Corticosteroid Injections After Rotator Cuff Repair Improve Function, Reduce Pain, and Are Safe: A Systematic Review

Purpose

To review the literature on postoperative corticosteroid injections (CSIs) following primary rotator cuff repair (RCR) to evaluate efficacy and adverse effects.

Methods

A systematic review of the MEDLINE, EMBASE, and Cochrane databases were performed to identify all studies published within the last 15 years, which reported on outcomes of postoperative CSIs following RCR. Studies including patients who received only preoperative CSIs and revision RCRs were excluded. Included studies were evaluated for study methodology, patient demographics, outcome measures, physical examination parameters, results of imaging studies, and adverse effects or clinical complications.

Results

Seven studies comprising 5,528 patients satisfied inclusion criteria. Among included patients, 54.8% were female and mean age range from 52.3 ± 13.0 to 62.7 ± 6.6 years. Only 1 included investigation was a Level I study. Overall, 4 of 5 studies reported significant improvements in pain and outcome scores (Constant score, American Shoulder and Elbow Surgeons score) compared with controls. Across all studies, the majority of these effects were statistically significant at 3 months postoperatively but not beyond this time point. Five of the 6 included investigations reported no increased rate of retears after postoperative CSIs. One study did find an increase in retear in patients receiving postoperative CSIs but was unable to determine whether these retears were present before the patient received the CSI. Another investigation reported an increased rate of infection only if the CSI was administered in the first postoperative month.

Conclusions

Postoperative CSIs may improve pain and function for up to 3 months following primary RCR but not at later follow-up time points. CSIs should be administered only after the first postoperative month to minimize the potential risk for adverse events.

Level of Evidence

Systematic review of level I-IV studies.

How Long Does It Take to Achieve Clinically Significant Outcomes After Isolated Biceps Tenodesis?

Background:

Clinically significant outcomes (CSOs) connect patient-reported outcome measures data to patient-perceived benefit. Although investigators have established threshold values for various CSOs, the timeline to achieve these outcomes after isolated biceps tenodesis (BT) has yet to be defined.

Purpose:

To define the time-dependent nature of minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) achievement after isolated BT.

Study Design:

Case series; Level of evidence, 4.

Methods:

The American Shoulder and Elbow Surgeons score (ASES), the Single Assessment Numeric Evaluation, and the Constant-Murley score (CMS) were administered preoperatively and at 6 and 12 months postoperatively to patients undergoing isolated BT between 2014 and 2018 at our institution. Cumulative probabilities for achieving MCID, SCB, and PASS were calculated using Kaplan-Meier survival analysis. Weibull parametric regression evaluated the hazard ratios (HRs) of achieving earlier MCID, SCB, and PASS.

Results:

Overall cohort (N = 190) achievement rates ranged between 77.8% and 83.2% for MCID, between 42.2% and 80.2% for SCB, and between 59.7% and 62.9% for PASS. Median achievement time was 5.3 to 6.1 months for MCID, 5.9 to 6.4 months for SCB, and 6.07 to 6.1 months for PASS. Multivariate Weibull parametric regression identified older age, male sex, higher body mass index, preoperative thyroid disease, smoking history, and higher preoperative CMS as predictors of delayed CSO achievement (HR, 1.01-6.41), whereas normal tendon on arthroscopy, defined as absence of tenosynovitis or tendon tear on arthroscopy, predicted earlier CSO achievement (HR, 0.19-0.46). Location of tenodesis and worker compensation status did not significantly predict the time to achieve CSOs on multivariate analysis.

Conclusion:

After isolated BT, patients can expect to attain CSO by 13 months postoperatively, with most patients achieving this between 5 and 8 months. Patients tend to take longer to achieve PASS than MCID and SCB.

Machine-learning model successfully predicts patients at risk for prolonged postoperative opioid use following elective knee arthroscopy

PURPOSE

Recovery following elective knee arthroscopy can be compromised by prolonged postoperative opioid utilization, yet an effective and validated risk calculator for this outcome remains elusive. The purpose of this study is to develop and validate a machine-learning algorithm that can reliably and effectively predict prolonged opioid consumption in patients following elective knee arthroscopy.

METHODS

A retrospective review of an institutional outcome database was performed at a tertiary academic medical centre to identify adult patients who underwent knee arthroscopy between 2016 and 2018. Extended postoperative opioid consumption was defined as opioid consumption at least 150 days following surgery. Five machine-learning algorithms were assessed for the ability to predict this outcome. Performances of the algorithms were assessed through discrimination, calibration, and decision curve analysis.

RESULTS

Overall, of the 381 patients included, 60 (20.3%) demonstrated sustained postoperative opioid consumption. The factors determined for prediction of prolonged postoperative opioid prescriptions were reduced preoperative scores on the following patient-reported outcomes: the IKDC, KOOS ADL, VR12 MCS, KOOS pain, and KOOS Sport and Activities. The ensemble model achieved the best performance based on discrimination (AUC = 0.74), calibration, and decision curve analysis. This model was integrated into a web-based open-access application able to provide both predictions and explanations.

