Conversion rates and timing to total knee arthroplasty following anterior cruciate ligament reconstruction: a US population-based study.

PURPOSE: To define the rate of subsequent TKA following ACLR in a large US cohort and to identify factors that influence the risk of later undergoing TKA after ACLR. METHODS: The California's Office of Statewide Health Planning and Development (OSHPD) database was queried from 2000 to 2014 to identify patients who underwent primary ACLR (ACL group). An age-and gender-matched cohort that underwent appendectomy was selected as the control group. The cumulative incidence of TKA was calculated and ten-year survival was investigated using Kaplan-Meier analysis with failure defined as conversion to arthroplasty. Univariate and multivariate analyses were performed to explore the risk factors for conversion to TKA following ACLR. RESULTS: A total of 100,580 ACLR patients (mean age 34.48 years, 66.1%male) were matched to 100,545 patients from the general population. The ACL cohort had 1374 knee arthroplasty events; conversion rate was 0.71% at 2-year follow-up, 2.04% at 5-year follow-up, and 4.86% at 10-year follow-up. This conversion rate was higher than that of the control group at all time points, with an odds ratio of 3.44 (p<0.001) at 10-year follow-up. Decreasing survivorship following ACLR was observed with increasing age, female gender, and worker's compensation insurance, while increased survivorship was found in patients of Hispanic and Asian Pacific Islander racial heritage and those who underwent concomitant meniscal repair. CONCLUSIONS: In this US statewide study, the rate of TKA after ACLR is higher than reported elsewhere, with significantly increased odds when compared to a control group. Age, gender, concomitant knee procedures and other socioeconomic factors influence the rate of conversion to TKA following ACLR.

Scapulothoracic pathology: review of anatomy, pathophysiology, imaging findings, and an approach to management.

Symptomatic scapulothoracic disorders, including scapulothoracic crepitus and scapulothoracic bursitis are uncommon disorders involving the scapulothoracic articulation that have the potential to cause significant patient morbidity. Scapulothoracic crepitus is the presence of a grinding or popping sound with movement of the scapula that may or may not be symptomatic, while scapulothoracic bursitis refers to inflammation of bursa within the scapulothoracic articulation. Both entities may occur either concomitantly or independently. Nonetheless, the constellation of symptoms manifested by both entities has been referred to as the snapping scapula syndrome. Various causes of scapulothoracic crepitus include bursitis, variable scapular morphology, post-surgical or post-traumatic changes, osseous and soft tissue masses, scapular dyskinesis, and postural defects. Imaging is an important adjunct to the physical examination for accurate diagnosis and appropriate treatment management. Non-operative management such as physical therapy and local injection can be effective for symptoms secondary to scapular dyskinesis or benign, non-osseous lesions. Surgical treatment is utilized for osseous lesions, or if non-operative management for bursitis has failed. Open, arthroscopic, or combined methods have been performed with good clinical outcomes.

Coracoid Process: The Lighthouse of the Shoulder.

The coracoid process is a hook-shaped bone structure projecting anterolaterally from the superior aspect of the scapular neck. Surgeons often refer to the coracoid process as the "lighthouse of the shoulder" given its proximity to major neurovascular structures such as the brachial plexus and the axillary artery and vein, its role in guiding surgical approaches, and its utility as a landmark for other important structures in the shoulder. The coracoid also serves as a critical anchor for many tendinous and ligamentous attachments. These include the tendons of the pectoralis minor, coracobrachialis, and short head of the biceps brachii muscles, and the coracoclavicular, coracohumeral, coracoacromial, and transverse scapular ligaments. Consequently, the coracoid and its associated structures are linked to numerous shoulder pathologic conditions. This article will detail the anatomy of the coracoid and its associated structures and review the clinical and radiologic findings of corresponding pathologic conditions in this region with original illustrations and multimodality imaging examples. Highlighted in this article are the coracoclavicular joint, the classification and management of coracoid fractures, subcoracoid impingement, the coracoacromial arch and subacromial impingement, the coracohumeral ligament and the biceps pulley, the coracoclavicular ligament and its surgical reconstruction, adhesive capsulitis, the suprascapular notch and suprascapular notch impingement, subcoracoid bursitis, coracoid transfer procedures, and coracoid tumors. A brief summary of the pathophysiology, potential causes, and management options for each of the pathologic entities will also be discussed. ©RSNA, 2016.

