Publications

BACKGROUND: Treatment strategies for meniscal tears range from nonoperative management to surgical intervention. However, national trends in cost-related outcomes and patient factors related to the failure of nonoperative management remain poorly understood.

PURPOSE: To describe the costs associated with nonoperative versus operative management of meniscal tears in the 2 years after diagnosis and examine the relationship between patient characteristics and timing of surgery.

STUDY DESIGN: Cross-sectional study; Level of evidence, 3.

METHODS: This study was conducted using the MarketScan databases. Patients diagnosed with a meniscal tear without concomitant knee osteoarthritis between January 1 and December 31, 2017, were included. The primary outcome was the total cost of meniscal tear-related procedures-including insurance deductibles, coinsurance, and net insurance payments-in the 2 years after diagnosis. Procedures included were as follows: (1) surgery-including meniscectomy or meniscal repair; (2) physical therapy; (3) medication-including nonsteroidal anti-inflammatories, opioids, and acetaminophen; (4) intra-articular injections-including professional fee, hyaluronic acid, and corticosteroids; (5) imaging; and (6) clinic visits to orthopaedic specialists. Patients were grouped as having undergone early surgery (ES) (≤3 months of diagnosis), late surgery (LS) (>3 months after diagnosis), or no surgery (NS). Multivariate logistic regression was performed to determine the likelihood of undergoing surgery early and failing nonoperative treatment.

RESULTS: The study population included 29,924 patients with a mean age of 43.9 ± 12.9 years (ES: n = 9507 (31.8%); LS: n = 2021 (6.8%); NS: n = 18,396 (61.5%)). Complex (36.6%) and medial (58.8%) meniscal tears were the most common type and location of injuries, respectively. The mean cost of management per patient was $3835 ± $4795. Costs were lower in the NS group ($1905 ± $3175) compared with the ES group ($6759 ± $5155), while the highest costs were observed in the LS group ($7649 ± $5913) (P < .001). Patients who were men, >40 years, and with a bucket-handle or lateral meniscal tear were more likely to undergo surgery early. Patients who were men, <30 years, and with a complex tear or tear to the lateral meniscus were more likely to fail nonoperative management.

CONCLUSION: Nonoperative management had the lowest cost burden and should be recommended for patients with appropriate indications. However, if surgery is necessary, it should be performed earlier.

Background: Lower extremity reconstructive surgery is an evolving field wherein patients rely on accessible online materials to engage with their perioperative care. This study furthers existing research in this area by evaluating the readability, understandability, actionability, and cultural sensitivity of online health materials for lower extremity reconstruction. Methods: We identified the 10 first-appearing, educational sites found by searching the phrases "leg saving surgery", "limb salvage surgery," and "leg reconstruction surgery". Readability analysis was conducted with validated tools, including Simple Measure of Gobbledygook (SMOG). Understandability and actionability were assessed with Patient Education and Materials Assessment Tool (PEMAT), while cultural sensitivity was measured with Cultural Sensitivity Assessment Tool (CSAT). A Cohen's κ value was calculated (PEMAT and CSAT analyses) for inter-rater agreement. Results: The mean SMOG reading level for websites was 13.12 (college-freshman reading level). The mean PEMAT understandability score was 61.8% and actionability score was 26.0% (κ = 0.8022), both below the 70% acceptability threshold. The mean CSAT score was 2.6 (κ = 0.73), exceeding the 2.5 threshold for cultural appropriateness. Conclusion: Online PEM for lower extremity reconstruction continue to fall below standards of readability, understandability, and actionability; however, they meet standards of cultural appropriateness. As patients rely on these materials, creators can use validated tools and positive examples from existing PEM for greater patient accessibility.

BACKGROUND: Stemless shoulder arthroplasty offers several advantages, such as preserving bone stock and reducing periprosthetic fracture risk. However, implant motion can deter osteointegration and increase bone resorption, where micromotion less than 0.150 mm is crucial for bony ingrowth and vital to the success of the implant. The interaction between the implant and the metaphyseal bone and its effects on stability remains unclear. Therefore, this cadaveric study aims to assess the immediate stability of two stemless prostheses in low bone density specimens.

METHODS: Twenty cadaveric shoulders were used to compare the stability of two stemless shoulder implants by Zimmer-Biomet (model A) and Exactech (model B), subjected to loads of 220 N, 520 N, and 820 N to assess strain and micromotion.

FINDINGS: Micromotion at 220 N load was 0.061 ± 0.080 mm and 0.053 ± 0.050 mm, and at 520 N load, 0.279 ± 0.37 mm and 0.311 ± 0.35 mm for models A and B, respectively. The estimated mean force required to achieve a 150 μm micromotion was 356 ± 116 N and 315 ± 61 N for models A and B, respectively. Motion analysis revealed distinct movement patterns for each implant, with model B demonstrating better force distribution on the bone despite no significance.

INTERPRETATION: Forces over 520 N (high postoperative rehabilitation force) could hinder bone integration with prostheses due to excessive micromotion. Conversely, forces around 220 N (preconditioning loading force) are considered safe for prosthesis stability even with low bone density. These insights may caution against using stemless implants when bone density is low, and help guide clinical decisions on the duration of rehabilitation and sling use after stemless arthroplasty.

