Nerve Compression Syndromes of the Upper Extremity.

Nerve compression syndromes of the upper extremity are among the most common pathologies encountered in orthopaedic surgery. Symptoms can be debilitating for patients-affecting their work, activity level, sleep patterns, and overall quality of life. The community orthopaedic specialist should be familiar with the anatomy, etiology, and presentation of upper extremity nerve entrapment. Furthermore, knowledge of current evidence surrounding the management of these common syndromes can prove valuable for treating clinicians. Treatment ranges from nonsurgical (including medication and splinting) to surgical (when symptoms are severe). Although the gold standard treatment for nerve compression syndromes of the upper extremity is typically surgical release, nonsurgical methods should also be reviewed and understood because these can play an important role for patients as well. Community orthopaedic specialists should be well aware of the risks and complications associated with surgical releases.

Do You Really Need a Hand Surgeon? Distal Radius Fractures.

Distal radius fractures are one of the most common injuries treated by orthopaedic surgeons. As the number of distal radius fractures grows and practice patterns demonstrate more of these fractures are treated surgically, it is incumbent for orthopaedic surgeons to understand the fundamentals of evaluation, treatment, and rehabilitation.

Machine Learning for Predicting Lower Extremity Muscle Strain in National Basketball Association Athletes.

Background: In professional sports, injuries resulting in loss of playing time have serious implications for both the athlete and the organization. Efforts to quantify injury probability utilizing machine learning have been met with renewed interest, and the development of effective models has the potential to supplement the decision-making process of team physicians. Purpose/Hypothesis: The purpose of this study was to (1) characterize the epidemiology of time-loss lower extremity muscle strains (LEMSs) in the National Basketball Association (NBA) from 1999 to 2019 and (2) determine the validity of a machine-learning model in predicting injury risk. It was hypothesized that time-loss LEMSs would be infrequent in this cohort and that a machine-learning model would outperform conventional methods in the prediction of injury risk. Study Design: Case-control study; Level of evidence, 3. Methods: Performance data and rates of the 4 major muscle strain injury types (hamstring, quadriceps, calf, and groin) were compiled from the 1999 to 2019 NBA seasons. Injuries included all publicly reported injuries that resulted in lost playing time. Models to predict the occurrence of a LEMS were generated using random forest, extreme gradient boosting (XGBoost), neural network, support vector machines, elastic net penalized logistic regression, and generalized logistic regression. Performance was compared utilizing discrimination, calibration, decision curve analysis, and the Brier score. Results: A total of 736 LEMSs resulting in lost playing time occurred among 2103 athletes. Important variables for predicting LEMS included previous number of lower extremity injuries; age; recent history of injuries to the ankle, hamstring, or groin; and recent history of concussion as well as 3-point attempt rate and free throw attempt rate. The XGBoost machine achieved the best performance based on discrimination assessed via internal validation (area under the receiver operating characteristic curve, 0.840), calibration, and decision curve analysis. Conclusion: Machine learning algorithms such as XGBoost outperformed logistic regression in the prediction of a LEMS that will result in lost time. Several variables increased the risk of LEMS, including a history of various lower extremity injuries, recent concussion, and total number of previous injuries.

Corticosteroid Injections After Rotator Cuff Repair Improve Function, Reduce Pain, and Are Safe: A Systematic Review.

Purpose: To review the literature on postoperative corticosteroid injections (CSIs) following primary rotator cuff repair (RCR) to evaluate efficacy and adverse effects. Methods: A systematic review of the MEDLINE, EMBASE, and Cochrane databases were performed to identify all studies published within the last 15 years, which reported on outcomes of postoperative CSIs following RCR. Studies including patients who received only preoperative CSIs and revision RCRs were excluded. Included studies were evaluated for study methodology, patient demographics, outcome measures, physical examination parameters, results of imaging studies, and adverse effects or clinical complications. Results: Seven studies comprising 5,528 patients satisfied inclusion criteria. Among included patients, 54.8% were female and mean age range from 52.3 ± 13.0 to 62.7 ± 6.6 years. Only 1 included investigation was a Level I study. Overall, 4 of 5 studies reported significant improvements in pain and outcome scores (Constant score, American Shoulder and Elbow Surgeons score) compared with controls. Across all studies, the majority of these effects were statistically significant at 3 months postoperatively but not beyond this time point. Five of the 6 included investigations reported no increased rate of retears after postoperative CSIs. One study did find an increase in retear in patients receiving postoperative CSIs but was unable to determine whether these retears were present before the patient received the CSI. Another investigation reported an increased rate of infection only if the CSI was administered in the first postoperative month. Conclusions: Postoperative CSIs may improve pain and function for up to 3 months following primary RCR but not at later follow-up time points. CSIs should be administered only after the first postoperative month to minimize the potential risk for adverse events. Level of Evidence: Systematic review of level I-IV studies.

