Robert W. Westermann

The Effect of Suture-Button Fixation on Simulated Syndesmotic Malreduction: A Cadaveric Study

BACKGROUND The accuracy of reduction of distal tibiofibular syndesmosis disruptions has been associated with the clinical outcome. Suture-button fixation of the syndesmosis is a dynamic alternative mode of fixation. We hypothesized that with deliberate clamp-induced malreduction, suture-button fixation of the syndesmosis would allow a more anatomic post-fixation position compared with screw fixation. METHODS Forty-eight syndesmotic fixations were performed on twelve through-knee cadaveric specimens. The syndesmosis was destabilized and off-axis clamping was used to produce both anterior and posterior malreduction patterns. In twelve scenarios (six anterior and six posterior malreductions), syndesmotic screw fixation was used, followed by computed tomography. With tenacula holding the malreduction, the syndesmosis screws were exchanged for a suture-button construct and the specimens underwent a subsequent computed tomography scan. In the other twelve scenarios, the suture-button fixation was achieved first, followed by screw fixation. Standardized measurements of anterior-posterior and medial-lateral fibular displacement were performed by two observers blinded to the method of fixation. RESULTS With anterior off-axis clamping, the mean sagittal malreduction was 2.7 ± 2.0 mm with screw fixation and 1.0 ± 1.0 mm with suture-button fixation (p = 0.02). With posterior off-axis clamping, the sagittal malreduction was 7.2 ± 2.3 mm with screw fixation and 0.5 ± 1.4 mm with suture-button fixation (p < 0.01). No differences were observed between fixation types in the coronal plane (p = 0.20 for anterior malreductions and p = 0.06 for posterior malreductions). CONCLUSIONS With deliberate malreduction in a cadaver model, suture-button fixation of the syndesmosis results in less post-fixation displacement compared with screw fixation. The suture buttons ability to allow for natural correction of deliberate malreduction was greatest with posterior off-axis clamping. CLINICAL RELEVANCE Although the clinical relevance is unknown, dynamic syndesmotic fixation may mitigate clamp-induced malreduction.

Opioid Use After Total Knee Arthroplasty: Trends and Risk Factors for Prolonged Use

BACKGROUND The United States is in the midst of an opioid epidemic. Little is known about perioperative opioid use for total knee arthroplasty (TKA). The purpose of this study was to identify rates of preoperative opioid use, evaluate postoperative trends and identify risk factors for prolonged use after TKA. METHODS Patients who underwent primary TKA from 2007-2014 were identified within the Humana database. Postoperative opioid use was measured by monthly prescription refill rates. A preoperative opioid user (OU) was defined by history of opioid prescription within 3 months prior to TKA and a non-opioid user (NOU) was defined by no history of prior opioid use. Rates of opioid use were trended monthly for one year postoperatively for all cohorts. RESULTS 73,959 TKA patients were analyzed and 23,532 patients (31.2%) were OU. OU increased from 30.1% in 2007 to 39.3% in 2014 (P < .001). Preoperative opioid use was the strongest predictor for prolonged opioid use following TKA, with OU filling significantly more opioid prescriptions than NOU at every time point analyzed. Younger age, female sex and other intrinsic factors were found to significantly increase the rate of opioid refilling following TKA throughout the postoperative year. CONCLUSION Approximately one-third of TKA patients use opioids within 3 months prior to surgery and this percentage has increased over 9% during the years included in this study. Preoperative opioid use was most predictive of increased refills of opioids following TKA. However, other intrinsic patient characteristics were also predictive of prolonged opioid use.

