assessed using AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews Version 2). Fisher exact tests were used to examine associations between the different types of spin and other study characteristics such as AMSTAR 2 confidence rating, study design, and level of evidence. RESULTS: Spin was present in the abstracts of 13 of 15 articles (86.7%). There were significant associations between PRISMA adherence and lower incidences of spin types 3, 6, and 8 (P = .029 for each). A critically low AMSTAR 2 confidence rating was significantly associated with an increased incidence of spin type 9 (P = .01), and a higher AMSTAR 2 score was significantly associated with decreased spin type 4 and type 5 (P = .039 and P = .048, respectively). A more recent year of publication was correlated with a lower incidence of spin type 14 (P = .044). CONCLUSIONS: Spin is present in most systematic reviews and meta-analyses regarding primary repair of the ACL, with two-thirds of abstracts spinning evidence in favor of ACL repair. Standardized guidelines including the PRISMA guidelines and the AMSTAR 2 assessment tool were negatively correlated with spin. More recently published articles were found to contain significantly less spin, as were articles published in journals with higher Clarivate Impact Factors and Scopus CiteScores. LEVEL OF EVIDENCE: Level V, systematic review of Level III through V studies.

Evaluation of Spin in Systematic Reviews and Meta-Analyses of Minimally Invasive Surgical Techniques and Standard Microdiscectomies for Treating Lumbar Disc Herniation.

STUDY DESIGN: Systematic review. OBJECTIVES: Spin in scientific literature is defined as bias that overstates efficacy and/or underestimates harms of procedures undergoing review. While lumbar microdiscectomies (MD) are considered the gold standard for treating lumbar disc herniations (LDH), outcomes of novel procedures are being weighed against open MD. This study identifies the quantity and type of spin in systematic reviews and meta-analyses of LDH interventions. METHODS: A search was conducted on the PubMed, Scopus, and SPORTDiscus databases for systematic reviews and meta-analyses evaluating the outcomes of MD against other LDH interventions. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. Full texts were used in the assessment of study quality per AMSTAR 2. RESULTS: All 34 included studies were observed to have at least 1 form of spin, in either the abstract or full text. The most common type of spin identified was type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies"), which was observed in ten studies (10/34, 29.4%). There was a statistically significant association between studies not registered with PROSPERO and the failure to satisfy AMSTAR type 2 (P < .0001). CONCLUSION: Misleading reporting is the most common category of spin in literature related to LDH. Spin overwhelmingly tends to go in the positive direction, with results inappropriately favoring the efficacy or safety of an experimental intervention.

Harms reporting in randomized controlled trials underpinning the American Academy of Orthopaedic Surgeons clinical practice guidelines for glenohumeral osteoarthritis.

BACKGROUND: Glenohumeral osteoarthritis is one of the most common causes of shoulder pain. As such, the American Academy of Orthopaedic Surgeons (AAOS) has developed clinical practice guidelines (CPGs) to address the management of glenohumeral osteoarthritis. These CPG recommendations stem from the findings of randomized controlled trials (RCTs), which have been shown to influence clinical decision making and health policy. Therefore, it is essential that trial outcomes, including harms data (ie, adverse events), are adequately reported. We intend to evaluate the reporting quality of harms-related data in orthopedic literature specifically relating to AAOS CPG recommendations on the management of glenohumeral osteoarthritis. METHODS: We adhered to the Preferred Reporting Items for Systematic Reviews (PRISMA) as well as guidance for reporting meta-research. The AAOS CPGs for glenohumeral osteoarthritis were obtained from orthoguidelines.org, and 2 authors independently screened the guidelines for the RCTs referenced. A total of 14 studies were identified. Data were extracted from the 14 included studies independently by the same 2 authors. Adherence to the Consolidated Standards of Reporting Trials (CONSORT) Extension for Harms Checklist was assessed using an 18-item scoring chart, with 1 point being awarded for meeting a checklist item and 0 points being awarded for not meeting a checklist item. Descriptive statistics, such as frequencies, percentages, and 95% confidence intervals were used to summarize RCT adherence to the CONSORT checklist. RESULTS: The average score among the studies included was 7.36/18 items (39% adherence). No study adhered to all criteria, with the highest-performing study meeting 11 of 18 items (58%) and the lowest meeting 3 of 18 items (16%). A positive correlation between checklist score and year of publication was observed, with studies published more recently receiving a higher score on the CONSORT checklist (P < .05). Studies that disclosed funding information received a higher score than those that did not (P < .05), but there was no significant difference when the different funding sources were compared. Finally, double-blinded studies scored higher on the checklist than those with lower levels of blinding (single or no blinding, P < .05). CONCLUSION: Adverse events are poorly reported amongst RCTs cited as supporting evidence for AAOS Management of Glenohumeral Osteoarthritis CPGs, evidenced by a CONSORT checklist compliance rate of only 41% in this study. We recommend the development of an updated checklist with information that makes it easier for authors to recognize, evaluate, and report on harms data. Additionally, we encourage authors to include information about adverse events or negative outcomes in the abstract.

