Orthopaedic Literature Research Articles

A Review of Handgrip Strength and its Role as a Herald of Health

Measurement of grip strength using a handheld dynamometer is frequently performed as part of an orthopedic upper extremity examination. We review the technique of grip strength measurement and evaluation of the possible submaximal effort. What constitutes normal grip strength in one part of the world is not necessarily normal elsewhere. Additionally, there is considerable evidence, most of which is outside the orthopedic literature, that diminished grip strength is a proxy for poor health and a predictor of increased mortality.

Patient Satisfaction Scores Are a Poor Metric of Orthopedic Care.

Patient satisfaction scores are a popular metric used to evaluate orthopedic care. There is little consistency with how satisfaction is described in the orthopedic literature. Online physician reviews are a growing trend that directly and indirectly affect a surgeon's reputation. There is little correlation of higher satisfaction with improved surgical outcomes, so rating surgical care may be misguided and possibly dangerous. Patient satisfaction is an important part of the patient-centered care model, so rating systems should directly reflect quality. More research is needed to determine the relationship between patient satisfaction and the delivery of quality care. [Orthopedics. 2022;45(3):e127-e133.].

Anterior cervical discectomy and fusion in patients with preexisting dementia: Increased medical complications, costs, and 90-day readmissions

Study designRetrospective-Cohort IntroductionDementia is among the most common health concerns for the aging population, characterized by steep cognitive decline and subsequent loss of independence. Limited orthopedic literature examines the influence that dementia has on patients undergoing elective spinal surgeries. MethodsEmploying the PearlDriver Database, a study population consisting of patients who underwent primary elective ACDF with a prior diagnosis of dementia were selected using Internal Classification Disease-9 (ICD) and ICD-10 codes. Patients with a history of trauma, infection, or malignancy were excluded. Patients with dementia were compared to matched controls via logistical regression accounting for patient demographics, medical comorbidities and levels operated on. Patients were assessed for 90-day outcomes including medical complications, emergency department visits, readmissions, one-year reoperation, hospital length of stay (LOS) and total operative hospitalization costs, and 90-day postoperative cost. ResultsThere were 4104 patients in the dementia group and 20,269 patients in the matched control group who underwent primary ACDF. Multivariate analysis showed that patients with dementia undergoing ACDF were associated with increased 90-day major and minor medical complications (p < 0.001). Patients with dementia were also associated with an increased risk of dysphagia (p < 0.001), 90-day ER visits(p < 0.001), 90-day readmissions(p < 0.001), and increased LOS(p < 0.001) following ACDF compared to the control group. Additionally, both total hospitalization costs and 90-day postoperative costs were higher in the dementia cohort(p < 0.001). ConclusionPreoperative dementia diagnosis in patients undergoing ACDF is associated with increased number of readmissions, hospitalization and 90-day costs, and postoperative medical complications. Level of evidence3

A Surgeon's Guide to Understanding Artificial Intelligence and Machine Learning Studies in Orthopaedic Surgery.

In recent years, machine learning techniques have been increasingly utilized across medicine, impacting the practice and delivery of healthcare. The data-driven nature of orthopaedic surgery presents many targets for improvement through the use of artificial intelligence, which is reflected in the increasing number of publications in the medical literature. However, the unique methodologies utilized in AI studies can present a barrier to its widespread acceptance and use in orthopaedics. The purpose of our review is to provide a tool that can be used by practitioners to better understand and ultimately leverage AI studies. The increasing interest in machine learning across medicine is reflected in a greater utilization of AI in recent medical literature. The process of designing machine learning studies includes study design, model choice, data collection/handling, model development, training, testing, and interpretation. Recent studies leveraging ML in orthopaedics provide useful examples for future research endeavors. This manuscript intends to create a guide discussing the use of machine learning and artificial intelligence in orthopaedic surgery research. Our review outlines the process of creating a machine learning algorithm and discusses the different model types, utilizing examples from recent orthopaedic literature to illustrate the techniques involved.

Bibliometric Analysis of Top 100 Systematic Reviews and Meta-analyses in Orthopaedic Literature.