Preoperative risk factors for discharge to a postacute care facility after shoulder arthroplasty.

BACKGROUND: Shoulder arthroplasty procedures are becoming increasingly prevalent in the United States due to expanding indications and an aging population. Most patients are discharged home, but a subset of patients is discharged to a postacute care (PAC) facility. The purpose of this study was to identify the risk factors for discharge to a PAC facility after shoulder arthroplasty. METHODS: The Nationwide Inpatient Sample discharge records from 2011 to 2012 were analyzed for patients who underwent a total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). Patient and hospital characteristics were identified. Univariate and multivariate analysis were used to determine the statistically significant risk factors for discharge to a PAC facility while controlling for covariates. RESULTS: In 2011 and 2012, 103,798 patients underwent shoulder arthroplasty procedures: 58,937 TSAs and 44,893 RTSAs were identified. RTSA patients were 1.3 times as likely to be discharged to a PAC facility as TSA patients (P = .001). Medicare patients were 2 times as likely to be discharged to a PAC facility than those with private insurance (P < .001). In addition, women and patients presenting with a fracture, older age, or an increasing number of medical comorbidities were more likely to be discharged to a PAC facility (P < .001). CONCLUSION: The risk factors identified in our study can be used to stratify patients at high risk for postoperative discharge to PAC, allowing for greater improvement in overall care and the facilitation of postoperative discharge planning.

Surgical management of midshaft clavicle nonunions is associated with a higher rate of short-term complications compared with acute fractures.

BACKGROUND: Little is known about the perioperative complication rates of the surgical management of midshaft clavicle nonunions. The purpose of the current study was to report on the perioperative complication rates after surgical management of nonunions and to compare them with complication rates of acute fractures using a population cohort. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who had undergone open reduction-internal fixation of midshaft clavicle fractures between 2007 and 2013. Patients were stratified by operative indication: acute fracture or nonunion. Patient characteristics and 30-day complication rates were compared between the 2 groups using univariate and multivariate analyses. RESULTS: A total of 1215 patients were included in our analysis. Of these, 1006 (82.8%) were acute midshaft clavicle fractures and 209 (17.2%) were midshaft nonunions. Patients undergoing surgical fixation for nonunion had a higher rate of total complications compared with the acute fracture group (5.26% vs. 2.28%; P = .034). On multivariate analysis, patients with a nonunion were at a >2-fold increased risk of any postsurgical complication (odds ratio, 2.29 [95% confidence interval, 1.05-5.00]; P = .037) and >3-fold increased risk of a wound complication (odds ratio, 3.22 [95% confidence interval, 1.02-10.20]; P = .046) compared with acute fractures. CONCLUSION: On the basis of these findings, patients undergoing surgical fixation for a midshaft clavicle nonunion are at an increased risk of short-term complications compared with acute fractures. This study provides additional information to consider in making management decisions for these common injuries.

Complication rate and implant survival for reverse shoulder arthroplasty versus total shoulder arthroplasty: results during the initial 2 years.

BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has significantly increased in recent years. However, there is large variance in reported complication rates and sparse data on implant survival. This study used a statewide patient database to investigate complication rates and implant survival for RTSA. METHODS: All patients undergoing RTSA or total shoulder arthroplasty (TSA) from 2011 to 2013 were identified within a statewide database. The complication and revision rates at 30 days, 90 days, 1 year, and 2 years postoperatively were determined. Potential risk factors for complications were analyzed with logistic regression, and Kaplan-Meier survival curves were used to compare implant failure. RESULTS: During the 3-year period, 10,844 procedures (6,658 TSA; 4,186 RTSA) were found within the database. The all-cause complication rate at 90 days and 2 years postoperatively was significantly higher for RTSA (P < .001). RTSA patients had a significantly increased risk of infection (P < .05) and dislocation (P < .001) in the early and midterm postoperative course. Workers' compensation, male sex, preoperative anemia, and those aged younger than 65 years had a significantly higher risk for complications (P < .001). Although RTSA initially had a higher rate of implant failure than TSA during the early postoperative period, this rate equalized at approximately the 1-year mark. CONCLUSION: RTSA patients had significantly higher complication rates compared with TSA patients, with identifiable risk factors for all-cause complications postoperatively and equivalent accepted implant failure at 2 years. LEVEL OF EVIDENCE: Level III; Cross Sectional Design; Large Database Analysis.

