Effect of Sarcopenia on Postoperative Morbidity and Mortality After Thoracolumbar Spine Surgery

Sarcopenia is the loss of muscle mass associated with aging and advanced disease. This study retrospectively examined patients older than 55 years (N=46) who underwent thoracolumbar spine surgery between 2003 and 2015. Each patient's comorbidity burden was determined using the Charlson Comorbidity Index, and the Mirza Surgical Invasiveness Index was used to measure procedural complexity. Sarcopenia was diagnosed by measuring the total cross-sectional area of the psoas muscle at the L4 vertebrae using perioperative computed tomography scans. Of the 46 patients assessed, 16 were in the lowest third for L4 total psoas area (sarcopenic). Average follow-up time was 5.2 years (range, 6 days to 12.7 years). The cohort of patients with sarcopenia was significantly older than the cohort without sarcopenia (mean age, 76.4 vs 69.9 years; P=.01) but did not have a significantly different mean Charlson Comorbidity Index (3.3 vs 2.0; P=.32) or mean Mirza Surgical Invasiveness Index (7.1 vs 7.0; P=.49). Patients with sarcopenia had a hospital length of stay 1.7-fold longer than those without sarcopenia (8.1 vs 4.7 days; P=.02) and a 3-fold increase in postoperative in-hospital complications (1.2 vs 0.4; P=.02), and they were more likely to require discharge to a rehabilitation or nursing facility (81.2% vs 43.3%; P=.006). Patients with sarcopenia had a significantly lower cumulative survival (log rank=0.007). All 4 deaths occurred among patients with sarcopenia. Patients with sarcopenia have a significantly increased risk of in-hospital complications, longer length of stay, increased rates of discharge to rehabilitation facilities, and increased mortality following thoracolumbar spinal surgery, making sarcopenia a useful perioperative risk stratification tool. [Orthopedics. 2016; 39(6):e1159-e1164.].

Patient-Specific Orthopaedic Implants

Patient-specific orthopaedic implants are emerging as a clinically promising treatment option for a growing number of conditions to better match an individual's anatomy. Patient-specific implant (PSI) technology aims to reduce overall procedural costs, minimize surgical time, and maximize patient outcomes by achieving better biomechanical implant fit. With this commercially-available technology, computed tomography or magnetic resonance images can be used in conjunction with specialized computer programs to create preoperative patient-specific surgical plans and to develop custom cutting guides from 3-D reconstructed images of patient anatomy. Surgeons can then place these temporary guides or "jigs" during the procedure, allowing them to better recreate the exact resections of the computer-generated surgical plan. Over the past decade, patient-specific implants have seen increased use in orthopaedics and they have been widely indicated in total knee arthroplasty, total hip arthroplasty, and corrective osteotomies. Patient-specific implants have also been explored for use in total shoulder arthroplasty and spinal surgery. Despite their increasing popularity, significant support for PSI use in orthopaedics has been lacking in the literature and it is currently uncertain whether the theoretical biomechanical advantages of patient-specific orthopaedic implants carry true advantages in surgical outcomes when compared to standard procedures. The purpose of this review was to assess the current status of patient-specific orthopaedic implants, to explore their future direction, and to summarize any comparative published studies that measure definitive surgical characteristics of patient-specific orthopaedic implant use such as patient outcomes, biomechanical implant alignment, surgical cost, patient blood loss, or patient recovery.

Factors influencing survival following hip fracture among octogenarians and nonagenarians in the United States

INTRODUCTION

Hip fractures account for a significant disease burden in the Unites States. With an aging population, this disease burden is expected to increase in the upcoming decades.

MATERIALS AND METHODS

This represents a retrospective cohort study to assess mortality following hip fracture in the octogenarian and nonagenarian populations. Odds ratios for postoperative mortality were constructed using normalized patients from United States Social Security death tables. Kaplan Meier analysis and binary logistic regression were used to assess the impact of surgical delay and medical comorbidity (measured by the Carlson Comorbidity Index (CCI)) on postoperative mortality.

RESULTS

189 octogenarians and 95 nonagenarians were included. One-year mortality was nearly three times higher for both the octogenarians (OR: 3.1) and nonagenarians (OR: 3.14), and returned to that of the normal population 4 years post-op for octogenarians and 5 years post-op for nonagenarians. Higher preoperative medical comorbidity (CCI) was associated with higher post-op mortality for both octogenarians (log rank = 0.026) and nonagenarians (log rank = 0.034). A 48-h surgical delay resulted in significantly increased postoperative mortality among healthy patients (CCI of 0 or 1, OR: 18.1), but was protective for patients with significant medical comorbidity (CCI ≥ 3). Age, preoperative CCI, and 48-h surgical delay were all independent predictors of 1-year post-op mortality.

CONCLUSIONS

Following hip fracture, there is a 3-fold increase in mortality for octogenarians and nonagenarians at 1 year post-op. A 48-h surgical delay significantly increased mortality for healthier patients but was protective against mortality for sicker patients.