We performed a bibliometric analysis of top 100 systematic reviews (SR) and meta-analyses (MA) in orthopaedic literature and also evaluated articles with maximum average citation per year, which were unable to make up in the present top 100 cited list, but may have a promising future in the world of citations. This bibliometric study was performed by searching Web of Science database according to a specific search strategy by two independent authors according to eligibility criteria of the studies. Articles with more than 100 citations were eligible for analysis and were evaluated for following parameters: number of citations, journal name, publication date and year, first author, the total number of authors, average citations per year, methodological design of the study, geographic origin and institute associated. Inter-rater reliability was evaluated using Kappa coefficient. The number of citations ranged from 1073 to 198 with a total citation count of 30,589. Inter-rater reliability came to out in the good agreement (Kappa value-0.8). There was visible up-gradation of the research from the 2000year till today. Spine journal had the maximum articles (26) followed by Journal of Bone and Joint Surgery-America (12 articles). The topics "Spine" and "Sports Medicine" were the most frequently cited topics with 41 and 20 articles, respectively. USA has the maximum articles in the top 100 cited SR and MA. Based on the maximum average citations per year, 34 old articles were replaced in the list with the latest articles that have a bright future ahead and can be predicted to be in the top 100 cited SR and MA of Orthopaedics soon. This study recognizes those articles that have contributed significantly to the growth of knowledge and influenced clinical practices in orthopaedics. We believe that this will facilitate and encourage researchers and clinicians in their future research. The online version contains supplementary material available at 10.1007/s43465-022-00604-9.

High-Dose Vitamin D Supplementation Can Correct Hypovitaminosis D Prior to Total Knee Arthroplasty.

Vitamin D deficiency in the perioperative surgical period is associated with inferior surgical outcomes. There are no established preoperative supplementation regimens in the orthopedic literature. The purpose of this study is to compare the efficacy between 2 different supplementation regimens of vitamin D prior to total knee arthroplasty. We conducted a retrospective analysis of 174 patients identified as vitamin D deficient (25(OH)D < 30 ng/mL) who received one of 2 vitamin D supplementation protocols: (1) daily supplementation with D3 on a sliding scale from 1000 to 6000 IU or (2) a loading dose of 50,000 IU D3 weekly for 4 weeks then 2000 IU/d. Serum vitamin D levels were measured at 3 months and 1 month preoperatively. Mean patient age was 65.5(±8.6) years, and 54.6% were female. Deficiency was corrected in 73.3% of patients in the loading dose group and 42.4% of patients in the daily, low-dose group [χ2 (1, N= 174)= 16.53, P < .001]. Patients in the loading dose group also achieved a greater average correction in vitamin D levels. This is the first study to compare preoperative vitamin D supplementation protocols. A loading dose regimen of 50,000 IU weekly for 4 weeks followed by a maintenance dose of 2000 IU/d more effectively corrects vitamin D deficiency compared to a low-dose, daily regimen among total knee arthroplasty patients. We recommend this regimen for deficiency correction in patients who have been screened to be deficient in vitamin D preoperatively.

Is Autogenous Bone Still the "Gold Standard" in Oral Bone Grafting?

