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To compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries.The MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sampleWe identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (Single-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured.Level III, retrospective cohort study.

Background Stemless total shoulder arthroplasty (TSA) is aimed at better re-creating native anatomy, facilitating revision, and preserving bone. The purpose of this study is to determine which pre-operative patient characteristics or radiographic parameters were predictive of outcomes following stemless TSA. Methods This was a retrospective review of prospectively collected data. One hundred fifty-seven patients with glenohumeral osteoarthritis were prospectively enrolled as part of a multi-center FDA Investigational Device Exemption protocol in July 2011-November 2012. In the present study, one hundred forty-nine patients with minimum 2-year follow-up had imaging available for review and were included (107 men, 42 women). Mean age 65 years (range,37-84). Pre-operative patient demographics, baseline ASES and Constant scores, deltoid tuberosity index (DTI), combined cortical thickness, and postoperative glenoid version were analyzed to predict treatment success. Treatment success was defined by no revision procedures and an adjusted Constant score of >85% at final follow-up. Statistical analyses were performed using student T-test, multiple logistic regression, and Pearson correlation with a p-value of 0.05 defining significance. Intraclass correlation and kappa values were calculated to determine interrater reliability for radiographic measurements. Results Three patients (2.0%) underwent revision or explant due to infection, unstable implant, or glenoid loosening. Eleven (7.4%) had an adjusted Constant score Conclusion Patients younger than 60 years old had a 1.3x risk of suboptimal treatment outcome following stemless TSA, similar to what is seen with stemmed implants. Low radiographic bone density was not predictive of suboptimal constant score or reoperation at final follow-up. Older patients had decreased combined cortical thickness and deltoid tuberosity index, yet were more likely to have a successful outcome following stemless TSA compared to younger patients. Level of evidence Level III; Retrospective Cohort

The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability.A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures.Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48%10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure.The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

Mood symptoms may be due to shoulder-related depression or anxiety or clinical anxiety/depression. The objective of this study was to evaluate the relationship of shoulder-related and pre-existing diagnosis of depression or anxiety with changes in American Shoulder and Elbow Surgeons (ASES) score after rotator cuff repair.A retrospective review of prospectively collected data on subjects undergoing arthroscopic rotator cuff repair was reviewed. Preoperative and postoperative ASES, questions from the Western Ontario Rotator Cuff index questions directed to feelings of depression/anxiety related to the shoulder, and pre-existing diagnoses of depression and/or anxiety were recorded. The Wilcoxon rank sum test was used to compare changes, and Spearman's correlation was used to correlate changes in mood and ASES between male and female subjects and those with and without anxiety and/or depression.One hundred seventy-one subjects (53 female; mean age, 58.0 years; standard deviation [SD], 8.5) who underwent arthroscopic rotator cuff repair were evaluated with the mean follow-up of 36.6 months (SD, 17.5). Forty-six subjects (mean age, 58.8 years; SD, 8.2) had pre-existing diagnoses of depression and/or anxiety and 125 subjects (mean age, 57.7 years; SD, 8.7) did not. Patients showed improvement in Western Ontario Rotator Cuff shoulder-related depression (Δ 22.3) and anxiety (Δ 24.7). There was a strong correlation between the change in mood symptoms and the change in ASES score, for depression (r = 0.74) and anxiety (r = 0.71). Patients with and without clinical diagnosis of anxiety or depression experienced similar changes in mood symptoms related to the shoulder and ASES scores (P = .65, P = .39). Patients' ASES scores were less correlated with changes in shoulder-related mood symptoms; however, if patients had clinical depression/anxiety compared with those without (r = 0.68 vs. 0.75, P.0001 for depression; r = 0.56 vs. r = 0.74, P.0001 for anxiety).After rotator cuff repair, symptoms of depression/anxiety related to the shoulder improved dramatically with or without pre-existing clinical diagnosis of depression or anxiety. As the patient-reported functional outcomes of those with pre-existing clinical diagnosis of anxiety/depression improved, they did not experience as strong as an improvement in their mood symptoms as those without prior diagnoses and may benefit from directed treatment of these symptoms. Patients with shoulder-related mood symptoms only, conversely, experience a strong relationship between their improvement in function with their mood symptoms and may be ideal candidates for rotator cuff surgery. It is important for clinicians to separate mood symptoms related to adjustment disorder from the rotator cuff injury from clinical depression and anxiety.

Proximal hamstring injuries are common, and open surgical repair with suture anchors has been the gold standard when surgical intervention is warranted. Endoscopic techniques offer the opportunity of surgical repair with smaller incisions to limit complications and expedite rehabilitation. The purpose of this technique guide is to describe a modified endoscopic technique that allows a safe and anatomic repair of proximal hamstring injuries. The patient is positioned prone with the feet at the head of the bed, table in reverse Trendelenburg, and knees flexed to 90°. Four portals are used, 3 in horizontal alignment within the gluteal fold and 1 directly superior to the ischial tuberosity. The sciatic nerve is identified, dissected, and mobilized away from the operative field. Retraction sutures help retract the gluteus maximus and further protect the sciatic nerve. Dissection is within the interval between the conjoint and semimembranosus tendons. The tendons are freed and mobilized, the ischial tuberosity is decorticated, and an anatomic repair is performed via 4 suture anchors, 2 at each tendon footprint. Advancements in arthroscopy have permitted adequate visualization and exposure of the hamstring footprint, thus allowing for an anatomic repair with increased protection of the sciatic nerve and decreased resources and cost.