Efficacy and Cost-effectiveness of Topical Vancomycin Powder in Primary Cementless Total Hip Arthroplasty

Topical vancomycin has been shown to effectively reduce infections after spinal surgery while remaining safe and cost-effective; however, there are few studies evaluating topical vancomycin in total hip arthroplasty. The authors hypothesized that the incidence of periprosthetic joint infection would decrease with the use of topical vancomycin in total hip arthroplasty and that topical vancomycin would be cost-effective. A retrospective patient chart review was performed to evaluate consecutive primary cementless total hip arthroplasties performed in the authors' hospital system between April 2015 and December 2016. Demographic data were collected. Periprosthetic joint infection was defined by Musculoskeletal Infection Society criteria. Statistical analysis included t test, Fisher's exact test, and logistic regression. The costs of vancomycin and postoperative infection were used to determine the absolute risk reduction (1/number needed to treat) threshold needed for topical vancomycin to be cost-effective. In this study, 309 patients (55.7%) undergoing total hip arthroplasty were treated with topical vancomycin, and 246 patients (44.3%) did not receive treatment. There were 2 infections in the vancomycin group (0.6% incidence), and 4 in the no vancomycin group (1.6% incidence). There was no statistical difference in infection rate between the 2 cohorts (P=.414). The absolute risk reduction was 0.98%, and the number needed to treat with topical vancomycin was 102 patients to prevent 1 periprosthetic joint infection. Topical vancomycin ($12 per vial) resulted in an expected cost savings of $904 per patient. Topical vancomycin is inexpensive and cost-effective. Although not statistically significant, the topical vancomycin group had a 60% lower incidence of infection. Further research regarding appropriate prophylactic topical and intravenous antibiotic use is needed prior to widespread adoption. [Orthopedics. 2019; 42(5):e430-e436.].

Inpatient costs and blood transfusion rates of sarcopenic patients following thoracolumbar spine surgery

OBJECTIVE

Sarcopenia, the muscle atrophy associated with aging and disease progression, accounts for nearly $18.5 billion in health care expenditures annually. Given the high prevalence of sarcopenia in patients undergoing orthopedic surgery, the goal of this study was to assess the impact of sarcopenia on inpatient costs following thoracolumbar spine surgery.

METHODS

Patients older than 55 years undergoing thoracolumbar spine surgery from 2003 to 2015 were retrospectively analyzed. Sarcopenia was measured using total psoas area at the L-4 vertebra on perioperative CT scans. Hospital billing data were used to compare inpatient costs, transfusion rate, and rate of advanced imaging utilization.

RESULTS

Of the 50 patients assessed, 16 were sarcopenic. Mean total hospital costs were 1.75-fold greater for sarcopenic patients compared with nonsarcopenic patients ($53,128 vs $30,292, p = 0.04). Sarcopenic patients were 2.1 times as likely to require a blood transfusion (43.8% vs 20.6%, p = 0.04). Sarcopenic patients had a 2.6-fold greater usage of advanced imaging (68.8% vs 26.5%, p = 0.002) with associated higher diagnostic imaging costs ($2452 vs $801, p = 0.01). Sarcopenic patients also had greater pharmacy, laboratory, respiratory care, and emergency department costs.

CONCLUSIONS

This study is the first to show that sarcopenia is associated with higher postoperative costs and rates of blood transfusion following thoracolumbar spine surgery. Measuring the psoas area may represent a strategy for predicting perioperative costs in spine surgery patients.

Suture Anchor Versus Transosseous Tunnel Repair for Inferior Pole Patellar Fractures Treated With Partial Patellectomy and Tendon Advancement: A Biomechanical Study

Background:

Comminuted inferior pole patellar fractures can be treated in numerous ways. To date, there have been no studies comparing the biomechanical properties of transosseous tunnels versus suture anchor fixation for partial patellectomy and tendon advancement of inferior pole patellar fractures.

Hypothesis:

Suture anchor repair will result in less gapping at the repair site. We also hypothesize no difference in load to failure between the groups.

Study Design:

Controlled laboratory study.

Methods:

Ten cadaveric knee extensor mechanisms (5 matched pairs; patella and patellar tendon) were used to simulate a fracture of the extra-articular distal pole of the patella. The distal simulated fracture fragment was excised, and the patellar tendon was advanced and repaired with either transosseous bone tunnels through the patella or 2 single-loaded suture anchors preloaded with 1 suture per anchor. Load to failure and elongation from cycles 1 to 250 between 20 and 100 N of force were measured, and modes of failure were recorded. Statistical analysis was performed using a paired 2-tailed Student t test.

Results:

The suture anchor group had less gapping during cyclic loading as compared with the transosseous tunnel group (mean ± SD, 6.83 ± 2.23 vs 13.30 ± 5.74 mm; P = .047). There was no statistical difference in the load to failure between the groups. The most common mode of failure was at the suture-anchor interface in the suture anchor group (4 of 5) and at the knot proximally on the patella in the transosseous tunnel group (4 of 5).