Before answering this question, one must review the origin and evolution of the term “golden standard”. In 2005, Claassen, JA stated, “whereas the gold standard was never regarded as infallible, the incorrect term golden standard implies a level of perfection that is unattainable in medical science.”1 Consequently, the correct terminology is gold standard.The concept of a gold standard is derived from a monetary system where the value of the standard economic unit of account (currency) is based on a fixed quantity of gold. In 1971 the United States unilaterally terminated the conversion of the US dollar to gold, ending the Bretton Woods Agreement and the system of international currency exchange. The US dollar was thus turned into fiat money which is a mode of currency conversion not backed by a commodity.This brings the question; what is implied by the term “gold standard” in oral bone regeneration? In a 2010 editorial and a 2015 publication, Misch, CM stated: “From a biologic perspective, autogenous bone remains the gold standard for bone graft materials.”2, 3 The author further summarized that autogenous bone is associated with greater volume gains and superior quality. Returning to the definition of “gold standard” (a currency supported by the commodity gold) the “currency” here is autogenous bone and the “commodities” backing the currency are better bone volume and quality. This however raises the question of what constitutes better bone quality.A PubMed search using the key words “bone quality assessment” found multiple results in the orthopedic literature. Quality was assessed by the bone's susceptibility to fracture and capacity to turnover especially in conditions of osteoporosis. When the terms “bone quality assessment in oral bone grafting” are used, the results include review papers on histomorphometric findings and/or survival of dental implants in alveolar guided bone regeneration procedures or sinus augmentations. The use of various grafting materials including autogenous bone, allografts, alloplasts and xenografts were compared, and the results found that bone substitutes either performed in a like manner or superior to autogenous bone used alone.4,5 Furthermore, these positive results had the added major benefit of eliminating the second surgical site morbidity associated with harvesting autogenous donor grafts.The equal or superior findings are due principally to biotechnological improvements that bone substitutes have undergone in the previous two decades. Improvements in the allograft group include: (i) variety of particle sizes, (ii) density mixtures and (iii) exploiting the qualities of cortical and/or cancellous bone separately or in combination. These improvements have led to: (i) favorable bone quality, (ii) improved bone volume, (iii) lower material costs, (iv) more efficient surgical time, (v) absence of risk of disease transmission or antigenicity, (vi) less morbidity, and (vii) greater predictability especially in the repair of large defects. These were the same parameters used to label autogenous bone as the “gold standard”.In conclusion, the specialty of implant dentistry needs to do what the Federal Reserve of the United States did and terminate the association of autogenous bone to the “gold standard” and let the science and biology of bone substitutes float as a “fiat currency”. This would promote the evolution of bone grafting materials and allow more patients to be treated successfully and comfortably, while respecting the fundamentals of wound healing that never change.

Best Practices for the Orthopaedic Care of Children with Spinal Muscular Atrophy: A Consensus Statement from the European Neuromuscular Centre Standard of Care Orthopaedic Working Group

Purpose: Spinal muscular atrophy (SMA) is a genetic disease resulting in orthopaedic problems that warrant intervention. Recent genetic therapies appear to improve the natural course of this disease, prompting care providers to rethink treatment strategies. Insufficient high-quality evidence exists to guide optimal intervention in this new landscape. To address this, the European Neuromuscular Centre (ENMC) tasked an orthopaedic subgroup to update previous recommendations. Materials and Methods: A consensus statement on orthopaedic treatment of patients with SMA undergoing genetic therapy was sought via Delphi method. After review of the orthopaedic literature, three iterative surveys were administered from 2015-2016 to worldwide experts in orthopaedic care of children with SMA. Surveys identified important topics for optimal management, solicited responses regarding management and evaluation of identified topics, and clarified decision-making strategies and indications for evaluation and management, respectively. In light of new evidence of the long-term effects of gene therapy on SMA patients, an additional review of literature was used to contextualize the consensus recommendations. Results: Thirteen experts on orthopaedic management of SMA identified treatment of spine deformity, hip instability, and joint contractures as issues of importance. Experts recommended instrumentation in spinal deformity for major curves greater than 50 degrees, while monitoring pain, respiratory function, kyphosis, pelvic obliquity, functional status, trunk imbalance, and rib deformity. Preferential use of magnetically controlled growth constructs and performance of final fusion with skipped levels to accommodate intrathecal access were also endorsed. Additionally, experts advocated for surgical correction of hip instability and/or contractures that cause pain or functional impairment. Conclusions: Practice guidelines for management of scoliosis, hip instability and joint contractures were created to aid clinical decision-making in the era of genetic therapy.

Prof. M.O. Friedland. Private orthopedics. Kazan. Tatizdat. 1932 p. 237

Our book market is very poor in orthopedic literature. Along with a large number of periodical medical publications, in our Union there is only 1 journal (in Ukraine), dedicated specifically to the issues of orthopedics. To an even greater extent we feel the lack of book manuals on orthopedics. It is all the more gratifying to see the "Private Orthopedics" of Prof. MO Friedland, recently published by Tatizdat in Kazan, which is a logical continuation of his "General Orthopedics" published in 1928.

