Editorial Commentary: Female Patients With Lower Body Mass Index Show the Best Outcomes After Hip Arthroscopy, and Arthroscopic Treatment of Femoroacetabular Impingement in Higher-Body Mass Index Female Patients Results in Improved Outcomes.

Which patients will benefit most from hip arthroscopy? Careful patient selection and conservative indications, such as patients with an alpha angle of 60° or greater or a lateral center-edge angle of 40° or greater who fail a trial of conservative treatment, may benefit from hip arthroscopy for femoroacetabular impingement (FAI). In female patients in particular, a lower body mass index (BMI) will predict the most benefit from arthroscopic treatment. That said, patients with a higher BMI can also substantially improve after treatment of FAI. The true art of medicine is determining indications for an individual patient in addition to providing evidence-based counseling and education. We must not forget that sometimes "any improvement" can be a good outcome for a patient who is in pain.

Blood Flow Restriction Therapy for 2 Weeks Prior to Anterior Cruciate Ligament Reconstruction Did Not Impact Quadriceps Strength Compared to Standard Therapy.

PURPOSE: To evaluate the efficacy of a 2-week home-based blood flow restriction (BFR) prehabiliation program on quadriceps strength and patient-reported outcomes prior to anterior cruciate ligament (ACL) reconstruction. METHODS: Patients presenting with an ACL tear were randomized into two groups, BFR and control, at their initial clinic visit. Quadriceps strength was measured using a handheld dynamometer in order to calculate peak force, average force, and time to peak force during seated leg extension at the initial clinic visit and repeated on the day of surgery. All patients were provided education on standardized exercises to be performed 5 days per week for 2 weeks between the initial clinic visit and date of surgery. The BFR group was instructed to perform these exercises with a pneumatic cuff set to 80% of limb occlusion pressure placed over the proximal thigh. Patient-Reported Outcome Measurement System Physical Function (PROMIS-PF), knee range of motion, and quadriceps circumference were gathered at the initial clinic visit and day of surgery, and patients were monitored for adverse effects. RESULTS: A total 45 patients met inclusion criteria and elected to participate. There were 23 patients randomized to the BFR group and 22 patients randomized into the control group. No significant differences were noted between the BFR and control groups in any demographic characteristics (48% vs 64% male [P = .271] and average age 26.5 ± 12.0 vs 27.0 ± 11.0 [P = .879] in BFR and control, respectively). During the initial clinic visit, there were no significant differences in quadriceps circumference, peak quadriceps force generation, time to peak force, average force, pain, and PROMIS scales (P > .05 for all). Following completion of a 2-week home prehabilitation protocol, all patients indeterminant of cohort demonstrated decreased strength loss in the operative leg compared to the nonoperative leg (P < .05 for both) However, there were no significant differences in any strength or outcome measures between the BFR and control groups (P > .05 for all). There were no complications experienced in either group, and both were compliant with the home-based prehabilitation program. CONCLUSIONS: A 2-week standardized prehabilitation protocol preceding ACL reconstruction resulted in a significant improvement in personal quadriceps peak force measurements, both with and without the use of BFR. No difference in quadriceps circumference, strength, or patient reported outcomes were found between the BFR and the control group. The home-based BFR prehabiliation protocol was found to be feasible, accessible, and well tolerated by patients. LEVEL OF EVIDENCE: Level II, randomized controlled trial with small effect size.

What are patients asking and reading online? An analysis of online patient searches for rotator cuff repair.

BACKGROUND: Patients undergoing rotator cuff surgery often search the internet for information regarding the procedure. One popular source, Google, compiles frequently asked questions and links to websites that may provide answers. This study provides an analysis of the most frequently searched questions associated with rotator cuff surgery. We hypothesize that there will be distinct search patterns associated with online queries about rotator cuff surgery that could provide unique insights into patient concerns. METHODS: A set of search terms were entered into Google Web Search using a clean-install Google Chrome browser. Frequently associated questions and their webpages were extracted to a database via a data mining extension. Questions were categorized by topics relevant for rotator cuff arthroscopy. Websites were categorized by source and scored for quality using the JAMA Benchmark Criteria. Pearson's χ2 tests were used to analyze nominal data. Student t tests were performed to compare JAMA Benchmark Scores. RESULTS: Of the 595 questions generated from the initial search, 372 unique questions associated with 293 websites were extracted and categorized. The most popular question topics were activities/restrictions (20.7%), pain (18.8%), and indications/management (13.2%). The 2 most common websites searched were academic (35.2%) and medical practice (27.4%). Commercial websites were significantly more likely to be associated with questions about cost (57.1% of all cost questions, P = .01), anatomy/function (62.5%, P = .001), and evaluation of surgery (47.6%, P < .001). Academic websites were more likely to be associated with questions about technical details of surgery (58.1%, P < .001). Medical practice and social media websites were more likely associated with activities/restrictions (48.1%, P < .001, and 15.6%, P < .001, respectively). Government websites were more likely associated with timeline of recovery (12.8%, P = .01). On a scale of 0-4, commercial and academic websites had the highest JAMA scores (3.06 and 2.39, respectively). CONCLUSION: Patients seeking information regarding rotator cuff repair primarily use the Google search engine to ask questions regarding postoperative activity and restrictions, followed by pain, indications, and management. Academic websites, which were associated with technical details of surgery, and medical practice websites, which were associated with activities/restrictions, were the 2 most commonly searched resources. These results emphasize the need for orthopedic surgeons to provide detailed and informative instructions to patients undergoing rotator cuff repair, especially in the postoperative setting.

