Publications by authors named "Cale A Jacobs"

100 Publications

Self-Reported Health of Severely Obese US Adults With Osteoarthritis.

J Arthroplasty 2022 Jun 24. Epub 2022 Jun 24.

Institute of Etiological Research, Boca Raton, Florida.

Background: Severe obesity is associated with complications following arthroplasty, leading surgeons to increasingly counsel patients regarding weight loss. For patients seeking arthroplasty, learning that severe obesity may be a relative contraindication to surgery can create a challenging clinical interaction. We sought to describe the self-reported health of United States (US) adults who had severe obesity and osteoarthritis (OA) to better understand patient perspectives.

Methods: The National Health and Nutrition Examination Survey, a nationally representative sample of the US population, was used to identify adult participants who had a body mass index (BMI) over 35 and an OA diagnosis. In total, 889 participants representing a US population of 9,604,722 were included. Self-reported health was dichotomized as poor to fair versus good to excellent. Analyses were weighted to produce national estimates. Associations between obesity severity and patient characteristics with self-reported health were assessed.

Results: Of US adults with a BMI over 35 and OA diagnosis, 64% rated their health as good or better. For adults who had a BMI over 45, 55% still reported their health as good or better. The strongest predictors of self-reported health were measures of physical functioning. Only 37% of participants who had much difficulty walking a quarter mile rated their health as good or better compared to 86% without difficulty (P < .001).

Conclusion: Approximately two-thirds of patients who have severe obesity and OA do not perceive their health as compromised and consider decreased physical function as the primary driver of decreased health. This suggests that counseling about the association between obesity and overall health may improve shared decision making and that patient satisfaction metrics may be difficult to interpret in these clinical situations.
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http://dx.doi.org/10.1016/j.arth.2022.06.018DOI Listing
June 2022

Human synovial fluid interleukin-6, but not type II collagen breakdown, positively correlated with pain after anterior cruciate ligament injury and reconstruction.

J Orthop Res 2022 Apr 30. Epub 2022 Apr 30.

Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA.

Anterior cruciate ligament (ACL) injury initiates a biochemical cascade thought to contribute to the onset and progression of posttraumatic osteoarthritis (PTOA). Interleukin-1ß (IL-1ß), IL-6, and C-telopeptide fragments of type II collagen (CTX-II) are implicated in joint inflammation and cartilage degradation following ACL injury; however, their association with pain is still being explored. The purpose of this study was to evaluate the associations between synovial fluid concentrations of IL-1ß, IL-6, and CTX-II with pain following ACL injury and reconstruction. We hypothesized that greater IL-1ß, IL-6, and CTX-II would correlate with greater Pain Visual Analogue Scale (VAS) scores. This was a secondary analysis of 23 patients (mean age = 18.4 years, BMI = 27.4, 13 females/10 males) with acute ACL tears who participated in a pilot randomized trial. Synovial fluid and VAS scores were collected on the day of initial presentation, at ACL reconstruction, and 1 and 4 weeks after surgery. Synovial fluid concentrations of IL-1ß, IL-6, and CTX-II were assessed using enzyme-linked immunoabsorbent assays, and repeated measures correlations were used to assess the relationships between pain and synovial IL-1ß, IL-6, or CTX-II after ACL injury and reconstruction. Pain was positively correlated with synovial fluid IL-6 concentrations (r = 0.52, p < 0.001); however, pain was inversely correlated with CTX-II (r = -0.39, p = 0.002). IL-1ß had no significant correlation with pain. Statement of clinical relevance: PTOA has been described as a "silent killer" and these results suggest that early PTOA may have pro-inflammatory pathways that are not primarily associated with pain but still lead to progressive cartilage loss.
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http://dx.doi.org/10.1002/jor.25355DOI Listing
April 2022

Live Video Mind-Body Program for Patients With Knee Osteoarthritis, Comorbid Depression, and Obesity: Development and Feasibility Pilot Study.

JMIR Form Res 2022 Apr 27;6(4):e34654. Epub 2022 Apr 27.

Integrated Brain Health Clinical and Research Program, Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.

Background: Knee osteoarthritis (KOA) is the most common joint disorder in the United States and a leading cause of disability. Depression and obesity are highly comorbid with KOA and accelerate knee degeneration and disability through biopsychosocial mechanisms. Mind-body physical activity programs can engage biological, mechanical, and psychological mechanisms to improve outcomes in KOA, but such programs are not currently available.

Objective: This mixed methods study aims to adapt a mind-body activity program for the unique needs of patients with KOA, depression, and obesity (GetActive-OA) delivered via live video.

Methods: Participants were adults (aged ≥45 years) from rural Kentucky with obesity (BMI≥30 kg/m), idiopathic KOA with mild to moderate radiographic changes, and elevated depressive symptoms (9-item Patient Health Questionnaire ≥10) recruited from 2 orthopedic centers. In phase 1, we developed GetActive-OA and the study protocol using qualitative focus group feedback from the study population (N=9; 2 focus groups, 90 minutes) and multidisciplinary expertise from clinical psychologists and orthopedic researchers. In phase 2, we explored the initial feasibility, credibility, and acceptability of GetActive-OA, live video delivery, and study procedures via an open pilot with exit interviews (N=5; 1 group). This research was guided by National Institutes of Health (NIH) model stage IA.

Results: Phase 1 qualitative analyses revealed nuanced information about challenges with coping and increasing activity, high interest in a mind-body activity program, program participation facilitators (flexibility with technology) and barriers (amotivation and forgetfulness), and perceived challenges with data collection procedures (blood and urine samples and homework). Phase 2 quantitative analyses showed that GetActive-OA met most a priori feasibility markers: acceptability (80%), expectancy (100%), credibility (100%), clinician adherence (90%), homework adherence (80%), questionnaire data collection (100%), program satisfaction (100%), and safety (100%). Adherence to ActiGraph wear (80% baseline, 20% posttest) and collection of blood samples (60%) were low. Participation in GetActive-OA was associated with signals of improvements in general coping (Cohen d=2.41), pain catastrophizing (Cohen d=1.24), depression (Cohen d=0.88), anxiety (Cohen d=0.78), self-efficacy (Cohen d=0.73), pain (Cohen d=0.39), and KOA symptoms (Cohen d=0.36). Qualitative exit interviews confirmed quantitative findings and provided valuable information to optimize the program and protocol.

Conclusions: Patients with KOA, depression, and obesity from rural Kentucky were interested in a live video mind-body activity program. GetActive-OA shows promise; however, the program and protocol require further NIH stage I refinement before formal efficacy testing (NIH model stage II).

International Registered Report Identifier (irrid): RR2-10.1016/j.conctc.2021.100720.
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http://dx.doi.org/10.2196/34654DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9096632PMC
April 2022

Mood Disorders Are Associated with Increased Perioperative Opioid Usage and Health Care Costs in Patients Undergoing Knee Cartilage Restoration Procedure.

Cartilage 2022 Jan-Mar;13(1):19476035221087703

Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA.

Objective: To identify the prevalence of mood disorder diagnoses in patients undergoing cartilage transplantation procedures and determine the relationship between mood disorders, opioid usage, and postoperative health care costs.

Design: Patients with current procedural terminology (CPT) codes for osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) were identified in the Truven Health Marketscan database (January 2009-September 2014). Patients were grouped based on having a preoperative mood disorder diagnosis (preMDD). Preoperative opioids, postoperative opioids ≥90 days, and health care costs within the year postoperative were compared for those with and without mood disorders. Costs were analyzed, adjusting for preoperative cost, sex, age, and opioid usage, for those with and without mood disorders.