Partial semitendinosus tendon tear in a young athlete: a case report and review of the distal semitendinosus anatomy.

Distal semitendinosus tears have been infrequently reported in the radiology literature, and a detailed description of the anatomy and imaging features of these injuries is lacking. The semitendinosus tendon is clinically relevant, as it is frequently grafted in knee ligament reconstructions and plays an important role in performing competitive activities. We present a case of a 31-year-old man who developed a partial semitendinosus tear during competitive training. This case highlights the common clinical and imaging findings found with distal semitendinosus tears, and explores the various modalities available to treat this injury. We also review the clinically pertinent anatomy of the distal semitendinosus tendon and discuss the pitfalls that musculoskeletal radiologists may encounter, to avoid misdiagnosing these rare injuries.

Anatomy of the femoral footprint of the posterior cruciate ligament: a systematic review.

PURPOSE: The purpose of this study was to summarize the past 10 years of orthopaedic literature to better delineate the femoral origin of the posterior cruciate ligament (PCL). METHODS: A PubMed search was conducted by 2 independent reviewers (M.P., M.V.) using the search terms "posterior cruciate ligament" or "PCL," "femur" or "femoral," and "anatomy" or "origin" or "footprint." Cadaveric and radiographic studies performed between January 1, 2003, and November 30, 2013, were analyzed. RESULTS: Aggregate data from radiographic parameters indicate that the anatomic origin of the anterolateral bundle lies 40% of the distance from the anterior articular surface of the femur and 14.5% of the tangent distance from the Blumensaat line toward the intercondylar notch. The origin of the posteromedial bundle lies 56% from the anterior surface and 36.5% of the tangent distance toward the notch. On the basis of cadaveric data, the center of the anterolateral bundle is 8 mm from the anterior surface (27.5% of the Blumensaat line), 4.7 mm tangent from the Blumensaat line toward the notch (22.5% of the tangent distance), and 3.6 mm from the medial intercondylar ridge; the center of the posteromedial bundle is 11.9 mm from the anterior articular surface (42.5%), 10.9 mm along the tangent line (57.5%), and 3.1 mm from the medial intercondylar ridge. CONCLUSIONS: We were able to precisely delineate the femoral origin of the PCL through our systematic review. CLINICAL RELEVANCE: Our systematic review may assist arthroscopic knee surgeons in placing anatomic tunnels during reconstruction of the PCL.

Does patient sex affect the anatomic relationships between the sternoclavicular joint and posterior vascular structures?

BACKGROUND: Despite increased concern for injury during surgical reconstruction of the sternoclavicular joint, to our knowledge there are few studies detailing the vascular relationships adjacent to the joint. QUESTIONS/PURPOSES: We investigated sex differences in the following relationships for sternoclavicular joint reconstruction: (1) safe distance from the posterior surface of the medial clavicle's medial and lateral segments to the major vessels, (2) length of the first costal cartilage and safe distance from the first rib to the internal mammary artery, (3) minimum distance medial to the sternoclavicular joint for optimal hole placement, and (4) safe distance from the manubrium to the great vessels. METHODS: Fifty normal postcontrast CT scans of the chest were reviewed. Means, standard deviations, and 95% CI were calculated for each aforementioned measurement. A t-test was used to determine if a sex difference exists (p≤0.05). RESULTS: At the medial end of the clavicle, the safe distance from the medial segment (first 10 mm) to the major vessels was greater in males than in females (3.5 mm versus 2.4 mm, respectively; 95% CI, 3 mm-4 mm versus 1.7 mm-3 mm, respectively; p=0.014). For the lateral segment (next 10 mm), the distance also was safer in males than in females (3.3 mm versus 1.7 mm, respectively; 95% CI, 2.7 mm-4 mm versus 1.1 mm-2.3 mm, respectively; p<0.001). The mean length of the first costal cartilage also was greater in males (35.8 mm versus 30.1 mm, respectively; 95% CI, 33.8 mm-37.8 mm versus 28.5 mm-31.9 mm, respectively; p<0.001); the distance from the first costochondral joint to the internal mammary artery was safer in males than in females (19.1 mm versus 15.4 mm, respectively; 95% CI, 16.5 mm-21.8 mm versus 13 mm-17.9 mm, respectively; p=0.05). The minimum distance to avoid inadvertent penetration of the sternoclavicular joint was greater in males than in females (16 mm versus 12.3 mm, respectively; 95% CI, 14.6 mm-17.5 mm versus 11 mm-13.6 mm, respectively; p<0.001). The distance to vessels after penetration of the manubrium was not different between males and females (5.6 mm versus 3.9, respectively; 95% CI, 4.4 mm-6.8 mm versus 2.6 mm-5.2 mm, respectively; p=0.06). CONCLUSIONS: This study makes apparent the intimate relationships between vessels and the musculoskeletal structures associated with sternoclavicular reconstruction. Based on our findings, we recommend considering the sex of the patient, using caution when drilling, and protecting essential structures posterior to the joint.

