RANTES Concentration at the Time of Surgery Is Associated With Postoperative Stiffness in Patients Undergoing ACL Reconstruction
BACKGROUND/UNASSIGNED:Patients undergoing anterior cruciate ligament (ACL) reconstruction have been shown to be at risk for postoperative arthrofibrosis. Diagnostic biomarkers associated with the development of postoperative stiffness are unknown. HYPOTHESIS/UNASSIGNED:Biomarkers found in the synovial fluid at the time of surgery are associated with the development of postoperative arthrofibrosis in a cohort of patients undergoing ACL reconstruction. STUDY DESIGN/UNASSIGNED:Case-control study; Level of evidence, 3. METHODS/UNASSIGNED:Patients undergoing ACL reconstruction were prospectively enrolled. Synovial fluid was collected before surgical incision. A cohort of patients with postoperative stiffness requiring manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) was retrospectively identified. Matching of cases to controls was performed using a 1:2 pair matching algorithm. Risk factor-adjusted single-biomarker and multivariable models were used to assess the association of synovial fluid biomarkers with postoperative stiffness requiring MUA/LOA. Stepwise logistic regression controlling for clinical risk factors was used to identify biomarkers that are possible predictors of postoperative stiffness. RESULTS/UNASSIGNED:= .046). CONCLUSION/UNASSIGNED:Higher concentrations of synovial fluid biomarkers bFGF and RANTES were associated with increased risk for stiffness requiring intervention after ACL reconstruction. Interleukin 6 (IL-6), vascular endothelial growth factor A (VEGF-A), tissue inhibitor of metalloproteinases 1 (TIMP-1), interleukin 1 receptor antagonist (IL-1RA), matrix metalloproteinase 3 (MMP-3), monocyte chemotactic protein 1 (MCP-1), and macrophage inflammatory protein 1B (MIP-1B) were not associated with the development of postoperative arthrofibrosis.
Current Controversies in Arthroscopic Partial Meniscectomy
PURPOSE OF REVIEW/OBJECTIVE:Given the continued controversy among orthopedic surgeons regarding the indications and benefits of arthroscopic partial meniscectomy (APM), this review summarizes the current literature, indications, and outcomes of partial meniscectomy to treat symptomatic meniscal tears. RECENT FINDINGS/RESULTS:In patients with symptomatic meniscal tears, the location and tear pattern play a vital role in clinical management. Tears in the central white-white zone are less amenable to repair due to poor vascularity. Patients may be indicated for APM or non-surgical intervention depending on the tear pattern and symptoms. Non-surgical management for meniscal pathology includes non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), and intraarticular injections to reduce inflammation and relieve symptoms. There have been several landmark multicenter randomized controlled trials (RCTs) studying the outcomes of APM compared to PT or sham surgery in symptomatic degenerative meniscal tears. These most notably include the 2013 Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial, the 2018 ESCAPE trial, and the sham surgery-controlled Finnish Degenerative Meniscal Lesion Study (FIDELITY), which failed to identify substantial benefits of APM over nonoperative treatment or even placebo surgery. Despite an abundance of literature exploring outcomes of APM for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following APM. It is often difficult to determine if the presenting symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant OA. A central tenet of managing meniscal pathology is to preserve tissue whenever possible. Most RCTs show that exercise therapy may be non-inferior to APM in degenerative tears if repair is not possible. Given this evidence, patients who fail nonoperative treatment should be counseled regarding the risks of APM before proceeding to surgical management.