Results: A total of 3,682 patients were analyzed (ACI: 690, OAT: 1,294, OCA: 1,698). A quarter of patients had preMDD (ACI: 25.4%, OAT: 20.6%, OCA: 22.7%). Postoperative opioid use was more prevalent in preMDD patients (OAT: 37.1% vs. 24.1%, < 0.001; OCA: 30.4% vs. 24.8%, = 0.032; ACI: 33.7% vs. 26.2%, = 0.070) (odds ratio [OR] ranged from 1.29 to 1.86). First-year postoperative log-transformed costs were significantly greater for preMDD patients (ACI: $7,733 vs. $5,689*, = 0.012; OAT: $5,221 vs. $3,823*, < 0.001; OCA: $6,973 vs. $3,992*, < 0.001; *medians reported). The estimated adjusted first postoperative year cost increase for preMDD OCA patients was 41.7% ( < 0.001) and 28.0% for OAT patients ( = 0.034). There was no statistical difference for ACI patients ( = 0.654).

Conclusion: Cartilage transplantation patients have a high prevalence of preoperative mood disorders. Opioid use and health care costs were significantly greater for patients with preoperative mood disorder diagnoses.

Level Of Evidence: Level III, retrospective therapeutic study.
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http://dx.doi.org/10.1177/19476035221087703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9137305PMC
April 2022

MOntelukast as a potential CHondroprotective treatment following Anterior cruciate ligament reconstruction (MOCHA Trial): study protocol for a double-blind, randomized, placebo-controlled clinical trial.

Trials 2022 Jan 31;23(1):98. Epub 2022 Jan 31.

University of Kentucky, 740 S Limestone, Suite K401, Lexington, Kentucky, 40536-0284, USA.

Background: After anterior cruciate ligament (ACL) reconstruction, patient-reported outcomes are improved 10 years post-surgery; however, cytokine concentrations remain elevated years after surgery with over 80% of those with combined ACL and meniscus injuries having posttraumatic osteoarthritis (PTOA) within 10-15 years. The purpose of this multicenter, randomized, placebo-controlled trial is to assess whether a 6-month course of oral montelukast after ACL reconstruction reduces systemic markers of inflammation and biochemical and imaging biomarkers of cartilage degradation.

Methods: We will enroll 30 individuals undergoing primary ACL reconstruction to participate in this IRB-approved multicenter clinical trial. This trial will target those at greatest risk of a more rapid PTOA onset (age range 25-50 with concomitant meniscus injury). Patients will be randomly assigned to a group instructed to take 10 mg of montelukast daily for 6 months following ACL reconstruction or placebo. Patients will be assessed prior to surgery and 1, 6, and 12 months following surgery. To determine if montelukast alters systemic inflammation following surgery, we will compare systemic concentrations of prostaglandin E2, monocyte chemoattractant protein-1, and pro-inflammatory cytokines between groups. We will also compare degradative changes on magnetic resonance imaging (MRI) collected 1 and 12 months following surgery between groups with reductions in early biomarkers of cartilage degradation assessed with urinary biomarkers of type II collagen breakdown and bony remodeling.

Discussion: There is a complex interplay between the pro-inflammatory intra-articular environment, underlying bone remodeling, and progressive cartilage degradation. PTOA affects multiple tissues and appears to be more similar to rheumatoid arthritis than osteoarthritis with respect to inflammation. There is currently no treatment to delay or prevent PTOA after ACL injury. Since there is a larger and more persistent inflammatory response after ACL reconstruction than the initial insult of injury, treatment may need to be initiated after surgery, sustained over a period of time, and target multiple mechanisms in order to successfully alter the disease process. This study will assess whether a 6-month postoperative course of oral montelukast affects multiple PTOA mechanisms. Because montelukast administration can be safely sustained for long durations and offers a low-cost treatment option, should it be proven effective in the current trial, these results can be immediately incorporated into clinical practice.

Trial Registration: ClinicalTrials.gov NCT04572256 . Registered on October 1, 2020.
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http://dx.doi.org/10.1186/s13063-021-05982-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8802473PMC
January 2022

Temporal disruption of neuromuscular communication and muscle atrophy following noninvasive ACL injury in rats.

J Appl Physiol (1985) 2022 01 11;132(1):46-57. Epub 2021 Nov 11.

School of Kinesiology, University of Michigan, Ann Arbor, Michigan.

Many patients with anterior cruciate ligament (ACL) injuries have persistent quadriceps muscle atrophy, even after considerable time in rehabilitation. Understanding the factors that regulate muscle mass, and the time course of atrophic events, is important for identifying therapeutic interventions. With a noninvasive animal model of ACL injury, a longitudinal study was performed to elucidate key parameters underlying quadriceps muscle atrophy. Male Long-Evans rats were euthanized at 6, 12, 24, or 48 h or 1, 2, or 4 wk after ACL injury that was induced via tibial compression overload; controls were not injured. Vastus lateralis muscle size was determined by wet weight and fiber cross-sectional area (CSA). Evidence of disrupted neuromuscular communication was assessed via the expression of neural cell adhesion molecule (NCAM) and genes associated with denervation and neuromuscular junction instability. Abundance of muscle RING-finger protein-1 (MuRF-1), muscle atrophy F-box (MAFbx), and 45 s pre-rRNA along with 20S proteasome activity were determined to investigate mechanisms related to muscle atrophy. Finally, muscle damage-related parameters were assessed by measuring IgG permeability, centronucleation, CD68 mRNA, and satellite cell abundance. When compared with controls, we observed a greater percentage of NCAM-positive fibers at 6 h postinjury, followed by higher MAFbx abundance 48 h postinjury, and higher 20S proteasome activity at 1 wk postinjury. A loss of muscle wet weight, smaller fiber CSA, and the elevated expression of run-related transcription factor 1 (Runx1) were also observed at the 1 wk postinjury timepoint relative to controls. There also were no differences observed in any damage markers. These results indicate that alterations in neuromuscular communication precede the upregulation of atrophic factors that regulate quadriceps muscle mass early after noninvasive ACL injury. A novel preclinical model of ACL injury was used to establish that acute disruptions in neuromuscular communication precede atrophic events. These data help to establish the time course of muscle atrophy after ACL injury, suggesting that clinical care may benefit from the application of acute neurogenic interventions and early gait reloading strategies.
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http://dx.doi.org/10.1152/japplphysiol.00070.2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8742731PMC
January 2022

Injury rates in the National Football League during the 2020 COVID-19 season.

Phys Sportsmed 2021 Oct 6:1-6. Epub 2021 Oct 6.

Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA.

Objectives: The National Football League (NFL) altered the 2020 season due to the COVID-19 pandemic, which resulted in canceled preseason games and a dynamic regular season schedule to accommodate for canceled games. The purpose of this study was to evaluate if the disrupted training and preseason schedule lead to increased injury rates as seen in other professional sports. We hypothesized that the overall injury rate would be higher in the 2020 season compared to the 2018-2019 seasons and that this increase will affect all body regions equally.

Methods: Publicly released NFL weekly injury reports were queried to identify players listed as out or placed on the injured reserve for at least one game in the 2018-2020 seasons. Injuries were categorized into upper extremity, lower extremity, spine/core, head, illness, not injury related and undisclosed injuries. Incidents per 1000 athlete exposures were calculated for the prior two seasons (2018-2019) and for the 2020 season separately. Percentage of injuries occurring in each position was calculated separately for the pre-COVID-19 (2018 and 2019) and post-COVID-19 (2020) cohorts. Incidence rate ratios (IRR) and confidence intervals were used to compare injury rates in 2018-2019 versus 2020. The z-test for proportions was used to determine significant differences between injury incidences.

