Publications by authors named "Avinesh Agarwalla"

78 Publications

High Rate of Return to Work by Three Months Following Latarjet for Anterior Shoulder Instability.

Arthroscopy 2021 Jul 9. Epub 2021 Jul 9.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A.. Electronic address:

Purpose: To evaluate the rate and duration of return to work in patients undergoing Latarjet for failed soft-tissue stabilization or glenoid bone loss.

Methods: Consecutive patients undergoing Latarjet from 2005 to 2015 at our institution were retrospectively reviewed at a minimum of 2 years postoperatively. Patients completed a standardized and validated work questionnaire, Western Ontario Shoulder Instability Index Survey, and a satisfaction survey.

Results: Of 89 eligible patients who had Latarjet, 67 patients (75.3%) responded to the questionnaire, of whom 51 patients (76.1%) were employed within 3 years before surgery (mean age: 29.9 ± 11.8 years; mean follow-up: 54.6 ± 11.9 months) and had an average glenoid bone loss of 14.5 ± 6.1%. Fifty patients (98.0%) returned to work by 2.7 ± 3.0 months postoperatively; 45 patients (88.2%) patients returned to the same level of occupational intensity. Those who held sedentary, light, moderate, or heavy intensity occupations returned to their previous occupation at a rate of 100.0%, 93.3%, 90.0%, and 66.7% (P = .2) at a duration of 1.2 ± 1.6 months, 1.8 ± 1.9 months, 3.1 ± 3.5 months, and 6.5 ± 4.1 months (P = .001), respectively. The average postoperative Western Ontario Shoulder Instability Index score was 70.9 ± 34.2. Fifty patients (98.0%) noted at least "a little improvement" in their quality of life following surgery, with 35 patients (68.6%) noting great improvement. Furthermore, 49 patients (96.1%) reported being satisfied with their procedure, with 25 patients (49.0%) reporting being very satisfied. Four patients (7.8%) returned to the operating room, with 1 patient (2.0%) requiring arthroscopic shoulder stabilization.

Conclusions: Approximately 98% of patients who underwent Latarjet returned to work by 2.7 ± 3.0 months postoperatively. Patients with greater-intensity occupations had a longer duration of absence before returning to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

Level Of Evidence: IV, case series.
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http://dx.doi.org/10.1016/j.arthro.2021.06.027DOI Listing
July 2021

Predicting Patient Satisfaction With Maximal Outcome Improvement After Biceps Tenodesis.

Orthopedics 2021 May-Jun;44(3):e359-e366. Epub 2021 May 1.

The goal of this study was to determine the threshold for achieving maximal outcome improvement (MOI) on the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (CM) questionnaires that predict satisfaction after isolated biceps tenodesis without concomitant rotator cuff repair. A retrospective analysis of prospectively collected data was performed for patients undergoing isolated biceps tenodesis from 2014 to 2017 at a single institution with minimum 6-month follow-up. Receiver operating characteristic curve analysis was used to determine thresholds for MOI for the ASES, SANE, and CM questionnaires. Stepwise multivariate logistical regression analysis was performed to identify predictors for achieving the threshold for MOI. A total of 123 patients were included in the final analysis. Receiver operating characteristic analysis determined that achieving 43.1%, 62.1%, and 61.4% MOI was the threshold for satisfaction for the ASES, SANE, and CM questionnaires, respectively. Regression analysis showed that concomitant superior labrum anterior-posterior (SLAP) repair was predictive of achieving MOI on the ASES and SANE questionnaires, whereas partial rotator cuff tear was predictive of achieving MOI on the CM questionnaire (<.05 for both). Further, workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors of achieving MOI on the SANE and CM questionnaires (<.05 for all). Achieving MOI of 43.1%, 62.1%, and 61.4% is the threshold for satisfaction after biceps tenodesis for the ASES, SANE, and CM questionnaires, respectively. Concomitant SLAP repair was positively predictive of achieving MOI, whereas workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors. [. 2021;44(3):e359-e366.].
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http://dx.doi.org/10.3928/01477447-20210414-07DOI Listing
July 2021

All Inside Intraepiphyseal ACL Reconstruction Using Flexible Curved Instrumentation and Intraoperative Fluoroscopy in a Skeletally Immature Patient.

Case Rep Orthop 2021 21;2021:3956524. Epub 2021 Apr 21.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.

Case: A 13-year-old skeletally immature female presenting with an anterior cruciate ligament (ACL) rupture after a noncontact injury was treated with an intraepiphyseal ACL reconstruction. Flexible instrumentation was utilized to drill a femoral tunnel with an anatomic starting point, with a trajectory that curved inferolaterally away from the physis. At three years postoperatively, she had returned to her preinjury functioning and did not display any lower limb length growth abnormalities.

Conclusions: The novel application of curved guides and flexible instruments, with intraoperative fluoroscopy, facilitated growth plate avoidance and a successful outcome of ACL reconstruction in a skeletally immature patient.
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http://dx.doi.org/10.1155/2021/3956524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081639PMC
April 2021

Return to sport following Latarjet glenoid reconstruction for anterior shoulder instability.

J Shoulder Elbow Surg 2021 Apr 28. Epub 2021 Apr 28.

Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: Latarjet coracoid transfer reconstruction is the gold standard for the treatment of recurrent shoulder instability with anterior-inferior glenoid bone loss, and return to sport is often a primary outcome of interest in this patient population. The purpose of this study was to determine the rate of return to sport in patients undergoing the Latarjet procedure and variables that are associated with a higher likelihood of a successful return to sport.

Methods: A prospectively maintained institutional registry was retrospectively queried between August 2012 and August 2016 for all patients who underwent the Latarjet procedure. Patients were contacted electronically and via telephone to administer a previously validated and standardized return-to-sport survey. Patients self-reported return to sport, varying sports participation, recurrence of instability, and time to return to sport. Multivariate analysis was performed to determine variables associated with each outcome.

Results: Of 83 patients, 66 (75.3%) were available for final follow-up, of whom 60 participated in sports prior to surgery and were eligible for inclusion. The average follow-up period was 53.8 ± 11.8 months. The average age at surgery was 26.7 ± 11.3 years, and the average body mass index was 26.2 ± 4.0 kg/m. There were 54 patients (90%) who were able to return to sport at an average of 8.6 ± 4.1 months following surgery. In total, 36 patients (60%) were able to return to sport at the same level or a better level of intensity, 19 of 28 patients (67.9%) were able to return to throwing sports without difficulty, and 31 of 60 patients (51.7%) reported that their shoulder was a hindrance to some activity. An increased likelihood of returning to sport was associated with increased body mass index (P = .016), male sex (P = .028), and decreased humeral bone loss volume (P = .034). An increased likelihood of returning to sport at the same level or a better level of intensity was associated with reduced humeral bone loss volume (P = .026). Recurrent instability was associated with humeral bone loss (P = .038).