Predictors Using Machine Learning of Complete Peroneal Nerve Palsy Recovery After Multiligamentous Knee Injury: A Multicenter Retrospective Cohort Study
Background/UNASSIGNED:Peroneal nerve (PN) palsy is one of the most debilitating sequelae of multiligamentous knee injuries (MLKIs). There is limited research on recovery from complete PN palsy. Purpose/Hypothesis/UNASSIGNED:The purpose of this study was to characterize PN injuries and develop a predictive model of complete PN recovery after MLKI using machine learning. It was hypothesized that elevated body mass index (BMI) would be predictive of lower likelihood of recovery. Study Design/UNASSIGNED:Case-control study; Level of evidence, 3. Methods/UNASSIGNED:The authors conducted a retrospective review of patients seen at 2 urban hospital systems for treatment of MLKI with associated complete PN palsy, defined as the presence of complete foot drop with or without sensory deficits on physical examination. Recovery was defined as the complete resolution of foot drop. A random forest (RF) classifier algorithm was used to identify demographic, injury, treatment, and postoperative variables that were significant predictors of recovery from complete PN palsy. Validity of the RF model was assessed using overall accuracy, F1 score, and area under the receiver operating characteristic curve (AUC). Results/UNASSIGNED:Overall, 16 patients with MLKI with associated complete PN palsy were included in the cohort. Among them, 75% (12/16) had documented knee dislocation requiring reduction. Complete recovery occurred in 4 patients (25%). Nerve contusions on magnetic resonance imaging were more common among patients without PN recovery, but there were no other significant differences between recovery and nonrecovery groups. The RF model found that older age, increasing BMI, and male sex were predictive of worse likelihood of PN recovery. The model was found to have good validity, with a classification accuracy of 75%, F1 score of 0.86, and AUC of 0.64. Conclusion/UNASSIGNED:The RF model in this study found that increasing age, BMI, and male sex were predictive of decreased likelihood of nerve recovery. While further study of machine learning models with larger patient data sets is required to identify the most superior model, these findings present an opportunity for orthopaedic surgeons to better identify, counsel, and treat patients with MLKIs and concomitant complete PN palsy.
Analysis of the referral pattern and wait time for hip arthroscopy in a single payer publicly funded health care system
RATIONALE AND OBJECTIVES/OBJECTIVE:To analyse the referral pattern for hip pain and to investigate the wait time for an orthopaedic assessment by a hip arthroscopy surgeon in a single payer health care system. We hypothesized that a significant delay from time of onset of symptoms to time of assessment by a hip arthroscopy surgeon exists. METHOD/METHODS:Retrospective review of prospectively collected data in an academic hospital in a single payer health care system. An electronic database analysis was conducted searching for all referrals for hip pain between February 2017 and June 2017. Data were then analysed with the aim to identify the most common reason for hip referral, calculate the duration of symptoms between onset and orthopaedic assessment, and categorize previous investigations and treatments. RESULTS:A total of 96 patients were included (47 male and 49 female). Main source of referrals was Family Medicine Physicians in 37% of cases and Primary Care Sports Medicine Physicians in 35%. The most common reason for referral was labral tear in 44.7% of cases followed by combined femoroacetabular impingement and labral tear in 21.8%. The duration of symptoms was longer than 2Â years in 42% of cases and between 1 and 2Â years in 40% of cases. Twenty percent of patients had previous intra-articular injection while 53% of patients had physiotherapy treatment (64% of patient underwent physiotherapy for longer than 6Â months). CONCLUSION/CONCLUSIONS:In the Canadian single payer health care system, a significant delay from the time of onset of symptoms to the time of assessment by a hip arthroscopy surgeon exists with the vast majority of patients in our cohort waiting more than 1Â year. It is unknown if this delay affects the patient outcomes. This will require further investigation. Certainly, based on our findings, we should advocate for a better screening process, centralized referrals to hip arthroscopy specialists, and appropriate patient work-up.
Inter-surgeon variability in the identification of clock face landmarks when placing suture anchors in arthroscopic Bankart repair
BACKGROUND:The accuracy of surgeons in utilizing the clock face method for anchor placement has never been investigated. Our hypothesis was that shoulder arthroscopy surgeons would be able to place suture anchors at predetermined positions with accuracy and reliability. METHODS:Ten cadaveric shoulders were used. Five fellowship-trained shoulder arthroscopy surgeons were directed to place a suture anchor at 3:30, 4:30, and 5:30 clock in two shoulders each. The position of the anchors was determined with computed tomography. The accuracy of placement was calculated and data analyzed with one-way analysis of variance. The intraclass correlation coefficients were calculated. RESULTS:The overall accuracy was 57%. The accuracy of anchor placement at the 3:30 position was 40% (average position 2:24 o'clock), it was 50% at the 4:30 position (average position 3:42 o'clock) and 80% at the 5:30 position (average position 5:03 o'clock). No statistical difference in accuracy between the placement of the superior, middle, and inferior anchors (pâ€‰=â€‰0.145) was seen. The intraclass correlation coefficient for inter-surgeon reliability was 0.4 (fair) while the intraclass correlation coefficient for intra-surgeon reliability was 0.6 (moderate). DISCUSSION/CONCLUSIONS:The findings of this study suggest a moderate degree of accuracy and fair to moderate inter- and intra-surgeon reliability when using the clock face system to guide anchor placement.
