Particulated Juvenile Articular Cartilage Allograft Transplantation for Patellofemoral Defects Shows Favorable Return-to-Sport Rates and Patient-Reported Outcomes.

PURPOSE: To report return-to-sport rates, postoperative patient-reported outcomes (PROs), complication rates, and reoperation rates of a cohort of patients undergoing particulated juvenile articular cartilage (PJAC) allograft transplantation for patellofemoral articular cartilage defects. METHODS: We performed a single-institution retrospective review of all patients with patellofemoral articular cartilage defects who received PJAC allograft transplantation from 2014 to 2022. Baseline demographic characteristics and surgical data, including concomitant surgical procedures, were collected. Clinical outcomes recorded included return-to-sport rates, complications, reoperations, and the following PRO scores: Kujala knee score, Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference score, and PROMIS Physical Function score. RESULTS: Forty-one knees with a mean age of 23.4 ± 9.7 years and mean follow-up period of 30.3 months (range, 12-107 months) were included. The mean postoperative PROMIS Pain Interference, PROMIS Physical Function, and Kujala knee scores were 47.4 ± 7.7, 52.2 ± 10.8, and 81.7 ± 16.1, respectively, reflecting low residual anterior knee pain and a return to normal function. For patients playing organized sports at the high school and collegiate levels, the overall return-to-sport rate was 100% (17 of 17). During follow-up, complications developed in 12 knees (29.3%), the most common of which was anterior-based knee pain, and 6 knees (14.6%) required a total of 8 reoperations, which occurred from 6 to 32 months postoperatively. CONCLUSIONS: The 100% return-to-sport rate and satisfactory PRO scores in our study suggest that PJAC allograft transplantation can effectively address patellofemoral cartilage defects in many patients. The complication and reoperation rates of 29.3% and 14.6%, respectively, are consistent with the challenging and heterogeneous etiology and treatment of patellofemoral articular defects. LEVEL OF EVIDENCE: Level IV, case series.

Perioperative non-opioid analgesia strategies after high tibial osteotomy: a systematic review of prospective studies.

PURPOSE: Little is known about the optimal analgesia regimen after HTO. Thus, this study systematically reviewed the literature on clinical and patient-reported outcomes of pain management strategies for patients after HTO. METHODS: A comprehensive search of the PubMed, Cochrane CENTRAL, and CINAHL databases was conducted from inception through September 2023. Studies were included if they evaluated pain reduction with analgesia strategies after HTO and were excluded if they did not report pain control outcomes. RESULTS: Five studies with 217 patients were included. Patients with a multimodal intraoperative injection cocktail to the knee, femoral nerve block (FNB), or adductor canal block (ACB) for HTO had significant improvement in visual analog scale (VAS) and numerical rating scale (NRS) scores in the first 12 h postoperatively compared to controls. Patients on duloxetine had significantly lower NRS scores at 1, 7, and 14 days postoperatively and significantly lower nonsteroidal anti-inflammatory drug (NSAID) usage throughout the two-week postoperative period than the control group. Patients receiving an ACB had significantly lower opioid consumption than controls at 12 h postoperative. In patients with an FNB or ACB, no significant difference in quadriceps strength or time to straight leg raise postoperatively was observed compared to controls. CONCLUSION: A multimodal periarticular injection cocktail, FNB, or an ACB effectively reduces pain on the first day after HTO, with an ACB able to reduce opioid consumption on the first postoperative day. Duloxetine combined with an ACB effectively decreases pain for two weeks postoperatively while reducing NSAID consumption in patients after HTO. LEVEL OF EVIDENCE: IV.

Editorial Commentary: Obesity Is Associated With Lower Hip Function Pre- and Postoperatively and Increased Time to Patient Acceptable Symptom State After Hip Arthroscopy.

In 2015, worldwide, there were more than 1.9 billion adults classified as having overweight (body mass index [BMI] >25), with 600 million of these individuals meeting the definition of obesity (BMI >30). Hip arthroscopy in patients with obesity can lead to improve outcomes, albeit with lower absolute levels of patient-reported outcome scores and with increased risk of complications and conversion rates to total hip arthroplasty when compared with their counterparts without obesity. Importantly, a significantly longer time to patient acceptable symptoms state achievement is seen for patients with class I obese than patients with normal BMI. Unfortunately, the hip is quite susceptible to the effects of obesity, with greater acetabular depth/deformity, reduced femoral head cartilage, greater forces experienced with ambulation, and a predisposition to femoroacetabular impingement syndrome. Thus, almost 42% of patients operated on in North America for femoroacetabular impingement syndrome are classified as having overweight or obesity. This does not need to deter from the consideration of arthroscopic hip surgery in the population with obesity; rather, it supports a discussion between surgeon and patient on expectations and timeline for improvement.

