Diagnosing a periprosthetic shoulder infection: A systematic review

Introduction

The aim of this study was to systematically review the literature regarding accurate shoulder prosthetic joint infection (PJI) diagnosis.

Methods

Using PRISMA guidelines, we analyzed 25 studies reporting on 5535 patients and 646 infections.

Results

Cutibacterium acnes (C. acnes) cultures were positive in 60% of patients. Serum markers WBC, CRP, ESR, and IL-6 appear to lack diagnostic reliability. Synovial IL-6 and alpha-defensin may be more accurate in detecting infections.

Conclusion

Synovial IL-6 and alpha-defensin appear to have greater utility than serum markers. These may be incorporated into new criteria to accurately diagnose shoulder PJI.

Level of evidence

IV.

Predictors of two-year patient satisfaction following elective knee surgery

BACKGROUND

Patient satisfaction metrics are increasingly being utilized as tools to evaluate the quality of healthcare and affect reimbursements. The objectives of this study were to (1) identify factors associated with two-year patient satisfaction after elective knee surgery, (2) compare the Surgical Satisfaction Questionnaire-8 (SSQ-8) and a numeric satisfaction scale (NSS), and (3) determine if two-year patient satisfaction can be predicted based on preoperative factors.

METHODS

A total of 365 patients undergoing elective knee surgery at a single center were administered questionnaires to assess demographics, medical history, and various patient-reported outcomes preoperatively and at two years postoperatively. Patient satisfaction was measured at two years postoperatively with SSQ-8 and NSS. Bivariate and multivariate statistical analyses were performed to identify significant associations and independent predictors of satisfaction.

RESULTS

SSQ-8 and NSS scores were significantly correlated (r_s = 0.68, P < 0.0001). Lower SSQ-8 and NSS scores were associated with black race, higher BMI, more comorbidities, unemployment, smoking, higher ASA score, and greater Met Expectations (P < 0.05). Better scores on patient-based outcome measures and better improvement from baseline were significantly correlated with higher satisfaction on both SSQ-8 and NSS. Multivariable analysis identified greater Met Expectations and higher two-year Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scores as independent predictors of greater SSQ-8 scores (adjusted r² = .52). Greater Met Expectations and better two-year PROMIS Social Satisfaction scores were independent predictors of NSS score (adjusted r² = .41). In contrast, when only preoperative variables were considered, the multivariable regression model accounted for only 14% of the variance in SSQ-8 and 6% of the variance in NSS.

CONCLUSION

While there are multiple preoperative factors that are associated with two-year patient satisfaction after knee surgery, those factors contribute relatively little to satisfaction. Meeting expectations and better patient-based outcomes at two years are more important.

An accurate method of measuring shoulder sling compliance: a validation study

Background

The effect of postoperative shoulder sling compliance on surgical outcomes is unknown. The goal was to determine an accurate method to measure sling compliance. We compared volunteer recorded sling wear time with temperature-based sensors to monitor sling compliance.

Methods

Data loggers sutured at three locations measured heat generated in 15-minute intervals. Slings wearers logged sling wear to accurately cross-reference with temperature sensors. Secondary experiments analyzed whether surrounding ambient temperature can be discerned from actual sling wear. We created an algorithm to describe actual sling wear time as a function of heat recorded and calculated percent wear accuracy.

Results

The modified sling was worn for 172 h. The algorithm modeled sling on/off times by analyzing cutoff temperatures. Diagnostic accuracy was >99 % for the three locations, with no statistically significant differences among them. Compared with sling wear, ambient temperature took longer to reach critical temperature values determined by the algorithm, helping distinguish compliance from false positives.

Conclusions

The described algorithm can effectively quantify shoulder sling wear time based on heat-generated sensor readings. False positives from ambient temperature are minimal. This measurement method could be used to study the relationship between postoperative sling use and functional outcomes after shoulder surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04396-1.

Preoperative opioid use in patients undergoing shoulder surgery

BACKGROUND

Opioids are commonly used to manage pain from acute injury or chronic degenerative diseases. The objective of this study was to assess the prevalence of preoperative opioid use in patients undergoing shoulder surgery and the clinical factors associated with preoperative opioid use.

METHODS

This was an analytical cross-sectional study of 175 patients undergoing shoulder surgery at an urban hospital from June 2015 to June 2017. Multivariable regression models were used to determine independent associations.