CONCLUSION

Following appropriate external validation, the algorithm developed presently could augment timely identification of patients who are at risk of extended opioid use. Reduced scores on preoperative patient-reported outcomes, symptom duration and perioperative oral morphine equivalents were identified as novel predictors of prolonged postoperative opioid use. The predictive model can be easily deployed in the clinical setting to identify at risk patients thus allowing providers to optimize modifiable risk factors and appropriately counsel patients preoperatively.

LEVEL OF EVIDENCE

III.

A Risk Stratification Nomogram to Predict Inpatient Admissions After Total Shoulder Arthroplasty Among Patients Eligible for Medicare

The goal of this study was to establish a risk stratification nomogram to aid in determining the need for inpatient admission among patients who were eligible for Medicare and were undergoing primary total shoulder arthroplasty (TSA). The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients older than 65 years who underwent primary TSA between 2006 and 2016. The primary outcome measure was inpatient admission, as defined by hospital length of stay longer than 2 days. Multiple demographic, comorbid, and peri-operative variables were used in a multivariate logistic regression model to yield a risk stratification nomogram. A total of 1514 inpatient and 6020 out-patient admissions were analyzed. Age older than 80 years (odds ratio [OR], 2.69; P<.0001; 95% CI, 2.21-3.27), female sex (OR, 2.18; P<.0001; 95% CI, 1.90-2.51), dependent functional status (OR, 1.69; P<.0001; 95% CI, 1.2-2.38), dialysis (OR, 3.48; P=.029; 95% CI, 1.14-10.63), admission from an inpatient facility (OR, 1.76; P<.0001; 95% CI, 1.70-1.82), and inflammatory arthritis (OR, 1.69; P<.02; 95% CI, 1.25-13.78) were the greatest determinants of inpatient stay. The resulting predictive model showed acceptable discrimination and calibration. Our model enabled reliable and straightforward identification of the most suitable candidates for inpatient admission among patients who were eligible for Medicare and were undergoing primary TSA. Patients who were receiving dialysis, who had dyspnea at rest, and who had bleeding disorders were more likely to be admitted as inpatients after TSA. Larger multicenter studies are necessary to externally validate the proposed predictive nomogram. [Orthopedics. 2022;45(1):43-49.].

Evolution of the repression mechanisms in circadian clocks

BACKGROUND

Circadian (daily) timekeeping is essential to the survival of many organisms. An integral part of all circadian timekeeping systems is negative feedback between an activator and repressor. However, the role of this feedback varies widely between lower and higher organisms.

RESULTS

Here, we study repression mechanisms in the cyanobacterial and eukaryotic clocks through mathematical modeling and systems analysis. We find a common mathematical model that describes the mechanism by which organisms generate rhythms; however, transcription's role in this has diverged. In cyanobacteria, protein sequestration and phosphorylation generate and regulate rhythms while transcription regulation keeps proteins in proper stoichiometric balance. Based on recent experimental work, we propose a repressor phospholock mechanism that models the negative feedback through transcription in clocks of higher organisms. Interestingly, this model, when coupled with activator phosphorylation, allows for oscillations over a wide range of protein stoichiometries, thereby reconciling the negative feedback mechanism in Neurospora with that in mammals and cyanobacteria.

CONCLUSIONS

Taken together, these results paint a picture of how circadian timekeeping may have evolved.

Understanding Anterior Shoulder Instability Through Machine Learning: New Models That Predict Recurrence, Progression to Surgery, and Development of Arthritis

Background

Management of anterior shoulder instability (ASI) aims to reduce risk of future recurrence and prevent complications via nonoperative and surgical management. Machine learning may be able to reliably provide predictions to improve decision making for this condition.

Purpose

To develop and internally validate a machine-learning model to predict the following outcomes after ASI: (1) recurrent instability, (2) progression to surgery, and (3) the development of symptomatic osteoarthritis (OA) over long-term follow-up.

Study Design

Cohort study (prognosis); Level of evidence, 2.

Methods

An established geographic database of >500,000 patients was used to identify 654 patients aged <40 years with an initial diagnosis of ASI between 1994 and 2016; the mean follow-up was 11.1 years. Medical records were reviewed to obtain patient information, and models were generated to predict the outcomes of interest. Five candidate algorithms were trained in the development of each of the models, as well as an additional ensemble of the algorithms. Performance of the algorithms was assessed using discrimination, calibration, and decision curve analysis.

Results

Of the 654 included patients, 443 (67.7%) experienced multiple instability events, 228 (34.9%) underwent surgery, and 39 (5.9%) developed symptomatic OA. The ensemble gradient-boosted machines achieved the best performances based on discrimination (via area under the receiver operating characteristic curve [AUC]: AUC_recurrence = 0.86), AUC_surgery = 0.76, AUC_OA = 0.78), calibration, decision curve analysis, and Brier score (Brier_recurrence = 0.138, Brier_surgery = 0.185, Brier_OA = 0.05). For demonstration purposes, models were integrated into a single web-based open-access application able to provide predictions and explanations for practitioners and researchers.

Conclusion

After identification of key features, including time from initial instability, age at initial instability, sports involvement, and radiographic findings, machine-learning models were developed that effectively and reliably predicted recurrent instability, progression to surgery, and the development of OA in patients with ASI. After careful external validation, these models can be incorporated into open-access digital applications to inform patients, clinicians, and researchers regarding quantifiable risks of relevant outcomes in the clinic.

