Publications by authors named "Joseph N Liu"

113 Publications

Preoperative ASES Scores Can Predict Substantial Clinical Benefit at 2 Years Following Total Shoulder Arthroplasty.

Orthopedics 2021 Jul-Aug;44(4):e509-e514. Epub 2021 Jul 1.

Preoperative patient-reported outcome measures (PROMs) have been shown to influence outcomes after total shoulder arthroplasty (TSA), although little is known about this relationship. An institutional shoulder arthroplasty registry was retrospectively queried for preoperative and 2-year postoperative 12-Item Short Form Health Survey (SF-12) and American Shoulder and Elbow Surgeons (ASES) scores for patients who underwent anatomic TSA (aTSA) or reverse TSA (rTSA). Preoperative PROMs were evaluated for their effect on patient achievement of minimal clinically important improvement (MCII) and substantial clinical benefit (SCB). In total, 451 aTSA patients and 93 rTSA patients had preoperative and 2-year follow-up scores. A total of 91.7% and 70.4% of patients achieved MCII and SCB at 2 years, respectively (<.001). Preoperative ASES scores were more predictive of achieving SCB than MCII (area under the curve [AUC], 0.83 vs 0.71). When accounting for mental and emotional health, the predictive ability of SF-12 physical component threshold values improved (AUC, 0.68). Preoperative threshold PROMs were found to accurately predict achievement of clinically significant outcomes at 2 years. Considering mental and emotional health improved the accuracy of these predictions. These data will assist surgeons and patients alike in setting expectations for outcomes after TSA. [. 2021;44(4):e509-e514.].
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http://dx.doi.org/10.3928/01477447-20210618-09DOI Listing
July 2021

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

Arthroscopy 2021 Jul 9. Epub 2021 Jul 9.

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

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

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

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

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

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

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

Knee Surg Sports Traumatol Arthrosc 2021 Jun 16. 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
June 2021

Predicting Patient Satisfaction With Maximal Outcome Improvement After Biceps Tenodesis.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Study Design: Cross-sectional study.

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

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

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

Return to Sport After Medial Patellofemoral Ligament Reconstruction: A Systematic Review and Meta-analysis.

Am J Sports Med 2021 Mar 15:363546521990004. Epub 2021 Mar 15.

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

Background: Patellar instability is frequently encountered in the athletic population. Medial patellofemoral ligament (MPFL) reconstruction is a common strategy to treat recurrent patellar dislocation and demonstrates good clinical outcomes.

Purpose/hypothesis: The purpose was to examine return to sport after MPFL reconstruction for patellar instability. We hypothesized that patients would resume athletic activity at a high rate and that a large proportion would return to their preoperative level of performance.

Study Design: Systematic review and meta-analysis.

Methods: A systematic review of the literature was conducted using PubMed and Cochrane Library databases to identify articles reporting return to sport after MPFL reconstruction for recurrent patellar dislocation. Athletes were defined as those reporting a preoperative sport. A random-effects model was used to evaluate return to sport rates, subsequent level, and rate of instability recurrence. Meta-regression was used to compare return to sport rates in patients undergoing MPFL reconstruction without osteotomy compared with those treated with simultaneous tibial tubercle osteotomy or trochleoplasty.

Results: In total, 23 articles met inclusion criteria after full-text review. A total of 930 patients were analyzed, including 786 athletes. Women represented 61.3% of all patients. The overall mean age was 21.1 years (range, 9.5-60.0 years), with a mean follow-up time of 3.0 years (range, 0.8-8.5 years). The return to sport rate was 92.8% (95% CI, 86.4-97.6). Patients returned to or surpassed their preoperative level of activity in 71.3% (95% CI, 63.7-78.4) of cases. An osteotomy was performed on 10.5% of athletes. Return to sport did not differ significantly in patients undergoing MPFL reconstruction without osteotomy versus those receiving additional osteotomy (95.4% vs 86.9%; = .22). Patients returned to sport at a mean of 6.7 months (range, 3.0-6.4 months) postoperatively. Osteotomy did not affect return time. Complications occurred at an overall rate of 8.8%. The most common complication was recurrence of instability (1.9%; 95% CI, 0.4-4.0). The Kujala score was reported by 13 studies, with pre- and postoperative combined means of 60.3 and 90.0, respectively.

