Publications by authors named "Darby A Houck"

40 Publications

Clinical Outcomes Associated With Preoperative Opioid Use in Various Shoulder Surgical Procedures: A Systematic Review.

Orthop J Sports Med 2021 Apr 21;9(4):2325967121997601. Epub 2021 Apr 21.

Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA.

Background: The impact of preoperative opioid use on outcomes after shoulder surgery is unknown.

Purpose/hypothesis: To examine the role of preoperative opioid use on outcomes in patients after shoulder surgery. We hypothesized that preoperative opioid use in shoulder surgery will result in increased postoperative pain and functional deficits when compared with nonuse.

Study Design: Systematic review; Level of evidence, 3.

Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were all English-language studies comparing clinical outcomes of shoulder surgery in patients who used opioids preoperatively (opioid group) as well as patients who did not (nonopioid group) with a minimum follow-up of 1 year. Outcomes included range of motion, American Shoulder and Elbow Surgeons score, Constant-Murley score, and visual analog scale for pain. Study quality was evaluated with the Modified Coleman Methodology Score and the MINORS score (Methodological Index for Non-randomized Studies).

Results: Included were 5 studies (level 2, n = 1; level 3, n = 4): Two studies were on total shoulder arthroplasty, 2 on reverse total shoulder arthroplasty, 1 on both, and 1 on arthroscopic rotator cuff repair. There were 827 patients overall: 290 in the opioid group (age, 63.2 ± 4.0 years [mean ± SD]; follow-up, 38.9 ± 7.5 months) and 537 in the nonopioid group (age, 66.0 ± 4.7 years; follow-up, 39.5 ± 8.1 months). The opioid group demonstrated significantly worse pre- and postoperative visual analog scale and Constant-Murley score pain scores as compared with the nonopioid group. Mean American Shoulder and Elbow Surgeons scores were significantly lower in the opioid group at pre- and postoperative time points as compared with the nonopioid group ( < .05 for all). However, both groups experienced similar improvement in outcomes pre- to postoperatively. One study showed that the opioid group consumed significantly more opioids postoperatively than the nonopioid group and for a longer duration ( < .05). The overall mean Modified Coleman Methodology Score and MINORS score were 64.2 ± 14 and 15.8 ± 1.0, respectively.

Conclusion: Opioid use prior to various shoulder surgical procedures negatively affected postoperative pain and functionality. Although the opioid group showed significantly worse scores postoperatively, the groups experienced similar improvements.
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http://dx.doi.org/10.1177/2325967121997601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072861PMC
April 2021

The Everted Acetabular Labrum: Patho-anatomy, Magnetic Resonance Imaging and Arthroscopic Findings of a Native Variant.

Arthroscopy 2021 May 4. Epub 2021 May 4.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, U.S.A.. Electronic address:

Purpose: The purpose of this study was to introduce a native labral variant, the everted acetabular labrum, and to describe the patho-anatomy, magnetic resonance imaging and magnetic resonance arthrogram (MRI/MRA) characteristics and the arthroscopic findings in this condition.

Methods: All primary hip arthroscopy procedures performed by the senior author between June 2013 and January 2020 were reviewed retrospectively. An everted acetabular labrum was identified as a segment of labrum that lacked apposition to the femoral head with the hip off traction. All everted labra were treated with labral advancement and repair with or without augmentation or reconstruction. The labrum-to-femoral head distance was measured in 3T MRI/MRA at the 1-2 o'clock position. A random selection of 38 hips without an everted labrum served as controls to compare radiographic parameters.

Results: A total of 68 hips were identified as having an everted labrum during the study period (mean age, 29.1 years), and 55 hips had advanced imaging available for review. MRI/MRA scans revealed the everted labrum to have a triangular shape in 17 hips (31%) and a blunted/round shape in 38 hips (69%), which differed significantly from controls (triangular 25/38 [66%], blunted 13/38 [34%], P < 0.001). The average labrum-to-femoral head distance was 1.4 mm for everted labra versus 0.0 mm for controls (P < 0.0001) and the mean labral lengths and widths were significantly shorter than those of controls (both P < 0.01). Of the hips, 8 underwent labral reconstruction or augmentation, and 61 underwent labral advancement/repair.

Conclusion: The everted acetabular labrum is a native variant that is identifiable during hip arthroscopy by assessing the labral seal off traction. Preoperative MRI/MRA findings can be highly predictive of an everted labrum. Surgical treatment includes labral advancement and repair or reconstruction to restore contact between the labrum and the femoral head.

Level Of Evidence: III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2021.04.038DOI Listing
May 2021

Comparing Intra-articular Injections of Leukocyte-Poor Platelet-Rich Plasma Versus Low-Molecular Weight Hyaluronic Acid for the Treatment of Symptomatic Osteoarthritis of the Hip: A Double-Blind, Randomized Pilot Study.

Orthop J Sports Med 2021 Jan 20;9(1):2325967120969210. Epub 2021 Jan 20.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Hyaluronic acid (HA) and leukocyte-poor platelet-rich plasma (LP-PRP) are 2 nonoperative treatment options that have been studied in patients with hip osteoarthritis (OA).

Purpose: To compare the efficacy of intra-articular injections of low-molecular weight (LMW) HA and LP-PRP in patients with hip OA.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: A total of 34 patients (36 hips) presenting with signs of hip OA were randomized to receive 3 blinded, weekly intra-articular injections of either LP-PRP or LMW-HA. Patients were prospectively evaluated before injections and at 6 weeks and then at 3, 6, 12, and 24 months. The primary outcome, conversion to total hip arthroplasty (THA) or a hip resurfacing procedure, was analyzed along with secondary outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and hip range of motion.

Results: The final analysis included 33 hips (mean Kellgren-Lawrence grade, 2.73) (LMW-HA: n = 14; LP-PRP: n = 19) in 31 patients (18 male; mean age, 53.8 years). Significantly more patients converted to THA or a hip resurfacing procedure in the LMW-HA group (7/14; 50.0%) (mean, 1.3 years after first injection) than the LP-PRP group (3/19; 15.8%) (mean, 0.73 years after first injection) ( = .035). There was no significant improvement or decline in any outcome scores within the LMW-HA group from before injections to 6 weeks or 3, 6, and 12 months. For the LP-PRP group, WOMAC overall ( = .032), joint ( = .030), and function scores ( = .025) significantly improved from before injections to 6 weeks, and WOMAC joint scores significantly improved from before injections to 6 months ( = .036). When comparing the difference between groups in internal rotation at 90° of hip flexion from before injections to 6 months, the LP-PRP group demonstrated a mean 5.0° improvement, while the LMW-HA group showed a mean 1.5° decrease ( = .028).

Conclusion: Intra-articular hip injections of LP-PRP in patients with hip OA resulted in an improvement in WOMAC scores and hip internal rotation at 6 months and delayed the need for THA or a hip resurfacing procedure compared with treatment with LMW-HA. A longer follow-up is necessary to further compare the effects of LP-PRP and LMW-HA injections in patients with hip OA.

Registration: NCT01920152 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/2325967120969210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934058PMC
January 2021

Return-to-Play Outcomes in Professional Baseball Players After Nonoperative Treatment of Incomplete Medial Ulnar Collateral Ligament Injuries: A Long-Term Follow-up Study.

Am J Sports Med 2021 04 15;49(5):1137-1144. Epub 2021 Mar 15.

UCHealth Steadman Hawkins Clinic-Denver, Englewood, Colorado, USA.

Background: Medial ulnar collateral ligament (UCL) injuries are common among baseball players. There is sparse literature on long-term results after nonoperative treatment of UCL injuries in professional baseball players.

