Performance-Based Outcomes after Revision Ulnar Collateral Ligament Surgery in Professional Pitchers.

OBJECTIVE: To compare performance in baseball pitchers before and after revision ulnar collateral ligament (UCL) surgery using performance metrics. DESIGN: Case series. SETTING: Public online database. PATIENTS OR PARTICIPANTS: Players who underwent revision UCL surgery between 2015 and 2021 were identified. Players were included if they were Minor League (MiLB) or Major League (Major League baseball [MLB]) pitchers. Players were excluded if they were not pitchers, if they underwent their revision surgery as an amateur, or if there is no record of their primary reconstruction surgery. INTERVENTIONS: Revision UCL surgery (repair or reconstruction). MAIN OUTCOME MEASURES: Return to sport (RTS) rate, RTS time, pitch velocity, and pitch spin rate. RESULTS: Sixty-five pitchers underwent revision UCL surgery. MiLB pitchers had a shorter RTS time after their primary surgery (15.62 vs 20.77 months, P < 0.01) compared with MLB pitchers but similar RTS times after their revision reconstruction (19.64 vs 18.48 months, P = 0.44). There was also no difference in return to play (RTP) rate overall after primary versus revision reconstruction ( P = 1.00). Major League baseball pitchers also had decreased RTS time after primary compared with revision reconstruction (15.62 vs 19.64 months, P < 0.01) but similar RTP rates ( P = 0.28). Finally, MLB pitchers had similar pitch breakdowns, velocities, and spin rates before and after their primary and revision repair or reconstruction. CONCLUSIONS: Both revision UCL repair and reconstruction can return pitchers to preinjury performance levels. Pitchers and teams should be properly counseled on realistic RTP times and postsurgery performance when discussing revision UCL surgeries.

The incidence of subclinical infection in patients undergoing revision shoulder stabilization surgery: a retrospective chart review.

BACKGROUND: Shoulder instability continues to be a common problem that is difficult to treat. Part of this difficulty can be attributed to the numerous postoperative complications that can impact the clinical course. Our study aims to primarily identify the incidence of subclinical infection in patients undergoing revision shoulder stabilization surgery and secondarily identify any risk factors for developing a subclinical infection. MATERIALS AND METHODS: From January 2012 to December 2022, 94 charts of patients who underwent revision surgery by the senior author after a previous arthroscopic or open stabilization surgery for shoulder instability were reviewed. All patients of any age who underwent either bony or soft tissue revision surgery, regardless of the number of previous surgeries or corticosteroid injections, were included. Patients were excluded if they had a previous infection in the shoulder, if there was no record of the procedures performed in the previous surgery, or if cultures were not available for review. For each patient, demographic information (age, sex, race, smoking status, previous corticosteroid injections, malnutrition, renal failure, liver failure, diabetes mellitus, immunocompromised status, and intravenous drug use), surgical information (procedures performed, type of surgery, and date of surgery), and culture results were recorded. RESULTS: Overall, 107 patients were included in our study. Twenty-nine patients (27.1%) had positive cultures (60 cultures in total). Twenty-six patients had positive Cutibacterium acnes (C. acnes) cultures. On average, C. acnes cultures took 10.65 days to turn positive, whereas 24 of 27 patients had cultures that were positive within 14 days of the culture being obtained. There was no difference in infection incidence rates between soft tissue and bony stabilization procedures (P = .86) or arthroscopic and open procedures (P = .59). Males were more than 5 times more likely than females to be culture positive in our cohort (93.1% vs. 73.1%, relative risk [RR] = 1.27, P = .03). Finally, 10 control cultures were taken from the operating room air environment (8 distinct surgeries had 1 control culture taken, whereas 1 surgery had 2), 2 of which were positive for C. acnes (both taken from the same patient operation). This patient had their shoulder cultures positive for C. acnes as well. CONCLUSION: More than a quarter of patients requiring revision surgery after shoulder stabilization procedures have a subclinical shoulder infection, with males being at a higher risk of developing an infection than females. Surgeons should always consider infection as a reason for the lack of clinical improvement and possibly needing revision surgery after shoulder stabilization. The prompt diagnosis and treatment of these infections could be vital in improving results after these surgeries.