Effects of High Intensity Exercise on Oxidative Stress and Antioxidant Status in Untrained Humans: A Systematic Review

Participation in exercise promotes health. High intensity exercise (HIE) has become increasingly popular among the general population, however, its effects on exercise-induced oxidative stress and antioxidant status in untrained humans is not clear. The aim of this systematic review was to investigate the influence of HIE on oxidative stress and antioxidant status in untrained humans. Web of Science, PubMed, MEDLINE, and Scopus were searched until March 2021. A methodological quality assessment valuation/estimation was additionally carried out in the final sample of studies. Following the PRISMA selection process, 21 studies were finally included. There was strong evidence that acute oxidative stress following the cessation of HIE exists when compared to resting states. The HIE-induced oxidative stress is transient and is most likely restored to normal levels within 24 h due to the stimulated endogenous antioxidant system whose response was lagging and lasting. Physically active humans had better antioxidant systems and suffered less oxidative stress after HIE. A physically active lifestyle was considered to enhance antioxidant capacity. For untrained humans, HIE with intensities above 70% VO₂max are proposed for initial exercise levels based on the findings reported here.

Delaying ACL reconstruction beyond 6 months from injury impacts likelihood for clinically significant outcome improvement

BACKGROUND

The effect of surgical latency on outcomes of anterior cruciate ligament reconstruction (ACLR) is a topic that is heavily debated. Some studies report increased benefit when time from injury to surgery is decreased while other studies report no benefit. The purpose of our analysis was to compare achievement of clinically significant outcomes (CSOs) in patients with greater than six months of time from injury to ACLR to those with less than or equal to six months of time to surgery.

METHODS

Patients undergoing primary ACLR between January 2017 and January 2018 with minimum one year follow-up were included. International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were collected. Multivariate logistic regression was performed for outcome achievement and risk of revision ACLR and Weibull parametric survival analysis was performed for relative time to outcome achievement. The level of significance was set at α = 0.05.

RESULTS

379 patients were included of which, 140 patients sustained ACL injury greater than six months prior to surgery. This group of patients experienced reduced likelihood to achieve patient-acceptable symptomatic state (PASS) on the IKDC (p = 0.03), KOOS Pain (p = 0.01) and a greater likelihood to undergo revision ACLR (p = 0.001). There was no impact of surgical timing on minimal clinically important difference (MCID).

CONCLUSION

Patients with greater than 6 months from injury to ACLR reported reduced likelihood to achieve CSOs, delayed achievement of CSOs, and increased rates of revision surgery.

Isolated Biceps Tenodesis and Tenotomy: A Systematic Review of Indications and Patient Satisfaction

Biceps tenodesis and tenotomy are increasingly being used as treatment options for shoulder pathology, but patient satisfaction remains largely unstudied. A systematic review of the MEDLINE database was conducted to identify clinical outcome studies on isolated biceps tenodesis or tenotomy that reported patient satisfaction. Within the 15 investigations that were included, the indication for tenotomy was rotator cuff pathology, whereas the indication for tenodesis was biceps pathology or type 2 superior labral tear from anterior to posterior. Patients undergoing tenotomy were 13.6 years older than those undergoing tenodesis (P<.001). Patient satisfaction was high following both procedures, at 85.6% following tenotomy and 92.3% following tenodesis. [Orthopedics. 2021;44(6):333-340.].

The Minimally Clinically Important Difference and Substantial Clinical Benefit in Anterior Cruciate Ligament Reconstruction: A Time-to-Achievement Analysis

This study examined the time-dependent course of the minimally clinically important difference (MCID) and the substantial clinical benefit (SCB) achievement for International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales following anterior cruciate ligament reconstruction (ACLR). A prospective institutional registry was queried for patients receiving ACLR. The patient-reported outcome measures (PROMs) of interest included the IKDC score and KOOS sub-scales. One hundred forty-three patients (mean±SD age, 30.86±12.78 years; mean±SD body mass index, 25.51±4.64 kg/m²) were included in the analysis. Threshold values for the MCID/SCB were 18.9 of 29.6 on IKDC score, 15.7 of 25.3 on KOOS Symptom, 11.9 of 15.5 on KOOS Pain, 13.3 of 20.0 on KOOS ADL, 25.9 of 35.8 on KOOS Quality of Life (QoL), and 27.0 of 43.0 on KOOS Sport (area under the curve, 0.74-0.91). Overall, MCID achievement rates increased from 28.0% to 42.7% at 6 months to 41.9% to 70.8% at 12 months. Achievement rates of SCB increased from 16.1% to 30.4% at 6 months to 29.3% to 51.8% at 12 months. Statistically significant increases in MCID achievement (chi-square=47.95-79.36, all P<.001) and SCB achievement (chi-square=26.02-53.24, all P<.001) occurred from preoperative to 6-month time points across PROMs. From 6-month to 12-month time points, increases in MCID achievement occurred on IKDC score and KOOS QoL (chi-square=5.53-15.11, P<.001-.009). Statistically significant increases in MCID and SCB achievement occurred from preoperative to 6-month time points across IKDC score and KOOS subscales; however, statistically significant increases in achievement rates from 6 months to 1 year occurred on IKDC score, KOOS QoL, and KOOS Sport. This study underlines the importance of considering psychological factors and rehabilitative milestones when examining the achievement MCID and SCB after ACLR. [Orthopedics. 2021;44(5):299-305.].