RESULTS

Fifty-three patients reported preoperative opioid use, which was significantly associated with primary procedure performed (Current Procedural Terminology [CPT]), higher body mass index (BMI), unemployment, lower income, smoking, higher American Society of Anesthesiologists score, greater number of previous surgeries, higher comorbidity burden, and decreased expectations to exercise and do recreational activities (p < 0.05). Preoperative opioid use was independently associated with worse scores on the: Numeric Pain Scale, ASES, IPAQ, and PROMIS domains of Physical Function, Pain Interference, and Social Satisfaction (p < 0.05).

CONCLUSION

More than one in four patients reported preoperative opioid use. Several health measures, including worse pain, function, and social satisfaction were independently associated with preoperative opioid use. These findings suggest that orthopaedic surgeons need to identify patients using opioids preoperatively in order to effectively establish and execute a plan for pain management, which may include weaning off opioids prior to surgery, managing psychological distress, and optimizing coping strategies.Level of Evidence: III.

Impact of pre-operative recreational marijuana use on outcomes two years after orthopaedic surgery

PURPOSE

The purpose of this study was to investigate the relationship between recreational marijuana use and patient-reported outcomes two years after orthopaedic surgery. We hypothesized that pre-operative recreational marijuana use would be associated with less pain, better function, and better mental health measures two years after orthopaedic surgery.

METHODS

Patients were retrospectively analyzed from a prospective orthopaedic registry at a single urban institution. A total of 1710 patients completed the pre-operative assessment and 1103 patients (64.5%) completed the two-year follow-up questionnaires. The cohort was then divided into two groups based on reported preoperative recreational marijuana usage, and statistical analysis was performed to determine if marijuana use was associated with two-year outcomes. Multivariable analysis was used to control for confounding variables.

RESULTS

Marijuana use was reported by 47 (4.3%) patients. Significantly worse scores for two-year PROMIS Anxiety (53.2 vs. 49.2, p = 0.005), PROMIS Depression (51.1 vs. 46.5, p = 0.001), Met Expectations (63.1 vs. 74.4, p = 0.024), Surgical Satisfaction Questionnaire-8 (71.7 vs. 80.4, p = 0.005), and Numeric Satisfaction Scale (75.6 vs. 83.1, p = 0.041) were associated with marijuana use. Marijuana users also had less improvement of Numeric Pain Scores at the operative site (- 1.8 vs. - 2.7, p = 0.037) and greater decrease in Marx activity scores for lower extremities (- 12.3 vs. - 3.9, p = 0.024). Marijuana use was not an independent predictor of any outcome measure in the multivariable analysis.

CONCLUSION

Marijuana use was associated with worse mental health scores, lower activity level, less pain relief, and worse satisfaction two years after orthopaedic surgery. However, after controlling for confounding variables, marijuana use was not predictive of any two-year outcome measure.

STUDY DESIGN

Cross-sectional study.

Opioid Prescribing Habits for Common Arthroscopic Procedures in Opioid Naïve Patients

Background:

With the opioid epidemic and the increasing number of opioid-related deaths, there is growing awareness in the medical community regarding the dangers of opioid overprescription. As a result, there is a willingness among physicians to abandon old norms and adopt new data-driven prescribing practices.

Purpose:

To demonstrate patient-reported consumption data of opioid medications after anterior cruciate ligament (ACL) reconstructions (ACLRs), knee arthroscopies, and rotator cuff repairs to provide data-driven guidelines for prescribing opioids after these procedures.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included in the study were 168 patients who underwent an ACLR, knee arthroscopy, or arthroscopic rotator cuff repair over a 17-month period. Patients were excluded if they had an opioid allergy, had preexisting opioid use, had an acute postoperative complication requiring further surgery, required hospitalization, exhibited drug-seeking behaviors, or were lost to follow-up. Medical records were reviewed to determine the number of opioid pills prescribed and the number of pills taken postoperatively. Prescribing was standardized in that 15 hydrocodone/acetaminophen pills (5/325 mg) were prescribed for all knee arthroscopy procedures and 40 hydrocodone/acetaminophen pills were prescribed for all ACL and rotator cuff procedures. The mean number of pills consumed and percentage of prescribed pills taken were analyzed in association with specific procedures and patient demographics.

Results:

Overall, the mean (±SD) reported opioid consumption overall was 13.5 ± 13.0 pills, with a utilization rate of 45.6% of the prescription. The mean reported opioid consumption for ACLRs, knee arthroscopies, and rotator cuff repairs was 19.1 ± 15.4, 7.2 ± 5.4, and 17.2 ± 14.3 pills, respectively (P < .001). This represented a utilization rate of 48%, 47%, and 41%, respectively.