Purpose: The primary purpose was to assess long-term follow-up on reinjury rates, performance metrics, rate of return to the same level of play or higher (RTP), and ability to advance to the next level of play in professional baseball players after nonoperative treatment of incomplete UCL injuries. The secondary aim was to perform a matched-pair comparison between pitchers treated nonoperatively and a control group without a history of UCL injuries.

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

Methods: Twenty-eight professional baseball players (18 pitchers, 10 position players) treated nonoperatively were identified from a previous retrospective review of a single professional baseball organization between 2006 and 2011. UCL reinjury rates and player performance metrics were evaluated at long-term (minimum, 9 years) follow-up. Rates of RTP were calculated. A matched-pair comparison was made between the pitchers treated nonoperatively and pitchers without a history of UCL injuries.

Results: Overall, 27 players (17 pitchers, 10 position players) were available for long-term follow-up at a mean follow-up of 12 years (SD, 2 years). The overall rate of RTP was 85% (23/27), with the rate of RTP being 82% (14/17) in pitchers and 90% (9/10) in position players. Of the 23 players who did RTP, 18 (78%) reached a higher level of play and 5 (21.7%) stayed at the same level. Of the 9 position players who did RTP, the median number of seasons played after injury was 4.5 (interquartile range, 3.3). Of the 14 pitchers who did RTP, the mean number of seasons played after injury was 5.8 (SD, 3.8). In the matched-pair analysis, no significant differences were observed in any performance metrics (P > .05). The overall reinjury rate was 11.1% (3/27), with no players requiring UCL reconstruction.

Conclusion: There was a high rate of RTP for professional baseball players treated nonoperatively for incomplete UCL injuries. Compared with a matched cohort with no history of UCL injury, professional baseball pitchers treated nonoperatively had similar performance metrics. Reinjury rates were low, and no player had reinjury requiring UCL reconstruction. Nonoperative treatment of incomplete UCL injuries in professional baseball players, specifically pitchers, is a viable treatment option in the long term.
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http://dx.doi.org/10.1177/0363546521996706DOI Listing
April 2021

Effectiveness of Latarjet for anterior shoulder instability in patients with seizure disorder.

JSES Int 2021 Mar 10;5(2):171-174. Epub 2020 Dec 10.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO, USA.

Background: A paucity of literature exists on the outcomes after Latarjet for anterior shoulder instability in patients with seizure disorders (SDs). The purpose of this study was to determine the effectiveness of the Latarjet procedure for anterior shoulder instability in patients with SDs.

Methods: A retrospective review of patients undergoing Latarjet from 2013 to 2017 for anterior shoulder instability with minimum 2 years of clinical follow-up was performed. Patients were divided into two groups: patients diagnosed with SD, and patients without a history of seizure (control). Demographics, indications, SD details, and postoperative outcomes were collected. The incidence of complications, recurrent instability, revision surgery, and repeat seizure(s) were also examined.

Results: A total of 53 patients were identified, including 10 shoulders in 9 patients with an SD (88.9% male; mean age, 29.2 years [range, 20-37]), and 44 shoulders in 44 non-SD patients (86.4% male; mean age, 30.3 years [range, 18-52]). The mean follow-up time was 3.4 (range, 2.2-4.8) and 3.8 (range, 2.1-5.6) years in the SD and control group, respectively. During the follow-up period, 4 of 9 (44.4%) patients with an SD (50% shoulders) had a recurrent seizure postoperatively. Of those 4 patients, three sustained a recurrent dislocation of the operative shoulder(s) resulting from a postoperative seizure, including one who dislocated bilateral shoulders from a single seizure event after bilateral Latarjet procedures. There was no recurrent instability in patients who did not sustain a seizure in the postoperative period. Having a seizure in the postoperative period significantly increased the risk of recurrent dislocation (OR = 39.9,  = 0.04).

Conclusions: Latarjet is a successful operation for recurrent anterior shoulder instability in patients without an SD. While it can still be successful in patients with SD, adequate control of seizures postoperatively is paramount to prevent recurrent instability episodes. Patients with an SD can be advised that if their seizures can remain controlled, they have a high likelihood of clinical success equal to that of patients without an SD.
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http://dx.doi.org/10.1016/j.jseint.2020.09.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910724PMC
March 2021

Bone and body characteristics of freestyle and nonfreestyle skiers.

J Sports Med Phys Fitness 2021 Feb 8. Epub 2021 Feb 8.

Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.

Background: Freestyle skiers must optimize their aerial performance by maintaining the strength and coordination to propel themselves in the air and adapt to landings and take-offs on uneven surfaces. The purpose of this study is to investigate the differences in areal bone mineral density (aBMD) and body composition in freestyle skiers and nonfreestyle skiing controls.

Hypothesis: We hypothesized that the unique demands and summation of forces experienced by freestyle athletes would manifest as greater femoral neck aBMD, lower percent body fat, and lower BMI than nonfreestyle skiing controls.

Level Of Evidence: Level 3, Retrospective Cohort Study.

Methods: 18 freestyle skiers (14M 4F, [27.56 ± 5.22 years]) and 15 controls (7M 8F, [26.93 ± 3.54 years]) were measured with dual energy X-ray absorptiometry (DXA) to determine total body composition, hip and lumbar spine aBMD, and bone mineral composition (BMC). Height and weight were measured with an in-office stadiometer and scale. Questionnaires were used to determine physical activity and pertinent medical history. Between-group variations were analyzed with an analysis of variance (ANOVA) and stratified by sex.

Results: Percent body fat, hip and lumbar spine aBMD, BMC, and area were all similar between freeski and nonfreeski athletes (p<0.05 for all). BMI was significantly lower in male freeski athletes (23.97kg/m2, 95% CI [22.75-25.18]) compared to nonfreestyle skiing controls (26.64kg/m2, 95% CI [24.43-28.86]) (p=0.03).

Conclusions: Freestyle skiers have a lower BMI than nonfreestyle skiers. All skiers in this study has similar percent body fat, aBMD, and BMC. This pilot study supports that there are unique musculoskeletal adaptations based on type of skiing.

Clinical Relevance: Skiers endure a variety of intense physical forces yet remain understudied despite high orthopedic injury rates. This study serves to broaden the current sports health literature and explore the physical demands and subsequent physiology of freestyle skiers.
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http://dx.doi.org/10.23736/S0022-4707.21.12055-9DOI Listing
February 2021

Biceps tenodesis versus tenotomy: a systematic review and meta-analysis of level I randomized controlled trials.

J Shoulder Elbow Surg 2021 May 26;30(5):951-960. Epub 2020 Dec 26.

Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, USA.

Background: Biceps tenodesis and tenotomy are 2 surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior-to-posterior (SLAP) tears. The purpose of this systematic review was to compare the clinical outcomes and complications of biceps tenodesis and tenotomy for the treatment of LHBT or SLAP pathology during shoulder arthroscopy.

Methods: We performed a systematic review by searching PubMed, the Cochrane Library, and Embase to identify level I randomized controlled trials that compared the clinical outcomes of biceps tenodesis vs. tenotomy. The search phrase used was as follows: biceps tenodesis tenotomy randomized. Patients were assessed based on the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Constant-Murley score, as well as postoperative range of motion, strength, and cosmetic deformity.