Boundary Conditions Matter-Impact of Test Setup on Inferred Construct Mechanics in Plated Distal Femur Osteotomies.

The mechanics of distal femur fracture fixation has been widely studied in bench tests that employ a variety of approaches for holding and constraining femurs to apply loads. No standard test methods have been adopted for these tests and the impact of test setup on inferred construct mechanics has not been reported. Accordingly, the purpose of this study was to use finite element models to compare the mechanical performance of a supracondylar osteotomy with lateral plating under conditions that replicate several common bench test methods. A literature review was used to define a parameterized virtual model of a plated distal femur osteotomy in axial compression loading with four boundary condition sets ranging from minimally to highly constrained. Axial stiffness, fracture gap closure, and transverse motion at the fracture line were recorded for a range of applied loads and bridge spans. The results showed that construct mechanical performance was highly sensitive to boundary conditions imposed by the mechanical test fixtures. Increasing the degrees of constraint, for example, by potting and rigidly clamping one or more ends of the specimen, caused up to a 25× increase in axial stiffness of the construct. Transverse motion and gap closure at the fracture line, which is an important driver of interfragmentary strain, was also largely influenced by the constraint test setup. These results suggest that caution should be used when comparing reported results between bench tests that use different fixtures and that standardization of testing methods is needed in this field.

Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review.

OBJECTIVE: We present a review of revision anterior cruciate ligament (ACL) reconstruction in pediatric patients, discussing risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes. DATA SOURCES: PubMed, Cochrane, and Embase databases were queried for relevant articles about revision ACL topics. All types of manuscripts, including clinical studies, basic science studies, case series, current concepts reviews, and systematic reviews were analyzed for relevant information. Current concepts on risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes were synthesized. MAIN RESULTS: Surgical treatment should be individualized, and the graft type, fixation devices, tunnel placement, and complementary procedures (eg, extra-articular tenodesis) should be tailored to the patient's needs and previous surgeries. Rehabilitation programs should also be centered around eccentric strengthening, isometric quadriceps strengthening, active flexion range of motion of the knee, and an emphasis on closed chain exercises. Despite adherence to strict surgical and postoperative rehabilitation principles, graft refailure rate is high, and return to sports rate is low. CONCLUSION: Rerupture of the ACL in the pediatric population is a challenging complication that requires special attention. Diagnostic evaluation of repeat ACL ruptures is similar to primary injuries. Although outcomes after revision ACL reconstruction are expectedly worse than after primary reconstruction, athletes do return to sport after proper rehabilitation. Further research is needed to continue to improve outcomes in this high-risk population, aimed at continued knee stability, graft survivorship, and improved quality of life.

Liposomal Bupivacaine in Adductor Canal Blocks Before Total Knee Arthroplasty Leads to Improved Postoperative Outcomes: A Randomized Controlled Trial.

BACKGROUND: This study compares the use of liposomal bupivacaine (Exparel) versus ropivacaine in adductor canal blocks (ACB) before total knee arthroplasties (TKAs). METHODS: From the months of April 2020 to September 2021, 147 patients undergoing unilateral primary TKA were asked to participate in this prospective, double-blinded randomized controlled trial. Each patient received an iPACK block utilizing ropivacaine and was additionally randomized to receive an ACB with Exparel or Ropivacaine. For each patient, demographic information, inpatient hospital information, postoperative opioid use, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire scores were collected. RESULTS: Overall, 100 patients were included (50 in each cohort). The Exparel group had a lower hospital length of stay compared to the Control group (36.3 vs 49.7 hours, P < .01). Patients in the Exparel group reported an increased amount of Numerical Rating Scale pain score improvement at all postoperative timepoints. These patients also used a lower amount of inpatient opioids (40.9 vs 47.3 MME/d, P = .04) but a similar amount of outpatient opioids (33.4 vs 32.1 MME/d, P = .351). Finally, the Exparel group had increased improvements in all WOMAC subscores and total scores at most timepoints compared to the Control group (P < .05). CONCLUSION: Exparel peripheral regional nerve blocks lead to decreases in pain levels, shorter hospital lengths of stay, inpatient opioid usage, and improved WOMAC scores. Exparel can be safely used in ACB blocks before TKA to help in controlling postoperative pain and decrease length of stay.