Conclusion: MPFL reconstruction is an effective and reliable treatment in the setting of patellofemoral instability. Surgeons can counsel their patients that they can expect a high rate of return to sport after MPFL reconstruction surgery alone or with concomitant osteotomy.
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http://dx.doi.org/10.1177/0363546521990004DOI Listing
March 2021

Return to sport and weightlifting analysis following distal biceps tendon repair.

J Shoulder Elbow Surg 2021 Mar 3. Epub 2021 Mar 3.

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

Background: Rupture of the distal biceps tendon is an increasingly frequent injury sustained predominantly by middle-aged men. Despite the prevalence of sport in this age group, little is known regarding return to sport outcomes following surgery.

Methods: Patients undergoing distal biceps tendon repair (DBR) between January 2015 and January 2017 were contacted electronically via e-mail and via telephone to administer a previously validated and standard return to sport survey. Patients self-reported preinjury and current level of sport and activity as well as preinjury and current level of select weightlifts.

Results: A total of 77 of 124 patients were available for follow-up (62.1%). Of these patients, 61 endorsed preoperative sport and were included for analysis. Average follow-up was 38.7 ± 6.7 months. The mean age at surgery was 47.5 ± 8.8 years, and the mean body mass index was 30.3 ± 5.1. The dominant side was affected in 25 of 61 cases. Of the 61 included patients, 57 (93.4%) were able to return to sport at any level (lower, same, or higher intensity than preinjury activity level). Forty of the patients (65.6%) were able to return to sport at same or higher intensity. Mean time to return to sport was 6.0 ± 2.8 months. Days from injury to surgery (odds ratio [OR] 0.999, 95% confidence interval [CI] 0.998-0.999), suture anchor fixation in comparison to suture button (OR 0.602, 95% CI 0.427-0.850), and dominant-side surgery (OR 0.749, 95% CI 0.582-0.963) were associated with a decreased likelihood to return to sport at same or higher level of duty. Single-sided incision in comparison to double (OR 5.209, 95% CI 1.239-20.903) and dominant-side surgery (OR 6.370, 95% CI 1.639-24.762) were associated with increased duration to return to sport.

Conclusion: Distal biceps tendon rupture is a significant injury; however, patients can expect high levels of return to sport following DBR with some residual impairment compared with baseline. It is important to counsel patients on their expectations while taking into account the results of this study: that there will be a small but appreciable decrease in strength compared with preinjury levels.
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http://dx.doi.org/10.1016/j.jse.2021.01.034DOI Listing
March 2021

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

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

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

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

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

Study Design: Cross-sectional study.

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

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

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

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

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

Restore Orthopedics, Orange, CA 92868.

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

The Feasibility of Outpatient Shoulder Arthroplasty: Risk Stratification and Predictive Probability Modeling.

Orthopedics 2021 Mar-Apr;44(2):e215-e222. Epub 2020 Dec 30.

Whether shoulder arthroplasty can be performed on an outpatient basis depends on appropriate patient selection. The purpose of this study was to identify risk factors for adverse events (AEs) following shoulder arthroplasty and to generate predictive models to improve patient selection. This was a retrospective review of prospectively collected data using a single institution shoulder arthroplasty registry as well as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including subjects undergoing hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse TSA. Predicted probability of suitability for same-day discharge was calculated from multivariable logistic models for different patient subgroups based on age, comorbidities, and Charlson/Deyo Index scores. A total of 2314 shoulders (2079 subjects) in the institutional registry met inclusion criteria for this study. Younger age, higher body mass index (BMI), male sex, and prior steroid injection were all significantly associated with suitability for discharge, whereas preoperative narcotic use, comorbidities (heart disease and anemia/other blood disease), and Charlson/Deyo Index score of 2 were associated with AEs that might prevent same-day discharge. Compared with TSA, reverse TSA was associated with less suitability for discharge (=.01). On querying the ACS-NSQIP database, 15,254 patients were identified. Female sex, BMI less than 35 kg/m, American Society of Anesthesiologists class III/IV, preoperative anemia, functional dependence, low pre-operative albumin, and hemiarthroplasty were associated with unsuitability for discharge. Males 55 to 59 years old with no comorbidities nor history of narcotic use formed the lowest risk subgroup. Transfusion is the primary driver of AEs. Strategies to avoid this complication should be explored. Risk stratification will improve the ability to identify patients who can safely undergo outpatient shoulder arthroplasty. [. 2021;44(2):e215-e222.].
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http://dx.doi.org/10.3928/01477447-20201216-01DOI Listing
July 2021