Results: Five studies (all level I) met the inclusion criteria, including 236 patients undergoing biceps tenodesis (mean age, 60.3 years) and 232 patients undergoing biceps tenotomy (mean age, 59.7 years). The mean follow-up period was 23.0 months. Overall, 6.8% of tenodesis patients experienced cosmetic deformity at latest follow-up compared with 23.3% of tenotomy patients (P < .001). No differences in Constant-Murley, visual analog scale, or American Shoulder and Elbow Surgeons scores were found between groups in any study, and of all the studies evaluating strength and range of motion at latest follow-up, only 1 found a significant difference between groups, in which tenodesis patients demonstrated significantly increased forearm supination strength (P = .02). One study found tenodesis patients to experience significantly more biceps cramping at 6-month follow-up compared with tenotomy patients (P = .043), although no differences in complication rates at latest follow-up were found in any study.

Conclusion: Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes. There is an increased rate of cosmetic deformity in patients undergoing biceps tenotomy compared with tenodesis.
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http://dx.doi.org/10.1016/j.jse.2020.11.012DOI Listing
May 2021

Estimation of Location and Extent of Labral Tear Based on Preoperative Range of Motion in Patients Undergoing Arthroscopic Stabilization for Anterior Shoulder Instability.

Arthrosc Sports Med Rehabil 2020 Dec 16;2(6):e711-e721. Epub 2020 Nov 16.

Department of Orthopedics, Division of Sports Medicine and Shoulder Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.

Purpose: To determine whether range of motion (ROM) varies with the location and extent of labral tear seen in patients undergoing arthroscopic anterior shoulder stabilization.

Methods: Consecutive patients undergoing arthroscopic anterior shoulder stabilization who were enrolled in the Multicenter Orthopaedic Outcomes Network Shoulder Instability database underwent a preoperative physical examination and intraoperative examination under anesthesia in which ROM was recorded. Intraoperatively, the location and extent of the labral tear was recorded using conventional clock-face coordinates. Patients were grouped by combinations of quadrants involved in the labral tear (G1-G7): G1 = anterior only, G2 = anterior + inferior, G3 = anterior + inferior + posterior, G4 = all quadrants, G5 = superior + anterior, G6 = superior + anterior + inferior, and G7 = posterior + superior + anterior. Statistical analyses were performed with the Kruskal-Wallis rank-sum test. When < .05, a post-hoc Dunn's test was performed. For categorical variables, the χ test was performed. We performed a series of bivariate negative binomial regression models testing pairwise combinations of ROM parameters predicting the count of labral tear locations (possible: 0-5) within each quadrant.

Results: A total of 467 patients were included, with 13 (2.8%) in G1, 221 (47.3%) in G2, 40 (8.6%) in G3, 51 (10.9%) in G4, 18 (3.9%) in G5, 121 (25.9%) in G6, and 3 (0.6%) in G7. Multiple statistically significant differences were noted in ROM, specifically active internal rotation at side (IRS) ( = .005), active abduction ( = .02), passive IRS ( = .02), and passive external rotation in abduction ( = .0007). Regression modeling revealed a positive correlation between passive abduction and predicted count of labral tear locations in the superior quadrant and between passive IRS and predicted count of labral tear location in the inferior quadrant.

Conclusions: In patients undergoing arthroscopic shoulder stabilization for anterior instability, ROM varies with location and extent of labral tear. However, the clinical relevance of such small ROM differences remains undetermined.

Level Of Evidence: II, prospective comparative study.
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http://dx.doi.org/10.1016/j.asmr.2020.05.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754526PMC
December 2020

The Anterolateral Ligament of the Knee: An Updated Systematic Review of Anatomy, Biomechanics, and Clinical Outcomes.

Arthroscopy 2021 05 17;37(5):1654-1666. Epub 2020 Dec 17.

University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A.

Purpose: To perform an updated systematic review of the anatomy, biomechanics, function of the anterolateral ligament (ALL), and the clinical outcomes of anterolateral ligament reconstruction (ALLR) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR).

Methods: A systematic search of the literature was performed by searching PubMed, the Cochrane Library, and Embase with the search phrase anterolateral ligament for articles published from February 2017 to May 2020. Inclusion criteria included studies that evaluated the anatomy, function, or biomechanics of the ALL; surgical technique articles on ALLR; clinical articles reporting outcomes of ALLR; studies published in English; and full-text articles. Exclusion criteria included studies published before February 2017. A subjective synthesis was performed, in which ranges were reported, and individual study data were presented in forest plots.

Results: Overall, 40 articles were included in this systematic review, with 11 articles describing ALL anatomy, 14 articles analyzing ALL function and biomechanics, 7 articles discussing the surgical technique of combined ACLR and ALLR (ACLR/ALLR), and 8 articles describing the clinical outcomes of ACLR/ALLR. The addition of ALLR in combination with ACLR (ACLR+) results in lower graft failure rates for ACLR/ALLR (0.0%-15.7%) when compared with isolated ACLR (I-ACLR) patients (7.4%-21.7%). Three of 5 studies using the Subjective International Knee Documentation Committee score, 2 of 5 studies using the Lysholm score, and 1 of 2 studies using the Tegner score reported significantly better scores at latest follow-up among ACLR+ patients compared with I-ACLR (P < .05).

Conclusions: The ALL acts as a secondary stabilizer to the anterior cruciate ligament and helps resist internal knee rotation and anterior tibial translation. Based on the current literature, combined ACLR with ALLR may result in lower graft failure rates and improved patient-reported outcomes when compared with I-ACLR in patients with specific indications, although several studies have shown equivalent outcomes between these 2 cohorts.

Clinical Relevance: The contents of this review provide great insight for orthopaedic surgeons who are performing ACLR and considering additional procedures to increase overall knee stability and decrease likeliness for re-rupture. The postoperative functional and clinical outcomes shown in patients undergoing ACLR+ compared with I-ACLR should be given proper consideration when evaluating available treatment courses.
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http://dx.doi.org/10.1016/j.arthro.2020.12.190DOI Listing
May 2021

Tranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies.

Arthroscopy 2021 04 2;37(4):1323-1333. Epub 2020 Dec 2.

Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.

Purpose: To systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder.

Methods: A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed by searching PubMed, Cochrane Library, and Embase databases to locate randomized controlled trials comparing the clinical outcomes and postoperative complications of patients undergoing arthroscopy with and without TXA. Search terms used were "tranexamic acid," "arthroscopy," "knee," "hip," and "shoulder." Patients were evaluated based on early (<6 weeks) postoperative signs of hemarthrosis using the Coupens and Yates classification, postoperative complications (myocardial infarction, stroke, venous thromboembolism events), range of motion (ROM), and patient-reported outcome scores (Visual analog scale, Subjective International Knee Documentation Committee, Lysholm, and Tegner activity scores).

Results: Five studies (2 level I and 3 level II) met inclusion criteria, including a total of 299 patients undergoing arthroscopy with TXA and 299 patients without TXA. The average follow-up duration for all patients was 43.9 days. Procedures performed were partial meniscectomy, anterior cruciate ligament reconstruction, and rotator cuff repair. No studies evaluating TXA use in hip arthroscopy were identified. Coupens-Yates hemarthrosis grades significantly improved in the TXA groups across all studies. Three studies found TXA patients to experience significantly less postoperative pain at latest follow-up, 1 study found TXA patients to have significantly better postoperative Lysholm scores, and 1 study found TXA patients to have significantly more ROM at latest follow-up compared with non-TXA patients (P < .05).

Conclusion: Patients undergoing arthroscopy, particularly arthroscopic meniscectomy, arthroscopic-assisted anterior cruciate ligament reconstruction, and arthroscopic rotator cuff repair, with TXA can be expected to experience improved outcomes and less hemarthrosis-related complications in the early postoperative period compared with non-TXA patients.

