Postoperative Stiffness Research Articles

Nearly 14-Fold Increased Risk of Manipulation Under Anesthesia After Total Knee Arthroplasty When Previous Contralateral Total Knee Arthroplasty Required Manipulation Under Anesthesia

BackgroundStiffness remains a common complication after primary total knee arthroplasty (TKA). Manipulation under anesthesia (MUA) is the gold standard treatment for early postoperative stiffness; however, there remains a paucity of data on the risk of MUA after primary TKA if a prior contralateral TKA required MUA. MethodsWe performed a retrospective review of 3,102 patients who had staged primary TKAs between 2016 and 2021. The mean body mass index was 33 (range, 18 to 59) and the mean age was 67 years (range, 24 to 91). The mean preoperative range of motion for the first TKA was 2 to 104°, and for the contralateral TKA was 1 to 107°. The primary outcomes were MUA following first and second primary TKAs. Multivariable Poisson regressions were used to evaluate associations between risk factors and outcomes. ResultsThe rate of MUA after the first TKA was 2.6% (n = 83 of 3,102) and 1.3% (n = 40 of 3,102) after the contralateral TKA. After adjustment, there was a nearly 14-fold higher rate of MUA after the second TKA if the patient had an MUA after the first TKA (relative risk, 13.80; 95% CI [confidence interval], 7.14 to 26.66). For the first TKA, increasing age (adjusted risk ratio [ARR], 0.65; 95% CI, 0.50 to 0.83) and increasing body mass index (ARR, 0.65; 95% CI, 0.47 to 0.90) were associated with lower risk for MUA. For the second TKA, increasing age was associated with a lower risk of MUA (ARR, 0.60; 95% CI, 0.45 to 0.80). ConclusionsFor patients undergoing staged bilateral TKA, patients who undergo MUA following the first primary TKA are nearly 14-fold more likely to undergo an MUA following the contralateral primary TKA than those who did not have an MUA after their first TKA.

Design and Development of Automated Lower Limb Continuous Passive Motion (CPM) Machine

Abstract: Post-operative rehabilitation is critical in orthopedic surgery, especially for hip joint surgeries. Traditional therapies like manual exercises and resource limits in rehabilitation centers might be tough, but early mobilization and rehabilitation are critical for regaining joint function and allowing patient return to normal activities. Continuously Passive Motion (CPM) devices, primarily developed for knee joint rehabilitation, offer a non-invasive method for passive joint mobility, restoring joint range of motion and lowering post-operative stiffness risk. Their application in hip joint healing is gaining pace, offering better results and increased patient satisfaction. The research also investigates abduction mobility in the hip joint, which is necessary for daily actions like stepping to the side, getting out of bed, or exiting a car. Understanding hip joint biomechanics and range of motion parameters is vital for establishing efficient rehabilitation approaches. By merging clinical insights with technology innovations, this research intends to optimize post-surgery rehabilitation regimens, enhancing patient outcomes and quality of life. The subject of orthopedic rehabilitation continues to expand through interdisciplinary collaboration and innovation, bringing new choices for enhancing patient care and recovery trajectories.

Impact of Surgical Timing on Functional Outcomes after Anterior Cruciate Ligament Reconstruction.

Objectives: Although acute anterior cruciate ligament reconstruction (ACLR) is often avoided because of postoperative joint stiffness, delayed ACLR can lead to a longer recovery time and can have a negative impact on physical function due to detraining. This study aimed to determine the effects of acute ACLR on postoperative outcomes, including muscle strength, performance, and return to sports. Methods: A total of 110 patients who underwent anatomical ACLR using hamstring autografts were included in this study and were divided into three groups: acute (ACLR performed within 2 weeks after ACL injury), 2-6 weeks (ACLR performed between 2 and 6 weeks after injury), and 6-12 weeks (ACLR performed between 6 and 12 weeks after injury). Several parameters were evaluated, including range of motion, knee joint stability, isokinetic knee strength, performance, and return to sports. Results: No significant differences were found in the range of motion or knee joint stability between the groups. The acute group exhibited significantly greater quadriceps strength at 3 months postoperatively than the other groups (p < 0.05). The single-leg hop test showed that 66.7%, 38.7%, and 33.3% of the patients in the acute, 2-6 weeks, and 6-12 weeks groups, respectively, recovered to an LSI of 90% or greater (p = 0.09, Cramer's V = 0.27). All patients in the acute group were able to return to sports (p = 0.14; Cramer's V = 0.28). Conclusions: Acute ACLR is advantageous for the early recovery of strength and performance without adverse events. Acute ACLR may shorten the time spent away from sports activities.

