Hybrid Remnant-Sparing Anterior Cruciate Ligament Repair-Reconstruction

In anterior cruciate ligament (ACL) reconstruction, the remnant ACL is often debrided in an effort to improve visualization of patient anatomy and reduce surgical difficulty. However, retention of the tibial remnant of a torn ACL theoretically portends several advantages. These include preservation of knee proprioception and mechanoreceptors, an enhanced biological environment for healing, and accelerated revascularization and ligamentization of the graft. Despite these advantages, it is not a widely adopted practice and the optimal technique is still subject to debate. The purpose of this technical note is to describe our preferred technique for performing hybrid ACL reconstruction with remnant incorporation

Predictors of Functional Disability in Patients Undergoing Anterior Cruciate Ligament Reconstruction

Purpose: The primary purpose of this study was to identify the patient-centric factors that contribute to functional disability in patients undergoing ACL reconstruction, in an effort to help guide patient selection, counseling, and optimal timing of surgery. Methods: All patients undergoing ACL reconstruction by two fellowship-trained sports medicine surgeons from July 2017 to September 2018 were included.Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test (CAT) scores for physical function (PROMIS-PF), pain interference (PROMIS-PI), and depression (PROMIS-D) were recorded, as were patient demographic data. The correlation between psychosocial, demographic, and functional outcomes was then analyzed. Results: There were 145 patients (mean age 27 ± 11, 92 males) included in this review. There was a wide range of PROMIS-PF scores (23.2-61.7), PROMIS-PI scores (38.7-78.4), and PROMIS-D scores (34.2-78.1). Preoperative PROMIS-PF scores were negatively correlated with PROMIS-PI (p \u3c0.001), PROMIS-D (p \u3c0.001), and BMI (p = 0.024). Patients who attended physical therapy reported higher preoperative PROMIS-PF scores (p = 0.050), and patients with concomitant meniscal tears on MRI reported lower PROMIS-PF scores (p = 0.044). There was no association found between PROMIS-PF scores and age, sex, smoking status, or median household income. Conclusion: This study demonstrated that depression and pain, measured by PROMIS-D and PROMIS-PI, respectively, were correlated with decreased functional outcomes, measured by PROMIS-PF, in patients undergoing ACL reconstruction. Increased BMI and the presence of meniscal tears negatively influenced functional outcomes. Patients who attended physical therapy before surgery reported increased functional outcomes. PROMIS-PF scores varied widely in patients undergoing ACL reconstruction, and some patients with high scores may be less likely to improve following surgery. Our results lend to a greater understanding of the patient factors that influence PROMIS scores and suggest weight reduction and physical therapy as interventions to improve preoperative function.https://scholarlycommons.henryford.com/merf2019clinres/1019/thumbnail.jp

Characterization of miR-335-5p and miR-335-3p in human osteoarthritic tissues

OBJECTIVE: We aimed to characterize the expression patterns, gene targets, and functional effects of miR-335-5p and miR-335-3p among seven primary human knee and hip osteoarthritic tissue types. METHODS: We collected synovial fluid, subchondral bone, articular cartilage, synovium, meniscus/labrum, infrapatellar/acetabular fat, anterior cruciate ligament/ligamentum teres, and vastus medialis oblique/quadratus femoris muscle (n = 7-20) from surgical patients with early- or late-stage osteoarthritis (OA) and quantified miR-335-5p and miR-335-3p expression by real-time PCR. Predicted gene targets were measured in knee OA infrapatellar fat following miRNA inhibitor transfection (n = 3), and prioritized gene targets were validated following miRNA inhibitor and mimic transfection (n = 6). Following pathway analyses, we performed Oil-Red-O staining to assess changes in total lipid content in infrapatellar fat. RESULTS: Showing a 227-fold increase in knee OA infrapatellar fat (the highest expressing tissue) versus meniscus (the lowest expressing tissue), miR-335-5p was more abundant than miR-335-3p (92-fold increase). MiR-335-5p showed higher expression across knee tissues versus hip tissues, and in late-stage versus early-stage knee OA fat. Exploring candidate genes, VCAM1 and MMP13 were identified as putative direct targets of miR-335-5p and miR-335-3p, respectively, showing downregulation with miRNA mimic transfection. Exploring candidate pathways, predicted miR-335-5p gene targets were enriched in a canonical adipogenesis network (p = 2.1e - 5). Modulation of miR-335-5p in late-stage knee OA fat showed an inverse relationship to total lipid content. CONCLUSION: Our data suggest both miR-335-5p and miR-335-3p regulate gene targets in late-stage knee OA infrapatellar fat, though miR-335-5p appears to be more prominent, with tissue-, joint-, and stage-specific effects

