Liz Paxton

Fate of the anterior cruciate ligament-injured knee

Most patients with anterior cruciate ligament (ACL) injuries do well with activities of daily living even after follow-up in the range of 5 to 15 years. Most can participate in some sports activity if they are inclined to do so, but most will have some limitations in vigorous sports, and only a few will be entirely asymptomatic. The challenge to the clinician is to understand and predict how ACL deficiency in a given patient will affect that patientss life and activities. In counseling patients about treatment after an ACL injury, the clinician can use knee ligament arthrometry measurements and pre-injury sports activity to estimate the risk of injury over the next 5 to 10 years. Meniscus, chondral, and sub-chondral injuries are not uncommon, but rarely require surgical intervention in the early phase of ACL deficiency. The prevalence of clinically significant meniscal damage increases with time, and is associated with increasing disability, surgery, and arthrosis in high-risk patients. Ligament reconstruction has not been shown to prevent arthrosis, but in prospective studies it appears to reduce the risk of subsequent meniscal injury, improve passive anteroposterior knee motion limits, and facilitate return to high-level sporting activities.

Does Discharge Disposition After Primary Total Joint Arthroplasty Affect Readmission Rates

We reviewed 90-day readmission rates for 9150 patients with a primary total hip or knee arthroplasty performed between April 2001 and December 2004. Patients with an American Society of Anesthesiologists score of 3 or greater or with perioperative complications were excluded. We correlated the readmission rate with discharge disposition to either skilled nursing facilities (SNFs) or Home. Of the 9150 patients identified, 1447 were discharged to an SNF. After statistically adjusting for sex, age and American Society of Anesthesiologists scores, total hip arthroplasty and total knee arthroplasty patients discharged to SNFs had higher odds of hospital readmission within 90 days of surgery than those discharged home (total hip arthroplasty: odds ratio = 1.9; 95% confidence interval, 1.2-3.2; P = .008; total knee arthroplasty: odds ratio = 1.6; 95% confidence interval, 1.1-2.4; P = .01). Healthy patients discharged to SNFs after primary total joint arthroplasty need to be followed closely for complications.

Open Bankart Repair Correlation of Results With Postoperative Subscapularis Function

Background The potential weakness of the open Bankart procedure is the takedown and repair of the subscapularis tendon. It is not known to what extent this part of the procedure affects the final result. Hypothesis The function of the subscapularis muscle after surgery will be related to the patients perception of surgical success. Study Design Cohort study; Level of evidence, 2. Methods A total of 30 patients with traumatic anterior instability had an open Bankart repair by a single surgeon. These patients were observed for a mean of 4 years. At final follow-up, the patients filled out 3 self-assessment forms: the American Shoulder and Elbow Surgeons scale, the Western Ontario Shoulder Instability Index, and the Constant and Murley scale. An independent physician performed a complete physical examination. Strength testing of all muscle groups was performed and compared with the opposite normal side. Results Multiple factors were related to the patients perception of the result. Only subscapularis function was found to have a statistically significant correlation. Of the patients, 23% had an incompetent subscapularis with a mean of 27% strength as compared with the opposite side. These patients had a positive lift-off test result and reported 57% good and excellent results; only 57% would have the surgery again. Of the patients, 77% had a normal functioning subscapularis with at least 80% strength as compared with the opposite side. These patients had a negative lift-off test result and had 91% good and excellent results; 100% would have the surgery again. The Western Ontario Shoulder Instability Index was the only scale that differentiated between a patient with subscapularis function and a patient without subscapularis function. Conclusion Postoperative subscapularis function was the most critical factor in determining the patients perception of surgical success. Clinical Relevance It is likely that handling of the subscapularis tendon during surgery and protection of the subscapularis in the first weeks after surgery are critical to the success of the open Bankart repair.

Does anticoagulation do more harm than good?: A comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty☆

A cohort of 785 patients treated without any form of thromboprophylaxis was compared with an identical group of 957 patients treated with 6 weeks of low-dose warfarin. All complications seen within 90 days of surgery were recorded. The control group had a total complication rate of 2.2%, with a death rate from thromboembolic disease of 0.0% and a total death rate of 0.2%. The warfarin group had a total complication rate of 4.7%, with a death rate from thromboembolic disease of 0.0% and a total death rate of 0.1%. Both deaths in the control group were from cardiac disease, while the death in the warfarin group was due to a massive gastrointestinal bleeding. The warfarin group had twice the infection rate of the control group.

Rate of Infection After Carpal Tunnel Release Surgery and Effect of Antibiotic Prophylaxis

PURPOSE To determine the rate of postoperative wound infection and the association with prophylactic antibiotic use in uncomplicated carpal tunnel release surgery. METHODS We performed a multicenter, retrospective review of all the carpal tunnel release procedures performed between January 1, 2005, and August 30, 2007. Data reviewed included the use of prophylactic antibiotics, diabetic status, and the occurrence of postoperative wound infection. We determined the overall antibiotic usage rate and analyzed the correlation between antibiotic use and the development of postoperative wound infection. RESULTS The rate of surgical site infections in the 3003 patients who underwent carpal tunnel release surgery (group A) was 11. Antibiotic usage data were available for 2336 patients (group B). Six patients without prophylactic antibiotics had infection, as did 5 patients with prophylactic antibiotics. This difference was not statistically significant. Of the 11 surgical site infections, 4 were deep (organ/space) and 7 superficial (incisional). The number of patients with diabetes in the overall study population was 546, 3 of whom had infections. This was not statistically different from the nondiabetic population infection rate (8 patients). CONCLUSIONS The overall infection rate after carpal tunnel release surgery is low. In addition, the deep (organ/space) infection rate is much lower than previously reported. Antibiotic use did not decrease the risk of infection in this study population, including patients with diabetes. The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated. Surgeons should carefully consider the risks and benefits of routinely using prophylactic antibiotics in carpal tunnel release surgery. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Reliability of the International Knee Documentation Committee Radiographic Grading System