Return to Driving after Elective Foot &amp; Ankle Surgery: A Systematic Review

Category:Ankle; Arthroscopy; Midfoot/Forefoot; OtherIntroduction/Purpose:Studies investigating when patients can safely return to driving are becomingly increasingly numerous in the orthopedic literature because of the recognition of the importance of the activity to the lives of most adults. Previous systematic reviews have proven helpful by collecting and summarizing these studies to establish concise guidelines that can be presented to patients during the counseling surrounding a procedure. Having these guidelines can be even more crucial when discussing elective procedures. This systematic review summarizes the available studies investigating when it is safe to return to driving following elective foot and ankle procedures.Methods:A systematic review of the literature was performed using PubMed, Embase, and CINAHL to identify English-language studies from 1999 to present that investigate return to driving after right-sided elective foot and ankle procedures. Qualitative assessment of each of the included studies was performed independently by two authors. Then data from each study was extracted and broken down into distinct categories for comparison: study details, population, control group, method of evaluation, and results.Results:Eight studies met inclusion criteria. All of the studies investigate brake reaction time (BRT), via a driving simulator, as their primary outcome. A variety of objective and subjective secondary outcomes were collected. Patients undergoing right ankle or subtalar arthroscopic procedures have no significant difference in BRT compared to controls at 2 weeks post-operatively. 92% of patients undergoing right ankle arthroplasty had a BRT that was not significantly different to the control group at 6 weeks post- operatively. Patients who had an ankle arthrodesis had significantly delayed BRT compared to controls even past 1-year post- operatively. The majority of patients after corrective hallux valgus surgery have no significant difference in BRT at 6 weeks post- operatively compared to their pre-operative baselines depending upon how they are doing clinically. The included studies used a variety of patient reported outcomes that were helpful in predicting which patients would fail the driving simulation at the various timepoints.Conclusion:The recommendations from these reviewed studies can guide physicians when counseling their patients on when they can expect to safely return to driving after a specific, elective foot and ankle procedure. However, these recommendations are reliant on routine healing post-operatively and may need to be adjusted if a patient is experiencing any complications. A variety of patient surveys and other subjective scores can be very helpful in assuring a routine post-operative course.

Lesser Tarsal Metatarsal Joint Fusion Using Nitinol Staples, Bone Marrow Aspirate Concentrate and a Calcaneal Bone Dowel: A Retrospective Comparative Analysis

Category:Midfoot/Forefoot; Lesser ToesIntroduction/Purpose:Estimates suggest nonunion rates following lesser tarsometatarsal (TMT) fusion are up to 11.4%. Various techniques have been employed to improve fusion rates; however, none have shown significant improvement compared to other techniques. Autologous bone dowels, bone marrow aspirate concentrate (BMAC) and continuous compression devices (CCDs), such as nitinol staples, have each shown promising fusion rates in orthopedic literature. There is limited data that suggests using these techniques in conjunction with one another has been successfully employed in the fusion of lesser TMT joints. The aim of this study was to describe our technique using autologous calcaneal bone graft, CCDs and BMAC for lesser TMT fusion and to investigate whether this method improves fusion rates and decreases time to fusion in comparison to traditional constructs.Methods:All patients undergoing arthrodesis of the lesser (2nd/3rd) TMT joints from January 2015 to January 2020 were identified. Exclusion criteria included inadequate clinical or radiographic follow-up, those with only 1st TMT joint arthrodesis, and those less than 18 years old. Chart review allowed patient demographics, risk factors and surgical approach to be identified.Twenty patients (28 lesser TMT joints) treated with arthrodesis by the senior surgeon met inclusion criteria. These patients were then divided into two groups: 1) novel treatment (Nitinol staple, BMAC and calcaneal dowel) and 2) traditional treatment (compression plate and screw construct). We then assessed for radiographic union, time to union and complications.Results:All lesser TMT joints in the novel treatment arm went on to successful clinical and radiographic fusion. The radiographic union rate of the traditional treatment arm was 92% (P=.08). Overall time to fusion was 56 and 82 days for the novel and traditional constructs respectively (P <.05). All patients, regardless of construct, had returned to full weight bearing and maintained hardware at most recent follow-up (minimum 6 months).Conclusion:Continuous compression devices such as the nitinol staple and use of biologic adjuvants appear to decrease nonunion rates and significantly shorten overall time to fusion in lesser TMT joints. Further investigation towards identifying patient specific factors for nonunion is warranted.