Surgical timing for torsional ankle fractures is not associated with post-operative complications in patients with type II diabetes mellitus.

INTRODUCTION: Surgical stabilization of ankle fractures is one of the most commonly performed procedures in orthopedics, but these injuries can prove difficult to manage in patients with type II diabetes mellitus (DMII). The goal of this study is to determine if a correlation exists between surgical timing and complication rates among diabetic patients with ankle fractures. METHODS: This is a retrospective case-control study spanning from 2012 to 2019 including patients with DMII undergoing operative fixation for ankle fractures. The primary independent variable was surgical timing and the primary dependent variable was the rate of post-operative complications. RESULTS: The overall complication rate was 25.5% with 60% of these patients requiring repeat surgical intervention. The most common complication was superficial surgical-site infection. There was no significant difference in surgical timing between patients experiencing post-operative complication compared to those who did not. CONCLUSION: Among patients with DMII, we failed to show a correlation between surgical timing and post-operative complication.

Seasonal variability and age-related risk in youth trampoline injuries.

BACKGROUND: The aim of this work was to estimate the difference in severity between musculoskeletal trampoline park injuries (TPIs) and home trampoline injuries (HTI) and identify the factors that might mediate or modify that effect. METHODS: The National Electronic Injury Surveillance System database was used to identify musculoskeletal home trampoline injuries and TPIs in pediatric patients occurring in the 2009-2017 period. Injury mechanism and body region were inductively coded. The effect of TPI on risk of admission was estimated using a doubly robust logistic regression model for confounding adjustment. Adjustments were made for date, age, gender, injury mechanism, and body region. The comparative importance of injury mechanism and location and the effect modification of patient characteristics was explored using likelihood ratio tests. RESULTS: Trampoline park injuries were more likely to result in admission even in the model adjusted for injury mechanism and body region (odds ratio (OR) = 2.12 [1.30, 3.45]). Injuries sustained from falling off the trampoline were associated with significantly fewer hospitalizations (OR = 0.119 [0.029, 0.495]) than injuries from falling while on the trampoline. Patient age significantly modified the effect of setting on risk of admission (P = 0.042). Adolescents demonstrated an increased risk at trampoline parks (15 years old OR = 3.23 [1.38, 7.56]), whereas younger children demonstrated a marginally lower risk (5 years old OR = 0.77 [0.44, 1.35]). CONCLUSIONS: Trampoline park musculoskeletal injuries demonstrate an increased risk of admission even after rigorous adjustment for confounding. Injuries to the proximal limbs were associated with a much higher risk of admission than distal injuries. Adolescents face an increased risk of admission after TPI, underscoring the importance of public health interventions that target this age group.

The value of lateral glenohumeral offset in predicting construct failure in proximal humerus fractures following internal fixation.

