Trends in knee arthroscopy utilization: a gap in knowledge translation

Arthroscopic Electromechanical Assessment of Human Articular Cartilage Injury Correlates with ICRS Scores

PURPOSE

This study aimed to conduct arthroscopic evaluation of cartilage electromechanical properties and establish their correlation with International Cartilage Repair Society (ICRS) grading scores.

METHODS

In 18 patients, quantitative parameter (QP) measurements were taken on the weight-bearing surface of the medial femoral condyle. Adjacently, the same site was graded using ICRS scores (0-4). Electromechanical QPs for ICRS grades 0 to 3 were obtained during arthroscopy, while complete grade 4 injuries were assessed using femur cartilage-bone blocks from knee arthroplasty. The QP values for ICRS grades 0 to 2 were compared with grades 3 and 4 using Welch t test. The corresponding QP values were assigned to ICRS grades 0 to 4 and compared using Welch ANOVA (analysis of variance). Pearson's coefficient evaluated QP-ICRS grade relationship.

RESULTS

Healthy grade 0 cartilage displayed a mean QP value of 10.5 (±2.8 SD, n = 4). The ICRS grade 1 and grade 2 injuries were associated with QP values of 12 (±0.7, n = 2) and 13.25 (±1.77, n = 2), respectively. The grade 3 defects had QP values of 20.43 (±4.84, n = 4), whereas complete grade 4 defects showed electromechanical values of 30.17 (±2.19, n = 6). Significant differences in QP values were observed between ICRS grades 0 to 2 (mean QP 11.56 ± 2.3, n = 8) and grades 3 and 4 (26.27 ± 6, n = 10; P < 0.0001). Pearson's correlation coefficient of 0.9 indicated a strong association between higher ICRS cartilage injury grades and elevated QP values (P < 0.0001).

CONCLUSION

Arthroscopic electromechanical QP assessment robustly correlates with ICRS scores. The QP values for ICRS grades 0 to 2 are significantly lower, compared with grades 3 and 4.

Risk factors for prolonged opioid consumption following hip arthroscopy: A secondary analysis of the Femoroacetabular Impingement RandomiSed controlled Trial and embedded cohort study

PURPOSE

The purpose of the study was to identify prognostic risk factors for prolonged opioid use at 2 and 6 weeks after hip arthroscopy using data from the Femoroacetabular Impingement RandomiSed controlled Trial and its external validation cohort study.

METHODS

Opioids were prescribed for postoperative pain management at the surgeon's discretion, with a majority being prescribed a combination of oxycodone and paracetamol (5/325 mg). Prolonged opioid use was defined as the ongoing use of any dosage of opioids reported at either 2 or 6 weeks after surgery to treat femoroacetabular impingement, as recorded in the patient's study medication log. Multivariable logistic regressions were performed to evaluate patient and surgical characteristics, such as preoperative opioid use, type of surgical procedure and intraoperative cartilage state that may be associated with prolonged opioid use at either 2 and 6 weeks postoperatively.

RESULTS

A total of 265 and 231 patients were included for analysis at 2 and 6 weeks postoperatively, respectively. The median age of participants was 35 years (interquartile range [IQR]: 27-42) and 33% were female. At 2 weeks postoperatively, female sex (odds ratio [OR]: 2.56; 95% confidence interval: [CI] 1.34-4.98, p = 0.005), higher body mass index (BMI) (OR: 1.10; 95% CI: 1.02-1.18, p = 0.009), active tobacco use (OR: 4.06; 95% CI: 1.90-8.97, p < 0.001), preoperative opioid use (OR: 10.1; 95% CI: 3.25-39.1, p < 0.001) and an Outerbridge classification of ≥3 (OR: 2.33; 95% CI: 1.25-4.43, p = 0.009) were significantly associated with prolonged opioid use. At 6 weeks postoperatively, only preoperative opioid use was significantly associated with prolonged opioid consumption (OR: 10.6; 95% CI: 3.60-32.6, p < 0.001).

CONCLUSION

Preoperative opioid use was significantly associated with continued opioid use at 2 and 6 weeks postoperatively. Specific patient factors including female sex, higher BMI, active tobacco use and more severe cartilage damage should be considered in developing targeted strategies to limit opioid use after surgery.

LEVEL OF EVIDENCE

Level III.

