Distinct risk profiles for short-term surgical complications and venous thromboembolism exist among extensor mechanism repair procedures.

PURPOSE: Extensor mechanism injuries, which comprise patella fractures, patella tendon tears and quadriceps tendon tears, are severely debilitating injuries and a common cause of traumatic knee pathology that requires surgical intervention. Risk factors for short-term surgical complications and venous thromboembolism (VTE) in this population have not been well characterised. The aim of this study was to identify perioperative risk factors associated with these short-term complications. METHODS: The National Surgical Quality Improvement Program database was used to identify patients who underwent an isolated, primary extensor mechanism repair from 2015 to 2020. Patients were stratified by injury type. Demographic data were collected and compared. A multivariate logistic regression was used to control for demographic and comorbid factors while assessing risk factors for developing short-term complications. RESULTS: A total of 8355 patients were identified for inclusion in this study. Overall, 3% of patients sustained short-term surgical complications and 1% were diagnosed with VTE within 30 days of surgery. Patella fracture fixation had a nearly twofold higher risk for surgical complications compared to quadriceps tendon repair (p = 0.004). Patella tendon repair had a twofold higher risk for VTE (p = 0.045), specifically deep vein thrombosis (p = 0.020), compared to patella fracture fixation. Increasing age, smoking and American Society of Anesthesiologists Classifications 3 and 4 were also found to be risk factors for surgical complications (p = 0.012, p = 0.004, p = 0.011 and p = 0.032, respectively). CONCLUSION: This study used a nationally representative, widely validated, peer-reviewed database to provide valuable insights into risk factors for short-term postoperative complications associated with extensor mechanism repair procedures, revealing notable differences in risk profiles among distinct surgical procedures. The results of this study will inform surgeons and patients in enhancing risk assessment, guiding procedure-specific decision-making, optimising preoperative care, improving postoperative monitoring and contributing to future research of extensor mechanism injuries. LEVEL OF EVIDENCE: Level III.

Most Publications Regarding Platelet-Rich Plasma Use in the Knee Are From Asia, Investigate Injection for Osteoarthritis, and Show Outcome Improvement: A Scoping Review.

PURPOSE: To evaluate and synthesize the available literature related to platelet-rich plasma (PRP) treatment of knee pathologies and to provide recommendations to inform future research in the field. METHODS: PubMed, CINAHL, and Scopus databases were queried on October 6, 2023. All identified citations were collated and uploaded into Covidence for screening and data extraction. Studies were included if they were human studies published in English with adult cohorts that received PRP as a procedural injection or surgical augmentation for knee pathologies with patient-reported outcome measures (PROMs) and level of evidence Levels I-IV. RESULTS: Our search yielded 2,615 studies, of which 155 studies from 2006 to 2023 met the inclusion criteria. Median follow-up was 9 months (±11.2 months). Most studies (75.5%) characterized the leukocyte content of PRP, although most studies (86%) did not use a comprehensive classification scheme. In addition, most studies were from Asia (50%) and Europe (32%) and were from a single center (96%). In terms of treatment, 74% of studies examined PRP as a procedural injection, whereas 26% examined PRP as an augmentation. Most studies (68%) examined treatment of knee osteoarthritis. Many studies (83%) documented significant improvements in PROMs, including 93% of Level III/IV evidence studies and 72% of Level I/II evidence studies, although most studies (70%) failed to include minimal clinically important difference values. The visual analog scale was the most-used PROM (58% of studies), whereas the Short Form Health Survey 36-item was the least-used PROM (5% of studies). CONCLUSIONS: Most published investigations of knee PRP are performed in Asia, investigate procedural injection for osteoarthritis, and show significant outcome improvements. In addition, this review highlights the need for better classification of PRP formulations. LEVEL OF EVIDENCE: Level IV, scoping Review of level I-IV studies.

High Tibial Osteotomy in Knee Reconstruction and Joint Preservation.

High tibial osteotomy is a dynamic operation, used as an effective procedure in both joint preservation and knee stability. Applications and indications are expanding, with good results in the treatment of malalignment associated with arthrosis, knee instability, meniscus deficiency or transplants, and/or cartilage restoration. Appropriate patient selection and preoperative planning are critical to achieving good outcomes after surgery. Coronal and sagittal plane corrections made through the proximal tibia can effectively alter joint mechanics creating a more favorable environment for cartilage, meniscus, and ligamentous structures about the knee. Advancing techniques and technologies have allowed for more precise planning and execution of osteotomies.