The Influence of Sex on Outcomes at Various Time Points after Total Ankle Arthroplasty

Category:Ankle Arthritis; AnkleIntroduction/Purpose:Total ankle arthroplasty (TAA) is regarded as an increasingly accepted alternative to ankle arthrodesis in patients with ankle arthritis that have failed conservative management. While significant focus within orthopedic literature has been placed on determining various risk factors for particular outcomes, the stratification of outcomes based on sex has been insufficiently investigated. Moreover, as the number of TAAs performed continues to increase, there is a growing need to examine the effects of sex on outcomes after TAA. We sought to compare patient reported outcome measures (PROMs), ankle range of motion (ROM), and complications at multiple time points in the post-operative period after TAA as stratified by sex.Methods:undergoing TAA during the years 2013 to 2018 at a single academic institution who had minimum follow-up of two years. A total of 133 patients met inclusion criteria, comprising 55.6% males and 44.4% females. Patients were evaluated pre- operatively and at 6 months, 1-year, and 2-years post-operatively. PROMs, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, Visual Analog Scale (VAS) score, and the Short Form - 12 (SF-12) were administered, and ROM was assessed at all time points. Post-operative complications were also recorded. Student t-test were used to determine differences between the outcome measures. Eighty-nine patients received the Zimmer total ankle (39 females), whereas 44 patients (20 females) received the mobile bearing Hintegra.Results:The average age was 53.6 in the male cohort as compared to 53.8 in the female cohort (p=0.93). Both pre-operatively and at 6-months post-operative, the cohorts did not differ statistically in any of the measured outcomes. At 1-year post-operative, females had a lower SF-12 PCS score (44.1 versus 47.1, p=0.019) and less plantarflexion (20.5 versus 23.5, p=0.029) as compared to males. While both cohorts saw a significant step-wise increase in AOFAS scores between pre-operative, 6-months, and 1-year post-operative (p<0.001), the AOFAS score of the female cohort plateaued at 1-year while the male cohort continued to improve significantly (<0.015). Ultimately by 2-years post-operative, females had a statistically significant lower AOFAS score as compared to males (80.3 versus 85.4, p=0.04).Conclusion:Our results show that while both cohorts experienced significant improvement in all measured outcomes, women have lower SF-12 PCS scores and AOFAS score at 1- and 2-years post-operative, respectively, as well as less plantarflexion at 1- year post-operative with a trend towards increased complication rate after TAA. While our results add to the growing body of literature supporting TAA as a reliable means of treating ankle arthritis, our results are novel in that they were stratified and analyzed based on sex. Understanding these differences in outcomes is critically important for effectively managing expectations and treating both male and female populations.

Defining Return to Sport: A Systematic Review

Category:SportsIntroduction/Purpose:Return to sport (RTS) commonly serves as a measure for assessment of clinical outcomes in orthopaedic sports medicine surgery. Unfortunately, while RTS is commonly utilized in research for this purpose, currently, there is no widely accepted or standardized definition for when an athlete has officially returned to his or her sport. The purpose of this study was to conduct a systematic review to evaluate and report the differences in specific definitions of return to sport (RTS) utilized in the orthopaedic surgery literature.Methods:A systematic review was performed using PubMed, Embase and Cochrane databases per PRISMA guidelines. Search terms consisted of variations of 'RTS' combined with variations of 'orthopedic surgery' and 'define' to capture as many relevant articles as possible. The definition of return to sport was recorded and analyzed.Results:718 articles were identified in the initial search, 29 of which met eligibility criteria, providing a clear definition of RTS. Of the 29 studies included, 20 (69.0%) defined RTS as an athlete competing in a game or other competitive play, and these definitions are further broken down in Table 1. Three (10.3%) defined this as the athlete competing in a game or other competitive play, but with an explicitly stated competition-level modifier of the athlete returning to their pre-injury level of competition. Two articles (6.9%) included returning to training or practice and the remaining four articles (13.8%) used terminology other than the standard RTS.Conclusion:There is variability in the definition of RTS used in the literature. Most studies refer to the athlete competing in a game or other competitive play. Other variants include returning to practice/training and explicitly defined competition levels and objectives. Future studies should aim to standardize the definition of RTS to facilitate more precise assessment of outcome following sports medicine surgery. Using terminology that describes components of the recovery and rehabilitation process, such as 'return to participation' and 'return to performance' in addition to RTS will allow us to better understand the athlete's recovery and associated level of competition or performance.