BACKGROUND: Proximal humerus fractures are the third most common osteoporosis defining injury in the United States, yet operative fixation of these injuries remains technically challenging. Although several modifiable and nonmodifiable risk factors are correlated with failure of proximal humerus fixation, no study has investigated whether failure to restore glenohumeral offset plays a part in fixation failure. The goals of this study are: (1) to determine if lateral glenohumeral offset (LGHO) and humeral head diameter (HHD) can be measured radiographically with accuracy between observers, (2) to observe whether there is a correlation between failure to operatively restore an anatomic LGHO:HHD ratio and failure of fixation, and (3) if there is a correlation, can any recommendations be made in regard to the ideal LGHO:HHD ratio. METHODS: Retrospective review found 183 patients meeting inclusion criteria who underwent operative fixation for proximal humerus fractures between 2005 and 2018. Patients suffering construct failure requiring reoperation were compared with clinically successful surgeries on the basis of age, sex, fracture morphology, head-shaft angle, smoking history, presence or absence of a calcar screw, and LGHO:HHD ratio. The groups were compared using a combination of Student t-tests, χ2, and bivariate and multivariate logistic regression analyses where appropriate. The Student t-test and intraclass correlation coefficient were both used to assess interobserver reliability. RESULTS: We found that LGHO and HHD can be measured by independent observers accurately (intraclass correlation coefficient = 0.80, 95% confidence interval: 0.65-0.89). Patients suffering implant failure had a significantly lower LGHO:HHD ratios compared with those who did not (0.94 vs. 1.03, P ≤ .001). The LGHO:HHD ratio was an independent predictor of implant failure even after controlling for other potential risk factors. Patients with an LGHO:HHD of 1.0 or above have a <10% chance of failure compared with a 20% risk with a ratio of 0.9 and a 40% risk at 0.8. CONCLUSION: We found the LGHO:HHD ratio to be an independent predictor for construct failure after plate and screw fixation of proximal humerus fractures. Efforts should be made to restore an anatomic ratio of at least 1.0 to minimize the risk of failure.

Union rate, complication rate, and opioid usage after Vancouver B periprosthetic femur fractures: a comparison of fracture types.

INTRODUCTION: Periprosthetic femur fractures are complex injuries that can be difficult to treat and recover from. With a growing number of total hip arthroplasties (THA) and revision arthroplasties being performed in an aging population, the incidence of these injuries is on the rise. Multiple studies exist detailing outcomes associated with periprosthetic femur fractures after THA, but no study has directly compared the post-operative course between fracture types as classified by the Vancouver classification system. This study compares the three Vancouver B fracture types to see if any type is associated with an increase in post-operative complications than others. MATERIALS AND METHODS: This retrospective chart review was conducted at a suburban orthopedic surgery department. Overall, 122 patients who presented to our hospital with periprosthetic proximal femur fractures after hip arthroplasty over the past 13 years were reviewed. Patients were included if they underwent surgical stabilization of their femur fracture. Patients were excluded if they underwent non-operative treatment or had missing chart information. For each patient, demographic information, fracture information, surgical information, post-operative course, and post-operative opioid usage were recorded and compared among groups. RESULTS: Overall, 88 fractures were included. Fifty-five (62.5%) were Vancouver type B1, 27 (30.7%) were Vancouver type B2, and 6 (6.8%) were Vancouver type B3. Most of our patients were female (n = 62, 70.5%) and older than 81 years of age (n = 53, 60.2%) with uncemented prosthesis (n = 83, 94.3%). All three fracture groups had statistically similar union rates (p = 0.77), infection rates (p = 0.32), subsequent fractures (p = 0.63), repeat surgeries (p = 0.64), and post-operative opioid use (measured in milli-morphine equivalents) after surgical stabilization (p = 0.96). CONCLUSIONS: While periprosthetic femur fractures after hip arthroplasty are associated with high complication rates and poor outcomes, there is no difference in union rate, infection rate, subsequent fractures, repeat surgery rate, and opioid usage between the different Vancouver B fracture types. LEVEL OF EVIDENCE: Prognostic level III.

Risk factors for complications and return to the emergency department after interscalene block using liposomal bupivacaine for shoulder surgery.