Current trends in the prevention of adhesions after zone 2 flexor tendon repair.

Treating flexor tendon injuries within the digital flexor sheath (commonly referred to as palmar hand zone 2) presents both technical and logistical challenges. Success hinges on striking a delicate balance between safeguarding the surgical repair for tendon healing and initiating early rehabilitation to mitigate the formation of tendon adhesions. Adhesions between tendon slips and between tendons and the flexor sheath impede tendon movement, leading to postoperative stiffness and functional impairment. While current approaches to flexor tendon repair prioritize maximizing tendon strength for early mobilization and adhesion prevention, factors such as pain, swelling, and patient compliance may impede postoperative rehabilitation efforts. Moreover, premature mobilization could risk repair failure, necessitating additional surgical interventions. Pharmacological agents offer a potential avenue for minimizing inflammation and reducing adhesion formation while still promoting normal tendon healing. Although some systemic and local agents have shown promising results in animal studies, their clinical efficacy remains uncertain. Limitations in these studies include the relevance of chosen animal models to human populations and the adequacy of tools and measurement techniques in accurately assessing the impact of adhesions. This article provides an overview of the clinical challenges associated with flexor tendon injuries, discusses current on- and off-label agents aimed at minimizing adhesion formation, and examines investigational models designed to study adhesion reduction after intra-synovial flexor tendon repair. Understanding the clinical problem and experimental models may serve as a catalyst for future research aimed at addressing intra-synovial tendon adhesions following zone 2 flexor tendon repair.

CARTIVA SYNTHETIC CARTILAGE IMPLANT HEMIARTHROPLASTY FOR TREATMENT OF HALLUX RIGIDUS

ObjectivesCartiva synthetic cartilage implant (SCI) is licenced for use in management of symptomatic hallux rigidus in several countries including the UK. As for now, there are no independent comparative series for treatment of hallux rigidus utilising polyvinyl alcohol implants.Study design and methodsPatients at a single centre with symptomatic hallux rigidus who underwent Cartiva SCI implant procedure were identified. First metatarsophalangeal joint arthritis was radiographically graded according to the Hattrup and Johnson (HJ) classification. Pre-operative and post-operative patient-reported outcomes were evaluated using the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale and the Manchester-Oxford Foot Questionnaire (MOXFQ).Results66 patients (19M, 47F) (43R and 23L) were followed up for an average of 14 months (min=2, max=36). 17 patients suffered from HJ2/moderate arthritis and 49 patients with grade HJ3/severe arthritis. Post-operative mean FAAM scores showed statistically significant improvement (p&lt; 0.0001). Patients reported a 40% increase in functionality during activities of daily living. All 3 MOXFQ Domain scores improved significantly (p&lt; 0.02). The Index score improved by 28 points (p&lt; 0.0001). There was no correlation between length of follow up or age and PROMs (r=0.129). No statistical difference was demonstrated between sexes. However clinically, males and older patients exhibit better outcomes. There was a 89.4% patient satisfaction with the use of Cartiva.ConclusionsOur study shows excellent results with statistically significant improvements in functional outcomes, and promising short-term follow-up with low early revision rates. Pain in particular was significantly reduced. One third of patients developed post-operative stiffness requiring a manipulation under anaesthesia. Patient selection is key. Additional imaging may be required to assess sesamoid osteoarthritis. At 3 years the implant has demonstrated to be safe and efficacious in the management of hallux rigidus. Durability and survivability of the implant will continue to be studied in this cohort.

New dynamic suture material for tendon transfer surgeries in the upper extremity – a biomechanical comparative analysis

