Pain and Opioid use Following Total Knee Arthroplasty: Psycho-Social Factors are More Predictive Than Pharmacogenomics.

BACKGROUND: This prospective, observational study was designed to assess the phenotype variation of the genes associated with pain and opioid use following total knee arthroplasty (TKA) in comparison to psycho-social elements. METHODS: Preoperative demographic data and Patient-Reported Outcomes Measurement Information System-43 scores were obtained on 305 elective TKA patients. Patient visual analog scale pain scores and opioid use were extracted from the hospital record. Following discharge, participants completed a daily log of visual analog scale pain score, and medications used over 30 days. Pharmacogenomic testing was performed for three genes, CYP2D6, COMT, and OPRM1, which are involved in the opioid pathway and pain modulation. RESULTS: Other than increased pain seen in the COMT high activity group while in the hospital, none of the phenotype variations of the three genes were significantly associated with the participants' pain or opioid use. The Patient-Reported Outcomes Measurement Information System-43 domains of pain interference and anxiety were significantly associated with pain and opioid use using multiple logistic regression. CONCLUSIONS: Pharmacogenomic testing in this study was not predictive of pain and opioid use following TKA compared with psycho-social variables.

Arthroscopic repair of degenerative medial meniscus tears in patients aged over 45 years resulted in favorable clinical outcomes and low clinical failure rates at a minimum 2-year follow-up.

PURPOSE: This study aimed to investigate clinical and radiological results of arthroscopic repair for isolated medial degenerative meniscus tears (DMTs) in patients over 45 years old at a minimum 2-year follow-up. METHODS: From 2013 to 2017, patients aged over 45 years with isolated medial DMT refractory to conservative management or with true mechanical symptoms who had undergone arthroscopic repair were retrospectively reviewed. Arthroscopic meniscus repair was performed using all-inside or all-inside and inside-out technique in combination with bone marrow venting procedure. Tear patterns were classified according to arthroscopic findings. Magnetic resonance imaging (MRI) and outcome evaluations, including Lysholm score, Tegner activity score, and International Knee Documentation Committee (IKDC) score, were evaluated preoperatively and at the final follow-up. International Cartilage Repair Society grades of the medial compartments and MRI signal at tear sites were assessed preoperatively and at the final follow-up. A grade 0 to 2 signal at the repair site suggested a healed meniscus, whereas a grade 3 signal suggested an unhealed meniscus. Clinical failure was determined according to Barrett criteria. RESULTS: Twenty-seven patients (mean age, 57.7 ± 7.4 years) were enrolled. The mean follow-up was 52.0 ± 15.6 months. Among tear patterns, 48% were complex tears, 30% were horizontal tears, and 22% were other patterns. The mean Lysholm score and IKDC score significantly improved from 53 ± 25 to 89 ± 15 (p < 0.001) and 34 ± 24 to 72 ± 15 (p < 0.001) at the final follow-up, respectively. The median Tegner activity score significantly improved from 1 (range 1-4) to 4 (range 2-7, p < 0.001). Three (11%) patients were considered clinical failures, and five patients (19%) had cartilage lesion progression. At the final follow-up, MRI showed grade 0 in one (4%) patient, grade 1 in nine (33%) patients, grade 2 in six (22%) patients, and grade 3 in eleven (41%) patients. CONCLUSION: Arthroscopic repair of isolated medial DMT refractory to conservative management or with true mechanical symptoms in patients aged over 45 years had good to excellent clinical outcomes with low clinical failure rates, despite unhealed menisci being observed on MRI in 41% of patients at a mean 4.3-year follow-up. Arthroscopic repair could be a treatment option for these patients. LEVEL OF EVIDENCE: IV.

What do positive and negative Cutibacterium culture results in periprosthetic shoulder infection mean? A multi-institutional control study.