Causes and Predictors of 30-Day Readmission After Shoulder and Knee Arthroscopy: An Analysis of 15,167 Cases

PURPOSE To evaluate the incidence, causes, and risk factors for unplanned 30-day readmission after shoulder and knee arthroscopy. METHODS A multicenter, prospective clinic registry, the American College of Surgeons National Surgical Quality Improvement Program, was queried for Current Procedural Terminology codes representing the most common shoulder and knee arthroscopic procedures. Unplanned readmissions within 30 days were evaluated dichotomously, and causes of readmission were identified. Univariate and multivariate logistic regression analyses were used to identify variables predictive of readmission. RESULTS In total, we identified 15,167 patients who underwent shoulder and knee arthroscopic procedures in 2012. Overall, 136 (0.90%) were readmitted within 30 days, and the rates were similar after shoulder (0.86%) and knee (0.92%) procedures. Readmissions were most common after arthroscopic debridement of the knee (1.56%) and lowest after rotator cuff and labral repairs (0.68%) and cruciate reconstructions (0.78%). The most common causes of readmission were surgical-site infections (37.1%), deep venous thrombosis and pulmonary embolism (17.1%), and postoperative pain (7.1%). Multivariate analysis identified age older than 80 years (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.5 to 8.1), chronic steroid use (OR, 3.3; 95% CI, 1.5 to 7.2), and elevated American Society of Anesthesiologists class (OR, 4.2; 95% CI, 1.4 to 12.0) as independent risk factors for readmission. CONCLUSIONS The rate of unplanned readmissions within 30 days of shoulder and knee arthroscopic procedures is low, at 0.92%, with wound-related complications being the most common cause. In patients with advanced age, with chronic steroid use, and with chronic systemic disease, the risk of readmission may be higher. These findings may aid in the informed-consent process, patient optimization, and the quality-reporting risk-adjustment process. LEVEL OF EVIDENCE Level III, prognostic study.

The John N. Insall Award: Do Intraarticular Injections Increase the Risk of Infection After TKA?

BackgroundInfection after total knee arthroplasty (TKA) can result in disastrous consequences. Previous research regarding injections and risk of TKA infection have produced conflicting results and in general have been limited by small cohort size.Questions/purposesThe purpose of this study was to evaluate if intraarticular injection before TKA increases the risk of postoperative infection and to identify if time between injection and TKA affect the risk of TKA infection.MethodsThe Humana data set was reviewed from 2007 to 2014 for all patients who received a knee injection before TKA. Current Procedural Terminology (CPT) codes and laterality modifiers were used to identify patients who underwent knee injection followed by ipsilateral TKA. Postoperative infection within 6 months of TKA was identified using International Classification of Diseases, 9th Revision/CPT codes that represent two infectious endpoints: any postoperative surgical site infection (encompasses all severities of infection) and operative intervention for TKA infection (surrogate for deep TKA infection). The injection cohort was stratified into 12 subgroups by monthly intervals out to 12 months corresponding to the number of months that had elapsed between injection and TKA. Risk of postoperative infection was compared between the injection and no injection cohorts. In total, 29,603 TKAs (35%) had an injection in the ipsilateral knee before the TKA procedure and 54,081 TKA cases (65%) did not. The PearlDiver database does not currently support line-by-line output of patient data, and so we were unable to perform a multivariate analysis to determine whether other important factors may have varied between the study groups that might have had a differential influence on the risk of infection between those groups. However, the Charlson Comorbidity index was no different between the injection and no injection cohorts (2.9 for both) suggesting similar comorbidity profiles between the groups.ResultsThe proportion of TKAs developing any postoperative infection was higher among TKAs that received an injection before TKA than in those that did not (4.4% versus 3.6%; odds ratio [OR], 1.23; 95% confidence interval [CI], 1.15-1.33; p < 0.001). Likewise, the proportion of TKAs developing infection resulting in return to the operating room after TKA was also higher among TKAs that received an injection before TKA than those that did not (1.49% versus 1.04%; OR, 1.4; 95% CI, 1.3-1.63; p < 0.001). Month-by-month analysis of time between injection and TKA revealed the odds of any postoperative infection remained higher for the injection cohort out to a duration of 6 months between injection and TKA (ORs ranged 1.23 to 1.46 when 1-6 months between injection and TKA; p < 0.05 for all) as did the odds of operative intervention for TKA infection when injection occurred within 7 months of TKA (OR ranged from 1.38 to 1.88 when 1-7 months between injection and TKA; p < 0.05 for all). When the duration between injection and TKA was longer than 6 or 7 months, the ORs were no longer elevated at these endpoints, respectively.ConclusionsInjection before TKA was associated with a higher risk of postoperative infection and appears to be time-dependent with closer proximity between injection and TKA having increased odds of infection. Further research is needed to better evaluate the risk injection before TKA poses for TKA infection; a more definitive relationship could be established with a multivariate analysis to control for other known risk factors for TKA infection.Level of EvidenceLevel III, therapeutic study.