BackgroundEarly mobilization after tendon surgery is crucial to avoid commonly observed postoperative soft tissue adhesions. Recently, a new suture was introduced (DYNACORD; DC) with a salt-infused silicone core designed to minimize laxity and preserve consistent tissue approximation in order to avoid gap formation and allow early mobilization.AimsTo compare the biomechanical competence of DC against a conventional high strength suture (FiberWire; FW) in a human cadaveric tendon transfer model with an early rehabilitation protocol.MethodsSixteen tendon transfers (flexor digitorum superficialis (FDS) IV to flexor pollicis longus (FPL)) were performed in 8 pairs human cadaveric forearms using either DC or FW. Markings were set 0.8 cm proximally and 0.7 cm distally to the level of the interweaving zone of the transfer. All specimens underwent repetitive thumb flexion against resistance in 9 intermittent series of 300 cycles each, simulating an aggressive postoperative rehabilitation protocol. After each series, the distance of the proximal marker to the interweaving zone (proximal), the length of the interweaving zone (intermediate) and the distance of the distal marker to the interweaving zone (distal) were measured.ResultsPooled data over all nine series, normalized to the immediate postoperative status, demonstrated no significant differences between FW and DC (p ≥ 0.355) for the proximal and distal markers. However, at the intermediate zone, DC was associated with significant length shortening (p < 0.001) compared to FW without significant length changes (p = 0.351). Load to catastrophic failure demonstrated significant higher forces in FW (p = 0.011). Nevertheless, due to failure mainly proximal or distal of the transfer zone, these loads are not informative.ConclusionFrom a biomechanical perspective, DC preserved tissue approximation and might be considered as a valid alternative to conventional high-strength sutures in tendon transfer surgery. DC might allow for a shorter interweaving zone and a more aggressive early postoperative rehabilitation program, possibly avoiding commonly observed postoperative soft tissue adhesions and stiffness.

ACE Inhibitor Use Does Not Significantly Affect Occurrence of Manipulation Under Anesthesia Following Total Knee Arthroplasty

Introduction Common medications may attenuate fibroblast proliferation and scar tissue formation. This study aims to evaluate the association between angiotensin converting enzyme inhibitor (ACEI) use and post-operative stiffness assessed by rate of manipulation under anesthesia (MUA) and change in range of motion (ROM) following total knee arthroplasty (TKA). Methods Patients undergoing primary TKA January 2014 - September 2019 were identified. Demographic information, use of ACEI medications, occurrence of MUA in the 6 months following surgery, and ROM was determined by chart review. MUA was indicated upon failure to achieve 90° ROM at 1-month follow-up. Demographics were analyzed using Student’s t-test and Chi-Squared tests. SPSS (version 24, IBM) multivariate regression calculated odds ratios for MUA controlling for age, BMI, American Society of Anesthesiologist’s class, and gender. Results 1590 primary TKA’s were identified. 274 patients (17.3%) were taking ACEI medications. 46 patients required MUA (2.9%). Five patients (1.8%) taking an ACEI required MUA, versus 41 of the 1316 control patients (3.1%). No significant difference in MUA rates between the ACEI and control cohorts (odds ratio 0.670, 95% CI: 0.259 – 1.735, p=0.410) was identified. Change in ROM was not significantly different between cohorts at 1 and 3 month intervals. At 1-year, improvement in ROM was significantly less in patients taking ACEIs (+6.54° vs. +9.90°, p=0.035) and significantly fewer ACEI cohort patients achieved 118° flexion (56.9% vs. 68.4%, p=0.013). Conclusions This study supplies evidence that ACEIs do not reduce post-operative stiffness following TKA. Additionally, patients taking ACEI medications have significantly less improvement in ROM 1 year post-operatively.

Incidence and risk factors for shoulder stiffness after open and arthroscopic rotator cuff repair.

The aim of this study was to estimate the incidence of stiffness during the first 6 months after rotator cuff repair and to evaluate postoperative stiffness with respect to its risk factors and its influence on the outcome at 6 months postoperatively. In a prospective cohort of 117 patients (69 women, 48 men; average age 59) from our institutional rotator cuff registry, who underwent either arthroscopic (n = 77) or open (n = 40) rotator cuff repair, we measured shoulder range of motion (ROM) at 3 and 6 months post-surgery. We evaluated the incidence of stiffness and analyzed functional outcomes, comparing various preoperative and intraoperative factors in patients with stiffness to those without at the 6-month mark. Shoulder stiffness was observed in 31% of patients (36/117) at 3 months postoperatively, decreasing to 20% (23/117) at 6 months. No significant link was found between stiffness at 6 months and demographic factors, preoperative stiffness, tear characteristics, or the type of repair. Notably, patients undergoing arthroscopic repair exhibited a 4.3-fold higher risk (OR 4.3; 95% CI 1.2-15.6, p = 0.02) of developing stiffness at 6 months compared to those with mini-open repair. Despite these differences in stiffness rates, no significant variation was seen in the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, or Visual Analog Scale (VAS) scores at 6 months between the groups. The incidence of postoperative shoulder stiffness following rotator cuff repair was substantial at 31% at 3 months, reducing to 20% by 6 months. Mini-open repair was associated with a lower 6-month stiffness incidence than arthroscopic repair, likely due to variations in rehabilitation protocols. However, the presence of stiffness at 6 months post-surgery did not significantly affect functional outcomes or pain levels.

