Age but not BMI Predicts Accelerated Progression of KOA: Data from the Osteoarthritis Initiative

Background/Objectives: Knee osteoarthritis (KOA) accounts for about 35% of the arthritis burden among adults. Most adults with KOA have slowly-progressing, common knee osteoarthritis (CKOA); however, some individuals experience accelerated KOA (AKOA), rapid progression to end-stage disease within 48 months. This study analyzed individuals without radiographic evidence of KOA at baseline to determine which (baseline) characteristics were associated with progression to CKOA and/or AKOA status 48 months later.Methods: Data (n = 1,561) from the Osteoarthritis Initiative (OAI) were utilized. Multinomial logistic regression was employed to determine the magnitude of association between baseline risk factors and 48-month KOA status (AKOA and CKOA, compared to no KOA).Results: Older age (p = 0.032), greater baseline BMI (p < 0.001), female gender (p = 0.009), and greater baseline PASE score (p =0.036) were significantly associated with CKOA (11.9% of participants) and/or AKOA (3.5% of participants) at 48 months. Age, BMI, andPASE were all more strongly associated with greater risk of AKOA compared to risk of CKOA (Age: OR = 1.59 vs. 0.97; BMI: OR = 1.62vs. 1.28; PASE: OR = 1.21 vs. 1.08). Of these, only BMI was significantly associated with greater risk of both AKOA and CKOA.Conclusion: Certain factors impact the risk of AKOA and CKOA differently. Age did not increase the risk of CKOA, but among thosewith CKOA or AKOA, the proportion with AKOA increased with age. Thus, older age at onset is associated with more rapid KOA progression

Radiographic Measurements Correlate to Isolated Posterolateral Corner (PLC) Injury in a Novel Cadaveric Model

Introduction: Injury to the posterolateral corner (PLC) of the knee often requires surgical reconstruction. There remains no consensus on treatment for PLC injury, and, therefore, it is imperative to have a reproducible injury model to improve the general knowledge of PLC injuries. A novel cadaveric model of isolated PLC injury is proposed and evaluated using radiographic parameters as well as gross dissection. Material and methods: All protocols were reviewed by the Human Investigation and Research Committee of the home institution and were approved. Translational force in a defined posterior and lateral direction was applied to cadaveric native knees to induce PLC injury. Varus and recurvatum stress fluoroscopic imaging was obtained of each specimen before and after the injury model. Lateral joint distance and recurvatum angle after stress was measured on each image via picture archiving and communication software (PACS) imaging software. After the injury model, injured structures were assessed via saline loading and gross dissection. Any specimens found to be fractured were excluded from the analysis of stress radiography. Results: A total of 12 knees underwent testing and 6/12 successfully induced PLC injury without fracture. The lateral capsule was torn in every specimen. The popliteofibular ligament (PFL) was torn in 83% of specimens and the fibular collateral ligament (FCL) in 66.7% of specimens. The median lateral gapping after injury under varus stress radiography was 5.39 mm and the median recurvatum angle after injury was 14.25°. Radiographic parameters had a direct relationship with a number of structures injured. Conclusions: This is the first successful cadaver model of PLC injury. The lateral capsule was injured in every specimen emphasizing the importance of this structure to the PLC

Virtual Interviews in the Era of COVID-19: Expectations and Perceptions of Orthopaedic Surgery Residency Candidates and Program Directors