The multidisciplinary approach to managing prosthetic joint infection: could this lead to improved outcomes?

Periprosthetic joint infection (PJI) is a devastating complication of the total joint arthroplasty (TJA). It presents a great challenge for the treating clinician. Diagnosis as well as management can prove difficult with significant morbidity for the patients and cost for patients, health care providers and society as a whole. Outcomes of equally challenging pathology such as tumors and polytrauma have been shown to be improved when patients are managed by a team as specialists as opposed to single individuals. The purpose of this study is to review the role of the multi-disciplinary team (MDT) approach in the diagnosis and management of PJI. We examine the influence of this approach on clinical outcomes in patients with PJI. We also discuss the organisational and logistical issues associated with establishment of a MDT as well as several other issues not mentioned in the contemporary orthopaedic literature. All published literature examining the role of multidisciplinary care in the management of PJI and the influence of this approach to the management and outcomes of patients with this diagnosis were included. Studies published in languages other than English were excluded. There is a paucity of data on the influence of multidisciplinary care on outcomes of the management of PJI. Evidence suggests that the MDT has important role in ensuring all factors in the management of this complex group are considered and best possible care is delivered. Multicentre randomised clinical trials are required to assess the influence of MDT'S on outcome as well as important questions around the structuring of these teams.

The 100 Most Impactful Papers in Hand and Upper Extremity Surgery over the Last 25 Years: A Bibliometric Analysis of the Orthopaedic Literature

Introduction Despite growth in hand/upper extremity investigation, impactful studies have not been thoroughly identified. Previous studies have been limited in scope. This study sought to identify and characterize the most impactful orthopaedic papers in hand/upper extremity over the past 25 years.Materials and Methods The top 1,000 hand/upper extremity orthopaedic studies published from 1992 to 2017 were identified with Web of Science. After screening for relevance in order of decreasing citation number, the top 100 articles were identified for bibliometric analysis.Results The mean number of authors and citations were 4.51 (range, 1–21) and 169.4 (range, 105–863). Common study types included, case series (n = 52), randomized controlled trial (n = 17), and prospective cohort (n = 16), which predominantly covered topics related to shoulder (n = 34), wrist/forearm (n = 21), and hand (n = 17). Among wrist/forearm and hand studies, distal radius fractures (n = 12) and nerve-related topics (n = 10) were most frequently analyzed. Most studies were of level IV (n = 51) and level II (n = 16) evidence. Recent studies had greater impact (mean citations/year: 2011, 82.7/year vs. 1992, 16.1/year).Conclusion Most of the 100 top orthopaedic articles in hand/upper extremity were of level IV or II evidence, retrospective, and nonrandomized. Despite an observed recent increase in level I studies, a lack of prospective, randomized trials is apparent.

Postoperative Infection Rates After Total Ankle Arthroplasty: A Comparison With and Without the Use of a Surgical Helmet System

Following total joint arthroplasty, surgical site infections (SSI) and periprosthetic joint infections (PJI) are associated with increased patient morbidity and healthcare utilization. Current positive-pressure surgical sterile helmet system (SHS) were developed as a feasible, useful version of the body exhaust system.The use of SHS has not yet been proven to decrease infection rates in the orthopedic literature. The primary purpose of this study is to compare the infection rates between patients who underwent total ankle arthroplasty (TAA) with a surgical team wearing SHS versus without SHS.A retrospective chart review in patients undergoing primary TAA with the surgeon wearing SHS (Group 1) or standard surgical attire (Group 2) was conducted. The primary outcome was postoperative SSI and PJI. The rate of wound complications, revision rates, and associated procedures were also analyzed. We identified 109 patients in Group 1 and 151 patients in Group 2. The rate of SSI was 12.8% in Group 1 and 14.6% in Group 2 (p=.411). The rate of PJI was 0.92% in Group 1 and 2.6% in Group 2 (p=.411). There was no difference in revision rates between the two groups. This study suggests that SHS does not appear to protect against postoperative SSI or PJI after TAA. Conversely, we did not find a higher infection rate compared to standard surgical attire despite recent in-vitro studies suggesting SHS as a source of wound contamination. The utility of SHS does not appear to influence the prevalence of postoperative SSI or PJI.