A 23-year analysis of litigation in orthopedic elbow surgery

BackgroundThe reasons for malpractice litigation in elbow surgery are not well understood. The aim of this study is to report the most frequently litigated surgeries of the elbow and analyze the reasons for litigation and case outcomes. MethodsA retrospective review of the Westlaw legal database was performed, and all federal and state jurisdiction litigation cases involving the elbow from 2000-2023 were queried. Cases were excluded if they did not involve an orthopedic surgeon, nor primary elbow injury or procedure. Cases were reviewed for demographic information, surgical procedure based on reference CPT codes, complications, symptoms, and reasons for litigation. Quantitative information, including settlement and indemnity cost to the defendant orthopedic surgeon, was analyzed. Cases were sub-divided based on United States Census Bureau regions and states to assess regional frequency of litigation with ANOVA tests. ResultsThere were 59 cases meeting inclusion criteria from 2000-2023.The most litigated cases involved were ulnar nerve transposition/release and open reduction and internal fixation of the proximal radius and/or ulna at the elbow. The most litigated complication was claimed nerve damage (46%) and permanent disability (27%). Of the total cases, the most frequently litigated symptoms were nerve damage (46%) and loss of function (37%), while the least frequent was postoperative stiffness (2%). The Pacific region demonstrated the highest litigation rate (20%), while the East South Central, Mountain, and New England regions had the lowest litigation rate (3% each). A favorable verdict was given to the defendant orthopedic surgeon in 59% of the cases. The average loss incurred through settlement was $245,590, while the average indemnity paid through verdict was $523,334. ConclusionOperative fixation of the proximal ulna/radius and ulnar nerve release/transposition are the most litigated procedures of the elbow. Litigation is most associated with nerve injury. Across Census Bureau regions, there is no significant difference in monetary cost incurred through settlements and verdict losses. Although a majority of litigated cases are won by the defending orthopedic surgeon, thorough informed consent and perioperative expectation management may mitigate litigation risk.

Clinical effect of allogeneic peroneal bone marrow support combined with plate fixation for the treatment of Neer type Ⅳ proximal humeral fractures

To explore clinical effect of allogeneic peroneal bone marrow support combined with plate internal fixation in treating Neer type Ⅳproximal humeral fractures. From December 2017 to December 2020,12 patients with Neer type Ⅳ proximal humeral fractures were treated with allogeneic peroneal bone marrow support combined with plate internal fixation,including 7 males and 5 females,aged from 56 to 78 years old;the time from injury to operation ranged from 1 to7 days. Operative time,fracture healing time and complications during follow-up were observed,and clinical efficacy was evaluated by Constant-Murley score at the latest follow-up. All patients were obtained follow up for 20 to 29 months. All patients got bone healing and incisicons were healed at stageⅠ,operative time ranged from 95 to 138 min,blood loss ranged from 210 to 275 ml,fracture healing time ranged from 14 to 18 weeks. Two patients occurred postoperative shoulder stiffness and recovered after 2 weeks of passive exercise. There were no complications such as infection,poor wound healing,and failure (fracture and loosening) of internal fixators occurred. Constant-Murley shoulder function score ranged from 69 to 89 at the latest follow up,2 patients got excellent results,9 good and 1 fair. The application of allogeneic fibular bone marrow placement could provide effective support for medial humerus,which is conducive to assisting reduction of fracture end,reducing occurrence of internal fixation failure caused by collapse of humerus head and screw perforation,and significantly improving function of shoulder joint.

Complications associated with postoperative stiffness following primary anatomic and reverse total shoulder arthroplasty

BackgroundShoulder stiffness following both primary anatomic and reverse total shoulder arthroplasty (TSA) is a potential complication that is likely underreported. The deleterious effects of postoperative stiffness following TSA and the burden placed on both the patient and the healthcare system have not been well studied. The purpose of this study is to determine the incidence of postoperative stiffness following primary TSA and analyze the effect it has on short-term outcomes up to 180 days following primary TSA. MethodsThis was a retrospective, comparative cohort study. The Nationwide Readmissions Database was queried from 2010 to 2020 for patients who had undergone primary TSA using International Classification of Diseases Clinical Modification and Procedure Coding System codes. Patients were then separated into stiff and non-stiff cohorts. A one-to-one match was performed based on age, sex, and the Charlson comorbidity index. Statistical analyses included chi-square, sample t-tests, logistic, and linear regression. ResultsA total of 7792 subjects were included in the study. The overall incidence of postoperative stiffness was 1.8%. Patients with stiffness following primary TSA were 57% more likely to be readmitted within 180 days (odds ratio [OR] = 1.57) and had increased hospital costs by over $5000 (P < .001), but mortality rates were not increased. However, the odds of experiencing any medical complication or revision decreased by 52% and 76%, respectively, in the stiff group (OR = 0.48, and OR = 0.24, respectively). Postoperative stiffness was inversely predictive of prosthetic dislocation (OR = 0.03), loosening (OR = 0.03), and periprosthetic fracture (OR = 0.04). ConclusionThe incidence of postoperative stiffness following primary TSA was low at 1.8 %. These patients were found to be at increased risk for readmission within 180 days and incurred significantly higher hospital costs compared to the non-stiff cohort. However, postoperative stiffness did not increase the odds of experiencing increased medical complications, mechanical complications, mortality, or revision at 180 days. This information can help guide surgeons in discussion with and management of patients who develop stiffness following primary TSA.