Return to Play and Player Performance After Achilles Tendon Rupture in UEFA Professional Soccer Players: A Matched-Cohort Analysis of Players From 1999 to 2018

Background:

Achilles tendon rupture (ATR) is a potentially career-ending injury in professional athletes. Limited information exists regarding return to play (RTP) in professional soccer players after this injury.

Purpose:

To determine the RTP rate and time in professional soccer players after ATR and to evaluate player performance relative to matched controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We evaluated 132 professional soccer players who suffered an ATR between 1999 and 2018. These athletes were matched 2:1 to uninjured controls by position, age, season of injury, seasons played, and height. We collected information on the date of injury, the date of RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) from official team websites, public injury reports, and press releases. Changes in performance metrics for the 4 years after the season of injury were compared with metrics 1 season before injury. Univariate comparisons were performed using independent-sample, 2-group t tests and Wilcoxon rank-sum tests when normality of distributions was violated.

Results:

The mean age at ATR was 27.49 ± 4.06 years, and the mean time to RTP was 5.07 ± 2.61 months (18.19 ± 10.96 games). The RTP rate was 71% for the season after injury and 78% for return at any timepoint. Overall, 9% of the injured players experienced a rerupture during the study period. Compared with controls, the injured players played significantly less (-6.77 vs -1.81 games [P < .001] and -560.17 vs -171.17 minutes [P < .05]) and recorded fewer goals (-1.06 vs -0.29 [P < .05]) and assists (-0.76 vs -0.02 [P < .05]) during the season of their Achilles rupture. With the exception of midfielders, there were no significant differences in play time or performance metrics between injured and uninjured players at any postinjury timepoint.

Conclusion:

Soccer players who suffered an ATR had a 78% RTP rate, with a mean RTP time of 5 months. Injured players played less and demonstrated inferior performance during the season of injury. With the exception of midfielders, players displayed no significant differences in play time or performance during any of the 4 postinjury seasons.

Machine learning can reliably identify patients at risk of overnight hospital admission following anterior cruciate ligament reconstruction

PURPOSE

Overnight admission following anterior cruciate ligament reconstruction has implications on clinical outcomes as well as cost benefit, yet there are few validated risk calculators for reliable identification of appropriate candidates. The purpose of this study is to develop and validate a machine learning algorithm that can effectively identify patients requiring admission following elective anterior cruciate ligament (ACL) reconstruction.

METHODS

A retrospective review of a national surgical outcomes database was performed to identify patients who underwent elective ACL reconstruction from 2006 to 2018. Patients admitted overnight postoperatively were identified as those with length of stay of 1 or more days. Models were generated using random forest (RF), extreme gradient boosting (XGBoost), linear discriminant classifier (LDA), and adaptive boosting algorithms (AdaBoost), and an additional model was produced as a weighted ensemble of the four final algorithms.

RESULTS

Overall, of the 4,709 patients included, 531 patients (11.3%) required at least one overnight stay following ACL reconstruction. The factors determined most important for identification of candidates for inpatient admission were operative time, anesthesia type, age, gender, and BMI. Smoking history, history of COPD, and history of coagulopathy were identified as less important variables. The following factors supported overnight admission: operative time > 200 min, age < 35.8 or > 53.5 years, male gender, BMI < 25 or > 31.2 kg/m², positive smoking history, history of COPD and the presence of preoperative coagulopathy. The ensemble model achieved the best performance based on discrimination assessed via internal validation (AUC = 0.76), calibration, and decision curve analysis. The model was integrated into a web-based open-access application able to provide both predictions and explanations.

CONCLUSION

Modifiable risk factors identified by the model such as increased BMI, operative time, anesthesia type, and comorbidities can help clinicians optimize preoperative status to prevent costs associated with unnecessary admissions. If externally validated in independent populations, this algorithm could use these inputs to guide preoperative screening and risk stratification to identify patients requiring overnight admission for observation following ACL reconstruction.

LEVEL OF EVIDENCE

IV.

CircCNIH4 inhibits gastric cancer progression via regulating DKK2 and FRZB expression and Wnt/β-catenin pathway

Background

Circular RNAs (circRNAs) have been reported to play an important role in tumor progression in various cancer types, including gastric cancer. The aim of this study was to investigate the role of circCNIH4 (hsa_circ_0000190) in gastric cancer and the underlying mechanism.

Methods

The expression levels of circCNIH4 and Wnt antagonist genes were detected by quantitative real-time polymerase chain reaction (qRT-PCR). The protein levels of β-catenin, Ki67, Dickkopf 2 (DKK2) and Frizzled related protein (FRZB) were measured by western blot. Ectopic overexpression or knockdown of circCNIH4, proliferation, apoptosis, migration and invasion by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT), flow cytometry and transwell assay in vitro, and in vivo experiment, were employed to assess the role of circCNIH4 in gastric cancer.

Results

CircCNIH4 was downregulated in gastric cancer tissues and cells. Overexpression of circCNIH4 inhibited gastric cancer cell proliferation, migration and invasion and promoted apoptosis by inactivating Wnt/β-catenin pathway in vitro. CircCNIH4 induced the expression of DKK2 and FRZB in gastric cancer cells. Moreover, silencing of DKK2 or FRZB reversed circCNIH4 overexpression-mediated effects on gastric cancer cells. Additionally, circCNIH4 suppressed tumor growth via regulating DKK2 and FRZB expression in gastric cancer in vivo.