How Long Does It Take to Achieve Clinically Significant Outcomes After Isolated Biceps Tenodesis?

Background: Clinically significant outcomes (CSOs) connect patient-reported outcome measures data to patient-perceived benefit. Although investigators have established threshold values for various CSOs, the timeline to achieve these outcomes after isolated biceps tenodesis (BT) has yet to be defined. Purpose: To define the time-dependent nature of minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) achievement after isolated BT. Study Design: Case series; Level of evidence, 4. Methods: The American Shoulder and Elbow Surgeons score (ASES), the Single Assessment Numeric Evaluation, and the Constant-Murley score (CMS) were administered preoperatively and at 6 and 12 months postoperatively to patients undergoing isolated BT between 2014 and 2018 at our institution. Cumulative probabilities for achieving MCID, SCB, and PASS were calculated using Kaplan-Meier survival analysis. Weibull parametric regression evaluated the hazard ratios (HRs) of achieving earlier MCID, SCB, and PASS. Results: Overall cohort (N = 190) achievement rates ranged between 77.8% and 83.2% for MCID, between 42.2% and 80.2% for SCB, and between 59.7% and 62.9% for PASS. Median achievement time was 5.3 to 6.1 months for MCID, 5.9 to 6.4 months for SCB, and 6.07 to 6.1 months for PASS. Multivariate Weibull parametric regression identified older age, male sex, higher body mass index, preoperative thyroid disease, smoking history, and higher preoperative CMS as predictors of delayed CSO achievement (HR, 1.01-6.41), whereas normal tendon on arthroscopy, defined as absence of tenosynovitis or tendon tear on arthroscopy, predicted earlier CSO achievement (HR, 0.19-0.46). Location of tenodesis and worker compensation status did not significantly predict the time to achieve CSOs on multivariate analysis. Conclusion: After isolated BT, patients can expect to attain CSO by 13 months postoperatively, with most patients achieving this between 5 and 8 months. Patients tend to take longer to achieve PASS than MCID and SCB.

A Risk Stratification Nomogram to Predict Inpatient Admissions After Total Shoulder Arthroplasty Among Patients Eligible for Medicare.

The goal of this study was to establish a risk stratification nomogram to aid in determining the need for inpatient admission among patients who were eligible for Medicare and were undergoing primary total shoulder arthroplasty (TSA). The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients older than 65 years who underwent primary TSA between 2006 and 2016. The primary outcome measure was inpatient admission, as defined by hospital length of stay longer than 2 days. Multiple demographic, comorbid, and peri-operative variables were used in a multivariate logistic regression model to yield a risk stratification nomogram. A total of 1514 inpatient and 6020 out-patient admissions were analyzed. Age older than 80 years (odds ratio [OR], 2.69; P<.0001; 95% CI, 2.21-3.27), female sex (OR, 2.18; P<.0001; 95% CI, 1.90-2.51), dependent functional status (OR, 1.69; P<.0001; 95% CI, 1.2-2.38), dialysis (OR, 3.48; P=.029; 95% CI, 1.14-10.63), admission from an inpatient facility (OR, 1.76; P<.0001; 95% CI, 1.70-1.82), and inflammatory arthritis (OR, 1.69; P<.02; 95% CI, 1.25-13.78) were the greatest determinants of inpatient stay. The resulting predictive model showed acceptable discrimination and calibration. Our model enabled reliable and straightforward identification of the most suitable candidates for inpatient admission among patients who were eligible for Medicare and were undergoing primary TSA. Patients who were receiving dialysis, who had dyspnea at rest, and who had bleeding disorders were more likely to be admitted as inpatients after TSA. Larger multicenter studies are necessary to externally validate the proposed predictive nomogram. [Orthopedics. 2022;45(1):43-49.].