Level Of Evidence: II, systematic review of level I and II studies.
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http://dx.doi.org/10.1016/j.arthro.2020.11.051DOI Listing
April 2021

Sex-Based Differences in Recurrence Rates Following Arthroscopic Anterior Shoulder Stabilization: A Systematic Review.

Arthrosc Sports Med Rehabil 2020 Oct 14;2(5):e637-e644. Epub 2020 Oct 14.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO.

Purpose: The purpose of this systematic review was to examine the effect that sex has on recurrence of anterior shoulder instability following primary arthroscopic anterior shoulder stabilization.

Methods: A systematic review using PRISMA guidelines was performed by searching PubMed, Embase and Cochrane Library databases to identify studies reporting recurrence rates following arthroscopic anterior shoulder stabilization with a minimum follow-up period of 2 years. Patient demographics as well as preoperative, intraoperative and postoperative findings, including patient-reported outcomes and recurrence rates, were analyzed by 2 independent reviewers. Recurrence was defined as an episode of dislocation, subluxation or instability following primary arthroscopic anterior shoulder stabilization. Study methodological quality was evaluated with the Modified Coleman Methodology Score (MCMS). Risk bias was evaluated using the Methodological Index for Non-randomized Studies (MINORS score). Descriptive statistics are presented.

Results: Ten studies (1 Level I, 1 Level II, 5 Level III, and 3 Level IV), including a total of 7,102 patients with primary traumatic and/or recurrent traumatic shoulder instability without previous procedures who underwent primary arthroscopic anterior shoulder stabilization, were included (mean follow-up, 34.6 months; mean age, 25.4 years). There was a total of 5,097 males (71.8%) and 2,005 females (28.2%). There was a higher recurrence rate in males (6%-37%) compared to females (0-32%). Clinical outcomes were inconsistently reported, so no quantitative analysis of clinical outcomes or return-to-sport between sexes was possible. The average MCMS of all 10 studies was 76.8 ± 8.0, indicating good methodology.

Conclusions: Males may have higher recurrence rates than females following primary arthroscopic anterior shoulder stabilization; however, the heterogeneity of the included studies precludes any definitive conclusions.

Level Of Evidence: IV, Systematic Review of Level I-IV.
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http://dx.doi.org/10.1016/j.asmr.2020.04.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588602PMC
October 2020

Use of the Patient-Reported Outcomes Measurement Information System (PROMIS) for Operative Shoulder Outcomes.

Orthop J Sports Med 2020 Jun 16;8(6):2325967120924345. Epub 2020 Jun 16.

University of Colorado School of Medicine, Department of Orthopedics, Division of Sports Medicine and Shoulder Surgery, Aurora, Colorado, USA.

Background: Few studies have investigated the relationship between the Patient-Reported Outcomes Measurement Information System (PROMIS) and legacy patient-reported outcome (PRO) measurements.

Purpose: To compare patient-reported outcomes from the PROMIS physical function (PF) and upper extremity (UE) platforms against one another and against legacy PRO measurements to assess the potential strengths and weaknesses of the National Institutes of Health PROMIS initiative and expand on the use of PRO measurements in clinical orthopaedic practice.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic search of the PubMed, Embase, and Cochrane Library databases was conducted following PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. All English-language studies published between 2017 and 2019 using PROMIS to evaluate patients for shoulder surgery were analyzed. PROs were compared based on survey administered and the shoulder condition being investigated. Study quality was evaluated using the Modified Coleman Methodology Score and the Methodological Index for Non-Randomized Studies score.

Results: We included 9 studies (5 studies were level 2; 3 studies were level 3; 1 study was level 4) encompassing a total of 1130 patients (60.2% male; mean age, 52.6 ± 16.5 years; mean BMI, 29.8 ± 2.8 kg/m). Of these, 6 studies administered the PROMIS PF, and 6 studies administered the PROMIS UE. The strongest correlation was between PROMIS PF computer adaptive test and the 36-Item Short Form Health Survey Global Health (SF-36 GH) ( = 0.75). The highest overall correlation with the PROMIS UE was found with the American Shoulder and Elbow Surgeons (ASES) Shoulder Score ( = 0.70). The lowest correlations were found between PROMIS PF and the Marx Shoulder Activity Scale ( = 0.08) and the PROMIS UE and the Marx Shoulder Activity Scale ( = 0.18).

Conclusion: From available data, the PROMIS PF and PROMIS UE were most closely correlated with outcomes measured by the SF-36 GH. The PROMIS UE alone was most correlated with ASES Shoulder Score. Thus, either PROMIS PF or UE may provide a possible alternative to legacy PRO measurements but with a lower overall number of questions and higher generalizability. Future research should compare the time and question burden of the various PROMIS platforms with a more consistent evaluation of standard PRO measurements.
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http://dx.doi.org/10.1177/2325967120924345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298433PMC
June 2020

Do Older Skiers Have Worse Outcomes After Anterior Cruciate Ligament Reconstruction Compared With Non-Skiers or Younger Skiers?

Orthop J Sports Med 2020 Jun 16;8(6):2325967120923868. Epub 2020 Jun 16.

University of Colorado School of Medicine, Department of Orthopedics, Division of Sports Medicine and Shoulder Surgery, Aurora, Colorado, USA.

Background: There remains a paucity of literature comparing clinical outcomes after anterior cruciate ligament reconstruction (ACLR) between skiers and non-skiers, particularly in older patient populations.

Purpose: To compare clinical outcomes after ACLR between skiers and non-skiers, with a subanalysis based on age.

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

Methods: A nested cohort of 128 patients from the Multicenter Orthopaedic Outcomes Network cohort who underwent primary ACLR completed a series of patient-reported outcomes pre- and postoperatively at 2 and 6 years including the Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, and subjective International Knee Documentation Committee (IKDC) score. Data including patient sex, age at surgery, graft type, and sport participation were analyzed. Patients were stratified by participation in skiing (skiers vs non-skiers) and by age subgroup (≤29, 30-39, and ≥40 years). Student tests and analysis of variance were used to compare mean improvement between pre- and postoperative outcomes.

Results: A total of 44 skiers (female, 59.1%; age, 35.3 ± 11.6 years) and 84 non-skiers (female, 34.5%; age, 27.7 ± 11.3 years) were included. ACLR was performed using allograft in 36.7% (22 skiers, 25 non-skiers), autograft in 58.6% (19 skiers, 56 non-skiers), or hybrid autograft-allograft in 4.7% (3 skiers, 3 non-skiers). Although both non-skiers and skiers demonstrated improvements in outcomes from baseline to 2 and 6 years, non-skiers demonstrated significantly less overall improvement from 2 to 6 years postoperatively in KOOS Symptoms ( = .01), KOOS Pain ( = .002), and KOOS Activities of Daily Living ( = .03) subscales compared with skiers. There were 15 skiers who were 29 years or younger (34.1%), 14 skiers between 30 and 39 years (31.8%), and 15 skiers 40 years or older (34.1%). Skiers 40 years and older demonstrated significantly greater mean improvement in KOOS Symptoms ( = .02) and KOOS Quality of Life (QoL) ( = .01) subscales at 2 years and KOOS QoL ( = .01) at 6 years postoperatively compared with skiers 29 years or younger.

Conclusion: Compared with non-skiers, skiers demonstrated significantly greater mean improvements in KOOS scores between 2 and 6 years after ACLR. In addition, skiers 40 years or older showed greater improvement in KOOS QoL compared with younger skiers. This information can be used to counsel skiers, especially those older than 40 years, as to their expected outcomes after ACLR.
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http://dx.doi.org/10.1177/2325967120923868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298430PMC
June 2020

Sliding or Nonsliding Arthroscopic Knots for Shoulder Surgery: A Systematic Review.

