Discharge Opioid Dose Indirectly Associated With Functional Outcomes 2 Weeks After Shoulder and Knee Arthroscopy in a US Military Sample

INTRODUCTION

Postsurgical opioid utilization may be directly and indirectly associated with a range of patient-related and surgery-related factors, above and beyond pain intensity. However, most studies examine postsurgical opioid utilization without accounting for the multitude of co-occurring relationships among predictors. Therefore, this study aimed to identify factors associated with opioid utilization in the first 2 weeks after arthroscopic surgery and examine the relationship between discharge opioid prescription doses and acute postsurgical outcomes.

METHODS

In this prospective longitudinal observational study, 110 participants undergoing shoulder or knee arthroscopies from August 2016 to August 2018 at Walter Reed National Military Medical Center completed self-report measures before and at 14 days postoperatively. The association between opioid utilization and both patient-level and surgery-related factors was modeled using structural equation model path analysis.

RESULTS

Participants who were prescribed more opioids took more opioids, which was associated with worse physical function and sleep problems at day 14, as indicated by the significant indirect effects of discharge opioid dose on day 14 outcomes. Additional patient-level and surgery-related factors were also significantly related to opioid utilization dose and day 14 outcomes. Most participants had opioid medications leftover at day 14.

CONCLUSION

Excess opioid prescribing was common, did not result in improved pain alleviation, and was associated with poorer physical function and sleep 14 days after surgery. As such, higher prescribed opioid doses could reduce subacute functioning after surgery, without benefit in reducing pain. Future patient-centered studies to tailor opioid postsurgical prescribing are needed.

Post-total joint arthroplasty opioid prescribing practices vary widely and are not associated with opioid refill: an observational cohort study

INTRODUCTION

Optimized health system approaches to improving guideline-congruent care require evaluation of multilevel factors associated with prescribing practices and outcomes after total knee and hip arthroplasty.

MATERIALS AND METHODS

Electronic health data from patients who underwent a total knee or hip arthroplasty between January 2016-January 2020 in the Military Health System Data were retrospectively analyzed. A generalized linear mixed-effects model (GLMM) examined the relationship between fixed covariates, random effects, and the primary outcome (30-day opioid prescription refill).

RESULTS

In the sample (N = 9151, 65% knee, 35% hip), the median discharge morphine equivalent dose was 660 mg [450, 892] and varied across hospitals and several factors (e.g., joint, race and ethnicity, mental and chronic pain conditions, etc.). Probability of an opioid refill was higher in patients who underwent total knee arthroplasty, were white, had a chronic pain or mental health condition, had a lower age, and received a presurgical opioid prescription (all p < 0.01). Sex assigned in the medical record, hospital duration, discharge non-opioid prescription receipt, discharge morphine equivalent dose, and receipt of an opioid-only discharge prescription were not significantly associated with opioid refill.

CONCLUSION

In the present study, several patient-, care-, and hospital-level factors were associated with an increased probability of an opioid prescription refill within 30 days after arthroplasty. Future work is needed to identify optimal approaches to reduce unwarranted and inequitable healthcare variation within a patient-centered framework.

Longitudinal Predictors of PROMIS Satisfaction With Social Roles and Activities After Shoulder and Knee Sports Orthopaedic Surgery in United States Military Servicemembers: An Observational Study

Background

Satisfaction with social roles and activities is an important outcome for postsurgical rehabilitation and quality of life but not commonly assessed.

Purpose

To evaluate longitudinal patterns of the Patient-Reported Outcomes Measurement Information System (PROMIS) Satisfaction with Social Roles and Activities measure, including how it relates to other biopsychosocial factors, before and up to 6 months after sports-related orthopaedic surgery.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

Participants (N = 223) who underwent knee and shoulder sports orthopaedic surgeries between August 2016 and October 2020 completed PROMIS computer-adaptive testing item banks and pain-related measures before surgery and at 6-week, 3-month, and 6-month follow-ups. In a generalized additive mixed model, covariates included time point; peripheral nerve block; the PROMIS Anxiety, Sleep Disturbance, and Pain Behavior measures; and previous 24-hour pain intensity. Patient-reported outcomes were modeled as nonlinear (smoothed) effects.

Results

The linear (estimate, 2.06; 95% CI, 0.77-3.35; P = .002) and quadratic (estimate, 2.93; 95% CI, 1.78-4.08; P < .001) effects of time, as well the nonlinear effects of PROMIS Anxiety (P < .001), PROMIS Sleep Disturbance (P < .001), PROMIS Pain Behavior (P < .001), and pain intensity (P = .02), were significantly associated with PROMIS Satisfaction with Social Roles and Activities. The cubic effect of time (P = .06) and peripheral nerve block (P = .28) were not. The proportion of patients with a 0.5-SD improvement in the primary outcome increased from 23% at 6 weeks to 52% by 6 months postsurgery, whereas those reporting worsening PROMIS Satisfaction with Social Roles and Activities decreased from 30% at 6 weeks to 13% at 6 months.

Conclusion

The PROMIS Satisfaction with Social Roles and Activities measure was found to be related to additional domains of function (eg, mental health, behavioral, pain) associated with postsurgical rehabilitation.

