Publications by authors named "Nikhil Verma"

468 Publications

Humeral Head Resurfacing for Isolated Primary Humeral Osteoarthritis With a Large Chondral Defect.

Arthrosc Tech 2022 Jul 14;11(7):e1223-e1231. Epub 2022 Jun 14.

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

Primary, isolated humeral head arthritis or focal chondral defects are uncommon and difficult to diagnose preoperatively. While these lesions have traditionally been treated with total shoulder arthroplasty, shoulder hemiarthroplasty is a viable option for patients with isolated humeral head disease and minimal degenerative changes in the glenoid. This approach can be performed in a minimally invasive fashion, which preserves bone stock and native biomechanics, and can be beneficial if conversion to total shoulder arthroplasty is required in the future and avoids risk of glenoid loosening or failure in younger and more active individuals. In this Technical Note and accompanying video, we describe our technique of humeral head resurfacing in a patient with isolated primary humeral osteoarthritis with a large focal chondral defect in the humeral head.
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http://dx.doi.org/10.1016/j.eats.2022.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9353195PMC
July 2022

The fifty most cited publications in shoulder arthroplasty research.

Shoulder Elbow 2022 Aug 8;14(4):368-377. Epub 2021 Feb 8.

Department of Orthopedic Surgery, Division of Sports Medicine and Shoulder Surgery, Rush University Medical Center, Chicago, IL, USA.

Introduction: Frequency of citation provides one quantitative metric of the impact that an article has on a given field. The purpose of this study was to evaluate characteristics of the 50 most cited publications on shoulder arthroplasty.

Methods: The Web of Science database was used to determine the 50 most frequently cited shoulder arthroplasty articles. Articles were evaluated for several factors including type of arthroplasty, citation frequency and rate, source journal, country of origin, study type, and level of evidence.

Results: The most common countries of origin were the United States (60%) followed by France (24%) and Switzerland (6%). A total of 27 (54%) articles included anatomic total shoulder arthroplasty (TSA), 18 (36%) included reverse total shoulder arthroplasty (RTSA), and 15 (30%) included hemiarthroplasty. Articles including RTSA had the greatest number of citations compared to those on TSA ( = 0.037) and hemiarthroplasty ( = 0.035). Citations per year were also greatest with RTSA compared to TSA and hemiarthroplasty ( ≤ 0.001).

Discussion: This citation analysis includes many of the landmark studies that shaped, and continue to impact, the field of shoulder arthroplasty. This list provides a group of influential articles that provide a foundation for future research in shoulder arthroplasty.
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http://dx.doi.org/10.1177/1758573221989669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9284308PMC
August 2022

InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears: A Multicenter, Single-Blinded, Randomized Controlled Trial.

J Bone Joint Surg Am 2022 Jul 25;104(14):1250-1262. Epub 2022 Apr 25.

Division of Shoulder and Elbow Surgery, The Sidney Kimmel Medical College, Thomas Jefferson University, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania.

Background: The purpose of this study was to prospectively evaluate the efficacy and safety of a subacromial balloon spacer (InSpace implant; Stryker) compared with arthroscopic partial repair in patients with irreparable, posterosuperior massive rotator cuff tears.

Methods: Patients ≥40 years of age with symptomatic, irreparable, posterosuperior, massive rotator cuff tears and an intact subscapularis who underwent failed nonoperative management were included in this randomized controlled trial comparing the InSpace implant with partial repair. Clinical outcome data were collected at baseline through a 24-month follow-up. The primary outcome was improvement in the American Shoulder and Elbow Surgeons (ASES) scores. The secondary outcomes included change from baseline in the Western Ontario Rotator Cuff (WORC) score, the visual analog scale (VAS) pain score, the Constant-Murley shoulder score, the EuroQol-5 Dimensions-5-Level (EQ-5D-5L) score, active range of motion, and operative time. Complications and reoperations for each group were also recorded.

Results: Twenty sites randomized 184 patients: 93 in the InSpace group and 91 in the partial repair group. Significant and clinically relevant improvements in the ASES score from baseline were noted in both groups at Month 12 and were maintained at Month 24. Overall, 83% of patients in the InSpace group and 81% of patients in the partial repair group achieved the ASES minimally clinically important difference threshold, and 82% of patients in the InSpace group and 79% of patients in the partial repair group achieved the substantial clinical benefit threshold. Forward elevation was significantly greater in the InSpace group compared with the partial repair group at Day 10 (p = 0.04), Week 6 (p = 0.0001), Month 12 (p = 0.005), and Month 24 (p = 0.003). The operative time was significantly shorter in the InSpace group (p < 0.0001). No device-related surgical complications were noted, and 4 reoperations after InSpace implantation and 3 reoperations after partial repair were required.

Conclusions: The InSpace implant is an appropriate alternative to partial repair in patients with irreparable posterosuperior massive rotator cuff tears and an intact subscapularis. Notable benefits include early functional recovery and pain relief combined with a shorter operative time.

Level Of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.21.00667DOI Listing
July 2022

Technique Articles Are More Effective at Increasing Social Media Attention in Comparison With Original Research Articles: An Altmetrics-Based Analysis.

Arthrosc Sports Med Rehabil 2022 Jun 26;4(3):e989-e995. Epub 2022 Mar 26.

Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To compare social media attention and citation rates between technique articles and matched original research articles (ORAs) regarding surgical procedures.

Methods: All technique articles published from August 2019 through July 2020 in the free, electronic versions of and were matched by topic to articles in the "Original Research" sections of and in a 4:1 ratio within this time frame. The primary outcome was the Altmetric Attention Score (AAS). Secondary outcomes included citations, bibliometrics, and social media metrics. Independent tests were used to compare primary and secondary outcomes between technique articles and ORAs. A multivariate linear regression analysis was performed to determine the association between article type and social media attention while controlling for confounding bibliometric characteristics.

Results: A total of 285 matched research articles (n = 57, 20.0%) and technique articles (n = 228, 80.0%) were included. The mean AAS among all technique articles was 3.63 ± 10.08 (range, 0-96) whereas the mean AAS among all ORAs was 1.30 ± 3.98 (range, 0-25), representing a statistically significant difference ( = .016). The mean citation rate among all technique articles was not significantly different from that among ORAs ( = .73). Multivariate linear regression analysis showed a statistically significant positive association between AAS and article type, with an additional mean increase in the AAS of 2.91 (95% confidence interval, 0.04-5.77;  = .047) for every technique article compared with an ORA. Furthermore, a significant positive relation was noted between the article origin and the AAS, with an increase in the AAS of 3.00 (95% confidence interval, 0.82-5.17;  = .007) for every article published in North America compared with an article originating from another continent.

Conclusions: Technique articles resulted in significantly greater AASs and social media attention in comparison with open-access ORAs on similar topics. Publications that described technical procedures in a technique journal and studies from North America were positively associated with greater AASs and greater numbers of citations received by articles.