Orthop J Sports Med 2020 Apr 24;8(4):2325967120911646. Epub 2020 Apr 24.

Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Knot tying is a crucial component of successful arthroscopic shoulder surgery. It is currently unknown whether sliding or nonsliding techniques result in superior clinical outcomes.

Purpose: To assess the clinical outcomes of arthroscopic sliding knot (SK)- versus nonsliding knot (NSK)-tying techniques during arthroscopic shoulder surgery, including rotator cuff repair, Bankart repair, and superior labral anterior-posterior (SLAP) repair.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic search of the PubMed, Embase, and Cochrane Library databases was performed using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. All English-language literature published between 2000 and 2018 reporting clinical outcomes utilizing SK- or NSK-tying techniques during rotator cuff repair, Bankart repair, and SLAP repair with a minimum 24-month follow-up was reviewed by 2 independent reviewers. Information on type of surgery, knot used, failure rate, patient satisfaction, and patient-reported outcomes was collected. Patient-reported outcome measures included the Constant-Murley score, Rowe score, and visual analog scale for pain. Study quality was evaluated using the modified Coleman Methodology Score.

Results: Overall, 9 studies (6 level 3 and 3 level 4) with a total of 671 patients (mean age, 52.8 years [range, 16-86 years]; 65.7% male; 206 SK and 465 NSK) were included. There were 4 studies that reported on Bankart repair in 148 patients (63 SK and 85 NSK), 3 on SLAP repair in 59 patients (59 SK), and 2 on rotator cuff repair in 464 patients (84 SK and 380 NSK). Also, 6 studies compared knot-tying with knotless techniques (3 Bankart repair studies and 3 SLAP repair studies), while the studies reporting the outcomes of SLAP repair evaluated SK-tying techniques only. The failure rate for Bankart repair was 3.2% (2/63) for SKs and 4.7% (4/85) for NSKs. The failure rate for rotator cuff repair was 2.4% (2/84) for SKs and 6.3% (24/380) for NSKs. The failure rate for SLAP repair was 11.9% (7/59). Because of inconsistencies in outcomes and procedures, no quantitative analysis was possible. The mean modified Coleman Methodology Score for all studies was 65.1 ± 8.77, indicating adequate methodology.

Conclusion: The literature on clinical outcomes using SKs or NSKs for shoulder procedures is limited to level 4 evidence. Future studies should be prospective and focus on comparing the use of SKs and NSKs for shoulder procedures to elucidate which arthroscopic knot results in superior clinical outcomes.
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http://dx.doi.org/10.1177/2325967120911646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7218991PMC
April 2020

Adductor Canal Versus Femoral Nerve Block after Anterior Cruciate Ligament Reconstruction: A Systematic Review of Level I Randomized Controlled Trials Comparing Early Postoperative Pain, Opioid Requirements, and Quadriceps Strength.

Arthroscopy 2020 07 18;36(7):1973-1980. Epub 2020 Apr 18.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.

Purpose: To systematically review the literature to compare the adductor canal block (ACB) with the femoral nerve block (FNB) following primary anterior cruciate ligament reconstruction (ACLR) in terms of early postoperative analgesic requirements and postoperative quadriceps strength.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to August 2019 to identify randomized controlled trials that compared postoperative pain and functional outcomes in patients following primary ACLR with ACB versus FNB. The search phrase used was: adductor canal femoral nerve anterior cruciate ligament. Patients were evaluated based on analgesic consumption and quadriceps muscle strength. Study quality and risk of bias were evaluated with the Modified Coleman Methodology Score and Cochrane risk-of-bias tool respectively.

Results: Five studies (all Level I evidence) were identified that met inclusion criteria, including 221 patients undergoing primary ACLR with ACB (mean age 26.8 years, 68.3% male) and 221 with FNB (mean age 28.2 years, 67.0% male). Statistical assessment for heterogeneity found for opioid consumption of ACB versus FNB groups was I = 97% (P < .0001). There were no significant differences in analgesic consumption within the first 24 hours following surgery between groups except in 1 study, in which patients receiving ACB required significantly greater analgesics (P < .001). Three studies using 3 different techniques to measure strength found patients receiving ACB to have significantly greater quadriceps muscle function within 24 hours of surgery when compared with patients receiving FNB (P < .05).

Conclusions: In patients undergoing ACLR, the ACB may provide similar analgesic requirements, and the included studies suggest a potential advantage in preserving muscle strength at short-term (24-48 hours) follow-up when compared with FNB. However, the differences in muscle strength assessments between studies do not allow for strong conclusions.

Level Of Evidence: I, systematic review and meta-analysis of Level I studies.
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http://dx.doi.org/10.1016/j.arthro.2020.03.040DOI Listing
July 2020

Prevention of Cutibacterium acnes infection in arthroscopic shoulder surgery: a systematic review.

J Shoulder Elbow Surg 2020 May;29(5):867-873

Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, USA.

Background: Cutibacterium acnes is a gram-positive anaerobe that can lead to postoperative shoulder infections. The purpose of this study was to determine the incidence of C acnes infections following shoulder arthroscopy and evaluate the efficacy of perioperative antibiotic prophylaxis in the prevention of these infections.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that evaluated the prevalence and clinical indications of C acnes infections after various arthroscopic shoulder surgical procedures. Patients were assessed based on positive culture rates, the contraction of infection, and antibiotic regimens used to prevent infection.

Results: A total of 9 studies (1 level I, 5 level II, 1 level III, and 2 level IV) met the inclusion criteria, including a total of 3758 patients with a mean age of 59.9 years (range, 17-87 years) at the time of surgery. The mean follow-up time was 1.6 months (range, 1.0-12.0 months). Overall, 37.3% of patients (173 of 464) had positive C acnes skin and/or joint culture results, and in 0.22% of patients (8 of 3586), a C acnes infection was diagnosed postoperatively. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery significantly reduced the positive culture rate from 41.6% to 9.6% (P < .001).

Conclusions: C acnes infections occur at a very low rate (0.22%) following shoulder arthroscopy. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery in combination with preoperative antibiotic prophylaxis significantly reduces the prevalence of C acnes in shoulder arthroscopy patients.
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http://dx.doi.org/10.1016/j.jse.2019.12.032DOI Listing
May 2020

Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Am J Sports Med 2021 01 17;49(1):249-260. Epub 2020 Apr 17.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are 2 nonoperative treatment options for knee osteoarthritis (OA) that are supposed to provide symptomatic relief and help delay surgical intervention.

Purpose: To systematically review the literature to compare the efficacy and safety of PRP and HA injections for the treatment of knee OA.

Study Design: Meta-analysis of level 1 studies.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 studies that compared the clinical efficacy of PRP and HA injections for knee OA. The search phrase used was . Patients were assessed via the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) scale. A subanalysis was also performed to isolate results from patients who received leukocyte-poor and leukocyte-rich PRP.

Results: A total of 18 studies (all level 1) met inclusion criteria, including 811 patients undergoing intra-articular injection with PRP (mean age, 57.6 years) and 797 patients with HA (mean age, 59.3 years). The mean follow-up was 11.1 months for both groups. Mean improvement was significantly higher in the PRP group (44.7%) than the HA group (12.6%) for WOMAC total scores ( < .01). Of 11 studies based on the VAS, 6 reported PRP patients to have significantly less pain at latest follow-up when compared with HA patients ( < .05). Of 6 studies based on the Subjective IKDC outcome score, 3 reported PRP patients to have significantly better scores at latest follow-up when compared with HA patients ( < .05). Finally, leukocyte-poor PRP was associated with significantly better Subjective IKDC scores versus leukocyte-rich PRP ( < .05).