Impact of Patient Demographic Factors on Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Pain Interference, and Depression Computer Adaptive Testing Scores in Patients Undergoing Shoulder and Elbow Surgery

Background: There has been a growing emphasis in orthopaedics on providing patient-centered care. The US National Institutes of Health launched the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative that incorporates patient-reported outcome measures across a number of medical domains. The relationship between PROMIS domains and the impact of patient demographic factors in those undergoing upper extremity surgery remains unclear. Purpose/Hypothesis: The goal of this study was to investigate the correlation between physical function, pain interference, and depression in patients undergoing shoulder and elbow surgery as measured by PROMIS computer adaptive testing (CAT) forms and to determine the impact of patient demographic factors. We hypothesized that there would be a significant negative correlation between physical function and both pain interference and depression in this patient population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All patients who underwent elective shoulder or elbow surgery by 3 shoulder, elbow, and/or sports medicine fellowship-trained orthopaedic surgeons were included in the study. Preoperative PROMIS-Upper Extremity (PROMIS-UE), PROMIS-Pain Interference (PROMIS-PI), and PROMIS-Depression (PROMIS-D) CAT scores were analyzed. Pearson correlations were calculated between PROMIS domains as well as between PROMIS outcomes with patient demographic factors. Results: Preoperative PROMIS CAT scores for all 3 domains were collected and analyzed from 172 unique patients (516 individual CAT forms) with shoulder and elbow injuries. A negative correlation of moderate strength was found between the PROMIS-UE and PROMIS-PI ( Conclusion: Before shoulder and elbow surgery, patients demonstrated impairments in physical function and pain interference as measured by CAT forms, with a moderate negative correlation between baseline upper extremity physical function and pain interference scores. In certain subpopulations, such as female patients, black patients, and current tobacco users, the correlations between these tested domains were stronger than in other groups

Infection and Rerupture After Surgical Repair of Achilles Tendons.

Background: Surgical repair of an Achilles tendon rupture has been shown to decrease rerupture rates. However, surgery also increases the risk of complications, including infection. Purpose: To determine the risk factors for infection and rerupture after primary repair of Achilles tendon ruptures. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on 423 patients who underwent operative treatment of Achilles tendon ruptures between the years 2008 and 2014. The primary outcome of interest was the total rate of infection, and the secondary outcome of interest was the incidence of rerupture within 2 years of operation. Results: A total of 423 patients were analyzed, with a mean age of 46 years (range, 16-83 years) and a mean body mass index of 31.4 kg/m2 (range, 17-55 kg/m2). The overall infection rate was 2.8%, and the rerupture rate was 1%. The median time between surgery and superficial surgical site infection was 30 days, and the median time between surgery and rerupture was 38 days. Longer tourniquet times (100.3 ± 34.7 minutes vs 69.9 ± 21.4 minutes; P = .04) and greater estimated blood loss (15.0 ± 9.1 mL vs 5.1 ± 12.0 mL; P = .01) were associated with an increased rate of deep surgical site infections. Patients who had longer operation and tourniquet times trended toward higher rerupture rates (P = .06 and .08, respectively). When compared with nonsmokers, current and previous smokers had an increased incidence of superficial or deep surgical site infections (6.25% vs 1.42%; P = .02). Age, sex, race, body mass index, alcohol use, diabetes, past steroid injections, and mechanism of injury did not contribute to complication rates. Conclusion: Achilles tendon repairs were associated with a low risk of infection and rerupture. Patients with longer tourniquet times, higher estimated blood loss, and a history of smoking were at increased risk for surgical site infections. Patients with longer operative times had increased rates of rerupture

Impact of Patient Demographic Factors on Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Pain Interference, and Depression Computer Adaptive Testing Scores in Patients Undergoing Shoulder and Elbow Surgery

