United States

Introduction: Surgical management of Superior Labrum Anterior-to-Posterior (SLAP) tears remains controversial. Current management utilizes two well established procedures: biceps tenodesis (BT) and SLAP repair.

Purpose: The purpose of this study is to evaluate the complications associated with arthroscopic SLAP repair versus an open or arthroscopic biceps tenodesis to further elucidate optimal surgical management.

Methods:
Design: In this retrospective cohort study, a multicenter research network was utilized to evaluate de-identified patient information from 50 healthcare organizations (HCOs) and over 90 million patients on the US collaborative network.

Participants: Three cohorts with SLAP lesions (ICD10:S43.43) were evaluated for this study. Cohort A was defined as patients that had undergone arthroscopic SLAP repair (CPT:29807). Cohort B was identified as patients that had undergone arthroscopic biceps tenodesis (CPT:29828). Cohort C was patients that had undergone open tenodesis of the biceps (CPT:23430). Cohorts were propensity matched for type 2 diabetes, nicotine dependence, alcohol related disorders, and BMI. Cohorts were similarly propensity matched for demographic factors such as age at event, ethnicity, race, and sex.

Setting: Data was gathered from HCOs from May 15th, 2003, to May 15th, 2023. The outcomes evaluated were: disruption of surgical wound, deep vein thrombosis, mononeuropathy of upper limb, shoulder contusion, humeral fracture, sepsis, deceased, acute post-op pain, revision, shoulder stiffness, and rotator cuff strain. All outcomes were evaluated within 1 year post procedure.

Results: A total of 11,081 arthroscopic SLAP repairs, 9,960 arthroscopic biceps tenodesis, and 9,420 open biceps tenodesis were matched. Compared to arthroscopic biceps tenodesis, patients that underwent arthroscopic SLAP repair were 1.8 times more likely for revision (2.9% vs 1.6%, p &lt; 0.0001). Compared to open biceps tenodesis, patients that underwent SLAP repair were 1.4 times more likely for revision (3.1% vs 2.3%, p = 0.0126) and 1.6 times more likely to have a subsequent rotator cuff strain diagnosis (5.1% vs 3.2%, p = 0.0002). Compared to SLAP repair, patients that underwent arthroscopic biceps tenodesis exhibited 1.3 times more instances of acute postoperative pain (5.2% vs 4.0%, p = 0.0112). Similarly, open biceps tenodesis exhibited 1.8 times more instances of acute postoperative pain (6.9% vs 3.8%, p &lt; 0.0001) and 1.3 times more shoulder stiffness (11.8% vs 9.0%, p &lt; 0.0001).

Conclusion: In the last 20 years (2003 to 2023), patients that had SLAP repair were associated with higher risk of revision surgery and subsequent rotator cuff strain diagnosis. Conversely, patients that underwent biceps tenodesis were associated with higher rates of acute postoperative pain and shoulder stiffness.


AMA Research Challenge 2023

Superior Labrum Anterior-to-Posterior (SLAP) Repair is Associated with Increased Rate of Subsequent Rotator Cuff Diagnoses and Revision Surgery: A Propensity-Matched Comparison

Introduction: Surgical management of Superior Labrum Anterior-to-Posterior (SLAP) tears remains controversial. Current management utilizes two well established procedures: biceps tenodesis (BT) and SLAP repair.

Purpose: The purpose of this study is to evaluate the complications associated with arthroscopic SLAP repair versus an open or arthroscopic biceps tenodesis to further elucidate optimal surgical management.

Methods:
Design: In this retrospective cohort study, a multicenter research network was utilized to evaluate de-identified patient information from 50 healthcare organizations (HCOs) and over 90 million patients on the US collaborative network.

Participants: Three cohorts with SLAP lesions (ICD10:S43.43) were evaluated for this study. Cohort A was defined as patients that had undergone arthroscopic SLAP repair (CPT:29807). Cohort B was identified as patients that had undergone arthroscopic biceps tenodesis (CPT:29828). Cohort C was patients that had undergone open tenodesis of the biceps (CPT:23430). Cohorts were propensity matched for type 2 diabetes, nicotine dependence, alcohol related disorders, and BMI. Cohorts were similarly propensity matched for demographic factors such as age at event, ethnicity, race, and sex.