Incidence of Total Knee Arthroplasty After Arthroscopic Surgery for Knee Osteoarthritis: A Secondary Analysis of a Randomized Clinical Trial

Importance

It is unclear whether arthroscopic resection of degenerative knee tissues among patients with osteoarthritis (OA) of the knee delays or hastens total knee arthroplasty (TKA); opposite findings have been reported.

Objective

To compare the long-term incidence of TKA in patients with OA of the knee after nonoperative management with or without additional arthroscopic surgery.

Design, Setting, and Participants

In this ad hoc secondary analysis of a single-center, assessor-blinded randomized clinical trial performed from January 1, 1999, to August 31, 2007, 178 patients were followed up through March 31, 2019. Participants included adults diagnosed with OA of the knee referred for potential arthroscopic surgery in a tertiary care center specializing in orthopedics in London, Ontario, Canada. All participants from the original randomized clinical trial were included. Data were analyzed from June 1, 2021, to October 20, 2022.

Exposures

Arthroscopic surgery (resection or debridement of degenerative tears of the menisci, fragments of articular cartilage, or chondral flaps and osteophytes that prevented full extension) plus nonoperative management (physical therapy plus medications as required) compared with nonoperative management only (control).

Main Outcomes and Measures

Total knee arthroplasty was identified by linking the randomized trial data with prospectively collected Canadian health administrative datasets where participants were followed up for a maximum of 20 years. Multivariable Cox proportional hazards regression models were used to compare the incidence of TKA between intervention groups.

Results

A total of 178 of 277 eligible patients (64.3%; 112 [62.9%] female; mean [SD] age, 59.0 [10.0] years) were included. The mean (SD) body mass index was 31.0 (6.5). With a median follow-up of 13.8 (IQR, 8.4-16.8) years, 31 of 92 patients (33.7%) in the arthroscopic surgery group vs 36 of 86 (41.9%) in the control group underwent TKA (adjusted hazard ratio [HR], 0.85 [95% CI, 0.52-1.40]). Results were similar when accounting for crossovers to arthroscopic surgery (13 of 86 [15.1%]) during follow-up (HR, 0.88 [95% CI, 0.53-1.44]). Within 5 years, the cumulative incidence was 10.2% vs 9.3% in the arthroscopic surgery group and control group, respectively (time-stratified HR for 0-5 years, 1.06 [95% CI, 0.41-2.75]); within 10 years, the cumulative incidence was 23.3% vs 21.4%, respectively (time-stratified HR for 5-10 years, 1.06 [95% CI, 0.45-2.51]). Sensitivity analyses yielded consistent results.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial of arthroscopic surgery for patients with OA of the knee, a statistically significant association with delaying or hastening TKA was not identified. Approximately 80% of patients did not undergo TKA within 10 years of nonoperative management with or without additional knee arthroscopic surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT00158431.

Arthroscopic Procedures Are Performed in 5% of Patients With Knee Osteoarthritis 1 Year Preceding Total Knee Arthroplasty and Are Associated With Increased Stiffness and Increased Costs

Purpose

To describe the different types of arthroscopic procedures that patients undergo in the year prior to total knee arthroplasty (TKA), reveal the cost associated with these procedures, and understand the relationship between preoperative arthroscopy and clinical outcomes after TKA.

Methods

An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with knee osteoarthritis who underwent unilateral isolated primary TKA between January 1, 2018, and September 30, 2019, were included. Knee arthroscopic procedures performed in the 1-year period before a primary TKA was identified. The primary outcomes of interest were cost of these procedures and the risk of 90-day postoperative complications.

Results

In total, 2,904 patients, representing 5.2% of the analyzed cohort, underwent arthroscopic procedures in the year prior to TKA. The most common procedure and diagnosis were meniscectomy and meniscal tear, respectively, with procedures performed an average of 7.2 ± 3.0 months before TKA. Average per patient costs were $9,716 ± $5,500 in the highest payment quartile vs $1,789 ± 636 in the lowest payment quartile. Patients with a history of arthroscopy were more likely to develop postoperative stiffness (P = .001), while no difference was found in the risk of 90-day periprosthetic joint infection (PJI).

Conclusions

Of the patients, 5.2% underwent knee arthroscopy in the year prior to TKA. While no association was seen with PJI risk, the costs associated with these procedures are high and may increase the overall cost of management of knee osteoarthritis.