BACKGROUND: Deep tissue culture specimens obtained at the time of revision shoulder arthroplasty are commonly positive for Cutibacterium. Clinical interpretation of positive cultures can be difficult. This was a multi-institutional study evaluating the accuracy of cultures for Cutibacterium using positive control (PC) and negative control (NC) samples. The relationship between time to culture positivity and strength of culture positivity was also studied. METHODS: Eleven different institutions were each sent 12 blinded samples (10 PC and 2 NC samples). The 10 PC samples included 2 sets of 5 different dilutions of a Cutibacterium isolate from a failed total shoulder arthroplasty with a probable periprosthetic infection. At each institution, the samples were handled as if they were received from the operating room. Specimen growth, time to culture positivity, and strength of culture positivity (based on semiquantitative assessment) were reported. RESULTS: A total of 110 PC samples and 22 NC samples were tested. One hundred percent of specimens at the 4 highest dilutions were positive for Cutibacterium. At the lowest dilution, 91% of samples showed positive findings. Cutibacterium grew in 14% of NC samples. Cutibacterium grew in PC samples at an average of 4.0 ± 1.3 days, and all of these samples showed growth within 7 days. The time to positivity was significantly shorter (P < .001) and the strength of positivity was significantly higher (P < .001) in true-positive cultures compared with false-positive cultures. CONCLUSIONS: This multi-institutional study suggests that different institutions may report highly consistent rates of culture positivity for revision shoulder arthroplasty samples with higher bacterial loads. In contrast, with lower bacterial loads, the results are somewhat less consistent. Clinicians should consider using a shorter time to positivity and a higher strength of positivity as adjuncts in determining whether a tissue culture sample is a true positive.

Evaluation of rotator cuff abduction moment arms for superior capsular reconstruction and reverse total shoulder arthroplasty.

PURPOSE: The rotator cuff (RC) muscles contribute to dynamic stability and rotational actions of the glenohumeral joint. Moment arm can be used to demonstrate the potential work a muscle contributes to a musculoskeletal joint rotation. This study aimed to understand the moment arm contributions of the RC muscles and explore changes following a complete supraspinatus tear treated with either superior capsular reconstruction (SCR) or reverse total shoulder arthroplasty (rTSA). METHODS: Five fresh-frozen cadaveric specimens were prepared and mounted in an apparatus where each intact RC muscle was held in tension with a line of action toward its origin on the scapula. Mean moment arms for each muscle were determined experimentally based on Optotrak data collected during cadaveric shoulder arm abduction. RESULTS: Using ANOVA testing, our analysis demonstrated significant differences (p < 0.001) in infraspinatus and teres minor moment arms after rTSA compared to the intact shoulder model. After SCR, significant differences (p < 0.001) were seen in teres minor, with these differences being statistically similar to the changes seen in teres minor after rTSA. Subscapularis showed no significant difference in moment arm values between the models (p = 0.148). CONCLUSION: Our results illustrate that mean moment arms were preserved in the RC muscles after complete supraspinatus tear. This study also shows evidence that subscapularis function may be maintained after SCR or rTSA. After SCR, infraspinatus may maintain similar abduction ability compared to the anatomical shoulder, while teres minor ability may increase. Infraspinatus may have decreased abduction ability after rTSA while teres minor may have increased ability.

Are Comorbidities Affecting Rotator Cuff Repair Outcomes? A Retrospective Review of Postoperative Costs and complications.

Our study examines the effect of comorbidities on rotator cuff repair (RCR) postoperative costs and complication rates. A retrospective review of patients receiving RCRs from 2008-2016 using the PearlDiver database was performed. We evaluated the effect of major comorbidities on postoperative costs and complications within one year of surgery. In total, 8,747 patients underwent RCR. Patients with no comorbidities had a 6-month and 12-month postoperative cost of $3,534 and $3,853, respectively. Patients with one comorbidity had 6-month postoperative costs ranging from $2,623 to $3,466 and 1-year postoperative costs ranging from $2,992 to $5,906. Patients with 3+ comorbidities receiving arthroscopic RCR had the highest complication rates at 1-, 3- and 6-month intervals (11.8%, 19.7% and 26.8%, respectively) compared to those with no comorbidities (8.1% [p = 0.139], 12.7% [p = 0.022] and 15.9% [p = 0.001], respectively). Patients with isolated comorbidities likely require similar healthcare utilization to those without, but patients with 3+ comorbidities risk greater complications and higher post-operative costs. (Journal of Surgical Orthopaedic Advances 30(1):024-029, 2021).

Trans-coracoacromial Ligament Glenohumeral Injection With Arthroscopic Confirmation.