BACKGROUND: Exparel (liposomal bupivacaine) has recently gained favor for use in interscalene regional blocks for shoulder surgery. While effective for pain relief, this does have adverse effects that can lead to postoperative emergency department (ED) visits. This study aimed to identify any patient risk factors that are associated with complications leading to ED return visits owing to interscalene blocks using Exparel before shoulder surgery. METHODS: A retrospective chart review was performed for all patients undergoing shoulder surgery with an Exparel interscalene block in an 8-month period. For each patient, demographic information, comorbidities, type of block, postoperative complications, ED return visits, and readmissions were recorded. The 5-factor modified Frailty Index score and the Charlson Comorbidity Index score were calculated. Univariate and multivariate logistic regressions were conducted to identify risk factors associated with increased complications and return to the ED. RESULTS: Overall, 352 patients were included; most patients were men, were aged between 51 and 70 years, and had a body mass index of 25.0-35.0. Postoperative complications related to the Exparel interscalene block occurred in 58 patients (16.5%), including 37 minor complications (10.5%) and 21 major complications (6.0%) that led to return ED visits. Univariate analysis yielded American Society of Anesthesiologists (ASA) score (P = .03) as a significant predictor of minor complications. Multivariate logistic regression analysis yielded ASA score (P = .096; odds ratio, 1.64) as trending toward being a significant risk factor for minor complications. Univariate analysis yielded age (P = .006), ASA score (P = .009), and Charlson Comorbidity Index score (P = .002) as significant predictors of major complications. Multivariate logistic regression analysis yielded ASA score (P = .049; odds ratio, 2.25) as the only significant risk factor for major complications. CONCLUSION: Surgeons and anesthesiologists should strongly consider a patient's ASA score, in addition to his or her pulmonary and cardiac history, when deciding whether the patient is an appropriate candidate for an interscalene regional block using Exparel for shoulder surgery.

Surgical fixation of pilon injuries: a comparison of the anterolateral and posterolateral approach.

PURPOSE: This study looks to compare patient outcomes in those with pilon fractures fixed with the anterolateral approach versus those with the posterolateral approach. METHODS: 135 patient charts of those with surgically treated pilon fractures over a 7-year period were retrospectively reviewed, recording demographic information, fracture description, surgical intervention timeline, operative outcomes, patient outcomes, and complication rates. RESULTS: Of the 44 included patients (32 anterolateral and 12 posterolateral), most were older than 40 years of age (65.9%) and male (63.6%). There was no difference seen between anterolateral approach and posterolateral approach tourniquet times (p = 0.80), operating room time (p = 0.40), or estimated blood loss (p = 0.73). There was also no reported difference in decrease in Numerical Rating Scale pain scores (p = 0.38), FOTO (Focus on Therapeutic Outcomes) percent increase (p = 0.13), active flexion-extension axis range of motion (p = 0.35), or inversion-eversion axis (p = 0.25) range of motion after an anterolateral approach versus a posterolateral approach. Finally, statistically similar complication rates (p = 0.75) were seen between anterolateral and posterolateral approaches, but patients who underwent a posterolateral approach surgical fixation were trending towards significantly using more post-operative outpatient opioid medications for pain control compared to those who underwent surgical fixation with an anterolateral approach (p = 0.09). CONCLUSIONS: Pilon injuries that lend themselves to anterolateral fixation have similar outcomes peri-operatively and post-operatively compared to injuries lending to posterolateral fixation. Both approaches can be used as dictated by the injury not fearing poorer outcomes or increased complication rates. However, surgeons must be wary of high complication rates associated with all pilon injury patterns. LEVEL OF EVIDENCE: Therapeutic Level IV.

Reducing Hypotension and Acute Kidney Injury in the Elective Total Joint Arthroplasty Population: A Multi-Disciplinary Approach.

BACKGROUND: When critically analyzing our hospital system's rate of hypotension and acute kidney injury (AKI) after total joint arthroplasty, our incidence rates (14.54%, 6.02%) were much higher than our peers (7.17%, 2.03%) and national rates (2.0%, 3.3%). We present a multi-disciplinary management intervention that aimed to decrease overall complication rates. METHOD: A multi-disciplinary team implemented a protocol at our suburban hospital to limit complication rates after joint replacement surgery. Hypotension, AKI, length of stay (LOS), re-admission rates, and mortality rates were compared before the protocol was implemented, after protocol implementation, and after protocol integration into our EMR (electronic medical record). RESULTS: In total, 1233 patients over 36 months were followed. Hypotension rates after protocol implementation into EMR (group 3) were significantly lower than rates before the protocol (group 1) (P = .002), with rates after protocol implementation without EMR (group 2) trending toward a significant decrease from group 1 (P = .064). AKI rates in group 3 were significantly lower than group 1 (P = .000) and group 2 (P = .006). No difference was seen in hypotension rates between group 2 and 3 (P = .792) or AKI rates between group 1 and 2 (P = .533). Finally, no significant difference was seen between groups in LOS (P = .560), re-admission rates (P = .378), and mortality rates (all 0.0%). CONCLUSION: By implementing a comprehensive electronic protocol consisting of pre-operative risk stratification, multi-disciplinary medical optimization, and an evolving post-operative management plan, significant decreases in hypotension and AKI can be seen.