Delaying ACL reconstruction beyond 6 months from injury impacts likelihood for clinically significant outcome improvement.

BACKGROUND: The effect of surgical latency on outcomes of anterior cruciate ligament reconstruction (ACLR) is a topic that is heavily debated. Some studies report increased benefit when time from injury to surgery is decreased while other studies report no benefit. The purpose of our analysis was to compare achievement of clinically significant outcomes (CSOs) in patients with greater than six months of time from injury to ACLR to those with less than or equal to six months of time to surgery. METHODS: Patients undergoing primary ACLR between January 2017 and January 2018 with minimum one year follow-up were included. International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were collected. Multivariate logistic regression was performed for outcome achievement and risk of revision ACLR and Weibull parametric survival analysis was performed for relative time to outcome achievement. The level of significance was set at α = 0.05. RESULTS: 379 patients were included of which, 140 patients sustained ACL injury greater than six months prior to surgery. This group of patients experienced reduced likelihood to achieve patient-acceptable symptomatic state (PASS) on the IKDC (p = 0.03), KOOS Pain (p = 0.01) and a greater likelihood to undergo revision ACLR (p = 0.001). There was no impact of surgical timing on minimal clinically important difference (MCID). CONCLUSION: Patients with greater than 6 months from injury to ACLR reported reduced likelihood to achieve CSOs, delayed achievement of CSOs, and increased rates of revision surgery.

Isolated Biceps Tenodesis and Tenotomy: A Systematic Review of Indications and Patient Satisfaction.

Biceps tenodesis and tenotomy are increasingly being used as treatment options for shoulder pathology, but patient satisfaction remains largely unstudied. A systematic review of the MEDLINE database was conducted to identify clinical outcome studies on isolated biceps tenodesis or tenotomy that reported patient satisfaction. Within the 15 investigations that were included, the indication for tenotomy was rotator cuff pathology, whereas the indication for tenodesis was biceps pathology or type 2 superior labral tear from anterior to posterior. Patients undergoing tenotomy were 13.6 years older than those undergoing tenodesis (P<.001). Patient satisfaction was high following both procedures, at 85.6% following tenotomy and 92.3% following tenodesis. [Orthopedics. 2021;44(6):333-340.].

How can we define clinically important improvement in pain scores after biceps tenodesis?

BACKGROUND: Patient postoperative pain is an important consideration following biceps tenodesis. The visual analog scale (VAS) for pain is one of the most commonly used measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain. PURPOSE: To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing open subpectoral (OSPBT) or arthroscopic suprapectoral biceps tenodesis (ASPBT) at 1 year from surgery; and to identify preoperative predictors of achieving each outcome end point. METHODS: Data from consecutive patients who underwent isolated biceps tenodesis between January 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome (PRO) scores were recorded at 1 year postoperatively. In order to quantify the clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated. RESULTS: A total of 165 patients were included in the final analysis. The VAS pain score threshold for achieving MCID was defined as a decrease of 12.9 (0-100). PASS was defined as achieving a 2-year postoperative score of 27.4 points (0-100), and SCB was defined as a decrease of 25.1 (0-100) at 1-year follow-up. The rates of achieving MCID, PASS, and SCB were 73.3%, 52.8%, and 45.9%, respectively. Multivariate regression analysis demonstrated that ASPBT (P = .01) and a lower preoperative Constant-Murley score were predictive of achieving the MCID (P = .01). In contrast, a lower preoperative score on the SF-12 Physical Component Summary (P = .01) and a higher score on the preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) were predictive of achieving the SCB and PASS, respectively. Preoperative duration of symptoms >6 months was predictive of a reduced likelihood to achieve PASS. CONCLUSION: This study identified scores for VAS pain that can be used to define clinically significant outcome after biceps tenodesis. Specifically, a decrease in pain score of 12.9 was a clinically important improvement in VAS pain, whereas a decrease of 25.1 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.

Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials.

PURPOSE: To determine which interventions optimize clinical outcomes in adhesive capsulitis by performing a network meta-analysis of randomized controlled trials. METHODS: A systematic review was conducted of all clinical trials on adhesive capsulitis published since 2008. Patient cohorts were grouped into treatment categories; data collected included range of motion (ROM) and patient-reported outcome measures (PROMs). Interventions were compared across groups by means of arm-based Bayesian network meta-analysis in a random-effects model. RESULTS: Sixty-six studies comprising 4042 shoulders (57.6% female patients, age 54.8 ± 3.2 years [mean ± standard deviation]) were included. The most commonly studied interventions were physical therapy (PT) or shoulder injections. Network meta-analysis demonstrated that arthroscopic surgical capsular release was the most effective treatment in increasing ROM. This effect was apparent in forward flexion (effect difference [ED] versus placebo, 44°, 95% confidence interval [CI] 31° to 58°), abduction (ED 58°, 45° to 71°), internal rotation (ED 34°, 24° to 44°), and external rotation (ED 59°, 37° to 80°). Interventions most effective for pain relief included PT supplemented with either medical therapy (ED -4.50, -9.80 to 2.80) or ultrasound therapy (ED -5.10, -5.10 to -1.40). Interventions most effective for improvement of functional status included PT, manipulation under anesthesia (MUA), intra-articular or subacromial steroid injection, surgical capsular release, and supplementation of PT with alternative therapy. CONCLUSIONS: No one treatment emerged superior in regard to ROM, pain symptoms, and functional status. Surgery (after failure of conservative treatment) ranked highest across all ROM domains. Treatments that ranked highest for treatment of pain included PT supplemented with either medical therapy or ultrasound. Finally, treatments that ranked highest for improvements in functional status included MUA, PT with medical therapy, surgical intervention, PT with ultrasound, PT with injection, and injection alone. LEVEL OF EVIDENCE: II, systematic review and network meta-analysis of level I and II studies.

Maximal Medical Improvement Following Shoulder Stabilization Surgery May Require up to 1 Year: A Systematic Review.

BACKGROUND: There is increased emphasis on properly allocating healthcare resources to optimize value within orthopedic surgery. Establishing time to maximal medical improvement (MMI) can inform clinical decision-making and practice guidelines. PURPOSE: We sought (1) to evaluate the time to MMI as predicted by commonly used patient-reported outcome measures (PROMs) for evaluation of shoulder stabilization and (2) to evaluate typical time to return to sports and employment following surgery. METHODS: A systematic review of the Medline database was conducted to identify outcome studies reporting sequential follow-up at multiple time points, up to a minimum of 2 years after shoulder stabilization surgery. The included studies examined the outcomes of arthroscopic or open surgical techniques on anterior instability. Clinically significant improvements were evaluated utilizing the minimal clinically important difference specific to each PROM. Secondary outcomes included range of motion, return to sport/work, and recurrent instability. RESULTS: Ten studies comprising 590 surgically managed cases of anterior shoulder instability were included (78% arthroscopic, 22% open). Clinically significant improvements in PROMs were achieved up to 1 year post-operatively for Rowe, Western Ontario Instability Index (WOSI), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) scores. For the three most utilized tools (Rowe, WOSI, ASES), the majority of improvement occurred in the first 6 post-operative months. Clinically significant improvements in Constant Score and Oxford Shoulder Instability Score (OSIS) were achieved up to 6 months and 2 years after surgery, respectively. No clinically significant improvements were achieved on the Disabilities of the Arm, Shoulder, and Hand (DASH) tool. CONCLUSION: Maximal medical improvement as determined by commonly utilized PROMs occurs by 1 year after operative management of anterior shoulder instability. The DASH tool does not appear to demonstrate a reliable time frame for clinically significant outcome improvement.

Influence of workers' compensation status on postoperative outcomes in patients following biceps tenodesis: a matched-pair cohort analysis.