The effect of subscapularis-specific rehabilitation following total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial.

BACKGROUND: Patients undergoing a total shoulder arthroplasty (TSA) through a deltopectoral approach will require repair of the subscapularis tendon. There are no universal postoperative guidelines for rehabilitation of the subscapularis specifically. We hypothesize that the addition of a subscapularis-specific regimen will result in improved subscapularis strength and function. METHODS: Adult patients undergoing anatomic TSA for the treatment of primary glenohumeral osteoarthritis were included. Patients were randomized into either the traditional rehabilitation (TR) control group or the subscapularis rehabilitation (SR) group, which consisted of the traditional therapy along with early and additional subscapularis exercises. Baseline demographics, patient-reported outcome measures (PROMs), range of motion (ROM), provocative tests, and subscapularis strength using a handheld dynamometer were measured preoperatively at the initial clinic visit (ICV) as well as 3 months, 6 months, and 1 year postoperatively. The primary outcome of interest was a comparison of subscapularis strength between cohorts relative to preoperative baseline, whereas secondary outcomes were functional, ROM, and PROMs. RESULTS: Sixty-six patients were included in the final analysis (32 TR vs. 34 SR). There were no statistically significant differences between cohorts at the ICV with regard to demographics, baseline subscapularis strength, functional testing, or PROMs. All postoperative time points demonstrated similar subscapularis strength testing between TR and SR groups (P > .05). Additionally, peak and average subscapularis strength testing at 3, 6, and 12 months postoperatively were similar to baseline ICV testing in both groups. Both groups demonstrated improvements across several provocative tests, ROM, and PROM outcome metrics at every postoperative time point as compared to baseline ICV values (P < .05). CONCLUSIONS: Patients undergoing anatomic TSA return to baseline internal rotation strength by 3 months postoperatively and demonstrate significant improvements in function, ROM, and several patient-reported outcome measures. The addition of early and focused subscapularis strengthening exercises does not appear to significantly impact any outcomes when compared to traditional rehabilitation programs.

Editorial Commentary: Surgeons Planning Hip Labral Arthroscopic Repair Should Have a Backup Plan of Labral Reconstruction or Augmentation Based on Intraoperative Labral Degeneration, Hypoplasia, or Ossification.

The arena of hip arthroscopy has seen leaps in practices over the past decade, evolving from surgical debridement of the labrum to improvements in techniques which now allow repair, augmentation, and circumferential reconstruction. But as the operating theater continues to change its act, so too must the preoperative choreography. Recent advancements in the understanding of preoperative risk factors for failure of primary labral repair have identified the diminutive or hypoplastic labra on prescreening magnetic resonance imaging as a negative predictor of success. While this quantitative assessment predicts the anatomical coverage of the labrum, we are still limited in our ability to qualify the latter's tissue substance preoperatively. Ossified or degenerative labra may not have the inherent functional capacity to restore the suction seal of the hip in a primary repair setting. If the applause from the audience fails to reach a significant threshold, we must rethink our act, and that begins with the choreography. The next step in hip arthroscopy is determining if a primary augmentation or reconstruction, in lieu of primary repair, warrants further consideration. Until we develop reliable methods of quantifying and qualifying the labral tissue, both preoperatively and optimally, we should establish backup for surprises encountered while on the "stage."

Preoperative Opioid Use Is Associated With Inferior Patient-Reported Outcomes Measurement Information System Scores Following Rotator Cuff Repair.