Orthopaedic surgery residency program directors (PDs) and candidates consider interviews to be central to the application process. In-person interviews are typical, but virtual interviews present a potentially appealing alternative. Candidate and PD expectations and perceptions of virtual interviews during the 2020/2021 orthopaedic surgery application cycle were assessed. Methods: Candidates and PDs were surveyed electronically. Questions covered pre-virtual-interview and post-virtual-interview expectations and perceptions, and past in-person experiences (PDs and reapplicants) on the relative importance of application components, ability to assess fit, interview costs, and preferred interview mode. Identical questions allowed between-group comparisons. Results: Responses included n = 29 PDs and n = 99 candidates. PDs reported diminished ability to assess candidate fit; social, clinical, and surgical skills; and genuine interest in the virtual context (each p ≤ 0.01). They placed greater importance on research and less on the interview in the virtual vs. in-person context (each p = 0.02). Most candidates (78%) reported fair/good ability to demonstrate potential and were better able to assess research opportunities than expected (p \u3c 0.01). Candidates expected virtual interviews to increase the importance of research, transcripts, and recommendations (for each, p ≤ 0.02) and decrease the importance of the interview itself (p \u3c 0.01). Compared with PDs, candidates overvalued research, United States Medical Licensing Examination scores, transcripts, and recommendations (each p ≤ 0.02) and may have slightly undervalued the virtual interview (p = 0.08). Most candidates (81%) and PDs (79%) preferred in-person interviews, despite both groups reporting monetary savings. Conclusions: Despite cost savings associated with virtual interviews, orthopaedic surgery residency PDs and candidates identified reduced abilities to assess candidate or program fit and displayed a preference for in-person interviews

Effects of Pubertal Growth Variation on Knee Mechanics During Walking in Female and Male Adolescents

Introduction: Puberty substantially alters the body\u27s mechanical properties, neuromuscular control, and sex differences therein, likely contributing to increased, sex-biased knee injury risk during adolescence. Female adolescents have higher risk for knee injuries than male adolescents of similar age engaging in similar physical activities, and much research has investigated sex differences in mechanical risk factors. However, few studies address the considerable variation in pubertal growth (timing, pace), knee mechanics, and injury susceptibility within sexes, or the impact of such growth variation on mechanical injury risk. Objectives: The present study tested for effects of variation in pubertal growth on established mechanical knee injury risk factors, examining relationships between and within sexes. Methods: Pubertal growth indices describing variation in the timing and rate of pubertal growth were developed using principal component analysis and auxological data from serial stature measurements. Linear mixed models were applied to evaluate relationships between these indices and knee mechanics during walking in a sample of adolescents. Results: Later developing female adolescents with slower pubertal growth had higher extension moments throughout stance, whereas earlier developers had higher valgus knee angles and moments. In male adolescents, faster and later growth were related to higher extension moments throughout gait. In both sexes, faster growers had higher internal rotation moments at foot-strike. Conclusions: Pubertal growth variation has important effects on mechanical knee injury risk in adolescence, affecting females and males differently. Earlier developing females exhibit greater injury risk via frontal plane factors, whereas later/faster developing males have elevated risk via sagittal plane mechanisms

Effects of Ohio Opioid Prescribing Policy on Postsurgical Prescriptions Following Sports Procedures

Background: Prescribed opioid medication after orthopedic sports surgery has been shown to exceed patient requirements. In 2017, as a response to the opioid epidemic, Ohio passed Opioid Prescribing Guidelines (OPG) limiting narcotic prescriptions for acute pain. This study sought to evaluate the effects of the OPG on prescribing behavior of orthopedists following knee arthroscopy (KA), shoulder arthroscopy (SA), and anterior cruciate ligament reconstruction (ACLR). Methods: An institutional database was queried to calculate morphine equivalent dose (MED) prescribed at discharge, acute follow-up (\u3c90 days), and chronic follow-up (\u3e90 days) and compare MED pre- and post-OPG. Cases were identified over a 2-year period starting 1 year prior to OPG implementation. Individual surgeon data were tracked to control for inter-surgeon variability. Results: A total of 1663 patients were included in the analysis. Demographic variables were similar pre- and post-OPG for each procedure group. With all surgeons included, average discharge MED decreased significantly for all procedures from pre- to post-OPG. Surgeons qualified for individual analysis if they had at least 10 surgeries pre- and post-OPG. Of qualifying providers, 80% of KA, 25% of SA, and 0% of ACLR surgeons reduced discharge MED prescribed post-OPG. MED prescribed during follow-up was largely unaffected by implementation of the OPG. Conclusion: Average discharge morphine equivalent dose (MED) prescribed after SA, KA, and ACLR decreased following the implementation of the OPG. The MED reduction effect of the OPG was the greatest in magnitude after SA, and SA was the only surgery that showed MED reductions that persisted during acute follow up. Opioid prescriptions beyond 90 days postoperatively were unchanged by the OPG for all surgeries. Policy that restricts postoperative opioid prescriptions can be an effective, but incomplete method to address the opioid crisis