Setting: Data was gathered from HCOs from May 15th, 2003, to May 15th, 2023. The outcomes evaluated were: disruption of surgical wound, deep vein thrombosis, mononeuropathy of upper limb, shoulder contusion, humeral fracture, sepsis, deceased, acute post-op pain, revision, shoulder stiffness, and rotator cuff strain. All outcomes were evaluated within 1 year post procedure.

Results: A total of 11,081 arthroscopic SLAP repairs, 9,960 arthroscopic biceps tenodesis, and 9,420 open biceps tenodesis were matched. Compared to arthroscopic biceps tenodesis, patients that underwent arthroscopic SLAP repair were 1.8 times more likely for revision (2.9% vs 1.6%, p < 0.0001). Compared to open biceps tenodesis, patients that underwent SLAP repair were 1.4 times more likely for revision (3.1% vs 2.3%, p = 0.0126) and 1.6 times more likely to have a subsequent rotator cuff strain diagnosis (5.1% vs 3.2%, p = 0.0002). Compared to SLAP repair, patients that underwent arthroscopic biceps tenodesis exhibited 1.3 times more instances of acute postoperative pain (5.2% vs 4.0%, p = 0.0112). Similarly, open biceps tenodesis exhibited 1.8 times more instances of acute postoperative pain (6.9% vs 3.8%, p < 0.0001) and 1.3 times more shoulder stiffness (11.8% vs 9.0%, p < 0.0001).

Conclusion: In the last 20 years (2003 to 2023), patients that had SLAP repair were associated with higher risk of revision surgery and subsequent rotator cuff strain diagnosis. Conversely, patients that underwent biceps tenodesis were associated with higher rates of acute postoperative pain and shoulder stiffness.

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Background
The success of modern total hip arthroplasty (THA) depends on accurate placement of implants in order to obtain a durable result. As direct anterior (DA) approach THA has become increasingly popular, more surgeons are now using intra-operative fluoroscopy to navigate cup position and to assess leg length. One limitation of traditional fluoroscopy is that it has historically been a qualitative, but not quantitative technology. Recently, fluoroscopy-assisted computer navigation software with the capability to assess intra-operative parameters quantitatively has emerged. Few studies have investigated the accuracy of this software in comparison to post-operative radiographs. Such a study would be an important contributor to the literature, as it would allow the arthroplasty surgeon to predict with confidence whether these measurements would be similar to those obtained by post-operative radiographs.
Methods
This is a prospective cohort study of consecutive patients undergoing unilateral anterior THA. 199 hips were analyzed fluoroscopically with intra-operative computer software (OrthoGrid Systems, Inc), determining LLD. At the two-week post-operative visit, these measurements were repeated on standing AP radiographs. Continuous variables were analyzed using Student’s t-test.
Results
The mean intra-operative LLD was 0.3 mm and the mean LLD on two-week follow-up was 0.6 mm (p=0.13). Intraoperatively, all 199 patients (100%) were navigated to LLDs within 5 mm; similarly on final standing AP films the number of patients with LLD within 5 mm was 196/199 (98%) (p = 0.25). The mean difference between the intra-operative LLD and post-operative LLD (ΔLLD) was 0 mm.
Conclusion
Total hip arthroplasty continues to be a tremendously successful procedure for eliminating pain and improving function of the arthritic hip, and a successful outcome in part depends on accurate placement of implants. We demonstrate in the present prospective study that fluoroscopy-assisted computer navigation software accurately predicts post-operative leg length discrepancy. For differences in measurements of leg-length discrepancy (ΔLLD), 69% of navigated measurements were within 2mm of those on post-op films, and 99% of measurements were within 5mm.

Does Fluoroscopy-Assisted Computer Navigation Accurately Predict Cup Position and Leg Length for Anterior Hip Arthroplasty?