The Chitranjan S. Ranawat Award: Manipulation Under Anesthesia to Treat Postoperative Stiffness After Total Knee Arthroplasty: A Multicenter Randomized Clinical Trial

BackgroundManipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy on range of motion (ROM) and outcomes. MethodsThere were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and physical therapy, while the treatment group also received one dose of pre-MUA intravenous dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov. ResultsThe ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < .001). The ROM was similar between the treatment and control groups at 6 weeks following MUA (101 versus 99°, respectively; P = .35) and at one year following MUA (108 versus 108°, respectively; P = .98). Clinical outcomes were similar at both end points. ConclusionsIn this multicenter randomized clinical trial, the addition of intravenous dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatory medications remains warranted. Level of evidenceLevel 1, RCT.

Biceps tenotomy vs. tenodesis in patients undergoing transtendinous repair of partial thickness rotator cuff tears

BackgroundPatients with partial-thickness rotator cuff tears (PTRCTs) often present with concurrent pathology of the long head of the biceps (LHB) tendon. To address both conditions simultaneously, LHB tenotomy or tenodesis can be performed at the time of arthroscopic rotator cuff repair (RCR). This study aims to compare postoperative shoulder active range of motion (AROM) and complications following transtendinous RCR with concurrent LHB tenodesis or tenotomy. MethodsA total of 90 patients with PTRCTs met inclusion criteria for this study. Patients who underwent tear-completion-and-repair, revision surgery, or open repair of the LHB tendon were excluded. Patients were stratified into tenotomy, arthroscopic suprapectoral tenodesis, or no biceps operation cohorts and were propensity matched 1:1:1 on age, sex, body mass index (BMI), and smoking status. Primary outcome measures included AROM in forward flexion, abduction, external rotation, and internal rotation at 6 weeks, 3 months, and 6 months postoperatively. The development of severe stiffness and rates of rotator cuff retear at final follow-up were recorded as secondary outcomes. ResultsWhen comparing the tenotomy and tenodesis cohorts, tenotomy patients were found to have increased AROM at 3 months in forward flexion (153.2° vs 130.1°, p=0.004), abduction (138.6° vs 114.2°, p=0.019), and external rotation (60.4° vs 43.8°, p=0.014), with differences in forward flexion remaining significant at 6 months (162.4° vs 149.4°, p=0.009). There were no significant differences in interval rates of recovery in any plane between cohorts. Additionally, there were no significant differences in rates of symptomatic retears between groups (p=0.458). Rates of severe postoperative stiffness approached but did not achieve statistical significance between tenotomy (4.2%) and tenodesis (29.2%) cohorts (p=0.066). Smoking status was a significant predictor of severe stiffness (odds ratio, 13.69; p=0.010). ConclusionDespite significant differences in absolute AROM between cohorts, the decision to perform tenotomy or tenodesis was not found to differentially affect rates of AROM recovery for patients undergoing arthroscopic transtendinous RCR for PTRCT. Notably, however, transient stiffness complications were more commonly observed in smokers, and data trends suggested an increased risk of stiffness for patients undergoing LHB tenodesis. Overall, postoperative stiffness is likely multifactorial and attributable to both patient- and procedure-specific factors, and LHB tenotomy may be more appropriate for patients with risk factors for developing stiffness postoperatively.