Ulnar collateral ligament repair in professional baseball players.

BACKGROUND: While initial reports of surgical repair of ulnar collateral ligament tears are promising, studies detailing post-repair outcomes are lacking. This study explores the effectiveness of ulnar collateral ligament (UCL) repair in returning professional baseball players to their pre-injury level of play. Our hypothesis is that professional baseball players undergoing UCL repair will have successful outcomes and high return to sport rates after surgery. METHODS: Publicly available databases were utilized to search for data on professional baseball players who underwent UCL repair from 2016 to 2021. Players undergoing primary UCL repair with an internal brace were included. Amateur players were excluded as were those undergoing revision UCL repair or UCL reconstruction. RESULTS: Of the 11 pitchers who underwent UCL repair, minor league baseball (MiLB) pitchers returned to the sport at an average of 17.5 months. MiLB pitchers had similar earned run averages (ERAs), games played, innings pitched, and walks plus hits per inning pitched ratios (WHIPs) before and after surgery. Four major league baseball (MLB) pitchers (80%) returned to the sport at 9.55 months. MLB pitchers played fewer games and pitched fewer innings than before the surgery, but their ERAs and WHIPs were similar before and after surgery. Pitch velocity and spin rates after surgery varied based on pitch type. The seven positional players who underwent UCL repair showed no differences in batting or fielding performance before and after surgery. CONCLUSIONS: UCL repair can successfully return both pitchers and positional players at both the MiLB and MLB levels to play at pre-injury performance levels. Repair can be considered as an option for qualifying injuries in players hoping to maximize performance after surgery with minimal recovery time. Level of Evidence: IV.

Perceptions of Orthopaedic Sports Medicine Surgeons About Medical Cannabidiol Use: A Survey Study.

INTRODUCTION: Multiple studies exist identifying cannabidiol (CBD) as an effective part of an orthopaedic patient's pain regimen; however, there is a paucity of studies elucidating orthopaedic surgeons' perception of the use and prescription of CBD in the medical setting. This study surveys orthopaedic sports medicine surgeons about their previous education on and current perceptions and usage of CBD in their medical practice. METHODS: Between April 2023 and July 2023, orthopaedic sports medicine surgeons from across the country were surveyed. This survey was designed in hopes of identifying physician perceptions and current use of CBD as well as their previous education and training on its use. RESULTS: Overall, 75 orthopaedic surgeons responded. More than three-fourths of responders had not received formal education on medical CBD use, nor did they have partners or colleagues who used CBD in their practice. More than half of all surgeons believed that there is a stigma associated with CBD use. A higher proportion of surgeons from CBD legal states recommended CBD to help patients control their pain (53.7% vs. 37.5%). Less than 15% of responders believed that CBD can adversely affect surgical outcomes. Finally, four-fifths of all responders believed that CBD is easy to legally access and affordable to buy by patients who desire it. DISCUSSION: The relative novelty of CBD inclusion in medicine has led to a lack of early education and overall experience with its use among orthopaedic sports medicine surgeons. Still, surgeons believe that CBD is a safe and effective option to control pain. As surgeons continue to gain more familiarity and trust with CBD's medical uses over time, it has the potential to be a mainstay in orthopaedic multimodal pain regimens.

Mesenchymal stem cells in orthopaedics: A systematic review of applications to practice.