Background: There currently is a paucity of literature regarding the risks gender-affirming hormone therapy (GAHT) presents in the transgender population. Understanding the effect of GAHT on transgender bone health and fracture risk is essential. The purpose of this study is to analyze the prevalence and locations of fractures in trans compared to cis patients while assessing the comorbidities present that may affect fracture risk. 

Methods: A retrospective analysis of fractures from 01/01/2020 to 01/01/2021 was performed with chart review being utilized to identify trans patients. The prevalence and anatomic locations of fractures in trans patients were then compared to that of cis patients. Comorbidities of both populations and assessment of bone mineral density with Dual-Energy X-ray Absorptiometry (DXA) scans in trans patients was also recorded. 

Results: The transgender population experienced more shoulder and upper arm fractures (p=0.004) and less lumbar spine fractures (p=.009). There was no difference in the anatomic distribution of other fractures. The number of fractures per individual in both cohorts was similar (p=.984). The prevalence of hypertension and depression was higher in the trans population (p<.001). Osteoporosis was lower in prevalence in the transgender population (p<.001). 

Conclusion: Fracture prevalence and anatomical location do not seem to be significantly different between the trans and cisgender populations. However, longitudinal prospective studies are needed to better understand the impact of GAHT on fracture risk among transgender patients. An emphasis on adequate charting for gender identity disorders and DXA scans is important for medical management in patients receiving GAHT.

A retrospective analysis of fractures in the transgender population 

Plantar fasciitis is one of the most common foot conditions presenting to a foot and ankle specialist. Surgical treatment outcomes following plantar fasciotomy vary but short-term studies have reported excellent early pain relief and significant improvements in symptoms. This study evaluates patient reported outcome scores collected pre- and post-op for patients who underwent percutaneous ultrasonic micro-tenotomy (PUT) plantar fasciotomy with PRP injection vs PUT plantar fasciotomy alone. 

Chart review data was collected on pain Visual Analog Scales (VAS), for patients treated surgically (plantar fasciectomy) by Orthopaedic Surgery department foot & ankle faculty members between December 2007 and December 2022. A total of 30 patients were identified. Exclusion criteria were patients younger than 18 years old and patients who had undergone plantar fasciectomy without the use of PUT or those who had undergone PUT but did not complete their pain VAS surveys. All statistical analyses were carried out using SAS 9.4 (SAS Inc., Cary, NC, USA). Descriptive statistics (mean, standard deviation, median, range, frequency, and percentage) were employed for summarizing measurements. Paired t test and two-sample t test were conducted to compare the measurements. Fisher’s exact test was used to compare gender distribution. The level of significance was set at 5%. 

Patients who received PUT with PRP had a statistically significant decrease in pain level compared to the PUT without PRP group. There was a significant decrease in pain level from pre-op visit (at least 1 month prior to operation) to last follow-up visit. The mean pain VAS at the pre-op visit was 7.69, with a standard deviation (SD) of 2.26 and the mean pain VAS at the last follow-up visit was 4.85, with a SD of 2.75. A paired t-test paired showed there was significant difference between pre-op and post-op pain VAS for each group, with a p-value of <0.0001. The pain VAS change in the PUT with PRP group was significantly larger than in the PUT without PRP group, a paired t-test yieled a p-value of <0.0325. The mean time between the initial visit and last follow-up visit was 19 months. The mean time following surgical intervention was 10 months. 

In the literature, most studies have found that PUT or PRP individually were successful in producing clinically and statistically significant improvements in pain and quality of life. However, there are limited studies looking at the synergistic use of PUT & PRP to show their combined impact on patient outcomes and pain relief. The findings of our study suggest that the dual use of PUT & PRP treatments could potentially lead to an increase in the longevity of pain relief.

Retrospective Evaluation of Ultrasound Guided Percutaneous Plantar Fasciotomy With and Without Platelet Rich Plasma

Background: Primary spine tumors are aggressive in nature and en bloc resection and reconstruction can be essential for preventing recurrence and improving survival. Although stereotactic navigation is becoming an indispensable tool for the placement of instrumentation in complex spine surgery, the evidence for its application in primary spine tumors is limited. 