Cruciate ligament avulsion fractures: anatomy, biomechanics, injury patterns, and approach to management.

Injury to the ACL or PCL of the knee most commonly involves a tear of the collagenous fibers of the ligament. Less frequently, a cruciate ligament injury involves an avulsion fracture at the origin or insertion of the ligament, usually from the insertion site on the tibial surface. Avulsion fractures of the cruciate ligaments are important, as they can be identified on radiographs, allowing a specific diagnosis. Although more common in children, when they occur in adults, they are more commonly associated with other injuries. The treatment of cruciate ligament avulsion fractures is different than the treatment of intrasubstance tears of the cruciate ligaments. These injuries can be treated conservatively or surgically with good outcomes. Recently arthroscopic fixation of these injuries with various fixation devices has become more frequent. Treatment largely depends on the type of fracture, particularly, the size, displacement, comminution, and orientation of the avulsed fracture fragment, in addition to the integrity of the attached cruciate ligament. This review article covers the anatomy and biomechanics of the cruciate ligaments, their injury patterns, and approach to management.

Effect of Ulnar Collateral Ligament Reconstruction on Pitch Accuracy, Velocity, and Movement in Major League Baseball Pitchers.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction is frequently performed on Major League Baseball (MLB) pitchers. Previous studies have investigated the effects of UCL reconstruction on fastball and curveball velocity, but no study to date has evaluated its effect on fastball accuracy or curveball movement among MLB pitchers. PURPOSE/HYPOTHESIS: The primary purpose of this study was to determine the effects of UCL reconstruction on fastball accuracy, fastball velocity, and curveball movement in MLB pitchers. Our hypothesis was that MLB pitchers who underwent UCL reconstruction would return to their presurgery fastball velocity, fastball accuracy, and curveball movement. The secondary purpose of this study was to determine which factors, if any, were predictive of poor performance after UCL reconstruction. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: MLB pitchers who underwent UCL reconstruction surgery between 2011 and 2012 were identified. Performance data including fastball velocity, fastball accuracy, and curveball movement were evaluated 1 year preoperatively and up to 3 years of play postoperatively. A repeated-measures analysis of variance with a Tukey-Kramer post hoc test was used to determine statistically significant changes in performance over time. Characteristic factors and presurgery performance statistics were compared between poor performers (>20% decrease in fastball accuracy) and non-poor performers. RESULTS: We identified 56 pitchers with a total of 230,995 individual pitches for this study. After exclusion for lack of return to play (n = 14) and revision surgery (n = 3), 39 pitchers were included in the final analysis. The mean presurgery fastball pitch-to-target distance was 32.9 cm. There was a statistically significant decrease in fastball accuracy after reconstruction, which was present up to 3 years postoperatively (P = .007). The mean presurgery fastball velocity of 91.82 mph did not significantly change after surgery (P = .194). The mean presurgery curveball movement of 34.49 cm vertically and 5.89 cm horizontally also did not change significantly (P = .937 and .161, respectively). CONCLUSION: Fastball accuracy among MLB pitchers significantly decreased after UCL reconstruction for up to 3 years postoperatively. There were no statistically significant differences in characteristic factors or presurgery performance statistics between poor and non--poor performers.