Conclusion

Our study demonstrated that circCNIH4 played a tumor-inhibiting role through upregulating DKK2 and FRZB expression and suppressing Wnt/β-catenin pathway in gastric cancer, which might provide a potential biomarker for the diagnosis and treatment of gastric cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40709-021-00140-x.

Comparison of Muscle Activity and Ultrasound Response of Lower Extremity Muscles During Treadmill and Track Running

Purpose: The purpose of this study was to compare the changes in lower extremity muscle morphology and electromyography (EMG) signals during treadmill running (TR) and plastic track running (PR). Methods: A total of 10 healthy male runners aged 22.5±1.3 years, height: 175.5±4.5 cm; weight: 71.9±2.7 kg; BMI: 22.1±1.1 volunteered to participate in this study. Muscle morphology data were collected by a portable ultrasound scanner before and after running. Median frequency (MF), mean power frequency (MPF) and root mean square (RMS) were monitored during TR and PR. Results: The results indicated that muscle thickness and pennation angle have increased after running. The muscle thickness after PR showed significantly higher than TR in tested muscle except tibialis anterior (TA) and medial gastrocnemius (MG). In contrast, only the pennation angle of TA and lateral gastrocnemius (LG) after PR was significantly different from that after TR (P <0.001, P = 0.002). The most significant difference in the change rate of muscle thickness was found at TA. In addition, TA and MG showed significantly higher change rate of the pennation angle after TR than that after PR. Both of MF and MPF showed a downward trend after TR and PR. It could discover that the MF and MPF of LG during TR showed a significantly lower than that during PR both in two phases (P =0.001, P <0.001). However, in the last 5 minutes, MF and MPF of MQ during PR were smaller than that during PR (P = 0.001, P = 0.015). Furthermore, MF of RF during TR showed significantly different from that during PR (P = 0.017). From the point of RMS, in the first five minutes, the RMS of medical quadriceps (MQ), lateral quadriceps (LQ), hamstring muscles (HM) and MG during TR was significantly higher than that of PR (P <0.05). In addition, the RMS of all tested muscles after TR was significantly higher than after PR during the last 5 minutes (P <0.05). Conclusions: The current study indicated that TR and PR would cause different effects to lower extremity muscle morphology. In addition, the EMG signals based on running surfaces are also unconformity. Compared with the plastic track, the treadmill will bring more stimulation to the lower extremity muscles. The preliminary findings provide further insights into the rationality of runners’ choice of the running surface.

Factors Predictive of Prolonged Postoperative Narcotic Usage Following Orthopaedic Surgery

BACKGROUND

The purpose of this comprehensive review was to investigate risk factors associated with prolonged opioid use after orthopaedic procedures. A comprehensive review of the opioid literature may help to better guide preoperative management of expectations as well as opioid-prescribing practices.

METHODS

A systematic review of all studies pertaining to opioid use in relation to orthopaedic procedures was conducted using the MEDLINE, Embase, and CINAHL databases. Data from studies reporting on postoperative opioid use at various time points were collected. Opioid use and risk of prolonged opioid use were subcategorized by subspecialty, and aggregate data for each category were calculated.

RESULTS

There were a total of 1,445 eligible studies, of which 45 met inclusion criteria. Subspecialties included joint arthroplasty, spine, trauma, sports, and hand surgery. A total of 458,993 patients were included, including 353,330 (77%) prolonged postoperative opioid users and 105,663 (23%) non-opioid users. Factors associated with prolonged postoperative opioid use among all evaluated studies included body mass index (BMI) of ≥40 kg/m (relative risk [RR], 1.06 to 2.32), prior substance abuse (RR, 1.08 to 3.59), prior use of other medications (RR, 1.01 to 1.46), psychiatric comorbidities (RR, 1.08 to 1.54), and chronic pain conditions including chronic back pain (RR, 1.01 to 10.90), fibromyalgia (RR, 1.01 to 2.30), and migraines (RR, 1.01 to 5.11). Age cohorts associated with a decreased risk of prolonged postoperative opioid use were those ≥31 years of age for hand procedures (RR, 0.47 to 0.94), ≥50 years of age for total hip arthroplasty (RR, 0.70 to 0.80), and ≥70 years of age for total knee arthroplasty (RR, 0.40 to 0.80). Age cohorts associated with an increased risk of prolonged postoperative opioid use were those ≥50 years of age for sports procedures (RR, 1.11 to 2.57) or total shoulder arthroplasty (RR, 1.26 to 1.40) and those ≥70 years of age for spine procedures (RR, 1.61). Identified risk factors for postoperative use were similar across subspecialties.