PURPOSE: To arthroscopically evaluate the trans-coracoacromial ligament glenohumeral (GH) injection technique by understanding intra-articular needle-tip placement and potential misplacement and complications. METHODS: The technique relies on the palpation of 3 bony landmarks: anterolateral corner of the acromion, superolateral border of the coracoid tip, and curved depression of the distal clavicle. The skin entry site lies on the line connecting the curved depression of the distal clavicle and superolateral border of the coracoid tip, two-thirds of the way from the former and one-third of the way from the latter. The direction of the needle is perpendicular to the triangle formed by the 3 bony landmarks. The technique is used to insufflate the GH joint at the start of shoulder arthroscopy procedures with patients in the beach-chair position. Saline solution is injected, and the position of the needle tip in the GH joint is evaluated arthroscopically. An injection is considered successful if saline solution can be injected and the needle tip can be visualized intra-articularly. RESULTS: This study enrolled 195 patients undergoing shoulder arthroscopy. Successful needle placement in the GH joint occurred in 179 patients (91.8%); placement occurred through the rotator interval in 122 of these, adjacent or through the long head of the biceps tendon in 41, through the upper subscapularis or anterior supraspinatus in 13, and through the anterior labrum in 3. Regarding the 16 failures (8.2%), the needle position did not allow saline solution to be injected because of high resistance in 3 patients whereas the needle tip was not visualized in 13. The needle tip was presumed to rest within the subscapularis muscle or tendon or the labrum in 10 failed injections. CONCLUSIONS: The trans-coracoacromial ligament injection technique showed a high success rate (91.8%) in anesthetized patients about to undergo arthroscopy, whereas the failed injections mainly occurred because the needle was inserted into the subscapularis or labrum. This technique can be used for awake patients with different diagnoses in multiple settings. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Coracoid morphology is not associated with subscapularis tears.

BACKGROUND: The observation of the roller-wringer effect fueled the idea that coracoid morphology is related to subscapularis pathology. We aimed to examine this relationship, specifically focusing on how the coracohumeral distance (CHD) and 2 new metrics of coracoid morphology relate to subscapularis tears. METHODS: In this retrospective study, we identified consecutive patients 45 years or older who underwent shoulder arthroscopy for any indication. We blindly reviewed preoperative magnetic resonance imaging studies of each patient, measuring the CHD, lateral extent (LE), and caudal extent (CE) of the coracoid process. Patients' subscapularis condition was assessed via operative reports; stratified according to Lafosse grade criteria; and compared for differences in the CHD, LE, and CE by 1-way analysis of variance and 2-tailed t tests. RESULTS: The study included 201 patients. Of these, 112 had no evidence of subscapularis injury, whereas Lafosse grade I injuries were identified in 52 patients; grade II, in 19; and grades III-V, in 18. The CHD, LE, and CE were not correlated with subscapularis injury (CHD, P = .36; LE, P = .36; and CE, P = .13). CONCLUSIONS: We found no correlation between subscapularis injury and the CHD, LE, and CE. These findings support the idea that coracoid morphology may not be a cause of subscapularis pathology and suggest that coracoplasty may not be necessary prophylactically or as part of subscapularis repair.

Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response.

BACKGROUND: There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies. METHODS: The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds. RESULTS: No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate. CONCLUSION: There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

Editorial Commentary: "A Rush of Blood From the Head"-Predicting and Preventing Cerebral Deoxygenation During Beach-Chair Shoulder Surgery.

Orthopaedic surgeons and anesthesiologists need to work together to avoid catastrophic cerebral ischemic injuries when surgery is performed with patients in the beach-chair position. Patient risk factors include body mass index but are not strongly predictive. Anesthetic management choices, such as regional anesthesia with sedation or normotensive general anesthesia with gradual and limited head elevation and hypercapnia, can significantly decrease the risk of cerebral deoxygenation.

Tibiofemoral Contact Mechanics With Horizontal Cleavage Tears and Treatment of the Lateral Meniscus in the Human Knee: An In Vitro Cadaver Study.