Time to Achievement of Clinically Significant Outcomes After Isolated Arthroscopic Partial Meniscectomy: A Multivariate Analysis.

Arthrosc Sports Med Rehabil 2020 Dec 15;2(6):e723-e733. Epub 2020 Dec 15.

Department of Orthopedic Surgery, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To define the time required to achieve the minimally clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) for isolated arthroscopic partial meniscectomy (APM), and define preoperative and intraoperative factors that predict both early and late achievement of the stated metrics.

Methods: Patients who underwent isolated APM between 2014 and 2017 were retrospectively included. Patients without preoperative and 6-month patient-reported outcome measure scores, revision procedures, and significant concomitant procedures were excluded. The MCID, SCB, and PASS were calculated for knee-based patient-reported outcome measure scores using receiver operating curve analysis. Kaplan-Meier survival analysis established the time required to achieve MCID, SCB and PASS. Hazard ratios from multivariate Cox regression allowed for the isolation of demographic and intraoperative factors predictive of the delayed time required to achieve MCID, SCB and PASS.

Results: A total of 126 patients (42.86% female, age: 48.9 ± 12.4 years) were included. Overall achievement rates ranged between 73.0% and 89.7% for MCID, 43.7% and 68.2% for SCB, and 50.8% and 68.3% for PASS. Median achievement time for MCID was 5.68-5.78 months, 5.73-6.05 months for SCB and 6.54-7.72 months for PASS. Multivariate Cox regression identified older age, workers' compensation status, diabetes, and various tear types (i.e., longitudinal, transverse, bucket handle, complex) as predictors of early clinically significant outcome achievement (hazard ratio: 1.02-24.72), whereas subsequent steroid injection, higher preoperative scores and root and flap tears predicted delays in clinically significant outcome achievement (hazard ratio: 0.12-0.99).

Conclusions: The majority of patients undergoing APM achieve benefit within 6 months of surgery, with diminishing proportions at later timepoints. Important factors for consideration of the the timeline of achieving clinically significant outcome include age, diabetes, workers' compensation, preoperative score, and tear type. The timeline for achieving improvement that was established by this study may aid in setting patient expectations and designing future outcome studies involving APM.

Study Design: Level IV, Therapeutic Case Series.
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http://dx.doi.org/10.1016/j.asmr.2020.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754524PMC
December 2020

Return to Work After Distal Femoral Varus Osteotomy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Effect of Vancomycin Soaking on Anterior Cruciate Ligament Graft Biomechanics.

Arthroscopy 2021 03 29;37(3):953-960. Epub 2020 Oct 29.

Sports Medicine Institute, Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To evaluate the effect of soaking of anterior cruciate ligament (ACL) grafts in vancomycin solution on graft biomechanical properties at the time of implantation.

Methods: The central third of patellar tendons was harvested from mature bovine knees and prepared as a tendon-only graft or a bone-tendon-bone (BTB) graft. Tendons were wrapped in gauze soaked in vancomycin solution (VS) (5 mg/mL) or normal saline (NS) and left to stand for 30 minutes at room temperature, simulating graft exposure times in the operating room during ACL reconstruction. Tensile testing was carried out on a materials testing system with (1) low-magnitude loading (60 N at 3 mm/s) with repeated testing of tendon-only grafts; and (2) high-magnitude loading (600 N at 10 mm/min) of BTB grafts. For tendon-only grafts, specimens were first wrapped in NS-soaked gauze and underwent testing, with repeated testing performed after wrapping in gauze soaked in VS or buffered VS (pH 7.0). For BTB grafts, specimens were randomly assigned to treatment with VS or NS.