BACKGROUND AND HYPOTHESIS: Although the literature on the association of workers' compensation (WC) status with negative outcomes after orthopedic surgery is extensive, there is a paucity of evidence on outcomes in WC recipients undergoing biceps tenodesis. We hypothesized that WC patients would report significantly worse outcomes postoperatively on patient-reported outcome measures (PROMs). METHODS: Functional and health-related quality-of-life PROMs and a visual analog scale score for pain were administered preoperatively and at 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018 at our institution. Thirty-eight WC patients were matched 1:2 to non-WC patients by age, body mass index, and operative limb. The minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state were calculated for all patients via anchor- and distribution-based methods. Rates of achievement and the likelihood of achievement were determined. RESULTS: All patients showed significant improvements in all outcome measures (P < .001). WC patients reported inferior postoperative scores on all PROMs examined. WC status significantly predicted a reduced likelihood of achieving substantial clinical benefit for the American Shoulder and Elbow Surgeons score (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.17-0.81; P = .01) and the patient acceptable symptom state (OR, 0.28; 95% CI, 0.12-0.65; P = .003) for the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (OR, 0.24; 95% CI, 0.10-0.61; P = .003), Constant-Murley Subjective Assessment (OR, 0.25; 95% CI, 0.08-0.77; P = .016), and visual analog scale pain score (OR, 0.27; 95% CI, 0.16-0.47; P < .001). CONCLUSION: WC patients reported inferior scores on all postoperative PROMs and demonstrated lower odds of achieving substantial benefit and satisfaction regarding improvements in both function and pain compared with non-WC patients.

Performance of PROMIS Physical Function, Pain Interference, and Depression Computer Adaptive Tests Instruments in Patients Undergoing Meniscal Surgery.

PURPOSE: To compare the performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PIF), and depression computer adaptive tests (CAT) relative to legacy instruments in patients undergoing meniscal surgery. METHODS: Patients scheduled to undergo meniscal surgery completed legacy knee function PROMs (International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score [KOOS] subscores), Marx Activity Rating Scale (MARS), Veterans-Rand 12 (VR12), Short Form 12 (SF12), and the Brief Resilience Scale (BRS) alongside PROMIS PF, PIF, and Depression preoperatively. Spearman rank correlations were calculated, and score distributions were examined for floor and ceiling effects. RESULTS: 152 patients (46.6 ± 14.9 years, 67.1% male) completed PROMs for appropriate inclusion. PROMIS PF yielded high-moderate to high correlations with the IKDC and KOOS subscales (r = 0.61 to 0.73), demonstrating similar performance to the IKDC. PROMIS PIF demonstrated moderately high-moderate to high correlations with the IKDC, KOOS subscales, VR-12 Physical Component Score (PCS), and SF12 PCS (r = 0.62 to 0.71), performing comparably to KOOS Pain (r = 0.55 to 0.92). PROMIS Depression demonstrated moderate to high-moderate correlations with the mental health legacies (r = 0.46 to 0.66). Significant ceiling effects were observed for MARS (n = 29, 18.8%), and significant floor effects were exhibited by PROMIS Depression (n = 38, 25%) and MARS (n = 27, 17.6%). CONCLUSION: The PROMIS PF, PIF CAT, and Depression instruments exhibit comparable performance profiles relative to legacy knee PROMs. PROMIS PF and PIF demonstrated no floor and ceiling effects, whereas PROMIS Depression exhibited a significant relative floor effect. PROMIS PF and PIF may be appropriately used to establish functional baselines preoperatively. LEVEL OF EVIDENCE: IV, diagnostic case series.

Accelerometer-Based, Computer-Navigated Total Knee Arthroplasty to Correct a Complex Deformity in a Patient With Multiple Hereditary Exostoses.