Outcomes After Arthroscopic Revision Bankart Repair: An Updated Systematic Review of Recent Literature.

PURPOSE: To provide an update of recent literature with a specialized focus on clinical outcomes following arthroscopic revision Bankart repair (ARBR) by performing a systematic review of all available literature published between 2013 and 2020. METHODS: A literature search reporting clinical outcomes after ARBR was performed. Criteria for inclusion consisted of original studies; Level of Evidence of I-IV; studies focusing on clinical outcomes after ARBR published between January 1, 2013, and January 4, 2021; studies reporting recurrent dislocation or instability rate after ARBR; reoperation/revision following ARBR, return to sport rates following ARBR; and patient-reported outcomes. The primary outcomes of interest were failure defined as recurrent instability or dislocation, return to sport rates, and patient-reported outcomes at follow-up. RESULTS: A large proportion of patients undergoing arthroscopic revision Bankart repair were male, ranging between 67.7% and 93.8%. Failure rate and return to sports rate ranged between 6.1% and 46.8% and 25.9% and 88.3%, respectively, when patients with significant or greater than 20% glenoid bone loss was excluded. Patient-reported outcome scores, which included American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale, saw significant improvement over mean follow-up of ranging 21.64 to 60 months. CONCLUSIONS: Both the failure rate and RTS rates after ARBR had a wide range, given the heterogeneity of the studies included, which varied in patient selection criteria pertaining to patients with greater than 20% glenoid bone. Although there have been advancements in arthroscopic techniques and a trend favoring arthroscopic stabilization procedures, there is a lack of consensus in recent literature for careful patient selection criteria that would minimize failure rates and maximize RTS rates after ARBR. LEVEL OF EVIDENCE: Level IV, a systematic review of Level III-IV studies.

Inconsistencies in reporting risk factors for ulnar collateral ligament reconstruction failure: a systematic review.

BACKGROUND: When return to sport (RTS) at a competitive level is desired, treatment of injury to the ulnar collateral ligament (UCL) frequently involves surgical reconstruction. Although RTS rates between 66% and 98% have been reported, there remains a paucity of comparative clinical studies, with far fewer reporting statistically significant risk factors for reconstruction failure. The goal of this study was to perform a systematic review of the literature to demonstrate the variety and inconsistency with which risk factors associated with reconstruction failure are reported. MATERIALS AND METHODS: A systematic review of the PubMed Central and MEDLINE databases was performed to identify clinical outcome studies reporting ≥1 statistically significant risk factor associated with failure of UCL reconstruction. Failure was defined as (1) reinjury, recurrent instability, or need for revision surgery; (2) failure show improvement in postoperative patient-reported outcomes (PROs); or (3) failure to RTS at the preinjury level (RSL). RESULTS: A total of 349 unique studies were initially identified, of which 12 were deemed eligible for inclusion in our study. Of these 12 studies, 4 defined outcomes based on recurrent instability, reinjury, or revision surgery; 2 defined outcomes based on PROs; and 6 defined outcomes based on RSL. In the group with instability, reinjury, or revision failure, 11 significant risk factors were identified across all studies: age, height, body mass index, professional experience, injury to the nondominant arm, history of competitive throwing, mechanism of injury, history of a psychiatric diagnosis, presence of preoperative instability or stiffness, postoperative workload, and time to RTS. In the PRO failure group, 12 risk factors were identified across all studies: age, status as a military cadet, injury to the nondominant arm, graft type, baseball position, current injury to the ipsilateral arm, current level of competition attributed to reconstruction surgery, shoulder surgery after reconstruction, no competitive throwing history, non-throwing mechanism of injury, history of a psychiatric diagnosis, and preoperative instability or stiffness. In the RSL failure group, 4 risk factors were identified across all studies: age, ulnar neuritis, level of professional play, and amount of time spent at the professional level. CONCLUSIONS: Age, level of professional play prior to surgery, postoperative workload, and time at the professional level are the most commonly reported risk factors associated with UCL reconstruction failure. There remains a paucity of data associating risk factors with patient-specific outcomes and marked levels of inconsistency and conflict among the studies that report such data.