Results: The overall incidence rate per 1000 athlete exposures in 2020 was not significantly different compared to pre-COVID-19 seasons (21.6 versus 23.1, IRR 0.94, 95% CI: 0.9-1.0 p > 0.999). The proportion of injuries by position did not change before and after COVID-19 either (p > 0.999). Out listings due to illness were significantly increased during the 2020 season (0.8 versus 0.3, IRR 2.8, 95% CI: 1.4-5.2, p = 0.004).

Conclusion: The incidence of NFL injuries did not significantly change in 2020. The distribution of injuries did not change with respect to position.
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http://dx.doi.org/10.1080/00913847.2021.1984819DOI Listing
October 2021

Psychological Healthcare Burden Lessens After Hip Arthroscopy for Those With Comorbid Depression or Anxiety.

Arthrosc Sports Med Rehabil 2021 Aug 17;3(4):e1171-e1175. Epub 2021 Jun 17.

Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A.

Purpose: In this study, we investigated whether patients undergoing arthroscopic treatment of femoral acetabular impingement syndrome (FAIS) seek health care for treatment of comorbid depression and anxiety in the year following hip arthroscopy.

Methods: Using the Truven Health Marketscan database, FAIS patients who underwent hip arthroscopy between January 2009 and December 2016 were identified. Claims related to depression or anxiety filed during the year before surgery were required for inclusion. Using claims for pharmaceutical and psychological therapy treatments for mental health disorders, four groups of patients were analyzed on the basis of preoperative anxiety/depression treatment: medication only, therapy only, medication + therapy, and no treatment. Number of opioid pain prescriptions within 180 days prior to surgery and >90 days after hip arthroscopy were also compared.

Results: Depression and anxiety claims were identified in 5,208/14,830 (35.1%) patients. Preoperative treatment for depression and anxiety included medication only ( = 648, 12.4%), therapy only ( = 899, 17.3%), medication + therapy ( = 252, 4.8%), and no treatment ( = 3,409, 65.5%). Of the 900 patients who filled an anxiety/depression-related prescription prior to surgery, 422 (46.9%) patients did not fill a similar prescription in the postoperative year. Of the 1,151 patients receiving anxiety/depression-related therapy prior to surgery, 549 (47.7%) did not receive therapy in the postoperative year. Preoperative opioid prescriptions were filled for 393 patients (60.6%) in medication-only group, 275 (30.6%) in therapy-only group, 156 (61.9%) in medication + therapy group, and 1,059 (31.1%) in the group receiving no treatment. Opioid prescriptions >90 days postoperatively were filled for 330 (50.9%), 225 (25.0%), 120 (47.6%), and 861 (25.3%) patients, respectively.

Conclusion: Hip arthroscopy for FAIS is associated with a decreased postoperative use of health care resources for the treatment of depression and anxiety. Clinicians should also be aware of the potential interplay between preoperative psychotropic medication use and prolonged opioid use when counseling patients.

Level Of Evidence: IV, therapeutic case series.
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http://dx.doi.org/10.1016/j.asmr.2021.05.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8365206PMC
August 2021

Novel Cemented Technique for Trochanteric Fixation and Reconstruction of the Abductor Mechanism in Proximal and Total Femoral Arthroplasty: An Observational Study.

Arthroplast Today 2021 Oct 9;11:10-14. Epub 2021 Aug 9.

Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA.

Background: Little evidence exists regarding the clinical outcomes of cemented trochanteric fixation for abductor mechanism reconstruction in proximal or total femoral replacements. Clinical outcomes were assessed for a novel cemented technique for trochanteric fixation in femoral megaprostheses.

Methods: A descriptive series of 13 patients who underwent proximal or total femoral arthroplasty from 2016 to 2019 were reviewed. Radiographic trochanteric displacement >1 cm defined construct failure. A Kaplan-Meier survival analysis was performed to determine survival rates for these cemented constructs Demographic information was obtained to better characterize the patient population in whom this technique was used.

Results: Eleven patients were included (age = 63.6 years; 45.4% females; body mass index = 31.7). Mean time to final radiographic follow-up was 73.8 weeks. Three of 11 (27.2%) patients had construct failure. Overall, survival at 1 year was 81.8%. At 2 years, survival of cemented constructs was 65.5%. More construct failures occurred in patients who sustained a postoperative dislocation than in those who did not ( = .05).

Conclusions: This novel cemented trochanteric fixation technique for reconstruction of the abductor mechanism in femoral megaprostheses had 81.8% survival at 1 year postoperatively. While longitudinal comparative studies with larger samples are needed, the cemented technique may provide a viable alternative to traditional cementless methods of trochanteric fixation. Increased construct failure rates after postoperative dislocation highlight the importance of robust abductor reconstruction in these implants.
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http://dx.doi.org/10.1016/j.artd.2021.06.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8360973PMC
October 2021

Psychosocial factors 3-months after anterior cruciate ligament reconstruction predict 6-month subjective and objective knee outcomes.

J Orthop Res 2022 Jan 22;40(1):231-238. Epub 2021 Jun 22.

Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Kentucky, USA.

The objective of the study was to determine if psychological readiness for sport and knee self-efficacy assessed early (3 months) after anterior cruciate ligament reconstruction (ACLR) are predictive of self-reported functional outcomes, quadriceps strength, and knee mechanics while running at the time of return to sport training (6 months). Thirty athletes with unilateral ACLR completed the ACL Return to Sport after Injury (ACL-RSI) and Knee Self-Efficacy Scale (K-SES) 3 months after ACLR and completed self-reported functional outcomes, isometric quadriceps strength testing, and three-dimensional running gait analysis 6 months after ACLR. The 3-month ACL-RSI significantly correlated with the 6-month International Knee Documentation Committee (IKDC; r = 0.565, p = 0.001), Knee Injury and Osteoarthritis Outcome Score (KOOS) sport/recreational activities (KOOS ; r = 0.548, p = 0.002) and quality of life (KOOS ; r = 0.431, p = 0.017), and quadriceps strength (r = 0.528, p = 0.003). The 3-month K-SES significantly correlated with the 6-month IKDC (r = 0.528, p = 0.003), KOOS (r = 0.430, p = 0.018), KOOS (r = 0.411, p = 0.024), quadriceps strength (r = 0.465, p = 0.010), and knee flexion excursion (r = 0.472, p = 0.008). With multivariate modeling, both the ACL-RSI and K-SES were predictive of the IKDC (R  = 0.411; p = 0.001). Only the ACL-RSI was predictive of the KOOS (R  = 0.300; p = 0.002), KOOS (R  = 0.186; p = 0.017), and quadriceps strength (R  = 0.279; p = 0.003), whereas only the K-SES was predictive of knee flexion excursion (R  = 0.173; p = 0.022). Athletes with greater psychological readiness for sport and knee self-efficacy at 3 months demonstrated higher scores on self-reported functional outcomes, greater quadriceps strength, and greater knee flexion excursion at 6 months after ACLR. This study indicates that psychosocial measures may be important to include into early post-surgical evaluations to help guide and facilitate interventions to restore subjective and objective knee function.
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http://dx.doi.org/10.1002/jor.25120DOI Listing
January 2022

Patient-reported outcome scores following patellar instability surgery-high prevalence does not equal high responsiveness: a systematic review.