Lagged effect of Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance on subacute postsurgical PROMIS Pain Behavior

Sleep disturbance is a modifiable risk factor that, when reduced, may improve subacute postsurgical outcomes (e.g., pain-related impact). Evidence also indicates that pain and sleep may have a bidirectional longitudinal relationship before to (sub) acutely after surgery. The objective of the present study is to examine the degree to which sleep disturbances and pain behavior have uni- or bidirectional relationships in a sample of patients undergoing sports orthopedic surgery. In this observational, longitudinal cohort study, participants ( = 296) were adult (ages 18+) active duty service members who underwent open or arthroscopic shoulder or knee surgery at Walter Reed National Military Medical Center. Participants were asked to complete PROMIS Sleep Disturbance and Pain Behavior computer adaptive testing item banks before surgery, 6 weeks postsurgery, and 3 months postsurgery. Patient-level covariates were analyzed for interrelationships using nonparametric bivariate statistics. Autoregressive and cross-lagged structural equation modeling examined the bidirectional relationships of patient-level covariates and PROMIS outcomes. When controlling for patient-level covariates, sleep disturbance at presurgical and 2-week postsurgical timepoints were positively associated with both sleep disturbance and pain behavior at the subsequent timepoint. Sleep disturbance may contribute to pain-related functioning and quality of life after sports orthopedic surgery. Future studies utilizing multidimensional patient report outcomes and robust analytics are needed to better understand whether sleep-targeted interventions can improve subacute and long-term orthopedic sports surgery outcomes.

Platelet-Rich Plasma Improves Strength and Speed of Recovery in an Active-Duty Soldier with Isolated Injury to the Lateral Collateral Ligament of the Knee: A Case Report

Ligamentous injuries of the knee occur in the military, but constitute an overwhelmingly disproportionate number of medical discharges, which can be due to prolonged recovery through traditional use of physical therapy (PT) and other non-operative modalities. The use of platelet-rich plasma (PRP) may substantially increase the speed of recovery and patient outcomes but is little explored for less common isolated ligamentous injuries, such as the lateral collateral ligament, especially in active-duty populations. We describe the use of PRP in a young, otherwise healthy active-duty male to treat an isolated LCL injury with significant positive outcomes. These findings support consideration for early use of PRP in similar cases to improve recovery timelines and aid in return to duty.

Pain Catastrophizing Predicts Opioid and Health-Care Utilization After Orthopaedic Surgery: A Secondary Analysis of Trial Participants with Spine and Lower-Extremity Disorders

BACKGROUND

Most individuals undergoing elective surgery expect to discontinue opioid use after surgery, but many do not. Modifiable risk factors including psychosocial factors are associated with poor postsurgical outcomes. We wanted to know whether pain catastrophizing is specifically associated with postsurgical opioid and health-care use.

METHODS

This was a longitudinal cohort study of trial participants undergoing elective spine (lumbar or cervical) or lower-extremity (hip or knee osteoarthritis) surgery between 2015 and 2018. Primary and secondary outcomes were 12-month postsurgical days' supply of opioids and surgery-related health-care utilization, respectively. Self-reported and medical record data included presurgical Pain Catastrophizing Scale (PCS) scores, surgical success expectations, opioid use, and pain interference duration.

RESULTS

Complete outcomes were analyzed for 240 participants with a median age of 42 years (34% were female, and 56% were active-duty military service members). In the multivariable generalized additive model, greater presurgical days' supply of opioids (F = 17.23, p < 0.001), higher pain catastrophizing (F = 1.89, p = 0.004), spine versus lower-extremity surgery (coefficient estimate = 1.66 [95% confidence interval (CI), 0.50 to 2.82]; p = 0.005), and female relative to male sex (coefficient estimate = -1.25 [95% CI, -2.38 to -0.12]; p = 0.03) were associated with greater 12-month postsurgical days' supply of opioids. Presurgical opioid days' supply (chi-square = 111.95; p < 0.001), pain catastrophizing (chi-square = 96.06; p < 0.001), and lower extremity surgery (coefficient estimate = -0.17 [95% CI, -0.24 to -0.11]; p < 0.001), in addition to age (chi-square = 344.60; p < 0.001), expected recovery after surgery (chi-square = 54.44; p < 0.001), active-duty status (coefficient estimate = 0.58 [95% CI, 0.49 to 0.67]; p < 0.001), and pain interference duration (chi-square = 43.47; p < 0.001) were associated with greater health-care utilization.

CONCLUSIONS

Greater presurgical days' supply of opioids and pain catastrophizing accounted for greater postsurgical days' supply of opioids and health-care utilization. Consideration of several modifiable factors provides an opportunity to improve postsurgical outcomes.

LEVEL OF EVIDENCE

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

Magnetic resonance imaging does not reliably detect Kaplan fiber injury in the setting of anterior cruciate ligament tear

PURPOSE

There has been a continued effort to better understand the role Kaplan fiber injury plays in persistent instability following ACL tears. However, the prevalence of these injuries remains poorly understood. Therefore, the purpose of this study was to define the prevalence of Kaplan fiber injury in the setting of complete anterior cruciate ligament tear using a commonly used grading system for assessing ligament injuries. The inter-rater reliability of this commonly used grading system and the relationship between Kaplan fiber injury and injury to other structures commonly found in conjunction with ACL tears was also evaluated.

