Publications by authors named "Matthew J Salzler"

44 Publications

Single-Stage Revision Anterior Cruciate Ligament Reconstruction Using the Stacked Screws Technique.

Arthrosc Tech 2022 Jul 21;11(7):e1341-e1345. Epub 2022 Jun 21.

Professor of Orthopaedic Surgery, Tufts University School of Medicine, Boston, Massachusetts.

Single-stage revision anterior cruciate ligament (ACL) reconstruction is preferable to 2-stage revision, when possible, as it avoids an additional surgery and recovery period. Malpositioned and/or widened bone tunnels are a common cause of ACL reconstruction failure and are challenging to manage in revision reconstructions. The "stacked screws construct" fills the previous malpositioned tunnels and bone voids with an oversized biocomposite screw as graft material. The revised tunnel can then be drilled in an anatomic "primary" location, even partially overlapping the filler screw. This technique simplifies tunnel management in revision ACL reconstruction.
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http://dx.doi.org/10.1016/j.eats.2022.03.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9353588PMC
July 2022

Current Status Regarding the Safety of Inpatient Versus Outpatient Total Shoulder Arthroplasty: A Systematic Review.

HSS J 2022 Aug 5;18(3):428-438. Epub 2021 Jul 5.

Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.

Background: Surgeons have begun to transition total shoulder arthroplasty (TSA) to the outpatient setting in order to contain costs and reallocate resources.

Purpose: The purpose of this systematic review was to evaluate the safety and cost of outpatient TSA by assessing associated complication rates, clinical outcomes, and total treatment charges.

Methods: The MEDLINE, Embase, and Cochrane Library online databases were queried in March 2020 for studies on outpatient shoulder arthroplasty. Inclusion criteria were (1) a study population undergoing TSA, (2) discharge on the day of surgery, and (3) inclusion of at least 1 reported outcome.

Results: Of 20 studies identified that met inclusion criteria, 14 were comparative studies involving an inpatient control group, 2 of which were matched by age and comorbidities. The remaining studies used control groups consisting of inpatient TSAs who were older or more medically infirm according to American Society of Anesthesiologists (ASA) or Charlson Comorbidity Index (CCI) scores. The combined average age of the outpatient and inpatient groups was 66.5 and 70.1 years, respectively. Patients who underwent outpatient TSA had similar rates of readmissions, emergency department visits, and perioperative complications in comparison to inpatients. Patients also reported comparably high levels of satisfaction with outpatient procedures. Four economic analyses demonstrated substantial cost savings with outpatient TSA in comparison to inpatient surgery.

Conclusion: In carefully selected patients, outpatient TSA appears to be equally safe but less resource intensive than inpatient arthroplasty. Nonetheless, there remains a need for larger prospective studies to decisively characterize the relative safety of outpatient TSA among patients with similar baseline health.
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http://dx.doi.org/10.1177/15563316211019398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9247601PMC
August 2022

Revision Soft Tissue Allograft Anterior Cruciate Ligament Reconstruction is Associated with Lower Patient Reported Outcomes Compared with Primary Anterior Cruciate Ligament Reconstruction in Patients Aged 40 and Older.

Arthroscopy 2022 Jul 12. Epub 2022 Jul 12.

Tufts Medical Center, Boston, MA;. Electronic address:

Purpose: To evaluate patient reported outcomes (PROs) and graft failure rates in revision allograft anterior cruciate ligament (ACL) reconstruction (ACLR) in patients aged 40 and older and compare them with primary ACLRs.

Methods: Patients aged 40 and older who underwent arthroscopic soft tissue allograft ACLR between 2005 and 2016 with a minimum 2-year follow-up were retrospectively reviewed. Patients were grouped based on revision versus primary ACLR. The rate of achieving an International Knee Documentation Committee (IKDC) patient acceptable symptom state (PASS) score was recorded. Patient satisfaction, PROs, and graft failure were compared between groups using chi-square test, Fisher's exact test, and Mann-Whitney U test.

Results: We identified 32 revision ACLR patients and 201 primary ACLR patients aged 40 and older who met inclusion criteria with a mean follow-up of 6.2 and 6.9 years, respectively (p=0.042). There was a lower rate of concomitant meniscal repair in the primary ACLR group (6% vs. 21.9%, p=0.007) There were no other differences in chondral injuries, mechanism of injury, or meniscal injuries between groups. The median IKDC score was higher in the primary ACLR group as compared to the revision ACLR group (83.9 vs. 70.6, p<0.001). Revision ACLR patients were less likely to achieve the IKDC PASS threshold (82.5% vs. 56.3%, p=0.001) and were less likely to report satisfaction as compared to primary ACLR patients (90.5% vs. 78.1%, p=0.038). No difference in graft failure rates was identified between groups (8% vs. 15.6%, p=0.180).

Conclusion: Revision allograft ACLR in patients aged 40 and older was associated with lower PROs compared with primary ACLR. Patients that underwent revision ACLR failed to meet the IKDC PASS threshold more often and were dissatisfied with procedure results more than twice as often as patients that underwent primary ACLR.

Study Design: Level III, retrospective cohort study.
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http://dx.doi.org/10.1016/j.arthro.2022.06.035DOI Listing
July 2022

Fracture Dislocations of the Proximal Humerus Treated with Open Reduction and Internal Fixation: A Systematic Review.

J Shoulder Elbow Surg 2022 May 20. Epub 2022 May 20.

Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA. Electronic address:

Background: The treatment of proximal humerus fracture-dislocations can be challenging given the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head often seen in these injuries. The purpose of this study is to undertake a systematic review of the literature on the functional outcomes, rate of revision, and short- and long-term complications for proximal humerus fracture-dislocations treated with open reduction and internal fixation (ORIF).

Methods: The PubMed and OVID Embase databases were queried for literature reporting on proximal humerus fracture dislocations treated with ORIF. Data including study design, patient demographics, functional outcomes, and complications were recorded.

Results: Twelve studies including 294 patients with Neer type 2-, 3-, or 4-part proximal humerus fracture-dislocations met the criteria for inclusion. The mean patient age was 53.4 years (19-89 years) with an average follow-up of 2.9 years (1.15-4.9 years). At final follow-up, the mean Constant Score was 73.2 (52 - 87.3) and the mean Disabilities of the Arm Shoulder and Hand (DASH) score was 26.6 (17.5- 32). Avascular necrosis (AVN) was observed in 20.0% (0%-82.3%) and non-union was observed in 3.0% (0% - 7.7%) of patients. Conversion to arthroplasty was observed in 10.7% (5% - 20%) and a total reoperation was observed in 35.6% (11.8%-89.1%) of patients in studies explicitly reporting these outcomes. In addition to conversion to arthroplasty, common causes of reoperation were revision ORIF (5.2%) and hardware removal (22.2%).