PURPOSE: To determine the influence of preoperative opioid use on Patient-Reported Outcomes Measurement Information System (PROMIS) scores pre- and postoperatively in patients undergoing arthroscopic rotator cuff repair (RCR). METHODS: A retrospective review of all RCR patients aged >18 years old was performed. PROMIS pain interference ("PROMIS PI"), upper extremity function ("PROMIS UE"), and depression ("PROMIS D") scores, were reviewed. These measures were collected at preoperative, 6-month, and 1-year postoperative time points. A prescription drug-monitoring program was queried to track opioid prescriptions. Patients were categorized as chronic users, acute users, and nonusers based on prescriptions filled. Comparison of means were carried out using analysis of variance and least squares means. Effect sizes and 95% confidence intervals were calculated. RESULTS: In total, 184 patients who underwent RCR were included. Preoperatively, nonusers (n = 92) had superior PROMIS UE (30.6 vs 28.9 vs 26.1; P < .05) and PI scores (61.5 vs 64.9 vs 65.3; P < .001) compared with acute users (n = 65) and chronic users (n = 27), respectively. At 6 months postoperatively; nonusers demonstrated significantly greater PROMIS UE (41.7 vs 35.6 vs. 33.5; P < .001), lower PROMIS D (41.6 vs 45.8 vs 51.1; P < .001), and lower PROMIS PI scores (50.7 vs 56.3 vs 58.1; P < .01) when compared with acute and chronic users, respectively. Nonusers had lower PROMIS PI (47.9 vs 54.3 vs 57.4; P < .0001) and PROMIS D (41.6 vs 48.3 vs 49.2; P = .0002) scores compared with acute and chronic users at 1-year postoperatively. Nonusers experienced a significantly greater magnitude of improvement in PROMIS D 6 months postoperatively compared with chronic opioid users (-5.9 vs 0.0; P < .01). CONCLUSIONS: Patients undergoing RCR demonstrated superior PROMIS scores pre- and postoperatively if they did not use opioids within 3 months before surgery. LEVEL OF EVIDENCE: III, retrospective comparative trial.

Perceived effectiveness of video interviews for orthopaedic surgery residency during COVID-19.

BACKGROUND: During the 2020-21 residency interview season, interviews were conducted through virtual platforms due to the COVID-19 pandemic. The purpose of this study is to assess the general perceptions of applicants, residents and attendings at a single, large, metropolitan orthopaedic residency with regards to the video interview process before and after the interview season. METHODS: Surveys were sent to all orthopaedic applicants, residents, and attendings before the interview season. Applicants who received interviews and responded to the first survey (46) and faculty who responded to the first survey (28) were sent a second survey after interviews to assess how their perceptions of video interviews changed. RESULTS: Initially, 50% of applicants (360/722) and 50% of faculty and residents (28/56) responded before interview season. After interviews, 55% of interviewees (25/46) and 64% of faculty and residents (18/28) responded. Before interviews, 91% of applicants stated they would prefer in-person interviews and 71% were worried that video interviews would prevent them from finding the best program fit. Before interviews, 100% of faculty and residents stated they would rather conduct in-person interviews and 86% felt that residencies would be less likely to find applicants who best fit the program. Comparing responses before and after interviews, 16% fewer applicants (p = 0.01) perceived that in-person interviews provide a better sense of a residency program and faculty and residents' perceived ability to build rapport with interviewees improved in 11% of respondents (p = 0.01). However, in-person interviews were still heavily favored by interviewees (84%) and faculty and residents (88%) after the interview season. CONCLUSIONS: In-person interviews for Orthopaedic Surgery Residency are perceived as superior and are preferred among the overwhelming majority of applicants, residents, and interviewers. Nevertheless, perceptions toward video interviews improved in certain domains after interview season, identifying potential areas of improvement and alternative interview options for future applicants.

Incidental findings detected on preoperative CT imaging obtained for robotic-assisted joint replacements: clinical importance and the effect on the scheduled arthroplasty.

OBJECTIVE: To determine the type and frequency of incidental findings detected on preoperative computed tomography (CT) imaging obtained for robotic-assisted joint replacements and their effect on the planned arthroplasty. MATERIALS AND METHODS: All preoperative CT examinations performed for a robotic-assisted knee or total hip arthroplasty were obtained. This resulted in 1432 examinations performed between September 2016 and February 2020 at our institution. These examinations were initially interpreted by 1 of 9 fellowship-trained musculoskeletal radiologists. Using a diagnosis search, the examination reports were then reviewed to catalog all incidental findings and further classify as significant or non-significant findings. Demographic information was obtained. In those with significant findings, a chart review was performed to record the relevant workup, outcomes, and if the planned arthroplasty was affected. RESULTS: Incidental findings were diagnosed in 740 (51.7%) patients. Of those with incidental findings, 41 (5.5%) were considered significant. A significant finding was more likely to be detected in males (P = 0.007) and on the hip protocol CT (P = 0.014). In 8 patients, these diagnoses resulted in either delay or cancelation of the arthroplasty. A planned total hip arthroplasty was more likely to be altered as compared to a knee arthroplasty (P = 0.018). CONCLUSION: Incidental findings are commonly detected by radiologists on preoperative CT imaging obtained for robotic-assisted joint replacement. Several were valuable findings and resulted in a delay or even cancelation of the planned arthroplasty after the detection of critical diagnoses, which if not identified may have resulted in devastating outcomes.