Level of Evidence

Level III, retrospective comparative study.

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review

PURPOSE

To perform a systematic review of complications associated with elbow arthroscopy in adults and children.

METHODS

A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool.

RESULT

A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication.

CONCLUSIONS

Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates.

LEVEL OF EVIDENCE

Level IV; systematic review of Level I-IV studies.

National Patterns in Utilization of Knee and Hip Arthroscopy: An Analysis of Racial, Ethnic, and Geographic Disparities in the United States

Background

Racial and ethnic disparities in the field of orthopaedic surgery have been reported extensively across many subspecialties. However, these data remain relatively sparse in orthopaedic sports medicine, especially with respect to commonly performed procedures including knee and hip arthroscopy.

Purpose

To assess (1) differences in utilization of knee and hip arthroscopy between White, Black, Hispanic, and Asian or Pacific Islander patients in the United States (US) and (2) how these differences vary by geographical region.

Study Design

Descriptive epidemiology study.

Methods

The study sample was acquired from the 2019 National Ambulatory Surgery Sample database. Racial and ethnic differences in age-standardized utilization rates of hip and knee arthroscopy were calculated using survey weights and population estimates from US census data. Poisson regression was used to model age-standardized utilization rates for hip and knee arthroscopy while controlling for several demographic and clinical variables.

Results

During the study period, rates of knee arthroscopy utilization among White patients were significantly higher than those of Black, Hispanic, and Asian or Pacific Islander patients (ie, per 100,000, White: 180.5, Black: 113.2, Hispanic: 122.2, and Asian: 58.6). Disparities were even more pronounced among patients undergoing hip arthroscopy, with White patients receiving the procedure at almost 4 to 5 times higher rates (ie, per 100,000, White: 12.6, Black: 3.2, Hispanic: 2.3, Asian or Pacific Islander: 1.8). Disparities in knee and hip arthroscopy utilization between White and non-White patients varied significantly by region, with gaps in knee arthroscopy being most pronounced in the Midwest (adjusted rate ratio, 2.0 [95% CI, 1.9-2.1]) and those in hip arthroscopy being greatest in the West (adjusted rate ratio, 5.3 [95% CI, 4.9-5.6]).

Conclusion

Racial and ethnic disparities in the use of knee and hip arthroscopy were found across the US, with decreased rates among Black, Hispanic, and Asian or Pacific Islander patients compared with White patients. Disparities were most pronounced in the Midwest and South and greater for hip than knee arthroscopy, possibly demonstrating emerging inequality in a rapidly growing and evolving procedure across the country.

Unplanned return to the operating room after arthroscopic procedures: a need to consider 12 months after the initial surgery

INTRODUCTION

The purpose of this study was to report the proportion and cause of unplanned revision surgery rates within 1 year following arthroscopic procedures. Our hypothesis was that there is a significant rate of unplanned returns (URs) occurring between 3 and 12 months after the initial procedure and that causes of revision are different when considering the delay after the index surgery.

MATERIALS AND METHODS

Among 4142 consecutive patients who underwent an arthroscopic procedure in a single department of orthopedics and traumatology, patients undergoing revision surgery for any reasons directly related to the primary procedure were included. Cause for revision, surgical site, delay from index procedure, and number of revisions were screened.

RESULTS

Seventy-eight patients underwent 97 revision surgeries (2.3%) for reasons directly related to the primary procedure. Most revision surgeries were performed after month 3 following index surgery (59 patients, 60.8%). Mean time to revision surgery was 5.3 ± 4.3 months (range 0-365 days). Usual early-onset (< 3 months) reasons for unplanned revision were surgical site infection (17 patients, 0.41%), wound-healing defect (12 patients, 0.29%), and hemorrhagic complication (7 patients, 0.17%). Reasons for delayed unplanned revision (> 3 months) were index procedure failure (21 patients, 0.51%), stiffness (18 patients, 0.43%), and removal of hardware (16 patients, 0.41%).

CONCLUSIONS

Reasons for return to the operating room (OR) are different depending on the timepoint from index procedure. Patients should receive relevant information accordingly when scheduling any arthroscopic procedure, including up to 1-year potential complications.

LEVEL OF EVIDENCE

Prognostic study, Case series, Level IV.