Conclusion:

Suture anchors yielded similar strength profiles and less tendon gapping with cyclic loading when compared with transosseous tunnels in the treatment of comminuted distal pole of the patellar fractures managed with partial patellectomy and patellar tendon advancement.

Clinical Relevance:

Suture anchors may offer robust repair and earlier range of motion in the treatment of fractures of the distal pole of the patella. Clinical randomized controlled trials would help clinicians better understand the difference in repair techniques and confirm the translational efficacy in clinical practice.

Posterior Glenoid Osteotomy With Capsulolabral Repair Improves Resistance Forces in a Critical Glenoid Bone Loss Model

Background:

There is no widespread consensus on the surgical treatment of posterior shoulder instability with critical posterior glenoid bone loss.

Hypothesis:

That opening posterior glenoid wedge osteotomy with soft tissue repair would improve the resistance forces of instability when compared with soft tissue repair alone in the setting of 20% critical bone lose.

Study Design:

Controlled laboratory study.

Methods:

Native glenoid retroversion was measured on 9 shoulders using computed tomography (CT) scans. The humerus was potted in 90° of forward flexion and 30° of internal rotation relative to the scapula, and a posterior dislocation was performed to create a posterior capsulolabral injury model. The specimens were each taken through a fixed sequence of testing: (1) posteroinferior capsulolabral tear, (2) no glenoid bone loss with posteroinferior capsulolabral repair, (3) 20% posterior glenoid bone loss with posteroinferior capsulolabral repair, and (4) 20% glenoid bone loss with posterior glenoid opening wedge osteotomy and posteroinferior capsulolabral repair. Bone loss was created using a sagittal saw. The resultant peak forces with 1 cm of posterior translation were measured. A 1-way repeated-measures analysis of variance was used to compare mean force values.

Results:

After the initial dislocation event, all shoulders had a resultant posterior capsulolabral injury. The resulting labral injury was extended from 6- to 9-o’clock in all specimens to homogenize the extent of injury. Repairing the capsulolabral complex in the 20% posterior glenoid bone loss group did not result in a statistically significant increase in resistance force compared with the labral deficient group (34.1 vs 22.2 N; P = .068). When 20% posterior bone loss was created, the posterior glenoid osteotomy with capsulolabral repair was significantly stronger (43.8 N) than the posterior repair alone both with (34.1 N) and without (31.8 N) bone loss (P = .008 and .045, respectively).

Conclusion:

In the setting of critical posterior glenoid bone loss, an opening wedge posterior glenoid osteotomy with capsulolabral repair improved resistance to posterior humeral translation significantly compared with capsulolabral repair alone.

Clinical Relevance:

The results of this biomechanical cadaveric study may aid in surgical planning for this complex patient population.

Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction

» The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).» The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.» QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.» The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.» There are emerging data that the QT autograft is a viable option in revision ACLR.

Ulnar Collateral Ligament Injuries in Overhead Athletes: Diagnosis, Management, and Clinical Outcomes

Ulnar collateral ligament (UCL) injuries are a common source of pain and disability in overhead and throwing athletes. The prolonged nature of healing often results in notable time lost from competitive sports regardless of the definitive management strategy. A thorough history and physical examination are critical in the diagnosis of UCL injury and understanding patient goals and expectations. In carefully selected patients, nonsurgical management, including rest and slow progression back to activities, can result in successful return to sport. Recent literature has suggested that administration of platelet-rich plasma may be effective in aiding in the healing process, particularly in proximal and partial-thickness tears; however, additional study is warranted. UCL reconstruction has been the benchmark for tears not amendable to nonsurgical treatment, with flexor-pronator complex preservation being important. UCL repair has historically been most commonly used in partial avulsions, but indications have yet to be completely well defined. Knowledge regarding appropriate UCL treatment continues to evolve with patient-specific treatment being essential.

Arthroscopic Side-to-Side Suture Repair for Full-Thickness Transtendinous Supraspinatus Rotator Cuff Tear

Background

Full-thickness, transtendinous supraspinatus tears involve a significant portion of the remnant tendon that remains attached to the greater tuberosity footprint. This tear type often leaves insufficient medial tissue for tension-free footprint restoration with traditional repair techniques. In these clinical scenarios, side-to-side suture repair is an effective repair technique.

Indications

Indications for this procedure include an acute mechanism of injury, sufficient remnant tendon left on the greater tuberosity, and a medial tear location such that primary repair of the medial tendon would not result in overtensioning of the repair.

Technique Description

Following diagnostic arthroscopy, 2 suture tapes are passed through the medial and lateral portion of the tendon surface in a simple side-to-side fashion. Two FiberLink sutures (Arthrex) are then placed in luggage tag fashion, in between the side-to-side sutures within the myotendinous portion of the tear. The suture tapes are then tied in an arthroscopic fashion, completing the side-to-side repair. The looped sutures are then secured through a 4.75-mm BioComposite SwiveLock lateral row anchor (Arthrex) as an added reinforcement to prevent medial retraction of the myotendinous portion of the tear, creating a tension-free environment for optimal tear healing.