Conclusion:

This study provides important information regarding opioid utilization after common arthroscopic procedures. For ACLRs, knee arthroscopies, and rotator cuff repairs, by respectively prescribing 20, 10, and 20 pills postoperatively, the amount of unused medications would decrease by 60%, 47%, and 64%, respectively. We recommend prescribing no more than 20, 10, and 20 hydrocodone/acetaminophen pills (5/325 mg) for ACLRs, knee arthroscopies, and arthroscopic rotator cuff repairs, respectively.

Predictors of postoperative pain using PROMIS pain interference two-years following knee surgery

Introduction

The purpose of this study was to identify preoperative factors associated with worse PROMIS Pain Interference (PI) two years following knee surgery.

Methods

Participants completed surveys preoperatively and two years postoperatively. Data collected included demographics, medical history, and multiple patient-reported outcomes measures, including PROMIS PI.

Results

After controlling for confounders, lower income, smoking, worse PROMIS Anxiety, worse Numeric Pain Score body pain, and worse Marx Activity Rating Scale were independent predictors for worse PROMIS PI two years after surgery.

Conclusion

Worse PROMIS PI two years after elective knee surgery is associated with multiple socio-demographic patient identifiers.

Preoperative Expectations of Patients Undergoing Knee Surgery

There is limited validated data regarding the relationship between preoperative expectations and patient-reported outcomes (PROs) in patients undergoing knee surgery. The purpose of this study was to (1) assess the preoperative expectations of patients undergoing knee surgery and (2) determine the relationship between preoperative patient demographics, PROs, and preoperative patient expectations. We hypothesized that younger patients with worse function and worse general health status would have greater expectations of knee surgery. We analyzed data from 399 patients undergoing knee surgery at an urban academic medical center. We utilized the Musculoskeletal Outcomes Data Evaluation and Management System to measure preoperative expectations. Multiple legacy PRO measures were recorded, as well as the new Patient-Reported Outcomes Measurement Information Systems (PROMIS) Computer Adaptive Testing. Nonparametric statistical analyses were performed to determine significance. Overall, patients undergoing knee surgery had high expectations, with a mean of 88.0 (95% confidence interval [CI], 86.7-89.3) and median of 91.7 (95% CI, 89.2-94.3). Greater preoperative expectations of knee surgery were associated with higher income, surgically naïve knee, lower Charlson Comorbidity Index, better PROMIS Depression and Anxiety scores, greater Marx knee activity scores, and lower total body pain (p < 0.05). Preoperative expectations of patients undergoing knee surgery are associated with a history of prior knee surgery, income, general and mental health, activity, and pain. Expectations were also found to be associated with PRO measures of function and psychological well-being. These findings may have implications for patient education and shared decision-making preoperatively. The level of evidence for the study is IV.

Predictors of met expectations two years after knee surgery

Introduction

The purpose of this study is to determine which patient factors predict two-year postoperative met expectations in a cohort of patients undergoing knee surgery. Additionally, this study aims to measure the association between met expectations and postoperative outcomes.

Methods

319 patients undergoing knee surgery at one institution were studied. Patients completed patient-reported outcome questionnaires prior to surgery and again two years postoperatively. Preoperative Expectations and postoperative Met Expectations were measured using the Musculoskeletal Outcomes and Data Evaluation Management System (MODEMS) Expectations domain.

Results

The mean Met Expectations score was significantly lower than the preoperative Expectations Score. Worse two-year Met Expectations were associated with older age, higher BMI, greater comorbidities, more previous surgeries, black race, unemployment, lower income, government insurance, Worker's Compensation, smoking, and no injury prior to surgery. Greater Met Expectations were correlated with better scores on all two-year outcome measures as well as greater improvement on most outcome measures. Race, insurance status, function, mental health, and knee pain were found to be independent predictors of Met Expectations.

Conclusion

This study identified multiple patient factors and outcome measures that were associated with Met Expectations two years after knee surgery.

Cartiform Implantation for focal cartilage defects in the knee: A 2-year clinical and magnetic resonance imaging follow-up study