Simple Arthroscopic Technique to Perform Retrograde Drilling for Osteonecrosis of the Femoral Condyles with the Use of Anterior Cruciate Ligament Guide

This technical note describes a simple arthroscopic technique that was introduced without the need for further staff during an operation to address osteonecrosis of the medial femoral condyle. A 2.4 mm pin was positioned through the sleeve of an anterior cruciate ligament (ACL) tibial guide and marked with a steri-strip at its body, aiming at 5-10 mm distance between the tips of guide and the pin. The steri-strip serves as a marker and as a stop for inadvertent violation of the cartilage. The tip of the ACL was positioned just over the bone lesion, while the marked 2.4 mm pin was inserted through the ACL tibial guide from anterior surface of the femur. A stab incision was made and without advancing the sleeve to the bone, the pin was drilled to the marked position while cartilage integrity was confirmed arthroscopically. This arthroscopic technique is simple, fast and effective and is performed without the need for special equipment.

Trends in Lateral Retinacular Release from 2010 to 2017

Historically, lateral retinacular release (LRR) procedures have been utilized in the treatment of a variety of patellofemoral disorders, including lateral patellar instability. However, in the past decade, there has been an increasing awareness of the importance of the lateral stabilizers in patellar stability, as well as the complications of LRR, such as recurrent medial patellar instability. The purpose of this study was to investigate current trends in LRR procedures from 2010 through 2017 using a large national database. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for arthroscopic LRR procedures (the Current Procedural Terminology [CPT] code, 29873) from 2010 to 2017. The number and incidence of lateral release procedures, both isolated and nonisolated, were analyzed and separated into cohorts for analysis. Age and gender of the LRR cohort was investigated and compared with all other orthopaedic procedures during the same time period in the NSQIP database. In addition, concomitant procedures and associated International Classification of Disease-9th Revision (ICD-9) and ICD-10th Revision (ICD-10) codes were analyzed over time and between LRR groups. From 2010 to 2017, 3,117 arthroscopic LRRs were performed. The incidence for LRR was 481.9 per 100,000 orthopaedic surgeries in 2010 and significantly decreased to 186.9 per 100,000 orthopaedic surgeries in 2017 (p < 0.01). LRR was more commonly performed in females (66%) and 58% of patients were under 44 years of age. In addition, LRR was most commonly performed with a concomitant meniscectomy (36%), synovectomy (19%), or microfracture (13%), and for a diagnosis of pain (22%). The overall incidence of LRR procedures significantly decreased from 2010 to 2017. LRRs were more commonly performed in younger, female patients for a diagnosis of pain with the most common concomitant procedure being meniscectomy, synovectomy, or microfracture.

Intra-Articular Magnesium Plus Bupivacaine Is the Most Effective and Safe Postoperative Analgesic Option Following Knee Arthroscopy: A Network Meta-analysis

PURPOSE

To evaluate the comparative efficacy and safety of single-dose intra-articular injection of commonly used analgesics after knee arthroscopy.

METHODS

A systematic literature review was done to search for randomized controlled trials (RCTs) published from database inception to October 1, 2020, that compared analgesics (i.e., morphine, bupivacaine, ropivacaine, and magnesium alone or in combination) with placebo or each other after knee arthroscopy. The primary outcomes were postoperative pain intensity at 2 hours and 24 hours. Secondary outcomes included the time to first analgesic request, number of patients requiring supplementary analgesics and side effects. We estimated summary standardized mean differences (SMDs) or odds ratios with 95% credible intervals (95% CrIs) using Bayesian network meta-analysis with random effects.

RESULTS

In total, 78 randomized controlled trials comprising 4,425 participants were included. Compared with placebo, magnesium plus bupivacaine was most likely to be effective in relieving pain at both 2-hour (SMD = -3.81, 95% CrI -5.28 to -2.35) and 24-hour after surgery (SMD = -2.81, 95% CrI: -4.29 to -1.30). Following was morphine plus bupivacaine (2-hour: SMD = -2.19, 95% CrI -3.05 to -1.31; 24-hour: SMD = -1.44, 95% CrI -2.14 to -0.73) and bupivacaine alone (2-hour: SMD = -1.66, 95% CrI -2.33 to -0.98; 24-hour: SMD = -0.67, 95% CrI -1.22 to -0.07); ropivacaine alone and magnesium alone were not effective on pain relief. The interval time to first analgesic request was significantly extended compared with placebo except for ropivacaine alone and magnesium alone. The number of patients requiring supplementary analgesics was reduced in all groups except ropivacaine alone. No statistically significant difference was found between any studied analgesics or placebo with regard to side effects.

