Faculty Bibliography

BACKGROUND:Given the relatively low incidence of infection, the role of prophylactic antibiotics for infection prevention in arthroscopic surgery is unclear. Without established evidence-based guidelines, it becomes important to understand the trends and common practices in the field. HYPOTHESIS/OBJECTIVE:We hypothesized that a majority of surgeons would use preoperative intravenous antibiotics and that postoperative antibiotics would be rarely used. METHODS:A web-based link containing a questionnaire on perioperative antibiotic use for arthroscopic surgery of the knee and shoulder was sent to sports medicine surgeons at several institutions in the New York tri-state region. The questionnaire addressed antibiotic use both preoperatively and postoperatively and the type of medication used. RESULTS:During the study period, 86 surgeons responded to the knee portion of the survey and 139 surgeons responded to the shoulder portion of the survey. A significant majority (94.24% for knee and 93.02% for shoulder) of the respondents routinely preferred to use preoperative intravenous antibiotics for both shoulder and knee surgery. The antibiotic of choice for a majority of the respondents was cefazolin (98.1% respondents). In patients with penicillin allergies, most preferred to use clindamycin. Most respondents (84.5%) did not routinely use postoperative oral antibiotics. CONCLUSION/CONCLUSIONS:There is significant consensus among orthopedic surgeons performing knee and shoulder arthroscopic surgery regarding use of preoperative antibiotics, with the majority routinely prescribing preoperative intravenous antibiotics for prophylaxis and cefazolin being the most commonly used antibiotic. The majority of surgeons prefer not to use postoperative oral antibiotics. CLINICAL RELEVANCE/CONCLUSIONS:This study describes the current trends in the use of perioperative antibiotics among orthopedic surgeons for routine arthroscopic procedures in the shoulder and knee.

BACKGROUND:This study evaluates the incidence of bariatric surgery (BS) before total joint arthroplasty (TJA) in New York State and compares patient comorbidities and 90-day postoperative complications of patients with and without BS before TJA. METHODS:The NY Statewide Planning and Research Cooperative System database between 2005 and 2014 was reviewed and 343,710 patients with TJA were identified. Patients were stratified into the following three cohorts: group 1 (patients who underwent BS < 2 years before TJA [N = 1,478]); group 2 (obese patients without preoperative BS [N = 60,259]); and group 3 (nonobese patients without preoperative BS [N = 281,973]). Principal outcomes measured were patient comorbidities, 90-day complication rates, length of inpatient stay, discharge disposition, mortality rate, and total hospital costs. RESULTS:BS before TJA incidence increased from 0.11 of 100,000 to 2.4 of 100,000 from 2006 to 2014. Preoperative BS did not notably change the number of patient comorbidities at the time of TJA. Group 1 had more patients with 90-day complications (40.7% versus 36.0%, P < 0.001) than group 2. No difference was found between group 1 and the other groups in home discharge, pulmonary embolism, deep vein thrombosis, and mortality rates. Total hospital costs were higher for group 1 ($18,869 ± 9,022 versus $17,843 ± 8,095, P < 0.001) compared with those for group 2. CONCLUSION/CONCLUSIONS:BS before TJA has increased annually over a 10-year period in New York State and is associated with greater 90-day postoperative complication rates and higher immediate hospital costs when compared with obese patients without BS.