Questions/purposes: The purpose of this systematic review was to describe: (1) the advances in technology and their application in primary spine tumor resection and reconstruction, (2) the efficacy in adequately achieving negative margins, and (3) the perioperative outcomes of these techniques.

Methods: A systematic review was registered with PROSPERO and performed according to PRISMA guidelines using the PubMed, Embase, and Ovid MEDLINE databases. All level I-IV clinical studies published in the English language investigating the application of stereotactic navigation for primary spinal tumors were included. 

Results: A total of 13 articles with 169 patients (94 males, 75 females) were included in the analysis. One study was level III evidence and 12 studies were level IV. Intraoperative computer tomography (CT) scan alone for stereotactic navigation was performed in 10 articles with 136 patients. Preoperative magnetic resonance imaging (MRI) was merged with intraoperative computer tomography (CT) in three studies with 33 patients. Nine studies with 131 patients reported intraoperative margins, of which, 103 patients had negative margins, 28 patients had positive margins. Eleven studies with 164 patients reported perioperative outcomes, of which 46 patients experienced one or more perioperative complications. 

Conclusion: 
There is moderate evidence to suggest that frameless stereotactic navigation is a safe and effective tool for obtaining negative margins during en bloc resections of primary spinal column tumors. Further cohort studies are necessary to critically evaluate if these initial trends persist across larger cohorts.


Advances in Stereotactic Navigation for Primary Spinal and Pelvic Tumor Resection and Reconstruction: A Systematic Review

Chat Generative Pre-Trained Transformer, or ChatGPT, is a large language model that has gained increased popularity among the general public, which can lead to unwarranted use of the model to make clinical recommendations for the treatment of anterior cruciate ligament (ACL) injuries. This study will evaluate and compare ChatGPT's two models, GPT-3.5 and GPT-4.0, in their ability to predict appropriate clinical recommendation ratings for 10 ACL treatment options based on 56 patient scenarios, as set by the AAOS Appropriate Use Criteria for ACL Treatment. In doing so, we hope to inform orthopedic surgeons and patients alike to remain cautious of ChatGPT's response in this field.

Can ChatGPT Models Appropriately Predict Treatment Options for Anterior Cruciate Ligament Injuries?

Background: Efforts have been made to promote awareness of female athlete differences from their male counterparts as well as minimize discrepancies in their wages and publicity. However, a critical component has been overlooked: establishing evidence-based recommendations specific to female athletes. Smith et al. notes that “female-targeted research related to sports science/sports medicine has failed to mirror the increase in participation and popularity of women’s sport.”(Smith et al., 2022) Achilles tendon rupture is one of the most common musculoskeletal injuries, occurring in 15 – 55 per 100,000 people annually.(Huttunen et al., 2014) Differences in injury rate and complications could be due hormonal effects, as estrogen receptors have been identified in lower limb tendons along with decreased Achilles tendon strain based on oral contraceptive use.(Bridgeman et al., 2010; Bryant et al., 2008; Liu et al., 1996) The primary purpose of this study is to audit the representation of female athletes in the literature regarding Achilles tendon repair.

Methods: An electronic search was performed using PubMed to identify articles related to Achilles repair using the standardized protocol by Smith et al. to assess female representation in research. (Smith et al., 2022) Studies were assessed by population, size, athletic caliber, study impact, research theme, and menstrual status.

Results: Female representation across all studies was 1783/10673 subjects (16.71%). Composition of included studies was predominantly mixed sex cohorts with 131/169 (77.51%) included studies. Within mixed sex cohort studies, the total representation of female athletes was 1651/8741 participants (18.89%). 32 studies were male only cohorts constituting 1540 participants while 3 studies were female only cohort studies comprised of 86 athletes. Importantly, the disparity between male and female representation worsened as the athletic caliber of the study population increased with 4.96% female representation in studies with professional athletes. No study collected data related to menstrual status and its potential relationship to Achilles rupture or post operative outcomes.