Effect of Age at Menarche on Anterior Cruciate Ligament Injury Incidence and Anterior Knee Laxity in Collegiate Athletes

Female athletes suffer painful, costly, and career-limiting non-contact anterior cruciate ligament (ACL) injuries more often than males. Previous research suggests that pubertal neuromusculoskeletal development contributes to this sex-bias, but the manner in which variation in pubertal development affects injury risk within females is poorly understood. Age at menarche is a variable, significant pubertal developmental event, signaling the onset of estrogen cycling and affecting musculoskeletal development. Earlier menarche may increase injury risk, possibly by increasing anterior knee laxity through prolonged estrogen exposure. The purpose of this case-control study was to test the primary hypothesis that collegiate athletes with previous ACL injuries have earlier age at menarche than their uninjured peers, and to test the secondary hypothesis that earlier menarche is related to greater anterior knee laxity in injured and uninjured athletes. The study sample consisted of female NCAA Division-I varsity athletes (N=14 injured, N=120 uninjured). Outcome measures included: menstrual history and ACL injury details (injury age, activity at time of injury, contact vs. non-contact), assessed by questionnaire; and anterior knee laxity assessed by KT-1000 arthrometer. Correlation, t-tests, and regression analysis were used to test for associations between age at menarche, injury incidence, and knee laxity. Fourteen athletes reported ≥1 non-contact ACL injury, and had significantly earlier menarche than uninjured athletes (12.6±1.3 y vs. 13.4±1.4 y; P=0.05). Earlier menarche also significantly predicted injury status (Wald c2=7.43; Pb=-1.02±0.37; OR=0.36; 95% CI:0.17-0.75), but was not correlated with anterior knee laxity. Within injured athletes, however, laxity in the unaffected knee was significantly related to time since menarche (r2=0.79, Pr2=0.72,

Primary Hemiarthroplasty for the Treatment of Basicervical Femoral Neck Fractures

Purpose Basicervical femoral neck fractures are uncommon injuries that occur at the extracapsular base of the femoral neck at its transition with the intertrochanteric line. Controversy remains in the orthopedic literature as to the optimal method of treatment for this fracture type given the inherent instability and greater rate of implant failure with traditional fixation constructs. The purpose of this study is to quantify the incidence and preferred treatment methods of basicervical hip fractures at a single, regional, Level 1 trauma center and to identify differences in postoperative complications between treatment options. Methods The present study is a retrospective case series from a single regional health network, including 316 patients with hip fractures. Basicervical femoral neck fractures were identified. Reoperation rates within 90 days, implant failures or nonunions, postoperative ambulation distances and range of motion, and discharge dispositions were compared across patients grouped by surgical treatment with either cephalomedullary nail, sliding hip screw, or hemiarthroplasty (HA). Results Basicervical femoral neck fractures represented 6.6% of this study population. The cephalomedullary nail group demonstrated rates of implant failure and return to the operating room within 90 days of 40% (4/10) and 20% (2/10), respectively. No patients who underwent hemiarthroplasty experienced a failure of fixation or return to the operating room. Conclusions This study suggests a much lower rate of fixation failure or need for reoperation with hemiarthroplasty treatment compared to cephalomedullary nail construct for basicervical femoral neck fractures and may be an underutilized treatment method for this fracture type. The promising results seen with this case series should encourage further investigation into HA as a primary treatment for these uncommon, yet challenging, fractures

Novel Enhanced Recovery After Surgery Pathway Reduces Length of Stay and Postoperative Opioid Usage in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion

Purpose: The goal of this study was to compare our institution’s recently implemented enhanced recovery after surgery (ERAS) protocol to previous post-operative management for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion, specifically assessing length of stay, opioid consumption, and pain scores. Methods: This is a retrospective analysis that compares the length of stay, opioid consumption, and pain scores of patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Patients were analyzed prior to the implementation of our ERAS protocol, deemed the traditional pain pathway (TPP), to those who underwent the ERAS pathway. All patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis were included. Patients were excluded if they weighed less than 40kg, had significant comorbidities, or had non-idiopathic causes of scoliosis. Results: We examined 22 patients in the TPP cohort and 20 in the ERAS cohort. Length of stay in the ERAS cohort was significantly reduced compared to the TPP by 1.7 days (P\u3c0.01). Overall opioid consumption was also significantly reduced in the ERAS with 1.4 ± 0.7 morphine equivalents (ME)/kg compared to the TPP 2.4 ± 1.1 ME/kg (P \u3c 0.01). We found no difference in pain scores between the two groups. Conclusion: Implementation of an ERAS pathway at our institution significantly reduced length of stay and opioid consumption in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. These outcomes reduce morbidity and costs associated with posterior spinal fusion and provide an overall improvement in the quality of care for our patients

Postmenopausal Health and Disease from the Perspective of Evolutionary Medicine

Menopause normally occurs between 45-55 years of age, marks the end of a woman’s reproductive lifespan, and is accompanied by a reduction in estrogen that has substantial physiological effects. The standard medical view is that these changes underlie high postmenopausal disease rates, defining menopause as an estrogen deficiency condition needing treatment. This view stems from the idea that extended postmenopausal longevity is a consequence of recent technological developments, such that women now outlive their evolutionarily-programmed physiological functional lifespan.Increasingly, however, researchers employing an evolutionary medicine framework have used data from comparative demography, comparative biology, and human behavioral ecology to challenge the mainstream medical view. Instead, these data suggest that a two-decade human postmenopausal lifespan is an evolved, species-typical trait that distinguishes humans from other primates, and has deep roots in our evolutionary past. This view rejects the inevitability of high rates of postmenopausal disease and the concept of menopause as pathology. Rather, high postmenopausal disease risk likely stems from specific lifestyle differences between industrialized societies and foraging societies of the type that dominated human evolutionary history. Women in industrialized societies tend to have higher estrogen levels during premenopausal life, and experience a greater reduction in estrogen across menopause than do women living in foraging societies, with potentially important physiological consequences. The anthropological approach to understanding postmenopausal disease risk reframes the postmenopausal lifespan as an integral period in the human life cycle, and offers alternative avenues for disease prevention by highlighting the importance of lifestyle effects on health

Physical activity and metabolic physiology in postmenopausal women : an evolutionary approach

Humans diverge from our close relatives (chimpanzees/ bonobos) in high survivorship to menopause and decades of postmenopausal longevity. Evolutionary perspectives see the human postmenopausal lifespan as a species-typical life history trait that has evolved by selection for maintenance of physiological systems at increasingly older ages. Maintenance of body composition and low rates of metabolic and cardiovascular disease should thus characterize the early postmenopausal period, which they do in hunter-gatherers despite little access to Western medicine. In contrast, women in industrialized society tend to increase body fat and have high rates of metabolic syndrome during the early postmenopausal period; as such, the prevailing medical view is that menopause itself increases disease risk. Physical activity relates to metabolic health, and may help explain this disparity: older hunter-gatherers tend to be highly active, while women in industrialized society tend to be increasingly sedentary with age. Within the framework of evolutionary medicine, the present study investigates the effects of physical activity on body composition and resting energy expenditure (REE) in postmenopausal women from San Diego. Low REE, low fat-free mass and high body fat are risk factors for metabolic syndrome; exercise may increase fat- free mass and REE, and lower body fat. Long-term, habitually-active women were compared to sedentary women who completed a 16-week training program. In this sample, active women tended to have less body fat, but did not have higher fat-free mass or REE. Despite strength and aerobic fitness gains, the training program failed to increase fat-free mass and REE. Comparison of this study's subjects to published results from highly-trained athletes and data on hunter-gatherers suggests that even the active women in the present sample were rather sedentary, consistent with the idea of an intensity threshold for the effects of exercise on metabolism. Additionally, the training program's lack of effect is consistent with some past studies, supporting the idea that the metabolic response to exercise is muted with age and sedentary behavior. Thus, both the intensity and timing of exercise may be important to reducing metabolic disease risk, possibilities that can be evaluated by continuing to study postmenopausal health from the perspective of evolutionary medicin