Background: Mesenchymal stem cells (MSCs) have alluring interest for clinical use in orthopaedics based on their therapeutic potential through directed pluripotent differentiation. While many studies and reviews have discussed the importance of this approach, few have reduced it to practice using reproducible criteria. This study was designed to systematically review and synthesize current evidence regarding clinical use of clearly defined MSCs in orthopaedics. Methods: Studies of any level of evidence and sample size, regardless of MSC source, orthopaedic pathology, and patient population, were reviewed. In vitro and animal studies, and articles written in a language other than English, were excluded. Studies were then screened for final inclusion based on documented MSC verification using testing of the therapeutic cellular population for at least one of the following phenotypic markers: CD 73, CD 90, and CD 105. In addition, therapeutic cellular populations could not have higher percentages of CD34, CD45, CD14, HLA-DR, CD11b, or CD19 markers compared to the aforementioned markers. From each studies' results, sample size, procedural methods, radiographic outcomes, clinical outcomes, patient-report outcomes (PROs), and adverse events were tabulated. Results: Overall, 43 studies were included. Twenty-three studies (53.5 %) derived their MSCs from iliac crest bone marrow while 12 (27.9 %) studied adipose-derived MSCs. Included studies explored MSC use in Osteoarthritis, Cartilage Defects, Osteonecrosis, Bone Defects and Nonunions, Spine, and Other. MSC use in all pathologies led to improvement of studied radiographic, clinical, and patient-reported outcomes. Conclusions: Mesenchymal stem cells have proven to have successful and safe uses in multiple orthopaedic applications, including treating chondral defects, osteoarthritis, and osteonecrosis. A stringent and reproducible process for evaluating obtained human stem cells using CD markers for clinical use is necessary to both evaluate previous studies and continue to evaluate for future uses. Level of evidence: Level V.

The evolution of anesthetic management for total knee arthroplasty (TKA) patients: A hospital network experience.

Introduction: In the face of an ongoing opioid epidemic and an aging population, the utilization of a successful multimodal pain regimen in patients undergoing total knee arthroplasty (TKA) is vital. This study looks to explore the effect of different types of anesthesia in addition to a multimodal pain regimen on post-operative outcomes after undergoing TKA. Materials and methods: From January 2016 to December 2022, 783 charts of patients undergoing an elective TKA were reviewed. Patients undergoing primary, isolated, and unilateral TKA procedures were included. Patients were grouped into three study arms: 1) general anesthesia (GA); 2) general anesthesia with a local anesthetic adductor canal block (GA + ACB); 3) spinal anesthesia with local anesthetic adductor canal block (SA + ACB). Patients who received other anesthesia types or received ACB utilizing liposomal bupivacaine were excluded. Results: Of the 420 included patients, 63 patients received GA, 148 GA + ACB, and 209 SA + ACB. Patients in the SA + ACB group had a shorter LOS compared to both the GA + ACB and GA groups (p < 0.01. The SA + ACB group had the lowest daily average OME requirement (p < 0.01). Finally, patients in the SA + ACB group had the lowest average total cost of $11,683.91 (p < 0.01). Discussion: Spinal anesthesia with adductor canal block is effective in decreasing opioid usage and improving postoperative outcomes after TKA. Surgeons and anesthesiologists should look to utilize this anesthetic option along with a multimodal regimen when deciding how to best manage postoperative pain after TKA procedures. Level of evidence: Level III.

Trampolines Versus Playgrounds - A Comparative Assessment of Pediatric Fractures Sustained From Recreational Play.

INTRODUCTION: Using the Pediatric Health Information System, this study compared the relative severity of fractures sustained from trampolines with those from other playground equipment. METHODS: Pediatric patients were identified in the Pediatric Health Information System with trampoline-related injuries (TRIs) or playground-related injuries (PRIs) diagnosed as fractures. Adjustments were made for hospital, year of injury, sex, age, race, median household income, and rurality through propensity score weighting. Four injury-related outcome measures were examined as a proxy for injury severity. RESULTS: A total of 133,232 patients met inclusion criteria. In unadjusted univariate analyses, TRIs were associated with greater odds of severe fracture and lower odds of receiving surgical treatment (OR = 0.954) compared with PRIs. After adjustment, TRIs sustained in late childhood and adolescence were more likely to receive surgical management (OR = 1.092 and OR = 1.192, respectively) while TRIs sustained in younger children were less likely (OR = 0.607) than PRIs. DISCUSSION: Youths in late childhood and adolescence are at increased odds of undergoing surgical management after trampoline fractures. Beyond underscoring the risks of trampoline play, our results highlight the importance of considering age in recreational injury epidemiology and the public health safety initiatives aimed at specific age groups.