CONCLUSIONS

We provide a comprehensive review of the various preoperative and postoperative risk factors associated with prolonged opioid use after elective and nonelective orthopaedic procedures. Increased BMI, prior substance abuse, psychiatric comorbidities, and chronic pain conditions were most commonly associated with prolonged postoperative opioid use. Careful consideration of elective surgical intervention for painful conditions and perioperative identification of risk factors within each patient's biopsychosocial context will be essential for future modulation of physician opioid-prescribing patterns.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of (5 + 2) Cycloadditions Involving Oxidopyrylium and Oxidopyridinium Ions: Relative Reactivities

A variety of (5 + 2) cycloaddition reactions involving oxidopyridinium and oxidopyrylium zwitterions are compared to investigate the effects of nitrogen-for-oxygen substitution on reactivity. Activation barriers for nitrogen-containing systems are predicted to be larger than those for analogous oxygen-containing systems. Correlations between barrier heights and synchronicity of C-C bond formation, changes to aromaticity, reactant distortion, and interaction energies between zwitterions and alkenes were assessed, leading to the conclusion that reactivity depends more on distortion effects (including aromaticity loss) than on interaction effects (such as those associated with highest occupied molecular orbital-lowest unoccupied molecular orbital (HOMO-LUMO) interactions).

Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To determine which interventions optimize clinical outcomes in adhesive capsulitis by performing a network meta-analysis of randomized controlled trials.

METHODS

A systematic review was conducted of all clinical trials on adhesive capsulitis published since 2008. Patient cohorts were grouped into treatment categories; data collected included range of motion (ROM) and patient-reported outcome measures (PROMs). Interventions were compared across groups by means of arm-based Bayesian network meta-analysis in a random-effects model.

RESULTS

Sixty-six studies comprising 4042 shoulders (57.6% female patients, age 54.8 ± 3.2 years [mean ± standard deviation]) were included. The most commonly studied interventions were physical therapy (PT) or shoulder injections. Network meta-analysis demonstrated that arthroscopic surgical capsular release was the most effective treatment in increasing ROM. This effect was apparent in forward flexion (effect difference [ED] versus placebo, 44°, 95% confidence interval [CI] 31° to 58°), abduction (ED 58°, 45° to 71°), internal rotation (ED 34°, 24° to 44°), and external rotation (ED 59°, 37° to 80°). Interventions most effective for pain relief included PT supplemented with either medical therapy (ED -4.50, -9.80 to 2.80) or ultrasound therapy (ED -5.10, -5.10 to -1.40). Interventions most effective for improvement of functional status included PT, manipulation under anesthesia (MUA), intra-articular or subacromial steroid injection, surgical capsular release, and supplementation of PT with alternative therapy.

CONCLUSIONS

No one treatment emerged superior in regard to ROM, pain symptoms, and functional status. Surgery (after failure of conservative treatment) ranked highest across all ROM domains. Treatments that ranked highest for treatment of pain included PT supplemented with either medical therapy or ultrasound. Finally, treatments that ranked highest for improvements in functional status included MUA, PT with medical therapy, surgical intervention, PT with ultrasound, PT with injection, and injection alone.

LEVEL OF EVIDENCE

II, systematic review and network meta-analysis of level I and II studies.

Establishing Clinically Significant Outcomes for Patient-Reported Outcomes Measurement Information System After Biceps Tenodesis

PURPOSE

To establish thresholds for improvement in patient-reported outcome scores that correspond with clinically significant outcomes (CSOs) including the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive testing (CAT) and pain interference (PIF) CAT after biceps tenodesis (BT) and to assess patient variables that are associated with achieving these outcomes.

METHODS

After institutional review board approval was obtained, a prospectively maintained institutional database was queried for patients undergoing BT between December 2017 and August 2019. Patients undergoing BT in isolation or BT in conjunction with rotator cuff debridement, SLAP repair, subacromial decompression, or distal clavicle excision were included in the analysis. Anchor- and distribution-based methods were used to calculate the MCID whereas an anchor-based method was used to calculate SCB and the PASS for PROMIS UE CAT and PIF CAT.

RESULTS

A total of 112 patients (86.8% follow-up) who underwent BT were included for analysis. The MCID, net SCB, absolute SCB, and PASS for PROMIS UE CAT were 4.02, 9.25, 43.4, and 41.1, respectively. The MCID, net SCB, absolute SCB, and PASS for PROMIS PIF CAT were -4.12, -10.7, 52.4, and 52.4, respectively. Higher preoperative UE CAT and PIF CAT scores, preoperative opioid use, depression, and living alone were negative predictors of CSO achievement. Male sex and regular participation in exercise were positive predictors of CSO achievement.

CONCLUSIONS

Patients with higher preoperative UE scores were less likely to achieve the MCID (odds ratio [OR], 0.84), whereas patients with higher preoperative PIF scores were less likely to achieve absolute SCB and the PASS (OR, 0.83-0.89). Most patients achieved the MCID for PIF CAT (70.5%) and UE CAT (62.5%) at final follow-up. Male sex (OR, 4.38-9.15) and regular exercise participation (OR, 6.45-18.94) positively predicted CSO achievement, whereas preoperative opioid use (OR, 0.06), depression (OR, 0.23), and living alone (OR, 0.90) were negative predictors of CSO achievement.

LEVEL OF EVIDENCE

Level IV, case series.

Development of a Machine Learning Algorithm to Predict Nonroutine Discharge Following Unicompartmental Knee Arthroplasty

BACKGROUND

Reliable and effective prediction of discharge destination following unicompartmental knee arthroplasty (UKA) can optimize patient outcomes and system expenditure. The purpose of this study is to develop a machine learning algorithm that can predict nonhome discharge in patients undergoing UKA.