Conclusion: Patients undergoing ORIF for proximal humerus fracture-dislocations have reasonable functional outcomes but relatively high AVN and reoperation rates. This information can be used to counsel patients and set expectations about the potential for further surgeries.
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http://dx.doi.org/10.1016/j.jse.2022.04.018DOI Listing
May 2022

Corticosteroid Injections After Rotator Cuff Repair Improve Function, Reduce Pain, and Are Safe: A Systematic Review.

Arthrosc Sports Med Rehabil 2022 Apr 20;4(2):e763-e774. Epub 2021 Dec 20.

Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, U.S.A.

Purpose: To review the literature on postoperative corticosteroid injections (CSIs) following primary rotator cuff repair (RCR) to evaluate efficacy and adverse effects.

Methods: A systematic review of the MEDLINE, EMBASE, and Cochrane databases were performed to identify all studies published within the last 15 years, which reported on outcomes of postoperative CSIs following RCR. Studies including patients who received only preoperative CSIs and revision RCRs were excluded. Included studies were evaluated for study methodology, patient demographics, outcome measures, physical examination parameters, results of imaging studies, and adverse effects or clinical complications.

Results: Seven studies comprising 5,528 patients satisfied inclusion criteria. Among included patients, 54.8% were female and mean age range from 52.3 ± 13.0 to 62.7 ± 6.6 years. Only 1 included investigation was a Level I study. Overall, 4 of 5 studies reported significant improvements in pain and outcome scores (Constant score, American Shoulder and Elbow Surgeons score) compared with controls. Across all studies, the majority of these effects were statistically significant at 3 months postoperatively but not beyond this time point. Five of the 6 included investigations reported no increased rate of retears after postoperative CSIs. One study did find an increase in retear in patients receiving postoperative CSIs but was unable to determine whether these retears were present before the patient received the CSI. Another investigation reported an increased rate of infection only if the CSI was administered in the first postoperative month.

Conclusions: Postoperative CSIs may improve pain and function for up to 3 months following primary RCR but not at later follow-up time points. CSIs should be administered only after the first postoperative month to minimize the potential risk for adverse events.

Level Of Evidence: Systematic review of level I-IV studies.
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http://dx.doi.org/10.1016/j.asmr.2021.10.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9042756PMC
April 2022

Corticosteroid Injections After Rotator Cuff Repair Improve Function, Reduce Pain, and Are Safe: A Systematic Review.

Arthrosc Sports Med Rehabil 2022 Apr 20;4(2):e763-e774. Epub 2021 Dec 20.

Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, U.S.A.

Purpose: To review the literature on postoperative corticosteroid injections (CSIs) following primary rotator cuff repair (RCR) to evaluate efficacy and adverse effects.

Methods: A systematic review of the MEDLINE, EMBASE, and Cochrane databases were performed to identify all studies published within the last 15 years, which reported on outcomes of postoperative CSIs following RCR. Studies including patients who received only preoperative CSIs and revision RCRs were excluded. Included studies were evaluated for study methodology, patient demographics, outcome measures, physical examination parameters, results of imaging studies, and adverse effects or clinical complications.

Results: Seven studies comprising 5,528 patients satisfied inclusion criteria. Among included patients, 54.8% were female and mean age range from 52.3 ± 13.0 to 62.7 ± 6.6 years. Only 1 included investigation was a Level I study. Overall, 4 of 5 studies reported significant improvements in pain and outcome scores (Constant score, American Shoulder and Elbow Surgeons score) compared with controls. Across all studies, the majority of these effects were statistically significant at 3 months postoperatively but not beyond this time point. Five of the 6 included investigations reported no increased rate of retears after postoperative CSIs. One study did find an increase in retear in patients receiving postoperative CSIs but was unable to determine whether these retears were present before the patient received the CSI. Another investigation reported an increased rate of infection only if the CSI was administered in the first postoperative month.

Conclusions: Postoperative CSIs may improve pain and function for up to 3 months following primary RCR but not at later follow-up time points. CSIs should be administered only after the first postoperative month to minimize the potential risk for adverse events.

Level Of Evidence: Systematic review of level I-IV studies.
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http://dx.doi.org/10.1016/j.asmr.2021.10.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9042756PMC
April 2022

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Allograft in Patients Aged 50 and Older Leads to Improved Activity Levels and Acceptable Patient-Reported Outcomes.

Arthrosc Sports Med Rehabil 2021 Dec 14;3(6):e1961-e1965. Epub 2021 Nov 14.

Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, U.S.A.

Purpose: To evaluate patient-reported outcomes in patients aged 50 years and older undergoing anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone (BPTB) allograft with minimum 2-year follow-up.

Methods: A retrospective review was performed on a consecutive series of patients aged 50 and older who underwent ACLR using BPTB allograft by a single surgeon with minimum 2-year follow-up. Postoperative International Knee Documentation Committee (IKDC), Lysholm, and Physical Component Summary of the 12-item Short-Form Health Survey were used to assess outcomes, as well as preoperative and postoperative Tegner activity scores, which were compared using a paired sample test.

Results: Fifty patients met inclusion criteria, with a mean age of 55.3 ± 4.4 years and mean follow-up of 4.8 ± 1.9 years. Tegner activity scores improved from a mean preoperative score of 3.26 to a mean postoperative score of 5.25 ( < .001). The mean postoperative scores for Lysholm, IKDC, and Physical Component Summary were 87.3, 81.1, and 54.3, respectively. In total, 36 (72%) patients achieved a patient acceptable symptom state score for IKDC and 37 (74%) patients achieved a minimal clinically important difference for Tegner activity score. Thirty-eight (76%) patients reported good-to-excellent results, 6 (12%) patients reported fair results, and 6 (12%) patients reported poor results.

Conclusions: ACLR with BPTB allograft in patients aged 50 and older leads to good patient-reported outcomes with significantly increased postoperative activity status at a minimum 2-year follow-up.

Level Of Evidence: Level IV, therapeutic case series.
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http://dx.doi.org/10.1016/j.asmr.2021.09.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8689261PMC
December 2021

The Majority of Patients Aged 40 and Older Having Allograft Anterior Cruciate Ligament Reconstruction Achieve a Patient Acceptable Symptomatic State.

Arthroscopy 2022 05 1;38(5):1537-1543. Epub 2021 Oct 1.

Tufts Medical Center, Boston, Massachusetts, U.S.A.