PURPOSE/OBJECTIVE:The number of arthroscopic knee surgeries performed annually has increased over the last decade. It remains unclear what proportion of individuals undergoing knee arthroscopy is at risk for subsequent ipsilateral procedures. Better knowledge of risk factors and the incidence of reoperative ipsilateral arthroscopy are important in setting expectations and counselling patients on treatment options. The aim of this study is to determine the incidence of repeat ipsilateral knee arthroscopy, and the risk factors associated with subsequent surgery over long-term follow-up. METHODS:The New York Statewide Planning and Research Cooperative Systems outpatient database was reviewed from 2003 to 2016 to identify patients who underwent elective, primary knee arthroscopy for one of the following diagnosis-related categories of procedures: Group 1: cartilage repair and transfer; Group 2: osteochondritis dissecans (OCD) lesions; Group 3: meniscal repair, debridement, chondroplasty, and synovectomy; Group 4: multiple different procedures. Subjects were followed for 10 years to determine the odds of subsequent ipsilateral knee arthroscopy. Risk factors including the group of arthroscopic surgery, age group, gender, race, insurance type, surgeon volume, and comorbidities were analysed to identify factors predicting subsequent surgery. RESULTS:A total of 765,144 patients who underwent knee arthroscopy between 2003 and 2016, were identified. The majority (751,873) underwent meniscus-related arthroscopy. The proportion of patients undergoing subsequent ipsilateral knee arthroscopy was 2.1% at 1-year, 5.5% at 5 years, and 6.7% at 10 years of follow-up. Among patients who underwent subsequent arthroscopic surgery at 1-, 5-, and 10-year follow-up, there was a greater proportion of patients with worker's compensation insurance (p < 0.001), index operations performed by very high volume surgeons (p < 0.001), and cartilage restoration index procedures (p < 0.001), compared with those who never underwent repeat ipsilateral surgery. CONCLUSION/CONCLUSIONS:Understanding the incidence of subsequent knee arthroscopy after index procedure in different age groups and the patterns over 10 years of follow-up is important in counselling patients and setting future expectations. The majority of subsequent surgeries occur within the first 5 years after index surgery, and subjects tend to have higher odds of ipsilateral reoperation for up to 10 years if they have worker's compensation insurance, or if their index surgery was performed by a very high volume surgeon, or was a cartilage restoration procedure. LEVEL OF EVIDENCE/METHODS:III.

Objectives: The current opioid epidemic necessitates physicians to seek ways to decrease patients' requirements of narcotic medications without sacrificing their postoperative comfort level. This study evaluated patients' pain following arthroscopic shoulder instability repair and compared the use of narcotic medications between patients prescribed NSAIDs with rescue opioid prescription to those prescribed opioids alone. We hypothesized there would not be a significant difference in postoperative pain and addition of NSAIDs would result in decreased opioid use.
Method(s): Forty patients scheduled to undergo an arthroscopic shoulder instability repair were randomized to receive Ibuprofen 600mg and a 10-pill rescue prescription of Percocet 5/325mg (n=20) or Percocet 5/325mg (n=20). Primary outcomes were the amount of Percocet tablets used in the first week and VAS on postoperative day (POD) 1, 4, and 7. Statistical analysis was done using independent t-tests and bivariate analysis for correlation. Findings were considered significant at p<0.05.
Result(s): Forty patients with a mean age of 35.08 (+/- 8.48)were enrolled between December 2017 and May 2018. The total amount of opioid consumption was statistically significantly lower in the multimodal group compared to the opioid group (p <0.04) as well as Percocet consumption between POD 0-4 (p <0.04). There were no significant differences in VAS at any point between the two groups. One patient in the Ibuprofen cohort experienced dizziness on POD 1. Two patients in the Percocet cohort experienced nausea and vomiting on POD 1 and POD 4.
Conclusion(s): Multimodal analgesia using NSAIDs with an opioid rescue prescription has resulted in significant reduction in postoperative narcotic consumption. As both cohorts showed similar pain levels, it is possible to alleviate postoperative pain with lower amounts of opioids than are currently being prescribed. The public health crisis of opioid abuse requires an immediate solution beginning with the reduction of post-operative narcotics distribution

PURPOSE/OBJECTIVE:To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids following arthroscopic partial meniscectomy. METHODS:This was a single-center, prospective, nonrandomized, comparative observational study. Patients ages 18 to 65 years who were indicated for arthroscopic meniscectomy were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) ibuprofen (600 mg every 6-8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg as needed for breakthrough pain) or (2) 30 to 40 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 8 hours, 24 hours, 48 hours, and 1 week after surgery, which included medication usage, visual analog scale pain score, incidence of adverse events, and patient satisfaction. RESULTS:Sixty-eight patients with mean age 51.2 years (±10.4 years) were enrolled between October 2016 and February 2017. Enrollment in the opioid group continued until 30 patients were enrolled in the NSAID group, and at final analysis there were 28 patients in the NSAID group and 40 in the opioid group. There were no significant differences in sex, visual analog scale pain score, or patient satisfaction between the 2 groups at any time point. Patients in the opioid group had a significantly higher mean opioid consumption on postoperative day 1 (1.1 vs 0.5 tablets, P < .03) and postoperative days 3 to 7 (2.6 vs 0.5 tablets, P < .02) compared with NSAID group patients. There was a trend toward greater total (1 week) opioid usage (4.7 vs 2.0 tablets) in the opioid group; however, this was not statistically significant (P < .08). Fifty-three percent of opioid group patients independently chose to forego their opioid medication for an over-the-counter NSAID and/or acetaminophen instead. No patients requested a medication refill. CONCLUSIONS:We found no significant difference in pain control, satisfaction, and total 1-week opioid use between patients prescribed NSAIDs with opioids and those prescribed opioids alone. All patients used only limited amounts of opioids to control postoperative pain, suggesting we are currently overprescribing opioids after arthroscopic partial meniscectomy. LEVEL OF EVIDENCE/METHODS:Level II, prospective comparative study.