Clinical Relevance: An improved understanding of how much attention is given to technique articles versus matched ORAs by social media may influence the methods authors and journals use for distributing content. The present study suggests that one option to increase the amount of social media attention received for a particular study may be to utilize an accompanying surgical technique video or illustrations as these are easily shareable on social media and offer rapid dissemination of knowledge, similar to that of an infographic. However, physicians who view multimedia within technique articles should be encouraged to review the accompanying articles and the supporting original research as a primary source before making changes in their clinical practice.
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http://dx.doi.org/10.1016/j.asmr.2022.02.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9210375PMC
June 2022

Arthroscopic all - Inside repair of meniscal ramp lesions.

J ISAKOS 2022 Apr 30. Epub 2022 Apr 30.

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

Meniscal ramp lesions are disruptions of the posterior meniscotibial attachment of the medial meniscus and are commonly associated with anterior cruciate ligament injuries. However, they can be frequently missed when reviewing standard magnetic resonance imaging and difficult to treat. In this presentation, we describe our approach to repair a meniscal ramp lesion using a minimally invasive all-inside technique. We use this technique for the following surgical indications: meniscal tears involving the peripheral and meniscocapsular attachment of the posterior horn resulting in increased meniscal translation. The procedure is performed using standard arthroscopic portals along with a posteromedial portal placed using spinal needle localisation to ensure access around the lesion. Advantages of this technique include a minimally invasive repair that avoids the typical medial knee incision and dissection needed for traditional inside-out repairs, as well as direct visualisation of the repair site to ensure an appropriately tensioned anatomic repair. Technical pearls including adequate arthroscopic visualisation of the posteromedial compartment allowing the creation of a posteromedial working portal, direct passage of sutures through the edges of the ramp lesion facilitating an anatomic repair, and tensioning of the repair with arthroscopic knots to ensure restoration of the posterior horn stability are all critical to a good outcome. Furthermore, the use of two different curve directions for more displaced tears may be necessary to achieve an anatomic repair. In this case and in our experience, we use a Corkscrew SutureLasso 45° curve left for the meniscus bite and right for the capsular bite, as well as a long 8.25 mm by 70 mm twist-in cannula to accommodate the passing of insertion instrumentation in larger patients.
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http://dx.doi.org/10.1016/j.jisako.2022.04.004DOI Listing
April 2022

Arthroscopic biceps tenodesis using the knotless lasso technique.

J ISAKOS 2022 Mar 31. Epub 2022 Mar 31.

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

Long head biceps tendinopathy can be a significant pain generator, often presenting with pain localised to the anterior shoulder. Biceps tenodesis, both open and arthroscopic, is a well-established treatment for long head biceps pathology. In this presentation, we describe a novel arthroscopic onlay technique for long head biceps tenodesis using a lasso configuration with two knotless suture anchors that provide an efficient, low-profile construct to limit scarring and adhesions while providing circumferential fixation. We use this technique for the following surgical indications: severe tendinosis refractory to non-operative management, unable superior labral anterior to posterior (SLAP) tears, biceps instability and partial or complete tearing. The procedure is performed using standard shoulder arthroscopy portals with the addition of an anterolateral biceps working portal approximately 2 cm inferior and 2 cm lateral to the anterior rotator interval portal. Novel advantages of this technique include a low-profile knotless construct, efficient suture passage and circumferential two-point fixation while maintaining anatomic biceps tensioning. Technical pearls including visualisation, release of the biceps tendon from the groove and location of two point tenodesis fixation are all critical to a good outcome.
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http://dx.doi.org/10.1016/j.jisako.2022.03.004DOI Listing
March 2022

Safety and Efficacy of Postoperative Nonsteroidal Anti-inflammatory Drugs in Sports Medicine.

J Am Acad Orthop Surg 2022 Jun;30(12):535-542

From the Department of Orthopaedic Surgery and Rehabilitation, Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, Winston-Salem, NC (Trasolini), and Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University, Medical Center, Chicago, IL (Yanke, Verma, and Cole).

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for multimodal pain control after surgery. These medications work by selective or nonselective inhibition of cyclooxygenase, which has downstream effects on thromboxanes, prostaglandins, and prostacyclins. Clinical studies have shown beneficial effects for alleviating pain and reducing opioid consumption after surgery. Within hip arthroscopy, there is evidence that postoperative NSAIDs can also reduce the risk of symptomatic heterotopic bone formation. However, preclinical and animal studies have raised concern over the effect of NSAIDs on bone and soft-tissue healing. In addition, selective and nonselective cyclooxygenase 2 inhibitors may have different safety profiles regarding postoperative soft-tissue healing. The purpose of this review was to outline the mechanisms of action, efficacy, and effect on soft-tissue healing of postoperative NSAIDs and to provide evidence-based recommendations for appropriate use.
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http://dx.doi.org/10.5435/JAAOS-D-21-01228DOI Listing
June 2022

Incidence and effectiveness of manipulation under anaesthesia for stiffness following primary total knee arthroplasty.

Acta Orthop Belg 2022 Mar;88(1):113-120

Background: There are various modalities of cor- rection of stiffness following total knee arthro-plasty. Manipulation under anaesthesia (MUA) is generally indicated for people who fail to achieve their pre operative range of motion at 12 weeks. The purpose of this study was to determine: (1) the effect of MUA on Flexion arc (2) the influence of timing of MUA from index procedure and of diabetes mellitus on final flexion achieved.

Methods: We retrospectively evaluated patients who underwent manipulation following total knee arthroplasty at our institution between January 2016 to December 2018. For the purpose of analysis, we have divided the patients into two groups. Those who underwent manipulation within 12 weeks and later than 12 weeks. We have also compared the effect of MUA between diabetic and non-diabetic patients. All were operated with posterior stabilised (PS) prosthesis by a single senior arthroplasty surgeon. The final flexion achieved during their last clinical follow-up were recorded and compared with the pre MUA flexion.

Results: The incidence of MUA after TKA at our institute during this period is about 1.14 %. There was a significant statistical difference between the pre and post manipulation flexion, with p value <0.01. There was no significant statistical difference between those who were manipulated before 12 weeks and after 12 weeks in improving the Flexion of the operated knees. We have found that both the diabetic and non diabetic group had comparable flexion after the manipulation in our study.

Conclusion: Manipulation after anaesthesia is a safe first intervention to improve post operative stiffness and gain additional range of motion following TKA in patients who develop stiffness. It can be done even after 12 weeks of surgery with reasonably good gain in range of motion.
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http://dx.doi.org/10.52628/88.1.14DOI Listing
March 2022

No Difference in Clinical Outcomes for Arthroscopic Suprapectoral Versus Open Subpectoral Biceps Tenodesis at Midterm Follow-up: A Randomized Prospective Analysis.

Am J Sports Med 2022 05;50(6):1486-1494

Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, USA.