METHODS

All isolated, complete anterior cruciate ligament tears confirmed on magnetic resonance imaging within 90 days of injury between 2014 and 2020 at a single institution were included for analysis. Each scan was read by two, fellowship-trained musculoskeletal radiologists. Kaplan fiber injury was evaluated using a previously described grading scheme. Kappa, [Formula: see text], of inter-rater agreement was determined for all magnetic resonance image scans. Kruskal Wallis test was performed to assess for associations between Kaplan fiber injury and magnet strength (1.5 T vs. 3.0 T), patient gender, the presence of medial and/or lateral meniscal tears, and/or posterolateral tibial bone bruise.

RESULTS

Between 2014 and 2020, 131 patients (94 males, 37 females) with a complete anterior cruciate ligament tear were included in the final analysis. The mean age of the cohort was 27.8 ± 6.8 years. Kaplan fiber injuries were identified in 51 of 131 (38.9%, CI 31.0-47.5%) scans with complete anterior cruciate ligament injuries (Grade 1: 28, Grade 2: 18, and Grade 3: 5). Inter-rater agreement for Kaplan fiber injury was fair ([Formula: see text] with 43 (32.8%) scans requiring third reviewer adjudication. There were no significant associations between Kaplan fiber injury and gender, magnet strength, meniscal tears, or posterolateral tibial bone bruise.

CONCLUSION

The prevalence of Kaplan fiber injuries was comparable to previously described rates; however, the classification system used to report Kaplan fiber injury was associated with low inter-rater reliability. The presence of Kaplan fiber injury was not associated with other injuries commonly observed in conjunction with ACL tear. The previously proposed Kaplan fiber injury classification system is not reproducible nor is it likely to aid surgeons in distinguishing higher grades of rotatory knee instability.

LEVEL OF EVIDENCE

Level IV.

High Incidence of Combined and Posterior Labral Tears in Military Patients With Operative Shoulder Instability

BACKGROUND

Anterior shoulder instability is the pattern most commonly reported in the civilian population, but military servicemembers may represent a unique population. At 1.7 per 1000 person-years, servicemembers not only have a higher incidence of instability events compared with civilians (reported rate of 0.2-0.8), but the distribution of labral tears in the military may differ significantly as well.

HYPOTHESIS

The incidence of combined and posterior labral tears in the military population will be greater than numbers previously reported.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The Wounded, Ill, and Injured Registry, a Department of Defense patient reported outcomes data collection platform that includes all military branches, was queried retrospectively for all patients who had undergone a primary arthroscopic or open shoulder stabilization procedure (Current Procedural Terminology codes 29806, 23455, 23462) between October 2016 and January 2019. Demographic information was obtained through intake forms completed by patients at the time of enrollment into the Military Orthopaedics Tracking Injuries and Outcomes Network. Tear location was determined arthroscopically and labeled as anterior, inferior, posterior, superior, or any combination thereof. Chi-square analysis was used to compare the percentage of patients with isolated anterior, isolated posterior, isolated inferior, or combined labral tears in the current study cohort with those in a previously reported cohort of patients with operative shoulder instability at a single military treatment facility.

RESULTS

A total of 311 patients were included who had undergone primary shoulder stabilization during the study period. Of these patients, 94 (30.2%) had isolated anterior tears, 76 (24.4%) had isolated posterior tears, and 136 (43.7%) had combined tears. We observed a higher percentage of combined tears in our data set than in a data set from a single military treatment facility (χ²(2) = 48.2; P < .00001). Chi-square analysis demonstrated that significantly more female patients had an isolated anterior labral tear (51.2%) compared with male patients (27.1%; χ²(2) = 9.4; P = .009).

CONCLUSION

The incidence of combined and posterior labral tears in the military population is greater than numbers previously reported in both military and civilian populations.

On-field Emergencies and Emergency Action Plans

Sideline coverage can be an enjoyable experience and provide the opportunity to witness and evaluate an athlete's pathology at the time of injury. While the majority of on-field injury will likely be of low acuity, it is essential to develop an Emergency Action Plan (EAP) to deliver excellent medical care efficiently. The EAP should provide a written, standardized multidisciplinary approach involving key personnel. The EAP should be rehearsed on at least an annual basis and should highlight the initial assessment of the patient while also accounting for the various types of trauma that may occur on the field and appropriate field extrication procedures. As most players who have a true on-field emergency will not return to same-day play, a thorough understanding of how to deliver emergency care and transfer the player to a higher level of care is essential.

Multivitamin Use in Enhanced Recovery After Surgery Protocols: A Cost Analysis

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) protocols have shown significant benefits in multiple areas including early mobilization, improved pain control, and early oral intake. Deficient nutritional states may compromise the operative outcomes. Several essential vitamins, e.g., B12, C, D, and E, have demonstrated anti-inflammatory properties and may promote wound healing. Given the low risk of oral multivitamin supplementation and the potential benefits, we hypothesized that adding a multivitamin to our institution's ERAS protocols would be a low-cost perioperative intervention accounting for a very small fraction of the annual pharmacy budget.

METHODS

A cost analysis for vitamin supplementation for all adult orthopedic surgical cases for the fiscal year 2018 was conducted. To assess the potential cost for multivitamin supplementation in the perioperative period, the fiscal year 2018 pharmacy budget and current costs of multivitamins were obtained from the hospital pharmacy. Medication costs were obtained from the medical logistics ordering system at per unit (i.e., bottle) and per tablet levels for all formulary oral multivitamins. We also determined the number of adult orthopedic surgical cases for our facility in the fiscal year 2018 from our surgery scheduling system. The cost for supplementation for a single day (day of surgery), 1 week (first postoperative week), 6 weeks plus 1 week preop, and 6 months plus 1 week preop for all cases was then calculated.