Outcomes of subacromial balloon spacer implantation for irreparable rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: The management of irreparable rotator cuff tears remains a topic of considerable debate among orthopedic surgeons. Currently, there is little consensus regarding the gold-standard treatment; however, an emerging option involves the use of a biodegradable subacromial spacer. The purpose of this study, therefore, was to systematically review and synthesize the current literature reporting on the clinical outcomes following implantation of a subacromial balloon spacer (SABS) for the treatment of patients with irreparable rotator cuff tears. METHODS: A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, and Cochrane Library databases from inception through December 2022 was performed. Clinical outcome studies reporting on functional and clinical outcomes, as well as postoperative complications, were included. RESULTS: A total of 127 studies were initially identified, of which 28 were deemed eligible for inclusion in our review. Of these studies, 17 reported adequate preoperative and postoperative data (mean and a measure of variance) and thus were included in the meta-analysis. Among the included studies, a total of 894 shoulders (886 patients) were included; the mean age was 67.4 years (range, 61.7-76.2 years). The average follow-up period was 30.4 months (range, 12-56 months). All postoperative patient-reported outcomes improved significantly from baseline, including the Constant score (mean difference, 33.53; P < .001), American Shoulder and Elbow Surgeons score (mean difference, 40.38; P < .001), Oxford Shoulder Score (mean difference, 12.05; P = .004), and visual analog scale pain score or Numeric Pain Rating Scale score (mean difference, -3.79; P < .001). Forward elevation (mean difference, 24°; P < .001), abduction (mean difference, 52°; P = .02), and external rotation (mean difference, 15°; P < .001) improved. Device-related complications occurred at a rate of 3.6%, the most common of which were balloon migration (1.0%) and synovitis (0.6%). Ultimately, 5% of patients required salvage reverse shoulder arthroplasty. CONCLUSION: Short-term outcomes suggest that SABS implantation can be a safe and effective treatment and appears to be associated with early improvements in postoperative pain and function. Clinical heterogeneity, use of concomitant procedures, and variations in patient selection limit our ability to conclusively interpret the available evidence. We do not yet know the potential therapeutic value of SABS implantation relative to other currently accepted treatment strategies, the length of symptomatic improvement that can be expected, or the long-term implications of SABS use on the outcomes of further salvage procedures.

Adjustable-loop cortical suspension device for posterolateral corner reconstruction in the setting of fibular avulsion fracture: a case series and novel technique description.

INTRODUCTION: A novel technique using an adjustable-loop cortical suspension toggle device for reduction of a fibular head avulsion fracture (arcuate fracture) in posterolateral corner (PLC) reconstruction is described. Results of clinical follow-up are presented. MATERIALS AND METHODS: 9 patients were retrospectively identified who underwent posterolateral corner reconstruction using an adjustable-loop cortical suspension toggle device. Radiographic examination was used to evaluate the successful healing of the avulsed fibular head fragments post-operatively. RESULTS: 7 patients reported satisfactory results with their clinical outcome with no feelings of knee instability or objective instability on exam at final follow-up. Post-operative radiographs obtained > 6 months following reconstruction demonstrated well reduced and healed fracture in 5 of 6 patients, with 1 patient demonstrating maintained reduction but incomplete fracture union at 6 months. CONCLUSION: This novel surgical technique for PLC reconstruction with an avulsed fibular head fracture is a viable alternative to previously described methods. The majority of patients report subjective satisfaction with a stable knee post-operatively. LEVEL OF EVIDENCE: IV.

Editorial Commentary: Arthroscopic Bankart Repair With Remplissage, Irrespective of Glenoid Bone Loss, May Be Advantageous Over Latarjet: Don't Widen the Lane, Just Fill in the Pothole!

Anterior glenohumeral instability has an incidence of 21.9 individuals per 100,000 in the general population. When recurrent instability occurs, bone loss to the anteroinferior glenoid can occur. The concept of "on-track" and "off-track" Hill-Sachs lesions is significant in cases of bipolar bone loss, because if humeral-sided bony injury also requires treatment, a remplissage combined with arthroscopic Bankart repair (ABR) may be an alternative to a Latarjet procedure. The Latarjet often is touted as a "definitive," because it adds bone to increase the glenoid surface area that the humeral head must travel to dislocate, and adds the dynamic "sling effect" of the conjoint tendon to further tension the lower part of the subscapularis in abduction and reduce anterior-directed forces. However, compared with ABR plus remplissage, Latarjet shows a greater risk of complications: as high as a 7.37 times relative risk. As an evidence-based surgeon who believes in the power of soft-tissue repair plus ABR, I prefer to avoid the increased complication risks of a primary Latarjet when possible. Also, my patients describe the postoperative shoulder as feeling more like the contralateral, unaffected shoulder after ABR than Latarjet.

Intraoperative and Early (90-Day) Postoperative Complications and Associated Variables with Multiligamentous Knee Reconstruction: 15-year Experience from a Single Academic Institution.