Conclusion: Although a large majority of patients were able to return to sport following the Latarjet procedure, some patients experienced limitation with throwing and return to sport at the preinjury level. Greater humeral bone loss was associated with inferior outcomes. These findings should be discussed with patients in the preoperative setting to manage expectations appropriately.
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http://dx.doi.org/10.1016/j.jse.2021.04.020DOI Listing
April 2021

Assessment and Trends in the Methodological Quality of the Top 50 Most Cited Articles in Shoulder Instability.

Orthop J Sports Med 2020 Dec 15;8(12):2325967120967082. Epub 2020 Dec 15.

Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA.

Background: Citation counts have often been used as a surrogate for the scholarly impact of a particular study, but they do not necessarily correlate with higher-quality investigations. In recent decades, much of the literature regarding shoulder instability is focused on surgical techniques to correct bone loss and prevent recurrence.

Purpose: To determine (1) the top 50 most cited articles in shoulder instability and (2) if there is a correlation between the number of citations and level of evidence or methodological quality.

Study Design: Cross-sectional study.

Methods: A literature search was performed on both the Scopus and the Web of Science databases to determine the top 50 most cited articles in shoulder instability between 1985 and 2019. The search terms used included "shoulder instability," "humeral defect," and "glenoid bone loss." Methodological scores were calculated using the Modified Coleman Methodology Score (MCMS), Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS) score.

Results: The mean number of citations and mean citation density were 222.7 ± 123.5 (range, 124-881.5) and 16.0 ± 7.9 (range, 6.9-49.0), respectively. The most common type of study represented was the retrospective case series (evidence level, 4; n = 16; 32%) The overall mean MCMS, Jadad score, and MINORS score were 61.1 ± 10.1, 1.4 ± 0.9, and 16.0 ± 3.0, respectively. There were also no correlations found between mean citations or citation density versus each of the methodological quality scores.

Conclusion: The list of top 50 most cited articles in shoulder instability comprised studies with low-level evidence and low methodological quality. Higher-quality study methodology does not appear to be a significant factor in whether studies are frequently cited in the literature.
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http://dx.doi.org/10.1177/2325967120967082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8008137PMC
December 2020

Corticosteroid Injections 1 Month Before Arthroscopic Meniscectomy Increase the Risk of Surgical-Site Infection.

Arthroscopy 2021 Mar 31. Epub 2021 Mar 31.

University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, U.S.A.

Purpose: To define the incidence of postoperative infections in patients who receive corticosteroid injections prior to arthroscopic meniscectomy, to determine whether there is a temporal relation between injections and the risk of surgical-site infections, and to identify corresponding risk factors.

Methods: The Humana administrative claims database was reviewed for patients undergoing arthroscopic meniscectomy within 1 year of injection and those undergoing arthroscopic meniscectomy without prior injection. Patients with preoperative injections were further stratified by the duration in months between the injection and the surgical procedure. Surgical-site infection within 6 months of surgery was recorded. Univariate analysis and binary logistic regression were performed to determine independent risk factors for surgical-site infection. Statistical significance was defined as P < .05.

Results: We identified patients with (n = 11,652) and without (n = 37,261) a history of a knee corticosteroid injection within 1 year of arthroscopic meniscectomy with at least 6 months of database activity from 2007 to 2017. In patients who received knee injections within 1 month prior to surgery, the rate of development of postoperative infections was twice that in patients who did not receive an injection (1.28% vs 0.63%; odds ratio [OR], 1.84; 95% confidence interval [CI], 1.24-2.62; P = .001). Multivariate logistic regression identified male sex (OR, 1.39; 95% CI, 1.14-1.71; P = .001), diabetes (OR, 1.48; 95% CI, 1.19-1.85; P < .001), chronic obstructive pulmonary disease (OR, 1.57; 95% CI, 1.27-1.94; P < .001), obesity (OR, 1.32; 95% CI, 1.07-1.63; P = .010), tobacco use (OR, 1.61; 95% CI, 1.30-1.98; P < .001), and preoperative injections within 1 month of surgery (OR, 1.78; 95% CI, 1.21-2.54; P = .002) as significant predictors, whereas injections administered more than 1 month before surgery were not significantly associated with postoperative surgical-site infection after arthroscopic meniscectomy.

Conclusions: Injections 1 month before arthroscopic meniscectomy significantly increase the risk of surgical-site infection. However, injections can be safely administered more than 1 month prior to surgery because there is no increased risk of postoperative infection at this time point.

Level Of Evidence: Level III, retrospective cohort study.
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http://dx.doi.org/10.1016/j.arthro.2021.02.047DOI Listing
March 2021

Humeral Head Fracture Dislocation with Displacement into the Mediastinum: A Case Report.

JBJS Case Connect 2021 02 19;11(1). Epub 2021 Feb 19.

Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, New York.

Case: A 70-year-old woman pedestrian struck by a motor vehicle presented with multiple orthopaedic injuries including a humeral head fracture dislocation with a large segment of humeral head located in the mediastinum. Thoracic surgery personnel performed a minimally-invasive video-assisted thoracoscopic extraction of the humeral head, and the patient underwent subsequent reverse total shoulder arthroplasty.

Conclusion: Intramediastinal displacement of the humeral head is a rare, yet serious traumatic injury that necessitates early recognition and comanagement with cardiothoracic or thoracic surgery. Early thoracic intervention to extract the humeral head and replacement arthroplasty is an effective treatment modality.
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http://dx.doi.org/10.2106/JBJS.CC.20.00437DOI Listing
February 2021

Assessment and Trends of the Methodological Quality of the Top 50 Most Cited Articles on Patellar Instability.

Orthop J Sports Med 2021 Jan 29;9(1):2325967120972016. Epub 2021 Jan 29.

Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA.

Background: Studies with a low level of evidence (LOE) have dominated the top cited research in many areas of orthopaedics. The wide range of treatment options for patellar instability necessitates an investigation to determine the types of studies that drive clinical practice.

Purpose: To determine (1) the top 50 most cited articles on patellar instability and (2) the correlation between the number of citations and LOE or methodological quality.

Study Design: Cross-sectional study.

Methods: The Scopus and Web of Science databases were assessed to determine the top 50 most cited articles on patellar instability between 1985 and 2019. Bibliographic information, number of citations, and LOE were collected. Methodological quality was calculated using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS). Mean citations and mean citation density (citations per year) were correlated with LOE, MCMS, and MINORS scores.