CONCLUSIONS

Of 6 common postoperative intra-articular analgesics, magnesium plus bupivacaine provides the most effective pain relief without increasing short-term side effects after knee arthroscopy.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II studies.

Effectiveness of exercise versus arthroscopic partial meniscectomy plus exercise in the management of degenerative meniscal tears at 5-year follow-up: a systematic review and meta-analysis

INTRODUCTION

There are no meta-analytical data in the long term for comparing surgery and exercise for meniscal tear. The aim of this study is to compare the effectiveness of exercise versus arthroscopic partial meniscectomy (APM) plus exercise for degenerative meniscal tears (DMT) in knee function at 5-year follow-up.

MATERIALS AND METHODS

A systematic search of Medline, EMBASE, Web of Science, SciELO, SPORTDiscus, Scopus, and Cochrane Library was performed. The studies were included if they were randomized controlled trials performed in patients aged ≥ 18 years with DMT, that compared physical therapy to APM at 5-year follow-up, and reported at least one outcome measure of knee function/disability. Risk of bias was analyzed with the Cochrane RoB-2 tool and certainty of evidence with GRADE recommendations. A random effects model meta-analysis was performed.

RESULTS

3743 articles were identified and 4 met the criteria. Three had low risk of bias and one had some concerns. There were no significant between-group differences, in within-group changes from baseline to 5-year, on the Knee Injury and Osteoarthritis Outcome Score pain (- 2.28; 95% CI - 5.41 to 0.84), symptoms (- 0.24; 95% CI - 4.13 to 3.64), activities of daily living (- 2.16; 95% CI - 6.16 to 1.83) and quality of life (- 3.98; 95% CI - 9.05 to 1.10). There was a significant difference in support of APM plus exercise for sport/recreation (- 9.28; 95% CI - 18.28 to - 0.29). Leave-one-out sensitivity analysis revealed a non-significant difference in sport/recreation (- 5.05; 95% CI - 12.04 to 1.94). There were no differences in other patient-reported outcome measures.

CONCLUSION

Moderate certainty of evidence suggests that the addition of APM to an exercise program adds no benefits in knee function at 5-year follow-up.

Demographics and surgery-related complications lead to 30-day readmission rates among knee arthroscopic procedures

PURPOSE

The study objectives were (1) to evaluate risk factors related to 30-day hospital readmissions after arthroscopic knee surgeries and (2) to determine the complications that may arise from surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database data from 2012 to 2017 were researched. Patients were identified using Current Procedural Terminology codes for knee arthroscopic procedures. Ordinal logistic fit regression and decision tree analysis were used to examine study objectives.

RESULTS

There were 83,083 knee arthroscopic procedures between 2012 and 2017 obtained from the National Surgical Quality Improvement Program database. The overall readmission rate was 0.87%. The complication rates were highest for synovectomy and cartilage procedures, 1.6% and 1.3% respectively. A majority of readmissions were related to the procedure (71.1%) with wound complications being the primary reason (28.2%) followed by pulmonary embolism and deep vein thrombosis, 12.7% and 10.6%, respectively. Gender and body mass index were not significant factors and age over 65 years was an independent risk factor. Wound infection, deep vein thrombosis, and pulmonary embolism were the most prevalent complications.

CONCLUSION

Healthcare professionals have a unique opportunity to modify treatment plans based on patient risk factors. For patients who are at higher risk of inferior surgical outcomes, clinicians should carefully weigh risk factors when considering surgical and non-surgical approaches.

LEVEL OF EVIDENCE

III.

Failure of Orthopaedic Residents to Voluntarily Participate in a Laboratory Skills Training

INTRODUCTION

Arthroscopy simulation is increasingly used in orthopaedic residency training. The implementation of a curriculum to accommodate these new training tools is a point of interest. We assessed the use of a high-fidelity arthroscopy simulator in a strictly voluntary curriculum to gauge resident interest and educational return.