PURPOSE: We sought to determine the rate of intraoperative and early postoperative (90-day) complications of multiligamentous knee reconstruction surgeries, both medical and surgical, and associated variables from the 15-year experience of a single academic institution. METHODS: Patients treated at a single academic institution between 2005 and 2019 who underwent multiligament knee surgery were identified. Inclusion criteria included intervention with 2+ ligament reconstructions performed concurrently, and more than 90 days postoperative follow-up. Exclusion criteria included revision ligamentous knee surgery. Patient demographics, mechanism of injury, and associated injuries of patients with intraoperative and postoperative complications, time from injury to multiligamentous knee reconstruction, and surgical data, including tourniquet time, procedure time, and type of procedures performed were retrospectively recorded. RESULTS: 301 knees in 296 patients met the eligibility criteria. There were 11 intraoperative complications in 9 knees (rate of 3%) and 136 postoperative complications in 90 knees (rate of 30%). Shorter time from injury to date of surgery was associated with arthrofibrosis (P = .001) and superficial wound infections (P = .015). Concurrent head injuries were associated with less complications (P = .029). Procedural time >300 minutes was associated with intraoperative blood transfusions (P > .05), deep infections (P = .003) and arthrofibrosis (P = .012). Inside-out meniscal repair was associated with superficial and deep infections (P = .006 and .0004). Tibial-based posterolateral corner (PLC) reconstruction was associated with symptomatic hardware (P = .037) and arthrofibrosis (P = .019) in comparison with fibular-based PLC reconstruction. Posterior cruciate ligament (PCL) reconstruction was associated with deep infections (P = .015), arthrofibrosis (P = .003), and postoperative blood transfusions (P = .018). CONCLUSION: Our 15-year data reveal there is a low intraoperative complication rate and high early postoperative complication rate with multiligamentous knee surgery. Surgeons should be wary of the increased intraoperative and postoperative complications associated with longer procedure times, inside-out meniscal repair, tibia-based PLC reconstruction, PCL reconstruction, and shorter time to surgery. LEVEL OF EVIDENCE: Case series: IV.

Outcomes and reoperation rates after tibial tubercle transfer and medial patellofemoral ligament reconstruction: higher revision stabilization in patients with trochlear dysplasia and patella alta.

PURPOSE: To determine the reoperation rate, risk factors for reoperation, and patient-reported outcomes after isolated or combined tibial tubercle transfer and medial patellofemoral ligament reconstruction, for patellofemoral instability surgery. METHODS: Patient's records who underwent medial patellofemoral ligament reconstruction and/or tibial tubercle transfer for patellar instability by 35 surgeons from 2002 to 2018 at a single academic institution were retrospectively reviewed using CPT codes. Four-hundred-and-eighty-six patients were identified. Radiographic measurements, demographic parameters, and subsequent revision procedures and their indications were identified. A modified anterior knee pain survey was conducted by mail and with follow-up phone survey. RESULTS: The overall rate of reoperation was 120/486 (24.7%). The most common cause for reoperation was removal of hardware 42/486 (8.6%). The rate of reoperation for isolated medial patellofemoral ligament reconstruction 43/226 (19%) was lower than that of isolated tibial tubercle transfer 45/133 (33.8%) or a combined procedure 32/127 (25.2%) (P = 0.007). Woman had a higher rate of reoperation (29.4%) compared to men (15.9%) (P = 0.002). Patients at risk for a revision stabilization procedure included those with severe trochlear morphology (C or D) (6.1%) and those with Caton-Deschamps index > 1.3 (7.3%). Patients who underwent reoperation of any kind had poorer patient-reported outcomes. CONCLUSION: The overall reoperation rate after patellofemoral instability surgery remains high, and any reoperation portends worse patient-reported outcomes. Re-operations for instability are more likely in patients with trochlear dysplasia and patella alta and may benefit from more aggressive initial treatment, such as medial patellofemoral ligament reconstruction and tibial tubercle transfer in combination. Using the results of this study, surgeons will be able to engage in meaningful discussion with patients to counsel patients on expectations postoperatively. LEVEL OF EVIDENCE: IV.