The relationship between musculoskeletal health literacy and upper extremity patient-reported outcome measures (PROMs) in the setting of atraumatic shoulder pain

IntroductionPatient-reported outcome measures (PROMs) are commonly utilized to assess patient-derived orthopaedic health status and function. The prevalence of limited musculoskeletal health literacy (MHL) has been demonstrated to be high within the orthopaedic literature. The purpose of this study was to evaluate the association between MHL and upper extremity-specific PROMs and to determine which patient- and symptom-related factors affect baseline PROMs in patients with atraumatic shoulder pain. HypothesisPatients with limited MHL would demonstrate lower median scores on baseline PROMs compared with those with adequate MHL. Materials and methodsNew patients with atraumatic shoulder pain presenting to an academic practice were administered the Literacy in Musculoskeletal Problems (LiMP), in addition to the American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and Single Assessment Numeric Evaluation (SANE) questionnaires. A detailed physical exam and history was performed by a fellowship-trained shoulder surgeon. Demographic patient data, in addition to prior imaging and orthopaedic treatment, was tabulated. The association between demographics, pain-related variables, and MHL with the ASES, SANE, and QuickDASH scores were examined using Spearman correlation coefficients for continuous variables and Wilcoxon rank-sum tests for categorical variables. Non-parametric analysis of covariance (ANCOVA) was used to examine the independent association of predictor variables with PROMs. ResultsA total of 439 patients met the inclusion criteria and were enrolled. The mean age was 58.8±12.6years (range: 24–93) with 162 (37%) being men. Overall, 172 patients (39.2%) attained a college degree or higher and 183 (41.7%) were currently employed. MHL was significantly associated with ASES (p=0.03), but not with the QuickDASH (p=0.75) or SANE score (p=0.16). Similarly, age, having been in the medical profession or having previously visited an orthopaedist were not associated with PROMs, while employment status correlated to the SANE score (p=0.002). Visual Analogue Scale (VAS) pain level demonstrated varying strengths of association with each of the scores [ASES (r=−0.729, p<0.001), QuickDASH (r=0.557, p<0.001), and SANE (r=−0.430, p<0.001)]. MHL demonstrated no association with initial patient-derived treatment selection. DiscussionThe SANE and QuickDASH may be administered to patients presenting for atraumatic shoulder pain in the outpatient setting regardless of MHL. Further research should be focused on the utility of the ASES instrument amongst patients with lower educational levels and/or limited MHL. Level of evidenceII; diagnostic.

The Minimal Clinically Important Difference: A Review of Clinical Significance

Background: The minimal clinically important difference (MCID) is a term synonymous with orthopaedic clinical research over the past decade. The term represents the smallest change in a patient-reported outcome measure that is of genuine clinical value to patients. It has been derived in a myriad of ways in existing orthopaedic literature. Purpose: To describe the various modalities for deriving the MCID. Study Design: Narrative review; Level of evidence, 4. Methods: The definitions of common MCID determinations were first identified. These were then evaluated by their clinical and statistical merits and limitations. Results: There are 3 primary ways for determining the MCID: anchor-based analysis, distribution-based analysis, and sensitivity- and specificity-based analysis. Each has unique strengths and weaknesses with respect to its ability to evaluate the patient’s clinical status change from baseline to posttreatment. Anchor-based analyses are inherently tied to clinical status yet lack standardization. Distribution-based analyses are the opposite, with strong foundations in statistics, yet they fail to adequately address the clinical status change. Sensitivity and specificity analyses offer a compromise of the other methodologies but still rely on a somewhat arbitrarily defined global transition question. Conclusion: This current concepts review demonstrates the need for (1) better standardization in the establishment of MCIDs for orthopaedic patient-reported outcome measures and (2) better study design—namely, until a universally accepted MCID derivation exists, studies attempting to derive the MCID should utilize the anchor-based within-cohort design based on Food and Drug Administration recommendations. Ideally, large studies reporting the MCID as an outcome will also derive the value for their populations. It is important to consider that there may be reasonable replacements for current derivations of the MCID. As such, future research should consider an alternative threshold score with a more universal method of derivation.