Results: For tendon-only grafts, there was no difference in Young's modulus (YM) after soaking with VS soaking (baseline, 12.69 MPa; treatment, 16.07 ± 4.44 MPa; P = .99) or buffered VS (baseline, 12.45 ± 4.55 MPa; treatment, 15.56 ± 2.83 MPa; P = .99). For BTB grafts, there were no differences in elongation strain (VS, 46.8% ± 7.0%; NS, 31.5% ± 13.5%, P = .19) or YM (VS, 158.4 ± 15.8 MPa; NS, 158.5 ± 23.3 MPa, P = .99).

Conclusions: According to controlled biomechanical tests, vancomycin soaking of patellar tendon grafts does not adversely affect time-zero material properties.

Clinical Relevance: This study suggests that vancomycin wrapping has no immediate adverse effects on the biomechanical properties of ACL grafts. Randomized controlled trials are warranted to validate the widespread use of vancomycin soaking of tendon grafts for infection prophylaxis during ACL reconstruction.
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March 2021

Return to Work After Shoulder Replacement for Glenohumeral Osteoarthritis Is Similar When Hemiarthroplasty Is Compared to Total Shoulder Arthroplasty.

HSS J 2020 Oct 17;16(3):212-217. Epub 2019 Jun 17.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY USA.

Background: Return to work after shoulder arthroplasty for glenohumeral osteoarthritis (OA) is an important consideration for an aging workforce.

Questions/purposes: The aim of this study was to compare the shoulder function, pain levels, and rate of return to work in patients treated with anatomic total shoulder arthroplasty (aTSA) versus humeral hemiarthroplasty (HHA).

Methods: A retrospective review of consecutive HHA patients was performed of our institution's shoulder arthroplasty registry. Inclusion criteria were pre-operative diagnosis of end-stage OA and more than 2 years' follow-up. HHA patients were statistically matched to aTSA patients and then screened for pre-operative work status; 26 HHA and 23 aTSA patients worked before surgery. There was no difference in average age (HHA, 62.4 years; aTSA, 61.7 years) or follow-up (HHA, 67.5 months; aTSA, 66.9 months).

Results: Average American Shoulder and Elbow Surgeons (ASES) scores (HHA, 37.6 to 70.3; aTSA, 35.6 to 80.1) and visual analogue scale (VAS) for pain scores (HHA, 6.1 to 2.3; aTSA, 6.5 to 0.6) improved in both groups. However, HHA patients had worse final VAS scores, and aTSA patients were more satisfied (100% vs 77%); 61.5% of HHA patients returned to work post-operatively versus 87.0% of aTSA patients. There was no difference in time to return to work (HHA, 1.9 ± 2.3 months; aTSA, 1.3 ± 1.0 months).

Conclusion: Patients with shoulder OA undergoing aTSA have higher rates of return to work, function, and satisfaction than those undergoing HHA.
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http://dx.doi.org/10.1007/s11420-019-09692-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534888PMC
October 2020

Time Required to Achieve Clinically Significant Outcomes After Arthroscopic Rotator Cuff Repair.

Am J Sports Med 2020 12 20;48(14):3447-3453. Epub 2020 Oct 20.

Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA.

Background: Recent literature has focused on correlating statistically significant changes in outcome measures with clinically significant outcomes (CSOs). CSO benchmarks are being established for arthroscopic rotator cuff repair (RCR), but more remains to be defined about them.

Purpose: To define the time-dependent nature of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptomatic State (PASS) after RCR and to define what factors affect this time to CSO achievement.

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

Methods: An institutional registry was queried for patients who underwent arthroscopic RCR between 2014 and 2016 and completed preoperative, 6-month, 1-year, and 2-year patient-reported outcome measures (PROMs). Threshold values for MCID, SCB, and PASS were obtained from previous literature for the American Shoulder and Elbow Surgeons score (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant score. The time in which patients achieved MCID, SCB, and PASS was calculated using Kaplan-Meier analysis. A Cox multivariate regression model was used to identify variables correlated with earlier or later achievement of CSOs.