Comorbidity scores reported in anatomic and reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: Due to the aging population, the number of reverse shoulder arthroplasty (RSA) and anatomic shoulder arthroplasty (TSA) continue to increase annually. Although outcome measures are frequently reported in literature for patients who undergo shoulder arthroplasty, no studies have analyzed reporting of patient comorbidities in this population. The purpose of this study was to evaluate reporting of comorbidity indices in shoulder arthroplasty literature and assess how this reporting may inform management and outcomes. METHODS: A database was compiled systematically using PubMed to identify articles pertaining to shoulder arthroplasty published between 2019 and 2021. The search terms, "reverse shoulder arthroplasty" and "anatomic shoulder arthroplasty," were used to identify clinical studies. Non-clinical (e.g., translational and basic science) and review articles were excluded. Included studies were then analyzed for reporting of comorbidity indices. RESULTS: A total of 199 articles were included in this review and reported comorbidities. Of these, 15.6% (31 of 199) pertained to TSA, while 84.4% (168 of 199) pertained to RSA. Within this review, 57.8% (115 of 199) articles utilized comorbidity scores, while 42.2% (84 of 199) reported only comorbid diagnoses. Among the scores utilized, the American Society of Anesthesiologists (ASA) physical status classification system was the most widely used among both the TSA (52.9%, 9 of 17) and the RSA studies (58.2%, 57 of 98). Additional scores within the RSA literature included the Charlson Comorbidity Index (CCI) (35.3%, 6 of 17), the Charlson Comorbidity Index by Deyo et al. (J Clin Epidemiol. 45(6):613-9, 1992) (CCI-Deyo; 5.9%, 1 of 17), the Modified Charlson Comorbidity Index (modified-CCI) (5.9%, 1 of 17), the Elixhauser et al. (Med Care. 36(1):8-27, 1998) Comorbidity Measure (ECM) (11.8%, 2 of 17), and the Modified Frailty Index (mFI) (5.9%, 1 of 17). With the TSA literature, the additional comorbidity scores included the CCI (30.6%, 30 of 98), the CCI-Deyo (6.1%, 6 of 98), the modified-CCI (1.0%, 1 of 98), the ECM (8.2%, 8 of 98), the Factor-5 modified Frailty Index (mFI-5) (1.0%, 1 of 98), and the mFI (1.0%, 1 of 98). CONCLUSION: The reporting of comorbidity indices is an important factor when considering patient outcomes and complications reported in shoulder arthroplasty literature. Although the reporting of these scores appears to be more prevalent in current literature, there is no standard or consistency in terms of which scores are reported. Given this diversity in comorbidity scores, further research is necessary to develop a single standardized score to properly analyze the effect of comorbidities on shoulder arthroplasty patient outcomes.

Outcomes and failure rates after revision meniscal repair: a systematic review and meta-analysis.

PURPOSE: The purpose of this meta-analysis is to determine the outcomes and failure rates for revision meniscus repairs in patients with re-tears after primary repair failure. METHODS: A literature search was conducted using PubMed and Embase with the terms "Meniscus," "Meniscal," "Revised," and "Revision." The search strategy was based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) protocol and included four articles (79 patients). The search criteria were limited to studies reporting outcomes and failure rates. The exclusion criteria included languages other than English, biomechanical studies, letters to editors, non-full text, review articles, meta-analysis, and case reports. RESULTS: Four comparative studies with 79 patients (53 males, 26 females) with a mean age of 23.9 ± 6.4 years treated with a revision meniscus repair were included in the final analysis. Within this analysis, we found a failure rate of 25.3% (20 of 79 patients). Of these failed repairs, 30.95% (13 of 42) were of the medial meniscus, and 18.9% (7 of 37) were of the lateral meniscus. In the four articles, the postoperative Tegner sports activity score was found to be 6.1 ± 1.6 (range, 2 to 10). The post-operative Lysholm score was reported in three articles (45 patients). At a mean follow-up of 58.3 ± 23.9 months, the mean post-operative Lysholm score was 89.1 ± 7.6 (range, 38 to 100). The Coleman score for the included articles ranged between 52 and 59. CONCLUSION: This analysis found that revision meniscus repairs in patients with re-tears after primary repair failure result in clinical outcomes similar to that of primary repairs.

Allograft Augmentation of Hamstring Autograft in Anterior Cruciate Ligament Reconstruction Results in Equivalent Outcomes to Autograft Alone.

PURPOSE: To examine allograft augmentation of undersized hamstring (HS) autograft tendons at the time of anterior cruciate ligament (ACL) reconstruction, compared with un-augmented autograft HS ACL reconstruction. METHODS: Patients who underwent ACL reconstruction at our institution between 2005 and 2015 were reviewed. Inclusion criteria included patients who underwent (1) primary ACL reconstruction, (2) use of a hybrid HS autograft with allograft augmentation, and (3) had a minimum 2-year postoperative follow-up. Patients with revision ACL, multiligamentous injuries, all-epiphyseal fixation techniques, or additional procedures beyond chondroplasty or meniscal repair/debridement were excluded. Data collected included demographics, graft size, concomitant procedures, revision operation, revision ACL reconstruction, and patient-reported outcomes. RESULTS: In total, 59 patients met criteria for inclusion into the hybrid group, and 80 patients were eligible for inclusion into the control group. The average age of the cohort was 22.9 (interquartile range Q1:17, Q3: 38.3), and 51.8% of the patients were female. Seven patients (11.9%) in the hybrid ACL group underwent revision ACL surgery versus 15 (18.8%) in the control group (P = .27). There was no difference in patient-reported outcomes between groups. CONCLUSIONS: Augmenting an HS ACL autograft that is 8 mm or less with allograft tissue to increase the overall size of the ACL graft shows no difference in overall reoperation or revision of ACL failure. The hybrid autograft/allograft ACL reconstruction patients showed no clinically important difference between groups in patient-reported outcome measures. LEVEL OF EVIDENCE: Level III, case-control comparative analysis.