Background: We have previously reported the 1-year outcomes of arthroscopic suprapectoral biceps tenodesis (ASPBT) versus open subpectoral biceps tenodesis (OSPBT) for the management of long head of the biceps tendon (LHBT) pathology. While patients had similar 1-year biceps muscle strength and pain, longer-term functional outcomes are unknown.

Purpose: To directly compare clinical outcomes of ASPBT versus OSPBT with interference screw fixation, distal to the bony bicipital groove, at a minimum of 2 years' follow-up.

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

Methods: A total of 85 patients undergoing biceps tenodesis (BT) for LHBT disease were randomized into the ASPBT or OSPBT group. Both techniques utilized polyether ether ketone inference screws for tenodesis fixation. Patients completed American Shoulder and Elbow Surgeons (ASES), Constant subjective, and Single Assessment Numeric Evaluation (SANE) questionnaires preoperatively and again at 6 months, 12 months, and at the final follow-up at a minimum of 24 months.

Results: A total of 73 patients (37/42 randomized to ASPBT [88%]; 36/42 randomized to OSPBT [86%]) with a mean age of 50.4 ± 10.3 years and a mean body mass index of 29 ± 7.9 were included in clinical outcome analyses. The mean final follow-up was 2.9 years (ASPBT, 3 years; OSPBT, 2.8 years [range 2-5.2 years]). Comparison of demographic characteristics and intraoperative findings showed no significant differences in age, sex, concomitant procedures, and rotator cuff disease. No statistically significant differences in the ASES ( = .25), Constant subjective ( = .52), and SANE scores ( = .61) were found at the final follow-up. Clinical outcomes scores showed no significant improvement from a mean of 12.6 months to the final follow-up at 34.5 months (ASPBT: ASES, = .43; Constant, = .25; SANE, = .45 vs OSPBT: ASES, = .65; Constant, = .78; SANE, = .70). No patients required revision of BT in either group.

Conclusion: This study reported a minimum of 2-year follow-up of patients undergoing ASPBT or OSPBT, utilizing the same interference screw technique, for the management of LHBT pathology in the setting of concomitant shoulder procedures. There were no significant differences in patient-reported outcomes and complication rates found at any time point.

Registration: NCT02192073 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/03635465221084731DOI Listing
May 2022

Travel Distance Does Not Affect Outcomes After Arthroscopic Rotator Cuff Repair.

Arthrosc Sports Med Rehabil 2022 Apr 24;4(2):e511-e517. Epub 2021 Dec 24.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To determine the effect of travel distance on achieving the minimal clinically important difference (MCID) on patient-reported outcome measures (PROMs) at least 1 year after arthroscopic rotator cuff repair (RCR).

Methods: Patients undergoing primary arthroscopic RCR with a minimum 1-year follow-up at a high-volume tertiary referral center between May 2017 and June 2019 were retrospectively reviewed. Patients were divided into two groups: driving distance of >50 miles from the institution (referral group) and <50 miles (local group). American Shoulder and Elbow Score (ASES), Single Assessment Numeric Evaluation (SANE) score and Constant score at minimum 1-year follow-up were assessed. Chi-square analysis was used to analyze achievement of MCID on any PROM. Subgroup analysis by tear complexity (1 tendon vs. >2 tendons torn) was conducted. Logistic regression was performed to determine whether travel distance and other variables of interest had an effect on achieving MCID.

Results: Of 996 patients reviewed, 385 patients (38.7%) had minimum 1-year follow-up. Of these, 62 (16%) traveled >50 miles to their orthopedic provider, and 212 (55%) had a complex tear. MCID for at least one PROM was reached by 305 (94%) patients in the local group and 56 (90%) patients in the referral group. There was no significant difference between groups in reaching MCID for any PROM. Subgroup analysis by tear complexity revealed no significant difference in preoperative PROMs or achieving MCID postoperatively between referral groups. There was no significant difference between groups when controlling for age, sex, adjusted gross income (AGI), primary health insurance, tear chronicity, and tear complexity.

Conclusions: When controlling for age, sex, AGI, primary health insurance, tear chronicity, and tear complexity, distance to a high-volume shoulder arthroscopy surgery center did not have an effect on achieving the MCID for any PROM at least 1 year after arthroscopic RCR.

Level Of Evidence: Level III, retrospective cohort study.
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http://dx.doi.org/10.1016/j.asmr.2021.10.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9042758PMC
April 2022

Magnetic Resonance Imaging Findings of the Asymptomatic Shoulder May Impact Performance, Not Future Injury List Placement in Major League Baseball Pitchers.

Arthrosc Sports Med Rehabil 2022 Apr 16;4(2):e487-e493. Epub 2022 Feb 16.

Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, U.S.A.

Purpose: To evaluate preseason shoulder magnetic resonance images (MRIs) obtained from pitchers entering either major or minor league baseball (MLB) and correlate findings with subsequent injury, operative repair, and placement on the injured list (IL).

Methods: Preseason-MRI of the throwing shoulders of professional-level baseball pitchers, taken during routine evaluations at a single organization (2004-2017) were retrospectively reviewed. Publicly available databases were queried to exclude pitchers with known injuries prior to pre-signing imaging. Three blinded reviewers reviewed all MRI scans independently to evaluate for the presence of abnormalities in the rotator cuff (RTC), labrum, capsule, long-head of the biceps tendon (LHBT), and humeral head. Binary imaging findings were correlated to future placement on the IL for subsequent shoulder complaints. Bivariate statistics using Student's -tests and Fisher exact tests (both α = .05) were used in this study.

Results: A total of 38 asymptomatic pitchers with shoulder MRIs were included. Pitchers had a mean (±SD) age of 28.2 ± 4.9 and had pitched an average of 119.6 ± 143.8 career games. Pitchers with partial articular-sided RTC tears ( = .04) or intra-articular BT hyperintensity ( = .04) on preseason MRI demonstrated an association with the need for future surgery. Pitchers with evidence of labral heterogeneity demonstrated greater total career pitch counts (10,034.1 vs 2,465.3;  = .04). Evidence of a posterior-superior humeral cyst was associated with decreased strikeouts per 9 innings (6.1 vs 8.0;  = .039) and total strikeout percentage (16.1% vs 23.2%;  = .04).

Conclusion: Although there was a significant difference in the percent of various radiographic findings between the injured and healthy cohort, no MRI findings were predictive of future IL placement or duration of placement. The presence of a posterior superior humeral cyst was associated with decreased strikeout rates at 2 and 3 years, the presence of a labral tear was associated with decreased earned run average (ERA) at 3 years and decreased career strikeout percentages, and increased capsular signal was associated with decreased 5-year ERA.

Level Of Evidence: Level IV, retrospective study.
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http://dx.doi.org/10.1016/j.asmr.2021.10.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9042760PMC
April 2022

The Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient-Acceptable Symptomatic State after Medial Patellofemoral Ligament Reconstruction.

Arthrosc Sports Med Rehabil 2022 Apr 5;4(2):e661-e678. Epub 2022 Feb 5.

Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To define the minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient-acceptable symptomatic state (PASS) for patient-reported outcome measures (PROMs) after medial patellofemoral ligament reconstruction (MPFLR) and to investigate the role of preoperative, demographic, and intraoperative variables for predicting achievement of these thresholds.

Methods: This retrospective cohort study used a prospectively maintained database of patients undergoing primary MPFLR between August 2015 and December 2019. PROMs included the International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), KOOS joint replacement (JR), and Kujala. Anchor-based and distribution-based methods were used to calculate the MCID, SCB, and PASS. Regression analyses were performed to identify prognosticators for achievement of clinically significant thresholds.

Results: 139 patients met inclusion criteria (mean age: 21.7± 8.2 years). At 6 months, the MCID values were 8.3 (KOOS-Pain) and 8.5/13.5 (Kujala); SCB values were 1.4 (KOOS-Pain) and 43.7 (KOOS-QOL); and PASS values were 64.9 (IKDC), 83.3 (KOOS-Symptom), 76.8 (KOOS-Pain), 91.2 (KOOS-ADL), 47.5 (KOOS-Sport), 40.6 (KOOS-QOL), and 78.1 (KOOS-JR). At 1 year, the MCID values were 4.2 (KOOS-Pain), 7.2 (KOOS-ADL), 12.4 (KOOS-QOL) and 25.2 (KOOS-JR); SCB were 23.6 (IKDC), 4.2 (KOOS-Symptom), 19.7 (KOOS-Pain), 6.5 (KOOS-ADL), 55.0 (KOOS-Sport), 6.3 (KOOS-QOL), and 19.6/25.2 (KOOS-JR); and PASS were 65.5 (IKDC), 80.4 (KOOS-Symptom), 84.7 (KOOS-Pain), 99.3 (KOOS-ADL), 57.5 (KOOS-Sport), 53.1 (KOOS-QOL), and 76.3 (KOOS-JR). In regression analysis, greater age, body mass index, and preoperative PROMs were negative prognosticators for achieving clinically significant thresholds. Conversely, male gender increased the likelihood of achieving PASS for Kujala at 6 months and KOOS-ADL at 1 year.

Conclusions: This study established thresholds for the MCID, SCB, and PASS at 6 months and 1 year after MPFLR, providing physicians an evidence-based method to advise patients and assess outcomes with this surgery. Older patients and those with higher preoperative outcome scores are less likely to report improvement and satisfaction with MPFLR, while male patients are more likely to report some satisfaction.

Level Of Evidence: Level III, retrospective cohort study (diagnosis).
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http://dx.doi.org/10.1016/j.asmr.2021.12.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9042905PMC
April 2022

Determining the Roles of the Anterior Cruciate Ligament, Posterolateral Corner, and Medial Collateral Ligament in Knee Hyperextension Using the Heel-Height Test.

Orthop J Sports Med 2022 Apr 8;10(4):23259671221086669. Epub 2022 Apr 8.

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

Background: Anterior cruciate ligament (ACL) tears are often associated with other ligamentous injuries. The side-to-side difference in heel height can represent a valuable diagnostic tool in the setting of multiligamentous injuries.

Purpose: To assess in a cadaveric model how sequential sectioning of the static stabilizing structures of the knee (ACL, fibular collateral ligament [FCL], popliteus tendon [PLT], popliteofibular ligament [PFL], and medial collateral ligament [MCL]) influences heel-height measurements when comparing groups undergoing initial transection of the ACL versus FCL and to assess posterior tibial slope after sequential sectioning.

Study Design: Controlled laboratory study.

Methods: A total of 16 fresh cadaveric knees were carefully dissected to expose the ACL, FCL, PLT, PFL, and MCL. Each knee was randomized to either the ACL-first or FCL-first group based on the initial structure sectioned. The sectioning order was as follows: (1) ACL or FCL, (2) FCL or ACL, (3) PLT, (4) PFL, and (5) MCL. Heel height was measured with a standardized superiorly directed 12-N·m force applied to the knee while stabilizing the femur; heel height was also measured with a clinician-applied force. The measurements were compared between and within groups for each sectioned state. The correlation between tibial slope and heel-height measurements was analyzed.

Results: There were no significant differences in heel-height measurements between the ACL-first and FCL-first groups ( = .863). Combined ACL-FCL injuries led to a 2.85 ± 0.83-cm increase in heel height compared to the intact state. Significant increases in heel height occurred after all sectioned states, except the PFL sectioned state. Combined ACL-posterolateral corner (PLC) injuries resulted in a 3.72 ± 1.02-cm increase in heel height, and additional sectioning of the MCL resulted in a 4.73 ± 1.35-cm increase compared to the intact state. Tibial slope was not correlated with increases in heel height after each sectioning ( = .154).

Conclusion: Combined ACL-FCL, ACL-PLC, and ACL-PLC-MCL injuries resulted in increasing mean heel-height measurements (2.85, 3.72, and 4.73 cm, respectively) compared to the intact state. Tibial slope was not found to influence increases in heel height.

Clinical Relevance: The side-to-side difference in heel height may be a clinically relevant examination tool for diagnosing multiligament knee injuries.
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http://dx.doi.org/10.1177/23259671221086669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9016545PMC
April 2022

Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts.

Knee Surg Sports Traumatol Arthrosc 2022 Apr 18. Epub 2022 Apr 18.

P D Hinduja Hospitals Mumbai, Global Hospital Parel, Mumbai, India.

Purpose: There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic.

Methods: The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus.

Results: Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis.

Conclusion: It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.
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http://dx.doi.org/10.1007/s00167-022-06973-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9013735PMC
April 2022

Does native glenoid anatomy predispose to shoulder instability? An MRI analysis.

J Shoulder Elbow Surg 2022 Jun 1;31(6S):S110-S116. Epub 2022 Apr 1.

Division of Sports Medicine and Shoulder Surgery, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: It is unclear if native glenohumeral anatomic features predispose young patients to instability and if such anatomic risk factors differ between males and females. The purpose of this study was to compare glenoid and humeral head dimensions between patients with a documented instability event without bone loss to matched controls and to evaluate for sex-based differences across measurements. The authors hypothesized that a smaller glenoid width and glenoid surface area would be significant risk factors for instability, whereas humeral head width would not.

Methods: A prospectively maintained database was queried for patients aged <21 years who underwent magnetic resonance imaging (MRI) for shoulder instability. Patients with prior shoulder surgery, bony Bankart, or glenoid or humeral bone loss were excluded. Patients were matched by sex and age to control patients who had no history of shoulder instability. Two blinded independent raters measured glenoid height, glenoid width, and humeral head width on sagittal MRI. Glenoid surface area, glenoid index (ratio of glenoid height to width), and glenohumeral mismatch ratio (ratio of humeral head width to glenoid width) were calculated.