Purpose: To evaluate patient satisfaction, retear rates, and patient-reported outcomes (PROs) in patients aged 40 and older undergoing allograft anterior cruciate ligament reconstruction (ACLR). The secondary goal was to compare these parameters between groups of patients with intact versus failed grafts, and to evaluate these in relation to a historically reported International Knee Documentation Committee (IKDC) patient-acceptable symptoms state (PASS) score.

Methods: Records of patients aged 40 and older who underwent ACLR between 2005 and 2016 at a single institution with a minimum 2-year follow-up were retrospectively reviewed. Patient-reported satisfaction, outcome scores, and failure rates were analyzed. The rate of achieving a previously defined IKDC PASS score based on younger cohorts was reported, and an updated PASS threshold for older patients was calculated.

Results: 201 patients were included with a mean age of 48.6 years (range: 40-68) and mean follow-up of 6.2 years (range: 2.8-11.2). 182 (90.5%) patients reported satisfaction following surgery. 16 (8.0%) patients experienced failure of their ACLR, 10 of which underwent revision ACLR. The median IKDC score in the intact ACLR group was 86.2, compared to 66.7 in the failure group (P < .001). In total, 134 (72.4%) patients in the intact group achieved the historical PASS score of 75.9 on IKDC compared to only 4 (25%) in the failure group (χ = 15.396, P < .001). An updated IKDC PASS threshold for older cohorts was calculated to be 66.7.

Conclusion: Patients aged 40 and older who underwent allograft ACLR had an 8.0% failure rate at a mean follow-up of 6 years. Graft failure in patients aged 40 and older was associated with worse PROs. The majority of patients achieved the historically reported IKDC PASS threshold. Additionally, an updated age-appropriate IKDC PASS score of 66.7 was calculated to aid in future ACLR studies assessing older patients.

Study Design: Level IV.
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http://dx.doi.org/10.1016/j.arthro.2021.09.024DOI Listing
May 2022

Patient Perceptions of Telehealth Orthopedic Services in the Era of COVID-19 and Beyond.

Orthopedics 2021 Sep-Oct;44(5):e668-e674. Epub 2021 Sep 1.

The coronavirus disease 2019 (COVID-19) pandemic necessitated an unprecedented increase in the use of telehealth services in orthopedics. Patient attitudes toward and satisfaction with virtual orthopedic services remain largely unexplored. A prospective study of all orthopedic patients at a tertiary academic medical center who had a telehealth appointment between April 1, 2020, and May 5, 2020, was performed to assess patients' experience with a validated 21-item telehealth satisfaction questionnaire. The survey contained statements designed to assess patients' level of agreement with numerous aspects of telehealth, including convenience, the surgeon's ability to engage in care, ease of use, and future use of telehealth. Most respondents (86.7%) were satisfied with the telehealth system. The majority of patients expressed that the system is easy to use (90.0%), is convenient (86.7%), and saves them time (83.3%). Nearly all (95%) patients agreed that their surgeon could answer their questions with the use of this technology, although nearly half (46.6%) identified the lack of physical contact during the examination as problematic. Only 46.7% of patients agreed that telehealth should be a standard form of health care delivery in the future; these patients were found to have significantly longer commute times compared with those who did not (52.1±58.2 vs 28.3±19.2, =.03). Patient perspectives on the widespread adoption of telehealth, such as ease of use, privacy protection, and convenience, showed that these anticipated barriers may be some of the greatest advantages of telehealth. The COVID-19 pandemic may have provided the momentum for telehealth to become a mainstay of orthopedic health care delivery in the future. [. 2021;44(5):e668-e674.].
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http://dx.doi.org/10.3928/01477447-20210817-07DOI Listing
October 2021

Predictors of Inpatient Morbidity and Mortality After 1- and 2-Level Anterior Cervical Diskectomy and Fusion Based on the National Inpatient Sample Database From 2006 Through 2010.

Orthopedics 2021 Sep-Oct;44(5):e675-e681. Epub 2021 Sep 1.

Spine procedures, including anterior cervical diskectomy and fusion (ACDF), are more commonly being performed in an outpatient setting to maximize value. Early complications after ACDF are rare but can have devastating consequences. The authors sought to determine risk factors for inpatient complications after 1-and 2-level ACDF by performing a retrospective review of the National Inpatient Sample (NIS) administrative database from 2006 through 2010. A total of 78,771 patients were identified. Multivariate logistic regression analysis was performed to identify preoperative risk factors for medical and surgical complications, including mortality, airway compromise, new neurologic deficit, and surgical-site infection. Inpatient mortality and overall complication rates were 0.074% and 3.73%, respectively. The risk of any medical complication was 3.13%. Airway compromise, neurologic deficit, and surgical-site infection occurred in 0.75%, 0.05%, and 0.04% of cases, respectively. Chronic kidney disease was the strongest predictor of mortality, with an odds ratio (OR) of 11.14 (<.001). Airway complication was associated with age older than 65 years, male sex, myelopathy, diabetes mellitus, anemia, bleeding disorder, chronic obstructive pulmonary disease, obesity, and obstructive sleep apnea (<.05). Preoperative diagnosis of myelopathy was most strongly associated with an increased rate of neurologic complication (OR, 6.67; <.001). Anemia was associated with a significantly increased rate of surgical-site infection, with an OR of 14.34 (<.001). Age older than 65 years; certain medical comorbidities, particularly kidney disease and anemia; and a preoperative diagnosis of myelopathy are associated with increased risk of early complication following ACDF surgery. Surgeons should consider these risk factors when deciding to perform ACDF surgery in an outpatient setting. [. 2021;44(5):e675-e681.].
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http://dx.doi.org/10.3928/01477447-20210817-08DOI Listing
October 2021

Early sports specialisation and the incidence of lower extremity injuries in youth athletes: current concepts.

J ISAKOS 2021 11 6;6(6):339-343. Epub 2021 Jul 6.

Orthopedics, Tufts University School of Medicine, Boston, Massachusetts, USA

Year-round intensive, single-sport training beginning at an young age is an increasingly common trend in the youth athlete population. Early sport specialisation may be ineffective for long-term athletic success and contribute to an increased risk of physical injury and burn-out. The medical community has noted that repetitive movement patterns may occur in non-diversified activity and this may contribute to overuse injury in young athletes. Studies have begun to identify an association between early sport specialisation and lower extremity injuries in the youth athlete population that is independent of training volume. Recent literature has suggested that sport diversification, not specialisation, is a better path for athletic success and minimised lower extremity injury risk.
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http://dx.doi.org/10.1136/jisakos-2019-000288DOI Listing
November 2021

Public Opinion and Expectations of Stem Cell Therapies in Orthopaedics.