Career Longevity and Performance After Shoulder Instability in National Football League Athletes.

PURPOSE: To investigate the career longevity, game utilization, and performance of National Football League (NFL) athletes after glenohumeral instability events treated operatively versus nonoperatively. METHODS: Using public resources, we identified NFL players who sustained a shoulder instability event from September 2000 to February 2019. Players with prior shoulder instability, without NFL experience before injury, or who did not return to play (RTP) after injury were excluded. Demographic information, utilization (games and seasons), and season approximate value (SAV) statistics were recorded 1 year prior to injury and 3 years after RTP. Statistical analysis compared utilization and the SAV after RTP for athletes managed operatively versus nonoperatively. RESULTS: We identified 97 NFL players who sustained their first instability event while playing in the NFL, 91 of whom returned to play (93.8%). Quarterbacks were significantly more likely to undergo immediate surgical management compared with players in other positions (P = .023). The final analysis included 58 players managed operatively and 33 managed nonoperatively by the end of the index season. Players treated operatively played in significantly more seasons after RTP during their remaining careers (4.1 ± 2.7 seasons vs 2.8 ± 2.5 seasons, P = .015). There were no differences in games played or started, offensive or defensive snap count percentage, or performance (SAV) before and after injury when compared between cohorts (P > .05). After surgical stabilization, time to RTP (36.62 ± 10.32 weeks vs 5.43 ± 12.33 weeks, P < .05) and time interval before recurrent instability (105.7 ± 100.1 weeks vs 24.7 ± 40.6 weeks, P < .001) were significantly longer than with nonoperative treatment. Additionally, the operative cohort experienced less recurrent instability (27% vs 50%, P = .035). CONCLUSIONS: Athletes who RTP in the NFL after a shoulder instability injury do so with a similar workload and performance irrespective of surgical or nonsurgical management. Whereas nonoperative treatment is associated with faster RTP, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Elbow Torque Is Reduced in Asymptomatic College Pitchers With Elbow Laxity: A Dynamic Ultrasound Study.

PURPOSE: To determine the relation between medial elbow torque, as measured by wearable sensor technology, and adaptations of the medial elbow structures on dynamic ultrasound imaging in asymptomatic collegiate pitchers. METHODS: Thirty-four pitchers from National Collegiate Athletic Association Division II universities were eligible for preseason testing. The exclusion criteria included age younger than 18 years, history of surgery, non-pitcher, or current restrictions. Pitchers were fitted with a wearable sensor sleeve that recorded elbow torque, arm slot, arm speed, and arm rotation. Pitchers threw 5 fastballs in a standardized manner off the mound at game-speed effort. They also underwent dynamic ultrasound imaging of the elbow by a musculoskeletal sonographer, with standardized valgus loading. Images were deidentified, and measurements of the ulnar collateral ligament (UCL) and ulnohumeral joint space (UHJS), to assess elbow laxity, were performed by a musculoskeletal radiologist. RESULTS: The final analysis included 28 pitchers with an average age of 20.1 years (standard deviation, 1.3 years; range, 18-23 years) and playing experience of 15.3 years (standard deviation, 1.8 years; range, 11-19 years). The dominant UCL thickness (P < .001), loaded UHJS (P = .039), and delta UHJS (P < .001) were significantly greater than the nondominant measurements. An inverse correlation was found between loaded UHJS and medial elbow torque (r = -0.4, P < .001). Additionally, every 1-mm increase in UHJS significantly reduced medial elbow torque by 2.27 Nm (P = .032) and arm slot by 8.8° (P = .019) and increased arm rotation by 5.3° (P = .043). Pitchers with a loaded UHJS of 4.4 mm or greater and delta UHJS of 1.25 mm or greater had significantly reduced medial elbow torque (P < .001). Pitchers with a UCL thickness of 1.65 mm or greater had significantly increased medial elbow torque (47.4 Nm vs 44.8 Nm, P = .006). CONCLUSIONS: Pitchers with increased dynamic elbow laxity were found to experience reduced medial elbow torque while pitching. Additionally, pitchers with greater UCL thickness on ultrasound were found to experience increased medial elbow torque while pitching. This study's findings suggest a relation between anatomic adaptations found on ultrasound of the pitching elbow and medial elbow torque. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Multimodal nonopioid pain protocol provides equivalent pain control versus opioids following arthroscopic shoulder labral surgery: a prospective randomized controlled trial.