Early Postoperative Stiffness After Arthroscopic Rotator Cuff Repair Correlates With Improved Tendon Healing

PurposeThis study assessed if early postoperative stiffness predicts long-term stiffness and its relationship with repair integrity in arthroscopic rotator cuff repair (ARCR) patients. MethodsSingle-center retrospective study. 427 patients undergoing primary ARCR by a board-certified orthopaedic surgeon over four years were considered. Patients with at least one year of follow-up were categorized into stiff and non-stiff groups based on their range of motion (ROM) at three months postoperatively. Stiffness was defined as passive forward flexion <120°, external rotation <30°, or internal rotation below L3. We evaluated clinical outcomes using demographics, ROM, Constant Shoulder (CS) score, University of California, Los Angeles (UCLA) score, and visual analog scale (VAS) for pain preoperatively and at 3, 6, and 12 months postoperatively. Stiffness, retear rates, and tendon integrity were assessed via MRI at 12 months. ResultsOf 155 patients meeting the inclusion criteria, 68 (43.9%) were stiff, and 87 (56.1%) were non-stiff. The stiff group had significantly lower preoperative CS and UCLA scores (P=.013/.014) and higher VAS score (P=.034). At 3 months, this group showed lower ROM and functional scores (P<.001), persisting at 6 and 12 months (except internal rotation) (P<.001). Their 12-month VAS score was higher (P=.024). Postoperative stiffness occurred in 10.3% of the stiff group and 2.3% of the non-stiff group (P=.035). The 12-month retear rate was 5.9% in the stiff group and 17.2% in the non-stiff group (P=.032). Minimal clinically important difference (MCID) analysis indicated ROM changes but limited functional score changes in the two groups. ConclusionThis study showed that early postoperative shoulder stiffness correlates with lower preoperative functional scores and higher pain levels. Shoulder stiffness at three months post-ARCR predicts 12-month shoulder stiffness but indicates better tendon integrity. While early stiffness is linked to lower functional scores and more pain, its long-term clinical impact seems limited.

Superior labrum anterior to posterior (SLAP) repair is associated with increased rate of subsequent rotator cuff diagnoses and revision surgery: a propensity-matched comparison

Surgical management of superior labral anterior to posterior (SLAP) tears remains controversial. Current management utilizes 2 well-established procedures: biceps tenodesis and SLAP repair. This study evaluates the complications associated with arthroscopic SLAP repair vs. an open or arthroscopic biceps tenodesis to further elucidate optimal surgical management. In this retrospective cohort study, the TriNetX database was utilized to evaluate patients who underwent repair of SLAP lesions (International Classification of Diseases, Tenth Revision code: S43.43) from May 15, 2003, to May 15, 2023. Three patient cohorts were evaluated: those who underwent arthroscopic SLAP repair (Current Procedural Terminology [CPT] code: 29807), those who underwent arthroscopic biceps tenodesis (CPT code: 29828), and those who underwent open tenodesis of the biceps (CPT code: 23430). Cohorts were propensity matched for type 2 diabetes, nicotine dependence, alcohol-related disorders, body mass index, and demographic factors such as age at event, ethnicity, race, and sex. The outcomes evaluated were disruption of surgical wound, deep vein thrombosis, mononeuropathy of upper limb, shoulder contusion, humeral fracture, sepsis, deceased, acute postoperative pain, revision, shoulder stiffness, and rotator cuff strain. All outcomes were evaluated within 1 year postprocedure. A total of 11,081 arthroscopic SLAP repairs, 9960 arthroscopic biceps tenodesis, and 9420 open biceps tenodesis were matched. Compared with patients who underwent arthroscopic biceps tenodesis, those who underwent arthroscopic SLAP repair were 1.8 times more likely to undergo revision (2.9% vs. 1.6%, P<.0001). Compared with those who underwent open biceps tenodesis, patients who had SLAP repair performed were 1.4 times more likely to undergo revision (3.1% vs. 2.3%, P=.013) and 1.6 times more likely to have a subsequent rotator cuff strain diagnosis (5.1% vs. 3.2%, P=.0002). Compared with patients who underwent SLAP repair, those who underwent arthroscopic biceps tenodesis exhibited 1.3 times more instances of acute postoperative pain (5.2% vs. 4.0%, P=.011). Similarly, open biceps tenodesis exhibited 1.8 times more instances of acute postoperative pain (6.9% vs. 3.8%, P<.0001) and 1.3 times more shoulder stiffness (11.8% vs. 9.0%, P<.0001). In the last 20 years, patients who underwent SLAP repair were associated with higher risk of revision surgery and subsequent rotator cuff strain diagnosis. Conversely, patients who underwent biceps tenodesis were associated with higher rates of acute postoperative pain and shoulder stiffness.