Knee Surg Sports Traumatol Arthrosc 2022 Apr 16;30(4):1453-1460. Epub 2021 Jun 16.

Division of Sports Medicine, Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, 740 S. Limestone, K401, Lexington, KY, 40503, USA.

Purpose: The purpose of this study was to determine the utilization and responsiveness of common patient-reported outcomes (PROs) in patients undergoing surgery for patellar instability.

Methods: Using PRISMA guidelines, a systematic review of studies reporting outcomes following surgical intervention for patellar instability was conducted using Pubmed, Cochrane, OVID Medline, and Google Scholar. Subgroup analysis of articles reporting at least two PROs with baseline and follow-up data were used to evaluate responsiveness of instruments using relative efficiency and effect size.

Results: From the search, 2,848 unique articles were found, of which 178 were included in final analysis (7,122 patients, mean age 22.6, 63.6% female). The most commonly used PRO was the Kujala score (79.2%), followed by the Lysholm (34.8%), and Tegner (30.9%). Seventy-nine articles were eligible for subgroup analysis. The Kujala had a higher relative efficiency than ten of the 14 instruments to which it was compared but had lower relative efficiency compared to the IKDC and Lysholm scores. The Banff Patella Instability Instrument (BPII) and the Norwich score, condition-specific tools, were unable to be fully assessed due to rarity of use and lack of comparisons.

Conclusion: The hypothesis that the Kujala score is the most commonly used PRO for patellar instability, although other instruments offer greater efficiency was supported by our results. The IKDC and Lysholm scores had similar effect sizes but higher relative efficiencies than the Kujala, thus suggesting better responsiveness. This analysis adds useful information for surgeons on the effectiveness of the most common PRO's for evaluating patellofemoral instability outcomes.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1007/s00167-021-06625-5DOI Listing
April 2022

Age at the Time of Surgery Is Not Predictive of Early Patient-Reported Outcomes After Periacetabular Osteotomy.

J Arthroplasty 2021 Oct 25;36(10):3388-3391. Epub 2021 May 25.

Washington University in St. Louis, Department of Orthopaedic Surgery, St. Louis, MO.

Background: The clinical success of periacetabular osteotomy (PAO) for the treatment of symptomatic acetabular dysplasia is well-documented. Conflicting evidence exists regarding the correlation of age with clinical outcomes. Hip disability and Osteoarthritis Outcome Score - global (HOOSglobal) is a recently validated patient-reported outcome measure following PAO. The purpose of this study is to asses HOOSglobal and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at early follow-up based on age at the time of PAO.

Methods: A prospective multicenter cohort of 391 patients undergoing PAO with minimum 2-year follow-up (average 4.71 years) were identified. Patients were categorized into 4 age groups: <20 years (N = 131), 20-29 (N = 102), 30-39 (N = 65), and ≥40 (N = 34). A 4 × 2 repeated measures analysis of variance (Age Group × Time) was used to compare preoperative and postoperative HOOSglobal and WOMAC scores between age groups. A multiple linear regression was used to identify predictors of postoperative HOOSglobal scores.

Results: HOOSglobal and WOMAC scores increased across all age groups; however, a statistically greater increase in preoperative to postoperative HOOSglobal and WOMAC scores was found in those ≥40 years compared to those <20 (P< .002), 20-29 (P = .01), and 30-39 years (P = .02). Higher preoperative HOOSglobal scores were predictive of greater postoperative HOOSglobal scores (P < .001) but age (P = .65), gender (P = .80), body mass index (P = .50), and Tönnis Classification (P = .07) were not independent predictors of 1-year outcomes.

Conclusion: The absence of differences in early postoperative patient-reported outcomes across multiple age ranges emphasizes that PAO in the setting of symptomatic acetabular dysplasia can be successful regardless of patient age alone. Therefore, age alone might not be an appropriate selection criterion when evaluating surgical candidates for PAO.

Level Of Evidence: II.
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http://dx.doi.org/10.1016/j.arth.2021.05.029DOI Listing
October 2021

Which Risk Factors Are Associated with Pain and Patient-reported Function in Patients with a Rotator Cuff Tear?

Clin Orthop Relat Res 2021 09;479(9):1982-1992

Department of Physical Therapy, University of Kentucky, Lexington, KY, USA.

Background: Patient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores.

Question/purpose: After controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores?

Methods: Fifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05.

Results: This model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r2 = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.65; p < 0.001).

Conclusion: Our results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan.

Level Of Evidence: Level II, prognostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373537PMC
September 2021

Making Sense of Hip Preservation Procedural Coding-Getting Paid for Your Work!

Arthroplast Today 2021 Apr 8;8:110-113. Epub 2021 Mar 8.

Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, UK HealthCare, Lexington, KY, USA.

Hip preservation and peri-trochanteric procedures are becoming more commonplace for the arthroplasty surgeon. Understanding the reimbursement for these procedures remains a challenge for those looking to expand this portion of their practice. In order to financially maximize the surgeon's efforts, we present recommendations for hip preservation procedural coding.
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http://dx.doi.org/10.1016/j.artd.2021.01.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7943960PMC
April 2021

Most orthopaedic trauma patients are using the internet, but do you know where they're going?

Injury 2021 Nov 24;52(11):3299-3303. Epub 2021 Feb 24.

University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, United States. Electronic address:

Purpose: The Internet is a resource that patients can use to learn about their injuries, treatment options, and surgeon. Previously, it was demonstrated that orthopaedic trauma patients are unlikely to use a reliable, provided source. It is unknown however, if patients are seeking information from elsewhere. The purpose of this study was to determine if orthopaedic trauma patients utilize the Internet and what websites are utilized. Our hypothesis was that the majority of patients use the Internet and when they do, are unlikely to use a reliable source.

Methods: Orthopaedic trauma patients were surveyed in clinic at a Level I trauma center in the United States. The survey queried demographics, injury information, Internet access, and eHealth Literacy Scale (eHEALS). Data were analyzed using t-tests, Chi-squared tests, and a multivariate logistic regression, as appropriate.

Results: 138 patients with a mean age of 47.1 years (95% confidence interval: 44.0-50.3; 51.1% female) were included in the analysis. Despite 94.1% reporting access, only 55.8% of trauma patients used the Internet for information about their injury. Of those, 64.5% used at least one unreliable source. WebMD (54.8%) was the highest utilized website. Age, sex, employment, and greater eHEALS score were associated with increased Internet use (p<0.001).

Conclusion: The Internet has potential to be a useful, low cost, and readily available informational source for orthopaedic trauma patients. This study illustrates that a majority of patients seek information from the Internet after their injury, including unreliable websites like Wikipedia and Facebook. Our study emphasizes the need for active referral to trusted websites and initiation of organizational partnerships (e.g. OTA/AAOS) with common content providers (e.g. WebMD) to provide patients with accurate information about their injury and treatment.

Level Of Evidence: Prognostic, Level II.
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http://dx.doi.org/10.1016/j.injury.2021.02.029DOI Listing
November 2021

Low self-efficacy increases the odds of elevated post-operative pain following hip arthroscopy for femoroacetabular impingement syndrome.

J Athl Train 2021 Feb 24. Epub 2021 Feb 24.

Cale Jacobs, PhD, ATC, Director, Orthopaedic Research, University of Kentucky, Department of Orthopaedic Surgery & Sports Medicine 740 S. Limestone, Room K426, Lexington, KY 40536,

Context: Low mental health scores, depression, and anxiety are associated with worse pain and functional outcomes following hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Pre-operative screening of psychosocial factors such as pain catastrophizing, self-efficacy, and kinesiophobia may further aid in identifying patients at-risk for poorer outcomes.