Is postoperative glucose variability associated with adverse outcomes following shoulder arthroplasty?

BACKGROUND: Postoperative infection after shoulder arthroplasty is a devastating complication. Multiple patient risk factors have been associated with postoperative infection, including increased body mass index and diabetes. Although the association between preoperative glucose control and infection has been established, little is known about the effect of perioperative glycemic control on outcomes following shoulder arthroplasty. The purpose of this study was to investigate the association between postoperative glycemic variability and short-term complications after total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). METHODS: A retrospective study was performed at a large, single-specialty center from January 2015 to December 2018. Patients were included if they underwent primary TSA or RTSA with a minimum of 90 days' follow-up and had a minimum of 1 serum glucose value obtained per day of the hospital stay or had ≥3 measurements obtained during the hospital admission period. The primary outcome variable was postoperative infection per accepted definitions of surgical-site infection or periprosthetic joint infection. Secondary outcome variables included stiffness, periprosthetic fracture, periprosthetic dislocation, and reoperation. RESULTS: In total, 1074 TSAs or RTSAs (in 1032 patients) met the eligibility criteria. The mean patient age was 69.9 ± 8.4 years, and 40.3% of patients had a preoperative diagnosis of diabetes mellitus. Of the patients, 670 (62%) had a calculable coefficient of variation. A younger patient age (median, 65 years [interquartile range (IQR), 13.5 years] vs. 71 years [IQR, 11.0 years]; P = .02) and a preoperative diagnosis of diabetes mellitus (P = .01) showed statistically significant associations with postoperative infection. The first in-hospital glucose measurement beyond the reference tertile of 70-140 mg/dL showed a statistically significant association with postoperative infection, with a median of 128.0 mg/dL (IQR, 43 mg/dL) vs. 167.5 mg/dL (IQR, 37.0 mg/dL; P = .01), whereas the second and third glucose measurements showed no association with postoperative infection. We found no associations between the coefficient of variation and reoperations or complications including surgical-site infection, periprosthetic joint infection, death, postoperative infection, periprosthetic fracture, or stiffness. CONCLUSION: We found an association between a preoperative diagnosis of diabetes mellitus and postoperative infection following shoulder arthroplasty. We also found that an elevated first glucose measurement is associated with the development of postoperative infection. In-hospital glycemic control, as well as preoperative glycemic control and optimization, may be beneficial for reducing postoperative infections following shoulder arthroplasty.

Clinical outcomes of a unique ulnar collateral ligament reconstruction hybrid technique with ulnar-sided suspensory fixation.

BACKGROUND: Ulnar collateral ligament reconstruction (UCLR) is the gold standard for treating ulnar collateral ligament injuries in throwing athletes who have failed conservative treatment. There are several described techniques that produce successful and reproducible outcomes. In addition, there is biomechanical evidence that supports hybrid fixation of the graft with a docking technique on the humeral side and suspensory fixation on the ulnar side. However, as of this writing there are no clinical studies that have reported results. This retrospective case series is the first of its kind to report on clinical outcomes following UCLR with hybrid suspensory fixation. METHODS: Fifty throwing athletes who underwent ULCR with hybrid suspensory fixation from 2010-2017 by one of 5 surgeons at a single institution were available at a median follow-up of 7 years. Return to sport, level of sport, and postoperative complications were recorded at final follow-up. RESULTS: A total of 50 patients were included in final analysis. Nearly all were able to return to sport at the same level or higher (48/50, 96%). One of these 50 athletes (2%) played professionally, 27 (54%) played collegiately, and 21 (42%) played at the high school level. Seven patients (14%) underwent reoperation following the index procedure. The median (interquartile range) Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 0.098 (0-4.5) at final follow-up. CONCLUSION: Hybrid suspensory fixation is a safe and effective technique for UCLR in the throwing athlete. Throwers can expect to return to sport at a very high rate with low risks for postoperative complications.

Outcomes of posterior labral repair with or without concomitant high-grade glenohumeral chondral pathology: a retrospective cohort with minimum 2-year follow-up.