Osteonecrosis of Humeral Head after Arthroscopic Capsular Release for Postoperative Shoulder Joint Stiffness: A Case Report

An arthroscopic capsular release (ACR) is used for persistent shoulder stiffness after an index surgery. No cases of post-ACR humeral head osteonecrosis have been reported to date. A 56-year-old male patient underwent open reduction and internal fixation using a hook plate for acromioclavicular joint dislocation. Despite hardware removal, the patient presented with unresolved shoulder pain and range-of-motion (ROM) limitations. He had a history of hypertension, chronic hepatitis B infection, and alcohol consumption. His preoperative ROM was 90° for active forward flexion, 90° for abduction, 40° for external rotation, and at a sacral level for internal rotation. His preoperative functional status was a visual analog scale (VAS) score of 4, an American Shoulder and Elbow Surgeons (ASES) score of 51, and a Constant–Murley (CMS) score of 48 through normal radiography and magnetic resonance imaging. A standard ACR was performed with a 360° release of the joint capsule via electrocautery ablation. Six months post-ACR, his ROM (forward flexion: 135°; abduction: 135°; external rotation: 70°; internal rotation: T10 vertebra) and functional outcomes (VAS 2; ASES 79; CMS 75) were significantly improved, without an interval change in radiographic assessment. However, 15 months post-operation, the patient experienced a recurrence of shoulder pain and subsequently underwent triamcinolone injections in both the 15th and 21st postoperative months. Radiography revealed humeral head osteonecrosis. Patients with intrinsic or extrinsic risk factors related to humeral head circulation disturbance should be monitored for humeral head osteonecrosis post-ACR.

Complications after total wrist arthroplasty.

We reviewed the incidence and management of complications after total wrist arthroplasty, as reported in the literature, with so-called fourth-generation implants and other recent designs. While early intraoperative and postoperative complications, including fractures, tendon lacerations, infection, nerve compression, tendonitis, stiffness and chronic regional pain syndrome, had an acceptable incidence, late complications, such as periprosthetic osteolysis and implant loosening, occurred more frequently. Implant survival at 10 years was in the range of 70%-80% in most publications. Several of the implants have been modified or withdrawn. Instability and dislocation were frequent after a pyrocarbon spacer. Failed arthroplasties can be salvaged by revision arthroplasty or total wrist arthrodesis. Revision arthroplasty has a lower survival rate than primary arthroplasty and does not clearly offer important significant advantages over total wrist arthrodesis in terms of patient-reported outcome measures. Further development of prosthetic design, new materials and more knowledge on patient-related risk factors are needed.

Influence of patients' preoperative expectations on postoperative outcomes after total knee or hip arthroplasty: a systematic review.

The association between preoperative expectations and treatment outcomes in total hip arthroplasty (THA) or total knee arthroplasty (TKA) is still unclear. Therefore the aim is to examine the association between preoperative outcome expectations, process expectations, and self-efficacy, and the postoperative outcomes overall outcome, pain, function, stiffness, satisfaction, and quality of life following THA/TKA. A systematic review with narrative synthesis was conducted. PubMed, EMBASE, PsycINFO, CINAHL and Cochrane Library were searched from inception to October 17, 2022. Included were prospective longitudinal cohort studies published in English, German, or Dutch, with an adult population undergoing THA/TKA, and including at least one measure of preoperative expectations and the postoperative outcomes mentioned earlier. Two independent reviewers screened the retrieved articles for eligibility, a third solved disagreements. Risk of bias (RoB) was assessed using the QUIPS tool. Of the 50 included studies, 38 had high RoB and 12 moderate RoB. Unadjusted results suggest a positive association between preoperative outcome expectations and overall outcome in the medium and long term, and between self-efficacy and change in 'overall outcome' in the long term. Adjusted results suggest positive associations between outcome expectations and function and between self-efficacy and overall outcome in the medium term, and for outcome expectations with pain and change in pain, respectively, and self-efficacy and stiffness in the long term. Preoperative expectations show a possible positive association with specific outcome measures, such as pain or function. For future research, it is advised to link matching specific expectations with specific outcomes.

Knotless Bioabsorbable Anchors Placed on the Glenoid Face for Arthroscopic Bankart Repair