METHODS

Fifty-eight months of simulator use data were collected from a single institution to analyze trends in resident use. Comparable data from two additional residency programs were analyzed as well, for comparison. Orthopaedic residents were surveyed to gauge interest in continued simulation training.

RESULTS

Average annual simulator use at the study institution was 27.7 hours (standard deviation = 26.8 hours). Orthopaedic residents spent an average of 1.7 hours practicing on the simulation trainer during the observation period. A total of 21% of residents met or exceeded a minimum of 3 hours of simulation time required for skill improvement defined by literature. Most (86%) of the residents agreed that the simulator in use should become a mandated component of a junior resident training.

CONCLUSION

Although surgical simulation has a role in orthopaedic training, voluntary simulator use is sporadic, resulting in many residents not receiving the full educational benefits of such training. Implementation of a mandated simulation training curriculum is desired by residents and could improve the educational return of surgical simulators in residency training.

The Majority of Complaints About Orthopedic Sports Surgeons on Yelp Are Nonclinical

Purpose

To examine and characterize extremely negative Yelp reviews of orthopedic sports surgeons in the United States.

Methods

A search for reviews was performed using the keywords “Orthopedic Sports Medicine” on Yelp.com for 8 major metropolitan areas. Single-star reviews were isolated for analysis, and individual complaints were then categorized as clinical or nonclinical. The reviews were classified as surgical or nonsurgical.

Results

A total of 11,033 reviews were surveyed. Of these, 1,045 (9.5%) were identified as 1-star, and 289 were ultimately included in the study. These reviews encompassed 566 total complaints, 133 (23%) of which were clinical, and 433 (77%) of which were nonclinical in nature. The most common clinical complaints concerned complications (32 complaints; 6%), misdiagnosis (29 complaints; 5%), and uncontrolled pain (21 complaints; 4%). The most common nonclinical complaints concerned physicians’ bedside manner (120 complaints; 21%), unprofessional staff (98 complaints; 17%), and finances (78 complaints; 14%). Patients who had undergone surgery wrote 47 reviews that resulted in 114 complaints (20.5% of total complaints), whereas nonsurgical patients were responsible for 242 reviews and a total of 452 complaints (81.3% of total complaints). The difference in the number of complaints by patients after surgery and patients without surgery was statistically significant (P < 0.05) for all categories except for uncontrolled pain, delay in care, bedside manner of midlevel staff, and facilities.

Conclusion

Our study of extremely negative Yelp reviews found that 77% of negative complaints were nonclinical in nature. The most common clinical complaints were complications, misdiagnoses and uncontrolled pain. Only 16% of 1-star reviews were from surgical patients.

Clinical Relevance

Patients use online review platforms when choosing surgeons. A comprehensive understanding of factors affecting patient satisfaction and dissatisfaction is needed. The results of our study could be used to guide future quality-improvement measures and to assist surgeons in maintaining favorable online reputations.

Fundamentals of Arthroscopy Fluid Management and Strategies to Safely Improve Visualization

Arthroscopy has become increasingly relevant to various subspecialties within the orthopaedic surgery. From a patient safety standpoint and surgical efficiency standpoint, it is critical to know the fundamental concepts of fluid management such as those related to the fluid, pressure, and flow. A satisfactory field of view during arthroscopy can be achieved with the use of gravity-dependent or automated fluid management systems. Fluid management parameters and their physiological impact on the patient should be continuously monitored to avoid morbidity or delayed recovery. Local and systemic complications can occur from careless use of techniques that improve visualization such as tourniquet, epinephrine-diluted irrigation, and controlled hypotensive anesthesia. The purpose of this article is to review the fundamental concepts of fluid management in arthroscopy and the techniques to safely improve arthroscopic visualization.

Magnetic resonance imaging scans in patients with dorsal root ganglion stimulation

OBJECTIVE

Patients fitted with a neurostimulator face a greater need to undergo magnetic resonance imaging (MRI) scans. Given the lack of literature in this regard, this study aims to review our experience with MRI examinations on patients implanted with a dorsal root ganglion stimulation (DRG-S) system and their potential adverse events.

MATERIALS AND METHODS

We conducted a retrospective analysis of the prospective treatment documentation gathered from November 2011 to October 2020. We identified 259 MRI registrations for patients with an implanted neurostimulation system; the MRI examinations were performed using a 1.5 Tesla MRI system in accordance with a structured scheme.