The purpose of this study was to evaluate clinical and magnetic resonance imaging (MRI) outcomes in patients who underwent cryopreserved viable osteochondral allograft (CVOCA) implantation for focal cartilage defects in the knee at a minimum of 2-years postoperatively. This is a retrospective follow-up study of twelve patients who underwent CVOCA implantation from 2013 to 2015 by a single surgeon for a International Cartilage Repair Society (ICRS) grade 3 or 4 chondral defect. Patient-reported outcome (PRO) measurements and MRI were obtained 2-years postoperatively. Collected PRO measures included: International Knee Documentation Committee (IKDC) form; Visual Analog Scale (VAS) pain score; Veterans RAND 12-Item Health Survey (VR-12); Knee Injury and Osteoarthritis Outcome Score (KOOS); and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC). Patients completed a standard return to work and sports/recreation survey. A blinded, fellowship-trained musculoskeletal radiologist independently evaluated each MRI to determine the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Mean follow-up was 2.1 years (2.0-2.3). There were 6 women and 6 men with a mean age of 46.2 ± 11.9 years. Mean PRO scores were: IKDC 72.6 ± 17.4; VAS 2.9 ± 2.8; WOMAC 84.2 ± 15.1; KOOS- Pain 83.8 ± 18.5, Symptoms 77.6 ± 16.0, ADL 88.0 ± 16.9, Sports/Rec 67.7 ± 33.3, QOL 54.8 ± 24.2; and VR-12 PCS 45.0 ± 8.5 and MCS 51.1 ± 9.5. The mean MOCART score was 59.5 ± 12.9. To our knowledge, this is the largest study to report clinical and MRI outcomes of CVOCA implantation in the knee. With positive functional outcomes and lack of failures at 2-year follow-up, CVOCA is a promising treatment option for focal chondral defects in the knee.

STUDY DESIGN

Retrospective case series, Level of evidence 4.

Difference in Resident Versus Attending Perspective of Competency and Autonomy During Arthroscopic Rotator Cuff Repairs

A noted deficiency in orthopaedic resident education is a lack of intraoperative autonomy; however, no studies exist evaluating this issue. The purpose of this study was to determine whether there is a difference between resident and attending perception of resident competency and autonomy during arthroscopic rotator cuff repairs and whether increased perceived competency leads to more autonomy.

Editorial Commentary: Suprascapular Nerve Decompression Can Be Effective, But Should You Have the Nerve to Do It?

Isolated suprascapular neuropathy that requires surgical decompression is rare. Arthroscopic suprascapular nerve decompression is an effective treatment for correctly indicated patients, but identifying which patients would benefit from decompression is challenging. While good outcomes and low complication rates after arthroscopic suprascapular nerve decompression have been reported by expert surgeons, this procedure has potential for neurovascular injury in inexperienced hands. Given the rarity of the condition, the difficulty with accurate diagnosis, and the potential risks from surgical intervention, we believe that these patients are best treated in a tertiary referral practice.

Predictors of early postoperative pain interference following orthopaedic surgery

Introduction

Despite the increasing incidence of orthopaedic surgeries, there is a lack of data reporting on patient experience and recovery following surgery. As such, there is a need to better characterize the natural history of pain interference (PI) after orthopaedic surgery to better manage patients' expectations and recovery.

Purpose

To identify factors associated with greater pain interference two weeks following orthopaedic surgery.

Methods

All patients undergoing elective outpatient orthopaedic surgery at a single urban academic institution were evaluated preoperatively from August 2016 to March 2018. Patients completed a baseline assessment consisting of demographic information, PROMIS computer adaptive testing in 6 domains including Pain Interference (PI), Physical Function, Social Satisfaction, Fatigue, Anxiety, and Depression. Two weeks following surgery, patients completed the same questionnaires along with assessments of Improvement and Satisfaction. Bivariate and multivariable regression analyses were performed. Categorical data was compared with ANOVA and continuous data was compared with Spearman's correlation coefficient (r_s).

Results

435 patients (age = 41.1 ± 15.7, 47% female) were studied. Mean PI was 60.1 ± 7.0 prior to surgery and 61.7 ± 7.6 at 2 weeks postoperative. Worse 2 week PROMIS PI was associated with lower extremity surgery, prior surgery on the joint, preoperative opioid use, depression, lower income, lower education, and higher ASA score (p < 0.05). Better 2 week PROMIS PI was correlated with better baseline and better 2 week scores on all outcome measures. Multivariable analysis demonstrated that lower extremity surgery, worse preoperative pain scores, and worse preoperative pain interference were independent predictors of worse pain interference after surgery.

Conclusion

Early postoperative pain interference is associated with function, demographic, and psychosocial factors.

PROMIS physical function two weeks following orthopaedic surgery

Many patients opt for elective orthopaedic procedures to regain physical function. However, little data exist about patient-reported early postoperative function.

PURPOSE

To characterize physical function two weeks postoperative from upper and lower extremity orthopaedic surgery and to determine pre-operative factors that are associated with physical function two weeks following surgery.