Results

Available literature suggests that the side-to-side repair technique in patients with transtendinous supraspinatus rotator cuff tears yields excellent outcomes equivalent to that of tendon-to-bone double-row suture anchor repair for conventional tendon to bone type tears. This surgical technique reduces risk of overtensioning the repair and optimizes the healing environment in this rare clinical scenario.

Discussion/Conclusion

Side-to-side suture repair for full-thickness transtendinous supraspinatus tears is an effective treatment for patients with this uncommon presentation. When healthy tendon is present, a robust repair can be achieved with excellent outcomes and low rates of surgical complications.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Salter-Harris Type III Fracture of the Distal Phalanx: A Rare Juxtaphyseal Variant

Juxtaphyseal fractures of the distal phalanges of upper extremity digits are most commonly of the Salter-Harris II variety and occur most commonly in the thumb. The diagnosis of this injury is essential as it may present as an open fracture with a nailbed injury ("Seymour fracture"). However, an intra-articular, epiphyseal fracture may also occur and mimic a mallet deformity or Seymour fracture. Prompt diagnosis is essential to rule out an open fracture and obtain anatomical alignment and stability to attempt to reduce complications such as physeal arrest. Here, we present a patient with a displaced Salter-Harris type III fracture of his thumb distal phalanx and review his management and early-term outcome. We present this case to bring attention to this rare and unique injury, review the available literature, and discuss management and outcomes.

Anterior Glenohumeral Instability: Clinical Anatomy, Clinical Evaluation, Imaging, Nonoperative and Operative Management, and Postoperative Rehabilitation

➢ Anterior glenohumeral instability is a complex orthopaedic problem that requires a detailed history, a thorough physical examination, and a meticulous review of advanced imaging in order to make individualized treatment decisions and optimize patient outcomes.➢ Nonoperative management of primary instability events can be considered in low-demand patients, including elderly individuals or younger, recreational athletes not participating in high-risk activities, and select in-season athletes. Recurrence can result in increased severity of soft-tissue and osseous damage, further increasing the complexity of subsequent surgical management.➢ Surgical stabilization following primary anterior instability is recommended in young athletes who have additional risk factors for failure, including participation in high-risk sports, hyperlaxity, and presence of bipolar bone loss, defined as the presence of both glenoid (anteroinferior glenoid) and humeral head (Hill-Sachs deformity) bone loss.➢ Several surgical treatment options exist, including arthroscopic Bankart repair with or without additional procedures such as remplissage, open Bankart repair, and osseous restoration procedures, including the Latarjet procedure.➢ Favorable results can be expected following arthroscopic Bankart repair with minimal (<13.5%) bone loss and on-track Hill-Sachs lesions following a primary instability event. However, adjunct procedures such as remplissage should be performed for off-track lesions and should be considered in the setting of subcritical glenoid bone loss, select high-risk patients, and near-track lesions.➢ Bone-grafting of anterior glenoid defects, including autograft and allograft options, should be considered in cases with >20% glenoid bone loss.

Bridge-Enhanced Anterior Cruciate Ligament Repair: The Next Step Forward in ACL Treatment

Anterior cruciate ligament (ACL) injuries are common in young and active patients. In this patient population, surgical treatment with an autograft tendon is recommended to reconstruct a new ACL. ACL reconstruction has a high patient satisfaction, improved patient reported outcomes and allows young patients to return to an active lifestyle, including sports. However, long-term follow-up shows these patients are at higher risk for degenerative arthritis, frequently at a young age. Recent research has focused on re-investigating the utility of performing an ACL repair rather than a reconstruction in the hopes that maintaining a patient's native ligament may not only restore knee stability, but provide improved knee kinematics and lessen the risk of late osteoarthritis and also limit donor site morbidity from autograft harvests. Historically, patients undergoing ACL repair suffered poor outcomes due to issues with intra-articular healing of the ligament; but now, with new bioengineering techniques, bridge-enhanced ACL repairs may provide a feasible alternative in the treatment of ACL injuries.

A Posterior Acromial Bone Block Augmentation Is Biomechanically Effective at Restoring the Force Required To Translate the Humeral Head Posteriorly in a Cadaveric, Posterior Glenohumeral Instability Model

PURPOSE

To assess the biomechanical utility of a posterior acromial bone block (PABB) for the treatment of posterior glenohumeral instability.