BACKGROUND: This study aimed to compare postoperative pain and patient satisfaction in patients undergoing primary arthroscopic labral surgery managed with either a nonopioid alternative pain regimen or a traditional opioid pain regimen. METHODS: Sixty consecutive patients undergoing primary arthroscopic shoulder labral surgery were assessed for participation. In accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement, a prospective randomized controlled trial was performed. The 2 arms of the study were a multimodal nonopioid analgesic protocol as the experimental group and a standard opioid regimen as the control group. The primary outcome was postoperative pain scores (on a visual analog scale [VAS]) for the first 10 days postoperatively. Secondary outcomes included patient satisfaction, patient-reported outcomes, and complications. Randomization was performed with a random number generator, and all data were collected by blinded observers. Patients were not blinded. RESULTS: Twelve patients did not meet the inclusion criteria or declined to participate. Thus, 48 patients were included in the final analysis: 24 in the nonopioid group and 24 in the opioid group. There was no significant difference in VAS or PROMIS (Patient-Reported Outcomes Measurement Information System) scores between patients in the 2 cohorts on any postoperative day (P > .05). When we controlled for confounding factors with repeated-measures mixed models, the nonopioid cohort reported significantly lower VAS and PROMIS (Patient-Reported Outcomes Measurement Information System) Pain Interference scores (P < .01) at all time points. No difference was found in reported adverse events (constipation, diarrhea, drowsiness, nausea, and upset stomach) between cohorts at any time point (P > .05). CONCLUSION: This study found that a multimodal nonopioid pain regimen provided, at the minimum, equivalent pain control, an equivalent adverse reaction profile, and equivalent patient satisfaction when compared with a standard opioid-based regimen following arthroscopic shoulder labral surgery.

The relationship between shoulder range of motion and elbow stress in college pitchers.

HYPOTHESIS: College pitchers with increased external rotation gain (ERG) produce increased medial elbow torque (elbow stress) whereas those with reduced total rotational range of motion (ROM) have reduced medial elbow torque during pitching. METHODS: Pitchers were recruited from 3 college baseball teams. Players with prior injury or on pitching restrictions because of pain were excluded. Players were evaluated within 2 weeks before their first game of the season. Pitchers completed an intake survey, and shoulder and arm measurements were taken. Pitchers were fitted with a baseball sleeve that included a sensor at the medial elbow. The sensor calculated elbow torque, arm speed, arm slot, and shoulder rotation for each pitch, while a radar gun measured peak ball velocity. After adequate warm-up, pitchers threw 5 fastballs in a standardized manner off the mound at game-speed effort. The primary outcome evaluated the relationship between shoulder ROM and medial elbow torque. Additional outcomes evaluated pitcher characteristics and demographic characteristics in the context of shoulder ROM. RESULTS: Twenty-eight pitchers were included in the preseason analysis. The average age and playing experience were 20.1 years (standard deviation [SD], 1.3 years) and 15.3 years (SD, 1.8 years), respectively, with 2.5 years (SD, 1.2 years) playing at collegiate level. The dominant shoulder showed decreased internal rotation and increased external rotation (ER) relative to the nondominant side (P < .001). The average glenohumeral internal rotation deficit and ERG were 11.3° (SD, 9.87°) and 5.71° (SD, 8.8°), respectively. ERG ≥ 5° was a significant predictor of elbow stress during pitching (47.4 Nm [SD, 0.7 Nm] vs. 45.1 Nm [SD, 0.6 Nm], P = .014). Univariate associations showed that each additional degree of ER resulted in increased elbow torque (ß estimate, 0.35 ± 0.06 Nm; P = .003). Conversely, decreased medial elbow torque was found in pitchers with reduced shoulder ROM (glenohumeral internal rotation deficit ≥ 20°: 43.5 Nm [SD, 1.1 Nm] vs. 46.6 Nm [SD, 0.5 Nm], P = .011; loss of total rotational ROM ≥ 5°: 43.6 Nm [SD, 1.1 Nm] vs. 46.6 Nm [SD, 0.5 Nm], P = .013) and in those with greater arm length (P < .05). CONCLUSIONS: College pitchers with increased ER produce greater medial elbow torque during the pitching movement. Each degree of increased ER was found to correlate with increased elbow torque and ball velocity. On the contrary, arm length and reduced shoulder ROM were associated with reduced medial elbow torque. This study suggests that increased ER in pitchers is associated with greater elbow stress during pitching.

A Multimodal Protocol to Diminish Pain Following Common Orthopedic Sports Procedures: Can We Eliminate Postoperative Opioids?