METHODS

Patients 17 years and older undergoing elective orthopaedic surgery at one institution were enrolled prospectively and completed questionnaires prior to surgery and again two weeks postoperatively. The questionnaires included: six of the PROMIS computer adaptive questionnaires: Physical Function (PF), Pain Interference, Fatigue, Social Satisfaction, Anxiety, and Depression; a joint-specific function questionnaire, a joint numeric pain scale, and a body numeric pain scale. Physical activity levels were measured using Tegner, IPAQ, and Marx. Responses were analyzed using Spearman's correlation coefficient, ANOVA, and multivariate linear stepwise regression with two-week PF as the dependent variable.

RESULTS

435 patients (47% female) with mean age 41.1 ± 15.7 were included in our final analysis. Mean baseline PF score was 42.1 and mean two-week PF score was 35.5 (p < .0001). Patients undergoing upper extremity surgery had higher PF at two weeks than those undergoing lower extremity surgery (39.1 vs 32.2, p < .0001). Younger age, Hispanic ethnicity, preoperative narcotic use, injury prior to surgery, and procedure all had a significant relationship with lower 2-week postoperative PF score (p < 0.05). Numerous baseline and 2-week measures were correlated with postoperative PF score, with 2-week Social Satisfaction demonstrating the strongest correlation (r_s = 0.604, p < .0001). Multivariable regression confirmed that the better preoperative PF score and upper extremity surgery were independent preoperative predictors of better 2-week PF scores.

CONCLUSIONS

Patients have a significant decline in physical function following orthopaedic surgery, with those undergoing lower extremity surgery having a significantly greater decline. Many factors are associated with activity levels, including mental health, pain, and satisfaction. This information can be used to help manage patients' short-term expectations.

Preoperative expectations and early postoperative met expectations of extremity orthopaedic surgery

BACKGROUND

Preoperative patient expectations and met expectations are likely associated with the outcome of treatment. However, there is a lack of data regarding the preoperative expectations and early postoperative met expectations of patients undergoing extremity orthopaedic surgery. The purpose of this study was to identify the predictors of early postoperative met expectations in a cohort of patients undergoing extremity orthopaedic surgery and to assess the relationship between patient expectations and patient-reported outcome (PRO) measures. We hypothesized that patients with higher preoperative expectation scores and higher postoperative met expectation scores would have better early postoperative outcomes.

METHODS

Four hundred thirty-five patients age seventeen and older who underwent extremity orthopaedic surgery at one institution were prospectively enrolled in this study. Each patient completed a preoperative questionnaire that included an assessment of demographics, pain, function, general health, treatment expectations, activity level, and Patient-Reported Outcome Measurement Information System (PROMIS) computer adaptive testing. Expectations were evaluated using the Expectations Domain of the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire. Patients completed a follow-up questionnaire two weeks after surgery that also assessed MODEMS met expectations and satisfaction (Surgical Satisfaction Questionnaire (SSQ-8)).

RESULTS

The mean preoperative expectation score was 86.95 ± 16.59, and the mean postoperative met expectation score was 55.02 ± 27.63 (0-100 scale with 100 representing the highest level of expectations). Greater met expectations were significantly associated with white race (p = 0.025), college degree (p = 0.011), and higher income (p = 0.002). Greater met expectations were also significantly associated with greater postoperative physical function, social satisfaction, activity level, and subjective improvement, as well as lower pain interference, joint pain, body pain, fatigue, anxiety, and depression (p < 0.01 for each). Multivariable analysis results found that less postoperative joint pain and greater postoperative social satisfaction, improvement, and physical function were all significant independent predictors of greater met expectations at two weeks postoperative (p < 0.01 for each).

CONCLUSION

Greater preoperative expectations are associated with better activity and less pain two weeks after surgery. Met expectations of extremity orthopaedic surgery were associated with postoperative physical function, social satisfaction, activity, pain, anxiety, depression, and subjective improvement. These results may have implications for preoperative counseling and risk factor modification.

Early patient satisfaction following orthopaedic surgery

BACKGROUND

The healthcare industry is shifting its focus from traditional clinical outcome measures to patient satisfaction metrics. This change has caused orthopaedic surgeons to become increasingly interested in factors influencing patient satisfaction, which would allow them to potentially modify these factors in an effort to increase postoperative satisfaction. The objective of this study was to identify factors associated with patient satisfaction two weeks following extremity orthopaedic surgery.

METHODS

Patients completed questionnaires preoperatively to assess demographics, activity, pain, expectations, and Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing for Physical Function, Pain Interference, Social Satisfaction, Depression, Anxiety, and Fatigue. Two weeks after their operation, patients completed the same questionnaires in addition to an Improvement Survey and Met Expectations. Satisfaction was assessed with the Surgical Satisfaction Questionnaire.