Results: A total of 203 patients with an average age of 56.19 ± 9.96 years and average body mass index was 30.29 ± 6.49 were included. The time of mean achievement of MCID, SCB, and PASS for ASES was 5.77 ± 1.79 months, 6.22 ± 2.85 months, and 7.23 ± 3.81 months, respectively. The time of mean achievement of MCID, SCB, and PASS for SANE was 6.25 ± 2.42 months, 7.05 ± 4.10 months, and 9.26 ± 5.89 months, respectively. The time of mean achievement of MCID, SCB, and PASS for Constant was 6.94 ± 3.85 months, 7.13 ± 4.13 months, and 8.66 ± 5.46 months, respectively. Patients with dominant-sided surgery (hazard ratio [HR], 1.363; 95% CI, 1.065-1.745; = .014) achieved CSOs earlier on ASES, while patients with workers' compensation status (HR, 0.752; 95% CI, 0.592-0.955; = .019), who were current smokers (HR, 0.323; 95% CI, 0.119-0.882; = .028), and with concomitant biceps tenodesis (HR, 0.763; 95% CI, 0.607-0.959; = .021) achieved CSOs on ASES at later timepoints. Patients with distal clavicle excision (HR, 1.484; 95% CI, 1.028-2.143; = .035) achieved CSOs earlier on SANE. Patients with distal clavicle excision (HR, 1.689; 95% CI, 1.183-2.411, = .004) achieved CSOs earlier on Constant, while patients with workers' compensation insurance status (HR, 0.671; 95% CI, 0.506-0.891; = .006) and partial-thickness tears (HR, 0.410; 95% CI, 0.250-0.671; < .001) achieved CSOs later on Constant. Greater preoperative score was associated with delayed achievement of CSOs for ASES, SANE (HR, 0.993; 95% CI, 0.987-0.999; = .020), and Constant (HR, 0.941; 95% CI, 0.928-0.962; < .001).

Conclusion: A majority of patients achieved MCID by 6 months after surgery. Dominant-sided surgery and concomitant distal clavicle excision resulted in faster CSO achievement, while workers' compensation status, concomitant biceps tenodesis, current smoking, partial-thickness rotator cuff tears, and higher preoperative PROMs resulted in delayed CSO achievement.
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December 2020

Return to work following distal triceps repair.

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

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

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

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

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

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

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

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

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

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

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

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

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

Return to Work Following Arthroscopic Meniscal Allograft Transplantation.

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

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

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

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

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

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

Timeline for maximal subjective outcome improvement following total ankle arthroplasty.

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

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

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

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

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

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

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

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

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

Seattle Orthopaedic Center, Seattle, Washington, USA.

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

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

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

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

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

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

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

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

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

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

Return to Sport and Patient Satisfaction After Meniscal Allograft Transplantation.

Arthroscopy 2020 09 7;36(9):2456-2463. Epub 2020 May 7.

Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.; McGaw Northwestern University Medical Center, Chicago, Illinois, U.S.A.; Orthopedic Specialists of Seattle, Seattle, Washington, U.S.A.; Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, California, U.S.A.; University of Illinois College of Medicine, Chicago, Illinois, U.S.A.; Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.. Electronic address:

Purpose: To investigate patient return to sport and satisfaction after meniscal allograft transplantation (MAT).

Methods: Patients undergoing MAT using a bone bridge technique between 2013 and 2015 with minimum 2-year follow-up were retrospectively reviewed. They completed a survey regarding return to sport, satisfaction, and subsequent surgery in addition to patient-reported outcome measures.