Results: Most studies were cadaveric (n = 10; 20.0%), published in the (n = 13; 26.0%), published between 2000 and 2009 (n = 41; 82.0%), and conducted in the United States (n = 17; 34.0%). The mean number of citations and the citation density were 158.61 ± 59.53 (range, 95.5-400.5) and 12.74 ± 5.12, respectively. The mean MCMS and MINORS scores were 59.62 ± 12.58 and 16.24 ± 3.72, respectively. No correlation was seen between mean number of citations or citation density versus LOE. A significant difference was found in the mean LOE of articles published between 1990 and 1999 (5.0 ± 0) versus those published between 2000 and 2009 (3.12 ± 1.38; = .03) and between 2010 and 2019 (3.00 ± 1.10; = .01).

Conclusion: There was a shift in research from anatomy toward outcomes in patellar instability; however, these articles demonstrated low LOE and methodological quality. Higher quality studies are necessary to establish informed standards of management of patellar instability.
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http://dx.doi.org/10.1177/2325967120972016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869164PMC
January 2021

Safety and Efficacy of Cultured/Noncultured Mesenchymal Stromal Cells without Concurrent Surgery for Knee Osteoarthritis: A Systematic Review of Randomized Controlled Trials.

J Long Term Eff Med Implants 2020 ;30(1):31-47

Restore Orthopedics, Orange, CA 92868.

The quantity of studies investigating mesenchymal stromal cells (MSCs) for knee osteoarthritis (OA) treatment is not restricted, unlike the amount of randomized controlled trials (RCTs) that can be found in the literature. MSCs demonstrate a promising potential for safe pain relief of OA, yet indeterminate conclusions prevail due to heterogeneous reporting and study design. By evaluating PubMed and ScienceDirect for RCTs that describe patient-reported outcome measures (PROMs) and adverse events (AEs), we investigate safety and efficacy of MSCs for knee OA unaccompanied by adjuvant surgical intervention. This systematic review is performed in alignment with preferred reported items for systematic reviews and meta-analyses guidelines. In addition to PROMs and AEs, we review included studies for stromal cell variants, follow-up, and imaging modalities, reporting our results in tables and text. Twelve studies that ranged from 1 wk to 4 yr and examined 428 patients and 856 knees met inclusion criteria. Six studies (50%) evaluated bone marrow MSCs, five (42%) evaluated adipose-derived MSCs, and one (8%) evaluated umbilical cord MSCs. All studies reported significant PROM improvement. Mean improvements in the visual analog scale and Western Ontario and McMaster Universities Arthritis Index, ranging from 0 to 40 and 10 to 32 points, respectively, were observed. Of 343 total patients, 135 (39%) experienced AEs. Whereas most AEs involved self-limiting knee swelling and pain, only three (0.8%) were severe enough to require overnight hospitalization. MSCs without adjuvant surgery offer a safe and efficacious conservative treatment option in knee OA patients by alleviating and decreasing pain for up to 12 mo. However, study limitations and contradictory findings require more evidence regarding cartilage repair.
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http://dx.doi.org/10.1615/JLongTermEffMedImplants.2020035281DOI Listing
January 2020

Maximal Medical Improvement Following Shoulder Stabilization Surgery May Require up to 1 Year: A Systematic Review.

HSS J 2020 Dec 10;16(Suppl 2):534-543. Epub 2020 Sep 10.

Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, IL USA.

Background: There is increased emphasis on properly allocating healthcare resources to optimize value within orthopedic surgery. Establishing time to maximal medical improvement (MMI) can inform clinical decision-making and practice guidelines.

Purpose: We sought (1) to evaluate the time to MMI as predicted by commonly used patient-reported outcome measures (PROMs) for evaluation of shoulder stabilization and (2) to evaluate typical time to return to sports and employment following surgery.

Methods: A systematic review of the Medline database was conducted to identify outcome studies reporting sequential follow-up at multiple time points, up to a minimum of 2 years after shoulder stabilization surgery. The included studies examined the outcomes of arthroscopic or open surgical techniques on anterior instability. Clinically significant improvements were evaluated utilizing the minimal clinically important difference specific to each PROM. Secondary outcomes included range of motion, return to sport/work, and recurrent instability.

Results: Ten studies comprising 590 surgically managed cases of anterior shoulder instability were included (78% arthroscopic, 22% open). Clinically significant improvements in PROMs were achieved up to 1 year post-operatively for Rowe, Western Ontario Instability Index (WOSI), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) scores. For the three most utilized tools (Rowe, WOSI, ASES), the majority of improvement occurred in the first 6 post-operative months. Clinically significant improvements in Constant Score and Oxford Shoulder Instability Score (OSIS) were achieved up to 6 months and 2 years after surgery, respectively. No clinically significant improvements were achieved on the Disabilities of the Arm, Shoulder, and Hand (DASH) tool.

Conclusion: Maximal medical improvement as determined by commonly utilized PROMs occurs by 1 year after operative management of anterior shoulder instability. The DASH tool does not appear to demonstrate a reliable time frame for clinically significant outcome improvement.
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http://dx.doi.org/10.1007/s11420-020-09773-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749924PMC
December 2020

Development of a Machine Learning Algorithm to Predict Nonroutine Discharge Following Unicompartmental Knee Arthroplasty.

J Arthroplasty 2021 05 4;36(5):1568-1576. Epub 2020 Dec 4.

Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MI.

Background: Reliable and effective prediction of discharge destination following unicompartmental knee arthroplasty (UKA) can optimize patient outcomes and system expenditure. The purpose of this study is to develop a machine learning algorithm that can predict nonhome discharge in patients undergoing UKA.

Methods: A retrospective review of a prospectively collected national surgical outcomes database was performed to identify adult patients who underwent UKA from 2015 to 2019. Nonroutine discharge was defined as discharge to a location other than home. Five machine learning algorithms were developed to predict this outcome. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis.

Results: Overall, of the 7275 patients included, 263 (3.6) patients were unable to return home upon discharge following UKA. The factors determined most important for identification of candidates for nonroutine discharge were total hospital length of stay, preoperative hematocrit, body mass index, preoperative sodium, American Society of Anesthesiologists classification, gender, and functional status. The extreme boosted model achieved the best performance based on discrimination (area under the curve = 0.875), calibration, and decision curve analysis. This model was integrated into a web-based open access application able to provide both predictions and explanations.