RESULTS

Greater surgical satisfaction two weeks following orthopaedic surgery was associated with higher education, alcohol use, better scores on all PROMIS domains at baseline and two weeks, greater activity levels at baseline and two weeks, less bodily pain at baseline and two weeks, less pain in the surgical site at two weeks, greater met expectations, and greater improvement (p < 0.05).

CONCLUSION

This study provides important information about patient satisfaction two weeks after orthopaedic surgery.

Risk factors for increased shoulder Cutibacterium acnes burden

Background

Cutibacterium acnes is the primary cause of shoulder surgery infections, but the predisposition to larger skin counts and potentially higher risk for postoperative infection remains unclear. This study aimed to quantify risk factors influencing endogenous C. acnes burden and to compare counts among 4 shoulder sites.

Methods

C. acnes counts were quantified via a detergent scrub technique for 173 participants. Bivariate and multivariable stepwise linear regression statistical analyses were used to investigate the association of sex, age, ethnicity, degree of hirsutism, diabetes, smoking status, body mass index, and location with counts. A separate Wilcoxon rank-sum test was performed analyzing counts of East/Southeast Asians vs. all other ethnicities.

Results

Sex, age, degree of hirsutism, diabetes, smoking status, and body mass index were included in the multivariable stepwise linear regression analysis. The multiple regression analysis isolated individuals <40 years with the highest burden (P = .001). Males had a 191% increase in C. acnes counts compared with females (P = .001). Increased hirsutism was further indicated to be a risk factor for the male sex although not in a dose-dependent manner (P = .027). Wilcoxon rank-sum test results found that East/Southeast Asians had the lowest load (P = .019), although not significant in the multivariate model.

Conclusion

Surgical site C. acnes infections occur more frequently in younger males, and males <40 years with shoulder-specific hirsutism have the highest preoperative burden. East/Southeast Asians have lower raw counts of C. acnes compared with other ethnicities that may be related to less hirsutism.

Evaluation of Preoperative Pain Using PROMIS Pain Interference in Knee Surgery Patients

Given that pain relief is often the primary goal of orthopaedic surgery, an accurate assessment of pain is paramount. The objectives of this cross-sectional analytical study were to (1) compare how the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) computer adaptive test (CT) performs against the Numeric Pain Scale (NPS) measure in evaluating pain, and (2) to determine demographic, clinical, and psychosocial correlates of PI in an urban population undergoing a variety of knee surgeries. We hypothesized that there would be a strong correlation between PI and NPS, with minimal floor and ceiling effects; and that a worse PI score would be associated with a worse general health profile. The sample consisted of 412 patients undergoing knee surgery at an urban academic center. Patients were preoperatively administered measures of health-related quality of life (HRQOL). Bivariate and multivariable statistical analyses were performed to identify significant independent predictors. The mean PI score was 60.3 ± 7.2 and had no floor or ceiling effects, whereas NPS demonstrated a greater percentage of patients scoring at the extremes of the measure. Worse PI scores were associated with older age, higher body mass index (BMI), greater comorbidity, lower income, smoking, female gender, Hispanic ethnicity, Black race, unemployment, opioid use, lower expectations, and greater American Society of Anesthesiologists score (p < 0.05). Compared with other procedures, total knee arthroplasty was associated with worse PI scores and anterior cruciate ligament reconstruction was associated with better PI scores. Furthermore, PI demonstrated significant associations with a wide range of HRQOL measures. After controlling for confounding variables, worse PI was independently associated with older age, lower income, higher BMI, and smoking.

Evaluation of the PROMIS Physical Function Computer Adaptive Test in Patients Undergoing Knee Surgery

A cross-sectional analysis of data derived from patients undergoing knee surgery at a single institution was conducted. The objectives of the study were to (1) compare how the Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) computer adaptive test performs against the International Knee Documentation Committee (IKDC) Subjective Knee Form in evaluating functional status, and (2) to determine demographic, clinical, and psychosocial correlates of each outcome measure in an urban population undergoing a variety of knee surgeries. We hypothesized that there would be a strong correlation between PROMIS PF and IKDC, with minimal floor and ceiling effects, and similar clinical correlates. The sample consisted of 412 patients undergoing knee surgery. Bivariate and multivariable statistical analyses were performed to identify significant independent predictors. The PROMIS PF and IKDC scores were strongly correlated (r _s = 0.71, p < 0.001), and neither exhibited floor nor ceiling effects. Lower body mass index, no preoperative opioid use, lower Charlson comorbidity index score, employment, and lower income were found to be significant independent predictors for better scores on both PROMIS PF and IKDC. Patients undergoing total knee arthroplasty had significantly lower PROMIS PF and IKDC scores (p < 0.05). Potential explanations for these findings are presented, and clinical implications are discussed.