BACKGROUND: Augmentation of an arthroscopic Bankart repair with the remplissage (ABR) procedure has shown to confer a decrease in recurrence rates, yet, at the expense of potentially compromising shoulder motion.

PURPOSE/HYPOTHESIS: The purpose was to examine clinical studies that described a post-operative rehabilitation protocol after an arthroscopic Bankart repair and remplissage procedure. It was hypothesized that a review of the literature would find variability among the studies and that, among comparative studies, there would be a limited distinction from protocols for isolated Bankart repairs.

STUDY DESIGN: Systematic Review.

MATERIALS AND METHODS: A search was conducted using three databases (PubMed, EMBASE, and CINAHL) according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. The following terms were combined while utilizing Boolean operators: (Bankart lesion OR labral tear) AND (remplissage). Studies evaluating patients after arthroscopic stabilization for unidirectional anterior glenohumeral instability with the addition of the remplissage procedure and at least 1 year follow-up were included for analysis.

RESULTS: A total of 41 studies (14 Level IV, 24 Level III, 2 Level II, and 1 Level I) were included with a total of 1,307 patients who underwent ABR. All patients had <30% glenoid bone loss and a range of 10-50% humeral head size Hill-Sachs lesion. Type and position of immobilization were the most reported outcomes (41/41) followed by time of immobilization (40/41). Moreover, 23/41 studies described their initial post-operative shoulder range of motion restrictions, while 17/41 specified any shoulder motion allowed during this restrictive phase. Time to return to sport was also described in 37/41 of the retrieved studies. Finally, only two of the 27 comparative studies tailored their rehabilitation protocol according to the specific procedure performed, underscoring the lack of an individualized approach (i.e. same rehabilitation protocol for different procedures).

CONCLUSION: The results of the present systematic review expose the variability among rehabilitation protocols following ABR. This variability prompts consideration of the underlying factors influencing these disparities and underscores the need for future research to elucidate optimal rehabilitation. Based on the results of this systematic review and the senior authors´ clinical experience, a rehabilitation approach similar to an isolated Bankart repair appears warranted, with additional precautions being utilized regarding internal rotation range of motion and external rotation strengthening.

LEVEL OF EVIDENCE: Level 3.

INTRODUCTION: Over 6.8 million fractures occur annually in the US, with 10% experiencing delayed- or non-union. Anabolic therapeutics like PTH analogs stimulate fracture repair, and small molecule salt inducible kinase (SIK) inhibitors mimic PTH action. This study tests whether the SIK inhibitor YKL-05-099 accelerates fracture callus osteogenesis.

METHODS: 126 female mice underwent femoral shaft pinning and midshaft fracture, receiving daily injections of PBS, YKL-05-099, or PTH. Callus tissues were analyzed via RT-qPCR, histology, single-cell RNA-seq, and μCT imaging. Biomechanical testing evaluated tissue rigidity. A hydrogel-based delivery system for PTH and siRNAs targeting SIK2/SIK3 was developed and tested.

RESULTS: YKL-05-099 and PTH-treated mice showed higher mineralized callus volume fraction and improved structural rigidity. RNA-seq indicated YKL-05-099 increased osteoblast subsets and reduced chondrocyte precursors. Hydrogel-released siRNAs maintained target knockdown, accelerating callus mineralization.

DISCUSSION: YKL-05-099 enhances fracture repair, supporting selective SIK inhibitors' development for clinical use. Hydrogel-based siRNA delivery offers targeted localized treatment at fracture sites.

Background: Free tissue transfer is a valuable surgical option for the reconstruction of a myriad of complex lower extremity defects. Currently, there is a paucity of data that examines the risks of complications for each of these unique indications. Methods: Patients undergoing lower extremity free flap reconstruction from the ACS-NSQIP 2011-2019 database were stratified into groups based on the etiology and indication for reconstruction. Rates of major, surgical wound, and medical complications were compared over the first post-operative month. Multivariable logistic regression was used to identify complication predictors. Results: 425 lower extremity free flaps were analyzed. The most common indications for lower extremity free flap reconstruction were wound-related (29%), malignancy (21%), and trauma (17%). Seventeen percent of free flaps had a major post-operative complication, 9% had a surgical wound complication, and 16% had a medical complication. There were no significant differences in major complications between the indications. However, the independent risk factors for major complications varied widely. Those with an indication of malignancy and those who received a musculocutaneous free flap were significantly more likely to have a surgical wound complication compared to the remaining cohort (p < 0.05). Those requiring free flap reconstruction for orthopedic hardware related concerns as well as those with wound related indications were significantly more likely to have a post-operative medical complication (p < 0.05). Conclusion: Understanding the unique risk profiles between the various indications and populations of patients undergoing lower extremity free flap reconstruction is critical for providing accurate risk estimations and optimizing post-operative outcomes and monitoring. Keywords microsurgery, lower extremity free flap, free flap reconstruction.