Tape-Reinforced Graft Suturing and Retensioning of Adjustable-Loop Cortical Buttons Improve Quadriceps Tendon Autograft Biomechanics in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study.

PURPOSE: To investigate the biomechanical effects of tape-reinforced graft suturing and graft retensioning for all-soft tissue quadriceps tendon (ASTQT) anterior cruciate ligament reconstruction (ACLR) in a full-construct human cadaveric model. METHODS: Harvested cadaveric ASTQT grafts were assigned to either (1) double-suspensory adjustable-loop cortical button device (ALD) fixation in which both graft ends were fixed with a suspensory fixation device with (n = 5) or without (n = 5) tape-reinforced suturing or (2) single-suspensory distal tendon fixation in which only the patellar end was fixed with an ALD (n = 5) or fixed-loop cortical button device (FLD) (n = 5). All specimens were prepared using a No. 2 whipstitch technique, and tape-reinforced specimens had an integrated braided tape implant. Graft preparation time was recorded for double-suspensory constructs. Samples were tested on an electromechanical testing machine using a previously published protocol simulating rehabilitative kinematics and loading. RESULTS: Tape-reinforced graft suturing resulted in greater graft load retention after cycling (11.9% difference, P = .021), less total elongation (mean [95% confidence interval (CI)], 5.57 mm [3.50-7.65 mm] vs 32.14 mm [25.38-38.90 mm]; P < .001), greater ultimate failure stiffness (mean [95% CI], 171.9 N/mm [158.8-185.0 N/mm] vs 119.4 N/mm [108.7-130.0 N/mm]; P < .001), and less graft preparation time (36.4% difference, P < .001) when compared with unreinforced specimens. Retensioned ALD constructs had less cyclic elongation compared with FLD constructs (mean total elongation [95% CI], 7.04 mm [5.47-8.61 mm] vs 12.96 mm [8.67-17.26 mm]; P = .004). CONCLUSIONS: Tape-reinforced graft suturing improves time-zero ASTQT ACLR construct biomechanics in a cadaveric model with 83% less total elongation, 44% greater stiffness, and reduced preparation time compared with a whipstitched graft without tape reinforcement. ALD fixation improves construct mechanics when compared with FLD fixation as evidenced by 46% less total elongation. CLINICAL RELEVANCE: Tape-reinforced implants and graft retensioning using ALDs improve time-zero ACLR graft construct biomechanics in a time-zero biomechanical model. Clinical studies will be necessary to determine whether these implants improve clinical outcomes including knee laxity and the incidence of graft rupture.

Quadriceps tendon autograft has similar clinical outcomes when compared to hamstring tendon and bone-patellar tendon-bone autografts for revision ACL reconstruction: a systematic review and meta-analysis.