An increasing trend of posterior cruciate ligament reconstruction in South Korea: epidemiologic analysis using Korean National Health Insurance System Database

BackgroundThe posterior cruciate ligament is crucial for posterior stability of the knee joint, and, as well as anterior cruciate ligament reconstruction, posterior cruciate ligament reconstruction (PCLR) has attracted interest in orthopedic literature. A few studies have investigated epidemiologic data of PCLR in Western countries. However, there has been no report on the epidemiological pattern of PCLR in the Asian population, including South Korea. Therefore, this study investigated the incidence and trends of PCLR in South Korea using the Korean National Health Insurance (NHI) System Database.MethodsThe data was collected by the Korean Health Insurance Review and Assessment Service (HIRA) from 2008 to 2016 in South Korea. Patients with a record of cruciate ligament reconstruction and PCLR were allocated from the database. An analysis of the total number and incidence per 100,000 people/year of PCLR procedures and other epidemiologic parameters was conducted according to sex and age.ResultsThe incidence of PCLR procedures rose from 2.3 to 2.6 per 100,000 people (from 1101 to 1299 total cases; 13% increase) between 2008 and 2016: from 3.8 to 4.0 (from 901 to 1000) in males, and from 0.8 to 1.2 (from 200 to 299) in females. PCLR was performed more frequently in males than in females, however, the rate of increase was higher in females than males. The incidence of PCLR over 9 years was highest in patients in their 20s, followed by patients in their 40s and 30s.ConclusionThe incidence of PCLR procedures increased by 13% over 9 years in South Korea. PCLR was performed approximately three times more in men than in women. The incidence of PCLR was highest in patients in their 20s, followed by those in their 40s. The current study will enhance our understanding of the epidemiology of PCLR.Study designDescriptive Epidemiology Study.

Discharge Opioid Prescribing Patterns in an Academic Orthopaedic Setting: Level of Training and Subspecialty Patterns.

Despite increased research on opioids in the orthopaedic literature, little is known of the prescribing practices of orthopaedic providers based on their level of training. The purpose of this study was to describe the discharge opioid prescribing patterns of orthopaedic providers, stratifying by level of training and orthopaedic subspecialty, within a single medical system. A retrospective review of orthopaedic surgical encounters was performed over a 1-year period for adults who received a discharge opioid prescription. Patient demographics and prescriber characteristics were collected, including the provider's level of training (attending, fellow, resident, physician assistant [PA], and nurse practitioner [NP]) and surgical subspecialty. Junior residents were postgraduate year 1 to 3, whereas senior residents/fellows were postgraduate year 4 to 6. Discharge opioids were converted to milligram morphine equivalents (MMEs). Overprescribing was defined as a prescribing more than a seven-day supply or >45 MMEs per day. Multivariable linear regression analysis determined the factors associated with discharge MMEs, whereas logistic regression determined the factors associated with overprescribing opioids. Of the 3,786 patients reviewed, 1,500 met the criteria for inclusion in the study. The greatest proportion of opioid prescriptions was written by junior residents (33.9%), followed by NPs (30.1%), PAs (24.1%), senior residents/fellows (10.6%), and attendings (1.2%). Compared with junior residents, senior residents prescribed -59.4 MMEs, NPs prescribed +104 MMEs, and attendings prescribed +168 MMEs (P < 0.05), whereas PAs prescribed similar amounts (P > 0.05). Orthopaedic subspecialty was also predictive of discharge MMEs (P < 0.05). Senior residents and attendings were more likely to prescribe more than seven days of opioids (P < 0.05), whereas NPs and PAs were more likely to prescribe >45 MMEs per day (P < 0.05). This study demonstrates significant variability in opioid prescribing practices according to provider level of training and subspecialty. National guidelines for opioid prescribing practices and educational programs may help reduce such variability. Level III, retrospective cohort study.