Performance Assessment of Arthroscopic Rotator Cuff Repair and Labral Repair in a Dry Shoulder Simulator
PURPOSE/OBJECTIVE:To evaluate the use of dry models to assess performance of arthroscopic rotator cuff repair (RCR) and labral repair (LR). METHODS:Residents, fellows, and sports medicine staff performed an arthroscopic RCR and LR on a dry model. Any prior RCR and LR experience was noted. Staff surgeons assessed participants by use of task-specific checklists, the Arthroscopic Surgical Skill Evaluation Tool (ASSET), and a final overall global rating. All procedures were video recorded and were scored by a fellow blinded to the year of training of each participant. RESULTS:A total of 51 participants and 46 participants performed arthroscopic RCR and LR, respectively, on dry models. The internal consistency or reliability (Cronbach Î±) using the total ASSET score for the RCR and LR was high (>0.9). One-way analysis of variance for the total ASSET score showed a difference between participants based on year of training (P < .001) for both procedures. The inter-rater reliability for the ASSET score was excellent (>0.9) for both procedures. A good correlation was seen between the ASSET score and the year of training, as well as the previous number of sports rotations. CONCLUSIONS:The results of this study show evidence of construct validity when using dry models to assess performance of arthroscopic RCR and LR by residents. CLINICAL RELEVANCE/CONCLUSIONS:The results of this study support the use of arthroscopic simulation in the training of residents and fellows learning arthroscopic shoulder surgery.
Arthroscopic transtendon repair of partial articular-sided supraspinatus tendon avulsion
PURPOSE/OBJECTIVE:To evaluate the outcomes of arthroscopic transtendon repair of partial articular-sided supraspinatus tendon avulsion (PASTA) in a large study group. METHODS:A retrospective review of prospectively collected data was conducted. One hundred and eighteen patients with PASTA lesion (grade A2-A3) who underwent arthroscopic transtendon repair were identified, of which 110 were eligible for the study. Ten patients were lost at final follow-up leaving a study group of 100 patients (52 male, 48 female). The average follow-up was 37Â months (minimum 24Â months, range 24-50, median 40). Mean age at the time of surgery was 50.4 (range 17-71, median 45). Patients were assessed before surgery and at 24-month follow-up, using the Simple Shoulder Test (SST), UCLA shoulder rating scale and the visual analogue scale (VAS). ROM was measured bilaterally and was evaluated before surgery, at 3-, 6- and 24-month follow-up. The satisfaction rate was calculated. Data were analysed using a paired Student's t test with 95Â % confidence interval (significance pÂ <Â 0.05). RESULTS:Significant improvement in UCLA, SST and VAS score was observed. Fifty-four cases were rated excellent, 42 good, 2 fair, 2 poor according to the UCLA score. No significant differences in ROM were noted compared to the contra-lateral side (pÂ <Â 0.001) at the 24-month follow-up. Eighteen patients presented with a stiff shoulder at the 3-month follow-up, but they recovered full ROM by the 6-month follow-up evaluation. CONCLUSIONS:The arthroscopic transtendon repair of partial articular-sided rotator cuff tears is an effective procedure that leads to significant improvement in pain and shoulder function, with high patients' satisfaction rate, while the complication rate is low. This study demonstrated the effectiveness and safety of this technique in a large homogeneous study group. LEVEL OF EVIDENCE/METHODS:IV.
Towards an understanding of the painful total knee: what is the role of patient biology?
Total knee arthroplasty (TKA) remains the treatment of choice for end-stage osteoarthritis of the knee. With an aging population, the demand for TKA continues to increase, placing a significant burden on a health care system that must function with limited resources. Although generally accepted as a successful procedure, 15-30Â % of patients report persistent pain following TKA. Classically, pain generators have been divided into intra-articular and extra-articular causes. However, there remains a significant subset of patients for whom pain remains unexplained. Recent studies have questioned the role of biology (inflammation) in the persistence of pain following TKA. This article aims to serve as a review of previously identified causes of knee pain following TKA, as well as to explore the potential role of biology as a predictor of pain following knee replacement surgery.