Conclusion: To our knowledge, this is the first review auditing the representation of female athletes in research related to Achilles rupture and repair. Mixed sex cohort studies underrepresented female athletes and male only cohort studies were more common than female only studies. These findings indicate a need for increased representation of female athletes in research related to Achilles repair. Future studies should focus on equal representation of female athletes and data collection related to sex specific hormones and menstrual status to improve recommendations and treatment of Achilles tendon ruptures for female athletes.


Auditing the Representation of Female Athletes in Sports Medicine Research: Achilles Repair

Periprosthetic joint infections are relatively rare complications of total joint replacements that are becoming increasingly common. The standard of care involves the placement of a temporary spacer made out of polymethyl methacrylate (PMMA) bone cement combined with antibiotics. The rate of major complication can be as high as 12 % for PMMA spacers. Therefore, the purpose of this study was to develop a method to produce a biocompatible material that could be 3D printed, provide mechanical support needed for ambulation, and deliver a therapeutic dose of antibiotics. Printed structures were successfully fabricated out of Biomed Clear (BMC) doped with up to 16% Gentamicin or 10 % Vancomycin. PMMA and BMC composites were characterized with differential scanning calorimetry, dynamic mechanical analysis, wear testing, compression testing, and a 30-day drug elution study. The thermoset properties of the BMC allowed for the compressive properties to remain unchanged as antibiotics were added to the polymer, but limited the amount of drug that eluted out of the composite. In contrast, the thermoplastic properties of PMMA led to the compressive properties to decrease with the addition of antibiotics, but PMMA was able to elute significantly more antibiotics. This study described a novel method to 3D print load bearing structures that can release antibiotics over 30 days. BMC composites have some advantages and disadvantages compared to PMMA that need to be considered when developing new treatments for orthopaedic infections. 


A 3D printed, High Strength and Drug Eluting Composite for the Treatment of Periprosthetic Joint Infections


INTRODUCTION: Obesity is the most common modifiable risk factor necessitating medical optimization prior to total joint arthroplasty surgery. At our institution, patients with a BMI >40 are referred to an interdisciplinary medical weight management program. The purpose of this study is to examine whether sustained treatment in the program leads to increased weight loss, continued orthopedic follow-up, and an increased likelihood of undergoing total joint arthroplasty surgery.

METHODS: A retrospective review of the medical record identified 136 patients with hip or knee arthritis and a BMI >40 who were referred to our medical weight management clinic over a two-year period. These patients were divided into three groups: those that failed to participate, those with a single visit, and those who underwent sustained treatment. Records were reviewed for demographic data, treatment interventions, and weight-loss and follow-up outcome measures. Continuous variables were assessed with t-test, and Fisher’s exact test was performed for categorical variables.

RESULTS: Patients with sustained treatment lost an average of 14 pounds versus 1.3 in those who attended a single appointment (p=0.01). 61.1% of patients with sustained treatment continued to follow-up in the orthopedic clinic, compared to 27% of patients who did not participate (p<0.01). 22.2% of patients with sustained treatment eventually underwent total joint arthroplasty surgery compared with 6.3% of patients who did not participate (p=0.02). 88.9% of patients with sustained treatment were treated with novel weight loss medications, with semaglutide the most popular choice.

CONCLUSION: Morbidly obese patients that engage in sustained treatment in an interdisciplinary medical weight management program experience greater weight loss, improved orthopedic follow-up rates, and a higher rate of total joint arthroplasty surgery when compared to those with minimal or no participation. The use of novel weight loss medications in achieving optimal outcomes in this cohort remains promising.

Sustained Medical Weight Management Program Leads to Increased Weight Loss and Arthroplasty Surgery

Background
Bone autograft is a mainstay in the surgical treatment of fracture nonunion. A traditional donor site for autologous bone graft harvest is the anterior or posterior iliac crest. A bone grafting technique that has gained favor over the past decade has been the Reamer/Irrigator/Aspirator (RIA) system (Synthes,Inc, West Chester, PA). Both techniques come with complications including donor site pain and iatrogenic fracture. The purpose of this study is to compare complications between autogenous bone graft harvest using the RIA system with subsequent prophylactic retrograde intramedullary nailing (rIMN) and the more common posterior iliac crest bone graft (PICBG) technique, as reported in the literature.