Conclusion: The present model can, following appropriate external validation, be used to augment clinician decision-making in patients undergoing elective UKA. Patients with high preoperative probabilities of nonroutine discharge based on nonmodifiable risk factors should be counseled to start the insurance authorization process with case management to avoid unnecessary inpatient stay, and those with modifiable risk can attempt prehabilitation to optimize these parameters before surgery.
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http://dx.doi.org/10.1016/j.arth.2020.12.003DOI Listing
May 2021

Return to Work After Distal Femoral Varus Osteotomy.

Orthop J Sports Med 2020 Dec 3;8(12):2325967120965966. Epub 2020 Dec 3.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA.

Background: Distal femoral varus osteotomy (DFVO) is a well-described procedure to address valgus deformity of the knee. There is a paucity of information available regarding patients' ability to return to work (RTW) after DFVO.

Purpose: To report the objective findings for RTW rates and times for patients receiving a DFVO for lateral compartment osteoarthritis secondary to valgus deformity of the knee.

Study Design: Cohort study; Level of evidence, 3.

Methods: This was a retrospective study of patients who received a lateral-wedge opening DFVO. Patients must have worked within 3 years before their operation to be included for analysis. Patients were contacted at a minimum of 2 years postoperatively for interview and questionnaire evaluation, including a subjective work questionnaire, visual analog scale (VAS) for pain, Single Assessment Numerical Evaluation (SANE), and a satisfaction questionnaire.

Results: Overall, 32 patients were contacted at a mean follow-up of 7.1 ± 4.1 years (range, 2.2-13.3 years). The mean ± SD age at the time of surgery was 30.8 ± 8.8 years (range, 17.2-46.5 years), and 65.6% of patients were female. Eleven patients (34.4%) received a concomitant meniscal allograft transplant, and 12 (37.5%) received a cartilage grafting procedure. The average VAS pain score decreased significantly from 6.1 preoperatively to 3.2 postoperatively ( = .03). All patients were able to RTW, at a mean time of 6.0 ± 13.2 months postoperatively (range, 0-72 months). When stratified by work intensity, the average time to return was 13.8, 3.1, 2.7, and 2.9 months for high, moderate, light, and sedentary occupations, respectively. There was no significant difference between these RTW times ( = .16), although this analysis may have been limited by the small sample size. Four patients whose work was classified as heavy work (50%) and 3 whose work was classified as moderate work (18.8%) either switched jobs or kept the same job with lighter physical duties as a result of their procedures.

Conclusion: In a young and active population, DFVO for valgus deformity reliably afforded the ability to RTW within a relatively short time for patients with sedentary, light, and moderate occupational demands. However, patients with moderate- to high-intensity occupational demands may be unable to RTW at their preoperative level.
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http://dx.doi.org/10.1177/2325967120965966DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720305PMC
December 2020

Influence of workers' compensation status on postoperative outcomes in patients following biceps tenodesis: a matched-pair cohort analysis.

J Shoulder Elbow Surg 2020 Dec 9;29(12):2530-2537. Epub 2020 Jun 9.

Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background And Hypothesis: Although the literature on the association of workers' compensation (WC) status with negative outcomes after orthopedic surgery is extensive, there is a paucity of evidence on outcomes in WC recipients undergoing biceps tenodesis. We hypothesized that WC patients would report significantly worse outcomes postoperatively on patient-reported outcome measures (PROMs).

Methods: Functional and health-related quality-of-life PROMs and a visual analog scale score for pain were administered preoperatively and at 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018 at our institution. Thirty-eight WC patients were matched 1:2 to non-WC patients by age, body mass index, and operative limb. The minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state were calculated for all patients via anchor- and distribution-based methods. Rates of achievement and the likelihood of achievement were determined.

Results: All patients showed significant improvements in all outcome measures (P < .001). WC patients reported inferior postoperative scores on all PROMs examined. WC status significantly predicted a reduced likelihood of achieving substantial clinical benefit for the American Shoulder and Elbow Surgeons score (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.17-0.81; P = .01) and the patient acceptable symptom state (OR, 0.28; 95% CI, 0.12-0.65; P = .003) for the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (OR, 0.24; 95% CI, 0.10-0.61; P = .003), Constant-Murley Subjective Assessment (OR, 0.25; 95% CI, 0.08-0.77; P = .016), and visual analog scale pain score (OR, 0.27; 95% CI, 0.16-0.47; P < .001).

Conclusion: WC patients reported inferior scores on all postoperative PROMs and demonstrated lower odds of achieving substantial benefit and satisfaction regarding improvements in both function and pain compared with non-WC patients.
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http://dx.doi.org/10.1016/j.jse.2020.03.048DOI Listing
December 2020

Rates and Risk Factors of Revision Arthroscopy or Conversion to Total Knee Arthroplasty Within 1 Year Following Isolated Meniscectomy.

Arthrosc Sports Med Rehabil 2020 Oct 24;2(5):e443-e449. Epub 2020 Oct 24.

Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A.

Purpose: To identify the rates of and risk factors for revision arthroscopy and conversion to total knee arthroplasty (TKA) within 1 year of isolated meniscectomy.

Methods: Humana and Medicare national insurance databases were queried for patients who underwent isolated meniscectomy. Patients who underwent revision arthroscopy or TKA within 1 year postoperatively were identified by International Classification of Diseases Procedural Codes, Ninth Revision, and Current Procedural Terminology codes. Multivariate binomial logistic regression analysis was used to identify risk factors, and adjusted odds ratios (ORs) and 95% confidence intervals (Cis) were calculated, with < .05 considered significant.

Results: A total of 13,142 patients and 407,888 patients underwent isolated meniscectomy in the Humana and Medicare databases, respectively. Of the patients, 395 (3.01%) and 3,770 patients (0.92%) underwent revision arthroscopy, and 629 patients (4.79%) and 38,630 patients (9.47%) underwent TKA within 1 year of meniscectomy in the Humana and Medicare databases, respectively. Obesity (Humana: OR = 1.33,  = 0.003; Medicare: OR = 1.10, < 0.001) and age < 20 years (Humana: OR = 2.64,  = 0.022), 20-29 years (Humana: OR = 3.30,  = 0.002), 40-49 years (Humana: OR = 3.80, < 0.001), 50-59 years (Humana: OR = 1.99,  = 0.027), and < 64 years (Medicare: OR = 1.74, < 0.001) were risk factors for revision arthroscopy. Obesity (Humana: OR = 1.64, < 0.001; Medicare: OR = 1.37, < 0.001), morbid obesity (Medicare: OR = 1.20, < 0.001), age 70-74 (Medicare: OR = 1.12, < 0.001), 75-79 (Medicare: OR = 1.25, < 0.001), 80-84 (Medicare: OR = 1.20, < 0.001), and concomitant osteoarthritis (Humana: OR = 1.42, < 0.001; Medicare: OR = 1.46, < 0.001) were risk factors for conversion to TKA.