Results: Of 117 patients, 87 (74.4%) were available at an average follow-up of 3.64 years (range, 2.01-5.13 years). The mean age at the time of surgery was 28.99 ± 8.26 years. Lateral MAT was performed in 44 cases (50.6%); medial MAT, 42 (48.3%); and combined medial and lateral MAT, 1 (1.1%). Concomitant procedures were performed in 72 patients (82.7%) including cartilage restoration (n = 65, 74.7%), realignment (n = 9, 10.3%), and anterior cruciate ligament reconstruction (n = 9, 10.3%). Patients experienced significant improvement in the Lysholm score (P < .001), International Knee Documentation Committee score (P < .001), Knee Injury and Osteoarthritis Outcome Score (KOOS)-Quality of Life (P < .001), KOOS-Activities of Daily Living (ADL) (P < .001), KOOS-Pain (P < .001), KOOS-Sports (P = .001), KOOS-Symptoms (P = .003), Short Form 12 physical score (P < .001), and Veterans Rand-12 physical score (P < .001). Reoperation was performed in 26 patients (29.9%); failure occurred in 12 patients (13.8%; total knee arthroplasty in 1, unicompartmental arthroplasty in 2, and total meniscectomy in 9). Overall, 77.0% of patients were satisfied with their outcome. Prior to MAT, 82 patients (94.3%) participated in sporting activities; 62 patients (75.6%) returned to at least one sport at 12.58 ± 6.20 months postoperatively, with 30 (48.4%) reaching their preoperative level of intensity and 72 (87.8%) discontinuing at least one of their preoperative sports. The most common reasons for sports discontinuation postoperatively were prevention of further damage (73.6%), pain with activity (51.4%), fear of further injury (48.6%), surgeon recommendation (33.3%), and swelling with activity (30.6%). Patients were satisfied with their sports participation at a rate of 62.1%.

Conclusions: In a complex patient population undergoing arthroscopic MAT, 75.6% of patients were able to return to at least one sport at an average of 12.58 ± 6.20 months postoperatively. The level of sport declined, with 93.5% of patients restricting involvement to recreational sports after MAT and 48.4% returning to their preoperative level of activity intensity. In addition, 87.8% of patients reported discontinuing a sport in which they had participated preoperatively. The most common reasons for decreasing level of sport were prevention of further damage, pain or swelling with sports, and fear of further injury. The reoperation rate after MAT was 29.9%. Most patients were satisfied with the outcome of surgery, with 77.0% satisfied in general and 62.1% satisfied with their ability to play sports.

Level Of Evidence: Level IV, retrospective case series.
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September 2020

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

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

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

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

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

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

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

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

How Is Maximum Outcome Improvement Defined in Patients Undergoing Shoulder Arthroscopy for Rotator Cuff Repair? A 1-Year Follow-Up Study.

Arthroscopy 2020 07 20;36(7):1805-1810. Epub 2020 Mar 20.

Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A.

Purpose: To (1) determine the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley subjective score thresholds for achieving maximal outcome improvement (MOI) after arthroscopic rotator cuff repair and (2) identify preoperative predictors of reaching the ASES threshold for achieving MOI.

Methods: A retrospective cohort study was performed to identify patients undergoing rotator cuff repair at a high-volume institution from January 2014 to January 2017 with a 1-year minimum follow-up. Patient characteristics, as well as preoperative and postoperative outcome scores, were analyzed. MOI for the ASES and SANE score were calculated as previously described, and a receiver operating characteristic (ROC) curve analysis was used to determine thresholds for percentage of maximal improvements for each outcome measure based on a satisfaction anchor question. Last, a logistic regression model was used to identify predictors of reaching the ASES threshold for achieving MOI.

Results: A total of 220 patients were included in the final analysis. There was a statistically significant increase in score average across all 3 outcome measures (P < .001 for all), with 162 (73.6%) patients rating their surgical outcome as satisfactory at 1-year follow-up. The ROC curve analysis demonstrated that ASES, SANE, and Constant-Murley threshold percentages for achieving MOI was 69.5% (area under the curve [AUC], 0.86; 95% confidence interval [CI], 0.81-0.91; P < .001), 75% (AUC, 0.814; 95% CI, 0.758-0.871; P < .001), and 55.1% (AUC, 0.84; 95% CI, 0.783-0.898; P < .001), respectively. Logistic regression demonstrated that workers compensation cases (odds ratio, 0.69; 95% CI, 0.55-0.86; P = .001) and dominant-sided surgery (odds ratio, 0.72; 95% CI, 0.59-0.88; P = .002) were predictors of not achieving maximal improvement on the ASES score.

Conclusion: Achieving 69.5% of maximal ASES score improvement or 75% of maximal SANE score improvement is indicative of achieving patient satisfaction after arthroscopic rotator cuff repair. Preoperative variables including workers compensation cases and surgery to the dominant side were predictors of not achieving maximal improvement.

Level Of Evidence: IV, case series.
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July 2020

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

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

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

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