Background: There has been a growing emphasis in orthopaedics on providing patient-centered care. The US National Institutes of Health launched the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative that incorporates patient-reported outcome measures across a number of medical domains. The relationship between PROMIS domains and the impact of patient demographic factors in those undergoing upper extremity surgery remains unclear. Purpose/Hypothesis: The goal of this study was to investigate the correlation between physical function, pain interference, and depression in patients undergoing shoulder and elbow surgery as measured by PROMIS computer adaptive testing (CAT) forms and to determine the impact of patient demographic factors. We hypothesized that there would be a significant negative correlation between physical function and both pain interference and depression in this patient population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All patients who underwent elective shoulder or elbow surgery by 3 shoulder, elbow, and/or sports medicine fellowship–trained orthopaedic surgeons were included in the study. Preoperative PROMIS–Upper Extremity (PROMIS-UE), PROMIS–Pain Interference (PROMIS-PI), and PROMIS-Depression (PROMIS-D) CAT scores were analyzed. Pearson correlations were calculated between PROMIS domains as well as between PROMIS outcomes with patient demographic factors. Results: Preoperative PROMIS CAT scores for all 3 domains were collected and analyzed from 172 unique patients (516 individual CAT forms) with shoulder and elbow injuries. A negative correlation of moderate strength was found between the PROMIS-UE and PROMIS-PI (R = –0.61; P \u3c.001), and a negligible correlation was found between the PROMIS-UE and PROMIS-D (R = –0.28; P \u3c.001). When stratified by patient demographic factors, the correlation between the PROMIS-UE and PROMIS-PI was stronger in female patients compared with male patients (R = –0.77 vs –0.46, respectively; P \u3c.001 for both), stronger in black patients compared with white patients (R = –0.72 vs –0.56, respectively; P \u3c.001 for both), and highest in current tobacco users (R = –0.80; P \u3c.001). Conclusion: Before shoulder and elbow surgery, patients demonstrated impairments in physical function and pain interference as measured by CAT forms, with a moderate negative correlation between baseline upper extremity physical function and pain interference scores. In certain subpopulations, such as female patients, black patients, and current tobacco users, the correlations between these tested domains were stronger than in other groups

: Preoperative Patient-centric Predictors of Postoperative Outcomes in Patients Undergoing Arthroscopic Meniscectomy

The Patient-Reported Outcomes Measurement Information System (PROMIS) is a valid and efficient means of collecting patient outcomes in patients with meniscal tears. The studies purpose was to define the minimally clinical important difference (MCID) for PROMIS domains following meniscectomy procedures. Secondary aims included determining the role of pre-operative PROMIS computer adaptive test (CAT) scores in predicting achievement of MCID following meniscectomy. Patients undergoing arthroscopic meniscectomy who completed PROMIS CAT forms for physical function (PROMIS-PF), pain interference (PROMIS-PI), and depression (PROMIS-D), from July 2017 to July 2019, at a single institution were utilized. MCID was calculated according to the distribution methodology, and receiver operating characteristics (ROC) were utilized to determine if pre-operative scores were predictive of post-operative outcomes. A total of 135 patients met inclusion criteria. Postoperative PROMIS-PF (45.6), PROMIS-PI (54.6), and PROMIS-D (44.1) significantly improved 3 months after surgery (

Return to Play After Revision Anterior Cruciate Ligament Reconstruction in National Football League Players.

BACKGROUND: National Football League (NFL) players who undergo anterior cruciate ligament (ACL) reconstruction have been shown to have a lower return to play (RTP) than previously expected. However, RTP in the NFL after revision ACL reconstruction (RACLR) is not well defined. PURPOSE/HYPOTHESIS: The purpose of this study is to determine the RTP of NFL players after RACLR and evaluate factors that predict RTP. Our hypothesis was that more experienced and established players would be more likely to RTP after RACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 24 NFL players who underwent RACLR between 2007 and 2014 were reviewed and evaluated. Return to NFL play, time to return, seasons and games played prior to and after revision surgery, draft status, and demographic data were collected. Overall RTP was determined, and players who did RTP were compared with those unable to RTP. Data were also compared with control players matched for age, position, size, and experience. RESULTS: After RACLR, 79% (19/24) of NFL players returned to NFL regular-season play at an average of 12.6 months. All players who were drafted in the first 4 rounds, played in at least 55 games, or played 4 seasons of NFL play prior to injury were able to RTP. Players drafted in the first 4 rounds of the NFL draft were more likely to RTP than those who were not (odds ratio, 0.1; 95% CI, 0.01-1.00; P = .05). Those who returned to NFL play played in significantly less games and seasons after their injury than before (P = .01 and P = .01, respectively). However, these values did not differ when compared with matched controls (P = .67 and P = .33). CONCLUSION: NFL players who RTP after RACLR do so at a similar rate but prolonged time period compared with after primary ACL reconstruction. Athletes who were drafted in earlier rounds were more likely to RTP than those who were not. Additionally, player experience prior to injury is an important factor when predicting RTP after RACLR