RESULTS

Our institution's pharmacy budget for the fiscal year 2018 was $123 million dollars with two oral multivitamins on formulary. Prenatal tablets, containing vitamins A-E, calcium, iron, and zinc, cost $1.52 per bottle of 100 tablets and $0.0152 per tablet, while renal formulation tablets, containing water-soluble vitamins B and C, cost $2.79 per bottle of 100 tablets and $0.0279 per tablet. For one fiscal year, the medication cost to supplement every adult orthopedic surgery patient with an oral multivitamin for 1 day, 1 week, 6 weeks plus 1 week preop, and 6 months plus 1 week preop would range from $60.47 to $110.99, from $423.29 to $776.93, from $2,963.03 to $5,438.51, and from $10,582.25 to $19,423.25, respectively, depending on which multivitamin was prescribed. These costs would represent between 0.00005% and 0.00009% of the annual pharmacy budget for 1 day, between 0.0003% and 0.0006% for 1 week, between 0.00245% and 0.441% for 6 weeks plus 1 week preop, and between 0.00875% and 1.575% for 6 months plus 1 week preop, respectively.

DISCUSSION/CONCLUSIONS

The relative nutrient-deficient state in the perioperative patient from decreased oral intake contributes to the metabolic derangements resulting from the surgery. The current ERAS protocols help to mitigate this with early feeding, and the addition of multivitamin supplementation may enhance this process. Multivitamins are safe, widely accessible, and inexpensive, and early investigations of pain control and healing have shown encouraging results. Further prospective studies are needed for incorporating multivitamins into ERAS protocols in order to elucidate the effective dosages, duration of treatment, and effect on outcomes.

Femoral Nerve Blockade Does Not Lead to Subjective Functional Deficits After Anterior Cruciate Ligament Reconstruction

INTRODUCTION

Anterior cruciate ligament reconstruction (ACLR) ranks among the most common surgeries performed in civilian as well as military orthopedic settings. Regional anesthesia, and the femoral nerve block (FNB) in particular, has demonstrated efficacy in reducing postoperative pain and opioid use after ACLR, however concerns linger about possible impaired functional outcomes. The purpose of the current investigation was to assess International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) scores at 6 to 12 months after ACLR in patients who did (FNB) and did not (NoFNB) receive a perioperative FNB.

MATERIALS AND METHODS

All patients undergoing unilateral ACLR in the study period were reviewed in this institutional process improvement analysis. The primary outcome was prospectively collected IKDC-SKF scores obtained at 6-12 months post-surgery. Demographic and surgical information collected as potential covariates included age, sex, body mass index (BMI), preoperative IKDC-SKF score, use of an FNB, use of another (not femoral nerve) block, American Society of Anesthesiologists (ASA) score, graft type (auto vs. allograft), concomitant meniscus or cartilage procedures, tobacco use, tourniquet time, and primary vs. revision surgery. Assuming a 1:2 ratio of patients who did not vs. did receive FNBs and a clinically meaningful difference of 7 points on the IKDC-SKF, 112 patients were required for 80% power. A regression model averaging approach examined the relationships between covariates and postoperative IKDC-SKF scores.

RESULTS

One hundred nineteen patients met inclusion criteria (FNB 79 and NoFNB 40). The cohorts were significantly different in several factors including BMI, ASA level, graft type, and other peripheral nerve blocks, which were controlled for through regression modeling. Regressions with model averaging examined the relationship between treatment groups and postoperative IKDC-SKF scores, along with other potential predictor variables. Estimated adjusted marginal differences in postoperative IKDC-SKF scores from the best-fitting model revealed a very small 0.66-point mean (P = .86) difference between NoFNB and FNB groups that was not statistically significant. Those who reported tobacco use had a 10.51 point (P = .008) lower mean postoperative IKDC-SKF score than those who did not report tobacco use. Every 1-point increase in the preoperative IKDC-SKF score was associated with a 0.28-point (P = .02) increase in the postsurgical IKDC-SKF score.

CONCLUSIONS

Active tobacco use may negatively impact short-term subjective patient-reported outcomes after ACLR, as reported by the IKDC-SKF. Lower preoperative scores are also associated with significantly lower postoperative IKDC-SKF scores while the use of a FNB was not associated with lower postoperative scores. The negative association between tobacco use and patient-reported functional outcomes after ACLR lends further support to tobacco cessation programs within the military.

Generating the American Shoulder and Elbow Surgeons Score Using Multivariable Predictive Models and Computer Adaptive Testing to Reduce Survey Burden

BACKGROUND

The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores.

PURPOSE

To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis.

RESULTS

A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R² = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores.

CONCLUSION

The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

Current Practice Patterns in Anterior Cruciate Ligament Reconstruction Among Fellowship-Trained Military Orthopaedic Surgeons

Purpose

To evaluate current practice patterns in anterior cruciate ligament reconstruction (ACLR) surgery among fellowship-trained military surgeons.

Methods

The MOTION database is a prospectively collected dataset of intraoperative variables across the Military Health System. This database was queried using Current Procedural Terminology code 29888 for ACLR among active-duty service members between October 2016 and December 2019. The intraoperative data pertaining to ACLR involving both isolated primary ACLRs and primary ACLRs combined with meniscal or chondral injuries were extracted with patient age, sex, and rank.