BACKGROUND: Partial meniscectomy is one of the most commonly performed orthopaedic procedures for a meniscus tear. Decreased contact area and increased contact pressure have been seen in partial meniscectomies from treatment of various types of meniscal tears; however, the biomechanical effect of a horizontal cleavage tear in the lateral meniscus and subsequent treatment are unknown. QUESTIONS/PURPOSES: This study asked whether a horizontal cleavage tear of the lateral meniscus, resecting the inferior leaf, and further resecting the superior leaf would (1) decrease contact area and (2) increase peak contact pressure. METHODS: Eleven fresh-frozen human cadaveric knees were evaluated under five conditions of intact meniscus, horizontal cleavage tear, inferior leaf resection, and resection of the inferior and superior leaves of the lateral meniscus. Tibiofemoral contact area and pressure were measured at 0° and 60° knee flexion under an 800-N load, normalized to that at the intact condition of the corresponding knee flexion, and compared across the five previously described conditions. RESULTS: At 0° knee flexion, normalized contact area with inferior leaf resection (65.4% ± 14.1%) was smaller than that at the intact condition (100% ± 0.0%, p < 0.001); smaller than horizontal cleavage tear (94.1% ± 5.8%, p = 0.001) contact area; and smaller than repaired horizontal tear (92.8% ± 8.2%, p = 0.001) contact area. Normalized contact area with further superior leaf resection (50.5% ± 7.3%) was smaller than that at the intact condition (100% ± 0.0%, p < 0.001); smaller than horizontal cleavage tear (94.1% ± 5.8%, p < 0.001) contact area; and smaller than repaired horizontal tear (92.8% ± 8.2%, p < 0.001) contact area. At 60° flexion, normalized contact area with inferior leaf resection (76.1% ± 14.8%) was smaller than that at the intact condition (100% ± 0.0%, p = 0.004); smaller than horizontal cleavage tear (101.8% ± 7.2%, p = 0.006) contact area; and smaller than repaired horizontal tear (104.0% ± 13.3%, p < 0.001) contact area. Normalized contact area with further superior leaf resection (52.1% ± 16.7%) was smaller than that at the intact condition (100% ± 0.0%, p < 0.001); smaller than horizontal cleavage tear (101.8% ± 7.2%, p < 0.001) contact area; and smaller than repaired horizontal tear (104.0% ± 13.3%, p < 0.001) contact area. At 60° flexion, contact area with both leaf resection (52.1% ± 16.7%) was smaller than that with inferior leaf resection (76.1% ± 14.8%, p = 0.039). At 0° knee flexion, peak pressure increased to 127.0% ± 22.1% with inferior leaf resection (p = 0.026) and to 138.6% ± 24.3% with further superior leaf resection (p = 0.002) compared with that at the intact condition (100% ± 0.0%). At 60° flexion, compared with that at the intact condition (100% ± 0.0%), peak pressure increased to 139% ± 33.6% with inferior leaf resection (p = 0.035) and to 155.5% ± 34.7% (p = 0.004) with further superior leaf resection. CONCLUSIONS: Resection of the inferior leaf or both leaves of the lateral meniscus after a horizontal cleavage tear resulted in decreased contact area and increased peak contact pressure at 0° and 60° knee flexion. CLINICAL RELEVANCE: In vitro resection of one or both leaves of a horizontal cleavage tear of the lateral meniscus causes increases in peak pressure, consistent with other types of partial meniscectomies associated in a clinical setting with excessive loading and damage to knee cartilage. Clinical outcomes in patients undergoing partial leaf meniscectomy could confirm this theory. Avoidance of resection may be relatively beneficial for long-term function. The findings of this in vitro study lend biomechanical support for nonoperative management.

Arthroscopic treatment successfully treats posterior elbow impingement in an athletic population.

PURPOSE: Posterior elbow impingement can cause disabling pain and limited motion during activities involving elbow extension. Less understood is whether arthroscopic treatment, compared to open surgery, can result in effective management of pain, loss of range of motion, and return athletes to previous levels of activity. This study determined whether arthroscopic debridement is a safe and effective treatment for posterior elbow impingement and whether it enables athletes to return to a previous level of function. METHODS: A retrospective review of 36 consecutive patients that underwent arthroscopic debridement of the posterior elbow was performed. There were 34 male and 2 female patients, with a median age of 32 years (17-54 years). There were 7 professional athletes, 6 college athletes, and 23 high school or recreational athletes. All patients had a positive posterior impingement test for posterior pain with extension and limitations of activity. Arthroscopic debridement and additional surgical procedures were performed, and patients underwent follow-up visits at a median 51 months (range 14-81). RESULTS: Significant improvements were seen in pain, motion, and function. No neurovascular complications were seen related to the arthroscopic debridement. The mean Andrews and Timmerman elbow score improved from 159 ± 27 to 193 ± 11 (p < 0.01). Thirty-five of thirty-six (97%) patients returned to their previous level of activity, including all professional athletes. CONCLUSIONS: Arthroscopic management of posterior elbow impingement is safe and effective and can return patients, including professional athletes, to high-level athletic activity. Athletes with symptomatic posterior elbow impingement can be successfully and safely treated with arthroscopic debridement and typically will return to preinjury levels of activity. LEVEL OF EVIDENCE: IV.