PURPOSE: Research regarding revision anterior cruciate ligament reconstruction (RACLR) with quadriceps tendon (QT) autografts is lacking. The purpose of this study was to perform a systematic review and meta-analysis of RACLR with QT and compare its patient outcomes to RACLR with hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts. METHODS: Adhering to PRISMA guidelines, a search for studies using QT in RACLR was performed within PubMed, Scopus, and CINAHL from database date of inception through December 26, 2022. Primary outcomes sought included: failure rate, Lysholm scores, International Knee Documentation Committee (IKDC) scores, IKDC grades, arthrometric knee side-to-side differences (STSD), pivot shift grade, donor site morbidity, return to sport, visual analog scale (VAS) pain scores. RESULTS: Nine studies were included consisting of 606 RACLR: 349 QT, 169 HT, and 88 BTB. Overall failure rates were 7.6% QT, 13.3% HT, and 8.7% BTB. Mean weighted Lysholm scores were 85.8 ± 3.8 QT, 82.5 ± 3.8 HT and 86.6 ± 4.5 BTB. IKDC average scores were 82.3 ± 1.6 QT, 80.1 ± 1.7 HT, and 81.7 ± 5.5BTB. Combined rates of IKDC A/B grades were 88.4% and 80.0% for QT and HT, respectively. VAS average scores were 0.9 ± 1.1 QT, 1.4 ± 0.2 HT, and 0.7 ± 0.8 for BTB. Side-to-side difference was reported for QT and HT with average values of 1.7 ± 0.6 mm and 2.1 ± 0.5 mm, respectively. Grade 0 or 1 pivot shifts were reported in 96.2% of QT patients and 91.3% of HT. Donor site morbidity, only reported for QT and HT, was 14.6 ± 9.7% and 23.6 ± 14.1%, respectively. QT resulted in a mean Tegner score of 5.9 ± 1.5 versus HT 5.7 ± 1.5. Rate of return to pivoting sports was 38.0% QT, 48.6% HT, and 76.9% BTB. Across all outcomes, there was no significant difference when comparing QT to HT, QT to BTB, and QT compared to HT and BTB combined. CONCLUSIONS: RACLR with QT yields satisfactory patient reported outcomes, satisfactory improvement in knee laxity, expected return to sport rates, and has an overall 7.6% failure rate. Outcomes are comparative to those of HT and BTB making it an acceptable graft choice for RACLR. Surgeons should consider using QT autograft for RACLR, especially when other autografts are unavailable. LEVEL OF EVIDENCE: IV.

Reimagining the Path of an Unmatched Orthopaedic Residency Application: A Survey of Program Directors.

Background: Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. Methods: The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Results: Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Conclusions: Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level of Evidence: Level IV.

OrthoACCESS: Implementing a Sub-Internship Curriculum for MS4s Applying to Orthopaedic Surgery.

OBJECTIVE: Medical students pursuing orthopedic surgery residency build foundational knowledge during clinical rotations. Most clinical rotations, home and away, were paused during the COVID-19 pandemic. Given the lack of structured fourth-year medical student (MS4) education for basic orthopedics, educators developed the Ortho Acting-Intern Coordinated Clinical Education and Surgical Skills (OrthoACCESS) curriculum in 2019. This study demonstrates the accessibility and usability of a MS4 virtual orthopedic curriculum and examines the curriculum's role in increasing learner familiarity with basic orthopedic topics in 2020. DESIGN: OrthoACCESS faculty presented weekly lectures from July to October 2020 using Zoom Webinar. Website content included recorded webinars, external resources, and skills videos. Registrants were anonymously surveyed after each webinar characterizing the knowledge and utility of individual lectures. After the webinar series, registrants were emailed an anonymous post-curriculum survey characterizing their experience using the OrthoACCESS curriculum. RESULTS: OrthoACCESS had 1062 registrants, with 59% (624/1,062) MS4s. 4528 users accessed the OrthoACCESS website from 66 countries. The 15 lectures were viewed 3743 times, 1553 live views and 2190 asynchronous views. 444 postwebinar surveys were completed. Weekly response rates ranged from 18% to 45%. Respondents felt more knowledgeable and more able to apply their knowledge after viewing each lecture (p < 0.001), and found the webinars to be well-organized, well-paced, enthusiastically taught, and level-appropriate. 122/976 (13%) students and 45/291 (15%) faculty completed the postcurriculum survey. Faculty reported that OrthoACCESS was "quite useful" (4 [3-5]) for providing knowledge for an incoming orthopaedic intern. Faculty and students would recommend OrthoACCESS to future learners (5 [4-5]). CONCLUSIONS: OrthoACCESS delivered foundational musculoskeletal instruction during a period of increased need. In its initial iteration, this virtual curriculum demonstrated high utilization in the United States and internationally and improved participants' self-reported topical knowledge and ability to apply it clinically.

All-Inside Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed knee operations. An "all-inside" technique creates bone sockets for ACL graft passage, as opposed to more traditional full bone tunnels, and typically incorporates suspensory fixation instead of screw fixation to secure the graft. This technique may be indicated for any ACL reconstruction surgery, where adequate bone stock exists to drill sockets and to use cortical fixation. The technique may be used with all soft tissue, as well as bone plug ACL grafts and autograft hamstring or quadriceps tendon; most allograft tendon options may be performed with an all-inside technique. Advantages include anatomic tunnel/socket placement, decreased postoperative pain and swelling, minimal hardware, appropriate graft tensioning and retensioning, and circumferential graft to bone healing. Tips for successful all-inside surgery include matching graft diameter to socket diameter, drilling appropriate length sockets based on individual graft length, so as not to "bottom out" the graft and confirming cortical button fixation intraoperatively. Potential complications include graft-socket mismatch, full-tunnel reaming, and loss of cortical fixation. Multiple studies have shown the all-inside technique to have similar or superior biomechanical properties and clinical outcomes compared to the more traditional full-tunnel ACL reconstruction techniques.