METHODS

Ten fresh-frozen cadaveric specimens were obtained based upon an a priori power analysis. A 2.5-cm scapular spine autograft was harvested from all shoulders. A custom robot device was used to apply a 50-N compressive force to the glenohumeral joint. The humeral head was translated 10 mm posteroinferiorly at 30 degrees from the center of the glenoid at a rate of 1.0 mm/s in 6 consecutive conditions: (1) intact specimen, (2) intact with PABB, (3) posterior capsulolabral tear, (4) addition of the PABB, (5) removal of the PABB and repair of the capsulolabral tear (LR), and (6) addition of the PABB with LR. The maximum force required to obtain this translation was recorded. Paired t tests were performed to compare relevant testing conditions.

RESULTS

Ten cadavers with a mean ± SD age of 54.4 ± 13.1 years and mean ± SD glenoid retroversion of 6.5 ± 1.0 degrees were studied. The PABB provided greater resistance force to humeral head translation compared to the instability state (instability, 29.3 ± 15.3 N vs PABB, 47.6 ± 21.0 N; P = .001; 95% confidence interval [CI], -27.6 to -10.0). When comparing PABB to LR, the PABB produced higher resistance force than LR alone (PABB, 47.6 ± 21.0 N; LR, 34.2 ± 20.5 N; P = .012; 95% CI, -23.4 to -4.1). An instability lesion treated with the PABB, with LR (P = .056; 95% CI, -0.30 to 20.4) or without LR (P = .351; 95% CI, -6.8 to 15.7), produced resistance forces similar to the intact specimen.

CONCLUSIONS

A PABB is biomechanically effective at restoring the force required to translate the humeral head posteriorly in a cadaveric, posterior glenohumeral instability model. A posterior acromial bone block is a biomechanically feasible option to consider in patients with recurrent posterior instability.

CLINICAL RELEVANCE

Augmentation of the posterior acromion may be a biomechanically feasible option to treat posterior shoulder instability.

Performance of Artificial Intelligence in Addressing Questions Regarding Management of Osteochondritis Dissecans

BACKGROUND

Large language model (LLM)-based artificial intelligence (AI) chatbots, such as ChatGPT and Gemini, have become widespread sources of information. Few studies have evaluated LLM responses to questions about orthopaedic conditions, especially osteochondritis dissecans (OCD).

HYPOTHESIS

ChatGPT and Gemini will generate accurate responses that align with American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

Level 2.

METHODS

LLM prompts were created based on AAOS clinical guidelines on OCD diagnosis and treatment, and responses from ChatGPT and Gemini were collected. Seven fellowship-trained orthopaedic surgeons evaluated LLM responses on a 5-point Likert scale, based on 6 categories: relevance, accuracy, clarity, completeness, evidence-based, and consistency.

RESULTS

ChatGPT and Gemini exhibited strong performance across all criteria. ChatGPT mean scores were highest for clarity (4.771 ± 0.141 [mean ± SD]). Gemini scored highest for relevance and accuracy (4.286 ± 0.296, 4.286 ± 0.273). For both LLMs, the lowest scores were for evidence-based responses (ChatGPT, 3.857 ± 0.352; Gemini, 3.743 ± 0.353). For all other categories, ChatGPT mean scores were higher than Gemini scores. The consistency of responses between the 2 LLMs was rated at an overall mean of 3.486 ± 0.371. Inter-rater reliability ranged from 0.4 to 0.67 (mean, 0.59) and was highest (0.67) in the accuracy category and lowest (0.4) in the consistency category.

CONCLUSION

LLM performance emphasizes the potential for gathering clinically relevant and accurate answers to questions regarding the diagnosis and treatment of OCD and suggests that ChatGPT may be a better model for this purpose than the Gemini model. Further evaluation of LLM information regarding other orthopaedic procedures and conditions may be necessary before LLMs can be recommended as an accurate source of orthopaedic information.

CLINICAL RELEVANCE

Little is known about the ability of AI to provide answers regarding OCD.

In Patients With Rotator Cuff Tears, Female, Hispanic, African American, Asian, Socially Deprived, Federally Insured, and Uninsured Patients Are Less Commonly Treated Surgically

PURPOSE

To evaluate socioeconomic factors affecting whether a patient undergoes rotator cuff repair after a diagnosis of a rotator cuff tear.

METHODS

From 2009 through 2018, claims for adult (≥18 years of age) patients who were diagnosed with a primary rotator cuff injury were identified in the New York Statewide Planning and Research Cooperative System (SPARCS) database via International Classification of Diseases (ICD)-9th Revision-Clinical Modification (CM) and ICD-10-CM diagnostic codes. SPARCS is a comprehensive all-payer database collecting all inpatient and outpatient pre-adjudicated claims in New York. ICD-9-CM and ICD-10-CM codes were used to identify the initial diagnosis for each patient. Current Procedural Terminology codes were used to identify subsequent rotator cuff surgery. The procedures identified were linked with the initial diagnosis, and patients were noted as either having or not having rotator cuff surgery. Logistic regression analysis was performed for variables including age, sex, race, Social Deprivation Index (SDI), Charlson Comorbidity Index, and primary insurance type to determine the effect of patient factors on the likelihood of having surgery after a diagnosis of rotator cuff injury.