Arthroscopy 2021 12 12;37(12):3510-3517.e2. Epub 2021 Jun 12.

Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, U.S.A.. Electronic address:

Purpose: To explore public opinion, understanding, and preferences regarding the use of stem cell therapies for the treatment of joint and tendon pathologies using online crowdsourcing.

Methods: A 30-question survey was completed by 931 members of the public using Amazon Mechanical Turk, a validated crowdsourcing method. Outcomes included perceptions and preferences regarding the use of stem cells therapies for the nonsurgical treatment of orthopaedic conditions. Sociodemographic factors and a validated assessment of health literacy were collected. Inclusion criteria were adult participants 18 years or older, residence within the United States, and a valid Social Security number. Multivariable logistic regression modeling was used to determine population characteristics associated with the belief that stem cells represent the most effective treatment for long-standing joint or tendon disorders.

Results: Most respondents reported that stem cell therapies have convincing evidence to support their use for orthopaedic conditions (84.5%) and are approved and regulated by the Food and Drug Administration (65%). About three-quarters of respondents reported that stem cells can stop the progression of and alleviate pain from arthritis or damaged tendons, and over half (53.5%) reported that stem cells can cure arthritis. Factors with the greatest influence on respondents' decision to receive stem cell therapies are research supporting their safety and effectiveness and doctor recommendation. However, 63.3% of respondents stated that they would consider stem cells if their doctor recommended it, regardless of evidence supporting their effectiveness, and over half would seek another doctor if their orthopaedic surgeon did not offer this treatment option.

Conclusions: The public's limited understanding regarding the current evidence associated with stem cell therapies for osteoarthritis and tendinous pathologies may contribute to unrealistic expectations and misinformed decisions. This study highlights the importance of patient education and expectation setting, as well as evidence transparency, as stem cell therapies become increasingly accessible.

Level Of Evidence: Level IV, case series.
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http://dx.doi.org/10.1016/j.arthro.2021.05.058DOI Listing
December 2021

Stacked Biocomposite Screws in a Single-Stage Revision Anterior Cruciate Ligament Reconstruction Has Acceptable Fixation Strength in a Porcine Cadaveric Model.

Am J Sports Med 2021 07 28;49(8):2144-2149. Epub 2021 May 28.

Tufts University School of Medicine, Steward Healthcare System, and Boston Sports Medicine, Boston, Massachusetts, USA.

Background: Stacked screws is a commonly used technique in single-stage revision anterior cruciate ligament (ACL) reconstruction in the setting of bone loss, but there are limited data to support its use.

Hypothesis: Two configurations of a biocomposite stacked screws construct have similar fixation strength and linear stiffness as a primary ACL reconstruction construct in a biomechanical model.

Study Design: Controlled laboratory study.

Methods: A total of 30 porcine legs were divided into 3 groups. Group 1 underwent primary ACL reconstruction with a patellar tendon graft fixed into the femur, with an 8-mm biocomposite interference screw of beta-tricalcium phosphate and poly lactide-co-glycolide. For a revision ACL reconstruction model, groups 2 and 3 had bone tunnels created and subsequently filled with 12-mm biocomposite screws. New bone tunnels were drilled through the filler screw and the surrounding bone, and the patellar bone plug was inserted. Group 2 was fixed with 8-mm biocomposite screws on the side of the graft opposite the filler screw, while group 3 had the interference screw interposed between the graft and the filler screw. The construct was loaded at 1.5 mm/s in line with the tunnel until failure. Load to failure, linear stiffness, and mode of failure were recorded.

Results: The mean pullout strength for groups 1, 2, and 3 was 626 ± 145 N, 653 ± 152 N, and 720 ± 125 N, respectively ( = .328). The mean linear stiffness of the construct in groups 1, 2, and 3 was 71.4 ± 9.9 N/mm, 84.1 ± 11.1 N/mm, and 82.0 ± 10.8 N/mm, respectively. Group 2 was significantly stiffer than group 1 ( = .037).

Conclusion: Two configurations of a biocomposite stacked screws construct for a single-stage revision ACL reconstruction in the setting of bone loss show a similar fixation strength and linear stiffness to a primary ACL reconstruction at time zero in a porcine model.

Clinical Relevance: In the setting of bone loss from tunnel malpositioning, a single-stage revision ACL reconstruction using a stacked screws construct may provide adequate fixation strength and linear stiffness.
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http://dx.doi.org/10.1177/03635465211015192DOI Listing
July 2021

Pre-Operative Femoral Cartilage Ultrasound Characteristics Are Altered in People Who Report Symptoms at 1 year After Anterior Cruciate Ligament Reconstruction.

Ultrasound Med Biol 2021 07 27;47(7):1976-1984. Epub 2021 Apr 27.

Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA.

We assessed whether pre-operative femoral cartilage thickness and echo intensity on ultrasound are different between individuals who are symptomatic (n = 6) and asymptomatic (n = 7) at 1 year after a primary unilateral anterior cruciate ligament (ACL) reconstruction (age, 23 ± 4 y; 31% women, 69% men; body mass index, 24.9 ± 3.7 kg/m). A pre-operative, bilateral ultrasound assessment was used to quantify average thickness and echo intensity in the medial, middle and lateral femoral trochlear regions. An inter-limb ratio (ACL/contralateral limb) was calculated for average thickness and echo intensity. At 1 y after ACL reconstruction, we operationally defined the presence of symptoms as scoring ≤85% on at least two Knee Injury and Osteoarthritis Outcome Score subscales. Independent-sample t-tests and Cohen's d effect sizes were used to compare ultrasound pre-operative inter-limb ratios between participants with and without symptoms at 1 y after ACL reconstruction. For medial femoral cartilage, symptomatic participants had significantly greater average cartilage thickness inter-limb ratios (p = 0.01, d = -1.65) and significantly lower echo intensity inter-limb ratios (p = 0.01, d = 1.72) compared with asymptomatic participants. Middle and lateral femoral cartilage average thickness and echo intensity were not different between symptomatic and asymptomatic participants. These findings provide preliminary evidence that a clinically feasible ultrasound assessment of the femoral trochlear cartilage may be prognostic of self-reported symptoms at 1 y after ACL reconstruction.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2021.03.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169620PMC
July 2021

Vancomycin Presoaking of Anterior Cruciate Ligament Tendon Grafts Is Highly Cost-Effective for Preventing Infection.

Arthroscopy 2021 10 19;37(10):3152-3156. Epub 2021 Apr 19.

Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, Massachusetts, U.S.A.. Electronic address:

Purpose: This study aimed to (1) determine whether intraoperative graft soaking with vancomycin is a cost-effective measure for preventing infection after arthroscopic anterior cruciate ligament (ACL) reconstruction and (2) provide an adaptable model for providers and institutions to determine the cost effectiveness of this strategy over a range of initial infection rates, infection-related care costs, and vancomycin costs.

Methods: Baseline postoperative infection rates and the costs of antibiotics and infection-related care were gathered from the literature. The cost of treating infection was determined for 2 alternative protocols-irrigation and debridement with revision ACL reconstruction or ACL graft retention. Using a break-even economic analysis, we developed an equation to determine the absolute risk reduction (ARR) in infection rate required for the use of vancomycin graft soaking to be deemed cost-effective. To provide a widely applicable robust model, multiple simulations were performed at varying unit costs, infection rates, and ACL reconstruction postoperative infection related care costs. The number needed to treat was calculated from the ARR.

Results: Intraoperative vancomycin was determined to be cost-effective if it prevents 1 infection in 550 cases (ARR = 0.182%), given costs of $24,178 and $44/1,000 mg for revision ACL reconstruction and vancomycin, respectively. If the ACL graft is retained following infection, intraoperative vancomycin was considered cost-effective if it prevents 1 infection in 146 cases (ARR = 0.685%), given costs of $6,424 and $44/1,000 mg for arthroscopic debridement and vancomycin prophylaxis, respectively. For any specific cost of treating infection and cost of vancomycin, variation in baseline infection rates did not influence the economic viability of vancomycin graft soaking. This intervention remained economically viable over a wide range of unit costs of vancomycin.

Conclusions: Through break-even economic analysis, this study demonstrates that the use of intraoperative graft preparation with vancomycin is a highly cost-effective prophylactic measure for infection prevention in arthroscopic ACL reconstruction.

Level Of Evidence: IV, economic analysis.
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http://dx.doi.org/10.1016/j.arthro.2021.04.005DOI Listing
October 2021

Public perceptions and disparities in access to telehealth orthopaedic services in the COVID-19 era.

J Natl Med Assoc 2021 Aug 2;113(4):405-413. Epub 2021 Apr 2.

Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, Boston, MA, USA; New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA, USA. Electronic address:

Background: We used online crowdsourcing to explore public perceptions and attitudes towards virtual orthopaedic care, and to identify factors associated with perceived difficulty navigating telehealth services during the COVID-19 pandemic.

Methods: A modified version of the validated Telemedicine Satisfaction and Usefulness Questionnaire was completed by 816 individuals using crowd-sourcing methods. Multivariable logistic regression modelling was used to determine population characteristics associated with perceived difficulty using telehealth technology.

Results: Most respondents (85%) believed that telehealth visits would be a convenient form of healthcare delivery, and 64% would prefer them over in-person office visits. The majority (92%) agreed that telehealth would save them time, but 81% had concerns regarding the lack of physical contact during a musculoskeletal examination. More respondents would feel comfortable using telehealth for routine follow-up care (81%) compared to initial assessment visits (59%) and first postoperative appointments (60%). Roughly 1 in 15 (7%) expressed difficulty with using telehealth; these respondents were more often unmarried, lower-income, and more medically infirm, and reported greater symptoms of depression. After multivariable adjustment, lower income and poor health were retained as predictors of difficulty with navigating telehealth technology (p = 0.027,p = 0.036, respectively).

Conclusion: The majority of the public appears receptive to telehealth for orthopaedic care for both new patient visits and follow-up appointments. The finding that people with multiple chronic conditions and psychosocial needs struggle to engage with telehealth suggests that those who arguably stand to benefit the most from continued care are the ones being unintentionally left out of this digitization boom.
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http://dx.doi.org/10.1016/j.jnma.2021.02.007DOI Listing
August 2021

Patient-Reported Outcomes After Multiple-Revision ACL Reconstruction: Good but Not Great.

Arthrosc Sports Med Rehabil 2020 Oct 2;2(5):e539-e546. Epub 2020 Sep 2.

Boston Sports Medicine, Dedham, Massachusetts, U.S.A.

Purpose: To evaluate the patient-reported and objective functional outcomes of patients undergoing multiple-revision anterior cruciate ligament (ACL) reconstruction surgery. The secondary purpose was to determine failure rates and factors associated with failure, with a focus on posterior tibial slope.

Methods: All patients who underwent a repeat revision ACL reconstruction with a single surgeon over a 13-year period were identified. Chart data were obtained, including radiographic findings, operative details and findings, and postoperative examination findings. Failure was defined as subjective instability with evidence of graft incompetence on physical examination and MRI. Patients completed the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF) and Tegner Activity Level Scale. Patients who had outcomes scores completed a minimum of 2 years postoperatively were included.

Results: Fourteen patients were available for follow-up; 12 underwent secondary revision procedures, and 2 underwent tertiary revisions. Three patients (21%) had subsequent failure of the revision graft with mean time to failure of 27 months. Posterior tibial slope was significantly higher in the failures than in the nonfailures (13.3˚; 95% CI 10.1-16.6 versus 10.1˚; 95% CI 6.7-11.4;  = 0.049). Eleven patients completed outcomes measures at a mean of 42 months postoperatively (range 24-79 months). The mean Tegner activity score was 6.3 at follow-up, compared with 8.3 prior to the original ACL injury. The mean IKDC-SKF score was 70 at follow-up.

Conclusion: Multiple revision ACL reconstruction surgery appears to have reasonable functional outcomes but is associated with a relatively high failure rate. Activity level following repeat revision surgery is diminished compared to the preinjury state, but most patients are able to return to recreational sports.

Level Of Evidence: Therapeutic Study, Level IV.
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http://dx.doi.org/10.1016/j.asmr.2020.06.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588625PMC
October 2020

Femoral Cartilage Ultrasound Echo Intensity Associates with Arthroscopic Cartilage Damage.

Ultrasound Med Biol 2021 01 17;47(1):43-50. Epub 2020 Oct 17.

Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA.