Objective: Compare pre-operative function and psychosocial factors between patients with and without elevated post-operative pain three-months following hip arthroscopy for FAIS.

Design: Prospective cohort Setting: University health center Participants: 51 individuals with FAIS (41F/10M; age:37.6±12.3years; BMI:27.1±4.1kg/m2) Outcome measures: Pre-operatively participants completed the Pain Self-Efficacy Questionnaire (PSEQ), Tampa Scale for Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), 12-Item International Hip Outcome Tool (iHOT-12), and a 10-point visual analog scale (VAS) for hip pain at rest and during activity. Three-months post-operatively, participants completed the PSEQ, TSK, PCS, iHOT-12 and VAS. Pre-operative scores were compared between those with (VAS≥3) and without (VAS<3) elevated post-operative pain using Mann-Whitney U tests, and odds ratios were calculated to determine the odds of having elevated post-operative pain and lower post-operative function.

Results: Participants with elevated post-operative pain at rest and during activity had worse pre-operative psychosocial health (p≤0.04). Those with elevated pain at rest had worse pre-operative function (p≤0.001). The odds of having elevated post-operative pain at rest were 45 times and 4.5 times higher for those with low self-efficacy and high pain catastrophizing (p≤.03).
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http://dx.doi.org/10.4085/139-20DOI Listing
February 2021

Development of a mind body program for obese knee osteoarthritis patients with comorbid depression.

Contemp Clin Trials Commun 2021 Mar 28;21:100720. Epub 2021 Jan 28.

Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 1st Floor, Suite 100, Boston, 02114, MA, USA.

Knee osteoarthritis (OA) is the most common joint disorder in the U.S. and a leading cause of disability. Depression and obesity are highly comorbid among knee OA patients, and the combination of obesity and depression is associated with decreased physical activity, higher pain and disability, and more rapid cartilage degradation. Depression, obesity and OA exacerbate one another and share a common pathophysiology involving systemic inflammation and pro-inflammatory cytokines, reflecting a complex mind-body interaction. Current treatments for knee OA offer little to no benefit over placebo, and do not emphasize mind-body practices or physical activity to target the underlying pathophysiology. Mind-body interventions to lessen depressive symptoms and increase physical activity offer the ability to target biological, mechanical and psychological mechanisms of OA progression. Our long-term goals are to evaluate the mechanisms by which the Relaxation Response Resiliency Program (3RP) delivered via secure telehealth, and adapted for patients with depression, obesity and knee OA (GetActive-OA) promotes increases in physical activity and improved knee health. We hypothesize that the synergistic interaction between mindfulness, adaptive thinking, positive psychology and healthy living skills of the GetActive-OA will slow the progression of symptomatic knee OA by reducing pro-inflammatory cytokine expression and promoting optimal mechanical loading of the cartilage. Here we present the protocol for a mixed methods study that will adapt the 3RP for the needs of knee OA patients with depression and obesity with a focus on increasing physical activity (GetActive-OA), and iteratively maximize the feasibility, credibility and acceptability of the programs and research procedures.
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http://dx.doi.org/10.1016/j.conctc.2021.100720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859301PMC
March 2021

Tetracycline use in treating osteoarthritis: a systematic review.

Inflamm Res 2021 Mar 29;70(3):249-259. Epub 2021 Jan 29.

Division of Sports Medicine, Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, 740 S. Limestone, K403, Lexington, KY, 40536, USA.

Background And Aims: The purpose of the review was to synthesize the current literature regarding tetracyclines in the treatment of osteoarthritis.

Methods: Using multiple databases, a systematic review was performed with customized search terms crafted to identify studies examining doxycycline or minocycline in the treatment of osteoarthritis. Results were classified into basic science mechanistic studies, in vivo animal studies, and human clinical trials. A total of 1446 potentially relevant studies were reviewed, and after exclusion criteria were applied, 23 investigations were included in the final analysis.

Results: From 12 basic science mechanistic studies, we report on three main mechanisms by which tetracyclines may exert benefit in osteoarthritis progression: matrix metalloproteinase inhibition, immunomodulation, and nitric oxide synthase inhibition. Seven animal studies showed generally encouraging results. Four articles reported human clinical studies, showing mixed results in the treatment of osteoarthritis, potentially related to the choice of patient population, primary outcomes, and timing of treatment.

Conclusion: Tetracyclines have the potential to benefit osteoarthritis patients via multiple mechanisms. Further study is warranted to examine the optimal dose and timing of tetracycline treatment in osteoarthritis.
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http://dx.doi.org/10.1007/s00011-021-01435-4DOI Listing
March 2021

Male Sex, Western Ontario Shoulder Instability Index Score, and Sport as Predictors of Large Labral Tears of the Shoulder: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

Arthroscopy 2021 06 15;37(6):1740-1744. Epub 2021 Jan 15.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA.

Purpose: To identify factors predictive of a large labral tear at the time of shoulder instability surgery.

Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects.

Results: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007).

Conclusions: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf.

Level Of Evidence: I, prognostic study.
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http://dx.doi.org/10.1016/j.arthro.2021.01.007DOI Listing
June 2021

Low Self-Efficacy and High Kinesiophobia Are Associated With Worse Function in Patients With Femoroacetabular Impingement Syndrome.

J Sport Rehabil 2020 Oct 7;30(3):445-451. Epub 2020 Oct 7.

Context: Femoroacetabular impingement syndrome (FAIS) is a painfully debilitating hip condition disproportionately affecting active individuals. Mental health disorders are an important determinant of treatment outcomes for individuals with FAIS. Self-efficacy, kinesiophobia, and pain catastrophizing are psychosocial factors that have been linked to inferior outcomes for a variety of orthopedic conditions. However, these psychosocial factors and their relationships with mental health disorders, pain, and function have not been examined in individuals with FAIS.

Objective: (1) To examine relationships between self-efficacy, kinesiophobia, pain catastrophizing, pain, and function in patients with FAIS and (2) to determine if these variables differ between patients with and without a self-reported depression and/or anxiety.

Design: Cross-sectional.

Setting: University health center.

Participants: Fifty-one individuals with FAIS (42 females/9 males; age 35.7 [11.6] y; body mass index 27.1 [4.9] kg/m2).

Main Outcome Measures: Participants completed the Pain Self-Efficacy Questionnaire, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, visual analog scale for hip pain at rest and during activity, and the 12-item International Hip Outcome Tool. Self-reported depression and/or anxiety were recorded. The relationships between psychosocial factors, pain, and function were examined using Spearman rank-order correlations. Independent t tests and Mann-Whitney U tests were used to evaluate the effect of self-reported depression and/or anxiety on psychosocial factors, pain and function.

Results: The 12-item International Hip Outcome Tool was correlated with pain during activity (ρ = -.57, P ≤ .001), Tampa Scale for Kinesiophobia (ρ = -.52, P ≤ .001), and Pain Self-Efficacy Questionnaire (ρ = .71, P ≤ .001). The Pain Self-Efficacy Questionnaire was also correlated with pain at rest (ρ = -.43, P = .002) and pain during activity (ρ = -.46, P = .001). Individuals with self-reported depression and/or anxiety (18/51; 35.3%) had worse self-efficacy and pain catastrophizing (P ≤ .01).