Correlation of Quantitative Versus Semiquantitative Measures of Supraspinatus Intramuscular Fatty Infiltration to Shoulder Range of Motion and Strength: A Pilot Study

PURPOSE

The relationship of magnetic resonance imaging (MRI) measures of rotator cuff intramuscular fatty infiltration (FI) to shoulder range of motion (ROM) and strength are not well understood. Our purpose was to determine if supraspinatus quantitative Dixon fat fraction has superior correlation to shoulder ROM and strength as compared to semiquantitative Goutallier grade.

METHODS

Thirty-seven study subjects received shoulder MRI; and measurement of ipsilateral shoulder forward flexion ROM, abduction ROM and abduction strength. Supraspinatus Dixon fat fraction was measured on 6-point Dixon MRI by 2 diagnostic radiology residents. Supraspinatus Goutallier grade was assessed on T1-weighted MRI by 2 musculoskeletal radiologists. Questionnaires recorded demographics. Based on characteristics, study subjects were divided into 3 groups: Group 1, neither shoulder pain nor full-thickness supraspinatus tendon (SST) tear (n = 17; mean age, 63.0 ± 10.1 years); Group 2, positive complaint of shoulder pain but without full-thickness SST tear (n = 7; mean age, 57.4 ± 9.9 years); Group 3, positive complaint of shoulder pain and full-thickness SST tear (n = 13; mean age, 63.6 ± 8.1 years). One-way analysis of variance compared groups. Spearman (rho) rank order correlation was performed to determine correlation of supraspinatus Dixon fat fraction, or Goutallier grade, with measures of ROM and strength for the study population. Reliability analyses were performed for Dixon fat fraction and Goutallier grade.

RESULTS

No significant differences were present among groups for age. Significant differences existed among groups for forward flexion ROM (P= 0.001), abduction ROM (P < 0.001), Dixon fat fraction (P = 0.004) and Goutallier grade (P = 0.012). Dixon fat fraction showed statistically significant inverse correlations with forward flexion ROM (rho = -0.47; P = 0.005), abduction ROM (rho = -0.35, P = 0.041), and abduction strength (rho = -0.42; P = 0.013). Goutallier grade demonstrated weak inverse correlation that lacked statistical significance (P > 0.05) for the same measures. Dixon fat fraction showed strong interobserver and intraobserver reliability with intraclass correlation coefficients of 0.956 and 0.999, respectively. Goutallier grade showed poor interobserver (kappa, 0.188) and moderate intraobserver (kappa, 0.608) reliability.

CONCLUSION

Supraspinatus Dixon fat fraction has superior correlation to shoulder ROM and strength relative to Goutallier grade on MRI.

Superior Patella Periosteal Sleeve Avulsion After Ipsilateral Tibial Tubercle Fracture Fixation: A Case Report

CASE

A 14-year-old boy underwent open reduction and internal fixation (ORIF) of a tibial tubercle avulsion fracture. Seven weeks postoperatively, the patient slipped in the bathroom and was found to have a superior patellar pole periosteal sleeve avulsion injury.

CONCLUSION

We describe a rare case of periosteal sleeve avulsion fracture of the superior patella pole after tibial tubercle avulsion fracture ORIF in an adolescent male patient. The etiology of this injury pattern may be due to altered tensile forces transmitted through the extensor mechanism related to the previous surgery. Orthopaedic surgeons should be aware of this unusual sequela.

Patients undergoing shoulder surgery have high preoperative expectations

PURPOSE

The primary aims of this study were to (1) assess the preoperative expectations of patients undergoing shoulder surgery, and (2) determine the relationship between preoperative patient demographics, PROs, and preoperative patient expectations. It was hypothesized that younger patients with worse function and worse health status had higher expectations of shoulder surgery.

METHODS

Data from a total of 319 patients (319 shoulders) from 2015-2018 were analyzed. Patients completed a series of questionnaires covering demographics and patient-reported outcome measures. Expectations of treatment were evaluated using the Musculoskeletal Outcomes Data Evaluation and Management System. Bivariate analyses were performed to determine the significance of identified associations.