Results

Two hundred sixty-six primary ACLRs performed by 21 fellowship-trained orthopaedic surgeons at 9 MTFs were identified. The mean age of patients undergoing ACLR was 27.2 ± 7.7 years. Bone–patellar tendon–bone autograft was the most commonly used graft source (137 of 266 [51.5%] cases.) Meniscal injuries were treated with an isolated debridement in 53 of 156 (34.0%) tears, whereas meniscal repair was performed in 86 of 156 (55.1%) tears. Concomitant chondral pathology was noted in 43 of 266 cases (16.2%) and most commonly addressed with chondroplasty (25 of 49 [51.0%] chondral lesions).

Conclusions

Bone–patellar tendon–bone autograft was the most commonly used graft type in ACLR among fellowship-trained surgeons treating active-duty service members. Concomitant meniscal pathology was encountered at rates comparable with what has been previously reported, and meniscal repair was favored over meniscal debridement in more than 50% cases.

Level of Evidence

Level IV: Therapeutic case series.

Pathoanatomy of Shoulder Instability in Collegiate Female Athletes

BACKGROUND

Shoulder instability has been well described in young men; however, few studies have specifically evaluated the pathoanatomy and unique spectrum of injuries in women with shoulder instability.

PURPOSE

To describe the pathoanatomy of operative shoulder instability in a collegiate female cohort.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors performed a retrospective analysis of a consecutive series of female students at a National Collegiate Athletic Association Division I military service academy treated operatively for shoulder instability by a single surgeon between September 2008 and September 2014. Preoperative data collected included patient age, sport, mechanism of injury, number and frequency of dislocations, direction of instability, and co-occurring surgical abnormalities at the time of arthroscopy. Outcome variables included recurrent instability after surgery and need for revision.

RESULTS

Thirty-six female student athletes with an average age of 20 years (range, 18-22 years) were included. The majority of instability events were traumatic in nature (69%), and 61% of the total events were subluxations. Rugby was the most common sport for experiencing instability (7 patients), followed by obstacle course training (6 patients). Thirty-two patients (89%) reported multiple instability events, averaging 4 per shoulder. The primary direction of instability was anterior in 26, combined anterior and posterior in 7, and 3 met criteria for multidirectional instability. At the time of surgery, 26 patients (72%) had a Bankart tear, 9 (25%) had a posterior labral tear, and 5 (14%) had superior labrum anterior to posterior tears. Nine patients (25%) were found to have humeral avulsion of the glenohumeral ligament (HAGL) lesions, 7 (19%) had partial-thickness articular-sided rotator cuff tears, and only 1 patient (3%) had evidence of true attritional glenoid bone loss. Hill-Sachs lesions were found in 16 patients (44%). Recurrent instability occurred in 9 patients (25%) following arthroscopic stabilization, and revision surgery was performed in 6 (17%).

CONCLUSION

Shoulder instability in female athletes presents commonly as multiple subluxation events. While soft tissue Bankart lesions were found in numbers equal to those in previous studies include both sexes, bony Bankart lesions were less common in women. Finally, the presence of combined anterior and posterior labral tears and HAGLs in women was more common than previously reported.

Early vs Delayed Weightbearing After Microfracture of Osteochondral Lesions of the Talus: A Prospective Randomized Trial

Background:

Osteochondral lesions of the talus (OLTs) are common injuries in young, active patients. Microfracture is an effective treatment for lesions less than 150 mm² in size. Most commonly employed postoperative protocols involve delaying weightbearing for 6 to 8 weeks (DWB), though one study suggests that early weightbearing (EWB) may not be detrimental to patient outcomes. The goal of this research is to compare outcomes following EWB and DWB protocols after microfracture for OLTs.

Methods:

We performed a prospective, randomized, multicenter clinical trial of subjects with unilateral, primary, unifocal OLTs treated with microfracture. Thirty-eight subjects were randomized into EWB (18 subjects) and DWB (20 subjects) at their first postsurgical visit. The EWB group began unrestricted WB at that time, whereas the DWB group were instructed to remain strictly nonweightbearing for an additional 4 weeks. Primary outcome measures were the American Academy of Orthopaedic Surgery (AAOS) Foot and Ankle score and numeric rating scale (NRS) pain score.

Results:

The EWB group demonstrated significant improvement in AAOS Foot and Ankle Questionnaire scores at the 6-week follow-up appointment as compared to the DWB group (83.1 ± 13.5 vs 68.7 ± 15.8, P = .017). Following this point, there were no significant differences in AAOS scores between groups. At no point were NRS pain scores significantly different between the groups.

Conclusions:

EWB after microfracture for OLTs was associated with improved AAOS scores in the short term. Thereafter and through 2 years’ follow-up, no statistically significant differences were seen between EWB and DWB groups.

Level of Evidence:

Level II, prospective randomized trial.

Snapping scapula syndrome in the military

Snapping scapula syndrome is a rare condition resulting in painful crepitus of the scapulothoracic articulation that may be more common in a military population because of significant upper extremity load-bearing activities. Conservative management is the first-line therapy and is successful in up to 80% of patients. For those patients who fail conservative management, arthroscopic bursectomy and partial scapulectomy is a reasonable option, but is technically demanding and requires an in-depth understanding of the complex anatomy of the scapulothoracic region.

Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma?

BACKGROUND

Patients with severe lower extremity trauma have significant disability 2 years after injury that worsens by 7 years. Up to 15% seek late amputation. Recently, an energy-storing orthosis demonstrated improved function compared with standard orthoses; however, the effect when integrated with rehabilitation over time is unknown.

QUESTIONS/PURPOSES

(1) Does an 8-week integrated orthotic and rehabilitation initiative improve physical performance, pain, and outcomes in patients with lower extremity functional deficits or pain? (2) Is the magnitude of recovery different if enrolled more than 2 years after their injury versus earlier? (3) Does participation decrease the number considering late amputation?

METHODS

We prospectively evaluated 84 service members (53 less than and 31 > 2 years after injury) who enrolled in the initiative. Fifty-eight sustained fractures, 53 sustained nerve injuries with weakness, and six had arthritis (there was some overlap in the patients with fractures and nerve injuries, which resulted in a total of > 84). They completed 4 weeks of physical therapy without the orthosis followed by 4 weeks with it. Testing was conducted at Weeks 0, 4, and 8. Validated physical performance tests and patient-reported outcome surveys were used as well as questions pertaining to whether patients were considering an amputation.

RESULTS

By 8 weeks, patients improved in all physical performance measures and all relevant patient-reported outcomes. Patients less than and greater than 2 years after injury improved similarly. Forty-one of 50 patients initially considering amputation favored limb salvage at the end of 8 weeks.

CONCLUSIONS

We found this integrated orthotic and rehabilitation initiative improved physical performance, pain, and patient-reported outcomes in patients with severe, traumatic lower extremity deficits and that these improvements were sustained for > 2 years after injury. Efforts are underway to determine whether the Return to Run clinical pathway with the Intrepid Dynamic Exoskeletal Orthosis (IDEO) can be successfully implemented at additional military centers in patients > 2 years from injury while sustaining similar improvements in patient outcomes. The ability to translate this integrated orthotic and rehabilitation program into the civilian setting is unknown and warrants further investigation.

Intra-articular risks of suprapatellar nailing

To determine the risks to local anatomy near the starting point for tibial nailing during suprapatellar nailing, 15 fresh-frozen hemipelvis specimens were nailed using a suprapatellar technique. After nail passage, the menisci and articular surfaces, anterior cruciate ligament (ACL) insertion, intermeniscal ligament, and fat pad were assessed for injury. The distance from the entry portal to the menisci, articular surfaces, and ACL insertion was determined. Medial meniscus injury occurred in 1 (6.7%) specimen and medial articular injury in 2 (13%). Nails passed through the fat pad in all specimens; intermeniscal ligament injury occurred in 3 (20%) specimens. The ACL insertion and lateral structures were not injured in any specimen. The distance from the entry portal margin to the lateral and medial menisci was 6.46±2.47 mm and 4.74±3.17 mm, respectively. The distances to the lateral and medial articular margins measured 10.33±3.62 mm and 6.54±3.57 mm, respectively. The distance to the ACL insertion averaged 5.80±3.94 mm. Suprapatellar nailing is associated with a risk of injury to anterior knee structures comparable to other nailing techniques. Additional clinical studies are warranted to further define the role of this technique in the management of tibial fractures.

Quantification of posterior ankle exposure through an achilles tendon-splitting versus posterolateral approach

BACKGROUND

The optimal surgical exposure to the posterior ankle for trauma and reconstruction is a source of debate. We hypothesized that the Achilles tendon-splitting approach would provide greater exposure to the posterior ankle than the posterolateral approach.

METHODS

Forty surgical approaches were performed from twenty fresh-frozen cadavers. Achilles tendon-splitting and posterolateral approaches were performed using a randomized crossover design for surgical sequence. Six landmarks (medial malleolus, ankle joint, subtalar joint, incisura fibularis, lateral malleolus and medial gutter) were identified by direct visualization or palpation. A calibrated digital photograph was taken and Image J (http://rsb.info.nih.gov/ij/) was used to calculate the surface area of the distal tibia and talus exposed in neutral and dorsiflexion.

RESULTS

Using a posterolateral approach, the average distal tibia exposed was 11.3cm(2) in neutral and 10.2 cm(2) in dorsiflexion. The average talus exposed was 2.0 cm(2) in neutral and 2.4 cm(2) in dorsiflexion. Using an Achilles tendon-splitting approach, the average exposed distal tibia was 33% more (15.0 cm(2)) in neutral and 43% more (14.6 cm(2)) in dorsiflexion. The average talus exposed was 47% more (3.0 cm(2)) in neutral and 76% more (4.2 cm(2)) in dorsiflexion. All increases in exposure were statistically significant. The medial malleolus was visualized in 19 tendon-splitting and six posterolateral approaches. The medial gutter was visualized in 20 tendon-splitting and 13 posterolateral approaches. These differences were statistically significant. All other landmarks could be visualized through both approaches.

CONCLUSION

The Achilles tendon-splitting approach provided significantly greater exposure of the posterior distal tibia and talus compared to the posterolateral approach.

CLINICAL RELEVANCE

Prospective studies will help determine if the tendon-splitting approach is a safe and clinically useful approach for surgeries in which direct access to the entire posterior ankle and subtalar joint are required.