BACKGROUND: The purpose of this study was to compare outcomes of patients who underwent posterior labral repair with and without concomitant glenohumeral chondral pathology. METHODS: A retrospective review was performed on patients aged ≥18 years who underwent primary posterior labral repair over 5 years. Charts were reviewed to determine the presence and location of high-grade (Outerbridge grade III or IV) pathology. Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Western Ontario Stability Index (WOSI), visual analog scale (VAS), and Simple Shoulder Test (SST) scores were collected at median 71.5-month follow-up and compared between patients with and without concomitant chondral pathology during the index procedure. RESULTS: Of 100 patients who underwent primary posterior labral repair, 43% had glenoid and/or humeral-sided high-grade chondral pathology. Patients with chondral pathology were older than those without (P < .001). A higher proportion of patients with chondral pathology underwent concomitant biceps tenodesis (19.3% vs. 37.2%, P = .046). The type of anchor (all-suture or solid body, P = .010) used was different between patients with and without chondral pathology at time of posterior labrum repair. There was no difference in reoperation rates at final follow-up between patients with and without chondral damage at time of index procedure (P = .200). All outcome scores were similar between all comer patients with and without chondral pathology. Isolated glenoid pathology was significantly associated with lower QuickDASH (P = .018), higher SST (P = .013), lower VAS (P = .016), and lower WOSI scores (P = .046) compared to patients with bipolar lesions. After stratifying by age, there was an association between chondral pathology and lower VAS and WOSI scores in patients aged <35 years, and there was an association between chondral pathology and lower SST scores in patients aged ≥35 years. CONCLUSION: Based on median QuickDASH, SST, WOSI, and VAS scores, subjective and functional outcomes after primary arthroscopic posterior labral repair were not negatively influenced by the presence of concomitant chondral damage at the time of surgery for patients aged <35 years at minimum 2-year follow-up. Although our primary outcome score, the QuickDASH, was not significantly associated with the presence of chondral damage in patients aged >35 years, SST scores were negatively influenced by concomitant chondral damage in this older cohort, but this may not be adequately powered. It appeared that patients with chondral damage localized to the glenoid tended to have better outcomes scores that those with bipolar damage.

Cyclic and Load-to-Failure Properties of All-Suture Anchors in Human Cadaveric Shoulder Greater Tuberosities.

PURPOSE: The purpose of this study was to evaluate the cyclic displacement, stiffness, and ultimate load to failure of 3 all-suture anchors in human cadaveric greater tuberosities. METHODS: Three all-suture anchors indicated for rotator cuff repair were tested in 14 matched pairs of human cadaver fresh-frozen humeri. Anchors were inserted at 3 locations from anterior to posterior along the greater tuberosity and placed 5 mm from the articular margin. The constructs were cycled from 10 to 60 N at 1 Hz for 200 cycles. The anchors that survived cycling were then subjected to a single pull to failure test. A Kruskal-Wallis 1-way analysis of variance on ranks was performed to compare the displacement, stiffness, and ultimate load to failure of the different anchors tested. RESULTS: One matched pair was excluded because of poor bone quality; therefore, 13 matched pairs were included in the study. After 20, 100, and 200 cycles, there was no difference in median displacement between the anchors tested (P = .23, P = .21, P = .18, respectively). The median ultimate load-to-failure between the Iconix (295.2 N, 95% confidence interval [CI], 125-762.2), JuggerKnot (287.6 N, 95% CI, 152.9-584.4), and Q-fix (333.3 N, 95% CI, 165.0-671.9) showed no statistically significant difference (P = .58). After 20, 100, and 200 cycles, there was no difference in median stiffness between the anchors tested (P = .41, P = .19, P = .26 respectively). Displacement greater than 5 mm occurred in 0 Iconix anchors (0%), 1 JuggerKnot anchor (3.64%), and 2 Q-fix anchors (7.69%). One JuggerKnot anchor failed by anchor pullout during cyclic loading. CONCLUSIONS: When tested in human cadaveric humeral greater tuberosities 3 all-suture anchors, the 2.9-mm JuggerKnot, the 2.8-mm Q-fix, and the 2.3-mm Iconix, showed no significant differences in median displacement or stiffness after 20, 100, or 200 cycles or in median ultimate load to failure. Although not statistically significant, the Iconix was the only anchor tested to have no failures, whereas the JuggerKnot had both a clinical and catastrophic failure and the Q-fix had 2 clinical failures. LEVEL OF EVIDENCE: Level V, Controlled Laboratory Study.

Biomechanical Evaluation of an All-Inside Posterior Medial Meniscal Root Repair Technique Via Suture Fixation to the Posterior Cruciate Ligament.