Conclusion: Self-reported depression and/or anxiety, low self-efficacy, and high kinesiophobia were associated with more hip pain and worse function for patients with FAIS. These findings warrant further examination including psychosocial treatment strategies to improve the likelihood of a successful clinical outcome for this at-risk population.
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http://dx.doi.org/10.1123/jsr.2019-0498DOI Listing
October 2020

Early Antibiotic Administration Is Associated with a Reduced Infection Risk When Combined with Primary Wound Closure in Patients with Open Tibia Fractures.

Clin Orthop Relat Res 2021 Mar;479(3):613-619

D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA.

Background: Early administration of antibiotics and wound coverage have been shown to decrease the deep infection risk in all patients with Type 3 open tibia fractures. However, it is unknown whether early antibiotic administration decreases infection risk in patients with Types 1, 2, and 3A open tibia fractures treated with primary wound closure.

Questions/purposes: (1) Does decreased time to administration of the first dose of antibiotics decrease the deep infection risk in all open tibia fractures with primary wound closure? (2) What patient demographic factors are associated with an increased deep infection risk in Types 1, 2, and 3A open tibia fractures with primary wound closure?

Methods: We identified 361 open tibia fractures over a 5-year period at a Level I regional trauma center that receives direct admissions and transfers from other hospitals which produces large variation in the timing of antibiotic administration. Patients were excluded if they were younger than 18 years, had associated plafond or plateau fractures, associated with compartment syndrome, had a delay of more than 24 hours from injury to the operating room, underwent repeat débridement procedures, had incomplete data, and were treated with negative-pressure dressings or other adjunct wound management strategies that would preclude primary closure. Primary closure was at the descretion of the treating surgeon. We included patients with a minimum follow-up of 6 weeks with assessment at 6 months and 12 months. One hundred forty-three patients with were included in the analysis. Our primary endpoint was deep infection as defined by the CDC criteria. We obtained chronological data, including the time to the first dose of antibiotics and time to surgical débridement from ambulance run sheets, transferring hospital records, and the electronic medical record to answer our first question. We considered demographics, American Society of Anesthesiologists classification, mechanism of injury, smoking status, presence of diabetes, and Injury Severity Score in our analysis of other factors. These were compared using one-way ANOVA, chi-square, or Fisher's exact tests. Binary regression was used to to ascertain whether any factors were associated with postoperative infection. Receiver operator characteristic curves were used to identify threshold values.

Results: Increased time to first administration of antibiotics was associated with an increased infection risk in patients who were treated with primary wound closure; the greatest inflection point on that analysis occurred at 150 minutes, when the increased infection risk was greatest (20% [8 of 41] versus 4% [3 of 86]; odds ratio 5.6 [95% CI 1.4 to 22.2]; p = 0.01). After controlling for potential confounding variables like age, diabetes and smoking status, none of the variables we evaluated were associated with an increased risk of deep infection in Type 1, 2, and 3A open tibia fractures in patients treated with primary wound closure.

Conclusion: Our findings suggest that in open tibia fractures, which receive timely antibiotic administration, primary wound closure is associated with a decreased infection risk. We recognize that more definitive studies need to be performed to confirm these findings and confirm feasibility of early antibiotic administration, especially in the pre-hospital context.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899592PMC
March 2021

Responsiveness of patient-reported outcomes in shoulder arthroplasty: what are we actually measuring?

J Shoulder Elbow Surg 2021 May 2;30(5):1174-1180. Epub 2020 Sep 2.

Avera Orthopedics, Sioux Falls, SD, USA.

Hypothesis: The purpose of this study was to determine the prevalence and responsiveness of common patient-reported outcome (PRO) tools in patients undergoing primary total shoulder arthroplasty (TSA) for glenohumeral arthritis.

Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of anatomic and reverse TSA studies from PubMed, SportDiscus, Cochrane, and CINAHL was performed. Studies on primary TSA for glenohumeral arthritis that reported at least 1 PRO tool were included in the final analysis. A subgroup analysis of studies that reported preoperative and postoperative PRO scores with at least 2-year follow-up data was evaluated to compare the responsiveness between the different PRO instruments.

Results: After full-text review of 490 articles, 74 articles met all inclusion criteria and were included in the final analysis. Anatomic TSA was evaluated in 35 studies, reverse TSA in 32 studies, and both anatomic and reverse in 7 studies. There were a total of 7624 patients, and 25 different PRO tools were used. The most commonly reported PRO tools were the American Shoulder and Elbow Surgeons (44 studies), Constant (42 studies), the visual analog scale for pain (23 studies), and the Simple Shoulder Test (17 studies). A median of 3.0 PRO instruments were used in each study. All instruments had large effect sizes. The University of California at Los Angeles (UCLA) score was found to be the most responsive instrument, and the Single Assessment Numeric Evaluation score was least responsive. The American Shoulder and Elbow Surgeons score was the most responsive instrument that required only patient-reported data.

Conclusion: Overall, the UCLA score was found to be the most responsive followed by the Adjusted Constant. However, both the UCLA and Adjusted Constant scores require strength and range of motion assessment that may limit their widespread clinical use. The increased responsiveness of these measures, which include objective clinical testing, speaks to the predicted increases in strength and range of motion after shoulder arthroplasty. Of the measures that can be administered without in-person clinical evaluation, the American Shoulder and Elbow Surgeons score and Western Ontario Osteoarthritis of the Shoulder index were the most responsive.
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http://dx.doi.org/10.1016/j.jse.2020.08.019DOI Listing
May 2021

Secondary Injuries After Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review With Quantitative Analysis.

Am J Sports Med 2021 03 18;49(4):1086-1093. Epub 2020 Aug 18.

Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky, USA.

Background: In the skeletally mature anterior cruciate ligament (ACL) reconstruction population, patients aged <25 years are at significantly increased risk of graft failure and injury to the contralateral ACL. Skeletal immaturity often affects graft selection and reconstruction technique.

Purpose: To examine the incidence of ipsilateral graft failure and contralateral ACL injury in the skeletally immature patient population.

Study Design: Systematic review and meta-analysis.

Methods: Using the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines, we reviewed all literature that involved ACL reconstruction performed on skeletally immature patients between May 1976 and May 2019. Patient demographics, surgical technique, and the prevalence of ipsilateral graft failure or subsequent contralateral ACL injury were recorded. Ipsilateral, contralateral, and secondary ACL injuries were then compared between sexes via chi-square tests.

Results: A total of 24 articles (1254 children; 1258 knees) met inclusion criteria for analysis. Ipsilateral graft failures occurred in 105 of 1258 patients (8.3%), and there were no statistically significant sex differences in the prevalence of graft failures (female, 9.7%; male patients, 7.1%; = .14). The prevalence of contralateral ACL injury was significantly greater in female (29/129; 22.5%) than male (18/206; 8.7%; = .0004) patients in the 9 studies that reported contralateral injury. Skeletally immature female patients were at significantly increased risk of contralateral ACL injury (odds ratio = 3.0; = .0006) when compared with their male counterparts.

Conclusion: In the literature to date, 1 in 3 female skeletally immature patients experienced an ipsilateral graft failure or contralateral ACL injury. Regardless of sex, the 24% prevalence of secondary injury after pediatric ACL reconstruction is almost identical to previously published secondary injury rates in skeletally mature patients <25 years old. As such, skeletal maturity alone does not seem to be a determinant of secondary injury; however, there is a clear need to improve postoperative rehabilitation, activity progression, and return-to-play testing to allow a safe return to sports that protects the long-term health of the reconstructed and contralateral limbs, especially for female patients.
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http://dx.doi.org/10.1177/0363546520934774DOI Listing
March 2021

Anterior cruciate ligament reconstruction reinitiates an inflammatory and chondrodegenerative process in the knee joint.