All-Inside Versus Inside-Out Meniscal Repair With Concurrent Anterior Cruciate Ligament Reconstruction: A Meta-regression Analysis

Background: Meniscal tears are frequently repaired during anterior cruciate ligament reconstruction (ACLR). Purpose: To systematically evaluate differences in clinical failures between all-inside and inside-out meniscal repairs performed during ACLR. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic review was perfomed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases queried included MEDLINE, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials. All English-language studies reporting failure rates after meniscal repair with either the all-inside or inside-out technique performed in conjunction with ACLR were identified between 1980 and 2015. Studies with a minimum 2-year follow-up were included. Reported outcomes, clinical meniscal repair failures, and complications were assessed. Studies were weighted according to the size of the clinical series and mean follow-up length. Inverse-variance–weighted mixed models were used to evaluate whether there was a significant difference in pooled reoperation rates between repair techniques. Results: In total, 21 studies met inclusion criteria. Of these, 13 studies reported outcomes after all-inside repair, and 10 studies reported outcomes after inside-out repair (2 studies reported both). A total of 1126 patients were included in the analysis. The mean (±SD) follow-up for all-inside repair was 58.64 ± 22.24 months versus 76.25 ± 31.69 months for inside-out repair (P = .13). The clinical failure rate for all-inside meniscal repair performed concurrently with ACLR was 16% (121/744) compared with 10% (39/382) for inside-out repair, and this was found to be significant (P = .016). Implant irritation and device migration were the most common complications reported for all-inside repair; complication rates did not differ between the groups. Conclusion: There may be fewer early clinical failures when the inside-out technique is utilized for meniscal repair at the time of concomitant ACLR. Additional long-term studies will be useful to determine the operative success of these repairs over time.

Increasing Lower Extremity Injury Rates Across the 2009-2010 to 2014-2015 Seasons of National Collegiate Athletic Association Football: An Unintended Consequence of the “Targeting” Rule Used to Prevent Concussions?

Background: Sports-related concussions (SRCs) have gained increased societal interest in the past decade. The National Collegiate Athletic Association (NCAA) has implemented legislation and rule changes to decrease the incidence and risk of head injury impacts. The “targeting” rule forbids initiating contact with the crown of a helmet and targeting defenseless players in the head and neck area; however, there are concerns that this rule change has unintentionally led to an increased incidence of lower extremity injuries. Purpose/Hypothesis: The purpose of this study was to evaluate the change in lower extremity injury rates in NCAA football during the 2009-2010 to 2014-2015 seasons. We hypothesized that the lower extremity injury rate has increased across the time period. Study Design: Descriptive epidemiology study. Methods: Sixty-eight NCAA football programs provided 153 team-seasons of data to the NCAA Injury Surveillance Program. Lower extremity injuries (ie, hip/groin, upper leg/thigh, knee, lower leg/Achilles, foot/toes) and SRCs sustained during NCAA football games were examined. We calculated injury rates per 1000 athlete-exposures (AEs) for lower extremity injuries and SRCs. Rate ratios (RRs) compared injury rates between the 2009-2010 to 2011-2012 and 2012-2013 to 2014-2015 seasons. Results: Overall, 2400 lower extremity injuries were reported during the 2009-2010 to 2014-2015 seasons; most were to the knee (33.6%) and ankle (28.5%) and caused by player contact (59.2%). The lower extremity injury rate increased in 2012-2013 to 2014-2015 compared with 2009-2010 to 2011-2012 (23.55 vs 20.45/1000 AEs, respectively; RR, 1.15; 95% CI, 1.06-1.25). This finding was retained when restricted to injuries due to player contact (RR, 1.19; 95% CI, 1.07-1.32) but not for injuries due to noncontact/overuse (RR, 0.96; 95% CI, 0.80-1.14). When examining player contact injury rates by anatomic site, only ankle injuries had an increase (RR, 1.36; 95% CI, 1.13-1.64). The SRC rate also increased in 2012-2013 to 2014-2015 compared with 2009-2010 to 2011-2012 (3.52 vs 2.63/1000 AEs, respectively; RR, 1.34; 95% CI, 1.08-1.66). Conclusion: The lower extremity injury rate has increased in NCAA football athletes. Similarly, SRC rates have increased, although this may be caused by concurrent policies related to better education, identification, and management. Targeting rule changes may be contributing to increased rates of player contact–related ankle injuries. Alongside continued surveillance research to examine longitudinal time trends, more in-depth individual-level examinations of how targeting rule changes influence coaching and player behaviors are warranted.