Outcomes and complications after different surgical techniques for the treatment of chronic distal biceps tendon ruptures: a systematic review and quantitative synthesis.

Hypothesis: The purpose of this study was to perform a systematic review of the available literature evaluating surgical outcomes after chronic distal biceps tendon rupture. Surgical techniques, including primary repair, autograft reconstruction, and allograft reconstruction, were compared, as well as subjective and objective clinical outcomes and complication rates. Methods: A systematic literature search of Level I-IV studies reporting outcomes of surgically treated chronic distal biceps tendon ruptures were performed via PubMed, Cochrane Collaboration, Science Direct, and Google Scholar databases. Twenty-two papers were identified in the review, with 236 patients. A Modified Coleman Methodological Score (CMS) was determined for every article to assess study quality. Patient-reported outcomes, postoperative range of motion, flexion and supination strength, and postoperative complications were recorded. MAYO elbow scores (MEPS) were reported more consistently than the other outcome tools. Results: No Level I or level II studies were identified in our search, and the heterogeneity of outcome measures precluded meta-analysis. Studies demonstrated mean MEPS scores ranging between 86 and 100, regardless of the surgical technique utilized. All studies reported a mean flexion-extension arc equal to or greater than 5-130°. The reported mean postoperative flexion strength was within 10% of the unaffected contralateral side. The most common complication for both direct repair and reconstruction groups was paresthesia of the lateral antebrachial cutaneous nerve [direct repair: 18-16.8%; reconstruction: 8-6.2% (allograft: 4-6%; autograft: 4-7%)]. Rerupture was uncommon and occurred in three patients who had undergone direct repair and in one patient after autograft reconstruction. Conclusions: Surgical treatment of chronic distal biceps injuries yields favorable objective and subjective outcomes. Currently, available evidence suggests that direct repair, autograft reconstruction, or allograft reconstruction are all viable treatment options with similar outcomes.

COVID-19 modifications of offseason and preseason training for NFL athletes are associated with increased risk of regular season injuries.

OBJECTIVES: COVID-19 altered National Football League (NFL) player and team training during the 2020 offseason. All preseason games were cancelled resulting in absence of game play before the first week of the regular season. Thus, concerns exist regarding injury susceptibility of players during regular season games. The purpose of this study was to evaluate and compare injury rates during the 2020 NFL season versus injury rates from the unaffected 2017-2019 seasons. We hypothesized there would be an increased injury rate and an increased rate of season ending injuries during the modified 2020 season. METHODS: The NFL's public injury database was queried to identify players placed on the injury lists throughout the 2017-2020 seasons. All players listed as "out" and on the injured reserve due to physical injury were included in the data set. For further stratification, injury incidence was separated based on position. Time missed due to COVID-19 illness was not included. Injury rates were expressed as injuries per 1000 athlete exposures (AE). RESULTS: Overall, 893 individual players missed games due to injury during the 2020 NFL regular season compared to an average of 743 over the 2017-2019 seasons. Defensive players at all positions had a statistically significant increase in injury incidence from an average of 7.54 to 10.20 injuries per 1000 AE. Defensive backs were most affected with a 46% increase in players injured. There was no statistically significant difference in season ending injuries for any position. CONCLUSIONS: The COVID-19 stricken 2020 NFL regular season saw an increased rate and incidence of injuries. Specifically, defensive players had a higher incidence of injury overall with defensive backs experiencing the greatest increase in injury rates.

Perioperative Botulinum Toxin A in the Surgical Management of Seizure-Related Shoulder Instability: A Case Report.