Results: A total of 107 instability patients and 107 controls were included (150 males and 64 females). Among the entire cohort, there were no differences in glenoid height, glenoid width, glenoid surface area, humeral head width, or glenoid index between patients with instability and controls. Overall, those with instability had a greater glenohumeral mismatch ratio (P = .029) compared with controls. When stratified by sex, female controls and instability patients showed no differences in any of the glenoid or humerus dimensions. However, males with instability had a smaller glenoid width by 3.5% (P = .017), smaller glenoid surface area by 5.2% (P = .015), and a greater glenohumeral mismatch ratio (P = .027) compared with controls.

Conclusion: Compared with controls, males with instability were found to have smaller glenoid width and surface area, and a glenoid width that was proportionally smaller relative to humeral width. In contrast, bony glenohumeral morphology did not appear to be a significant risk factor for instability among females. These sex-based differences suggest that anatomic factors may influence risk of instability for male and female patients differently.
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http://dx.doi.org/10.1016/j.jse.2022.03.002DOI Listing
June 2022

Moderate Return to Play and Previous Performance After SLAP Repairs in Competitive Overhead Athletes: A Systematic Review.

Arthroscopy 2022 Mar 30. Epub 2022 Mar 30.

Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.. Electronic address:

Purpose: To perform a systematic review of return to play (RTP) and return to previous level of performance (RPP) in competitive overhead athletes after SLAP repair to identify factors associated with failure to RTP.

Methods: Systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Review was registered with PROSPERO International prospective register of systematic reviews (CRD42020215488). Inclusion criteria were literature reporting RTP or RPP following SLAP repair in overhead athletes were run in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Categories for data collection for each full article included (1) article information; (2) patient demographics; (3) surgical techniques; (4) level of competition; (5) rotator cuff treatment; (6) player position; (7) patient-reported outcome measures; and (8) RTP and RPP rates. The Methodological Index for Non-randomized Studies checklist was used to evaluate quality of all included studies.

Results: Eight studies with 333 subjects were identified. Overall RTP and RPP rates were 50% to 83.6% and 35.3% to 64%, respectively. Patients with surgically treated rotator cuff pathology had lower RTP (12.5%-64.7%) rates compared with those without (80.0%-83.6%). Professional athletes had similar RTP rates (62.5%-81.5%) compared with high-school (75.0%-90.0%) and college athletes (12.5%-83.3%). However, professional athletes demonstrated the lowest relative range of reported RPP rates (27.7%-55.6%). Pitchers had lower RTP (62.5%-80.0%) and RPP (52.0%-58.9%) compared with position players (91.3% RTP, 76.3%-78.2% RPP).

Conclusions: Studies reviewed reported moderate RTP and RPP rates following SLAP repairs in competitive overhead athletes. Those with associated rotator cuff tear requiring treatment, and baseball pitchers were less likely to RTP and RPP. Professional athletes had similar RTP to an amateur; however, they were less likely to RPP.

Level Of Evidence: Level IV, systematic review of Level III-IV studies.
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http://dx.doi.org/10.1016/j.arthro.2022.03.026DOI Listing
March 2022

Patients Follow 3 Different Rate-of-Recovery Patterns After Anterior Cruciate Ligament Reconstruction Based on International Knee Documentation Committee Score.

Arthroscopy 2022 Aug 22;38(8):2480-2490.e3. Epub 2022 Mar 22.

Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A.. Electronic address:

Purpose: To determine whether subgroups of patients exist based on the rate-of-recovery pattern of International Knee Documentation Committee (IKDC) scores after anterior cruciate ligament reconstruction (ACLR) and to determine clinical predictors for these subgroups.

Methods: Patients who underwent primary or revision ACLR at a single institution from January 2014 to January 2019 were identified. Latent class growth analyses and growth mixture models (GMMs) with 1 to 6 classes were used to identify subgroups of patients based on functional rate-of-recovery patterns by use of preoperative, 1-year postoperative, and 2-year postoperative IKDC scores.

Results: A total of 245 patients who underwent ACLR were included in the analysis. A 3-class GMM was chosen as the final model after 6 different models were run. Class 1, showing improvement from preoperatively to 1-year follow-up, with sustained improvement from 1 to 2 years postoperatively, constituted 77.1% of the study population (n = 189), whereas class 2, showing functional improvement between 1- and 2-year follow-up, was the smallest class, constituting 10.2% of the study population (n = 25), and class 3, showing slight improvement at 1-year follow-up, with a subsequent decline in IKDC scores between 1- and 2-year follow-up, constituted 12.7% of the study population (n = 31). Revision surgery (P = .005), a psychiatric history (P = .025), preoperative chronic knee pain (P = .024), and a subsequent knee injury within the follow-up period (P = .011) were the predictors of class 2 and class 3 rate-of-recovery patterns. Patient demographic characteristics, graft type, and concomitant ligament, meniscus, or cartilage injury at the time of surgery were not associated with the different recovery patterns described in this study.

Conclusions: Patients may follow different rate-of-recovery patterns after ACLR. By use of the GMMs, 3 different rate-of-recovery patterns based on IKDC scores were identified. Although most patients follow a more ideal rate-of-recovery pattern, fewer patients may follow less favorable patterns. Revision surgery, a history of psychiatric illness, preoperative chronic knee pain, and a subsequent knee injury within the follow-up period were predictive of less favorable rate-of-recovery patterns.

Level Of Evidence: Level III, retrospective cohort study.
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http://dx.doi.org/10.1016/j.arthro.2022.02.027DOI Listing
August 2022

Biomechanical Role of the Superior Capsule in a Rotator Cuff Sectioned and Repaired State: A Sequential Sectioning Study.

Am J Sports Med 2022 05 24;50(6):1541-1549. Epub 2022 Mar 24.

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

Background: Individual contributions of the rotator cuff (RC) and superior capsule (SC) to prevent superior translation of the humerus are not well understood.

Purpose: To evaluate the relative contributions of the SC and RC to normal and pathologic shoulder biomechanics by determining their independent effects on superior humeral translation.

Study Design: Controlled laboratory study.

Methods: Twelve cadaveric shoulders were tested at 0º, 45º, and 90º of abduction under 5 conditions: intact RC/SC, RC sectioned first, SC sectioned first, both structures sectioned, and RC repair. Matched pairs were randomly assigned to the second or third testing condition (RC or SC sectioned first). Specimens were tested under 2 static conditions (40-N deltoid load [balanced load], 80-N deltoid load [superiorly directed load]) and 1 dynamic condition during active abduction. A mixed-design 2-way repeated-measures analysis of variance with Bonferroni adjustments was performed to compare testing conditions. Paired tests were used to compare specimens in the intact state versus the repaired state. Significance was set at < .05.

Results: During balanced deltoid loading at 0° and 45º, there was significantly greater humeral translation when both structures were sectioned as compared with the intact state and with both isolated sectioned states ( < .05 for all). No significant differences were observed between or within groups at 90º of abduction. These effects remained consistent with superiorly directed loading. Dynamic testing of both groups showed a significant increase in superior translation for specimens in which the RC was deficient versus the intact state ( = .027), with no difference when the SC was sectioned. The RC repair state returned translation to values similar to the intact state at all abduction angles and loading conditions ( > .05).