Spinal column injuries among Americans in the global war on terrorism

BACKGROUND

While combat spinal injuries have been documented since the fourth century BC, a comprehensive analysis of such injuries has not been performed for any American military conflict. Recent literature has suggested that spinal injuries account for substantial disability in wounded service members.

METHODS

The Joint Theater Trauma Registry was queried to identify all American military personnel who sustained injuries to the back, spinal column, and/or spinal cord in Iraq or Afghanistan from October 2001 to December 2009. Spinal injuries were categorized according to anatomic location, neurological involvement, mechanism of injury, and concomitant wounds.

RESULTS

Of 10,979 evacuated combat casualties, 598 (5.45%) sustained 2101 spinal injuries. Explosions accounted for 56% of spinal injuries, motor vehicle collisions for 29%, and gunshots for 15%. Ninety-two percent of all injuries were fractures, with transverse process, compression, and burst fractures the most common. Spinal cord injuries were present in 17% (104) of the 598 patients. Concomitant injuries frequently occurred in the abdomen, chest, head, and face.

CONCLUSIONS

The incidence of spine trauma sustained by military personnel in Iraq and Afghanistan is higher than that reported for previous conflicts, and the nature of these injuries may be similar to those in severely injured civilians. Further research into optimal management and rehabilitation is critical for military service members and severely injured civilians with spine trauma.

Multiple associated injuries are common with spine fractures during war

BACKGROUND CONTEXT

The nature of concomitant injuries associated with spine fractures in American military personnel engaged in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) has been poorly documented in the literature.

PURPOSE

To characterize the incidence and epidemiology of associated injuries (AIs) in American military personnel with spine fractures sustained during OEF and OIF from 2001 to 2009.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR).

OUTCOME MEASURES

Not applicable.

METHODS

The JTTR was queried using International Statistical Classification of Disease, Ninth Revision codes to identify all individuals who sustained spine injuries in OEF or OIF from October 2001 to December 2009. Medical records of all identified service members were abstracted to ensure accuracy and avoid duplication. Demographic information, including sex, age, and military rank, were obtained for all patients. Information regarding fracture type, spine region, mechanism of injury, and the presence of AIs was collected for all patients.

RESULTS

Seventy-eight percent of patients with a spine fracture sustained at least one AI, with an average of 3.4 AIs per patient. Musculoskeletal injuries were most common, followed by chest, abdomen, and traumatic brain injuries. Most patients were injured by an explosive mechanism (62%). Head and face traumas were more common with cervical fractures, chest with thoracic injuries, and abdominopelvic injuries with lumbosacral fractures. Pelvis and acetabulum fractures were common after helicopter crashes, tibia/fibula injuries after explosions, thoracoabdominal injuries after gunshot wounds, and traumatic brain injuries after falls. Most patients (76%) sustained multiple spine fractures.

CONCLUSION

Spine fractures sustained in OEF and OIF have high rates of AIs. Musculoskeletal AIs are the most common, but visceral injuries adjacent to the spine fracture frequently occur. Multiple spine injuries are more prevalent after military trauma.

Are spine injuries sustained in battle truly different?

BACKGROUND CONTEXT

The severity and prognosis of combat-related injuries to the spine and spine injuries sustained unrelated to direct combat have not been previously compared. Differences may have implications on tactics, treatment strategies, and directions for future research.

PURPOSE

Compare the severity and prognosis of battle and nonbattle injuries to the spine.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR).

METHODS

The JTTR was queried using International Statistical Classification of Diseases, Ninth Revision codes to identify all individuals who sustained battle and nonbattle injuries to the neck, back, spinal column, or spinal cord in Operation Iraqi Freedom or Operation Enduring Freedom from October 2001 to December 2009. Medical records of all identified servicemembers were individually reviewed. Demographic information, including sex, age, military rank, date of injury, and final disposition, was obtained for all patients. Spinal injuries were categorized according to anatomic location, associated neurologic involvement, precipitating mechanism of injury (MOI), and concomitant wounds. These data points were compared for the groups battle spine injuries (BSIs) and nonbattle spine injuries (NBSIs).

RESULTS

Five hundred two servicemembers sustained a total of 1,834 battle injuries to the spinal column, including 1,687 fractures (92%), compared with 92 servicemembers sustaining 267 nonbattle spinal column injuries, with 241 (90%) fractures. Ninety-one BSI servicemembers (18% of patients) sustained spinal cord injuries (SCIs) with 41 (45%) complete SCIs, compared with 13 (14% of patients) nonbattle SCIs with six (46.2%) complete injuries (p=.92). The reported MOI for 335 BSI servicemembers (66.7%) was an explosion compared with one NBSI explosive injury. Eighty-four patients (17%) sustained gunshot wounds (GSWs) in battle compared with five (5.2%) nonbattle GSWs. Fifteen patients (3.0%) sustained a battle-related fall compared with 29 (30%) nonbattle-related falls. Battle spine injury servicemembers underwent significantly higher rates of surgical interventions (p<.0001), were injured by high-energy injury mechanisms at a significantly greater rate (p<.0001), and demonstrated a trend toward lower neurologic recovery rates after SCI (p=.16).

CONCLUSIONS

Battle spine injury and NBSI are separate entities that may ultimately have disparate long-term prognoses. Nonbattle spine injury patients, although having similar MOIs compared with civilian spinal trauma, maintain a different patient demographic. Further research must be directed at accurately quantifying the long-term disabilities of all spine injuries sustained in a combat theater, whether they are the result of battle or not.