PURPOSE: To determine whether postsurgical pain, measured by the visual analog scale (VAS), following common orthopaedic sports procedures could be managed effectively with a nonopioid multimodal analgesic protocol. METHODS: This prospective study evaluated a custom multimodal nonopioid pain protocol in patients undergoing common orthopaedic sports procedures by a single fellowship-trained orthopaedic sports surgeon from May 2018 to December 2018. Procedures included anterior cruciate ligament reconstruction, rotator cuff repair, arthroscopic partial meniscectomy, and labrum repair. The nonopioid pain protocol consisted of preoperative analgesics, intraoperative local infiltration analgesia, and a postoperative pain regimen. Patient pain was immediately reported after surgery and 1 week postoperatively using the VAS, whereas rescue opioids (oxycodone 5 mg) used were recorded using a prescription opioid journal. Statistical analysis of patient VAS scores, demographic correlations, and comparison between opioid rescue users versus nonusers was performed. RESULTS: A total of 141 patients were included. One week following surgery, patients reported a mean VAS level of 3.2 ± 2.3 and required on average 2.6 ± 3.6 breakthrough oxycodone pills (8.6 ± 12.0 morphine equivalents). Forty-five percent of patients did not require any breakthrough prescription opioids and reported satisfaction with pain management. Patients who required opioids were more likely to have a history of anxiety/depression (44.2% vs 23.8%, P = .012) and reported greater pain scores as compared with nonusers (3.94 ± 2.5 vs 2.41 ± 1.75, P = .016). The most common side effect of the pain protocol was feeling drowsy (23.5%). All patients were satisfied with their pain management postoperatively. CONCLUSIONS: A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures. Patients were found to have low levels of pain, require minimal rescue opioids, and had no severe side effects related to the protocol. These results suggest a nonopioid alternative to pain management following common orthopedic sports procedures. LEVEL OF EVIDENCE: Level IV, prospective case series.

Risk Factors for Postoperative Opioid Use in Arthroscopic Shoulder Labral Surgery.

PURPOSE: To determine the correlation between preoperative and postoperative opioid use in patients undergoing arthroscopic shoulder labral repair, as well as patient risk factors associated with increased postoperative opioid use after the procedure. METHODS: A retrospective review of all patients undergoing arthroscopic shoulder labral surgery at a single institution between August 2013 and November 2017 was performed. Patients were stratified as opioid nonusers, acute users, or chronic users based on preoperative consumption. Patient demographic characteristics, injury characteristics, surgical interventions, and postoperative opioid use for the first 12 months after surgery were then analyzed. RESULTS: A total of 340 patients were included in this study. The average age was 26.3 years (range, 13-68 years), and the average body mass index was 27.5 (range, 18.4-45.0). Preoperative opioid users (acute and chronic) were found to continue to receive opioid medications at extended time points beyond 2 months postoperatively compared with nonusers (P < .001). Patients with intraoperatively identified SLAP tears experienced more preoperative pain and required more postoperative opioid prescriptions (P = .018). On stratification for other common shoulder instability injury patterns, no differences were found between the number of postoperative opioid prescriptions filled and the presence of Bankart lesion, Hill-Sachs lesion, reverse Hill-Sachs lesion, anterior labroligamentous periosteal sleeve avulsion, glenolabral articular disruption, or humeral avulsion of the glenohumeral ligament (P > .05). CONCLUSIONS: In patients undergoing arthroscopic labral surgery, the chronicity of preoperative opioid use, number of concomitant procedures at the time of initial surgery, and presence of biceps tenodesis were found to significantly increase postoperative opioid demand. Orthopaedic surgeons should recognize risk factors for increased opioid use postoperatively and adapt treatment strategies and patient counseling accordingly. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Forms Demonstrate Responsiveness in Patients Undergoing Knee Arthroplasty.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) is an alternative to legacy outcome metrics. We investigated the relationship between Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS-JR) and PROMIS Global Health forms of Physical Health (PH) and Mental Health (MH) in knee arthroplasty patients. METHODS: This is a retrospective cohort study of knee arthroplasty patients from December 2017 through April 2019 who had surveys collected preoperatively and postoperatively. We excluded patients undergoing revision surgery. Outcome scores were analyzed for responsiveness, effect size index (ESI), minimal clinically important difference (MCID), and correlation with each other through 12 months postoperatively. RESULTS: A total of 875 patients were included. Floor and ceiling effects were 0% for PROMIS-PH. Postoperative PROMIS-PH and KOOS-JR scores significantly correlated with one another and increased from baseline at each postoperative time point (P < .001 for all). PROMIS-MH did not change between time points (P > .05). PROMIS-PH showed moderate responsiveness at 1 and 3 months (ESI >0.2) and excellent responsiveness at 6 and 12 months (ESI >0.8), whereas KOOS-JR was responsive at all time points (ESI >0.8). The MCID of PROMIS-PH correlated significantly with KOOS-JR, and a preoperative PROMIS-PH score of less than 32.5 predicted achieving MCID with 97% specificity. CONCLUSION: PROMIS global health forms are a valid metric which capture patient outcomes and correlate with KOOS-JR scores after knee arthroplasty. Although KOOS-JR may be more responsive in the early postoperative time period, both measures show excellent responsiveness at 6 and 12 months after knee arthroplasty.