Conclusion: In this cadaveric study, the SC and RC played an important role in preventing superior humeral translation; however, dynamic testing suggested preferential contribution of the RC. RC repair was effective in preventing superior humeral translation, even with a sectioned SC at the level of the glenohumeral joint.

Clinical Relevance: RC repair was effective in preventing superior humeral translation, even in the presence of a sectioned SC at the level of the glenohumeral joint in this cadaveric model. Our data lay the groundwork for future studies investigating the clinical effect of RC repair in an SC sectioned state.
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http://dx.doi.org/10.1177/03635465221083651DOI Listing
May 2022

Establishing Clinically Significant Outcomes After Anterior Cruciate Ligament Reconstruction in Pediatric Patients.

J Pediatr Orthop 2022 Jul 17;42(6):e641-e648. Epub 2022 Mar 17.

Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL.

Purpose: The purpose of this study was to establish clinically significant outcome values for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after anterior cruciate ligament reconstruction (ACLR) in the pediatric and adolescent populations and to assess factors that were associated with achieving these outcomes.

Methods: Patients between the age of 10 to 21 who underwent ACLR between 2016 and 2018 were identified and patient-reported outcomes (PROs) were collected preoperatively and postoperatively. Intraoperative variables collected included graft choice, graft size (diameter), graft fixation method, and concomitant procedures. PROs collected for analysis were the International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). MCID and PASS were calculated using receiver operating characteristic with area under the curve analyses for delta (ie, baseline-to-postoperative change) and absolute postoperative PRO scores, respectively.

Results: A total of 59 patients were included in the analysis. Of the entire study population, 53 (89.8%) reported satisfaction with their surgical outcome. The established MCID threshold values based on the study population were 33.3 for IKDC, 28.6 for (KOOS) Symptoms, 19.4 for Pain, 2.9 for activities of daily living (ADL), 45.0 for Sport, and 25.0 for Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 80.5 for IKDC, 75.0 (KOOS) Symptoms, 88.9 for Pain, 98.5 for ADL, 75.0 for Sport, and 68.8 for QoL.

Conclusion: Clinically meaningful outcomes including MCID and PASS were established for pediatric ACLR surgery using selected PRO measures, IKDC, and KOOS. Patient age, sex, graft type, and graft size were not associated with greater achievement of these outcomes. In contrast, collision sports, fixed-object high-impact rotational landing sports, and concomitant meniscectomy surgery were associated with a decreased likelihood of achieving clinically significant improvement. However, findings must be interpreted with caution due to limitations in follow-up and sample size.

Level Of Evidence: Level IV: case series.
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http://dx.doi.org/10.1097/BPO.0000000000002143DOI Listing
July 2022

How Long Does It Take to Achieve Clinically Significant Outcomes After Isolated Biceps Tenodesis?

Orthop J Sports Med 2022 Mar 8;10(3):23259671221070857. Epub 2022 Mar 8.

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

Background: Clinically significant outcomes (CSOs) connect patient-reported outcome measures data to patient-perceived benefit. Although investigators have established threshold values for various CSOs, the timeline to achieve these outcomes after isolated biceps tenodesis (BT) has yet to be defined.

Purpose: To define the time-dependent nature of minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) achievement after isolated BT.

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

Methods: The American Shoulder and Elbow Surgeons score (ASES), the Single Assessment Numeric Evaluation, and the Constant-Murley score (CMS) were administered preoperatively and at 6 and 12 months postoperatively to patients undergoing isolated BT between 2014 and 2018 at our institution. Cumulative probabilities for achieving MCID, SCB, and PASS were calculated using Kaplan-Meier survival analysis. Weibull parametric regression evaluated the hazard ratios (HRs) of achieving earlier MCID, SCB, and PASS.

Results: Overall cohort (N = 190) achievement rates ranged between 77.8% and 83.2% for MCID, between 42.2% and 80.2% for SCB, and between 59.7% and 62.9% for PASS. Median achievement time was 5.3 to 6.1 months for MCID, 5.9 to 6.4 months for SCB, and 6.07 to 6.1 months for PASS. Multivariate Weibull parametric regression identified older age, male sex, higher body mass index, preoperative thyroid disease, smoking history, and higher preoperative CMS as predictors of delayed CSO achievement (HR, 1.01-6.41), whereas normal tendon on arthroscopy, defined as absence of tenosynovitis or tendon tear on arthroscopy, predicted earlier CSO achievement (HR, 0.19-0.46). Location of tenodesis and worker compensation status did not significantly predict the time to achieve CSOs on multivariate analysis.

Conclusion: After isolated BT, patients can expect to attain CSO by 13 months postoperatively, with most patients achieving this between 5 and 8 months. Patients tend to take longer to achieve PASS than MCID and SCB.
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http://dx.doi.org/10.1177/23259671221070857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8908395PMC
March 2022

Natural recovery and regeneration of the central nervous system.

Regen Med 2022 04 21;17(4):233-244. Epub 2022 Feb 21.

University of Toledo College of Medicine & Life Sciences, Toledo, OH 43614, USA.

The diagnosis and management of CNS injuries comprises a large portion of psychiatric practice. Many clinical and preclinical studies have demonstrated the benefit of treating CNS injuries using various regenerative techniques and materials such as stem cells, biomaterials and genetic modification. Therefore it is the goal of this review article to briefly summarize the pathogenesis of CNS injuries, including traumatic brain injuries, spinal cord injuries and cerebrovascular accidents. Next, we discuss the role of natural recovery and regeneration of the CNS, explore the relevance in clinical practice and discuss emerging and cutting-edge treatments and current barriers in the field of regenerative medicine.
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http://dx.doi.org/10.2217/rme-2021-0084DOI Listing
April 2022

Upregulation of cytokine signalling in platelets increases risk of thrombophilia in severe COVID-19 patients.

Blood Cells Mol Dis 2022 05 11;94:102653. Epub 2022 Feb 11.