Patient-reported outcomes continue to grow in importance. This study compared the Single Assessment Numeric Evaluation (SANE) score with the American Shoulder and Elbow Surgeons (ASES) score and Western Ontario Rotator Cuff (WORC) index score in patients before and after primary rotator cuff repair.This study was a retrospective review of a prospectively filled database of 333 subjects who underwent primary rotator cuff repair by a single surgeon between 2010 and 2017. The database included preoperative and postoperative SANE, ASES, and WORC evaluations. The mean follow-up time was 37.5 months. Spearman correlation coefficients were calculated comparing each score preoperatively and at least 1 year postoperatively.A strong correlation was found between the SANE and ASES scores of subjects in the preoperative period (r = 0.769, P.0001) and the follow-up period of at least 1 year (r = 0.781, P.0001). A similarly strong correlation was found between the SANE and WORC scores of subjects in the preoperative period (r = 0.757, P.0001) and the follow-up period of at least 1 year (r = 0.813, P.0001). On stratification analysis, correlation of SANE scores with ASES and WORC scores was found when subjects were grouped by sex, age, cuff tear size, and workers' compensation status.This study shows a significant correlation between the SANE, ASES, and WORC scores of primary rotator cuff repair subjects in the preoperative and long-term follow-up periods. We recommend the SANE score as an adjunct to clinical outcome data that can be used in patients regardless of sex, cuff tear size, or workers' compensation status.

Purpose Handheld ultrasound technology is increasingly used in health care. Its use for fracture care has not been adequately evaluated. The purpose of this study was to evaluate handheld, pocket-sized ultrasound in the diagnosis and assessment of reductions in distal radius fractures. Methods A total of 23 patients with distal radius fractures (average age, 53 years; 13 women) and 20 control patients (average age, 53 years; 10 women) were prospectively enrolled. All patients with distal radius fractures underwent standard, 3-view radiographic and ultrasonographic examinations of the wrist before and after closed reduction. Control patients had a one-time standard radiographic and ultrasonographic examination of the wrist. Radiographs were used as the reference standard. All images were assessed for the presence or absence of a fracture by a board-certified, hand fellowship–trained orthopedic surgeon and musculoskeletal fellowship–trained radiologist who were blinded to the study protocol. If a fracture was detected, the adequacy of reduction was assessed. Results The sensitivity of distal radius fracture diagnosis on ultrasound was 100% and specificity ranged from 90% to 95%. The sensitivity of identifying a satisfactory reduction ranged from 76% to 93% and specificity was 93% to 94%. Interrater reliability between the musculoskeletal radiologist and hand surgeon was κ = 0.86 for diagnosing the fracture and κ = 0.82 for identifying a satisfactory reduction. Intrarater reliability ranged from κ = 0.82 to 0.86. Conclusions A pocket-sized, handheld diagnostic ultrasound device demonstrates the ability to diagnose distal radius fractures and assess fracture reductions. Type of study/level of evidence Diagnostic II.

Background Ankle fractures are a common orthopedic injury that frequently involves associated cartilage lesions, soft tissue damage, and a significant inflammatory burden. Despite studies revealing intra-articular pathology in up to 79% of ankle fractures, only 1% of open reduction and internal fixation (ORIF) procedures undergo arthroscopic evaluation. The primary purpose of this study was to determine the cost effectiveness of ankle arthroscopy performed at time of ORIF for ankle fracture. Methods An IRB approved retrospective review of patients who sustained ankle fractures and underwent ORIF with and without concomitant arthroscopic surgery between 2015 and 2020 were investigated. Patient demographics, fracture characteristics, outcomes, and cost data were collected and analyzed. Results There were 567 total ORIF and 28 ORIF and scope included for cost analysis purposes. Total surgical costs averaged $6,537.62 and $6,886.46 for the ORIF only and ORIF and scope procedures respectively. Total direct costs, including operating room time, for the same procedures were found to average $6,212.34 and $7,312.10 for the ORIF only and ORIF and scope procedures respectively. The cost difference between the ORIF only and with arthroscopy was not statistically significant (p = 0.1174). Twelve of the 28 arthroscopic patients (42.86%) had grade 3 or full thickness chondral lesions, and 11/28 (39.28%) arthroscopic patients were found to have grade 1–2 cartilage changes. Conclusion In the acute treatment of ankle fractures, concurrent arthroscopic evaluation does not add a significant cost to the procedure and may result in improved short and long term benefits for the patient. With improved arthroscopic efficiency, the cost differential can be further reduced. LOE IV.