BACKGROUND: Accelerometer-based computer-assisted navigation systems (ABCANSs) have been shown to improve alignment accuracy in total knee arthroplasty (TKA) and are effective in treating complex extra-articular deformity. We present an ABCANS-assisted TKA performed in a 68-year-old male with end-stage arthritis of the right knee, in the setting of a severe valgus deformity secondary to multiple hereditary exostoses. METHODS: The KneeAlign 2 system (OrthAlign, Inc.; Aliso Viejo, CA) was used to perform the TKA in this clinical scenario, given its functionality, which allows angular correction to be tailored to a given deformity, and its reported accuracy in performance of bony resection in TKA. The patient was prospectively followed up for one year postoperatively. Radiographs, PROMs, and patient satisfaction were reported. RESULTS: After the ABCANS-assisted TKA, the patient's alignment was improved from 25° to 4° of valgus. His final range of motion was 0-135° without an instability. In addition, the patient reported excellent scores on multiple joint-specific outcome measures, including the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, the Forgotten Joint Score, and the Oxford Knee Score. CONCLUSION: This case report illustrates the rationale, technique, and the excellent clinical outcomes achieved in a complex patient with extra-articular deformity using an ABCANS-assisted TKA.

Influence of mental health on postoperative outcomes in patients following biceps tenodesis.

PURPOSE: To evaluate the relationship between preoperative mental health measured by the Short-Form 12 health survey mental component score and outcomes after isolated biceps tenodesis. METHODS: The American Shoulder and Elbow Surgeons form (ASES), Single Assessment Numeric Evaluation (SANE), Constant-Murley score (CMS), and visual analog scale (VAS) for pain were administered preoperatively and at 6 and 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018. Minimal clinically important difference, substantial clinical benefit (SCB), patient-acceptable symptom state (PASS), and rates of achievement were calculated. Patients were stratified by mental health status based on preoperative scores on the Short-Form 12 health survey mental component score. Multivariate logistic regression was performed to evaluate preoperative mental health status on achievement of minimal clinically important difference, SCB, and PASS. RESULTS: Patients demonstrated significant improvements in all outcome measures (P < .001). Patients with depression reported inferior postoperative scores on all patient-reported outcome measures. Low preoperative mental health score significantly predicted reduced likelihood to achieve SCB (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.17-0.81, P = .01) and PASS (OR: 0.28, 95% CI: 0.12-0.65, P = .003) on the ASES form, SANE (OR: 0.24, 95% CI: 0.10-0.61, P = .003), CMS (OR: 0.25, 95% CI: 0.08-0.77, P = .016), and VAS pain (OR: 0.01, 95% CI: 0.00-0.31, P = .008). CONCLUSION: Patients with depression reported inferior scores on all postoperative patient-reported outcome measures and demonstrated lower odds of achieving the SCB and PASS on the ASES form and PASS on the SANE, CMS, and VAS pain, compared with nondepressed patients.

Big Data in Total Shoulder Arthroplasty: An In-depth Comparison of National Outcomes Databases.

INTRODUCTION: The practice of identifying trends in surgical decision-making through large-scale patient databases is commonplace. We hypothesize that notable differences exist between claims-based and prospectively collected clinical registries. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), a prospective surgical outcomes database, and PearlDiver (PD), a claims-based private insurance database, for patients undergoing primary total shoulder arthroplasties from 2007 to 2016. Comorbidities and 30-day complications were compared. Multiple regression analysis was performed for each cohort to identify notable contributors to 30-day revision surgery. RESULTS: Significant differences were observed in demographics, comorbidities, and postoperative complications for the age-matched groups between PD and NSQIP (P < 0.05 for all). Multiple regression analysis in PD identified morbid obesity and dyspnea to lead to an increased risk for revision surgery (P = 0.001) in the <65 cohort and dyspnea and diabetes to lead to an increased risk for revision surgery in the ≥65 cohort (P = 0.015, P < 0.001). Multiple regression did not reveal any risk factors for revision surgery in the <65 age group for the NSQIP; however, congestive heart failure was found to have an increased risk for revision surgery in the ≥65 cohort (P < 0.001). CONCLUSIONS: Notable differences in comorbidities and complications for patients undergoing primary total shoulder arthroplasty were present between PD and NSQIP. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

Inpatient admission following anterior cruciate ligament reconstruction is associated with higher postoperative complications.