RESULTS

The study population consisted of 186 males and 133 females. The mean age was 46.9 (± 17.2), and the mean BMI was 30.1 (± 6.8). Overall, patients had high expectations of shoulder surgery, with a mean score of 84.7 (± 19.3). The most commonly performed procedure in the study population was arthroscopic rotator cuff repair. There was a significant association between pre-treatment expectations and ethnicity, previous shoulder surgery, employment status, income level, tobacco use, preoperative opioid use, depression, and ASA score.

CONCLUSION

The findings suggest that patients undergoing shoulder surgery have high overall preoperative expectations, which were significantly associated with ethnicity, surgical history, opioid use, and employment status, and with multiple patient-reported outcome measures including physical function, pain interference, fatigue, and depression. Nevertheless, by discussing expectations preoperatively, orthopaedic surgeons can help patients develop high but realistic expectations to improve outcomes and satisfaction.

LEVEL OF EVIDENCE

IV.

Exosomes Isolated From Platelet-Rich Plasma and Mesenchymal Stem Cells Promote Recovery of Function After Muscle Injury

BACKGROUND

Clinical use of platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) has gained momentum as treatment for muscle injuries. Exosomes, or small cell-derived vesicles, could be helpful if they could deliver the same or better physiological effect without cell transplantation into the muscle.

HYPOTHESIS

Local delivery of exosomes derived from PRP (PRP-exos) or MSCs (MSC-exos) to injured muscles hastens recovery of contractile function.

STUDY DESIGN

Controlled laboratory study.

METHODS

In a rat model, platelets were isolated from blood, and MSCs were isolated from bone marrow and expanded in culture; exosomes from both were isolated through ultracentrifugation. The tibialis anterior muscles were injured in vivo using maximal lengthening contractions. Muscles were injected with PRP-exos or MSC-exos (immediately after injury and 5 and 10 days after injury); controls received an equal volume of saline. Histological and biochemical analysis was performed on tissues for all groups.

RESULTS

Injury resulted in a significant loss of maximal isometric torque (66% ± 3%) that gradually recovered over 2 weeks. Both PRP-exos and MSC-exos accelerated recovery, with similar faster recovery of contractile function over the saline-treated group at 5, 10, and 15 days after injury (P < .001). A significant increase in centrally nucleated fibers was seen with both types of exosome groups by day 15 (P < .01). Genes involved in skeletal muscle regeneration were modulated by different exosomes. Muscles treated with PRP-exos had increased expression of Myogenin gene (P < .05), whereas muscles treated with MSC-exos had reduced expression of TGF-β (P < .05) at 10 days after muscle injury.

CONCLUSION

Exosomes derived from PRP or MSCs can facilitate recovery after a muscle strain injury in a small-animal model likely because of factors that can modulate inflammation, fibrosis, and myogenesis.

CLINICAL RELEVANCE

Given their small size, low immunogenicity, and ease with which they can be obtained, exosomes could represent a novel therapy for many orthopaedic ailments.

Evaluation of preoperative pain in patients undergoing shoulder surgery using the PROMIS pain interference computer-adaptive test

OBJECTIVE

The purpose of this study was to evaluate the Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive testing Pain Interference (PROMIS PI) item bank in patients undergoing shoulder surgery. We hypothesized that PROMIS PI would exhibit a strong positive correlation with the numerical pain scale for the operative shoulder (shoulder NPS) with less floor and ceiling effects. Secondary study aims included assessing the relationships between patient characteristics and PROMIS PI.

DESIGN

Analytical cross-sectional study.

SETTING

Urban academic medical center.

PATIENTS

One-hundred and ninety-five patients undergoing shoulder surgery between June 2015 to June 2017.

MAIN OUTCOME MEASURES

All patients completed a series of patient-reported outcomes measures, including PROMIS PI and NPS. Non-parametric tests were used for bivariate analysis. Multivariable regression models were used to determine independent associations.

RESULTS

There was a moderate correlation between the PROMIS PI and shoulder NPS scores (r_s = 0.53; p < 0.001). PROMIS PI had no ceiling or floor effects while shoulder NPS had 26 patients (13.3%) at either the floor or the ceiling. PROMIS PI demonstrated a strong correlation with PROMIS Physical Function (r_s = -0.65; p < 0.001), ASES total score (r_s = -0.67; p < 0.001), and PROMIS Fatigue (r_s = 0.64; p < 0.001).

CONCLUSIONS

The strong association noted between PROMIS PI and psychosocial and behavioral factors, versus that of NPS, demonstrates that PROMIS Pain Interference may be a more appropriate choice as an outcome measure where the surgeon is concerned about a patient's improvement of functioning and decrease in the impact of pain in other aspects of wellbeing following shoulder surgery.

LEVEL OF EVIDENCE

IV.