RESULTS

Among the 259 MRI registrations identified in this study, 28 corresponded to patients with an implanted DRG-S system. In 2 cases, no MRI scan was performed, and thus, only 26 MRI examinations were evaluated in detail. The DRG-S device was approved for the requested MRI scans in only 2 of these 26 cases (7.7%). In addition, 2 minor adverse events (syncopal episode and connection problem) were identified, and only the second problem (3.8%) was related to neurostimulator operation.

CONCLUSIONS

Necessary MRI examinations in patients with DRG-S systems are rarely covered by the European CE/US Food and Drug Administration (CE/FDA) approval. Although the manufacturer recommendations are against the use of MRI in patients with implanted DRG-S in certain conditions, we performed these scans without causing injury to the patient or damaging the device. Given that data on safety are limited, MRIs should be conducted study related. We provide recommendations for the procedure that should be followed when an MRI is needed urgently.

Surgeons respond to growing evidence by performing less knee arthroscopic surgery in older patients

BACKGROUND

Recent research has shown that knee arthroscopy does not provide a meaningful clinical benefit for degenerative knee changes in the older population. The 2016 Australian Orthopaedic Association (AOA) Annual Scientific Meeting held a plenary session on this topic to educate surgeons about these research findings and communicate their clinical practice statement on this issue. This paper set out to find if there has been a change in clinical practice since this meeting.

METHODS

The analysis consisted of all knee arthroscopies performed in a single city of Far North Queensland, Australia, over an 8-year period. The number and type of arthroscopies performed in patients <50 and ≥50 years of age was compared before and after the 2016 AOA plenary session.

RESULTS

After the 2016 AOA educational session, there was a significant reduction in the number of debridement procedures performed in patients aged 50 years or older (275 vs. 142 per year, P < 0.01) but not in patients under 50 years of age (192 vs. 135 per year, P = 0.91). The annual number of repair procedures for all ages combined, increased from 11 per year to 60 per year (P < 0.01).

CONCLUSION

The surgeons of this city have changed their knee arthroscopy clinical practice in line with the evidence and advice from their professional body.

Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors

BACKGROUND

An important aim of high tibial osteotomy (HTO) is to prevent or delay the need for total knee replacement (TKR). We sought to estimate the frequency and timing of conversion from HTO to TKR and the factors associated with it.

METHODS

We prospectively evaluated patients with osteoarthritis (OA) of the knee who underwent medial opening wedge HTO from 2002 to 2014 and analyzed the cumulative incidence of TKR in July 2019. The presence or absence of TKR on the HTO limb was identified from the orthopedic surgery reports and knee radiographs contained in the electronic medical records for each patient at London Health Sciences Centre. We used cumulative incidence curves to evaluate the primary outcome of time to TKR. We used multivariable Cox proportional hazards analysis to assess potential preoperative predictors including radiographic disease severity, malalignment, correction size, pain, sex, age, body mass index (BMI) and year of surgery.

RESULTS

Among 556 patients who underwent 643 HTO procedures, the cumulative incidence of TKR was 5% (95% confidence interval [CI] 3%-7%) at 5 years and 21% (95% CI 17%-26%) at 10 years. With the Cox proportional hazards multivariable model, the following preoperative factors were significantly associated with an increased rate of conversion: radiographic OA severity (adjusted hazard ratio [HR] 1.96, 95% CI 1.12-3.45), pain (adjusted HR 0.85, 95% CI 0.75-0.96)], female sex (adjusted HR 1.67, 95% CI 1.08-2.58), age (adjusted HR 1.50 per 10 yr, 95% CI 1.17-1.93) and BMI (adjusted HR 1.31 per 5 kng/m2, 95% CI 1.12-1.53).

INTERPRETATION

We found that 79% of knees did not undergo TKR within 10 years after undergoing medial opening wedge HTO. The strongest predictor of conversion to TKR is greater radiographic disease at the time of HTO.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level III, retrospective comparative trial.

Trends and Complications of Arthroscopic-Assisted Tibial Plateau Fracture Fixation: A Matched Cohort Analysis

Purpose

To determine trends in arthroscopic-assisted tibial plateau fracture fixation (AATPFF), to evaluate trends in the overall rate of tibial plateau fracture fixation, and to compare postoperative complications between AATPFF and traditional tibial plateau fixation.