BACKGROUND: While rotator cuff tears are prevalent in the general population, the natural history of this disease is unclear. Understanding rotator cuff tear progression is crucial for refining surgical indications and evaluating the necessity of early interventions. This study presents an in-depth analysis of the existing literature on the definitions and progression rates of rotator cuff tears, aiming to enhance clinical decision making and patient outcomes.

METHODS: A systematic literature search was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using Medline (PubMed), Embase (Elsevier), and Web of Science databases on January 12, 2023. Articles were identified as relevant to the natural history and progression of asymptomatic and symptomatic partial-thickness (PT) and full-thickness (FT) rotator cuff tears. Those written in English reporting rotator cuff progression rates of tears in adults, based on magnetic resonance imaging (MRI) or ultrasound, were included. After reviewing the articles, the data on the rates of tear progression and associated risk factors were extracted, compiled, and analyzed. The risk of bias was determined using the Newcastle-Ottawa Scale.

RESULTS: Twenty-one articles met the inclusion criteria, with 1,831 tears included. The progression rate for all partial thickness tears was 26.7% ± 12.8% at an average follow-up of 2.2 ± 0.9 years, with 5 definitions for tear progression. For FT tears, the progression rate was 54.9% ± 18.6% at a follow-up time of 3.0 ± 2.0 years, with 8 definitions for tear enlargement. A significant difference (p < 0.0001) was found between the progression rates of PT and FT tears. Patients who were initially asymptomatic and became symptomatic had higher progression rates (33%-63%) than those who remained asymptomatic (4%-38%).

CONCLUSION: Further research would benefit by identifying a clinically relevant and standardized definition of rotator cuff tear progression, to describe the natural history of rotator cuff disease, making results more comparable and optimizing treatment planning.

LEVEL OF EVIDENCE: Level II. See Instructions for Authors for a complete description of levels of evidence.

Partial-thickness rotator cuff tears are a common cause of pain and disability and are central to developing full-thickness rotator cuff tears. However, limited knowledge exists regarding the alterations to the mechanical environment due to these lesions. Computational models that study the alterations to the mechanical environment of the supraspinatus tendon can help advance clinical management to avoid tear progression and provide a basis for surgical intervention. In this study, we use three-dimensional validated finite element models from six intact specimens to study the effects of low- and high-grade tears originating on the articular and bursal surfaces of the supraspinatus tendon. Bursal-sided tears generally had a lower failure load, modulus, and strain than articular-sided tears. Thus, caution should be taken when managing bursal-sided tears as they may be more susceptible to tear progression.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Accurately diagnose scaphoid fractures through examination and appropriate imaging selection. 2. Recognize those fractures that can be treated with nonoperative management. 3. Outline the different surgical approaches for scaphoid fractures. 4. Appreciate the surgical options for management of scaphoid nonunion.

SUMMARY: This article includes the most up-to-date information on the diagnosis, work-up, and treatment of scaphoid fractures.

BACKGROUND: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have inferior outcomes compared with primary ACL reconstruction. The reasons why remain unknown.

PURPOSE: To determine whether surgical factors performed at the time of revision ACL reconstruction can influence a patient's outcome at 6-year follow-up.

STUDY DESIGN: Cohort study; Level of evidence, 2.

METHODS: Patients who underwent revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline patient characteristics, surgical technique and pathology, and a series of validated patient-reported outcome instruments: Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) subjective form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity rating score. Patients were followed up for 6 years and asked to complete the identical set of outcome instruments. Regression analysis was used to control for baseline patient characteristics and surgical variables to assess the surgical risk factors for clinical outcomes 6 years after surgery.

RESULTS: A total of 1234 patients were enrolled (716 men, 58%; median age, 26 years), and 6-year follow-up was obtained on 79% of patients (980/1234). Using an interference screw for femoral fixation compared with a cross-pin resulted in significantly better outcomes in 6-year IKDC scores (odds ratio [OR], 2.2; 95% CI, 1.2-3.9; P = .008) and KOOS sports/recreation and quality of life subscale scores (OR range, 2.2-2.7; 95% CI, 1.2-4.8; P < .01). Use of an interference screw compared with a cross-pin resulted in a 2.6 times less likely chance of having a subsequent surgery within 6 years. Use of an interference screw for tibial fixation compared with any combination of tibial fixation techniques resulted in significantly improved scores for IKDC (OR, 1.96; 95% CI, 1.3-2.9; P = .001); KOOS pain, activities of daily living, and sports/recreation subscales (OR range, 1.5-1.6; 95% CI, 1.0-2.4; P < .05); and WOMAC pain and activities of daily living subscales (OR range, 1.5-1.8; 95% CI, 1.0-2.7; P < .05). Use of a transtibial surgical approach compared with an anteromedial portal approach resulted in significantly improved KOOS pain and quality of life subscale scores at 6 years (OR, 1.5; 95% CI, 1.02-2.2; P≤ .04).

CONCLUSION: There are surgical variables at the time of ACL revision that can modify clinical outcomes at 6 years. Opting for a transtibial surgical approach and choosing an interference screw for femoral and tibial fixation improved patients' odds of having a significantly better 6-year clinical outcome in this cohort.