An Increasing Rate of Surgical Management of Closed Tibia Fractures in an Adolescent Population: A National Database Study.

BACKGROUND: No consensus exists for the management of closed tibia fractures in the adolescent population. METHODS: The Kids' Inpatient Database was used to extract data on patients aged 10 to 18 years with closed diaphyseal tibia fractures. The frequency of closed reduction and internal fixation (IF) was calculated, and the temporal trends were evaluated. RESULTS: Between 1997 and 2012, the rate of IF for closed tibia fractures in the adolescent population increased by 29.8%. The rate of increase in IF between patients aged 10 to 12 years, 13 to 15 years, and 16 to 18 years was not statistically different (P = 0.092). Analysis of hospital variables demonstrated that large hospitals were more likely to perform IF compared with small- and medium-sized hospitals (P < 0.001). A significant difference exists between the IF and closed reduction groups in the length of hospital stay (3.85 ± 0.07 versus 2.44 ± 0.07; P < 0.001) and cost ($37,400 ± $890 versus $15,300 ± $670; P < 0.001). DISCUSSION: The results of this study show a shift in the management of closed tibia shaft fractures in the adolescent population admitted to the hospital, with an absolute rate increase of 29.8% in patients aged 10 to 18 years over a 15-year period. LEVEL OF EVIDENCE: Level III. A retrospective, comparative study.

Biomechanical Analysis of Porcine Cartilage Elasticity.

Grafting of tissue-engineered cartilage to joints with osteoarthritis has the potential to supersede arthroplasty as the standard of care. However, in order to support the development of functional tissue engineering methods, the subfailure biomechanics of the individual cartilage types that comprise joints must be determined. Current methods for analyzing tissues are based on imaging and are therefore unable to profile the strain dependence of mechanical behaviors within different cartilage types. Recently, an analysis technique based on Optical Fiber Polarimetric Elastography (OFPE) has overcome these challenges. OFPE has been used to characterize the different mechanical behaviors of a range of unprocessed biomaterials and tissues. In the present work, this technique is used to characterize the biomechanics of both articular cartilage and meniscal fibrocartilage within a porcine knee. OFPE testing of the tissue is conducted over a range of physiological loading and unloading values. These results demonstrate the distinctive mechanics of each cartilage type. Due to their different locations within the knee, each cartilage type exhibits distinctly unique biomechanical behavior. Based on the results of OFPE, we correlate the specific buckling, delamination, and bridging events to maxima and minima along the loading and unloading curves. This provides unprecedented detail with regard to the subfailure biomechanics. This information is integral to the design of the next generation of tissue-engineered constructs. Therefore, OFPE will be used across multiple disciplines to rapidly determine the mechanical behavior of tissue-engineered constructs to support functional tissue engineering efforts.

Performance of PROMIS Computer Adaptive Testing As Compared With Established Instruments for Multiple-Ligament Knee Injuries.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) is a patient-reported outcome metric that has been validated for anterior cruciate ligament (ACL) injuries, ACL reconstructions, and meniscal injuries. Thus far, the system has not been validated for multiligament knee injuries. The Multiligament Quality of Life (MLQOL) questionnaire is a validated, disease-specific patient-reported outcome instrument for this population that can serve as a gold standard for validation of the newer PROMIS. PURPOSE/HYPOTHESIS: The purpose of this study was to further validate the PROMIS CAT for multiligament knee reconstruction. We hypothesized that the PROMIS CAT modules would correlate with the Lysholm knee score (Lysholm), Tegner activity scale (Tegner), and MLQOL for postoperative multiligamentous knee injury patients and that the PROMIS CAT would use fewer question items than the Lysholm, Tegner, and MLQOL while still avoiding floor and ceiling effects. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 30 patients meeting the inclusion criteria were retrospectively identified and agreed to participate (87% male; mean ± SD age, 36.3 ± 13.5 years). Consenting patients were administered the Lysholm, Tegner, MLQOL, and PROMIS CAT for Physical Function, Mobility, and Pain Interference. Spearman correlations were used to test agreement across survey instruments. Floor and ceiling effects were assessed for all instruments. RESULTS: PROMIS Pain Interference had excellent correlation with MLQOL Activity Limitations (r = 0.71, P < .0001). Excellent-good correlations were detected between PROMIS Physical Function and MLQOL Activity Limitations (r = -0.63, P = .0002) and PROMIS Mobility and MLQOL Activity Limitations (r = -0.62, P < .0002). Good correlations were found between the Lysholm and the PROMIS Physical Function and PROMIS Mobility (for each, r = 0.50, P = .005). Additional correlations were present with other subsections. There were no floor or ceiling effects for the PROMIS CAT instrument in any category. CONCLUSION: The PROMIS CAT correlates well with existing outcome measures for multiligament knee injury patients without floor or ceiling effects. The PROMIS CAT is a concise adjunct to the validated injury-specific outcome tool for multiligament knee injury. Surgeons should consider implementing the PROMIS CAT because of its broad validity, including ACL injuries, meniscal tears, and now multiligament knee injuries.