CASE: A 20-year-old woman presented with recurrent bilateral shoulder instability concurrent with severe, treatment-refractory epilepsy. Imaging revealed glenoid bone loss of 25% to 28% and large Hill-Sachs defects bilaterally. Bone graft augmentation of the glenoid and infill of the Hill-Sachs defects was performed bilaterally. Perioperative neuromuscular paralysis of shoulder girdle muscles with botulinum toxin was performed to facilitate recovery. Both shoulders at 2.5 and 4 years, respectively, demonstrate excellent stability and radiographic union despite continued seizure activity. CONCLUSION: Perioperative neuromuscular paralysis with botulinum toxin may provide early graft protection after the surgical treatment of glenohumeral instability because of seizures.

Quadriceps tendon autograft is an effective alternative graft for posterior cruciate ligament reconstruction in isolated or multiligament injuries: a systematic review.

IMPORTANCE: High-grade posterior cruciate ligament (PCL) tears can be a significant cause of patient morbidity and knee instability. The graft of choice for operative repair remains controversial, although recently there has been increased interest in quadriceps tendon (QT) as an autologous graft option. OBJECTIVE: The purpose of this study was to perform a systematic review to assess reported clinical outcomes of PCL reconstructions using QT autografts. EVIDENCE REVIEW: A comprehensive review of clinical studies was performed evaluating PCL reconstruction with QT autograft including a systematic search of PubMed, Scopus, Cochrane and Google Scholar databases, and reference lists of relevant papers. Clinical results, stability results, functional outcomes, range-of-motion outcomes, complications and morbidity, and the conclusions of each study were evaluated. FINDINGS: Seven studies were included in the review of clinical results, including 145 subjects undergoing PCL reconstructions with QT autograft. All studies evaluated quadriceps tendon bone (QT-B) grafts. Among these seven studies, two included isolated PCL reconstruction while five included multiligamentous knee injury reconstruction. These studies suggest that QT-B autograft offers a viable graft option for primary PCL reconstruction with generally favourable patient-reported outcomes, knee stability and range of motion reported along with relatively low complication rates. CONCLUSIONS AND RELEVANCE: Use of the QT-B autograft may be a reasonable graft option for PCL reconstruction. However, high-quality prospective studies are required to evaluate the long-term safety, efficacy and functional outcomes. LEVEL OF EVIDENCE: Level IV (Systematic review of Level IV studies).

Resident Level Involvement Affects Operative Time and Surgical Complications in Lower Extremity Fracture Care.

OBJECTIVE: The purpose of this study is to evaluate the effect of resident participation on operative time and surgical complications in isolated lower extremity fracture care. SETTING: Patients who were treated at teaching hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. PARTICIPANTS: A total of 2,488 patients who underwent surgical fixation of isolated hip fractures, femoral or tibial shaft fractures, and ankle fractures. DESIGN: Patients were stratified by surgical procedure and post-graduate year (PGY) of the resident involved. Total operative time and surgical complications were analyzed with respect to resident participation and seniority. Multivariable logistic regression analyses were used to adjust for potential confounders including case complexity, wound class, and patient comorbidity burden. RESULTS: As PGY level increased, operative time increased for each procedure. The odds for a deep surgical site infection decreased as resident seniority increased, but the odds for wound dehiscence increased as resident seniority increased. We found no difference in the incidences of superficial infections or return to the OR with respect to PGY level. Academic quarter within the academic year did not correlate with any of the surgical complications. Furthermore, when cases performed with residents were compared to those performed without residents, there was no increased risk of superficial infections, deep infections, or return to the OR. CONCLUSIONS: This nationally representative dataset demonstrates that operative times for lower extremity orthopedic trauma increased as resident seniority increased. Additionally, senior resident participation was associated with increased wound dehiscence, whereas junior resident participation was associated with an increased risk of deep surgical site infections. However, there was no associated "July effect" for residents at any level of training and there was no increased risk for surgical site infections or return to the OR in cases involving resident participation.

Elevated BMI increases concurrent pathology and operative time in adolescent ACL reconstruction.