Background: Quantitative analysis of the glenoid face knotless-type anchor placement for arthroscopic Bankart repair has not been reported. Purpose: To evaluate the clinical and radiologic outcomes after arthroscopic Bankart repair using knotless bioabsorbable anchors depending on the anchor location. Study design: Case series, Level of evidence, 4. Methods: A total of 124 patients (113 men and 11 women; age, 25.6 ± 7.5 years; follow-up time, 46.5 ± 18.2 months [range, 6.2-75.5 months]) who underwent arthroscopic Bankart repair with the bioabsorbable knotless anchor between 2017 and 2021 were included in this study. Among them, 118 patients were observed for >2 years (mean, 48.2 ± 16.8 months [range, 24-75.5 months]) and were analyzed for final clinical and radiologic outcomes. Using postoperative 6-month magnetic resonance imaging, remnant glenoid (%) and labral height were measured. Shoulder range of motion (ROM), radiographic osteoarthritic change, dislocation, apprehension test, and return to sports were recorded. Three groups were established based on the remnant glenoid, which represented the percentage of the exposed glenoid anteroposterior diameter to the original diameter using the best-fit circle method—group A: lower quartile; group B: interquartile; and group C: upper quartile—and variables were analyzed. Results: Overall, the remnant glenoid was 57% ± 6.4% (range, 41.5%-75%) after the surgery. Osteoarthritic change, dislocations, and positive apprehension tests were observed in 5 (4.2%), 4 (3.4%), and 12 (10.2%) patients, respectively. A total of 34 (28.8%) and 64 (54.2%) patients could return to sports without and with restrictions, respectively. Comparing groups A, B, and C, postoperative labral height (7 ± 1, 7 ± 2, and 7 ± 1 mm; P = .623), final osteoarthritic change (1, 4, and 0; P = .440), positive apprehension tests (5, 5, and 2; P = .387), and return to sports (complete/restricted/unable, 6/18/5, 19/29/11, 9/17/4; P = .769) were not different. All ROM were similar across the groups (all P > .054), except for external rotation (ER) at postoperative 6 months (41.3°± 12.8°; 50.2°± 18.5°; and 49.8°± 15.2°; P = .050). However, ER after 1 year was similar across the groups (all P > .544). In further analysis, patients with positive apprehension tests had lower labral height compared with others (5 [4-6] mm and 7 [6-8] mm; P < .001). Conclusion: In arthroscopic Bankart repair, the placement of knotless bioabsorbable anchors on the glenoid face, combined with the remplissage procedure or rotator interval closure, resulted in a low recurrence rate and moderate return to sports. However, most patients had some restrictions in returning to sports. Moreover, this technique was not associated with postoperative arthritis and shoulder stiffness, including ER deficit, which was not affected by the position of the anchor on the glenoid face for a minimum 2-year follow-up.

Acute Anterior Cruciate Ligament Reconstruction Performed Within 10 Days of Injury Does Not Increase Risk of Postoperative Arthrofibrosis: A Systematic Review and Meta-analysis

Background: The optimal timing of anterior cruciate ligament (ACL) reconstruction (ACLR) remains a controversial topic. Previous reviews have demonstrated that there are no differences between early and delayed ACLR; however, these studies have been limited by heterogeneous definitions of acute ACL injury. Purpose: To evaluate postoperative patient functional outcomes and risk for arthrofibrosis after acute arthroscopic ACLR performed ≤10 days after injury. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using multiple medical databases. Inclusion criteria were studies that evaluated postoperative range of motion outcomes for patients undergoing ACLR ≤10 days after initial ACL injury. For included comparative studies comparing patient groups undergoing ACLR ≤10 days and patients undergoing “delayed” ACLR after ≥3 weeks of initial injury, quantitative analysis was performed to assess for differences in postoperative arthrofibrosis, reoperation rates, and patient-reported outcomes between groups. DerSimonian-Laird binary random-effects models were constructed to quantitatively describe the association between the ACLR time period and patient outcomes by generating effect estimates in the form of odds ratios with 95% CIs. Qualitative analysis was performed to describe variably reported patient outcomes and the risk of arthrofibrosis after ACLR for noncomparative studies. Results: Screening yielded 6 full-text articles with 448 patients who underwent ACLR (296 ACLR <10 days, 152 ACLR >3 weeks), with a pooled mean age of 28.1 years. For studies amenable to quantitative analysis, there were no significant differences between ACLR performed ≤10 days and ACLR performed at the 3-week point or after in terms of postoperative stiffness (3 studies; odds ratio, 1.27; P = .508), Tegner scores (2 studies; mean difference, –0.056; P = .155), or reoperation for stiffness (3 studies; odds ratio, 0.869; P = .462). The overall incidence of postoperative arthrofibrosis after 12 months of follow-up was 11 of 296 (3.7%) for ACLRs performed ≤10 days versus 6 of 152 (3.9%) for those performed at the 3-week point or after. Conclusion: ACLR performed ≤10 days after the inciting injury does not increase the risk of postoperative arthrofibrosis and demonstrates similar patient-reported outcomes compared with ACLR performed at the 3-week point or after.