Introduction: Posttraumatic arthritis (PTA) is a common sequela of proximal humerus fractures that is commonly managed with anatomic or reverse total shoulder arthroplasty (TSA). TSA for PTA is more challenging than that performed for primary osteoarthritis and frequently leads to worse patient outcomes. CPT uniformly classifies all cases of primary TSA, irrespective of procedural complexity and resource utilization. This study analyzes intraoperative differences and 30-day outcomes for anatomic and reverse TSA performed in the posttraumatic shoulder.
Method(s): Patients undergoing TSA from 2008 to 2015 were selected from the National Surgical Quality Improvement Program database and stratified according to concurrent procedures and administrative codes indicating posttraumatic diagnoses. Perioperative parameters and 30-day complications were recorded; multivariate analyses were performed to determine whether PTA was a risk factor for poor outcomes.
Result(s): A total of 8508 primary and 243 posttraumatic TSAs were identified. Posttraumatic TSA patients were slightly younger (P =.003), more likely to be female (P <.001), smokers (P =.029), and diabetic (P =.003). Diagnosis of PTA was an independent risk factor for prolonged operative times >=160 minutes (>=1 standard deviation above the mean, P =.003; odds ratio [OR]: 1.718; 95% confidence interval [CI]: 1.204-2.449) and increased bleeding requiring transfusion (P <.001; OR: 2.719; 95% CI: 1.607-4.600). Although posttraumatic TSA had a tendency for longer hospital admissions, 30-day readmissions were not significantly different between cohorts.
Conclusion(s): Compared with primary osteoarthritis, a preoperative diagnosis of PTA is an independent risk factor for prolonged operative times and postoperative transfusion in anatomic or reverse TSA patients; such patients may be less than optimal candidates for same-day discharges or outpatient shoulder arthroplasty.
Copyright

PURPOSE OF REVIEW/OBJECTIVE:The purposes of this review are to (1) discuss the epidemiology and workup of the rare posterior cruciate ligament (PCL) avulsion fracture, (2) review the indications for nonoperative and operative management of patients with PCL avulsion fractures, (3) examine surgical outcomes in this patient population, and (4) discuss the authors' preferred management algorithm and surgical approach. RECENT FINDINGS/RESULTS:In accordance with the rarity of these injuries, the literature is sparse regarding surgical outcomes. Many of these injuries are in the setting of a multi-ligamentous injury. Most authors suggest that displaced PCL avulsion fractures should undergo operative fixation and current data suggests excellent outcomes when treating these patients with either open or arthroscopic fixation, with a low complication rate. PCL avulsion fractures, although rare, should undergo fixation when displacement is present. Current studies report successful outcomes and a low complication rate.