J Orthop Res 2021 06 29;39(6):1281-1288. Epub 2020 Jun 29.

Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Anterior cruciate ligament (ACL) injury leads to a sustained increase in synovial fluid concentrations of inflammatory cytokines and biomarkers of cartilage breakdown. While this has been documented post-injury, it remains unclear whether ACL reconstruction surgery contributes to the inflammatory process and/or cartilage breakdown. This study is a secondary analysis of 14 patients (nine males/five females, mean age = 9, mean BMI = 28) enrolled in an IRB-approved randomized clinical trial. Arthrocentesis was performed at initial presentation (mean = 6 days post-injury), immediately prior to surgery (mean = 23 days post-injury), 1-week post-surgery, and 1-month post-surgery. Enzyme-linked immunosorbant assay kits were used to determine concentrations of carboxy-terminal telopeptides of type II collagen (CTXII), interleukin-6 (IL-6), and IL-1β in the synovial fluid. The log-transformed IL-1β was not normally distributed; therefore, changes between time points were evaluated using a non-parametric Kruskal-Wallis one-way ANOVA. IL-1β concentrations significantly increased from the day of surgery to the first postoperative time point (P ≤ .001) and significantly decreased at the 4-week postoperative visit (P = .03). IL-1β concentrations at the 4-week postoperative visit remained significantly greater than both preoperative time points (P > .05). IL-6 concentrations at 1-week post-surgery were significantly higher than at initial presentation (P = .013), the day of surgery (P < .001), and 4 weeks after surgery (P = .002). CTX-II concentrations did not differ between the first three-time points (P > .99) but significantly increased at 4 weeks post-surgery (P < .01). ACL reconstruction appears to reinitiate an inflammatory response followed by an increase in markers for cartilage degradation. ACL reconstruction appears to initiate a second "inflammatory hit" resulting in increased chondral breakdown suggesting that post-operative chondroprotection may be needed.
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http://dx.doi.org/10.1002/jor.24783DOI Listing
June 2021

Spine patients demystified: what are the predictive factors of poor surgical outcome in patients after elective cervical and lumbar spine surgery?

Spine J 2020 10 2;20(10):1529-1534. Epub 2020 Jun 2.

Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, 740 S Limestone, K403, Lexington, KY 40536-0284, USA.

Background Context: Pre-existing comorbid psychiatric mood disorders are a known risk factor for impaired health-related quality of life and poor long-term outcomes after spine surgery.

Purpose: The purpose of this study was to investigate the effect of preexisting mood disorders on (1) pre- and postoperative patient-reported outcomes, (2) complications, and (3) pre- and postoperative opioid consumption in patients undergoing elective cervical or lumbar spine surgery.

Study Design/setting: Retrospective review at a single academic institution from 2014 to 2017.

Patient Sample: Consecutive adult patients who underwent cervical or lumbar surgery.

Outcome Measures: Quantitative measurements of pain (visual analog scale [VAS]) and spinal region-specific disability scores (Neck Disability Index [NDI] and Oswestry Disability Index [ODI]).

Methods: This is a retrospective review of 435 consecutive patients (179 cervical, 256 lumbar) who underwent elective spine surgery at a single academic institution from 2014 to 2017. Patient preoperative diagnosis of psychiatric mood disorder (eg, depression, anxiety, schizophrenia, bipolar, or dementia), baseline characteristics, medical (nonpsychiatric) comorbidities, operative variables, and surgical complications (eg, superficial and deep infection, wound complication, emergency department [ED] visits, readmissions, and repeat operations) were recorded. Additionally, preoperative ED visits, pre- and postoperative opioid requirements, total opioid prescription quantities and most recent dateof opioid prescription were collected. VAS, NDI, and ODI scores were recorded preoperatively and at 2, 6, and 12 weeks after surgery. Continuous variables were compared between those with and without diagnosed psychiatric comorbidity using two-tailed independent t test, and categorical variables were compared using chi-square or Fisher's exact tests. Analyses of variance and analysis of covariance were used to compare patient-reported outcomes between groups. A multivariate approach was taken to account for contribution of potential covariates in significant findings. Multiple linear regressions were used to determine variables associated with the number of postoperative opioid prescriptions.

Results: Of the cervical and lumbar cohorts, 78 (43.6%) and 113 (44.1%), respectively, had a preoperative diagnosis of comorbid psychiatric mood disorder. Cervical patients with mood disorders received a significantly higher total number of opioid prescriptions post-operatively (4.6±5.2 vs. 2.8±3.9; p=.002). Patients with mood disorders had worse NDI scores at all time points (p=.04), however there were no differences in VAS pain scores (p=.5). There were no statistical differences between patients with and without mood disorders regarding baseline characteristics, medical (nonpsychiatric) comorbidities, operative variables, surgical complications, preoperative ED visits or prior opioid use (p>.05). For lumbar patients, patients with mood disorders were more commonly females (p=.04), tobacco users (p=.003), alcohol dependent (p=.01) and illicit-drug abusers (p=.03). There were no differences regarding surgical complications or opioid consumption. Tobacco use (p<.001) was the sole contributor to postoperative VAS pain scores. Patients with mood disorders had significantly higher VAS values both before and 3 months following surgery (p=.01), but there was no difference in ODI scores.

Conclusions: Patients with preoperative psychiatric mood disorders undergoing elective cervical surgery had worse NDI scores and received more opioid prescriptions, despite similar VAS scores as those without mood disorders. Lumbar surgery patients with mood disorders were demographically different than those without mood disorders and had worse pain before and after surgery, though ODI scores were not different. Tobacco use was the sole contributor to postoperative VAS pain scores. This information can be useful in counseling patients with mood disorders before elective spinal surgery.
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http://dx.doi.org/10.1016/j.spinee.2020.05.550DOI Listing
October 2020

Increased Health Care Costs and Opioid Use in Patients with Anxiety and Depression Undergoing Rotator Cuff Repair.

Arthroscopy 2020 10 1;36(10):2655-2660. Epub 2020 Jun 1.

Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A.

Purpose: To (1) quantify the prevalence of mood disorders in patients undergoing arthroscopic rotator cuff repair (RCR) by use of a large claims database and (2) compare opioid use and medical costs in the year before and the year after RCR between patients with and without comorbid mood disorders.

Methods: A large claims database was queried to identify patients who underwent arthroscopic RCR (Current Procedural Terminology code 29827) between October 2010 and December 2015. All patients were then screened for insurance claims relating to either anxiety or depression. We compared net costs and opioid use both 1 year preoperatively and 1 year postoperatively between patients with and without mood disorders by use of an analysis of covariance.

Results: A total of 170,329 patients (97,427 male patients [57.2%] and 72,902 female patients [42.8%]) undergoing arthroscopic RCR were identified. Of the 170,329 patients, 46,737 (27.4%) had comorbid anxiety or depression, and after adjustment for preoperative cost, sex, age, and both preoperative and postoperative opioid use, the 1-year postoperative cost was 7.05% higher for those with a preoperative mood disorder than for those without a mood disorder. In addition, opioid use both in the 180 days prior to surgery (36.7% vs 26.9%) and more than 90 days after surgery (33.0% vs 27.2%) was substantially greater in the group with comorbid depression or anxiety.

Conclusions: In patients with comorbid mood disorders, opioid use and health care costs were increased both preoperatively and postoperatively. The increased cost in this patient population is estimated at $62.3 million annually. In an effort to provide high-quality, value-based care, treatment strategies should be developed to identify these patients preoperatively and provide the appropriate resources needed to improve the probability of a successful surgical outcome.