RESULTS

Of the 67,584 rotator cuff patients included in the analysis, 19,770 (29.3%) of the patients underwent surgical intervention. From the logistic regression, females relative to males (odds ratio [OR] = 0.798, P < .0001), increased SDI (OR = 0.994, p < .0001), African American compared with White race (OR = 0.694, P < .0001), Asian compared with White (OR = 0.832, P < .0001), Hispanic compared with White (OR = 0.693, P < .0001), other race (OR = 0.58, P < .0001), those with Medicare (OR = 0.601, P < .0001) or Medicaid (OR = 0.614, P < .0001) relative to private insurance, and self-pay relative to private insurance (OR = 0.727, P < .0001) were all associated with decreased odds of undergoing rotator cuff surgery. Older patients (OR = 1.012, P < .0001) and Workers' Compensation relative to private insurance (OR = 1.664, P < .0001) had increased odds of undergoing surgery.

CONCLUSIONS

The results of the current study identified disparities in the likelihood of undergoing rotator cuff repair after a diagnosis of a rotator cuff tear based on patient demographic and socioeconomic factors. Individuals with higher SDI; African American, Asian, Hispanic, or other non-White races; and those with Medicare, Medicaid, or self-pay insurance had decreased odds of surgery, whereas older age and Workers' Compensation insurance were associated with increased odds of undergoing surgery.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Arthroscopic Bankart repair with remplissage yields similar outcomes to open Latarjet for primary and revision stabilization in the setting of subcritical glenoid bone loss

BACKGROUND

Management of patients with recurrent anterior glenohumeral instability in the setting of subcritical glenoid bone loss (GBL), defined in this study as 20% GBL or less, remains controversial. This study aimed to compare arthroscopic Bankart with remplissage (ABR + R) to open Latarjet for subcritical GBL in primary or revision procedures. We hypothesized that ABR + R would yield higher rates of recurrent instability and reoperation compared to Latarjet in both primary and revision settings.

METHODS

A retrospective study was conducted on patients undergoing either arthroscopic ABR + R or an open Latarjet procedure. Patients with connective tissue disorders, critical GBL (>20%), <2 year follow-up, or insufficient data were excluded. Recurrent instability and revision were the primary outcomes of interest. Additional outcomes of interest included subjective shoulder value, strength, and range of motion (ROM) RESULTS: One hundred eight patients (70 ABR + R, 38 Latarjet) were included with an average follow-up of 4.3 ± 2.1 years. In the primary and revision settings, similar rates of recurrent instability (Primary: P = .60; Revision: P = .28) and reoperation (Primary: P = .06; Revision: P = 1.00) were observed between Latarjet and ABR + R. Primary ABR + R exhibited better subjective shoulder value, active ROM, and internal rotation strength compared to primary open Latarjet. However, no differences were observed in the revision setting.

CONCLUSION

Similar rates of recurrent instability and reoperation in addition to comparable outcomes with no differences in ROM were found for ABR + R and Latarjet in patients with subcritical GBL in both the primary and revision settings. ABR + R can be a safe and effective procedure in appropriately selected patients with less than 20% GBL for both primary and revision stabilization.

Minimizing Risk of Recurrent Instability Following Surgical Stabilization for Anterior Glenohumeral Instability

The most common surgical treatment options for anterior shoulder instability include the arthroscopic Bankart repair with or without adjunct procedures such as remplissage, the open Bankart repair, the Bristow-Latarjet procedure, and anterior free bone block transfers. The choice between non-operative treatment and 1 of the aforementioned procedures inherently impact the risk of recurrent instability. The purpose of this article is to discuss the timing of surgery in the in-season athlete, evaluate the evolving concept of glenoid and bipolar bone loss, and to discuss various surgical treatment options with a specific focus on minimizing recurrent instability rates following surgical stabilization.

Arthroscopic Anterior and Inferior Labral Repair for Traumatic Shoulder Instability

Background

Anterior glenohumeral instability is common in the young and athletic population and can develop from a dislocation or subluxation event. Avulsion of the anterior inferior glenoid labrum (Bankart lesion) occurs in over 90% of these events. In patients who have unsuccessful conservative management or present with a high risk for redislocation, surgical intervention is indicated. This video presents our technique for arthroscopic anterior and inferior labral repair.

Indications

In addition to those patients who have unsuccessful conservative management, surgical management of anterior glenohumeral instability is indicated in patients who are at high risk for redislocation after an initial instability event. These patients include young age and participation in contact sports. Generally, glenoid bone loss over 25% warrants open bony augmentation, but arthroscopic bony augmentation techniques are evolving. Further, the management of "near-track" lesions, or "on-track" lesions with a small distance to dislocation value, remains controversial.

Technique Description

This procedure is performed in the lateral decubitus position. A second anterior portal is created distal and lateral to the first anterior portal, entering the shoulder joint just above the subscapularis. The anterior-inferior labrum is prepared with an arthroscopic elevator, followed by a rasp and superior labral anterior and posterior burr. A suture tape is then shuttled around the labrum and the anchor drilled in the appropriate position at the glenoid rim, not violating the cartilage. Anchor placement occurs from an inferior to a superior fashion until the entire labral injury is repaired.