This study compared quantitative cartilage ultrasound metrics between people with (n = 12) and without (n = 12) arthroscopic cartilage damage after anterior cruciate ligament injury (age, 24.9 ± 3.7 y; sex, 33% female, 67% male; days since injury = 50 ± 52). A transverse suprapatellar ultrasound assessment imaged the femoral cartilage in participants' injured knees before a clinical arthroscopy. A custom program automatically separated a manual cartilage segmentation into standardized medial and lateral femoral regions and calculated mean thickness (i.e., cross-sectional area/length of cartilage-bone interface), mean echo intensity and echo-intensity heterogeneity. An orthopedic surgeon assessed arthroscopic cartilage damage in the medial and lateral femoral condyles using the Outerbridge grading system (cartilage damage = Outerbridge ≥ 1). Separate logistic regressions for medial and lateral femoral cartilage were used to determine the association between each ultrasound metric and arthroscopic cartilage damage. In medial femoral cartilage, for every 1 standard deviation decrease in echo-intensity mean and heterogeneity, there is, respectively, a 91% (adjusted odds ratio, 0.09; 95% confidence interval, 0.01-0.69) and 97% (adjusted odds ratio, 0.03; 95% confidence interval, 0.002-0.50) increase in the odds of having arthroscopic cartilage damage. Lateral cartilage ultrasound metrics are not associated with lateral arthroscopic cartilage damage. This study provides preliminary evidence that femoral cartilage ultrasound echo intensity is a non-invasive measure associated with medial femoral cartilage health after anterior cruciate ligament injury.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2020.09.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568485PMC
January 2021

Patient-reported outcomes of meniscal repair and meniscectomy in patients 40 years of age and older show similar good results.

Knee Surg Sports Traumatol Arthrosc 2021 Sep 6;29(9):2911-2917. Epub 2020 Oct 6.

Department of Orthopaedics, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA.

The purpose of this study is to evaluate patient-reported outcome measures (PROMs) in patients aged 40 years and older who underwent meniscal repair or meniscectomy. All patients aged 40 and older who underwent a meniscal repair at a single institution from 2006 to 2017 were included. Meniscal repair cases were matched with a meniscectomy control group in a 1:3 ratio, selected for an equal proportion of concomitant ACL reconstruction in each group. PROMs, collected at a minimum follow-up of 24 months, included International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), Marx activity scale, and a patient satisfaction scale. The primary outcome was IKDC score, which was compared between groups using a Mann-Whitney U test. Rate of failure, defined as repeat ipsilateral knee surgery or surgeon report of failure, was reported. Thirty-five meniscal repair patients and 131 meniscectomy patients were identified; 28 (80.0%) and 67 (51.1%) completed all PROMs with mean follow-up of 4.9 and 5.2 years, respectively. The mean age was 48.5 ± 7.0 years in the meniscal repair cohort and 52.8 ± 7.1 years in the meniscectomy cohort (p = 0.009). Concomitant ACL reconstruction was present in 46.4% and 49.3% of the meniscal repair and meniscectomy cohorts, respectively (n.s.). The median IKDC score was 78 (IQR 66, 87) in the repair cohort and 77 (IQR 56, 86) in the meniscectomy cohort (n.s.). The median Marx activity scale was 3.5 (IQR 0, 8) in the repair cohort and 3.0 (IQR 0, 9) in the meniscectomy cohort (n.s.). Over 85% of both groups were satisfied or very satisfied with no between-group differences (n.s.). In patients aged 40 years and older, patient-reported outcomes at an average of 5 years postoperatively were satisfactory and similar in patients undergoing meniscal repair and meniscectomy, indicating that age alone should not be a contraindication to meniscal repair.Level of evidence: Level III.
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http://dx.doi.org/10.1007/s00167-020-06299-5DOI Listing
September 2021

The Role of High School Football Coverage in Resident Education.

Orthopedics 2020 Nov 3;43(6):e574-e578. Epub 2020 Sep 3.

Athletic team coverage experience varies widely across orthopedic surgery residency programs in the United States. There is a paucity of literature regarding whether serving as a team physician contributes to resident education and whether it can be performed within the bounds of current work-hour restrictions. Residents consider coverage of high school football games a valuable educational experience that does not adversely affect their 80-hour work week. Sixty-one orthopedic residents who served as high school football team physicians as part of their residency curriculum completed an 11-question survey. Responses ranged from strongly agree (1) to strongly disagree (5) on a Likert scale. The majority of residents agreed that serving as a team physician was an overall valuable experience (85%), that it enhanced their orthopedic sports medicine education (89%), and that it increased their awareness of the role played by athletic trainers (97%). The majority of respondents disagreed only with the statement that serving as a team physician had negatively affected their 80-hour work week (54%), and an additional 26% neither agreed nor disagreed. The vast majority of participating orthopedic residents consider high school football team coverage a valuable experience that enhances education and can be performed within work-hour limitations. [Orthopedics. 2020;43(6):e574-e578.].
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http://dx.doi.org/10.3928/01477447-20200827-08DOI Listing
November 2020

External Fixation Devices Within the Magnetic Resonance Imaging Bore: A Safety and Radiologic Analysis.

J Orthop Trauma 2021 01;35(1):e25-e30

Department of Orthopaedic Surgery, Lahey Hospital & Medical Center, Burlington, MA.

Objectives: To (1) report the thermal changes encountered at the pin/skin interface in a cadaver with a knee-spanning external fixator inside the magnetic resonance imaging (MRI) bore and (2) report on the quality of the MRI sequences collected.

Methods: Three commonly used external fixation systems were placed on cadaveric lower extremities to simulate knee external fixation. Fiber optic thermal probes were placed at the pin/skin interface of a femoral and tibial pin. A control probe was embedded in the soft tissues of the thigh. Full knee MRI scans were performed using a 1.5-Tesla magnet. Real-time thermal data were collected. A clinically significant increase in temperature compared with the control was defined as 2°C. Two blinded radiologists evaluated the images for image quality and overall diagnostic utility using a standardized 5-point grading scale.

Results: There were statistically significant differences in the temperature changes between the femoral/tibial pin sites and the control probe sites during each phase of the MRI scan. However, there was only one clinically significant difference in temperature change during a single sequence of one MRI scan of one of the external fixator devices. Overall image quality was graded as a 4 for each image set with 100% interobserver agreement (k = 1.0).

Conclusions: Despite significant differences in temperature changes between the pin sites and controls over multiple MRI sequences in commonly used external fixator devices, the differences in temperature change are likely not clinically relevant. Overall image quality and interpretability of the images were excellent.
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http://dx.doi.org/10.1097/BOT.0000000000001848DOI Listing
January 2021

Adverse Impact of Corticosteroids on Rotator Cuff Tendon Health and Repair: A Systematic Review of Basic Science Studies.

Arthrosc Sports Med Rehabil 2020 Apr 8;2(2):e161-e169. Epub 2020 Apr 8.

Tufts Medical Center, Boston, Massachusetts, U.S.A.

Purpose: To evaluate the in vitro effects of corticosteroid injections (CSIs) on rotator cuff tendon (RCT).

Methods: A systematic review of the MEDLINE database was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for all studies reporting on adverse biochemical and biomechanical effects of CSIs on RCT.