Level Of Evidence: Level III, retrospective, comparative therapeutic study.
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http://dx.doi.org/10.1016/j.arthro.2020.05.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554073PMC
October 2020

Surgical outcomes in the Frequency, Etiology, Direction, and Severity (FEDS) classification system for shoulder instability.

J Shoulder Elbow Surg 2020 Apr;29(4):784-793

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: The Frequency, Etiology, Direction, and Severity (FEDS) system was developed as a simple but reliable method for classifying shoulder instability based on 4 factors attainable by history and physical examination: frequency (solitary, occasional, or frequent); etiology (traumatic or atraumatic); direction (anterior, posterior, or inferior); and severity (subluxation or dislocation). This study investigated the epidemiology and 2-year surgical outcomes for the FEDS categories in the prospective Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort.

Methods: At the time of surgery, 1204 patients were assigned to the FEDS categories. Follow-up data were available for 636 of 734 patients (86.6%) who had undergone surgery at least 2 years prior to analysis. The most common categories were further analyzed by patient-reported outcomes (PROs) (American Shoulder and Elbow Surgeons, Western Ontario Shoulder Instability index, Single Assessment Numeric Evaluation scores) and rates of recurrent subluxation, recurrent dislocation, and revision surgery.

Results: Of the 36 FEDS categories, 16 represented at least 1% of patients. Occasional traumatic anterior dislocation (OTAD) was the most common category, with 16.4% of patients. Five other anterior categories (solitary traumatic anterior subluxation, occasional traumatic anterior subluxation [OTAS], frequent traumatic anterior subluxation [FTAS], solitary traumatic anterior dislocation, and frequent traumatic anterior dislocation) and one posterior category (solitary traumatic posterior subluxation [STPS]) represented at least 5% of patients. PROs improved significantly for each category. The highest rates of recurrent subluxation occurred in FTAS, OTAS, and OTAD cases; dislocation, OTAS and FTAS cases; and further surgery, OTAD cases. The lowest rates of failure occurred in STPS cases. Downward trends in PROs and higher failure rates were noted with an increasing number of preoperative dislocations.

Conclusion: Different FEDS categories showed varying degrees of improvement and failure rates, indicating that the system can be used to provide prognostic insight for presurgical education. Overall, outcomes decreased with a higher number of preoperative dislocations.
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http://dx.doi.org/10.1016/j.jse.2019.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197435PMC
April 2020

The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population.

Injury 2020 Apr 24;51(4):919-923. Epub 2020 Feb 24.

University of Kentucky, Department of Orthopaedic Surgery and Sports Medicine, Lexington, KY, United States. Electronic address:

Objective: The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications.

Design: Retrospective case control study.

Setting: Academic level-1 trauma center.

Patients/participants: Patients with long bone, lower extremity fractures requiring operative fixation.

Intervention: N/A.

Main Outcome Measures: Postoperative hospital admissions, emergency room (ER) visits, and reoperations.

Results: 399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003).

Conclusions: Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.
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http://dx.doi.org/10.1016/j.injury.2020.02.114DOI Listing
April 2020

The Prevalence and Clinical Implications of Comorbid Back Pain in Shoulder Instability: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

Orthop J Sports Med 2020 Feb 4;8(2):2325967119894738. Epub 2020 Feb 4.

Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA.

Background: Understanding predictors of pain is critical, as recent literature shows that comorbid back pain is an independent risk factor for worse functional and patient-reported outcomes (PROs) as well as increased opioid dependence after total joint arthroplasty.

Purpose/hypothesis: The purpose of this study was to evaluate whether comorbid back pain would be predictive of pain or self-reported instability symptoms at the time of stabilization surgery. We hypothesized that comorbid back pain will correlate with increased pain at the time of surgery as well as with worse scores on shoulder-related PRO measures.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients consented to participate in pre- and intraoperative data collection. Demographic characteristics, injury history, preoperative PRO scores, and radiologic and intraoperative findings were recorded for patients undergoing surgical shoulder stabilization. Patients were also asked, whether they had any back pain.

Results: The study cohort consisted of 1001 patients (81% male; mean age, 24.1 years). Patients with comorbid back pain (158 patients; 15.8%) were significantly older (28.1 vs 23.4 years; < .001) and were more likely to be female (25.3% vs 17.4%; = .02) but did not differ in terms of either preoperative imaging or intraoperative findings. Patients with self-reported back pain had significantly worse preoperative pain and shoulder-related PRO scores (American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index) ( < .001), more frequent depression (22.2% vs 8.3%; < .001), poorer mental health status (worse scores for the RAND 36-Item Health Survey Mental Component Score, Iowa Quick Screen, and Personality Assessment Screener) ( < .01), and worse preoperative expectations ( < .01).

Conclusion: Despite having similar physical findings, patients with comorbid back pain had more severe preoperative pain and self-reported symptoms of instability as well as more frequent depression and lower mental health scores. The combination of disproportionate shoulder pain, comorbid back pain and mental health conditions, and inferior preoperative expectations may affect not only the patient's preoperative state but also postoperative pain control and/or postoperative outcomes.
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http://dx.doi.org/10.1177/2325967119894738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000858PMC
February 2020

Pediatric Ganglion Cyst Recurrence: Location Isn't the Only Risk Factor.

J Pediatr Orthop 2020 Aug;40(7):340-343

Shriners Hospitals for Children Medical Center.

Introduction: Ganglion cysts represent the most common benign soft-tissue masses of the hand and wrist, most are treated nonoperatively, with relatively few local recurrences. Few studies have identified risk factors for recurrence in the pediatric population. The aim of this study is to identify risks of cyst recurrence and to establish if ultrasonographic imaging aids in the prediction of recurrence.

Methods: A single-center retrospective chart review was performed, identifying patients diagnosed with a ganglion cyst of the hand or wrist. Demographic information, cyst characteristics, and ultrasound examination reports were documented. Standard statistical and logistic regression analyses were performed.

Results: A total of 132 cysts were identified in 126 patients and the average age was 8.5 years old. The most common location was the dorsal wrist (57/132, 43.2%). There were 14 recurrences [11/14, (79%) dorsal wrist, 3/14 (21%) volar wrist, 0/14 (0%) in nonwrist locations]. The risk of recurrence was significantly greater for dorsal wrist cysts than nonwrist locations (odds ratio=18.1; 95% confidence interval: 1.02, 316.65; P=0.048); there was no statistical difference in recurrence rates between dorsal and volar cysts (P=0.15). Recurrence was noted in older patients (12.2 vs. 8.1 y, P<0.001) and those patients with painful masses (P=0.02). Patients undergoing surgical excision had a higher risk of recurrence than those who did not undergo surgical excision (P<0.001). Cyst volume as measured by ultrasound was performed in 37 cysts, with repeat ultrasounds in 12 cases demonstrating a decreased volume of 0.85 cm at baseline to 0.35 cm with repeat examination (P=0.40). In patients that received at least 1 ultrasound, there were no differences in cyst volume between those that recurred and those that did not (P=0.40).

Conclusions: Risk factors for recurrence in pediatric patients with a ganglion cyst include older age, symptomatic masses, cysts located around the wrist, and those requiring surgical excision. Ultrasound examination of cyst volume did not predict recurrence.

Level Of Evidence: Level III-therapeutic.
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http://dx.doi.org/10.1097/BPO.0000000000001517DOI Listing
August 2020
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