A Biological Spacer to Treat Irreparable Rotator Cuff Tears: A Biomechanical Study Utilizing a Secured Versus Unsecured Tensor Fascia Lata Graft.

BACKGROUND: Designed to help treat pain and loss of function after rotator cuff repair, allograft spacer procedures utilize a graft to act as a spacer in the subacromial space, decreasing pain from impingement of the greater tuberosity on the acromion at the extremes of overhead motion. PURPOSE: To evaluate the biomechanical characteristics of secured versus unsecured tensor fascia lata allografts used in an allograft spacer procedure. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 8 fresh-frozen cadaveric shoulder specimens were used. There were 4 conditions tested: (1) intact rotator cuff, (2) stage III rotator cuff tear (complete supraspinatus tendon and superior one-half of the infraspinatus tendon), (3) unsecured tensor fascia lata graft, and (4) secured tensor fascia lata graft. Both superior and posterior translation of the humeral head were calculated in each condition. A 4-cm × 5-cm × 6-mm tensor fascia lata graft was used in the subacromial space to act as a spacer. Grafts were secured at the lateral edge of the native rotator cuff footprint with 2 knotless anchors. RESULTS: With unbalanced loading, both secured and unsecured grafts varied in their ability to limit superior and posterior translation at various rotation angles back to levels seen with intact rotator cuffs at 0° and 20° of abduction. During balanced loading, both unsecured and secured grafts limited superior and posterior translation more than those seen in the rotator cuff-deficient condition (P < .01) and similar to those seen in the intact condition (P > .05). The secured and unsecured grafts allowed similar amounts of translation at every position with both unbalanced and balanced loading (P > .05). Finally, total graft motion was <7 mm in all positions. CONCLUSION: Unsecured tensor fascia lata grafts were biomechanically equivalent to secured grafts when used during allograft spacer procedures. CLINICAL RELEVANCE: While both grafts were successful at limiting superior and posterior translation of the humeral head during early range of motion, the unsecured graft represents a cheaper, easier option to utilize during allograft spacer procedures.

Comparative analysis of acute blood loss anemia in robotic assisted vs. manual instrumented total knee arthroplasty.

Introduction: Robotic assisted total knee arthroplasty has become an increasingly popular technique over the past several years. Manual total knee arthroplasty can be associated with acute blood loss anemia. Instrumentation of the femoral canal with the alignment guide may in part contribute to this blood loss. Because the femoral canal is not entered during robotic assisted total knee arthroplasty, the blood loss may be lower compared to that seen in manual total knee arthroplasty. The purpose of this study was to determine if acute blood loss is greater in manually instrumented total knee arthroplasty versus robotic assisted total knee arthroplasty. Materials and methods: This retrospective cohort study was performed in a large tertiary academic hospital network by two fellowship trained surgeons. Patients underwent either robotic assisted or manually instrumented total knee arthroplasty and were assessed for postoperative acute blood loss anemia, defined as hemoglobin <13 g/dL for males or <12 g/dL for females plus a 2 g/dL drop from preoperative levels, as well as postoperative drop in hemoglobin. Results: A total of 75 patients were included in each study arm. There was no significant difference (p > 0.05) in postoperative hemoglobin in robotic assisted (2.1 g/dL) compared to manually instrumented total knee arthroplasty (2.1 g/dL). There was no significant difference in the incidence of postoperative acute blood loss anemia between robotic assisted (45 %) and manually instrumented total knee arthroplasty (39 %). Higher BMI and increased age were protective against postoperative drop in hemoglobin. These protective effects were not significant when controlling for confounding variables. Surgical time was significantly longer for robotic assisted (99 min) versus manually instrumented total knee arthroplasty (86 min) (p < 0.001). Conclusions: There is no significant difference in acute blood loss when comparing patients undergoing robotic assisted and manually instrumented total knee arthroplasty.