Tranexamic Acid Is Safe in Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty.

BACKGROUND: Tranexamic acid (TXA) is increasingly utilized during total knee arthroplasty (TKA) and total hip arthroplasty (THA) to decrease blood loss; however, there are concerns with regard to potential thromboembolic complications, particularly in high-risk patients. This study sought to define a subset of patients at elevated risk for thromboembolic complications following total joint arthroplasty (TJA) and to compare postoperative outcomes between patients who received TXA and those who did not. METHODS: Patients who underwent primary, elective TJA from 2015 to 2021 were identified in the Premier Healthcare Database. Patients with a history of venous thromboembolism, defined as a history of pulmonary embolism or deep vein thrombosis, were identified and formed the high-risk cohort. Patient demographic characteristics, hospital factors, patient comorbidities, antithrombotic medication use, perioperative blood transfusion, and 90-day complications were assessed and compared between patients who received TXA and those who did not. Univariate regression and multivariable regression were performed to account for potential confounders. RESULTS: The high-risk cohort comprised 70,759 patients who underwent TJA, of whom 46,074 (65.1%) received TXA and 24,685 (34.9%) did not. After controlling for confounding factors, patients in the TXA cohort had similar risks of pulmonary embolism (adjusted odds ratio [OR], 0.90 [95% confidence interval (CI), 0.79 to 1.02]; p = 0.097), stroke (adjusted OR, 0.97 [95% CI, 0.69 to 1.37]; p = 0.867), and myocardial infarction (adjusted OR, 0.93 [95% CI, 0.69 to 1.24]; p = 0.614) compared with patients who did not receive TXA. Patients who received TXA demonstrated decreased risks of transfusion (adjusted OR, 0.42 [95% CI, 0.38 to 0.46]; p < 0.001) and 90-day readmission (adjusted OR, 0.87 [95% CI, 0.80 to 0.94]; p < 0.001). CONCLUSIONS: TXA utilization was not associated with an increased risk of postoperative pulmonary embolism, stroke, or myocardial infarction in patients with a history of venous thromboembolism. Furthermore, patients who received TXA had a decreased risk of transfusion and readmission. This evidence suggests that TXA may be safely utilized among select high-risk patients. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Evaluation of spin in reviews of biodegradable balloon spacers for massive irreparable rotator cuff tears.

HYPOTHESIS: Clinical studies are often at risk of spin, a form of bias where beneficial claims are overstated while negative findings are minimized or dismissed. Spin is often more problematic in abstracts given their brevity and can result in the misrepresentation of a study's actual findings. The goal of this study is to aggregate primary and secondary studies reporting the clinical outcomes of the use of subacromial balloon spacers in the treatment of massive irreparable rotator cuff tears to identify the incidence of spin and find any significant association with study design parameters. MATERIALS AND METHODS: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Independent searches were completed on 2 databases (PubMed and Embase) for primary studies, systematic and current concepts reviews, and meta-analyses and the results were compiled. Two authors independently screened the studies using a predetermined inclusion criteria and aggregated data including titles, publication journals and years, authors, study design, etc. Each study was independently assessed for the presence of 15 different types of spin. Statistical analysis was conducted to identify associations between study characteristics and spin. RESULTS: Twenty-nine studies met the inclusion criteria for our analysis, of which 10 were reviews or meta-analyses and 19 were primary studies. Spin was identified in every study except for 2 (27/29, 93.1%). Type 3 spin, "Selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention" and type 9 spin, "Conclusion claims the beneficial effect of the experimental treatment despite reporting bias" were most frequently noted in our study, both observed in 12/29 studies (41.4%). Date of publication, and adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses or "The International Prospective Register of Systematic Reviews" were study characteristics associated with a higher rate of certain types of spin. There was a statistically significant association between disclosure of external study funding source and the presence of spin type 4, but none of the other forms of spin. CONCLUSION: Spin is highly prevalent in the abstracts of primary studies, systematic reviews, and meta-analyses discussing the use of subacromial balloon spacer technology in the treatment of massive irreparable rotator cuff tears. Our findings revealed that spin in the abstract tended to favor the balloon spacer intervention. Further efforts are required in the future to mitigate spin within the abstracts of published manuscripts.