Background The International Knee Documentation Committee (IKDC) forms are commonly used to measure outcomes after anterior cruciate ligament (ACL) reconstruction. The knee examination portion of the IKDC forms includes a radiographic grading system to grade degenerative changes. The interrater and intrarater reliability of this radiographic grading system remain unknown. Hypothesis We hypothesize that the IKDC radiographic grading system will have acceptable interrater and intrarater reliability. Study Design Case series (diagnosis); Level of evidence, 4. Methods Radiographs of 205 ACL-reconstructed knees were obtained at 5-year follow-up. Specifically, weightbearing posteroanterior radiographs of the operative knee in 35° to 45° of flexion and a lateral radiograph in 30° of flexion were used. The radiographs were independently graded by 2 sports medicine fellowship—trained orthopaedic surgeons using the IKDC 2000 standard instructions. One surgeon graded the same radiographs 6 months apart, blinded to patient and prior IKDC grades. The percentage agreement was calculated for each of the 5 knee compartments as defined by the IKDC. Interrater reliability was evaluated using the intraclass correlation coefficient (ICC) 2-way mixed effect model with absolute agreement. The Spearman rank-order correlation coefficient (rs) was applied to evaluate intrarater reliability. Results The interrater agreement between the 2 surgeons was 59% for the medial joint space (ICC = 0.46; 95% confidence interval [CI] = 0.35-0.56), 54% for the lateral joint space (ICC = 0.45; 95% CI = 0.27-0.58), 49% for the patellofemoral joint (ICC = 0.40; 95% CI = 0.26-0.52), 63% for the anterior joint space (ICC = 0.20; 95% CI = 0.05-0.34), and 44% for the posterior joint space (ICC = 0.28; 95% CI = 0.15-0.40). The intrarater agreement was 83% for the medial joint space (rs = .77, P < .001), 86% for the lateral joint space (rs = .76, P < .001), 81% for the patellofemoral joint (rs = .79, P < .001), 91% for the anterior joint space (rs = .48, P < .001), and 69% for the posterior joint space (rs = .64, P < .001). Conclusions While intrarater reliability was acceptable, interrater reliability was poor. These findings suggest that multiple raters may score the same radiographs differently using the IKDC radiographic grading system. The use of a single rater to grade all radiographs when using the IKDC radiographic grading system maximizes reliability.

Meta-analysis of survival curve data using distributed health data networks: application to hip arthroplasty studies of the International Consortium of Orthopaedic Registries

The motivating example for this paper comes from a distributed health data network, the International Consortium of Orthopaedic Registries (ICOR), which aims to examine risk factors for orthopedic device failure for registries around the world. Unfortunately, regulatory, privacy, and propriety concerns made sharing of raw data impossible, even if de-identified. Therefore, this article describes an approach to extraction and analysis of aggregate time-to-event data from ICOR. Data extraction is based on obtaining a survival probability and variance estimate for each unique combination of the explanatory variables at each distinct event time for each registry. The extraction procedure allows for a great deal of flexibility; models can be specified after the data have been collected, for example, modeling of interaction effects and selection of subgroups of patients based on their values on the explanatory variables. Our analysis models are adapted from models presented elsewhere--but allowing for censoring in the calculation of the correlation between serial survival probabilities and using the square root of the covariance matrix to transform the data to avoid computational problems in model estimation. Simulations and a real-data example are provided with strengths and limitations of the approach discussed.

Patient demographic and surgical characteristics in anterior cruciate ligament reconstruction: a description of registries from six countries

Objective Findings from individual anterior cruciate ligament reconstruction (ACLR) registry studies are impactful, but how various registries from different countries compare with different patient populations and surgical techniques has not been described. We sought to describe six ACLR registry cohorts to understand variation across countries. Methods Five European registries and one US registry participated. For each registry, all primary ACLR registered between registry establishment through 31December 2014 were identified. Descriptive statistics included frequencies, proportions, medians and IQRs. Revision incidence rates following primary ACLR were computed. Results 101 125 ACLR were included: 21 820 in Denmark, 300 in Luxembourg, 17 556 in Norway, 30 422 in Sweden, 2972 in the UK and 28 055 in the US. In all six cohorts, males (range: 56.8%–72.4%) and soccer injuries (range: 14.1%–42.3%) were most common. European countries mostly used autografts (range: 93.7%–99.7%); allograft was most common in the US (39.9%). Interference screw was the most frequent femoral fixation in Luxembourg and the US (84.8% and 42.9%), and suspensory fixation was more frequent in the other countries (range: 43.9%–75.5%). Interference was the most frequent tibial fixation type in all six cohorts (range: 64.8%–98.2%). Three-year cumulative revision probabilities ranged from 2.8% to 3.7%. Conclusions Similarities in patient demographics and injury activity were observed between all cohorts of ACLR. However, graft and fixation choices differed. Revision rates were low. This work, including >100 000 ACLR, is the most comprehensive international description of contemporary practice to date.