Effect of Preoperative Opioid Usage on Pain After Total Shoulder Arthroplasty.

INTRODUCTION: Preoperative opioid use has recently been associated with increased perioperative pain. This study evaluates the effect of preoperative opioid use on postoperative pain and duration of opioid use after total shoulder arthroplasty (TSA). METHODS: We retrospectively identified 138 TSAs (69.1% reverse and 30.9% anatomic) between January 2013 and April 2017 that met inclusion criteria. Patients were stratified into two groups based on opioid usage within the 4 weeks before surgery. Primary outcome was resting pain at 3 months postoperatively using a 10-point numerical rating scale system. Duration of postoperative opioid consumption was also recorded and compared between cohorts. RESULTS: The opioid cohort (n = 50) reported significantly greater resting pain and pain with activity at 3 months postoperatively, at which time the reported numerical rating scale pain scores were 1.6 and 2.8 points greater in the opioid cohort compared with the non-opioid cohort (P < 0.001). Preoperative opioid use strongly predicted postoperative opioid use at all follow-up time points (P < 0.0001). DISCUSSION: Preoperative opioid consumption is associated with higher pain and increased duration of opioid use after TSA.

Primary Anterior Cruciate Ligament Single-Bundle Repair With Augmentation for a Partial Anterior Cruciate Ligament Tear.

Although anterior cruciate ligament (ACL) reconstruction remains the gold standard for the treatment of ACL tears, repair is regaining popularity as a treatment option for proximal or distal ACL avulsions. Historically, ACL repairs had poor outcomes. To remedy this, techniques were developed using graft-based augmentation but never gained widespread popularity. Recently, there has been a renewed interest in primary ligament repairs, with newer techniques incorporating modern synthetic materials to augment the repair site. The term "internal bracing," or ligament repair with augmentation, has been used to describe the new philosophy for primary ligament repair and augmentation. We present our technique for arthroscopic primary ACL repair with augmentation for a proximal posterolateral bundle tear. The advantages of this technique include preservation of the intact fibers of the anteromedial bundle, intuitive suture augmentation with standard ACL tunnel placement techniques, and the ability to calibrate ligament tension.

Quality of Life and Functional Outcomes after Multiligament Knee Reconstruction.

We aimed to determine factors that affect the quality of life of patients undergoing a standardized surgical and postoperative management protocol for knee dislocations. A total of 31 patients (33 knees) were included in this study. We contacted patients at a minimum of 12 months postoperatively (mean: 38 months; range, 12-111 months) and administered the previously validated Multiligament Quality of Life questionnaire (ML-QOL), 2000 International Knee Documentation Committee Subjective Knee Form (IKDC), and Lysholm Knee Scoring Scale. We performed independent two-sample t-tests and age-adjusted multivariable linear regression analysis to examine the difference in these scores. Patients who underwent previous knee ligament surgery had significantly worse mean ML-QOL scores relative to patients who did not undergo previous knee ligament surgery (114.3 versus 80.4; p = 0.004) (higher score indicates worse quality of life). All other differences in the ML-QOL scores were not statistically significant. IKDC and Lysholm scores did not differ significantly with regards to the studied variables. Among patients with no previous knee ligament surgery, patients undergoing surgery within 3 weeks of injury had significantly worse mean ML-QOL scores relative to patients undergoing surgery greater than 3 weeks after their injury (98.7 versus 74.7; p = 0.042) and patients with Schenck classification of III or IV had significantly worse mean ML-QOL scores relative to patient with a Schenck classification of I or II (88.7 versus 62.9; p = 0.015). We found that patients with a previous history of knee ligament surgery had a significantly worse quality of life relative to those with no history of knee ligament surgery. This is a level III, retrospective cohort study.