Mechanical stimulation enhances integration in an in vitro model of cartilage repair
PURPOSE/OBJECTIVE:(1) To characterize the effects of mechanical stimulation on the integration of a tissue-engineered construct in terms of histology, biochemistry and biomechanical properties; (2) to identify whether cells of the implant or host tissue were critical to implant integration; and (3) to study cells believed to be involved in lateral integration of tissue-engineered cartilage to host cartilage. We hypothesized that mechanical stimulation would enhance the integration of the repair implant with host cartilage in an in vitro integration model. METHODS:Articular cartilage was harvested from 6- to 9-month-old bovine metacarpal-phalangeal joints. Constructs composed of tissue-engineered cartilage implanted into host cartilage were placed in spinner bioreactors and maintained on a magnetic stir plate at either 0 (static control) or 90 (experimental) rotations per minute (RPM). The constructs from both the static and spinner bioreactors were harvested after either 2 or 4Â weeks of culture and evaluated histologically, biochemically, biomechanically and for gene expression. RESULTS:The extent and strength of integration between tissue-engineered cartilage and native cartilage improved significantly with both time and mechanical stimulation. Integration did not occur if the implant was not viable. The presence of stimulation led to a significant increase in collagen content in the integration zone between host and implant at 2Â weeks. The gene profile of cells in the integration zone differs from host cartilage demonstrating an increase in the expression of membrane type 1 matrix metalloproteinase (MT1-MMP), aggrecan and type II collagen. CONCLUSIONS:This study shows that the integration of in vitro tissue-engineered implants with host tissue improves with mechanical stimulation. The findings of this study suggests that consideration should be given to implementing early loading (mechanical stimulation) into future in vivo studies investigating the long-term viability and integration of tissue-engineered cartilage for the treatment of cartilage injuries. This could simply be done through the use of continuous passive motion (CPM) in the post-operative period or through a more complex and structured rehabilitation program with a gradual increase in forces across the joint over time.
Cognitive and Psychomotor Entrustable Professional Activities: Can Simulators Help Assess Competency in Trainees?
BACKGROUND:An entrustable professional activity describes a professional task that postgraduate residents must master during their training. The use of simulation to assess performance of entrustable professional activities requires further investigation. QUESTIONS/PURPOSES/OBJECTIVE:(1) Is simulation-based assessment of resident performance of entrustable professional activities reliable? (2) Is there evidence of important differences between Postgraduate Year (PGY)-1 and PGY-4 residents when performing simulated entrustable professional activities? METHODS:Three entrustable professional activities were chosen from a list of competencies: management of the patient for total knee arthroplasty (TKA); management of the patient with an intertrochanteric hip fracture; and management of the patient with an ankle fracture. Each assessment of entrustable professional activity was 40 minutes long with three components: preoperative management of a patient (history-taking, examination, image interpretation); performance of a technical procedure on a sawbones model; and postoperative management of a patient (postoperative orders, management of complications). Residents were assessed by six faculty members who used checklists based on a modified Delphi technique, an overall global rating scale as well as a previously validated global rating scale for the technical procedure component of each activity. Nine PGY-1 and nine PGY-4 residents participated in our simulated assessment. We assessed reliability by calculating the internal consistency of the mean global rating for each activity as well as the interrater reliability between the faculty assessment and blinded review of videotaped encounters. We sought evidence of a difference in performance between PGY-1 and PGY-4 residents on the overall global rating scale for each station of each entrustable professional activity. RESULTS:The reliability (Cronbach's Î±) for the hip fracture activity was 0.88, it was 0.89 for the ankle fracture activity, and it was 0.84 for the TKA activity. A strong correlation was seen between blinded observer video review and faculty scores (mean 0.87 [0.07], p < 0.001). For the hip fracture entrustable professional activity, the PGY-4 group had a higher mean global rating scale than the PGY-1 group for preoperative management (3.56 [0.5] versus 2.33 [0.5], p < 0.001), postoperative management (3.67 [0.5] versus 2.22 [0.7], p < 0.001), and technical procedures (3.11 [0.3] versus 3.67 [0.5], p = 0.015). For the TKA activity, the PGY-4 group scored higher for postoperative management (3.5 [0.8] versus 2.67 [0.5], p = 0.016) and technical procedures (3.22 [0.9] versus 2.22 [0.9], p = 0.04) than the PGY-1 group, but no difference for preoperative management with the numbers available (PGY-4, 3.44 [0.7] versus PGY-1 2.89 [0.8], p = 0.14). For the ankle fracture activity, the PGY-4 group scored higher for postoperative management (3.22 [0.8] versus 2.33 [0.7], p = 0.18) and technical procedures (3.22 [1.2] versus 2.0 [0.7], p = 0.018) than the PGY-1 groups, but no difference for preoperative management with the numbers available (PGY-4, 3.22 [0.8] versus PGY-1, 2.78 [0.7], p = 0.23). CONCLUSIONS:The results of our study show that simulated assessment of entrustable professional activities may be used to determine the ability of a resident to perform professional tasks that are critical components of medical training. In this manner, educators can ensure that competent performance of these skills in the simulated setting occurs before actual practice with patients in the clinical setting.