PURPOSE: To compare the occurrence of short-term postoperative complications between inpatient and outpatient anterior cruciate ligament reconstruction. METHODS: The ACS National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) from 2007 to 2017. A total of 18,052 patients were available for analysis following application of exclusion criteria. Patients were categorized based on location of surgery. Inpatients and outpatient ACLR groups were matched by demographics and preoperative laboratory values and differences in 30-day complication rates following surgery were assessed. Significance was set with alpha < 0.05. RESULTS: From 2007 to 2017, there was an increasing frequency for outpatient ACLR (p < 0.001), while the incidence of inpatient ACLR remained largely constant (n.s). Groups were matched to include 1818 patients in each cohort. Within the first 30 days of surgery, patients in the inpatient ACLR group experienced significantly greater rates of superficial incisional SSI (0.6% vs 0.1%, p = 0.026) and composite surgical complications (0.6% vs 0.2%, p = 0.019), as well as a greater rate of reoperation (0.7% vs 0.2%, p = 0.029). Inpatient procedures also demonstrated a greater rate of deep surgical incisional SSI (0.2% vs 0.0%, n.s) and readmission to hospital (0.8% vs 0.7%, n.s).Outpatient ACLR procedures were also associated with a significantly greater relative value unit (RVU)/h compared with inpatient ACLRs (0.17 vs 0.14, p < 0.001). CONCLUSIONS: Inpatient ACLR may have an increased risk of postoperative complications compared to outpatient ACLR during the short-term postoperative period. Although some patients may require admission post-operatively for medical and/or pain management, doing so is not necessarily without a degree of risk. LEVEL OF EVIDENCE: III.

Perioperative Opioid Use Predicts Postoperative Opioid Use and Inferior Outcomes After Shoulder Arthroscopy.

PURPOSE: The purpose of this study is to define the impact of preoperative opioid use on postoperative opioid use, patient-reported outcomes, and revision rates in a cohort of patients receiving arthroscopic shoulder surgery. METHODS: Patients who underwent shoulder arthroscopy were identified from an institutional database. Inclusion criteria were completion of preoperative and postoperative patient-reported outcome measures (PROMs) at 1-year follow-up and completion of a questionnaire on use of opioids and number of pills per day. Outcomes assessed included postoperative PROM scores, postoperative opioid use, persistent pain, and achievement of the patient acceptable symptomatic state. A matched cohort analysis was performed to evaluate the impact of opioid use on achievement of postoperative outcomes, whereas a multivariate regression was performed to determine additional risk factors. Receiver operating characteristic curves were used to establish threshold values in oral morphine equivalents (OMEs) that predicted each outcome. RESULTS: A total of 184 (16.3%) patients were included in the opioid use (OU) group and 1,058 in the no opioid use (NOU) group. The OU and NOU groups showed statistically significant differences in both preoperative and postoperative scores across all PROMs (P < .001). Multivariate logistic regression identified preoperative opioid use as a significant predictor of reduced achievement of the patient acceptable symptomatic state (odds ratio [OR], 0.69, 95% confidence interval [CI], 0.29-0.83, P = .008), increased likelihood of endorsing persistent pain (OR, 1.73, 95% CI, 1.17-2.56, P = .006), and increased opioid use at 1 year (OR, 21.3, 95% CI, 12.2-37.2, P < .001). Consuming a high dosage during the perioperative period increased risk of revision surgery (OR, 8.59, 95% CI, 2.12-34.78, P < .003). Results were confirmed by matched cohort analysis. Receiver operating characteristic analysis found that total OME >1430 mg/d in the perioperative period (area under the curve, 0.76) and perioperative daily OME >32.5 predicted postoperative opioid consumption (area under the curve, 0.79). CONCLUSIONS: Patients with a history of preoperative opioid use can achieve significant improvements in patient-reported outcomes after arthroscopic shoulder surgery. However, preoperative opioid use negatively impacts patients' level of satisfaction and is a significant predictor of pain and continued opioid usage. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Dynamic Three-Dimensional Computed Tomography Mapping of Isometric Posterior Cruciate Ligament Attachment Sites on the Tibia and Femur: Single- Versus Double-Bundle Analysis.