PURPOSE: The purpose of this study was to (1) report on the incidence of concurrent surgical pathology at the time of adolescent ACL reconstruction, (2) evaluate patient risk factors for concurrent pathology, and (3) measure the effect of BMI on operating room (OR) time. METHODS: A retrospective analysis of the NSQIP database for the years 2005-2017 was conducted. Nine-hundred and seventeen patients 18 years of age and younger who underwent ACL reconstruction (ACLR) were identified using CPT code 29888 and patients undergoing surgery for multi-ligamentous knee injuries were excluded. The mean patient age was 17.6 years (range 14-18, standard deviation 0.52) and consisted of 546 males (59.5%) and 371 females (40.5%). Logistic regression was used to assess the relationship between BMI and additional CPT codes for internal derangement at the time of surgery. Internal derangement was defined as any procedure for the treatment of a meniscal tear, chondral lesion, or loose body removal. Linear regression analysis was then performed to evaluate the effect of BMI on operative time. RESULTS: 43.7% of patients undergoing ACLR required an associated procedure for internal derangement. Additionally, the risk of requiring additional procedures for internal derangement increased by 3.1% per BMI point. BMI was also predictive of operative time, independent of the number of additional procedures. Specifically, the operative time increased by nearly one minute for every point increase in BMI (58.0 s). CONCLUSIONS: Adolescent patients with an elevated BMI were much more likely to require additional surgical procedures for internal derangement at the time of ACL reconstruction. Additionally, BMI was a significant predictor for longer operative times. LEVEL OF EVIDENCE: Level III.

Revision Anterior Cruciate Ligament Reconstruction with the All-Soft Tissue Quadriceps Tendon Autograft Has Acceptable Early and Intermediate-Term Outcomes.

PURPOSE: The purposes were to (1) examine early to intermediate-term clinical outcomes and complications of revision anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon (QT) autografts, and (2) compare quadriceps strength between patients who had hamstring versus patella tendon autografts in their previous reconstruction. METHODS: One hundred patients (52 males/48 females; 22.6 ± 8.0 years) undergoing revision ACLR with all-soft tissue QT autografts were prospectively followed. All revision procedures were performed by a single surgeon, using a minimally invasive graft harvest technique and suspensory fixation. Subjective assessment of knee function was obtained before and after surgery with the International Knee Documentation Committee (IKDC) survey. Postoperative knee laxity and isokinetic quadriceps strength were collected at regular intervals. Strength was reported as limb symmetry index (LSI; surgical side divided by nonsurgical side). Complications including hematomas, postoperative loss of knee extension, and graft failures were recorded. To determine clinical significance (P ≤ .05), outcomes were compared using analysis of variance or paired samples t-tests. RESULTS: The mean IKDC scores significantly improved (54.3 ± 13.0 vs 82.8 ± 13.8), with an average follow-up of 42.2 ± 21.2 months. There were no significant changes in knee laxity side-to-side differences: 6 weeks (1.2 ± 1.5 mm), 3 months (1.2 ± 1.8 mm), 6 months (1.4 ± 1.6 mm). Quadriceps LSIs significantly improved from 71.6% ± 19.3% at 6 months to 81.5% ± 19.3% at 12 months for 60°/s isokinetic testing and 76.6% ± 16.4% at 6 months to 83.9% ± 16.9% at 12 months for 180°/s testing. Graft harvest site hematomas developed in 2 patients, postoperative loss of knee extension in 4 patients, and graft failure in 11 patients. No significant differences in quadriceps or hamstrings LSIs were noted between patients with previous hamstring versus patella tendon autografts (P > .050). CONCLUSION: Revision ACLR with all-soft tissue QT autografts has acceptable early and intermediate-term outcomes with reasonable complication rates (11/80 patients with follow-up). Secondary insult to the extensor mechanism via QT autograft harvest does not adversely affect strength after prior patellar tendon versus hamstring autograft. LEVEL OF EVIDENCE: Level IV, cases series subgroup analysis.

Obesity and risk for open reduction and internal fixation of syndesmotic injuries in the setting of concomitant ankle fractures.