Conclusions: Medicare and Humana databases showed that 0.92%-3.01% and 4.79%-9.47% of patients undergo revision arthroscopy or conversion to TKA within a year of isolated meniscectomy. Obesity was a risk factor for early revision arthroscopy and conversion to TKA, whereas concomitant osteoarthritis was a risk factor for conversion to TKA.

Level Of Evidence: Level III, retrospective comparative trial
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http://dx.doi.org/10.1016/j.asmr.2020.04.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588599PMC
October 2020

Patient Satisfaction After Total Shoulder Arthroplasty.

Orthopedics 2020 Nov 20;43(6):e492-e497. Epub 2020 Aug 20.

Although patient-reported outcome measures use objective evaluations of impairment to focus on subjective responses, these measures may not necessarily reflect patient satisfaction with the outcome or the care provided. The goal of this study was to systematically review the available literature to assess patient satisfaction after total shoulder arthroplasty. Two investigators systematically reviewed the MEDLINE database for articles on satisfaction after this procedure. This study included 47 articles. The most commonly used method for assessing satisfaction was an ordinal scale (27 studies, 57.4%). Of the studies, 27 (57.5%) differentiated between patient satisfaction with the care provided and with the outcome achieved. Reported satisfaction rates after anatomic total shoulder arthroplasty ranged from 75% to 100%. For the included studies, increasing age, workers' compensation status, depression, opioid use, and visual analog scale pain score were the only preoperative factors that were significantly associated with worse postoperative satisfaction. Postoperative American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, Subjective Shoulder Value score, Short Form-36 mental component score, range of motion, visual analog scale pain score, and ability to perform activities of daily living showed a significant association with postoperative satisfaction. Studies of satisfaction after total shoulder arthroplasty are of low evidence levels. Although overall patient satisfaction is high, there is no standardized method for measuring satisfaction. For the identified studies, the most common assessment method was an ordinal scale that consists of qualitative values representing increasing levels of satisfaction. Orthopedic surgeons are increasingly expected to demonstrate the value of procedures, and a uniform and validated method of assessing patient satisfaction is needed. [Orthopedics. 2020;43(6):e492-e497.].
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http://dx.doi.org/10.3928/01477447-20200812-03DOI Listing
November 2020

Return to work following distal triceps repair.

J Shoulder Elbow Surg 2021 Apr 6;30(4):906-912. Epub 2020 Aug 6.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Purpose: The purpose of this study was to evaluate the rate and duration of return to work in patients undergoing distal triceps repair (DTR).

Methods: Consecutive patients undergoing DTR from 2009 to 2017 at our institution were retrospectively reviewed at a minimum of 1 year postoperatively. Patients completed a standardized and validated work questionnaire; a visual analog scale for pain; the Mayo Elbow Performance Score; the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and a satisfaction survey.

Results: Of 113 eligible patients who underwent DTR, 81 (71.7%) were contacted. Of these patients, 74 (91.4%) were employed within 3 years prior to surgery (mean age, 46.0 ± 10.7 years; mean follow-up, 5.9 ± 3.9 years). Sixty-nine patients (93.2%) returned to work by 2.2 ± 3.2 months postoperatively. Sixty-six patients (89.2%) were able to return to the same level of occupational intensity. Patients who held sedentary-, light-, medium-, and high-intensity occupations were able to return to work at a rate of 100.0%, 100.0%, 80.0%, and 76.9%, respectively, by 0.3 ± 0.5 months, 1.8 ± 1.5 months, 2.5 ± 3.6 months, and 4.8 ± 3.9 months, respectively, postoperatively. Of the workers' compensation patients, 15 (75%) returned to work by 6.5 ± 4.3 months postoperatively, whereas 100% of non-workers' compensation patients returned to work by 1.1 ± 1.6 months (P < .001). Seventy-one patients (95.9%) were at least somewhat satisfied, with 50 patients (67.6%) reporting excellent satisfaction. Seventy-two patients (97.3%) would undergo the operation again if presented the opportunity. A single patient (1.4%) required revision DTR.

Conclusions: Approximately 93% of patients who underwent DTR returned to work by 2.2 ± 3.2 months postoperatively. Patients with higher-intensity occupations had an equivalent rate of return to work but took longer to return to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.
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http://dx.doi.org/10.1016/j.jse.2020.07.036DOI Listing
April 2021

Big Data in Total Shoulder Arthroplasty: An In-depth Comparison of National Outcomes Databases.

J Am Acad Orthop Surg 2020 Jul;28(14):e626-e632

From Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL (Mr. Lu, Mr. Patel, Dr. Agarwalla, Dr. Cancienne, and Dr. Forsythe), the Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA (Mr. Khazi), and the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Werner).

Introduction: The practice of identifying trends in surgical decision-making through large-scale patient databases is commonplace. We hypothesize that notable differences exist between claims-based and prospectively collected clinical registries.

Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), a prospective surgical outcomes database, and PearlDiver (PD), a claims-based private insurance database, for patients undergoing primary total shoulder arthroplasties from 2007 to 2016. Comorbidities and 30-day complications were compared. Multiple regression analysis was performed for each cohort to identify notable contributors to 30-day revision surgery.

Results: Significant differences were observed in demographics, comorbidities, and postoperative complications for the age-matched groups between PD and NSQIP (P < 0.05 for all). Multiple regression analysis in PD identified morbid obesity and dyspnea to lead to an increased risk for revision surgery (P = 0.001) in the <65 cohort and dyspnea and diabetes to lead to an increased risk for revision surgery in the ≥65 cohort (P = 0.015, P < 0.001). Multiple regression did not reveal any risk factors for revision surgery in the <65 age group for the NSQIP; however, congestive heart failure was found to have an increased risk for revision surgery in the ≥65 cohort (P < 0.001).

Conclusions: Notable differences in comorbidities and complications for patients undergoing primary total shoulder arthroplasty were present between PD and NSQIP.

Level Of Evidence: Retrospective cohort study, level III.
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http://dx.doi.org/10.5435/JAAOS-D-19-00173DOI Listing
July 2020

Influence of mental health on postoperative outcomes in patients following biceps tenodesis.

J Shoulder Elbow Surg 2020 Nov 9;29(11):2248-2256. Epub 2020 Jun 9.

Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Purpose: To evaluate the relationship between preoperative mental health measured by the Short-Form 12 health survey mental component score and outcomes after isolated biceps tenodesis.