Methods

A retrospective review of patients undergoing AATPFF and traditional tibial plateau fixation was conducted using the Humana Inc. administrative database from 2007 to 2016. A 1:1 propensity match was utilized to match patients in the 2 study groups based on age, sex, obesity, diabetes, hypertension, chronic obstructive pulmonary disease, depression or anxiety, and smoking history. Postoperative complications were grouped as minor medical complications, major medical complications, surgical complications, emergency department visits, and reoperation. Linear regression analysis was used to assess trends and Pearson's χ² test was used to compare postoperative complications with statistical significance defined as P < .05.

Results

In total, 522 patients underwent AATPFF and 3920 patients underwent traditional tibial plateau fracture fixation. There was a 4-fold increase in the use of AATPFF over the study period (P = .0173). Similarly, there was an increase in the utilization of traditional tibial plateau fracture fixation, although to a lesser extent (1.33-fold). After propensity matching, the traditional fixation group demonstrated significantly higher rates of minor medical complications (8.2% vs 2.7%, P = .0002), major medical complications (9.9% vs 4.6%, P = .0018), surgical complications (13.2% vs 2.7%, P < .0001), and emergency department visits (21.4% vs 13.5%, P < .0001) within 90 days of surgery compared with the AATPFF group. There was no difference in reoperation rates within 90 days between the 2 groups (2.9% vs 3.6%, P = .85).

Conclusions

The incidence of tibial plateau fracture fixation is increasing, however, use of AATPFF is increasing at a faster rate compared to traditional techniques. Furthermore, the addition of knee arthroscopy to fracture fixation does not increase the risk of complication, reoperation, or emergency department visit within 90 days.

Level of Evidence

III, retrospective matched cohort.

Resident Involvement Is Not Associated With Increased Risk of Postoperative Complications After Arthroscopic Knee Surgery: A Propensity-Matched Study

PURPOSE

To investigate whether resident involvement in knee arthroscopy procedures affects postoperative complications or operative times.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program registry was queried to identify patients who underwent common knee arthroscopy procedures between 2006 through 2012. Patients with a history of knee arthroplasty, septic arthritis or osteomyelitis of the knee, concomitant open or mini-open procedures, or without information on resident involvement were excluded. A 1:1 propensity score match was performed based on age, sex, obesity, smoking history, and American Society of Anesthesiologist classification to match cases with resident involved to nonresident cases. Fisher exact tests, Pearson's χ² tests, and Wilcoxon rank sum tests were used to compare patient demographics, comorbidities, and 30-day complications. Wilcoxon rank sum tests were used to compare operative time and length of hospital stay between the 2 groups, with statistical significance defined as P < .05.

RESULTS

After matching, 2954 cases (50% resident involvement) were included in the study with no significant differences in demographics or comorbidities between the 2 cohorts. The overall rate of 30-day complications was 1.1% in the nonresident and resident involved group (P = 1.000). There was no significant difference in postoperative surgical (nonresident vs resident involved: 0.48% vs 0.83%, P = .2498) or medical (nonresident vs resident involved: 0.62% vs 0.83%, P = .5111) complications. However, knee arthroscopy cases that residents were involved with had significantly longer operative times (69.8 vs 66.8 minutes, P = .0002), and length of hospital stay (0.85 vs 0.21 days, P = .0332) when compared with cases performed without a resident.

CONCLUSIONS

Resident involvement in knee arthroscopy procedures is not a significant risk for medical or surgical 30-day postoperative complications. Resident participation in knee arthroscopy was associated with statistically significant but likely clinically insignificant increased operative time as well as length of hospital stay.

LEVEL OF EVIDENCE

Level III: Retrospective Cohort Study.

Partial Medial Meniscectomy Using Needle Arthroscopy and a Standardized Local Anesthetic Protocol

Needle arthroscopic procedures of the knee offer potential advantages over standard arthroscopic procedures. The small size of the instruments allows for surgery without the use of a scalpel or suture, potentially decreased recovery times, and potentially reduced complication rates compared with traditional arthroscopy. In some patients, the procedure can be performed without the use of either general anesthesia or sedation. The purpose of this article is to provide a standardized technique guide for needle arthroscopic partial medial meniscectomy under local anesthesia.