Conclusion: Patients undergoing treatment for knee OA with PRP can be expected to experience improved clinical outcomes when compared with HA. Additionally, leukocyte-poor PRP may be a superior line of treatment for knee OA over leukocyte-rich PRP, although further studies are needed that directly compare leukocyte content in PRP injections for treatment of knee OA.
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http://dx.doi.org/10.1177/0363546520909397DOI Listing
January 2021

All-Inside Repair of Bucket-Handle Meniscal Tears: Clinical Outcomes and Prognostic Factors.

Am J Sports Med 2020 11 20;48(13):3386-3393. Epub 2020 Mar 20.

Department of Orthopedics, Division of Sports Medicine and Shoulder Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: There is no consensus on technique of choice for repair of bucket-handle meniscal tears (BHMTs).

Purpose: To determine factors that affect patient outcomes and failure rates in patients undergoing all-inside repairs of BHMTs.

Study Design: Systematic review.

Methods: A systematic review of 3 databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. All English-language literature from 1993 to 2019 describing clinical outcomes for patients undergoing all-inside BHMT repair with ≥12-month follow-up was reviewed by 2 independent reviewers. Patient characteristics (patient sex, age), intraoperative factors (laterality, concomitant procedures, surgical technique, implants utilized), and postoperative outcomes (failure rates) were analyzed. Study quality was evaluated with the Modified Coleman Methodology Score (MCMS).

Results: Fifteen studies (1 level 1, 4 level 3, 10 level 4) with 763 total patients (64% male; average age, 26.4 years [range, 9-58 years]; average follow-up, 39.8 months [range, 12-120 months]) including 396 all-inside BHMT repairs were included. Six devices were used for repair including the Meniscal Repair System, FasT-Fix, Meniscus Arrow, Biofix Arrow, RapidLoc device, and PDS II suture, with failure rates of 13.5%, 22.4%, 27.1%, 42.9%, 45.2%, and 0%, respectively. The overall repair failure rate was 29.3% at an average of 13.0 months (range, 5.0-32.4 months), but 19.0% for devices still in use. The RapidLoc and Biofix Arrow had higher failure rates than other devices ( = .0003). Women (31%) were less likely to experience a failure than were men (69%) ( = .03). Longer follow-up duration resulted in higher failure rates (>30 months, 34.4%; <30 months, 23.4%; = .016). In 4 studies reporting on both all-inside and inside-out repairs, no significant differences in failure rates were observed. No significant differences in failure rates were found between medial and lateral repairs nor repair with and without concurrent anterior cruciate ligament reconstruction ( > .05 for all). The overall average MCMS was 54.4 ± 12.

Conclusion: The overall failure rate after all-inside repair of BHMTs is 29.3% at an average of 13.0 months, with no difference in failure rates between medial and lateral meniscal repairs. The variables shown to negatively affect the failure rates were the RapidLoc and Biofix Arrow, male sex, and longer follow-up duration.
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http://dx.doi.org/10.1177/0363546520906141DOI Listing
November 2020

Comparing Hamstring Autograft With Hybrid Graft for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Arthroscopy 2020 04 7;36(4):1189-1201. Epub 2020 Jan 7.

University of Colorado School of Medicine, Department of Orthopaedics, Aurora, Colorado.

Purpose: To systematically review the literature in an effort to compare the demographics and clinical outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with a hamstring tendon autograft (HT) versus an irradiated or nonirradiated hybrid autograft-allograft.

Methods: A systematic review of the PubMed, Cochrane Library, and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All English-language literature that reported general demographics and compared the clinical outcomes of patients undergoing primary ACLR with autograft versus hybrid graft (HG) with a minimum 2-year follow-up was reviewed by 2 independent reviewers. Search terms used were "anterior cruciate ligament" and "hybrid graft." Patients were assessed based on graft failure, anteroposterior laxity, and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, visual analog scale, Subjective International Knee Documentation Committee score, Lysholm, and Tegner scores). Study quality was evaluated with the Modified Coleman Methodology Score and ROBINS-I risk of bias tool.

Results: Twelve studies (1 level II, 11 level III) met inclusion criteria (follow-up, 2.0-8.9 years), including 471 patients undergoing ACLR with an irradiated hybrid graft (IH), 89 patients with a nonirradiated hybrid graft, and 829 patients with HT. Graft diameter ranged from 7.5 to 10.0 mm and from 6.5 to 10.0 mm in HG and HT patients, respectively. Overall, graft failure ranged from 0% to 30.0% and from 0% to 28.3% in HG and HT patients, respectively (I = 35.9%; 95% confidence interval 0%-74.8%). Among HG patients, graft failure ranged from 0%-30.0% and from 2.4%-4.2% in IH and nonirradiated hybrid graft groups, respectively (I = 33.6%; 95% confidence interval, 0%-71.8%). Results for postoperative anteroposterior laxity and patient-reported outcomes were also inconsistent.

Conclusions: Patients undergoing ACLR with HT demonstrate inconsistent differences in clinical outcomes at midterm follow-up compared with IH patients.

Level Of Evidence: III, systematic review of level II and III studies.
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http://dx.doi.org/10.1016/j.arthro.2019.10.010DOI Listing
April 2020

Outcomes of Arthroscopic Capsular Release in the Beach-Chair Versus Lateral Decubitus Position: A Systematic Review.

Orthop J Sports Med 2019 Dec 19;7(12):2325967119888173. Epub 2019 Dec 19.

Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Arthroscopic capsular release (ACR) for the treatment of adhesive capsulitis of the shoulder can be performed in either the beach-chair (BC) or lateral decubitus (LD) position.

Purpose: To determine the clinical outcomes and recurrence rates after ACR in the BC versus LD position.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed by searching PubMed, Embase, and the Cochrane Library databases for studies reporting clinical outcomes of patients undergoing ACR in either the BC or LD position. All English-language literature from 1990 through 2017 reporting on clinical outcomes after ACR with a minimum 3-month follow-up were reviewed by 2 independent reviewers. Recurrence rates, range of motion (ROM) results, and patient-reported outcome (PRO) scores were collected. Study methodological quality was evaluated using the modified Coleman Methodology Score (MCMS).

Results: A total of 30 studies (3 level 1 evidence, 2 level 2 evidence, 4 level 3 evidence, 21 level 4 evidence) including 665 shoulders undergoing ACR in the BC position (38.1% male; mean age, 52.0 ± 3.9 years; mean follow-up, 35.4 ± 18.4 months) and 603 shoulders in the LD position (41.8% male; mean age, 53.0 ± 2.3 years; mean follow-up, 37.2 ± 16.8 months) were included. There were no significant differences in overall mean recurrence rates between groups (BC, 2.5%; LD, 2.4%; = .81) or in any PRO scores between groups ( > .05). There were no significant differences in improvement in ROM between groups, including external rotation at the side (BC, 36.4°; LD, 42.8°; = .91), forward flexion (BC, 64.4°; LD, 79.3°; = .73), abduction (BC, 77.8°; LD, 81.5°; = .82), or internal rotation in 90° of abduction (BC, 40.8°; LD, 45.5°; = .70). Significantly more patients in the BC group (91.6%) underwent concomitant manipulation than in the LD group (63%) ( < .0001). There were significantly more patients with diabetes in the LD group (22.4%) versus the BC group (9.6%) ( < .0001).