METHODS

A retrospective review of a prospectively collected national surgical outcomes database was performed to identify adult patients who underwent UKA from 2015 to 2019. Nonroutine discharge was defined as discharge to a location other than home. Five machine learning algorithms were developed to predict this outcome. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis.

RESULTS

Overall, of the 7275 patients included, 263 (3.6) patients were unable to return home upon discharge following UKA. The factors determined most important for identification of candidates for nonroutine discharge were total hospital length of stay, preoperative hematocrit, body mass index, preoperative sodium, American Society of Anesthesiologists classification, gender, and functional status. The extreme boosted model achieved the best performance based on discrimination (area under the curve = 0.875), calibration, and decision curve analysis. This model was integrated into a web-based open access application able to provide both predictions and explanations.

CONCLUSION

The present model can, following appropriate external validation, be used to augment clinician decision-making in patients undergoing elective UKA. Patients with high preoperative probabilities of nonroutine discharge based on nonmodifiable risk factors should be counseled to start the insurance authorization process with case management to avoid unnecessary inpatient stay, and those with modifiable risk can attempt prehabilitation to optimize these parameters before surgery.

The Patient Acceptable Symptomatic State in Primary Anterior Cruciate Ligament Reconstruction: Predictors of Achievement

PURPOSE

To identify thresholds for patient acceptable symptomatic state (PASS) achievement in a cohort of primary anterior cruciate ligament reconstruction (ACLR) recipients, and to identify factors predictive of PASS achievement.

METHODS

A prospective clinical registry was queried for primary ACLR patients from January 2014 to April 2017 with serial patient-reported outcome measure (PROM) completion at 6, 12, and 24 months. Exclusion criteria included significant concomitant procedures. Knee-based PROMs included the International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores. PASS threshold values were calculated using receiver operating characteristic (ROC) curves with area under the curve (AUC) analysis. A stepwise multivariate regression identified preoperative and operative predictors of PASS achievement.

RESULTS

A total of 144 primary ACLR patients (30.86 ± 12.78 years, body mass index 25.51 ± 4.64, 41.0% male) were included in the analysis. PASS threshold values were established using ROC curve analysis, all of which exceeded 0.7 on AUC analysis (0.742 to 0.911). Factors impacting odds of PASS achievement in the ACLR cohort included preoperative exercises (odds ratio [OR] 2.95 to 4.74, P = .003 to .038), worker's compensation status (OR 0.25 to 0.28, P = .014 to .033), preoperative scores (OR 1.03 to 1.07, P = .005 to <.001), iliotibial band tenodesis (OR 11.08, P = .010), and anteromedial approach (OR 18.03 to 37.05, P < .001).

CONCLUSION

Factors predictive of PASS achievement in recipients of primary ACLR include functional status (e.g., preoperative exercise, preoperative KOOS Sport/Recreation score), worker's compensation status, technique (e.g., anteromedial) and preoperative PROMs. The results of our study are important in better informing shared decision-making models and improving evidence-based guidelines to optimize patient outcomes.

How can we define clinically important improvement in pain scores after biceps tenodesis?

BACKGROUND

Patient postoperative pain is an important consideration following biceps tenodesis. The visual analog scale (VAS) for pain is one of the most commonly used measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain.

PURPOSE

To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing open subpectoral (OSPBT) or arthroscopic suprapectoral biceps tenodesis (ASPBT) at 1 year from surgery; and to identify preoperative predictors of achieving each outcome end point.

METHODS

Data from consecutive patients who underwent isolated biceps tenodesis between January 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome (PRO) scores were recorded at 1 year postoperatively. In order to quantify the clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated.

RESULTS

A total of 165 patients were included in the final analysis. The VAS pain score threshold for achieving MCID was defined as a decrease of 12.9 (0-100). PASS was defined as achieving a 2-year postoperative score of 27.4 points (0-100), and SCB was defined as a decrease of 25.1 (0-100) at 1-year follow-up. The rates of achieving MCID, PASS, and SCB were 73.3%, 52.8%, and 45.9%, respectively. Multivariate regression analysis demonstrated that ASPBT (P = .01) and a lower preoperative Constant-Murley score were predictive of achieving the MCID (P = .01). In contrast, a lower preoperative score on the SF-12 Physical Component Summary (P = .01) and a higher score on the preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) were predictive of achieving the SCB and PASS, respectively. Preoperative duration of symptoms >6 months was predictive of a reduced likelihood to achieve PASS.

CONCLUSION

This study identified scores for VAS pain that can be used to define clinically significant outcome after biceps tenodesis. Specifically, a decrease in pain score of 12.9 was a clinically important improvement in VAS pain, whereas a decrease of 25.1 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.

Increased Operative Time Impacts Rates of Short-Term Complications After Unicompartmental Knee Arthroplasty

BACKGROUND

Previous evidence has demonstrated an exacerbating effect of increased operative time on short-term complications in total joint arthroplasty. While the same relationship may be expected for unicompartmental knee arthroplasty (UKA), supporting evidence remains sparse. The purpose of this study is to determine the impact of operative time on short-term complication rates after UKA and determine a critical threshold in operative times after which complications may increase.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project was queried from 2007 to 2018 to identify 11,633 UKA procedures that were included in the final analysis. The effect of operative time on complications within 30 days was evaluated using multivariate logistic regression models. Receiver operating characteristics curves and spline regression models were used to identify critical thresholds in operative time that increase the likelihood of short-term complications.