Results

This video presents a technique to achieve arthroscopic fixation of an anterior-inferior labral tear in a young athlete with anterior glenohumeral instability. Patients are taken through 3 phases of rehabilitation before return to sport-specific activities, such as contact sports, around 6 months postoperatively. Return-to-sport rates for contact and collision athletes range from 80% to 100%, with recurrent rates ranging from 5% to 20%.

Discussion/Conclusion

Arthroscopic anterior-inferior labral repair is a useful technique for minimally invasive glenohumeral stabilization in indicated patients who have minimal glenoid bone loss. Portal placement, labral mobilization, and glenoid preparation are paramount in optimizing the healing potential of the fixation construct.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Repair With Side-to-Side Sutures for Full-Thickness Transtendinous Supraspinatus Tears Versus Traditional Tendon to Bone Fixation: Outcomes and Retear Rates at 4-Year Follow-up

Background

Full-thickness, transtendinous supraspinatus rotator cuff tears involve a significant portion of the remanent tendon attached to the footprint.

Purpose

To compare outcomes and failure rates for arthroscopic side-to-side (STS) suture repair for transtendinous tears versus traditional double-row repair for common tendon-to-bone type tears.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective cohort of 18 patients with full-thickness transtendinous supraspinatus tears who underwent STS suture repair was compared with a group of 36 matched controls with classic tendon avulsion who underwent double-row knotless transosseous-equivalent (TOE) repair. All patients had ≥2 years of follow-up. Demographics, postoperative active range of motion, and patient-reported outcomes (PROs) including American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) for pain, and Subjective Shoulder Value (SSV), were collected.

Results

There were no significant differences between the STS and TOE groups regarding mean follow-up (48.2 ± 18.5 vs 47.9 ± 20.5 months; P = .70) or age (64.6 ± 7.2 vs 64.8 ± 7.3 years; P = .79). With respect to clinical outcomes and PROs, there were no differences in postoperative VAS pain score (STS vs TOE: 0.94 ± 1.5 vs 0.89 ± 1.8; P = .39), SSV score (92.4 ± 8.9 vs 90.1 ± 13.0; P = .79), or ASES score (90.8 ± 9.7 vs 92.6 ± 12.0; P = .15). No differences were identified for postoperative active forward flexion (STS vs TOE: 154.2° ± 13.3° vs 159.4° ± 11.3°; P = .10), external rotation (53.3° ± 6.2° vs 51.4° ± 8.7°; P = .47), or internal rotation (P = .69) score. Although there were larger anteroposterior tear sizes in the STS group (21.4 ± 9.3 vs 16.0 ± 6.7 for TOE; P = .04), there was no significant group difference in failure rates (11% [STS] vs 8% [TOE]; P > .99).

Conclusion

Arthroscopic STS suture repair for transtendinous supraspinatus tears yielded excellent outcomes with low failure rates, comparable with tendon-to-bone double-suture anchor repair for typical tendon avulsion-type cuff tears. Retention of the large tendon stump on the greater tuberosity with STS repair also allows restoration of anatomy without undue tension in this uncommon scenario.

Artificial Intelligence Large Language Models Address Anterior Cruciate Ligament Reconstruction: Superior Clarity and Completeness by Gemini Compared With ChatGPT-4 in Response to American Academy of Orthopaedic Surgeons Clinical Practice Guidelines

PURPOSE

To assess the ability of ChatGPT-4 and Gemini to generate accurate and relevant responses to the 2022 American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPG) for anterior cruciate ligament reconstruction (ACLR).

METHODS

Responses from ChatGPT-4 and Gemini to prompts derived from all 15 AAOS guidelines were evaluated by 7 fellowship-trained orthopaedic sports medicine surgeons using a structured questionnaire assessing 5 key characteristics on a scale from 1 to 5. The prompts were categorized into 3 areas: diagnosis and preoperative management, surgical timing and technique, and rehabilitation and prevention. Statistical analysis included mean scoring, standard deviation, and 2-sided t tests to compare the performance between the 2 large language models (LLMs). Scores were then evaluated for inter-rater reliability (IRR).

RESULTS

Overall, both LLMs performed well with mean scores >4 for the 5 key characteristics. Gemini demonstrated superior performance in overall clarity (4.848 ± 0.36 vs 4.743 ± 0.481, P = .034), but all other characteristics demonstrated nonsignificant differences (P > .05). Gemini also demonstrated superior clarity in the surgical timing and technique (P = .038) as well as the prevention and rehabilitation (P = .044) subcategories. Additionally, Gemini had superior performance completeness scores in the rehabilitation and prevention subcategory (P = .044), but no statistically significant differences were found amongst the other subcategories. The overall IRR was found to be 0.71 (moderate).