Conclusion: Low rates of recurrent shoulder stiffness and excellent improvements in ROM can be achieved after ACR in either the LD or BC position. Concomitant manipulation under anesthesia is performed more frequently in the BC position compared with the LD position.
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http://dx.doi.org/10.1177/2325967119888173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6923698PMC
December 2019

Primary Arthroscopic Repair of the Anterior Cruciate Ligament: A Systematic Review of Clinical Outcomes.

Arthroscopy 2019 12;35(12):3318-3327

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.

Purpose: To describe the clinical outcomes after primary arthroscopic anterior cruciate ligament (ACL) repair.

Methods: A systematic review of the PubMed, Embase, and Cochrane Library databases was performed according to the PRISMA guidelines. All English-language literature published from 2000 to 2018 that reported the clinical outcomes after primary arthroscopic repair (AR) of complete tear of the ACL (without augmentation) with a minimum 2-year follow-up was reviewed by 2 independent reviewers. Outcomes included repair failure, reoperation, postoperative knee stability, and patient-reported outcomes. Descriptive statistics are presented. Study quality was evaluated with the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Nonrandomized Studies (MINORS) score.

Results: Six studies (2 level III, 4 level IV) were included. The mean MCMS was 62.2. The mean MINORS score for noncomparative studies was 11.8, and for comparative studies, 18. Six studies reported outcomes of 89 patients who underwent AR of the ACL from 2007 to 2016 (age, 8 to 67 years; follow-up, 24 to 110 months). All 6 studies included exclusively proximal avulsion tears. Overall, 0% to 25.0% of patients experienced repair failure (I = 23.7%; 95% confidence interval, 0% to 67.6%), and 0% to 20.0% of patients had a subsequent reoperation (I = 12.1%; 95% confidence interval, 0% to 77.7%). Similar inconsistent results were shown for postoperative knee stability measures and patient-reported outcomes.

Conclusions: The literature on clinical outcomes of primary arthroscopic ACL repair is limited. The reported rates of repair failure and reoperation are highly inconsistent. Most studies report relatively high failure rates.

Level Of Evidence: IV, systematic review of level III and IV studies.
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http://dx.doi.org/10.1016/j.arthro.2019.06.034DOI Listing
December 2019

"Doctor, What Happens After My Meniscectomy?"

J Bone Joint Surg Am 2019 Nov;101(21):1965-1973

The Steadman Clinic, Vail, Colorado.

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http://dx.doi.org/10.2106/JBJS.19.00082DOI Listing
November 2019

Evaluation of information available on the internet regarding reverse total shoulder arthroplasty.

Shoulder Elbow 2019 Jul 13;11(2 Suppl):29-34. Epub 2017 Jun 13.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO, USA.

Background: Prior studies have analyzed the quality of information available on the Internet regarding common orthopaedic surgical procedures. The purpose of the present study was to evaluate the quality of information available for reverse total shoulder arthroplasty (rTSA).

Methods: Websites were identified using the search term 'reverse total shoulder arthroplasty' and the first 50 websites from three separate search engines (Google, Yahoo, and Bing) were selected for evaluation of authorship and quality of information using the DISCERN instrument (www.discern.org.uk). After disregarding duplicated or overlapping websites within and among search engines, 90 of the total 150 websites were evaluated. A one-way analysis of variance test was used to compare differences in DISCERN scores between three categories of authorship (academic, private, other).

Results: The majority of the websites evaluated were authored by academic (43%) and private institutions (36%). These were the most credible sources, providing overall better quality and reliability than other sources. DISCERN reliable ( = 0.017) and overall scores ( = 0.020) were significantly higher for academic institutions compared to other websites.

Conclusions: The information available on the Internet pertaining to reverse total shoulder arthroplasty is highly variable and provides moderate quality information about treatment choices with some limitations based on the DISCERN instrument.
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http://dx.doi.org/10.1177/1758573217713720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688157PMC
July 2019

Return to Sport After Proximal Hamstring Tendon Repair: A Systematic Review.

Orthop J Sports Med 2019 Jun 24;7(6):2325967119853218. Epub 2019 Jun 24.

Department of Orthopaedics, Tulane University School of Medicine, New Orleans, Louisiana, USA.

Background: Previous studies have evaluated functional outcomes and return-to-sport rates after proximal hamstring tendon (HT) repair.

Purpose: To systematically review the literature in an effort to evaluate return-to-sport rates after proximal HT repair.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that evaluated postoperative lower extremity function and return-to-sport rates in patients after proximal HT repair. Search terms used were "hamstring," "repair," "return to sport," and "return to play." Patients were assessed based on return to sport, return to preinjury activity level, type of HT tear (complete or partial), and interval from injury to surgery. Patients were also divided into subgroups depending on timing of the surgical intervention: early, <1 month; delayed, 1 to 6 months; and late, >6 months from the time of injury.

Results: Sixteen studies (one level 2, five level 3, ten level 4) met the inclusion criteria, including 374 patients with a complete proximal HT tear (CT group) and 93 patients with a partial proximal HT tear (PT group), with a mean follow-up of 2.9 years. Overall, 93.8% of patients (438/467) returned to sport, including 93.0% (348/374) in the CT group and 96.8% (90/93) in the PT group ( = .18). The mean time to return to sport was 5.7 months, and 83.5% of patients (330/395) returned to their preinjury activity level. The early group demonstrated the greatest rate of return to sport at 94.4% (186/197) as well as the quickest time to return at a mean of 4.8 months, although this was not found to be statistically significant.

Conclusion: Over 90% of patients undergoing repair of a complete or partial proximal HT tear can be expected to return to sport regardless of the tear type. Early surgical interventions of these injuries may be associated with a quicker return to sport, although the rate of return to sport does not differ based on timing of the surgical intervention.
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http://dx.doi.org/10.1177/2325967119853218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6591667PMC
June 2019

Treatment of Lateral Epicondylitis With Autologous Blood, Platelet-Rich Plasma, or Corticosteroid Injections: A Systematic Review of Overlapping Meta-analyses.

Orthop J Sports Med 2019 Mar 14;7(3):2325967119831052. Epub 2019 Mar 14.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Previous meta-analyses have been conducted to compare outcomes of various treatment injections for lateral epicondylitis (LE), including corticosteroid injection (CSI) and autologous blood products such as autologous blood (AB) and platelet-rich plasma (PRP).

Purpose: To conduct a systematic review of overlapping meta-analyses comparing different injection treatments (CSI, AB, PRP) for LE to determine which meta-analyses provide the best available evidence.

Study Design: Systematic review; Level of evidence, 2.

Methods: A systematic review was performed by searching PubMed, Embase, and the Cochrane Library to locate meta-analyses that compared clinical outcomes of CSI, AB, and PRP for the treatment of LE. Search terms included "injection," "corticosteroid," "platelet-rich plasma," "autologous blood," "tennis elbow," "lateral epicondylitis," and "meta-analysis." Results were reviewed to determine study eligibility. Patient outcomes were extracted from these meta-analyses. Meta-analysis quality was assessed with the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad decision algorithm was then used to determine which meta-analyses provided the best level of evidence.

Results: Nine meta-analyses (two level 1 studies, seven level 2 studies) containing 8656 patients met the eligibility criteria. Seven meta-analyses found that autologous blood products such as AB and PRP significantly improved pain and elbow function in the intermediate term (12-26 weeks), while 4 studies found that CSI effectively relieved pain and improved elbow function in the short term (<12 weeks). The study by Arirachakaran et al in 2016 received the highest QUOROM and Oxman-Guyatt scores; therefore, this meta-analysis appears to have the highest level of evidence. In addition, this study was rated the highest-quality study in this systematic review according to the Jadad decision algorithm. Lower-quality meta-analyses indicated that dosage, number of injections, and differences in therapeutic duration between CSI and autologous blood products may be essential factors in determining the appropriate treatment injection protocol for LE.