Methods: The American Shoulder and Elbow Surgeons form (ASES), Single Assessment Numeric Evaluation (SANE), Constant-Murley score (CMS), and visual analog scale (VAS) for pain were administered preoperatively and at 6 and 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018. Minimal clinically important difference, substantial clinical benefit (SCB), patient-acceptable symptom state (PASS), and rates of achievement were calculated. Patients were stratified by mental health status based on preoperative scores on the Short-Form 12 health survey mental component score. Multivariate logistic regression was performed to evaluate preoperative mental health status on achievement of minimal clinically important difference, SCB, and PASS.

Results: Patients demonstrated significant improvements in all outcome measures (P < .001). Patients with depression reported inferior postoperative scores on all patient-reported outcome measures. Low preoperative mental health score significantly predicted reduced likelihood to achieve SCB (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.17-0.81, P = .01) and PASS (OR: 0.28, 95% CI: 0.12-0.65, P = .003) on the ASES form, SANE (OR: 0.24, 95% CI: 0.10-0.61, P = .003), CMS (OR: 0.25, 95% CI: 0.08-0.77, P = .016), and VAS pain (OR: 0.01, 95% CI: 0.00-0.31, P = .008).

Conclusion: Patients with depression reported inferior scores on all postoperative patient-reported outcome measures and demonstrated lower odds of achieving the SCB and PASS on the ASES form and PASS on the SANE, CMS, and VAS pain, compared with nondepressed patients.
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http://dx.doi.org/10.1016/j.jse.2020.03.020DOI Listing
November 2020

Efficacy of the modified Frailty Index and the modified Charlson Comorbidity Index in predicting complications in patients undergoing operative management of proximal humerus fracture.

J Shoulder Elbow Surg 2021 Mar 7;30(3):658-667. Epub 2020 Jul 7.

Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA. Electronic address:

Background: Comorbidity indices such as the 5-factor modified Frailty Index (mFI-5) and modified Charlson Comorbidity Index (mCCI) are widely used in outcomes research.

Methods: A total of 3893 patients who underwent total shoulder arthroplasty (n=975), hemiarthroplasty (n=495), or open reduction and internal fixation (n=2423) for the treatment of proximal humerus fracture from 2005-2017 were identified from the National Surgical Quality Improvement Program database. Data regarding demographics, comorbidities, American Society of Anesthesiologists class, and postoperative complications were collected, and the mFI-5 and mCCI were calculated for each case. Multivariate logistic regression models and receiver operating characteristic curve analyses were performed.

Results: The patient population had a mean age of 68.0 ± 13.2 years, body mass index of 29.1 ± 8.1 and mean operative time of 119.9 ± 55.5 minutes. The most common complications within this cohort were extended length of stay (4 days or more) (1085/3893; 27.87%), transfusion (377/3893; 9.68%), unplanned reoperation (97/3893; 2.49%), urinary tract infection (43/3893; 1.10%), death (42/3893; 1.08%), and deep vein thrombosis (40/3893; 1.03%). After accounting for patient demographics, the mFI-5 (odds ratio [OR] = 1.105, P < .001) and mCCI (OR = 1.063, P < .001) were significantly associated with incidence of any adverse event. Both comorbidity indices had low positive predictive value and high negative predictive value for all adverse events.

Conclusion: The comorbidity indices mCCI and mFI-5 are both strongly associated with adverse events but have moderate ability to predict complications following surgical treatment of proximal humerus fractures.
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http://dx.doi.org/10.1016/j.jse.2020.06.014DOI Listing
March 2021

Return to Work Following Arthroscopic Meniscal Allograft Transplantation.

Cartilage 2020 Jul 2:1947603520938440. Epub 2020 Jul 2.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.

Purpose: Evaluate the ability of patients to return to work (RTW) following arthroscopic meniscal allograft transplantation (MAT) for meniscal deficiency.

Methods: Consecutive patients undergoing MAT were retrospectively reviewed at a minimum of 2 years postoperatively. Patients completed a subjective work questionnaire, Visual Analogue Scale for pain, Single Assessment Numerical Evaluation, and satisfaction.

Results: Forty-seven patients who were employed within 3 years prior to surgery (average age: 30.2 ± 6.9 years) were contacted at an average of 3.5 ± 0.9 years postoperatively. Forty-six patients (97.8%) returned to work by 2.7 ± 2.6 months postoperatively, and 44 patients (93.6%) returned to the same level of occupational intensity. Patients who held sedentary, light, medium, or high intensity occupations were able to RTW at a rate of 100.0%, 100.0%, 88.9%, and 85.7% ( = 0.4) by 1.1 ± 1.0 months, 2.5 ± 2.5 months, 3.5 ± 3.2 months, and 4.3 ± 2.8 months ( = 0.3) postoperatively. Thirty-eight patients (80.9%) were at least somewhat satisfied, and 43 patients (91.5%) would still have the operation if presented the opportunity. No patient underwent revision MAT or conversion to arthroplasty.

Conclusion: In patients with painful meniscal deficiency, MAT provides a high rate of RTW (97.8%) by 2.7 ± 2.6 months postoperatively. However, some patients may be unable to return to their previous level of occupational intensity. Although statistically insignificant, patients with higher intensity occupations may have a lower rate and longer duration until RTW than those with less physically demanding occupations. Information regarding RTW is imperative for appropriately managing postoperative expectations.
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http://dx.doi.org/10.1177/1947603520938440DOI Listing
July 2020

Timeline for maximal subjective outcome improvement following total ankle arthroplasty.

Foot Ankle Surg 2021 Apr 8;27(3):305-310. Epub 2020 Jun 8.

Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States. Electronic address:

Background: Maximal medical improvement (MMI) establishes the timepoint when patients no longer experience clinically significant improvements following surgery. The purpose of this investigation is to establish when patients achieve MMI following total ankle arthroplasty (TAA) through the use of patient reported outcome measures (PROMs).

Methods: A systematic review to identify studies on TAA which reported consecutive PROMs for two years postoperatively was performed. Pooled analysis was done at 6 months, 12 months, and 24 months. Clinically significant improvement was defined as improvement between time intervals exceeding the minimal clinically important difference.

Results: Twelve studies and 1514 patients met inclusion criteria. Clinically significant improvement was seen up to 6 months postoperatively in both the American Orthopaedic Foot and Ankle Society Ankle Hindfoot Score and Visual Analog Scale scoring systems. The Short Musculoskeletal Function Assessment Dysfunction and Bother subsections showed maximal clinically significant improvement by 1 year postoperatively.