INTRODUCTION: The association between obesity and the need for open reduction and surgical fixation of the syndesmosis in the setting of malleolar ankle fractures remains to be elucidated. Therefore, the primary objective of this study was to assess the relationship between obesity, ankle fracture complexity, and the need for open reduction and fixation of the syndesmosis. METHODS: A retrospective analysis of the NSQIP database was performed for patients undergoing surgical fixation of isolated, closed ankle fractures. Patients were grouped by fracture pattern into 6 cohorts (uni-, bi- and trimalleolar ankle fractures with or without syndesmotic injury). Demographic data was collected and compared between groups and logistic regression analyses were used to assess the relationship between body mass index (BMI) and ankle fracture pattern. RESULTS: A total of 15,841 patients (mean age 48.9 years) were identified for inclusion. Regression analyses revealed that BMI had a significant association with the incidence of open reduction and internal fixation of the ankle syndesmosis, but there was no association between BMI and malleolar fracture pattern. CONCLUSIONS: This study demonstrates that elevated BMI is associated with an increased risk for open reduction and internal fixation of the syndesmosis in malleolar ankle fractures. However, obesity was not associated with ankle fracture pattern itself, whereas older age, female sex, and white race were more significant predictors of fracture complexity. This data provides a framework for further evaluation of the effect that both modifiable and non-modifiable risk factors have on fracture complexity and operative management of patients with such injuries. LEVEL OF EVIDENCE: Case-control study. Level III.

Combined Oral Contraceptive Use Increases the Risk of Venous Thromboembolism After Knee Arthroscopy and Anterior Cruciate Ligament Reconstruction: An Analysis of 64,165 Patients in the Truven Database.

PURPOSE: To use the Truven MarketScan database to (1) report the incidence of venous thromboembolism (VTE), including deep vein thromboses (DVTs) and pulmonary embolism (PE), in patients undergoing simple knee arthroscopy and anterior cruciate ligament (ACL) reconstruction, and (2) evaluate combined oral contraceptive (COCP) use as a potential risk factor for VTE in patients undergoing knee arthroscopy. METHODS: All female patients between the ages of 16 and 40 years undergoing knee arthroscopy and ACL reconstruction between 2010 and 2015 were identified in the MarketScan database. Patients were stratified by whether they had a documented pharmaceutical claim for COCP therapy, and the primary outcome was the risk of DVT and or PE within 90 postoperative days. RESULTS: In total, 64,165 patients were identified for inclusion. While the overall incidence of VTE was low, patients taking COCPs had an increased risk of a DVT or PE compared with those not on COCPs (odds ratio [OR] 2.1, P < .001). When patients were analyzed by procedural subgroup (ACL reconstruction and simple knee arthroscopy), similar results held true. Furthermore, smoking and obesity had a synergistic effect when combined with COCPs use on the risk of VTE. Specifically, 3.1% of patients with obesity on COCPs (OR 3.1, P < .001) and 4.0% of smokers on COCPs (OR 4.3, P < .001) developed a postoperative VTE. CONCLUSIONS: This study demonstrates that COCP use is associated with an increased risk for a symptomatic DVT or PE (1.70% and 0.27%, respectively) after knee arthroscopy and an increased risk for DVT, but not PE (1.80% and 0.23%, respectively), after ACL reconstruction. In addition, patients with multiple risk factors present such as tobacco use, obesity, and COCP use had odds ratios greater than the sum of the individual risk factors alone. LEVEL OF EVIDENCE: level III prognostic cohort study.

Risk Factors for Infection Following Total Wrist Arthroplasty and Arthrodesis: An Analysis of 6641 Patients.

Background: Infection following wrist arthroplasty (WA) or wrist fusion (WF) is an uncommon but difficult complication often resulting in explantation and prolonged courses of antibiotics. The purposes of this study are to: (1) characterize the demographic trends of individuals undergoing WA and WF; (2) determine the incidence of postoperative infection; and (3) identify risk factors for postoperative infection. Methods: The PearlDiver database was used to query 100% Medicare Standard Analytic files from 2005 to 2014. Patients undergoing WA or radiocarpal WF were identified using Current Procedural Terminology (CPT) codes. Diagnosis for infection within 1 year of operative intervention was assessed by International Classification of Diseases, Ninth Revision codes or CPT codes related to infection. Multivariable logistic regression analyses were performed to evaluate the risk factors for postoperative infection. Results: Of the 6641 patients included, 1137 (17.1%) underwent arthroplasty and 5504 (82.9%) underwent arthrodesis. Within 1 year of the index procedure, 3.5% had a diagnosis of, or procedure for, postoperative infection (WA: n = 40 of 1137; WF: n = 192 of 5504). Risk factors for infection following WA include age >85, tobacco use, depression, diabetes mellitus, and chronic kidney disease. Risk factors following radiocarpal WF include male sex, age >85, body mass index <19 kg/m2, depression, diabetes mellitus, and chronic kidney disease. Posttraumatic origin of wrist arthritis was a risk factor for infection following both WA and WF. Conclusions: Infection following WA and WF is relatively uncommon in a nationally representative Medicare database cohort. Risk factors common to both WA and WF include age >85, depression, diabetes mellitus, chronic kidney disease, and posttraumatic arthritis.