RESULTS

Longer operative times (in minutes) were associated with higher rates of surgical site infection (90.4 ± 26.7 vs 84.8 ± 25.5, P = .003), blood transfusions (94.9 ± 28.6 vs 84.9 ± 25.5, P = .007), as well as reoperation rates (90.8 ± 27.9 vs 84.9 ± 25.5, P = .01), extended hospital length of stay (93.4 ± 29.8 vs 84.5 ± 25.2, P < .001), and mortality (110.4 ± 35.5 vs 84.9 ± 25.5, P = .008). Following multivariate logistic regression, operative time was found to independently predict increased surgical site infection, blood transfusion, myocardial infarction, extended length of stay, and mortality (odds ratio: 1.09 - 1.45, CI: 1.01 - 1.91, all P values <0.02). Receiver operating characteristics curves found an increase in mortality risk during the 30-day postoperative period after 88.5 minutes of operative time, a finding supported by spline regression plots.

CONCLUSION

The present study found a positive correlation between increased operative times and short-term postoperative complication rates after UKA. Despite a statistically significant association with increasing operative time, odds ratios of reported complications are relatively low.

Inpatient Arthroscopic Rotator Cuff Repair Is Associated With Higher Postoperative Complications Compared With Same-Day Discharge: A Matched Cohort Analysis

PURPOSE

To compare 90-day postoperative complications between patients undergoing outpatient versus inpatient arthroscopic rotator cuff repairs (RCR) and identify risk factors associated with postoperative complications.

METHODS

An administrative claims database was used to identify patients undergoing arthroscopic RCR from 2007 to 2015. Patients were categorized based on length of hospital stay (LOS) with inpatient RCR defined as patients with ≥1 day LOS, and outpatient RCR as patients discharged day of surgery (LOS = 0). Inpatient and outpatient RCR groups were matched based on age, sex, Charlson comorbidity index (CCI), and various medical comorbidities using 1:1 propensity score analysis. Patient factors, concomitant procedures, total adverse events (TAEs), medical adverse events (MAEs), and surgical adverse events (SAEs) were compared between the matched groups. Multiple logistic regression analysis was performed to identify risk factors associated with increased complications.

RESULTS

After matching, there were 2812 patients (50% outpatient) included in the study. Within 90 days following arthroscopic RCR, the incidence of TAEs (8.9% vs 3.6%, P < .0001), SAEs (2.7% vs 0.9%, P = .0002), and MAEs (6.4% vs 3.0%, P < .0001) were significantly greater for the inpatient RCR group. The multivariate model identified inpatient RCR (LOS ≥1 day), greater CCI, and anxiety or depression as independent predictors for TAEs after arthroscopic RCR. Open biceps tenodesis and inpatient RCR were independent predictors of SAEs, whereas greater CCI, anxiety or depression, and inpatient RCR were independent predictors for MAEs within 90 days after arthroscopic RCR.

CONCLUSIONS

Inpatient arthroscopic RCR is associated with increased risk of 90-day postoperative complications compared with outpatient. However, there is no difference for all-cause or pain-related emergency department visits within 90 days after surgery. In addition, the multivariate model identified inpatient RCR, greater CCI, and diagnosis of anxiety or depression as independent risk factors for 90-day TAEs after arthroscopic RCR.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Lysis of Adhesion for Arthrofibrosis After Total Knee Arthroplasty Is Associated With Increased Risk of Subsequent Revision Total Knee Arthroplasty

BACKGROUND

The aim of this study is to determine incidence of lysis of adhesion (LOA) for postoperative arthrofibrosis following primary total knee arthroplasty (TKA), patient factors associated with LOA, and impact of LOA on revision TKA.

METHODS

Patients who underwent primary TKA were identified in the Humana and Medicare databases. Patients who underwent LOA within 1 year after TKA were defined as the "LOA" cohort. Multiple binomial logistic regression analyses were performed to identify patient factors associated with undergoing LOA within 1 year after index TKA, and identify risk factors including LOA on risk for revision TKA within 2 years of index TKA.

RESULTS

In total, 58,538 and 48,336 patients underwent primary TKA in the Medicare and Humana databases, respectively. Incidence of LOA within 1 year after TKA was 0.56% in both databases. Age <75 years was a significant predictor of LOA in both databases (P < .05 for both). Incidence of revision TKA was significantly higher for the "LOA" cohort when compared to the "TKA Only" cohort in both databases (P < .0001 for both). LOA was the strongest predictor of revision TKA within 2 years after index TKA in both databases (P < .0001 for both). Additionally, age <65 years, male gender, obesity, fibromyalgia, smoking, alcohol abuse, and history of anxiety or depression were independently associated with increased odds of revision TKA within 2 years after index TKA (P < .05 for all).

CONCLUSION

Incidence of LOA after primary TKA is low, with younger age being the strongest predictor for requiring LOA. Patients who undergo LOA for arthrofibrosis within 1 year after primary TKA have a substantially high risk for subsequent early revision TKA.

LEVEL OF EVIDENCE

III, Retrospective Cohort Study.