Conclusion: Following TAA, MMI is seen by one year postoperatively. Physicians may allocate the majority of resources within the first year when most of the improvement is perceived. This data may help inform preoperative counseling as it establishes a timeline for MMI.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.fas.2020.05.012DOI Listing
April 2021

Dynamic Three-Dimensional Computed Tomography Mapping of Isometric Posterior Cruciate Ligament Attachment Sites on the Tibia and Femur: Single- Versus Double-Bundle Analysis.

Arthroscopy 2020 11 15;36(11):2875-2884. Epub 2020 Jun 15.

Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A.

Purpose: (1) To determine the area of posterior cruciate ligament (PCL) insertion sites on the lateral wall of the medial femoral condyle (LWMFC) that demonstrates the least amount of length change through full range of motion (ROM) and (2) to identify a range of flexion that would be favorable for graft tensioning for single-bundle (SB) and double-bundle (DB) PCL reconstruction.

Methods: Six fresh-frozen cadaveric knees were obtained. Three-dimensional computed tomography point-cloud models were obtained from 0° to 135°. A point grid was placed on the LWMFC and the tibial PCL facet. Intra-articular length was calculated for each point on the femur to the tibia at all flexion angles and grouped to represent areas for bone tunnels of SB and DB PCLR. Normalized length changes were evaluated.

Results: Femoral tunnel location and angle of graft fixation were significant contributors to mean, minimum, and maximum normalized length of the PCL (all p < .001). Tibial tunnel location was not significant in any case (all p < .22). A femoral tunnel in the location of the posteromedial bundle of the PCL resulted in the least length change at all tibial positions (maximum change 13%). Fixation of the anterolateral bundle in extension or at 30° flexion resulted in significant overconstraint of the PCL graft. The femoral tunnel location for a SB PCLR resulted in significant laxity at lower ranges of flexion.

Conclusion: PCL length was significantly dependent on femoral tunnel position and angle of fixation, whereas tibial tunnel position did not significantly contribute to observed differences. All PCL grafts demonstrated anisometry, with the anterolateral bundle being more anisometric than the posteromedial bundle. For DB PCLR, the posteromedial bundle demonstrated the highest degree of isometry throughout ROM, although no area of the LWMFC was truly isometric. The anterolateral bundle should be fixed at 90° to avoid overconstraint, and SB PCLR demonstrated significant laxity at lower ranges of flexion.

Clinical Relevance: Surgeons can apply the results of this investigation to surgical planning in PCLR to optimize isometry, which may ultimately reduce graft strain and the risk of graft failure. Additionally, DB PCLR demonstrated superiority compared with SB PCLR regarding graft isometry, as significant laxity was encountered at lower ranges of flexion in SB PCLRs. Fixation of the ALB at 90° flexion should be performed to avoid overconstraint in knee extension.
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http://dx.doi.org/10.1016/j.arthro.2020.06.006DOI Listing
November 2020

Return to Sport Following High Tibial Osteotomy With Concomitant Osteochondral Allograft Transplantation.

Am J Sports Med 2020 07 27;48(8):1945-1952. Epub 2020 May 27.

Seattle Orthopaedic Center, Seattle, Washington, USA.

Background: Young patients with symptomatic chondral defects in the medial compartment with varus malalignment may undergo opening wedge high tibial osteotomy (HTO) with concomitant osteochondral allograft transplantation (OCA) (HTO + OCA). Although patients have demonstrated favorable outcomes after HTO + OCA, limited information is available regarding return to sporting activities after this procedure.

Purpose: To evaluate (1) the timeline to return to sports (RTS), (2) patient satisfaction, and (3) reasons for discontinuing sporting activity after HTO + OCA, and to identify predictive factors of RTS.

Study Design: Case series; level of evidence, 4.

Methods: Consecutive patients who underwent HTO + OCA for varus deformity and medial femoral condyle focal chondral defects with a minimum 2-year follow-up were retrospectively reviewed. Patients completed a subjective sports questionnaire, satisfaction questionnaire, visual analog scale for pain, and Single Assessment Numerical Evaluation.

Results: Twenty-eight patients with a mean age of 36.97 ± 7.52 years were included at mean follow-up of 6.63 ± 4.06 years. Fourteen patients (50.0%) required reoperation during the follow-up period, with 3 (10.7%) undergoing knee arthroplasty. Twenty-four patients participated in sports within 3 years before surgery, with 19 patients (79.2%) able to return to at least 1 sport at a mean 11.41 ± 6.42 months postoperatively. However, only 41.7% (n = 10) were able to return to their preoperative level. The most common reasons for sports discontinuation (n = 20; 83.3%) were a desire to prevent further damage to the knee (70.0%), persistent pain (55.0%), persistent swelling (30.0%), and fear (25.0%).

Conclusion: In young, active patients with varus deformity and focal medial femoral condyle chondral defects, HTO + OCA enabled 79.2% of patients to RTS by 11.41 ± 6.42 months postoperatively. However, only 41.7% of patients were able to return to their preinjury level or better. It is imperative that patients be appropriately educated to manage postoperative expectations regarding sports participation after HTO + OCA.
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http://dx.doi.org/10.1177/0363546520920626DOI Listing
July 2020

Return to Sport following Isolated Lateral Opening Wedge Distal Femoral Osteotomy.

Cartilage 2020 May 25:1947603520924775. Epub 2020 May 25.

Midwest Orthopaedics at Rush University Medical Center, Chicago, IL, USA.

. The aims of this study were to (1) examine the timeline of return to sport (RTS) following isolated lateral opening wedge distal femoral osteotomy (DFO), (2) evaluate the degree of participation on RTS, and (3) identify risk factors for failure to RTS. . Nineteen consecutive patients undergoing isolated lateral opening wedge DFO were reviewed retrospectively at a minimum of 2 years postoperatively. Patients completed a sports questionnaire, visual analogue scale for pain (VAS-Pain), Single Assessment Numerical Evaluation (SANE), and a satisfaction questionnaire. . Seventeen patents (89.5%; age 32.1 ± 10.1 years; gender 9 males, 52.9%) were contacted at 7.3 ± 4.4 years (range 2.0-13.8 years). Twelve patients (70.6%) resumed playing ≥1 sport at an average time of 9.5 ± 3.3 months (range 3-12 months). Of these 12 patients, 6 returned to a lower level of participation (50.0%). Seven patients (41.2%) had returned to the operating room for further surgery, which included removal of hardware (5.9%) and total knee arthroplasty (5.9%). The average VAS-Pain, SANE, and Marx scores were 3.4 ± 2.6 (range 0-8), 56.2 ± 18.7 (range 20-85), and 5.0 ± 5.3 (range 0-16), respectively. Fourteen patients (82.4%) were at least somewhat satisfied with their procedure. . In patients with isolated lateral compartment osteoarthritis and valgus deformity, lateral opening wedge DFO allows 70.6% of patients to RTS by 9.5 ± 3.3 months. However, most patients may be unable to return to their presymptomatic level of function. Patient expectations regarding RTS can be appropriately managed with adequate preoperative patient education. . IV, case series.
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http://dx.doi.org/10.1177/1947603520924775DOI Listing
May 2020

Same-Day Discharge Following Total Joint Arthroplasty: Examining Trends, Discharge Dispositions, and Complications Over Time.