Insulin-Dependence Predicts Surgical Complications and Hospital Admission following Knee Arthroscopy.

While prior studies have demonstrated that insulin-dependence is an independent risk factor for postoperative complications, morbidity, and mortality following spine and shoulder, hip, and knee arthroplasty, it has not been evaluated in the setting of knee arthroscopy. Therefore, the purpose of this study is to compare the risk of postoperative complications among patients with insulin-dependent diabetes mellitus and noninsulin-dependent diabetes mellitus (IDDM and NIDDM respectively) with the general population following knee arthroscopy. A retrospective analysis of the National Surgical Quality Improvement Program's database for the years 2005 to 2016 was conducted. Logistic regression analyses were used to assess the relationship between diabetic status and outcomes. Multivariate models were established to adjust for age, sex, body mass index, hypertension, congestive heart failure, chronic obstructive pulmonary disease, smoking status, American Society of Anesthesiology classification, and functional status. A total of 86,023 patients were identified. Patients with IDDM were at a much higher risk of surgical complications (odds ratio [OR]: 2.186, 95% confidence interval [CI]: 1.226-1.157), including deep infections (OR: 3.082, 95% CI: 1.753-5.419) and return to operating room [OR] (OR: 1.933, 95% CI: 1.280-2.919), as well as unplanned hospital admission (OR: 1.770, 95% CI: 1.289-2.431). However, NIDDM was not an independent risk factor for subsequent medical or surgical complications, unplanned hospital admission, or 30-day mortality. Patients with IDDM were much more likely to have surgical complications, including deep infection and return to OR, as well as unplanned hospital admission following knee arthroscopy. These risks diminished among those with NIDDM, with their adjusted risk profiles comparable to those without diabetes. Since diabetes occurs in a heterogenous state, more weight should be given to those with insulin-dependence when risk-stratifying patients for surgery. This is a Level III, retrospective comparison study.

Shoulder Position During Magnetic Resonance Arthrogram Significantly Affects Capsular Measurements.

PURPOSE: To determine whether change in shoulder position between internal rotation (IR) and external rotation (ER) during magnetic resonance arthrography (MRA) affects previously defined capsular measurements and to determine the utility of rotation in the diagnosis of instability. METHODS: A retrospective study was conducted of patients who received a shoulder MRA with humeral IR and ER views. Patients with an arthroscopically confirmed diagnosis of instability and those with clinically stable shoulders, no history of instability, and no MRA findings of instability were identified and compared. Humeral rotation, glenoid retroversion, humeral head subluxation, capsular length, and capsular area using axial sequences of IR and ER views were recorded. Analysis compared IR, ER, and Δ capsular measurements between groups using independent t tests and univariate and multivariate regression. RESULTS: Thirty-one subjects who were diagnosed with instability were included, along with 28 control subjects. Capsular length, capsular area, and humeral subluxations were significantly greater with ER compared with IR views (P < .001, P < .001, P < .001). Patients with instability displayed greater ER capsular length (P = .0006) and ER capsular area (P = .005) relative to controls. Multivariate logistic regression identified age, weight, sex, ER capsular length, and retroversion to be significant predictors of instability. ER capsular length independently predicts instability with 86% sensitivity and 84% specificity. Interobserver reliability using the intraclass correlation coefficient was rated good or excellent on all measurements. CONCLUSION: Variance in humeral rotation during shoulder MRA significantly affects capsular measurements. Rotational views increase the utility of capsular measurements when assessing for instability, particularly capsular length and capsular area. The implementation of ER positioning enhances the ability to examine capsular changes of the shoulder joint and can assist in the diagnosis of instability. LEVEL OF EVIDENCE: III, retrospective comparative study.