Regional Centre for Biotechnology, National Capital Region Biotech Science Cluster, Faridabad, India. Electronic address:

Abnormal coagulation dynamics, including disseminated intravascular coagulopathy, pulmonary embolism, venous thromboembolism and risk of thrombosis are often associated with the severity of COVID-19. However, very little is known about the contribution of platelets in above pathogenesis. In order to decipher the pathophysiology of thrombophilia in COVID-19, we recruited severely ill patients from ICU, based on the above symptoms and higher D-dimer levels, and compared these parameters with their asymptomatic counterparts. Elevated levels of platelet-derived microparticles and platelet-leukocyte aggregates suggested the hyperactivation of platelets in ICU patients. Strikingly, platelet transcriptome analysis showed a greater association of IL-6 and TNF signalling pathways in ICU patients along with higher plasma levels of IL-6 and TNFα. In addition, upregulation of pathways like blood coagulation and hemostasis, as well as inflammation coexisted in platelets of these patients. Further, the increment of necrotic pathway and ROS-metabolic processes in platelets was suggestive of its procoagulant phenotype in ICU patients. This study suggests that higher plasma IL-6 and TNFα may trigger platelet activation and coagulation, and in turn aggravate thrombosis and hypercoagulation in severe COVID-19 patients. Therefore, the elevated IL-6 and TNFα, may serve as potential risk factors for platelet activation and thrombophilia in these patients.
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http://dx.doi.org/10.1016/j.bcmd.2022.102653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8832951PMC
May 2022

Technical Note: Arthroscopic Rotator Cuff Repair with Patch Augmentation with Acellular Dermal Allograft.

Arthrosc Tech 2022 Feb 6;11(2):e121-e125. Epub 2022 Jan 6.

Midwest Orthopedics at Rush University Medical Center, Chicago, Illinois, U.S.A.

Rotator cuff tears are one of the most common causes of shoulder pain and dysfunction seen by orthopaedic surgeons. Although rotator cuff repair (RCR) has been shown to provide optimal outcomes, retear rates average roughly 60% and have been reported to exceed 90%. Retear after RCR is especially prevalent in patients with large, multitendon tears with poor tissue quality. Allograft augmentation of RCR may reinforce anatomically reparable tears, particularly in patients with poor tissue quality. Although various techniques of patch augmented RCR have been described, the procedure remains challenging. This Technical Note describes RCR augmented with acellular dermal allograft using the CuffMend system (Arthrex Inc, Naples, FL), which significantly decreases surgeon demand and helps avoid the pitfalls common with this procedure.
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http://dx.doi.org/10.1016/j.eats.2021.09.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8820992PMC
February 2022

Trends in outpatient versus inpatient total shoulder arthroplasty over time.

JSES Int 2022 Jan 14;6(1):7-14. Epub 2021 Nov 14.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Background: The purpose of this study was to investigate the safety of outpatient and inpatient total shoulder arthroplasty (TSA) and to investigate changes over time.

Methods: Patients undergoing primary TSA during 2006-2019 as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Patients were divided into an early cohort (2006-2016, 12,401 patients) and a late cohort (2017-2019, 12,845 patients). Outpatient procedures were defined as those discharged on the day of surgery. Patient comorbidities and rate of adverse events within 30 days postoperatively were compared with adjustment for baseline characteristics using standard multivariate regression.

Results: There was a significant reduction in complications over time when considering all cases (5.69% in the early cohort vs. 3.67% in the late cohort, adjusted relative risk [RR] = 0.65, 95% confidence interval [CI] = 0.58-0.73,  < .001). The rate of complications decreased over time among inpatients (5.80% vs. 3.90%, adjusted RR = 0.68, 95% CI = 0.60-0.76,  < .001). However, there was no difference in the rate of complications among outpatients over time (1.98% vs. 1.38%, adjusted RR = 0.64, 95% CI = 0.28-1.47,  = .293). There were significantly more complications among inpatients vs. outpatients in both the early and late cohorts (early: 5.80% vs. 1.98%, adjusted RR = 2.57, 95% CI = 1.24-5.34,  = .011, late: 3.90% vs. 1.38%, adjusted RR = 2.28, 95% CI = 1.39-3.74,  = .001). TSA became more common in elderly patients over 70 years of age over time in both the inpatient and outpatient cohorts, whereas fewer young patients (aged 18-59 years) underwent TSA in the late cohorts than in the early cohorts for both the inpatient and outpatient samples ( < .001).

Conclusion: The overall complication rate of TSA has decreased over time as outpatient TSA has become increasingly common. When contemporary data are examined, the complication rate of outpatient procedures has remained constant over time while that of inpatient procedures decreased, despite the changing demographics of patients undergoing TSA. This indicates that outpatient TSA remains a safe procedure as patient selection criteria have evolved, while the safety of inpatient TSA continues to improve.
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http://dx.doi.org/10.1016/j.jseint.2021.09.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8811390PMC
January 2022

The "Not" Good, the Bad and the Ugly: Prevention and Management of Common Intraoperative and Delayed Complications in Orthopedic Sports Medicine Surgical Procedures.

Sports Med Arthrosc Rev 2022 Mar;30(1):42-53

Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, IL.

Despite advances in techniques designed to make arthroscopic sports medicine procedures simple, complications still arise in the operating room; even in the most trained hands. However, what marks a skilled surgeon is not just the ability to steer the ship amidst smooth seas, but a knack for getting out of trouble once things deviate from the set course. Each surgical case presents a unique challenge, and no 2 are the same. For this reason, a true expert surgeon must know how to deal with "complications" ranging from a mild swell to a raging storm. In this review we present strategies to prevent and navigate some of the most common, and fearsome complications a sports medicine surgeon may face during surgery. A great surgeon is one that acknowledges that throughout their career it is not a question of "if" these situations will arise, but "when"; and preparation is the key to success.
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http://dx.doi.org/10.1097/JSA.0000000000000315DOI Listing
March 2022

Return to Sport Following Distal Triceps Repair.

J Hand Surg Am 2022 Jan 22. Epub 2022 Jan 22.

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

Purpose: The purpose of this investigation was to examine the timeline of return-to-sport following distal triceps repair; evaluate the degree of participation and function upon returning to sport; and identify risk factors for failure to return to sport.

Methods: Patients who underwent distal triceps repair with a minimum of 1 year of follow-up were retrospectively reviewed. Patients completed a subjective sports questionnaire and were scored on a visual analog scale for pain; the Mayo Elbow Performance Index; the Quick Disabilities of the Arm, Shoulder, and Hand; and the Single Assessment Numerical Evaluation.

Results: Out of 113 eligible patients who had a distal triceps repair, 81 patients (71.7%) were contacted. Sixty-eight patients (84.0%) who participated in sports prior to surgery were included at 6.0 ± 4.0 years after surgery, and the average age was 46.6 ± 11.5 years. Sixty-one patients (89.7%) resumed playing at least 1 sport by 5.9 ± 4.4 months following distal triceps repair. However, 18 patients (29.5%) returned to a lower level of activity intensity. The average postoperative Quick Disabilities of the Arm, Shoulder, and Hand; Mayo Elbow Performance; visual analog scale for pain; and Single Assessment Numerical Evaluation scores were 8.2 ± 14.0, 89.5 ± 13.4, 2.0 ± 1.7, and 82.2 ± 24.3, respectively. No patients underwent revision surgery at the time of final follow-up.

Conclusions: Distal triceps repair enables 89.7% of patients to return to sport by 5.9 ± 4.4 months following surgery. However, 29.5% of patients were unable to return to their preinjury level of activity. It is imperative that patients are appropriately educated to manage postoperative expectations regarding sport participation following distal triceps repair.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.11.021DOI Listing
January 2022

Rotator Cuff Repair with Graft Augmentation Improves Function, Decreases Revisions, and Is Cost-Effective.