Orthopedics 2020 Jul 5;43(4):204-208. Epub 2020 May 5.

Administrative database studies have reported on the safety of same-day discharge (SDD) following total joint arthroplasty (TJA); however, most patient cohorts have been defined by length of stay (LOS), and the proportion discharged directly home remains unknown. The purpose of this investigation was to (1) determine common dispositions for patients undergoing SDD TJA; (2) understand changes in discharge disposition over time; and (3) determine the safety of SDD TJA, stratified by discharge disposition. The PearlDiver Database was reviewed for patients who underwent SDD TJA (LOS of 0 days) from 2011 to 2016. Patients were stratified by discharge disposition, and rates and complications following SDD TJA were assessed accordingly. Chi-square analysis was performed to compare demographics and complications between patient groups stratified by disposition. From 2011 to 2016, there was an exponential increase in the annual rate of SDD TJA from 0.95% to 20.5%, respectively; however, the annual proportion of patients discharged directly home remained unchanged (approximately 68%), with the remaining discharged directly to an alternate care facility, most commonly inpatient rehabilitation. Patients discharged to an alternate facility were significantly older (P<.001), had significantly higher comorbidity scores (P<.001), and had significantly more complications (P<.001) than those patients discharged directly home. Although the annual rate of SDD TJA is increasing, up to one-third of patients are not discharged directly home-a proportion unchanged over time. Moving forward, administrative database studies examining SDD TJA must account for discharge disposition; moreover, there is a need to understand the practice of SDD TJA to an alternate care facility. [Orthopedics. 2020;43(4):204-208.].
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http://dx.doi.org/10.3928/01477447-20200428-03DOI Listing
July 2020

Return to Work Following Tibial Tubercle Osteotomy for Patellofemoral Osteoarthritis and Pain.

Cartilage 2020 Apr 22:1947603520916544. Epub 2020 Apr 22.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Purpose: To evaluate the ability of patients to return to work following anteromedialization (AMZ) tibial tubercle osteotomy (TTO) due to isolated patellofemoral osteoarthritis or pain.

Methods: Consecutive patients undergoing AMZ TTO were reviewed retrospectively at a minimum of 1 year postoperatively. Patients completed a subjective work questionnaire, a visual analog scale for pain, as well as a Kujala questionnaire and satisfaction questionnaire.

Results: Fifty-seven patients (61 knees; average age: 32.7 ± 9.6 years) were contacted at an average follow-up of 4.86 ± 2.84 years postoperatively. The preoperative Kujala score improved from 55.7 ± 17.8 to 84.6 ± 15.8 at final follow-up ( < 0.001). Thirty-seven patients (64.9%) were employed within 3 years prior to surgery and 34 patients (91.9%) were able to return to work by 2.8 ± 2.6 months postoperatively. However, only 27 patients (73.0%) of patients were able to return to the same level of occupational intensity. Patients who held sedentary, light-, medium-, or high-intensity occupations were able to return to work at a rate of 100.0%, 93.8%, 77.8%, and 100.0% by 2.2 months, 3.0 months, 3.1 months, and 4.0 months, postoperatively. No patients underwent revision TTO or conversion to arthroplasty by the time of final follow-up.

Conclusion: In patients with focal patellofemoral osteoarthritis or pain, AMZ TTO provides a high rate of return to work (91.9%) by 2.8 ± 2.6 months postoperatively. Patients with higher intensity occupations may take longer to return to work than those with less physically demanding occupations.

Level Of Evidence: III.
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http://dx.doi.org/10.1177/1947603520916544DOI Listing
April 2020

Relationship between the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing and legacy instruments in patients undergoing isolated biceps tenodesis.

J Shoulder Elbow Surg 2020 Jun 26;29(6):1214-1222. Epub 2020 Feb 26.

Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Hypothesis: The purpose of this study was to correlate the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) domains with commonly used legacy patient-reported outcome measures (PROMs) preoperatively in a population of patients presenting to a tertiary care orthopedic center for biceps and labral pathology.

Methods: Prospective data were collected on 175 patients scheduled to undergo isolated biceps tenodesis at a tertiary center. Enrollees completed legacy scores (Veterans RAND 12-Item Health Survey, Short Form 12, American Shoulder and Elbow Surgeons [ASES] Assessment Form, Single Assessment Numeric Evaluation, and Constant-Murley score) and PROMIS CAT questionnaires (Upper Extremity [UE], Pain Interference [PIF], and Depression). In addition, patients were asked to provide an assessment of the strength, function, and pain of the affected shoulder using a custom visual analog scale (VAS) questionnaire. Spearman rank correlations of the PROMIS CAT with legacy measures and the custom VAS were calculated. Floor and ceiling effects were assessed.

Results: The UE CAT yielded moderate correlations with the ASES score (r = 0.57) and the custom VAS strength score (r = 0.50-0.57). The PIF CAT demonstrated moderate correlations with the VAS pain score (r = 0.45) and high-moderate correlations with the ASES score, VR6D score, and UE CAT (r = 0.61-0.66). The Depression CAT demonstrated high-moderate correlations with the mental health legacy measures (r = -0.64 to -0.61). There was a significant relative floor effect for the Depression CAT at a score of 34.2 (19%).

Conclusion: The PIF CAT was comparable to the ASES score, the current gold standard. Compared with legacy measures, both the UE CAT and PIF CAT are less burdensome and have few floor or ceiling effects. The PIF CAT may be a viable alternative to describe the physical and psychosocial impact of pain in biceps tenodesis patients.
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http://dx.doi.org/10.1016/j.jse.2019.11.003DOI Listing
June 2020

Response to Chelli and Boileau: "Let's 'recall' sensitivity and specificity".

J Shoulder Elbow Surg 2020 Mar;29(3):e100-e102

Department of Orthopaedic Surgery, Loma Linda Medical Center, Loma Linda, CA, USA.

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http://dx.doi.org/10.1016/j.jse.2019.10.030DOI Listing
March 2020
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