Conclusion: The current best available evidence suggests that CSI improves functional outcomes and pain relief in the short term, while AB and PRP are the most effective treatments in the intermediate term.
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http://dx.doi.org/10.1177/2325967119831052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6419259PMC
March 2019

Five-Strand Hamstring Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Orthop J Sports Med 2019 Feb 22;7(2):2325967119826094. Epub 2019 Feb 22.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Recent studies have described surgical techniques to increase the hamstring graft diameter for anterior cruciate ligament reconstruction (ACLR), particularly for 5-strand hamstring (5HS) autografts.

Purpose: To review the literature examining the biomechanical and clinical outcomes of 5HS autografts for ACLR.

Study Design: Systematic review; Level of evidence, 3.

Methods: A systematic review using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines was performed by searching PubMed, Embase, and the Cochrane Library for studies reporting the biomechanical and clinical outcomes of 5HS autografts. All English-language literature published from 2012 to 2018 that reported the biomechanical properties of 5HS grafts and/or clinical outcomes after ACLR with 5HS autografts with a minimum 1-year follow-up was reviewed by 2 independent reviewers. Graft diameter, stiffness, displacement, strength, failure rates, anteroposterior knee laxity, and patient-reported outcome scores were collected. The study methodology was evaluated using the modified Coleman Methodology Score.

Results: Two biomechanical and 3 clinical studies (1 with level 2 evidence, 2 with level 3 evidence) were included. The biomechanical studies compared the results of fourteen 4-strand hamstring (4HS) and fourteen 5HS graft specimens for ACLR (ovine grafts, n = 12; cadaveric grafts, n = 16) and found no significant differences in ultimate load, stiffness, displacement, and stress relaxation ( > .05), likely attributed to insufficient incorporation of the fifth strand. The mean 5HS cadaveric graft diameter (8.2 mm) was significantly greater than that of 4HS grafts (6.8 mm) ( .002), whereas the mean ovine graft diameters were not significantly different (4HS, 5.2 mm; 5HS, 5.3 mm) ( > .05). Two clinical studies compared the outcomes after ACLR of 53 patients with a 4HS autograft versus 62 patients with a 5HS autograft, while 1 clinical study reported the outcomes of 25 patients after ACLR with a 5HS autograft (mean age, 28.7 years; mean follow-up, 24.8 months). The overall mean diameter for 4HS and 5HS autografts was 8.4 and 9.1 mm, respectively. There was no significant difference in failure rates between 4HS and 5HS autografts ( = .82). None of the comparative studies reported significant differences in any clinical outcomes ( > .05 for all).

Conclusion: The available literature on traditional 4HS and 5HS autografts for ACLR is limited. Of the available data, clinical and biomechanical studies suggest no difference in outcomes after ACLR with either graft construct. Additional research is needed to determine whether creating a 5HS graft is beneficial.
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http://dx.doi.org/10.1177/2325967119826094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388455PMC
February 2019

"Doctor, What Happens After My Anterior Cruciate Ligament Reconstruction?"

J Bone Joint Surg Am 2019 Feb;101(4):372-379

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado.

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http://dx.doi.org/10.2106/JBJS.18.00426DOI Listing
February 2019

Knee Osteoarthritis After Single-Bundle Versus Double-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials.

Arthroscopy 2019 03 4;35(3):996-1003. Epub 2019 Feb 4.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.

Purpose: To systematically review high-quality studies in the literature to compare the postoperative radiographic incidence of knee osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) with a single-bundle (SB) versus double-bundle (DB) graft.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to locate randomized controlled trials that compared the postoperative progression of knee OA in SB versus DB ACLR patients. The search terms used were "anterior cruciate ligament reconstruction," "single-bundle," "double-bundle," "randomized," and "osteoarthritis." Patients were assessed based on radiographic evaluation (Kellgren-Lawrence [K-L] and objective International Knee Documentation Committee scales) and graft failure.

Results: A total of 7 studies (5 Level I and 2 Level II) met the inclusion criteria, including 375 SB and 477 DB ACLR patients with a mean follow-up period of 5.3 years. Graft failure occurred in 3.2% of patients overall (27 of 852), with no significant difference between groups (P = .10). No significant difference in overall K-L grade distribution was found between groups (P = .90). Overall, 15.1% of patients (58 of 383) were given a K-L grade of 2 or greater, including 14.4% in the SB group (31 of 215) and 16.1% in the DB group (27 of 168) (P = .65). Using other, unconventional grading schemes, 2 studies found DB ACLR patients to have significantly fewer signs of radiographic knee OA at follow-up compared with SB ACLR patients (P < .05).

Conclusions: Patients undergoing ACLR with either an SB or DB graft can be expected to experience a similar incidence of postoperative knee OA at midterm follow-up according to the K-L grading system.

Level Of Evidence: Level II, systematic review of Level I and II studies.
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http://dx.doi.org/10.1016/j.arthro.2018.10.127DOI Listing
March 2019

Outcomes of Arthroscopic Posterior Shoulder Stabilization in the Beach-Chair Versus Lateral Decubitus Position: A Systematic Review.

Orthop J Sports Med 2019 Jan 24;7(1):2325967118822452. Epub 2019 Jan 24.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Arthroscopic posterior shoulder stabilization can be performed with patients in the beach-chair (BC) and the lateral decubitus (LD) positions; however, the impact of patient positioning on clinical outcomes has not been evaluated.

Purpose: To compare clinical outcomes and recurrence rates after arthroscopic posterior shoulder stabilization performed in the BC and LD positions.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic review using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines was performed by searching PubMed, Embase, and the Cochrane Library for studies reporting the clinical outcomes of patients undergoing arthroscopic posterior shoulder stabilization in either the BC or LD position. All English-language studies from 1990 to 2017 reporting clinical outcomes after arthroscopic posterior shoulder stabilization with a minimum 2-year follow-up were reviewed by 2 independent reviewers. Data on the recurrent instability rate, return to activity or sport, range of motion, and patient-reported outcome scores were collected. Study methodological quality was evaluated using the Modified Coleman Methodology Score (MCMS) and Quality Appraisal Tool (QAT).

Results: A total of 15 studies (11 LD, 4 BC) with 731 shoulders met the inclusion criteria, including 626 shoulders in the LD position (mean patient age, 23.9 ± 4.1 years; mean follow-up, 37.5 ± 10.0 months) and 105 shoulders in the BC position (mean patient age, 27.8 ± 2.2 years; mean follow-up, 37.9 ± 16.6 months). There was no significant difference in the overall mean recurrent instability rate between the LD and BC groups (4.9% ± 3.6% vs 4.4% ± 5.1%, respectively; = .83), with similar results in a subanalysis of studies utilizing only suture anchor fixation (4.9% ± 3.6% vs 3.2% ± 5.6%, respectively; = .54). There was no significant difference in the return-to-sport rate between the BC and LD groups (96.2% ± 5.4% vs 88.6% ± 9.1%, respectively; = .30). Range of motion and other patient-reported outcome scores were not provided consistently across studies to allow for statistical comparisons.

Conclusion: Low rates of recurrent shoulder instability and high rates of return to sport can be achieved after arthroscopic posterior shoulder stabilization in either the LD or the BC position. Additional long-term randomized trials comparing these positions are needed to better understand the potential advantages and disadvantages of surgical positioning for posterior shoulder stabilization.
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http://dx.doi.org/10.1177/2325967118822452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6348524PMC
January 2019