CONCLUSIONS

Both Gemini and ChatGPT-4 demonstrate an overall good ability to generate accurate and relevant responses to question prompts based on the 2022 AAOS CPG for ACLR. However, Gemini demonstrated superior clarity in multiple domains in addition to superior completeness for questions pertaining to rehabilitation and prevention.

CLINICAL RELEVANCE

The current study addresses a current gap in the LLM and ACLR literature by comparing the performance of ChatGPT-4 to Gemini, which is growing in popularity with more than 300 million individual uses in May 2024 alone. Moreover, the results demonstrated superior performance of Gemini in both clarity and completeness, which are critical elements of a tool being used by patients for educational purposes. Additionally, the current study uses question prompts based on the AAOS CPG, which may be used as a method of standardization for future investigations on performance of LLM platforms. Thus, the results of this study may be of interest to both the readership of Arthroscopy and patients.

Revision Anterior Cruciate Ligament Reconstruction in Combination With Meniscal and Osteochondral Allograft Transplantation for Complex Knee Injury

Revision anterior cruciate ligament reconstruction (ACLR) may present a challenge as a result of several factors, including malpositioned bone tunnels, tunnel osteolysis, and the presence of previous hardware. In addition, concomitant pathology, specifically meniscal and cartilaginous injuries, may be present and should be addressed to minimize the risk of re-rupture. Revision ACLR and treatment of accompanying injuries can be performed either as a 1-stage or 2-stage procedure, yet the latter may increase surgical risk for the patient and extend recovery time. The over-the-top technique serves as a good option for revision ACLR and can be performed with careful consideration of patient-specific anatomy and with proper surgical planning. Therefore, this Technical Note aims to present our 1-stage surgical technique for revision ACLR using over-the-top technique with an Achilles tendon allograft, along with concomitant treatment for meniscal deficiency and a medial femoral condyle chondral defect using meniscal and osteochondral allografts, respectively.

Outpatient Total Joint Arthroplasty: A Review of the Current Stance and Future Direction

INTRODUCTION

The purpose of this review is to outline some of the major considerations when transitioning to performing total hip and knee arthroplasty in the out- patient setting. The review will discuss patient selections, peri-operative management pathways, and outcomes related to outpatient total joint arthroplasty (TJA).

PATIENT SELECTION

Appropriate patient selection is key to successful outpatient TJA. Multiple indices have been proposed to estimate patient risk before undergoing outpatient TJA. Perioperative Management: In order to provide a successful outpatient TJA experience, pre-operative education class and physical therapy session can set expectations and prepare the patient for the post-operative recovery at home. Specific anesthesia techniques focus on regional blocks, multi-modal pain control, and reduction of post-operative nausea and vomiting and rapid recovery protocols have been developed to provide early mobilization and physical therapy.

OUTCOMES

Nationwide analyses have found improved complication rates ranging from 1.3%-3% in outpatient TJA group compared to 3%-12% in the inpatient TJA group. Financial analyses have found significant cost savings for outpatient TJA mostly related to reduction in surgical floor care.

CONCLUSION

Outpatient TJA has the potential to improve patient experience with cost savings and no increased risk of complications in the appropriately selected patient population.

Double Row Rotator Cuff Repair for Massive Reparable Rotator Cuff Tear

Background

Massive rotator cuff tears, defined as those that involved 2 or more tendons or where the length of the greatest diameter is greater than 5 cm, present a unique surgical challenge as there can be significant scarring, retraction, and poor tissue quality. Furthermore, healing of these tears is less reliable. This video presents our technique for anatomic, double row repair of a massive reparable rotator cuff tear.

Indications

Indications for operative intervention include acute traumatic tears, as well as patients with pain and weakness who have failed to respond to conservative management, including physical therapy with confirmed large full thickness rotator cuff tear on advanced imaging. Of note, findings such as glenohumeral osteoarthritis, advanced muscle atrophy (Goutalier III/IV), superior migration of the humeral head >7 mm, and tears larger than 40 mm in length and width are concerning for irreparable tears, and may represent contraindications to surgical repair.

Technique Description

The patient is placed in the lateral decubitus position. After diagnostic arthroscopy is performed, a subacromial bursectomy is performed. A radiofrequency probe and arthroscopic shaver are used to perform releases in the subacromial space as well as superior to the glenoid. Preparation of the footprint of the humeral head is then performed to create a good healing surface. The rotator cuff is grasped to confirm tension free mobilization. The medial row anchors are then placed. Once placed, the sutures are incorporated into 2 lateral row anchors in sequential fashion. Subacromial decompression is then performed.

Results

Reduced pain and improved shoulder function are the goals of treatment, with sling immobilization lasting for roughly 6 weeks postoperatively prior to initiating strengthening and range of motion protocols.

Discussion/Conclusion

Arthroscopic double row repair produces an anatomic and stable reduction of reparable massive rotator cuff tears for patients that have failed conservative management.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.