Little research has been conducted evaluating surgical trends during the past 10 years and subsequent procedure risk factors for patients undergoing bone-blocking procedures for the treatment of anterior shoulder instability. The Statewide Planning and Research Cooperative System database was queried between 2003 and 2014 to identify patients undergoing soft tissue or bone-blocking procedures for anterior shoulder instability in New York. Patient demographics and 1-year subsequent procedures were analyzed. Multivariate logistic regression analyses were conducted to identify 1-year subsequent procedure risk factors. From 2003 through 2014, a total of 540 patients had Latarjet procedures performed. During this period, the volume of Latarjet procedures increased by 950%, from 12 procedures in 2003 to 126 procedures in 2014. The volume of open Bankart repairs declined by 77%; arthroscopic Bankart repairs fluctuated, being up (328%) between 2003 and 2012 and then down (6%) between 2012 and 2014. Of the 540 patients, 2.4% (13 of 540) required intervention for recurrent shoulder instability events. Age older than 20 years and workers' compensation were identified as independent risk factors for reoperation. The number of bone-blocking procedures, such as the Latarjet, has increased by nearly 1000% during the past decade in New York. Only 2.4% (13 of 540) of the patients had subsequent shoulder instability interventions. [Orthopedics. 201x; xx(x):xx-xx.].

The purpose of this study was to compare nonelective and all-cause readmission rates and to identify risk factors for readmission of total joint arthroplasty (TJA) patients who had preoperative bariatric surgery (BS) compared with TJA patients without preoperative BS. The New York Statewide Planning and Research Cooperative System database was queried to identify 343,710 TJA patients between 2005 and 2014. Three patient groups were evaluated: group 1 (patients with preoperative BS within 2 years of TJA [N=1478]); group 2 (obese patients without preoperative BS [N=60,259]); and group 3 (nonobese patients without preoperative BS [N=281,973]). Nonelective and all-cause readmission rates (30 days, 90 days, and 1 year) were compared, and multivariate analyses of readmission risk factors were performed. Group 1 had no significant difference in nonelective readmission rates compared with groups 2 and 3. However, when elective TJA readmissions were included, group 1 had significantly higher all-cause readmission rates at 30 days, 90 days, and 1 year compared with groups 2 and 3. Bariatric surgery was not a risk factor for nonelective readmissions at any time point. When elective TJA admissions were included, BS was an independent risk factor for all-cause readmission at all time points. Patients who have BS prior to TJA do not have higher nonelective readmission rates than obese TJA patients without BS. Bariatric surgery is not a risk factor for nonelective readmissions. However, BS is a significant predictor of elective TJA admissions up to 1 year following the index TJA. [Orthopedics. 201x; xx(x):xx-xx.].

PURPOSE/OBJECTIVE:To compare patellar instability with magnetic resonance imaging analysis using continuous real-time radial gradient-echo (GRE) imaging in the assessment of symptomatic patients and asymptomatic subjects. METHODS:Symptomatic patients with suspected patellofemoral maltracking and asymptomatic volunteers were scanned in real time by a radial 2-dimensional GRE sequence at 3 T in axial orientation at the patella level through a range of flexion-extension. The degree of lateral maltracking, as well as the associated tibial tubercle-trochlear groove distance and trochlea depth, was measured. Patellar lateralization was categorized as normal (≤2 mm), mild (>2 to ≤5 mm), moderate (>5 to ≤10 mm), or severe (>10 mm). The patellofemoral cartilage was also assessed according to the modified Outerbridge grading system. RESULTS:The study included 20 symptomatic patients (13 women and 7 men; mean age, 36 ± 12.8 years) and 10 asymptomatic subjects (3 women and 7 men; mean age, 33.1 years). The mean time to perform the dynamic component ranged from 3 to 7 minutes. Lateralization in the symptomatic group was normal in 10 patients, mild in 1, moderate in 8, and severe in 1. There was no lateral tracking greater than 3 mm in the volunteer group. Lateral maltracking was significantly higher in symptomatic patients than in asymptomatic subjects (4.4 ± 3.7 mm vs 1.5 ± 0.71 mm, P = .007). Lateral tracking significantly correlated with tibial tubercle-trochlear groove distance (r = 0.48, P = .006). There was excellent agreement on lateral tracking between the 2 reviewers (intraclass correlation coefficient, 0.979; 95% confidence interval, 0.956-0.990). CONCLUSIONS:The inclusion of a dynamic radial 2-dimensional GRE sequence is a rapid and easily performed addition to the standard magnetic resonance imaging protocol and allows dynamic quantitative assessment of patellar instability and lateral maltracking in symptomatic patients. With a paucity of reported data using this technique confirming that these results reach clinical significance, future work is required to determine how much lateral tracking is clinically significant. LEVEL OF EVIDENCE/METHODS:Level III, case control.