Anabolic steroids and tendons: A review of their mechanical, structural, and biologic effects.

One of the suspected deleterious effects of androgenic-anabolic steroids (AAS) is the increased risk for tendon rupture. However, investigations to date have produced inconsistent results and it is still unclear how AAS influence tendons. A systematic review of the literature was conducted to identify studies that have investigated the mechanical, structural, or biologic effects that AAS have on tendons. In total, 18 highly heterogeneous studies were identified. Small animal studies made up the vast majority of published research, and contradictory results were reported frequently. All of the included studies focused on the potential deleterious effects that AAS have on tendon, which is striking given the recent use of AAS in patients following tendon injury. Rather than providing strong evidence for or against the use of AAS, this review highlights the need for additional research. Future studies investigating the use of AAS as a possible treatment for tendon injury/pathology are supported by reports suggesting that AAS may counteract the irreparable structural/functional changes that occur in the musculotendinous unit following rotator cuff tears, as well as studies suggesting that the purported deleterious effects on tendon may be transient. Other possible areas for future research are discussed in the context of key findings that may have implications for the therapeutic application of AAS. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2830-2841, 2018.

Discharge Destination After Shoulder Arthroplasty: An Independent Risk Factor for Readmission and Complications.

INTRODUCTION: Postdischarge disposition after shoulder replacement lacks uniform guidelines. The goal of this study was to identify complication and readmission rates by discharge disposition and determine whether disposition was an independent risk factor for adverse events, using a statewide database. METHODS: Data from the California Office of Statewide Health Planning and Development discharge database were used. Patient information was assessed, and 30- and 90-day complication rates were identified. Univariate and multivariate analyses were used to determine the complication risk. RESULTS: From 2011 to 2013, 10,660 procedures were identified, with 7,709 patients discharged home, 1,858 discharged home with home health support, and 1,093 discharged to postacute care (PAC) facilities. Patients discharged to PAC facilities or to home with health support tended to be older, female, and using Medicare. After controlling for confounders, at 30 and 90 days, patients discharged to PAC facilities were found to be more likely to experience a complication. DISCUSSION: Discharge to a PAC facility was an independent risk factor for complications and readmission. LEVEL OF EVIDENCE: Level III, retrospective cohort design, observational study.

Direct Cost Analysis of Outpatient Arthroscopic Rotator Cuff Repair in Medicare and Non-Medicare Populations.

BACKGROUND: Providing high-quality care while also containing cost is a paramount goal in orthopaedic surgery. Increasingly, insurance providers in the United States, including government payers, are requiring financial and performance accountability for episodes of care, including a push toward bundled payments. HYPOTHESIS: The direct cost of outpatient arthroscopic rotator cuff repair was assessed to determine whether, due to an older population, rotator cuff surgery was more costly in Medicare-insured patients than in patients covered by other insurers. We hypothesized that operative time, implant cost, and overall higher cost would be observed in Medicare patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Billing and operative reports from 184 outpatient arthroscopic rotator cuff repairs performed by 5 fellowship-trained arthroscopic surgeons were reviewed. Operative time, number and cost of implants, hospital reimbursement, surgeon reimbursement, and insurance type were determined from billing records and operative reports. Patients were stratified by payer (Medicare vs non-Medicare), and these variables were compared. RESULTS: There were no statistically significant differences in the number of suture anchors used, implant cost, surgical duration, or overall cost of arthroscopic rotator cuff repair between Medicare and other insurers. Reimbursement was significantly higher for other payers when compared with Medicare, resulting in a mean per case deficit of $263.54 between billing and reimbursement for Medicare patients. CONCLUSION: Operating room time, implant cost, and total procedural cost was the same for Medicare patients as for patients with private payers. Further research needs to be conducted to understand the patient-specific factors that affect the cost of an episode of care for rotator cuff surgery.