Comparative effect of orthosis design on functional performance

BACKGROUND

High-energy extremity trauma is common in combat. Orthotic options for patients whose lower extremities have been salvaged are limited. A custom energy-storing ankle-foot orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), was created and used with high-intensity rehabilitation as part of the Return to Run clinical pathway. We hypothesized that the IDEO would improve functional performance compared with a non-custom carbon fiber orthosis (BlueRocker), a posterior leaf spring orthosis, and no brace.

METHODS

Eighteen subjects with unilateral dorsiflexion and/or plantar flexion weakness were evaluated with six functional tests while they were wearing the IDEO, BlueRocker, posterior leaf spring, or no brace. The brace order was randomized, and five trials were completed for each of the functional measures, which included a four-square step test, a sit-to-stand five times test, tests of self-selected walking velocity over level and rocky terrain, and a timed stair ascent. They also completed one trial of a forty-yard (37-m) dash, filled out a satisfaction questionnaire, and indicated whether they had ever considered an amputation and, if so, whether they still intended to proceed with it.

RESULTS

Performance was significantly better with the IDEO with respect to all functional measures compared with all other bracing conditions (p < 0.004), with the exception of the sit-to-stand five times test, in which there was a significant improvement only as compared with the BlueRocker (p = 0.014). The forty-yard dash improved by approximately 35% over the values for the posterior leaf spring and no-brace conditions, and by 28% over the BlueRocker. The BlueRocker demonstrated a significant improvement in the forty-yard dash compared with no brace (p = 0.033), and a significant improvement in self-selected walking velocity on level terrain compared with no brace and the posterior leaf spring orthosis (p < 0.028). However, no significant difference was found among the posterior leaf spring, BlueRocker, and no-brace conditions with respect to any other functional measure. Thirteen patients initially considered amputation, but after completion of the clinical pathway, eight desired limb salvage, two were undecided, and three still desired amputation.

CONCLUSIONS

Use of the IDEO significantly improves performance on validated tests of agility, power, and speed. The majority of subjects initially considering amputation favored limb salvage after this noninvasive intervention.

Can an ankle-foot orthosis change hearts and minds?

The current military conflicts of Operation Enduring Freedom and Operation Iraqi Freedom have been characterized by high-energy explosive wounding patterns, with the majority affecting the extremities. While many injuries have resulted in amputation, surgical advances have allowed the orthopaedic surgeon to pursue limb salvage in the face of injuries once considered unsalvageable. The military limb salvage patient is frequently highly active and motivated and expresses significant frustration with the slow nature of limb salvage rehabilitation and continued functional deficits. Inspired by these patients, efforts at this institution began to provide them with a more dynamic orthosis. Utilizing techniques and technology resulting from cerebral palsy, stroke, and amputation research, the Intrepid Dynamic Exoskeletal Orthosis was created. To date, this device has significantly improved the functional capabilities of the limb salvage wounded warrior population when combined with a high-intensity rehabilitation program. Clinical and biomechanical research is currently underway at this institution in order to fully characterize the device, its effect on patients, and what can be done to modify future generations of the device to best serve the combat-wounded limb salvage population.

Radiographic prevalence of femoroacetabular impingement in a young population with hip complaints is high

BACKGROUND

Femoroacetabular impingement (FAI) is reportedly a prearthritic condition in young adults that can progress to osteoarthritis. However, the prevalence of FAI is unknown in the young, active population presenting with hip complaints.

QUESTIONS/PURPOSES

We sought to determine (1) the prevalence of radiographic findings of FAI in a young, active patient population with complaints localized to the region of the hip presenting to primary care and orthopaedic clinics; (2) the percentage of films with FAI with an official reading suggesting the diagnosis; and (3) whether the Tönnis grades of osteoarthritis corresponded to the findings of FAI.

METHODS

We performed a database review of pelvic and hip radiographs obtained from 157 young (mean age 32 years; range, 18-50 years) patients presenting with hip-related complaints to primary care and orthopaedic clinics. Radiographs were analyzed for signs of FAI (herniation pits, pistol grip deformity, center-edge angle, alpha angle, and crossover sign) and Tönnis grade. Radiology reports were reviewed for a diagnosis of FAI.

RESULTS

At least one finding of FAI was found in 135 of the 155 patients (87%). Four hundred thirteen of 487 radiographs (85%) had been read as normal and one read as showing FAI. Tönnis grades did not correlate with radiographic signs of FAI.

CONCLUSIONS

Radiographic evidence of FAI is common in active patients with hip complaints. Increased awareness of FAI in primary care, radiology, and orthopaedic clinics and additional research into the long-term effects of management are warranted.

LEVEL OF EVIDENCE

Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Hemipelvic osteomyelitis in a hemodialysis patient associated with methicillin-resistant Staphylococcus aureus bacteremia

Proper management of infected tunneled-cuffed catheters (TCC) is essential in order to avoid catastrophic consequences for the patient. Hematogenous dissemination of infection can result in serious secondary infections, including infective endocarditis, osteomyelitis, and epidural abscess. Pelvic osteomyelitis is an extremely rare condition in adults with no reported cases of infection localized to more than one pelvic bone at a time. We present a case of a hemodialysis patient who developed osteomyelitis of the entire right hemipelvis due to MRSA bacteremia after repeated attempts at TCC salvage.