Arthroscopy 2022 07 20;38(7):2166-2174. Epub 2022 Jan 20.

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

Purpose: The purpose of this study is to evaluate the cost effectiveness of the use of extracellular matrix (ECM) augment at the time of primary rotator cuff repair utilizing a decision tree analysis.

Methods: A decision tree model was created utilizing the existing literature for retear rates with and without dermal graft augmentation. Costs for rotator cuff repair (hospital and surgeon fees) were based on published studies and the cost for graft augmentation was based on institutional data. Utility measures were based upon EQ-5D (European Quality of Life 5 Dimension) scores to assess for improvement in quality adjusted life years (QALY) over a 10-year postoperative period with and without graft augmentation. Cost effectiveness was assessed using the incremental cost effectiveness ratio (ICER), or the incremental cost for per QALY with graft augmentation. Cost effectiveness is based on previous literature whereby an intervention is considered cost effective if the ICER is less than $50,000/QALY.

Results: On the basis of our decision tree analysis, total cost for rotator cuff tear without augmentation was $12,763, while the cost increased to $16,039 with ECM augmentation. With graft augmentation there was an improvement in 2.29 QALY, while there was an improvement of 2.05 without graft augmentation. The ICER of graft augmentation is $14,000/QALY, well below the cost effectiveness cut-off of $50,000/QALY. Sensitivity analysis showed the maximum cost of the ECM augment to be cost effective is $11,921.

Conclusion: Graft augmentation does come with a significant upfront cost; however, on the basis of our decision-tree analysis, it may represent a cost-effective procedure. There is evidence to potentially consider more routine use in rotator cuff repairs, while being cost effective.

Level Of Evidence: Economic: Level IV: computer simulation model (Monte Carlo simulation, Markov model) with inputs derived from Level IV studies.
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http://dx.doi.org/10.1016/j.arthro.2022.01.011DOI Listing
July 2022

Bone Marrow Aspirate Concentrate Augmentation May Accelerate Allograft Ligamentization in Anterior Cruciate Ligament Reconstruction: A Double-Blinded Randomized Controlled Trial.

Arthroscopy 2022 07 15;38(7):2255-2264. Epub 2022 Jan 15.

Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A.

Purpose: To assess the effect of bone marrow aspiration concentrate (BMAC) augmentation on clinical outcomes and magnetic resonance imaging (MRI) findings in anterior cruciate ligament (ACL) reconstruction (ACLR) with bone-patellar tendon-bone (BTB) allografts.

Methods: A double-blinded, randomized controlled trial was conducted on 80 patients undergoing ACL reconstruction using BTB allografts. Patients were randomized to 2 groups: (1) bone marrow aspirate was collected from the iliac crest, concentrated, and approximately 2.5 mL was injected into the BTB allograft, or (2) a small sham incision was made at the iliac crest (control). MRI was performed at 3 months and 9 months postoperatively to determine the signal intensity ratio of the ACL graft.

Results: Seventy-three patients were available for follow-up at 1-year postoperatively (36 BMAC, 37 control). International Knee Documentation Committee (IKDC) scores were significantly greater in the BMAC group versus the control at the 9-month postoperative period (81.6 ± 10.5 vs 74.6 ± 14.2, P = .048). There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months (89% vs 85%; P = .7). Three months postoperatively, signal intensity ratio of the inferior third of the ACL graft was significantly greater in the BMAC group versus the control group (3.2 ± 2.2 vs 2.1 ± 1.5; P = .02).

Conclusions: Patients who received BMAC augmentation of the BTB allograft during ACL reconstruction demonstrated greater signal intensity scores on MRI at 3 months, suggesting increased metabolic activity and remodeling, and potentially accelerated ligamentization. Additionally, patients in the BMAC group had greater patient-reported outcomes (IKDC) at 9 months postoperatively when compared with those who underwent a standard surgical procedure. There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months, suggesting limited clinical significance at this time point.

Level Of Evidence: I, randomized control trial.
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http://dx.doi.org/10.1016/j.arthro.2022.01.010DOI Listing
July 2022

Transtibial Anterior Cruciate Ligament Reconstruction: Tips for a Successful Anatomic Reconstruction.

Arthrosc Tech 2021 Dec 29;10(12):e2783-e2788. Epub 2021 Nov 29.

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

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed orthopaedic sports procedures. Two main techniques are used for accomplishing an ACL reconstruction: transtibial and anteromedial portal techniques. The transtibial technique has been criticized for its inability to create an anatomic femoral tunnel given the intrinsic constraint of the tibial tunnel during drilling. However, technical modifications of the transtibial technique can result in anatomic tunnel entrance positioning and a properly oriented graft. This Technical Note presents our technique for anatomic transtibial ACL reconstruction.
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http://dx.doi.org/10.1016/j.eats.2021.08.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8719302PMC
December 2021

Retrospective Analysis of Patients Undergoing Arthroscopic Rotator Cuff Repair at a Single Institution Yields a 0.11% Postoperative Infection Rate.

Arthrosc Sports Med Rehabil 2021 Dec 1;3(6):e1853-e1856. Epub 2021 Nov 1.

Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To establish an infection rate following primary arthroscopic rotator cuff repair (ARCR) from a single institutional database and to ascertain whether there is a relationship between the use of preoperative corticosteroid injection (CSI) and the risk of postoperative infection.

Methods: All medical records at a single institution were retrospectively reviewed to identify patients who had undergone arthroscopic repair from January 2016 to December 2018. Patient charts were reviewed for CSI treatment within 6 months of surgery, superficial or deep infection within 2 months postoperatively, and specific treatment of the infection. Patient characteristics were summarized by descriptive statistics using means with standard deviations for continuous variables and frequencies with percentages for categorical variables. A χ correlation analysis was performed to determine the association between receiving an injection and having an infection.

Results: A total of 1773 patients were included for analysis with an average age of 59.24 ± 9.4 years. The overall infection rate was 0.11% (2/1773 patients). Both patients were treated with oral antibiotics. Of the included patients, 616 had a preoperative CSI within 6 months of their surgery, and 102 injections were administered within 1 month of surgery. None of these patients had a postoperative infection. A χ correlation analysis showed a negligible relationship between preoperative injections and postoperative infection (φ = 0.02, χ = 0.84).

Conclusions: Through this single-institution, large cohort retrospective review, we found an overall 0.11% rate of postoperative infection following primary arthroscopic RCR. In addition, we found no correlation between the use of preoperative CSI ahead of elective ARCR at any time point and risk of developing a postoperative infection. Infection is uncommon following ARCR, and preoperative steroid injection did not increase infection risk in our study population.

Level Of Evidence: Level IV, therapeutic case series.
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http://dx.doi.org/10.1016/j.asmr.2021.08.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8689265PMC
December 2021
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