Obesity is Not Associated with Increased Short-term Complications After Primary Total Shoulder Arthroplasty.

BACKGROUND: Few studies have analyzed the association between elevated BMI and complications after total shoulder arthroplasty (TSA). Previous studies have not consistently arrived at the same conclusion regarding whether obesity is associated with a greater number of postoperative complications. We used a national surgical database to compare the 30-day complication profile and hospitalization outcomes after primary TSA among patients in different BMI categories. QUESTIONS/PURPOSES: We asked: (1) Is obesity associated with an increased risk of complications within 30 days of primary TSA? (2) Is obesity associated with increased operative time? METHODS: The American College of Surgeons National Surgical Quality Improvement Program(®) database for 2006 to 2012 was queried to identify all patients who underwent a primary TSA for osteoarthritis of the shoulder. The ACS-NSQIP(®) database was selected for this study as it is a nationally representative database that provides prospectively collected perioperative data and a comprehensive patient medical profile. Exclusion criteria included revision TSA, infection, tumor, or fracture. We analyzed 4796 patients who underwent a primary TSA for osteoarthritis of the shoulder. Patients who underwent a TSA were divided in four BMI categories: normal (18.5-25 kg/m(2)), overweight (25-30 kg/m(2)), obesity Class 1 (30-35 kg/m(2)), and obesity Class 2 or greater (> 35 kg/m(2)). Perioperative hospitalization data and 30-day postoperative complications were compared among different BMI classes. Differences in patient demographics, preoperative laboratory values, and preexisting patient comorbidities also were analyzed among different BMI groups, and multivariate analysis was used to adjust for any potential confounding variables. RESULTS: There was no association between BMI and 30-day complications after surgery (normal as reference, overweight group relative risk: 0.57 [95% CI, 0.30-1.06], p = 0.076; obesity Class 1 relative risk: 0.52 [95% CI, 0.26-1.03], p = 0.061; obesity Class 2 or greater relative risk: 0.54 [95% CI, 0.25-1.17], p = 0.117). However, greater BMI was associated with longer surgical times (for normal BMI control group: 110 minutes, SD, 42 minutes; overweight group: 115 minutes, SD, 46 minutes, mean difference to control: 5 minutes [95% CI, -1 to 10 minutes], p = 0.096; obesity Class 1: 120 minutes, SD, 43 minutes, mean difference: 10 minutes [95% CI, 5-15 minutes], p < 0.001; obesity Class 2 or greater: 122 minutes, SD, 45 minutes, mean difference: 12 minutes [95% CI, 6-18 minutes], p < 0.001). CONCLUSIONS: Although the surgical time increased for patients with greater BMI, the 30-day complications and perioperative hospitalization data after TSA were not different in patients with increased BMI levels. Obesity alone should not be a contraindication for TSA, and obese patients can expect similar incidences of postoperative complications. The preoperative medical optimization plan should be consistent with that of patients who are not obese who undergo TSA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Comparison of perioperative complications after total elbow arthroplasty in patients with and without diabetes.