Evaluation of Spin in Systematic Reviews on the Use of Tendon Transfer for Massive Irreparable Rotator Cuff Tears.

PURPOSE: To identify, describe and account for the incidence of spin in systematic reviews and meta-analyses of tendon transfer for the treatment of massive, irreparable rotator cuff tears (MIRCT). The secondary objective was to characterize the studies in which spin was identified and to determine whether identifiable patterns exist among studies with spin. METHODS: This study was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each abstract was assessed for the presence of the 15 most common types of spin derived from a previously established methodology. General data that were extracted included study title, authors, publication year, journal, level of evidence, study design, funding source, reported adherence to PRISMA guidelines, preregistration of the study protocol, and methodologic quality per A Measurement Tool to Assess Systematic Reviews Version 2 (AMSTAR 2). RESULTS: The search yielded 53 articles, of which 13 were included in the final analysis. Articles were excluded if they were not published in a peer reviewed journal, not written in English, utilized cadaveric or nonhuman models, or lacked an abstract with accessible full text. 53.8% (7/13) of the included studies contained at least 1 type of spin in the abstract. Type 5 spin ("The conclusion claims beneficial effect of the experimental treatment despite a high risk of bias in primary studies") was the most common, appearing in 23.1% (3/13) of included abstracts. Nine of the spin categories did not appear in any of the included abstracts. A lower AMSTAR 2 score was significantly associated with the presence of spin in the abstract (p<0.006). CONCLUSION: Spin is highly prevalent in the abstracts of systematic reviews and meta-analyses concerning tendon transfer for massive rotator cuff tears. A lower overall AMSTAR 2 rating was associated with a higher incidence of spin. Future studies should continue to explore the prevalence of spin in orthopedic literature and identify any factors that may contribute to its presence.

Evaluation of Spin in the Abstracts of Systematic Reviews and Meta-Analyses of Ulnar Collateral Ligament Reconstruction.

Purpose: To identify the quantity and types of spin present in systematic reviews and meta-analyses of ulnar collateral ligament reconstruction (UCLR) outcomes and to characterize the studies with spin to determine if any patterns exist. Methods: This study was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In August 2022, PubMed, Scopus, and SportDiscus databases were searched using the terms "ulnar collateral ligament reconstruction" AND "systematic review" OR "meta-analysis." Each abstract was assessed for the presence of the 15 most common types of spin derived from a previously established methodology. General data that were extracted included study title, authors, publication year, journal, level of evidence, study design, funding source, reported adherence to PRISMA guidelines, preregistration of the study protocol, and methodologic quality per A Measurement Tool to Assess Systematic Reviews Version 2 (AMSTAR 2). Results: In total, 122 studies were identified during the preliminary search, of which 19 met the inclusion criteria. Each study had at least 1 form of spin. The most common type of spin identified was type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") (7/19, 36.8%). AMSTAR type 9 ("Did the review authors use a satisfactory technique for assessing the RoB [risk of bias] in individual studies that were included in the review?") was associated with both a lower Clarivate Impact Factor (P = .001) and a lower Scopus CiteScore (P = .015). Studies receiving external funding were associated with the failure to satisfy AMSTAR type 3 ("Did the review authors explain their selection of the study designs for inclusion in the review?") (P = .047). Conclusions: Spin is highly prevalent in the abstracts of systematic reviews and meta-analyses that investigate the outcomes of UCLR. Clinical Relevance: Spin has been identified in peer-reviewed articles published on various topics, including many in orthopaedics. Systematic reviews and meta-analyses contain the most comprehensive evidence regarding a clinical question, so it is important to identify spin that may be included in these reports. Greater efforts are needed to ensure that the abstracts of papers accurately represent the results in the full text.

Delivery of Growth Factors to Enhance Bone Repair.