PURPOSE: To evaluate the tibiofemoral contact mechanics of an all-inside posterior medial meniscal root repair technique via suture fixation to the posterior cruciate ligament (PCL) and to compare with that of the intact knee and the knee with a root tear. METHODS: Tibiofemoral contact mechanics were recorded in 8 human cadaveric knee specimens using pressure sensors. Each knee underwent 3 testing conditions related to the posterior medial meniscal root: (1) intact knee; (2) root tear; and (3) all-inside repair via suture fixation to the PCL. Knees were loaded with a 1000-N axial compressive force at 4 knee flexion angles (0°, 30°, 60°, 90°). Calculations were performed for contact area, mean contact pressure, and peak contact pressure. A generalized linear model with a Tukey adjusted least square means test was used to determine differences between testing conditions. RESULTS: Across all knee flexion angles, there was an overall mean 26.3% reduction in contact area with root tear (211.34 mm2 vs intact 286.64 mm2, P = .0002), and a 31.6% increase from root tear to repair (277.61 mm2, P = .0297). Across all knee flexion angles, there was an overall mean 24.3% increase in contact pressure with root tear (1849.12 N/mm2 vs. intact 1487.52 N/mm2, P < .0001), and a 31.1% decrease from root tear to repair (1410.7 N/mm2, P = .0037). Across all knee flexion angles, there was an overall mean 10.6% increase in peak contact pressure with root tear (4083.55 N/mm2 vs. intact 3693.68 N/mm2, P < .0001), and a 12.4% decrease from root tear to repair (3632.13 N/mm2, P = .531). CONCLUSIONS: In most testing conditions and with overall averaging across knee flexion angles, the all-inside posterior medial meniscal root repair with suture fixation to the adjacent PCL fibers restored contact area (from 26.3% reduction with root tear to 31.6% increase with repair), contact pressures (from 24.3% increase with root tear to 31.1% decrease with repair), and peak contact pressures (from 10.6% increase with root tear to 12.4% decrease with repair) to that of the intact knee This may be a future potential technique to limit complications associated with the traditional transtibial pull-out method of repair. CLINICAL RELEVANCE: This technique may provide a posterior medial meniscal root repair construct that restores most tibiofemoral contact mechanics and offers theoretical benefits of technical ease and potential for an acceptable, less "anatomic" repair location.

Editorial Commentary: "Mo' Data, Mo' Problems"? "Big Data" From National Database Studies in Orthopaedic Research and Concerns Over Generalizability.

Publications referencing patient information from national databases such as the National Surgical Quality Improvement Program continue to become more prevalent in the orthopaedic literature. Although there is great value in some of the outcome variables provided by these data sets, concern remains regarding the generalizability of these "big data" studies because patient demographic characteristics such as age, sex, body mass index, and race often differ significantly with high-volume orthopaedic practices, and this may confound the conclusions made. As these national databases continue to be used, we have a responsibility to be critical and analytical in our translation of their findings to daily practice.

Assessment of Association Between Spino-Pelvic Parameters and Outcomes Following Gluteus Medius Repair.

PURPOSE: To evaluate postoperative coronal/sagittal spinal plane and spinopelvic parameters in patients undergoing gluteus medius repair and to identify associations between outcomes and the aforementioned spinopelvic variables. METHODS: Patients who underwent gluteus medius/minimus repair by a single surgeon between January 20, 2012, and November 25, 2015, were retrospectively identified from a prospectively collected database. Radiographic measurements included Cobb angle, lumbar lordosis, sagittal vertical axis (SVA), pelvic tilt, sacral slope, and pelvic incidence. Patient-reported outcomes (PROs) were obtained at baseline and a minimum of 22 months after surgery. Bivariate correlation determined effects of spinopelvic measurements on PROs. Scoliosis and nonscoliosis groups were compared using independent samples t-test, and multivariate analysis determined whether the preoperative variables affected outcomes. RESULTS: Thirty-eight (80.9%) of 47 consecutive patients were radiographically evaluated with a scoliosis series. All patients demonstrated significant improvements in all PROs and pain (P < .001 for all), as well as at an average 28.2 ± 7.8 (range, 22-51) months after surgery. There were significant negative relationships between SVA and Hip Outcome Score-Activities of Daily Living (r = -0.405, P = .026) and Hip Outcome Score-Sports Specific (r = -0.492, P = .011) scores. Patients with a positive SVA (>0 cm) had significantly worse patient-reported outcomes than their counterparts with negative (≤0 cm) SVA. Also, patients with positive sagittal plane deformity (SVA >5 cm) had significantly worse HOS-SS than patients without positive sagittal plane deformity (SVA <5 cm) (47.0 ± 35.3, 73.2 ± 24.0; P = .04). Independent sample t-testing for the patients with scoliosis (n = 18) versus no scoliosis (n = 20) demonstrates a significantly worse postoperative International Hip Outcome Tool (short version) score in the patients with scoliosis (77.4 ± 15.1, 53.8 ± 37.1; P = .043). CONCLUSIONS: Patients with scoliosis presented with lower rates of symptom improvement and ability to return to an active lifestyle in patients with hip disorders. In addition, patients with positive sagittal plane deformity experienced lower hip-related sport-specific outcome scores. Although the direct relationship between the spine and the hip in patients after gluteus medius/minimus repair remains unclear, this study shows an association between these postoperative outcomes and spinopelvic parameters. LEVEL OF EVIDENCE: Level IV, case series.