BACKGROUND: Few studies have analyzed the effect of diabetes on outcomes after total elbow arthroplasty (TEA). We investigated the perioperative complications after TEA in patients with and without diabetes. METHODS: We evaluated the Nationwide Inpatient Sample (NIS) database from 2005 to 2010 for patients who underwent a TEA. Our retrospective study included 3184 patients based on International Classification of Diseases-Ninth Revision, Clinical Modification codes. We compared outcomes in 488 patients with diabetes and in 2696 patients without diabetes. RESULTS: Patients with diabetes had a significantly older mean age (66.8 vs 58.5 years, P < .001). There was no statistically significant difference when comparing length of stay (4.1 vs 3.7 days, P = .056) and cost of surgery ($56,582 vs $56,092, P = .833). A significantly higher percentage of diabetic patients underwent TEA for the indication of fracture (73.4% vs 65.3%), but a lower percentage for rheumatoid arthritis (10.2% vs 19.2%). They also had significantly increased rates of pneumonia (odds ratio [OR], 2.7), urinary tract infection (OR, 2.2), blood transfusion (OR, 2.1), and nonroutine discharge (OR, 1.9). After adjusting for significantly increased rates of comorbidities in diabetic patients, our multivariate analysis showed that having diabetes was independently associated with an increased risk of pneumonia (relative risk [RR], 2.6), urinary tract infection (RR, 1.9), and cerebrovascular accident (RR, 9.1). However, diabetes was not independently associated with hospital length of stay (P = .75), after correction, hospital cost (P = .63), or proportion of routine discharges (P = .12). CONCLUSION: Patients with diabetes have higher rates of comorbidities and perioperative complications after TEA.

Analysis of perioperative complications in patients after total shoulder arthroplasty and reverse total shoulder arthroplasty.

BACKGROUND: Data directly comparing the perioperative complication rates between total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) are limited. METHODS: The Nationwide Inpatient Sample database, which comprises data from a statistically representative sample of hospitals across the United States, was analyzed for the years 2010 and 2011. The International Classification of Diseases, Ninth Revision procedure codes differentiated the patients who received TSA (81.80) and RTSA (81.88). Demographic data, comorbidities, perioperative complications, and hospitalization data were compared. RESULTS: This retrospective analysis included 19,497 patients, with 14,031 patients in the TSA group and 5466 patients in the RTSA group. Patients who underwent RTSA were older (P < .001), were more likely to be female (P < .001), and had increased rates of fracture (P < .001). The RTSA group had significantly higher perioperative rates of mortality (P = .004), pneumonia (P < .001), deep venous thrombosis (P < .001), myocardial infarction (P = .005), urinary tract infection (P < .001), and blood transfusions (P < .001). In addition, the RTSA patients had longer hospital stays (P < .001) and higher hospital charges (P < .001). The rates of comorbidities were also higher in the patients who underwent RTSA. After adjustment for these differences in comorbidities and surgical indications with our multivariate analysis, RTSA was still independently associated with increased hospital charges (difference of $11,530; P < .001), longer hospitalization (difference of 0.24 day; P < .001), more blood transfusions (relative risk, 1.43; P < .001) and higher rates of pneumonia (relative risk, 1.61; P = .04) and deep venous thrombosis (relative risk, 2.24; P = .01). CONCLUSION: We found that RTSA patients, compared with TSA patients, had significantly longer length of stay, higher hospital charges that are not completely attributable to increased implant costs alone, and increased rates of perioperative complications.

Diversity in Orthopaedic Surgery: What Is Next? What is Needed Collectively? How Do You Go About Effecting Positive Change?

Orthopedic surgery as a field is the least diverse medical specialty. Multiple factors contribute to the lack of diversity, including lack of diversity in medical school, lack of role models and mentors, and discrimination and bias. Addressing the lack of diversity includes use of data, implementation of targeted pipeline programs, individual physician advocacy, institutional recruitment and DEI initiatives, and leadership from professional organizations. Targeted pipeline programs and role models and mentors are very effective in increasing diversity. Cultural change is occurring, and the future orthopaedic workforce will be more diverse.

Influence of medial patellofemoral ligament reconstruction on patellar tracking and patellofemoral contact pressures in patella alta.

Knee squatting was simulated to characterize the influence of medial patellofemoral ligament (MPFL) reconstruction on patellar tracking and contact pressures for knees with mild patella alta (Caton-Deschamps index = 1.3-1.4). Eight computational models represented knees in the pre-operative condition and following MPFL reconstruction. MPFL reconstruction significantly reduced patellar lateral tracking at low flexion angles based on bisect offset index, significantly decreased the maximum lateral pressure in mid-flexion, and significantly increased the maximum medial pressure in mid-flexion. MPFL reconstruction improves patellar stability for knees with mild patella alta and can reduce the pressure applied to lateral cartilage on the patella.