The Fate of Meniscus Tears Left In Situ at the Time of Anterior Cruciate Ligament Reconstruction A 6-Year Follow-up Study From the MOON Cohort

Objectives: Meniscus tears frequently accompany acute anterior cruciate ligament ruptures. Management of meniscus tears is highly variable and includes repair, meniscectomy, and non-treatment of tears identified at the time of ACL reconstruction. The purpose of this study is to determine the rate of subsequent reoperation and clinical outcome of meniscal tears left in situ without treatment at the time of ACL reconstruction with a minimum follow-up of 6 years. Methods: Patients with meniscus tears left untreated at the time of primary ACL reconstruction were identified from a multicenter study group between 2002 and 2004 with minimum 6-year follow-up. Patient demographic variables, comorbidities, meniscus tear characteristics, and information on subsequent surgery were obtained. The primary endpoint of the study was need for reoperation for meniscal pathology. Univariate and multivariate analyses were used in order to determine patient demographic variables and meniscus tear characteristics that served as risk factors for reoperation. Results: There were 1440 primary ACL reconstructions performed during the timeframe of the study. There were 955 patients (66.3%) with concomitant meniscal tears identified. Of these, 143 (15.3%) had meniscal tears left in situ at the time of surgery. There were 11 patients (7.9%) who underwent reoperation for meniscal pathology within the same compartment as the meniscal tear left in situ (Table 1). Reoperation was performed more frequently for medial meniscus tears as compared to lateral meniscus tears (17.6% vs. 4.3%, p = 0.048). Medial meniscus tears and tears ≥10 mm in length were identified as risk factors for reoperation. Conclusion: Lateral and medial meniscus tears left in situ at the time of ACL reconstruction did not require reoperation at minimum 6-year follow-up in 95.7% and 82.4% of patients, respectively. Our results suggest that surgeons should consider alternative treatment for medial meniscus tears and tears ≥ 10 mm in length at the time of ACL reconstruction.

Infection following Anterior Cruciate Ligament Reconstruction: An Analysis of 6,389 Cases

Abstract Infection following anterior cruciate ligament reconstruction (ACLR) is rare. Previous authors have concluded that diabetes, tobacco use, and previous knee surgery may influence infection rates following ACLR. The purpose of this study was to identify a cohort of patients undergoing ACLR and define (1) the incidence of infection after ACLR from a large multicenter database and (2) the risk factors for infection after ACLR. We identified patients undergoing elective ACLRs in the American College of Surgeons National Surgical Quality Improvement Program database between 2007 and 2013. The primary outcome was any surgical site infection within 30 days of surgery. We performed univariate and multivariate analyses comparing infected and noninfected cases to identify risk factors for infection. In total, 6,398 ACLRs were available for analysis of which 39 (0.61%) were diagnosed with a postoperative infection. Univariate analysis identified preoperative dyspnea, low hematocrit, operative time > 1 hour, and hospital admission following surgery as predictors of postoperative infection. Diabetes, tobacco use, age, and body mass index (BMI) were not associated with infection (p > 0.05). After multivariate analysis, the only independent predictor of postoperative infection was hospital admission following surgery (odds ratio, 2.67; 95% confidence interval, 1.02‐6.96; p = 0.04). Hospital admission following surgery was associated with an increased incidence of infection in this large, multicenter cohort. Smoking, elevated BMI, and diabetes did not increase the risk infection in the present study. Surgeons should optimize outpatient operating systems and practices to aid in same‐day discharges following ACLR.