The management of critical-sized bone defects caused by nonunion, trauma, infection, malignancy, pseudoarthrosis, and osteolysis poses complex reconstruction challenges for orthopedic surgeons. Current treatment modalities, including autograft, allograft, and distraction osteogenesis, are insufficient for the diverse range of pathology encountered in clinical practice, with significant complications associated with each. Therefore, there is significant interest in the development of delivery vehicles for growth factors to aid in bone repair in these settings. This article reviews innovative strategies for the management of critical-sized bone loss, including novel scaffolds designed for controlled release of rhBMP, bioengineered extracellular vesicles for delivery of intracellular signaling molecules, and advances in regional gene therapy for sustained signaling strategies. Improvement in the delivery of growth factors to areas of significant bone loss has the potential to revolutionize current treatment for this complex clinical challenge.

Postoperative Complications Associated with Non-Steroidal Anti-Inflammatory Combinations Used Status-Post Total Hip and Knee Arthroplasty.

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in multimodal pain control following total joint arthroplasty (TJA). However, few studies have assessed the complications associated with the combinations of NSAIDs in this population despite the known risks associated with this class of medications. The Premier Healthcare Database was queried to identify adults who underwent primary total hip or knee arthroplasty from 2005-2014. The following most common inpatient combinations of NSAIDs were chosen for analysis: aspirin + celecoxib (A + C), toradol + aspirin (T + A), toradol + ibuprofen (T + I), celecoxib + ibuprofen (C + I), ibuprofen + aspirin (I + A), and toradol + celecoxib (T + C). Primary outcomes included acute kidney injury (AKI), gastrointestinal bleed, and stroke. Secondary outcomes included periprosthetic joint infection (PJI), deep vein thrombosis, and pulmonary embolism. Univariate and multivariate regression analyses were used to compare differences and address confounds. Overall, 195,833 patients were identified. After controlling for confounds, increased odds of AKI was associated with A + C (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.09-1.34, p < 0.001) and decreased odds was associated with T + A (aOR 0.76, 95% CI: 0.69-0.83, p < 0.001). Increased odds of stroke was associated with A + C (aOR: 1.80, 95% CI: 1.15-2.84, p = 0.011); T + I (aOR 3.48, 95% CI: 1.25-9.73, p = 0.017); and I + A (aOR 4.29, 95% CI: 1.06-17.9, p = 0.046). Increased odds of PJI was associated with C + I (aOR: 10.3, 95% CI: 1.35-78.3, p = 0.024). In the TJA patient population, NSAID pairings should be regarded as distinct entities. Our results suggest that combinations including A + C, T + I, I + A, and C + I should be used cautiously. With this knowledge, providers should consider tailoring NSAID prescriptions appropriately.

Management of Hand and Wrist Injuries in NCAA Division I Football Players From a Single Institution: Factors Associated With Epidemiology, Surgical Intervention, and Return to Play.

Background: Upper extremity injuries account for approximately 16.9% of football injuries in the National Collegiate Athletic Association (NCAA). Purpose: To determine the epidemiology, management, and outcomes of hand/wrist injuries in collegiate football athletes so as to identify factors associated with surgical intervention and delayed return to play (RTP). Study Design: Descriptive epidemiology study. Methods: We retrospectively reviewed hand/wrist injuries that occurred within a single NCAA Division I football team from January 1, 2003, to December 31, 2020. Data analyzed included player position, college seniority, injury characteristics, injury management, surgical procedures performed, and timing of RTP. A univariate analysis was performed to identify factors associated with increased risk for surgical intervention and delayed (>21 days) RTP after hand and wrist injury in this cohort. Results: Overall, 124 patients with 168 hand/wrist injuries were identified (9.9 wrist/hand injuries per year). Sprain of the thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) was the most common diagnosis (19.6%). Surgery was required in 22% of injuries, with injury of the UCL of the thumb MCP joint (8/37) being the most common indication. Injuries occurring during competitive games (odds ratio = 4.29; 95% CI, 1.2-15.9) were associated with an increased risk for surgery. Most (70%) injuries did not lead to time missed from football, whereas the remaining 30% resulted in an average of 33 ± 36 days missed. Conclusion: Over 17 athletic seasons, the annual incidence of hand and wrist injury in these NCAA Division I football players was 9.9 injuries per year, with 22% requiring surgical treatment. Injury to the UCL of the thumb MCP joint was the most common injury and indication for surgery, and 30% of injuries resulted in approximately 1 month lost. Injuries sustained in games were associated with operative management and delayed RTP.