Results: Sixteen studies were identified that had been published in the last 15 years on the effects of corticosteroids on RCTs. Eight of these studies were on human RCTs, 6 were on rat tendons, 1 considered both human and rat tendons, and 1 was on dog tendon. Five studies analyzed the effects of corticosteroids on the biomechanical properties of RCT or rotator cuff repair, whereas the remaining observed the cellular and molecular effects of CSIs on RCT. Corticosteroids suppress an inflammatory response, induce apoptosis, and have negative effects on collagen and tendon cell viability in RCTs. The mechanical properties, including load to failure of RCTs and rotator cuff repair anchor pull-out strength, also are decreased by CSIs. These in vitro effects appear to be transient as well as frequency and dose dependent.

Conclusions: On a molecular level, CSIs decrease cellular proliferation, alter collagen and extracellular matrix composition, impede inflammatory pathways, decrease cellular viability, increase adipocyte differentiation, and increase apoptosis. These changes can be seen as early as 24 hours after corticosteroid exposure, last as long as 2 to 3 weeks, and are exacerbated by increased doses and decreased latency between doses. Biomechanical studies demonstrate that these changes result in decreased maximal load to failure, tendon stiffness, and suture anchor pull-out strength in rat shoulders up to 2 weeks but not at 3 and 4 weeks, post-CSI.

Clinical Relevance: Shoulder subacromial steroid injection is common, and practitioners should be aware of results both positive and deleterious.
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http://dx.doi.org/10.1016/j.asmr.2020.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7190543PMC
April 2020

Hospital Stays and Medical Expenses Increase Nationwide Among Patients With Septic Arthritis of the Shoulder Who Inject Drugs.

Orthopedics 2020 Jul 23;43(4):e270-e277. Epub 2020 Apr 23.

The authors determined the proportion of patients nationwide with septic arthritis of the shoulder who inject drugs, evaluated differences in hospitalization outcomes and charges between patients with and without injection drug use (IDU), and quantified demographic trends among patients with IDU from 2000 to 2013. Nationally representative data of patients with a principal discharge diagnosis of shoulder septic arthritis were obtained from the Nationwide Inpatient Sample 2000-2013. Using published algorithms, the authors classified septic arthritis of the shoulder as related or unrelated to IDU. They compared length of stay, leaving against medical advice, number of procedures, and mortality rates between the 2 groups, using regression models to control for age, sex, and race. Fifteen percent (95% confidence interval [CI], 13.6%-16.5%) of septic arthritis cases were associated with IDU. From 2000 to 2013, shoulder septic arthritis associated with IDU increased 4-fold. After controlling for age, sex, and race, individuals who inject drugs stayed in the hospital for 3.7 more days (95% CI, 2.4-5.0), incurred an average of $13,250 more charges for medical care (95% CI, $2635-$23,866), and were 5.54 times more likely (95% CI, 3.22-9.55) to leave against medical advice than those without IDU. From 2000 to 2013, there was an increase in the proportion of patients with IDU-related septic arthritis of the shoulder between 35 and 54 years old and 55 and 64 years old, and an increase in the proportion who were white. Injection drug use-related shoulder septic arthritis is linked to suboptimal inpatient outcomes and greater resource use. [Orthopedics. 2020;43(4):e270-e277.].
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http://dx.doi.org/10.3928/01477447-20200415-03DOI Listing
July 2020

Injection Drug Use in Patients With Spinal Epidural Abscess: Nationwide Data, 2000 to 2013.

Spine (Phila Pa 1976) 2020 Jun;45(12):843-850

Department of Orthopaedics, Tufts Medical Center, Boston, MA.

Study Design: Retrospective review of the Healthcare Cost and Utilization Project National Inpatient Sample, 2000 to 2013.

Objective: To determine the proportion of spinal epidural abscess (SEA) cases that were related to injection drug use (IDU) and to compare length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between SEA cases with and without IDU.

Summary Of Background Data: The US opioid epidemic impacts all aspects of healthcare, including spinal surgeons. Although injection drug use (IDU) is a risk factor for spinal epidural abscess (SEA), IDU among SEA patients and its effect on clinical outcomes is not well understood.

Methods: Cases aged 15 to 64 with principal diagnosis of SEA were classified as IDU-related (IDU-SEA) or non-IDU-related (non-IDU-SEA) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for illicit drug use and hepatitis C. We determined the proportion of SEA patients with IDU and compared length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between IDU-SEA and non-IDU-SEA patients.

Results: From 2000 to 2013, there were 20,425 admissions with a principal diagnosis of SEA (95% confidence interval (CI), 19,281-21,568); 19.1% were associated with IDU (95% CI, 17.7%-20.5%). The proportion of white IDU-SEA cases increased by 2.4 percentage points annually (95% CI, 1.4-3.4). After adjusting for age, sex, and race, IDU-SEA patients stayed a mean of 6.7 more days in the hospital (95% CI, 5.1-8.2) and were 4.8 times more likely to leave against medical advice (95% CI, 2.9-8.0). Mean hospital charges for IDU-SEA patients were $31,603 higher (95% CI: $20,721-$42,485). Patients with IDU-SEA were less likely to have cauda equina syndrome (adjusted odds ratio, 0.48, 95% CI, 0.26-0.87).

Conclusion: IDU-SEA patients stay in the hospital longer and more often leave against medical advice. Providers and hospitals may benefit from exploring how to better facilitate completion of inpatient treatment and achieve superior outcomes.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003401DOI Listing
June 2020

Comparing Reported Complication Rates in Shoulder Arthroplasty Between 2 Large Databases.

Orthopedics 2020 Mar 13;43(2):113-118. Epub 2020 Jan 13.

Large databases are commonly used to analyze surgical outcomes. Recent studies have suggested that there are differences in complication rates between databases across certain procedures, but the reasons for these differences are not fully understood. The goal of this study was to compare complications of shoulder arthroplasty across databases as well as to interpret the causes of any differences. The authors compared complication rates for shoulder arthroplasty as reported by the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2006 to 2010. The authors then restricted NIS data solely to hospitals that also contributed to NSQIP to provide a more direct comparison of the patient populations. The authors identified 48,287 discharges reported in NIS and 1679 discharges reported in NSQIP for patients who underwent shoulder arthroplasty. The complication rate for shoulder arthroplasty was significantly higher in the NIS population (12.6%; 95% confidence interval, 12.0%-13.2%) than in the NSQIP population (5.60%; 95% confidence interval, 4.59%-6.81%). When NIS data were restricted solely to hospitals that also participated in NSQIP, the rate of complications remained higher, at 13.4% (95% confidence interval, 11.2%-15.8%), and the rate increased relative to the nonrestricted data. The databases compared in this study had statistically significant differences in reported complication rates for shoulder arthroplasty. This difference persisted when NIS data were restricted to hospitals that also participated in NSQIP, suggesting that differences in database design contribute to important differences in data. Orthopedic surgeons and administrators must use caution when using complication rates derived from large database studies. [Orthopedics. 2020;43(2):113-118.].
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http://dx.doi.org/10.3928/01477447-20200107-05DOI Listing
March 2020

Biomechanics Following Isolated Posterolateral Corner Reconstruction Comparing a Fibular-Based Docking Technique With a Tibia and Fibular-Based Anatomic Technique Show Either Technique is Acceptable.