Multimodal Nonopioid Pain Protocol Provides Equivalent Pain Versus Opioid Control Following Meniscus Surgery: A Prospective Randomized Controlled Trial

PURPOSE: To assess the effectiveness of a nonopioid pain regimen in controlling postoperative pain as compared with a traditional opioid pain control following primary meniscectomy or meniscal repair. METHODS: Ninety-nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the Consolidated Standards of Reporting Trials 2010 statement. The 2 arms of the study included a multimodal nonopioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for the first 10 days postoperatively. Secondary outcomes included patient-reported outcomes, complications, and patient satisfaction. Randomization was achieved using a random-number generator. Patients were not blinded. Data collection was done by a blinded observer. RESULTS: Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen and 31 randomized to the nonopioid regimen. Patients receiving the nonopioid regimen demonstrated noninferior visual analog scale scores compared with patients who received opioid pain medication (P \u3e .05). No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, P = .724) or postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, P = .064) Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form scores. No difference was found in recorded side effects between both groups at any given time point: constipation, nausea, diarrhea, upset stomach, and drowsiness (P \u3e .05). CONCLUSIONS: This study found that a multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial

Preoperative PROMIS Scores Predict Postoperative Improvements Following Rotator Cuff Repair

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a valid and efficient means of collecting patient outcomes in patients with rotator cuff tear. The purpose of this study was to examine the role of pre-operative PROMIS computer adaptive test (CAT) scores in predicting post-operative PROMIS CAT scores as well as likelihood of achieving minimal clinically important difference (MCID) following rotator cuff repair. We hypothesize that pre-operative PROMIS CAT scores will directly impact both post-operative PROMIS CAT scores and likelihood of achieving MCID.Methods: Patients undergoing arthroscopic rotator cuff repair by one of three fellowship-trained surgeons were identified over a 12-month period. Only patients that completed pre-operative and 6-month post-operative PROMIS CAT assessments were included in this cohort. PROMIS CAT forms for upper extremity physical function (PROMIS-U), pain interference (PROMIS-PI), and depression (PROMIS-D) were utilized. MCID was calculated according to the distribution methodology, and receiver operating characteristics (ROC) were utilized to determine if pre-operative scores were predictive of post-operative outcomes. Preoperative cutoffs were used to predict which patients would likely meet MCID using 95% specificity. Results: A total of 80 patients met our inclusion criteria. PROMIS-UE, PROMIS-PI and PROMIS-D improved 6 months after surgery (p\u3c0.001). 76% of patients met MCID for PROMIS-UE, while 89% met MCID for PROMIS-PI, and 54% met MCID for PROMIS-D. Preoperative PROMIS scores were predictive of post-operative outcomes based on ROC analysis which demonstrated significant area under the curve (AUC) of .725 (p=0.003), .757 (p=0.013), and .789 (p\u3c0.001) for PROMIS-UE, PROMIS-PI, and PROMIS-D, respectively. Individuals with PROMIS-UE scores below 24.95 and PROMIS-PI scores above 65.65 yielded a 100% probability of achieving MCID, while a cutoff of 56.45 for PROMIS-D yielded a 91% probability of achieving MCID with 95% specificity. Conclusion: Patients undergoing arthroscopic rotator cuff repair experience significant improvements in upper extremity physical function, pain interference and depression as measured by PROMIS CAT domains. In particular, patients presenting with PROMIS upper extremity scores of \u3c24.95 are especially likely to achieve MCID.https://scholarlycommons.henryford.com/merf2019clinres/1053/thumbnail.jp