Mental Health and Tobacco Use Are Correlated With Physical Function Outcomes in Patients With Knee Pain and Injury.

PURPOSE: To examine the relation between the Patient-Reported Outcomes Measurement Information System (PROMIS) domains of Pain Interference (PROMIS-PI), Depression (PROMIS-D), and Physical Function (PROMIS-PF) for nonoperative patients presenting to our ambulatory sports orthopaedic clinic with knee complaints and to determine whether patient demographic characteristics influence PROMIS scores, particularly tobacco use. METHODS: All patients treated nonoperatively for a primary complaint of knee pain were recruited for participation. Patients were included if they completed all 3 PROMIS questionnaires prior to their clinical evaluation. Patients were excluded if their treatment plan determined that surgical intervention was warranted. Survey results were compiled, and statistical correlations were run between PROMIS domains and patient demographic characteristics. RESULTS: A total of 527 PROMIS questionnaire sets were included. PROMIS-PF had a strong negative correlation with PROMIS-PI (R = -0.75, P < .001) and a nearly moderate negative correlation with PROMIS-D (R = -0.47, P < .001). When evaluating patient demographic characteristics, we found a significant decrease in physical function scores and increases in pain and depression scores in both current and former tobacco users compared with nonsmokers. Differences in all PROMIS domains between smokers and nonsmokers exceeded minimal clinically important differences. CONCLUSIONS: Our study showed an inverse correlation between PROMIS-PI and PROMIS-PF, as well as between PROMIS-D and PROMIS-PI, in patients seen in the ambulatory setting for knee complaints treated nonoperatively. A positive correlation was found between PROMIS-PI and PROMIS-D. Tobacco use was a patient demographic factor found to significantly impact PROMIS scores leading to minimal clinically important differences across all 3 PROMIS domains. The findings of this study may be used to identify patients at high risk of poor outcomes. LEVEL OF EVIDENCE: Level III, observational study.

Risk Factors for Postoperative Opioid Use in Arthroscopic Meniscal Surgery.

PURPOSE: (1) To evaluate the influence of preoperative opioid use on postoperative consumption after arthroscopic meniscal surgery and (2) to determine preoperative patient factors associated with increased opioid use after meniscal surgery. METHODS: We performed a retrospective review of all patients with a primary diagnosis of a meniscal tear at a single institution between August 2013 and February 2017. Patients were classified as opioid nonusers if they had not received any opioid medications in the 3 months before meniscal surgery, as acute users if they received at least 1 opioid prescription within 1 month preceding meniscal surgery, or as chronic users if they received at least 1 opioid prescription within 3 months preceding meniscal surgery. Clinical records were reviewed for postoperative opioid use within a year after surgery. We also recorded patient demographic characteristics and the degree of knee osteoarthritis at the time of surgery using the Outerbridge classification. RESULTS: A total of 735 patients were included. The average age was 46.7 years (range, 12-79 years), and the average body mass index was 30.2 ± 6.2 (range, 13.3-55.4). Patients who were acute or chronic opioid users preoperatively were more likely to continue to use opioids beyond 1 month postoperatively (P < .001). A higher percentage of patients with advanced osteoarthritis (Outerbridge grade 3 or 4) were found to continue to use opioids at all time points beyond the first postoperative month (P < .05). Pair-wise comparisons showed that the number of total opioid prescriptions filled was significantly higher in the group with Outerbridge grade 1 or 2 and the group with Outerbridge grade 3 or 4 than the group with Outerbridge grade 0 (P = .023 and P = .014, respectively). No significant difference in postoperative opioid use was noted when we compared meniscal repair versus resection, primary procedure versus revision, different tear types, or concomitant procedures. CONCLUSIONS: In patients undergoing arthroscopic meniscal surgery, the chronicity of preoperative opioid intake and degree of knee osteoarthritis were found to have a significant effect on postoperative opioid use. LEVEL OF STUDY: Level III, retrospective comparative study.

Relative individual workload changes may be a risk factor for rerupture of ulnar collateral ligament reconstruction.