Arthroscopy 2020 05 17;36(5):1376-1385. Epub 2019 Dec 17.

Boston Sports Medicine, Dedham, Massachusetts, United States of America.

Purpose: To analyze the biomechanical integrity of 2 posterolateral corner (PLC) reconstruction techniques using a sophisticated robotic biomechanical system that enables analysis of joint kinematics under dynamic external loads.

Methods: Eight cadaveric human knee specimens were tested. Five N·m external torque followed by 5 N·m varus torque was dynamically applied to each specimen. The 6 degrees of freedom kinematics of the joint were measured in 4 states (intact, PLC-deficient, fibular-based docking, and anatomic PLC reconstructed) at 30°, 60°, and 90° of flexion. Tibial external rotation (ER) and varus rotation (VR) were compared.

Results: Under external torque, ER significantly increased from the intact state to the PLC-deficient state across all flexion angles. At 30° of flexion, ER was not significantly different between the intact state (19.9°) and fibular-based (18.7°, P = .336) and anatomic reconstructions (14.9°, P = .0977). At 60°, ER was not significantly different between the intact state and fibular-based reconstruction (22.4°, compared with 19.8° in intact; P = .152) but showed overconstraint after anatomic reconstruction (15.7°; P = .0315). At 90°, ER was not significantly different between the intact state and anatomic reconstruction (15.4°, compared with 19.7° in intact; P = .386) but was with the fibular-based technique (23.5°; P = .0125).

Conclusion: Both a fibular-based docking technique and an anatomic technique for isolated PLC reconstruction provided appropriate constraint through most tested knee range of motion, yet the fibular-based docking technique underconstrained the knee at 90°, and the anatomic reconstruction overconstrained the knee at 60°. Biomechanically, either technique may be considered for surgical treatment of high-grade isolated PLC injuries.

Clinical Relevance: This biomechanical study utilizing clinically-relevant dynamic forces on the knee shows that either a simplified fibular-based docking technique or a more complex anatomic technique may be considered for surgical treatment of high-grade isolated PLC injuries.
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http://dx.doi.org/10.1016/j.arthro.2019.12.007DOI Listing
May 2020

Adverse Impact of Corticosteroid Injection on Rotator Cuff Tendon Health and Repair: A Systematic Review.

Arthroscopy 2020 05 17;36(5):1468-1475. Epub 2019 Dec 17.

Tufts Medical Center, Boston, Massachusetts.

Purpose: To assess adverse effects of preoperative corticosteroid injections (CSIs) in patients with rotator cuff disease, especially before rotator cuff repair (RCR).

Methods: A systematic review of the MEDLINE database was performed according to guidelines from the Preferred Reporting Item for Systematic Reviews and Meta-Analyses for all studies reporting on adverse clinical effects of CSIs on rotator cuff tendon.

Results: A total of 8 articles were identified that report on adverse outcomes and risks associated with corticosteroid injections in the setting of rotator cuff tendinosis. Among these included articles, a single CSI for rotator cuff tendinosis was associated with increased risk of revision rotator cuff repair (odds ratio [OR]: range 1.3 [1.1-1.7] to 2.8 [2.2-3.4]) when administered up to a year before surgery and postoperative infections (OR: 2.1 [1.5-2.7]) when administered within a month before RCR. The risk of adverse outcomes after rotator cuff repair are greatest if a CSI is administered within 6 months of surgery (OR: 1.8 [1.3-2.6]) or if ≥2 injections are given within a year of surgery (OR: range 2.1 [1.8-2.5] to 3.3 [2.7-4.0]).

Conclusion: Several recent clinical trials have demonstrated that CSIs are correlated with increased risk of revision surgery after RCR in a temporal and dose dependent matter. Caution should be taken when deciding to inject a patient, and this treatment should be withheld if an RCR is to be performed within the following 6 months.

Level Of Evidence: IV, systematic review of Level III and IV studies.
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http://dx.doi.org/10.1016/j.arthro.2019.12.006DOI Listing
May 2020

Report of the 2018 Arthroscopy Association of North America Traveling Fellowship-Friendship and Mentorship.

Arthroscopy 2019 03;35(3):1006-1008

Dalhousie University & QEII Health Sciences Center, Halifax, Canada.

Thank you AANA for allowing us to participate in one of the most educational and transformative pieces of our careers to date. It was a great honor to be selected to participate in the 2018 Advanced Arthroscopy Training Fellowship. We journeyed to New York City, New Orleans, and Columbus, Ohio. This was a life-changing experience full of remarkable Friendship and Mentorship.
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http://dx.doi.org/10.1016/j.arthro.2019.01.009DOI Listing
March 2019

Increased Utilization of American Administrative Databases and Large-scale Clinical Registries in Orthopaedic Research, 1996 to 2016.

J Am Acad Orthop Surg Glob Res Rev 2018 Nov 16;2(11):e076. Epub 2018 Nov 16.

Tufts University School of Medicine (Mr. Karlson, Mr. Nezwek, and Dr. Tybor), and the Department of Orthopaedic Surgery (Dr. Menendez and Dr. Salzler), Tufts Medical Center, Boston, MA.

Introduction: Administrative databases and clinical registries provide large sample sizes that characterize specific outcomes and trends over time in orthopaedic surgery.

Methods: A literature review of all English-language orthopaedic surgery journals was conducted. All publications from 1996 to 2016 were reviewed for the utilization of an administrative database or clinical registry. We performed a linear regression with logarithmic transformation to identify trends in database utilization.

Results: Eight hundred forty-nine publications used a database from 1996 to 2016. Each year, 35.3% more database publications are reported than the previous year (95% confidence interval, 30.0 to 40.7), from zero articles in 1996 to 286 in 2016. The ratio of database research publications to overall orthopaedic publications increased from zero in 1996 to 2% in 2016. The most commonly used databases included the National Inpatient Sample and the National Surgical Quality Improvement Program.

Conclusion: Database research in orthopaedics has grown at a faster rate than orthopaedic literature as a whole.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-18-00076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324904PMC
November 2018
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