PURPOSE: (1) To determine the area of posterior cruciate ligament (PCL) insertion sites on the lateral wall of the medial femoral condyle (LWMFC) that demonstrates the least amount of length change through full range of motion (ROM) and (2) to identify a range of flexion that would be favorable for graft tensioning for single-bundle (SB) and double-bundle (DB) PCL reconstruction. METHODS: Six fresh-frozen cadaveric knees were obtained. Three-dimensional computed tomography point-cloud models were obtained from 0° to 135°. A point grid was placed on the LWMFC and the tibial PCL facet. Intra-articular length was calculated for each point on the femur to the tibia at all flexion angles and grouped to represent areas for bone tunnels of SB and DB PCLR. Normalized length changes were evaluated. RESULTS: Femoral tunnel location and angle of graft fixation were significant contributors to mean, minimum, and maximum normalized length of the PCL (all p < .001). Tibial tunnel location was not significant in any case (all p < .22). A femoral tunnel in the location of the posteromedial bundle of the PCL resulted in the least length change at all tibial positions (maximum change 13%). Fixation of the anterolateral bundle in extension or at 30° flexion resulted in significant overconstraint of the PCL graft. The femoral tunnel location for a SB PCLR resulted in significant laxity at lower ranges of flexion. CONCLUSION: PCL length was significantly dependent on femoral tunnel position and angle of fixation, whereas tibial tunnel position did not significantly contribute to observed differences. All PCL grafts demonstrated anisometry, with the anterolateral bundle being more anisometric than the posteromedial bundle. For DB PCLR, the posteromedial bundle demonstrated the highest degree of isometry throughout ROM, although no area of the LWMFC was truly isometric. The anterolateral bundle should be fixed at 90° to avoid overconstraint, and SB PCLR demonstrated significant laxity at lower ranges of flexion. CLINICAL RELEVANCE: Surgeons can apply the results of this investigation to surgical planning in PCLR to optimize isometry, which may ultimately reduce graft strain and the risk of graft failure. Additionally, DB PCLR demonstrated superiority compared with SB PCLR regarding graft isometry, as significant laxity was encountered at lower ranges of flexion in SB PCLRs. Fixation of the ALB at 90° flexion should be performed to avoid overconstraint in knee extension.

Adverse Impact of Corticosteroids on Rotator Cuff Tendon Health and Repair: A Systematic Review of Basic Science Studies.

PURPOSE: To evaluate the in vitro effects of corticosteroid injections (CSIs) on rotator cuff tendon (RCT). METHODS: A systematic review of the MEDLINE database was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for all studies reporting on adverse biochemical and biomechanical effects of CSIs on RCT. RESULTS: Sixteen studies were identified that had been published in the last 15 years on the effects of corticosteroids on RCTs. Eight of these studies were on human RCTs, 6 were on rat tendons, 1 considered both human and rat tendons, and 1 was on dog tendon. Five studies analyzed the effects of corticosteroids on the biomechanical properties of RCT or rotator cuff repair, whereas the remaining observed the cellular and molecular effects of CSIs on RCT. Corticosteroids suppress an inflammatory response, induce apoptosis, and have negative effects on collagen and tendon cell viability in RCTs. The mechanical properties, including load to failure of RCTs and rotator cuff repair anchor pull-out strength, also are decreased by CSIs. These in vitro effects appear to be transient as well as frequency and dose dependent. CONCLUSIONS: On a molecular level, CSIs decrease cellular proliferation, alter collagen and extracellular matrix composition, impede inflammatory pathways, decrease cellular viability, increase adipocyte differentiation, and increase apoptosis. These changes can be seen as early as 24 hours after corticosteroid exposure, last as long as 2 to 3 weeks, and are exacerbated by increased doses and decreased latency between doses. Biomechanical studies demonstrate that these changes result in decreased maximal load to failure, tendon stiffness, and suture anchor pull-out strength in rat shoulders up to 2 weeks but not at 3 and 4 weeks, post-CSI. CLINICAL RELEVANCE: Shoulder subacromial steroid injection is common, and practitioners should be aware of results both positive and deleterious.