Methods
A single center retrospective cohort study was conducted to evaluate all patients who underwent prophylactic retrograde intramedullary nailing after bone graft harvest of the femur using the RIA device between January 2017 and September 2022 by a single surgeon. All patients were over the age of 18 and treated at the institution. All operations performed during January 2017 and September 2022 were manually reviewed from the surgeon daily schedule to identify pertinent procedures. Data collection was performed using the digitized medical records from the institution’s EMR (EPIC). 

Results
Thirty-six patients who underwent retrograde Reamer-Irrigator-Aspirator (RIA) with prophylactic intramedullary nailing were evaluated in this study. Of the 36 patients, two reported harvest site pain (5%). Three patients (8%) had an osteoporosis diagnosis, eleven (30.5%) had an osteomyelitis diagnosis, and four (11%) received prophylactic nailing for cancer. No subjects demonstrated a femoral neck fracture following prophylactic retrograde intramedullary nailing.

Conclusion
RIA with Prophylactic Intramedullary Nailing is a favorable option for bone graft harvest and prophylactic fixation. It has a lower harvest site morbidity, measured by harvest site pain, as compared to anterior or posterior iliac crest bone graft technique.

Retrograde Reamer-Irrigator-Aspirator (RIA) with Prophylactic Intramedullary Nailing vs Posterior Iliac Crest for Bone Grafting

1. Background
Approximately 1.2 million spine surgeries are performed each year in the US. Of those, an estimated 60-80% are successful, while 20-40% require revision due to a wide range of causes. Additionally, recovery from spine surgery often requires significant rehabilitation and care plan adherence, which can be impacted by biopsychosocial factors. As follows, substance use and other psychiatric comorbidities can worsen spine surgery patient outcomes.
Per the US Department of Health and Human Services, 61.2 million Americans over 12 years old use an illicit substance, and 9.2 million misuse opioids. Furthermore, 46.3 million meet criteria for substance use disorder (SUD), but 94% receive no treatment, and the vast majority are unaware of their SUD. With both SUD and spine surgery numbers increasing, and the likelihood that the former negatively impacts the latter, more research is needed to better understand the effects of perioperative substance use, both illicit and prescription, on the outcomes of spine surgeries to elucidate the significance of this emerging public health threat.
2. Methods
The PubMed database was searched in June 2023 using spine disease, spine surgery, and substance use search terms. Opinion articles, studies on extraspinal surgeries, and ongoing studies were excluded, but review articles were eligible for inclusion. Included studies tracked perioperative substance use and related spine surgery outcomes.
3. Results
Thirteen of nineteen included studies investigated perioperative opioid use and collectively found deleterious postoperative effects of acute, subacute, and chronic opioid use in spine surgery patients. Impacts were consistent across prescription and illicit drugs, even in opioid naïve patients and those receiving low-dose
regimens, though SUD exacerbated effects.
One study investigated opioids and muscle relaxants and showed elevated reoperation risk with both compared to controls (40% and 19%, respectively). A case report series of patients with SUDs also found increased complications and inadequate follow-ups. Postoperative effects of these substances included increased pain, surgical site infection rates, reoperations, healthcare costs, and medical complication rates.
Data on cannabis use remains contradictory. One study demonstrated reduced complications; another, decreased length of hospital stays; others, no effect or increased complications.
4. Conclusion
Substance use diminishes spine surgery success rates and increases medical complications, reoperations, and healthcare costs, whether use is acute or continuous with chronic SUD. As such, enhanced preoperative screening and careful prescribing should be a high priority in these patients, and perioperative patient education may also mitigate risks resulting from postoperative pain management regimens.

Next from AMA Research Challenge 2023

Does Fluoroscopy-Assisted Computer Navigation Accurately Predict Cup Position and Leg Length for Anterior Hip Arthroplasty?