Evaluation of Men's and Women's Gymnastics Injuries: A 10-Year Observational Study.

Background: Injuries are common in collegiate gymnasts. Most descriptive studies of injury patterns in collegiate gymnasts are limited in duration or are only inclusive of women. Hypothesis: Injury patterns in men and women differ significantly; women sustain a higher rate of injuries than men. Study Design: Descriptive epidemiology study. Level of Evidence: Level 4. Methods: Musculoskeletal and head injuries reported in the Sports Injury Monitoring System at a single National Collegiate Athletic Association institution for Division 1 men’s and women’s gymnastics teams between 2001 and 2011 were identified. The variables assessed included sex, injured body part, year of eligibility, injury severity, surgical procedures, missed time, and team activity at the onset of injury. Results: From 2001 to 2011, 64 male gymnasts sustained 240 injuries, while 55 female gymnasts sustained 201 injuries. The injury incidence was 8.78 per 1000 athlete-exposures for men and 9.37 per 1000 athlete-exposures for women. Female gymnasts more commonly suffered major injuries compared with men, and more commonly underwent surgery after injury (24.4% of female injuries required surgery vs 9.2% in males). The anatomic region most often injured in men was the hand and wrist (24%). The anatomic region most often injured in women was the foot and ankle (39%). Overall, injury rates were highest in freshman-eligible athletes. Conclusion: Injury rates, overall, were similar in men and women gymnasts. Female gymnasts more commonly underwent surgical procedures after injury. Injury rates were higher in freshman-eligible athletes and decreased with increasing year of experience. Clinical Relevance: Specific attention should be given to gymnasts transitioning into collegiate-level gymnastics; injury prevention strategies should focus on the ankle and foot, as well as the elbow, wrist, and hand.

Return to Sport After Operative Management of Osteochondritis Dissecans of the Capitellum A Systematic Review and Meta-analysis

Background: Capitellar osteochondritis dissecans (OCD) is commonly managed surgically in symptomatic adolesent throwers and gymnasts. Little is known about the impact that surgical technique has on return to sport. Purpose: To evaluate the clinical outcomes and return-to-sport rates after operative management of OCD lesions in adolescent athletes. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed, CINAHL, EMBASE, SPORTDiscus (EBSCO), and Cochrane Central Register of Controlled Trials databases were queried for studies evaluating outcomes and return to sport after surgical management of OCD of the capitellum. Two independent reviewers conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting patient outcomes with return-to-sport data and minimum 6-month follow-up were included in the review. Results: After review, 24 studies reporting outcomes in 492 patients (mean age ± SD, 14.3 ± 0.9 years) were analyzed. The overall return-to-sport rate was 86% at a mean 5.6 months. Return to the highest preoperative level of sport was most common after osteochondral autograft procedures (94%) compared with debridement and marrow stimulation procedures (71%) or OCD fixation surgery (64%). Elbow range of motion improved by 15.9° after surgery. The Timmerman-Andrews subjective and objective scores significantly improved after surgery. Complications were low (<5%), with 2 cases of donor site morbidity after osteoarticular autograft transfer (OAT) autograft harvest. The most common indications for reoperation were repeat debridement/loose body removal. Conclusion: A high rate of return to sport was observed after operative management of capitellar OCD. Patients were more likely to return to their highest level of preoperative sport after OAT autograft compared with debridement or fixation. Significant improvements in elbow range of motion and patient outcomes are seen with low complication rates after OCD surgery.