BACKGROUND: With an increasing number of Major League Baseball (MLB) players undergoing ulnar collateral ligament (UCL) reconstruction, there remains limited literature on appropriate post-reconstruction workload management to limit the risk of reinjury. METHODS: A total of 28 MLB pitchers who underwent primary UCL reconstruction surgery and subsequently required revision reconstruction were identified and compared with 137 MLB pitchers who underwent primary reconstruction but did not later require revision surgery. Games pitched, pitch counts, and innings pitched were evaluated and compared 3 years before and after primary reconstruction. Results were then compared between groups. RESULTS: Pitchers who later required revision increased their games pitched by 14.1% after reconstruction whereas the no-revision group pitched 13.6% fewer games than before reconstruction (P < .01). Inning workload was reduced by 9.8% after surgery (89.8 innings after vs 99.6 innings before) for the revision group compared with the no-revision group, which threw 26% fewer innings after surgery (86.3 innings after vs 116.7 innings before) (P = .05). In addition, the revision group pitched 6.6% more pitches after reconstruction, 1138.9 pitches, compared with before reconstruction, 1068.6 pitches. Pitchers who did not require revision, in contrast, pitched 19.6% fewer pitches after reconstruction than before reconstruction (P = .08). CONCLUSIONS: This study's findings suggest that MLB pitchers who require revision UCL reconstruction after returning to play following primary UCL reconstruction pitch at or above their pre-primary UCL reconstruction workload whereas control pitchers who do not require revision pitch significantly less, below their pre-primary UCL reconstruction workload.

Percutaneous Achilles Tendon Repair Using Ultrasound Guidance: An Intraoperative Ultrasound Technique.

Rupture of the Achilles tendon is a common injury seen in patients of varying ages and activity levels. There are many considerations for treatment of these injuries, with both operative and nonoperative management providing satisfactory outcomes in the literature. The decision to proceed with surgical intervention should be individualized for each patient, including the patient's age, future athletic goals, and comorbidities. Recently, a minimally invasive percutaneous approach to repair the Achilles tendon has been proposed as an equivalent alternative to the traditional open repair, while avoiding wound complications associated with larger incisions. However, many surgeons have been hesitant to adopt these approaches due to poor visualization, concern that suture capture in the tendon is not as robust, and the potential for iatrogenic sural nerve injury. The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. This technique minimizes the drawbacks of poor visualization associated with percutaneous repair, while providing the benefit of a minimally invasive approach.

Effects of a Perioperative Blood Flow Restriction Therapy Program on Early Quadriceps Strength and Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction.

Background: Quadriceps muscle atrophy remains a limiting factor in returning to activity after anterior cruciate ligament reconstruction (ACLR). Blood flow restriction (BFR) therapy may accelerate quadriceps strengthening in the perioperative period. Purpose: To evaluate postoperative isometric quadriceps strength in patients who underwent ACLR with a perioperative BFR program. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients indicated for ACLR were randomized into 2 groups, BFR and control, at their initial clinic visit. All patients underwent 2 weeks of prehabilitation preoperatively, with the BFR group performing exercises with a pneumatic cuff set to 80% limb occlusion pressure placed over the proximal thigh. All patients also underwent a standardized postoperative 12-week physical therapy protocol, with the BFR group using pneumatic cuffs during exercise. Quadriceps strength was measured as peak and mean torque during seated leg extension and presented as quadriceps index (percentage vs healthy limb). Patient-reported outcomes (PROs), knee range of motion, and quadriceps circumference were also gathered at 6 weeks, 3 months, and 6 months postoperatively, and adverse effects were recorded. Results: Included were 46 patients, 22 in the BFR group (mean age, 25.4 ± 10.6 years) and 24 in the control group (mean age, 27.5 ± 12.0 years). At 6 weeks postoperatively, the BFR group demonstrated significantly greater strength compared with the controls (quadriceps index: 57% ± 24% vs 40% ± 18%; P = .029), and the BFR group had significantly better Patient-Reported Outcomes Measurement Information System-Physical Function (42.69 ± 5.64 vs 39.20 ± 5.51; P = .001) and International Knee Documentation Committee (58.22 ± 7.64 vs 47.05 ± 13.50; P = .011) scores. At 6 weeks postoperatively, controls demonstrated a significant drop in the peak torque generation of the operative versus nonoperative leg. There were no significant differences in strength or PROs at 3 or 6 months postoperatively. Three patients elected to drop out of the BFR group secondary to cuff intolerance during exercise; otherwise, no other severe adverse events were reported. Conclusion: Integrating BFR into perioperative physical therapy protocols led to improved strength and increased PROs at 6 weeks after ACLR. No differences in strength or PROs were found at 3 and 6 months between the 2 groups. Registration: NCT04374968 (ClinicalTrials.gov identifier).